Performed by – Khalid Al-Hourani, Alastair Davidson, Reza Mansouri, Zuhair Nawaz, Andrew Perry, James Singleton

The ACL (Anterior Cruciate Ligament) sits in the middle of the knee linking the tibia (shin bone) to the femur (thigh bone) and is important in controlling movement of the two bones, particularly during twisting pivoting sports and dancing.

Anterior Cruciate Ligament Tear
The anterior cruciate ligament is commonly ruptured by twisting injuries such as a bad tackle in football or a fall whilst skiing. Typically, the knee will ‘give way’ and there may be a painful ‘popping’ sensation. You may even find that you are not able to get up and walk. Typically, your knee will swell over the next hour as the ruptured ends of the ligament bleed into the knee. If nothing is done the knee will slowly settle over six weeks but if you return to sport, you may suffer ‘giving way’ episodes similar to your initial injury when you twist and turn. If things are bad you may experience such instability on normal day to day activities.

Diagnosis of ACL Injury

The diagnosis depends on a clinical examination at which time the laxity of the ligament can be assessed to see if the cartilages are also damaged. It is often very difficult to examine a knee soon after the initial injury as it is swollen and painful. In this case it is usual to arrange for an MRI scan to confirm the diagnosis and physiotherapy to mobilise the knee and and help it recover. After a few weeks it is easier to examine the knee and to confirm the diagnosis.

Torn Anterior Cruciate Ligament

Non-Operative management
It is possible to rehabilitate your knee and get it working well after injury by a course of physiotherapy. This aims to strengthen the muscles around the knee to stop it giving way. If your sporting desires are not high it may be possible to avoid surgery, but there is an increased risk of further injury as the knee can ‘give way’ and you may fall because of it. If you wish to get back to running twisting sports, physiotherapy is unlikely to make your knee stable enough and surgery is usually considered.

Operative management
Anterior cruciate ligament (ACL) reconstruction surgery is an arthroscopic (keyhole) surgical procedure. The same two small incisions as for arthroscopy are used at the front of the knee, with another small incision above the knee, and a 3-5cm incision at the front of the knee to obtain the graft and feed it into the knee. By operating with this technique we can perform this surgery as day case surgery under a general anaesthetic with a more rapid return to normal daily activities.

Anterior Cruciate Ligament graft

The procedure involves excising the damaged ACL and replacing it with a graft of your own tissues. The surgeons at Joint Reaction recommend using a hamstring graft. In this technique tendons from the inside of your knee are removed via a 3-5cm incision just below the knee and used to reconstruct your ACL. Despite the loss of these tendons you are unlikely to notice a significant reduction in the strength of your hamstrings.

The graft is threaded across the knee via two drill holes. The first drill hole enters the knee where the ACL attaches to the tibia and the second is across the knee in the femur, where the ACL is also attached. Both of these drill holes are made through the small incision used to remove the hamstring tendons as the entry point is at the hamstring insertion on the tibia. The graft is pulled through the knee and fixed in place using special devices and screws.

Hamstring Anterior Cruciate Ligament Graft

Revision ACL reconstruction
The surgeons at Joint Reaction have a large combined experience of this surgery due to treatment of a large population of sportsmen and women, as well as military personnel. Graft options used in revision cases will be discussed on an individual basis and may involve your own tissue or donor tissue ‘allografts’.

After surgery
Most ACL reconstructions are performed as a day case, but if the surgery is later in the day or if you live alone you may need to spend the night. The knee is filled with local anaesthetic at the end of the operation to numb the pain. You will be mobilised by a physiotherapist using crutches and given some exercises to perform. Your physiotherapy rehabilitation will start a week after surgery and is split into different phases. In the first 3 months you will regain a full range of movement mainly performing ‘closed chain exercises’. These are exercises with your foot on the floor or a pedal of a stationary bike that do not over stress the healing graft. After 3 months the graft has healed strongly to the bone in the tunnels either side of the knee joint and your rehabilitation can progress. Between 3 and 6 months you start ‘open chain exercises’ such as jogging in a straight line and progress to shuttle runs in the gym. You will also do ‘proprioception’ exercises to train the muscles to respond quickly. Between 6 and 9 months you can start sport specific training. If you want to play football you can return to training but should avoid tackling and competitive games. You can return to gentler sports such as tennis at this time.

Finally, at 9 months your rehabilitation is complete and you can return to your chosen sport, although it is often sensible to avoid full competitive contact until one-year post surgery.

Success of ACL reconstruction
90% of patients should be able to get back to their chosen sport after an ACL reconstruction. However, some avoid it due to the risk of further injury to either or the same knee. The risk of ACL graft rupture is an approximately 6%, but it is this is also the risk of rupture of the normal ACL in the other knee.