ACL Reconstruction

Indications for surgery

• Young patients wishing to maintain an active lifestyle.
• Sports involving twisting activities e.g., Soccer, netball, football Giving way with activities of daily living.
• People with dangerous occupations e.g., Policemen, firemen, roofers, scaffolders.
• It is advisable to have physiotherapy prior to surgery to regain motion and strengthen the muscles as much as possible.

Surgery

Surgical techniques have improved significantly over the last decade, complications are reduced and recovery much quicker than in the past.

The surgery is performed arthroscopically. The ruptured ligament is removed and then tunnels (holes) in the bone are drilled to accept the new graft. This graft which replaces your old ACL is usually taken from the quadriceps tendon or the patella tendon. There are advantages & disadvantages of each with the final decision based on Dr. Faucett’s and your preference.

The graft is prepared to take the form of a new ligament and passed through the drill holes in the bone. The new ligament is then fixed into the bone with various devices to hold it into place while the ligament heals into the bone (usually 6 months). The rest of the knee can be clearly visualized at the same time and any other damage is dealt with e.g., meniscal tears. The wounds then closed often with a drain and a dressing applied.

Graft Options

There are a number of graft options to reconstruct the torn ACL. These included the patients (Autograft) quadriceps tendon, patellar tendon, hamstring tendon, or donated (allograft) tissue. There is no “Perfect Graft.” Below are some of the considerations of the above graft options.

Graft	Pros	Cons	Dr. Faucetts Opinion
Quadriceps Tendon (Tendon above the knee cap)	Very Strong Graft Can reliably get a large volume ligament Like tissue healing (bone to bone) Minimal numbness Less chronic knee pain Smaller incisions	Small risk of patella fracture Early Post-Operative Pain (same as patellar tendon, less than hamstring and autograft)	This is Dr. Faucett’s preferred graft for ACL reconstruction. It has small incisions and limits the common anterior knee pain associated with the patellar tendon and has very low failure rates compared to allograft and hamstring
Patellar Tendon (Tendon below your knee cap)	Gold Standard graft with long track record Strong low failure rates Like tissue healing (bone to bone)	Most amount of chronic anterior knee pain Patella fracture Anterior knee numbness (infrapatellar nerve crosses the incision) Similar postoperative pain as quadriceps tendon	This is a great graft except it has higher risks of anterior knee skin numbness and chronic anterior knee pain. Very solid graft. Has slightly larger incision than quadriceps tendon
Hamstring Tendon (Tendon that flexes the knee in the back of the thigh)	Less early acute pain than the quadriceps and patellar tendon.	Highest infection rate Puts the ACL at risk because the muscle that protects the ACL is the hamstring Higher re-rupture rates than other grafts Smaller graft 6 weeks of hamstring cramping after surgery	This graft is rarely used by Dr. Faucett. It can be helpful in some specific situations.
Allograft	Less pain at the harvest site (no harvestng0 Can get variable sizes of tissue to fit perfectly	Graft rejection Slower incorporation Higher retear rates in younger patients (Under 40)	Dr. Faucett rarely uses this tissue. Only in revisions or knees with multiple ligament injuries (knee dislocations)

Post-Operation

Surgery is performed as an outpatient surgery, you will go home the same day.

You will have pain medication during the surgery by intravenous, but once you are awake you will receive narcotic and non-narcotic pain medication. You will receive a prescription for pain medication.

A brace is used to support the knee because it is often weak. The brace is often used for just a couple of weeks after surgery but when there is a meniscus repair you will need to wear it for 6 weeks.

You will be seen by a physiotherapist who will teach you to use crutches and show you some simple exercises to do at home.

Leave any waterproof dressings on your knee until your post-op appointment.

You should just put minimal weight in your leg until the strength has returned. If you had .

Avoid anti-inflammatories or aspirin for 10 days.

Put ice on the knee for 20 minutes at a time, as frequently as possible. Dr. Faucett’s team will coordinate getting an ice machine to your house. It is helpful to reduce the swelling and improve pain.

Post-op appointments will usually be at 7-10 days.

Physiotherapy should begin after a 1-3 days to start getting the knee moving, the muscles working, and the swelling down.

If you have any redness around the wound or increasing pain in the knee or feel unwell, you should contact Dr. Faucett as soon as possible.

Risks & Complications

Complications are not common but can occur. Prior to making the decision of have this operation. It is important you understand these so you can make an informed decision on the advantages and disadvantages of surgery.

These can be Medical (Anaesthetic) complications and surgical complications.

Medical (Anaesthetic) complications

Medical complications include those of the anaesthetic and your general well being. Almost any medical condition can occur so this list is not complete. Complications include:

• Allergic reactions to medications
• Blood loss requiring transfusion with its low risk of disease transmission Heart attacks, strokes, kidney failure, pneumonia, bladder infections. Complications from nerve blocks such as infection or nerve damage. Serious medical problems can lead to ongoing health concerns, prolonged hospitalization. The following is a list of surgical complications. These are all rare but can occur. Most are treatable and do not lead to long term problems.

Surgical complications

• Infection – Approximately 1 in 200. Treatment involves either oral or antibiotics through the drip, or rarely further surgery to wash the infection out.
• Deep vein thrombosis – These are clots in the veins of the leg. If they occur you may need blood thinning medication in the form of injections or tablets. Very rarely they can travel to the lung (Pulmonary Embolus) which can cause breathing difficulties or even death.
• Excessive swelling Bruising – This is due to bleeding in the soft tissues and will settle with time.
• Joint stiffness – Can result from scar tissue within the joint, and is minimized by advances in surgical technique and rapid rehabilitation. Full range of movements cannot always be guaranteed.
• Graft failure – The graft can fail the same as a normal cruciate ligament does. Failure rate is approximately 5%. If the graft stretches or ruptures it can still be revised if required by using tendons from the other leg.
• Damage to nerves or vessels – These are small nerves under the skin which cannot be avoided and cutting then leads to areas of numbness in the leg. This normally reduces in size over time and does not cause any functional problems with the knee. Very rarely there can be damage to more important nerves or vessels causing weakness in the leg.
• Hardware problems – All grafts need to be fixed to the bone using various devices (hardware) such as screws or staples. These can cause irritation of the wound and may require removal once the graft has grown into the bone.
• Donor site problems – Donor site means where the graft is taken from. In general either the hamstrings or patella tendon are used. These can be pain or swelling in these areas which usually resolves over time.
• Residual pain – Can occur especially if there is damage to other structures inside the knee.
• Reflex Sympathetic Dystrophy – An extremely rare condition that is not entirely understood, which can cause unexplained and excessive pain.

Summary

Anterior Cruciate Ligament reconstruction is a common and very successful procedure. In the hands of experienced surgeons who perform a lot of these procedures 95% of people have a successful result. It is generally recommended in the patient wishing to return to an active lifestyle especially those wishing to play sports involving running and twisting.

The above information hopefully has educated you on the choices available to you, the procedure and the risks involved. If you have any further questions you should consult with Dr. Faucett.