The Anterior Cruciate Ligament (ACL) is an important ligament that connects and stabilises the two bones that make up the knee (the femur and tibia).
The ACL can be be torn during sport or other injury. Due to a high prevalence of pivoting, contact and sudden-stop sports such as netball and AFL football, Australia has one of the highest incidence of ACL injuries anywhere in the world.
ACL reconstruction aims to rebuild the anterior cruciate ligament (ACL) after the native ACL has been ruptured. The native ACL does not have good ability to heal after injury and so patients who have torn their ACL are instead considered for reconstruction of the ACL if they experience instability of the knee, particularly with cutting and pivoting activities.
ACL reconstruction is performed arthroscopically (keyhole knee arthroscopy), using either the patients’ own tendon tissue (autograft) or donated tendon tissue (allograft). There are various autograft options available – most common being patella tendon, hamstring of quadriceps tensdon graft. Mr Freedman’s preferred reconstruction technique uses a central strip of the quadriceps tendon.
ACL injuries are often traumatic events, usually sustained during athletic activity. Often a “popping” sound may be heard and the knee commonly immediately swells and become painful. Other structures within and around the knee may be injured (meniscus, articular cartilage, collateral ligaments.
Who should have ACL reconstruction surgery?
Patients who have torn the ACL and are experiencing instability of the knee during day-to-day activities or during athletic activity are appropriate candidates for the procedure.
However, it is important to recognise that not everyone needs ACL reconstruction surgery after ACL injury. Patients may be able to compensate by good rehabilitation/physiotherapy and the use of a knee brace. Consideration for surgery will also depend on the level of athletic activity, sports and types of activities that the patient wishes to pursue afterwards.
Mr Freedman suggests that all patients with ACL injury undergo physiotherapy, as soon as possible after injury, regardless of whether surgery is planned or not so as to preserve full range of movement and avoid scarring inside the knee.
If surgery is considered the goals are to restore normal joint anatomy, to provide static and dynamic stability (and prevent damage to other structures within the knee) and to facilitate return to work and sporting activity.
How is ACL Reconstruction Surgery performed?
The operation is usually carried out under general anaesthetic. A 2-3cm incision is made at the upper inner aspect of the knee cap shin to allow withdrawal of a small slips of the quadriceps tendon. Alternatively, the hamstring tendons from the thigh are used. Knee arthroscopy technique is then used, during which a tunnel is made in the femur (thigh bone) from inside the knee, into which the new ligament will also be passed and fixed. At the end of surgery Mr Freedman will inject local anaesthetic and into the knee to help minimise post-operative discomfort. Dissolvable stitches are used and waterproof dressings are applied.
What happens after ACL surgery?
You will see a physiotherapist before discharge to be instructed on crutch use and post operative exercises to carry out. Crutches are advised for approximately 2 weeks. In most cases patients are allowed to weight-bear as tolerated. Swelling of the knee and lower leg and bruising is very common after ACL reconstruction, is to be expected and may persist for several weeks until full range of motion and mobility has been regained.
You will see Mr Freedman two weeks after surgery for a wound check and a physiotherapy program will commence. Compliance with the rehab program ensue thereafter is critical to the success of the operation. Each individual recovers and rehabilitates at a different pace. As a general guide, Mr Freedman recommends that you do not return to sport for 6 months after first time ACL reconstruction. Pivoting and contact sports may require a 9 month recovery period. Mr Freedman and your physiotherapist will work together to ensure realistic goals are set for you and will help you reach them.