ACL

About ACL

You have been listed for a procedure to reconstruct your anterior cruciate ligament (ACL) and deal with any other remediable knee pathology. ACL reconstruction is very commonly performed and is a safe operation. It has very high success rate with almost 100% of elite athletes getting back to their prior level of activity. That does not translate to the sub-elite level anywhere near as well, largely because patients cannot commit the time necessary for the rehabilitation required. A commitment to your recovery is critical.

It is important to consider that the surgery is undertaken to improve the mobility and the stability of the knee and reduce pain and stiffness. This will involve admission to the Hospital. The surgery can be a day case or 1 night stay and is performed under general anaesthetic. The key when undergoing such surgery is that you understand that there are alternatives, including non-operative management such as physiotherapy, activity modification, anti-inflammatories, and the use of braces.

An ACL involves an arthroscopy, where a camera is inserted into your knee to examine the rest of the structures and any other adjunctive surgery that is needed to the menisci or joint surface or other ligaments in order to make your knee stable. We will deal with both the ACL and other structures, and anything else that needs to be dealt with at the time. There are rare occasions when you will need a brace post-surgery.

It is expected that you will get discomfort, bruising swelling and pain in the peri-operative period. Management of these symptoms would include icing, elevating the leg, physiotherapy, anti-inflammatories, painkillers.

You will also have visible scars around the knee. The scars may initially be unsightly but usually improves over time. There will be numbness around the scars.

Common ongoing symptoms will include –numbness, weakness, joint swelling, knee stiffness, instability while your muscles come back to life.

Uncommon risks include blood clots, wound infection, and graft failure. Blood clots are prevented by limiting the time in surgery, by using compression stockings and by mobilising early as well as using some form of blood thinning medication, if we feel it is indicated in your case. The key risks to also mention is infection. Infection can affect just the wound or be deep, affecting the joint which would require further surgery. The risk of a significant infection requiring hospitalisation is well under 1 in 300. The risk of a minor infection requiring antibiotics is less than 1 in 20.

One of the “big side-effects” of ACL reconstruction is donor site morbidity. It is ongoing symptoms or problems from the site where the graft is taken. That will either to be your hamstring, your patella or your quadriceps tendon, usually the same knee. Very rarely do we use an allograft (a donor tendon). These are associated with less pain and donor site problems, but with a higher risk of infection and re-rupture, particularly in younger patients.

During surgery and in the immediate aftermath of the surgery other issues to consider are that we use a tourniquet for surgery which can lead to skin discolouration and/or bruising in the thigh. You would also get a swelling, numbness and heat around the knee and some of those symptoms may persist for a prolonged period. You are left with scars where the surgery is undertaken. These occasionally cause problems and/or numbness. Occasionally, numbness around the scars can be permanent. If the knee stiffens up it can be difficult to overcome that later, so early physiotherapy is important.

Having surgery will not stop you from getting wear and tear or osteoarthritis later in life. We believe that being more stable will stop you from further damage and hence allows you to recover to a higher activity level and gain more strength around the knee, but we recognise that arthritis is more common in knees that are injured and in knees that have had major surgery.

You are undergoing a reconstructive procedure of your knee and there is a risk that either the ACL or the menisci will not heal, in which case further surgery will be needed. In the longer term there are risks of re-tearing of the graft or re-injury to the menisci of the knee. This affects less than 5% of the cases but the knee may require further surgery. There is a risk that the knee will still feel weak either due to ongoing structural instability or failure to regain muscle mass.

This is a very highly successful procedure that we recommend for you, but it is part of our process to ensure that you are aware of potential pitfalls and have all your queries addressed in advance.

I appreciate that the info sheet is full of medical terminology.