Anterior Cruciate Ligament (ACL) Reconstruction

by TOI Admin March 25, 2013

ByTimothy Lane, M.D.

Each year, about 300,000 people worldwide undergo surgery to repair a damaged ACL. The anterior cruciate ligament (ACL) is a ligament that runs through the center of the knee joint. Its function is to help keep the position of the tibia (shin bone) stable relative to the femur (thigh bone). This is especially important during running and pivoting activities, such as playing basketball and soccer. In patients who have sustained an ACL tear, the tibia tends to slightly slide forward during sports activities. When the tibia is in this displaced position, excess stress can be placed on the surfaces of the joint which can create damage to the cartilage surrounding the knee. In addition to giving the person a feeling of instability, pain and swelling, this damage can over time accumulate and cause arthritic changes in the joint.

ACL injuries and tears can occur to men and women of various ages, at any level of athletics, and often without contact from another person. Studies have attempted to determine the factors that contribute to higher injury risk, but ACL injuries are usually complex and cannot be isolated to a single cause.

Once an ACL tear is diagnosed through a physical examination and when conservative treatment options are exhausted, anterior cruciate ligament reconstruction may be necessary. Anterior cruciate ligament reconstruction is an operation that is done to reconstruct a torn ACL. This involves replacing the torn ACL with new tissue. There are many potential tendon graft sources for the ACL, such as the patient’s own patellar tendon, hamstring tendon or quadriceps tendon. Additionally, ACL reconstruction is often performed using an allograft, which is a tendon obtained from a donor.

ACL reconstruction is usually performed as an outpatient procedure and is performed through small incisions on the front of the knee. A larger (roughly 1 to 2-inch) incision needs to be made for placement of the graft over the front of the tibia. Occasionally, other incisions need to be made as well. The anesthesia includes general anesthesia plus a nerve block.

Rehabilitation after ACL reconstruction surgery is a lengthy process and is important for a patient’s recovery. The surgeon will provide the patient with specific instructions following the surgery. It is important to adhere to the recommendations from the doctor and ask questions as needed.

Post-operation, patients typically leave the hospital with a combination of crutches or walker and a knee splint. The knee splint provides support for the leg while the nerve block is in place, which can last up to two days. During this time, range of motion exercises begin. After the nerve block has worn off, the knee splint should be removed and range of motion exercises on your knee continue to maintain motion and to reduce stiffness.

Physical therapy for the first few weeks after surgery focuses primarily on knee range of motion with bending and stretching exercises. The patient should use a walking aid such as crutches or a walker to limit stress on the leg and graft while it is beginning to heal. Your surgeon will evaluate your progress and advise you when you may discontinue using the crutches.

After about six weeks, the patient is allowed to bear full weight on the leg, but physical activity will need to gradually increase as muscle strength improves. Physical therapy and exercises will continue until the leg strength has improved dramatically. Usually, one needs to continue exercises for at least eight months after surgery. Running exercises should not begin for four to six months, while running and pivoting exercises should not begin for six to eight months. This is to allow time for the graft to heal to surrounding tissues.

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