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  • Anterior Cruciate Ligament (ACL) Surgery

    Definition

    This is surgery to reconstruct the anterior cruciate ligament (ACL) in the knee after it is torn. Often, a graft made of tendon is used to reconstruct the torn ligament.
    Anterior Cruciate Ligament Injury
    ACL injury
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    Reasons for Procedure

    ACL surgery is an elective procedure. This means that surgery is not always necessary; it may depend on your lifestyle and age. The decision to have surgery should be made after talking to your doctor about:
    • Your athletic and occupational needs
    • The level of joint stability in your knee
    • Any other damage to the knee
    Surgery may be recommended if you have:
    • A complete tear of the ACL
    • A high degree of joint instability
    • Injury to the knee that affects more than one ligament
    • A need to return to sports or other activities that require pivoting, turning, or sharp movements
    • No improvement with rehabilitative therapy

    Possible Complications

    Complications are rare, but no procedure is completely free of risk. If you are planning to have ACL surgery, your doctor will review a list of possible complications, which may include:
    • Instability of the knee (rupture or stretching of the new ligament)
    • Reconstructed ACL does not work properly
    • Kneecap pain after surgery
    • Stiffness in the knee
    • Loss of full range of motion
    • Numbness
    • Infection
    • Bleeding
    • Blood clot formation
    • Reaction to anesthesia
    Factors that may increase the risk of complications include:
    Discuss these risks with your doctor before the surgery.

    What to Expect

    Prior to Procedure

    Your doctor may do the following:
    • Physical exam and blood tests
    • X-ray of the knee—a test that uses radiation to take a picture of structures inside the body, especially bones
    • MRI scan —a test that uses magnetic waves to make pictures of structures inside the knee
    • Discuss the type of anesthesia that will be used and the potential risks
    Talk to your doctor about your medicines. You may be asked to stop taking some medicines up to one week before the procedure, like:
    • Aspirin or other anti-inflammatory drugs
    • Blood thinners (eg, warfarin , clopidogrel )
    Other things to keep in mind prior to the procedure:
    • Physical therapy is often required before ACL surgery.
    • Arrange for a ride home from the hospital.
    • Avoid eating and drinking for 6-8 hours before the procedure

    Anesthesia

    General or spinal anesthesia will be used. Both will block any pain. General anesthesia will keep you asleep through the surgery. It is given through a needle (IV) in your hand or arm. If you have spinal anesthesia, your doctor may give you a sedative to ease anxiety.

    Description of the Procedure

    IVs will be placed in your arm or hands for medicines and fluids. The doctor will examine the range of motion of the knee and confirm the ACL tear. Next, the doctor will locate another tendon in your knee or hamstring (called autograft) to reconstruct the torn ligament. Sometimes a donor graft (called allograft) is used. The doctor will form the graft tendon to the correct size.
    One or two small keyhole incisions will be made on the top of the knee. An arthroscope (or endoscope) and tiny tools will be inserted into the knee joint. The torn ACL is removed and other damage to the knee is trimmed or repaired. In order to reconstruct the tendon, the doctor will drill holes through bone structures in the thigh and shin. The new graft will be placed through these holes. Needles may be threaded through the holes to suture the new tendon into place, but other devices (eg, screws, washers, staples) are also used to hold the graft in place.
    Once the graft is securely in place, the doctor will test the knee’s range of motion. Other tests will be done as well. The skin will be closed with stitches. Bandages and/or a brace will be placed on the knee.

    How Long Will It Take?

    About two hours

    How Much Will It Hurt?

    Anesthesia prevents pain during surgery. Pain or soreness during recovery will be managed with pain medicine.

    Average Hospital Stay

    This procedure is done in a hospital setting. You can usually go home the same day. If you have complications, you may need to stay longer.

    Post-procedure Care

    At the Hospital
    After the procedure, the hospital staff may provide the following care:
    • Monitor your vital signs as you recover from the anesthesia.
    • Give you pain medicine as needed.
    • Place ice packs on your knee.
    • Show you how to use a continuous passive motion machine.
    • Teach you how to use crutches to keep pressure off your knee.
    At Home
    When you return home, do the following to help ensure a smooth recovery:
    • Take pain medicines as directed.
    • Use crutches for as long as the doctor recommends. This could be 2-6 weeks.
    • Apply the R.I.C.E. method (Rest, Ice, Elevation, Compression).
    • Work with a physical therapist.
    • Gradually begin low impact activities, such as swimming or cycling, to strengthen the knee.
    • Keep the incision area clean and dry.
    • Ask your doctor about when it is safe to shower, bathe, or soak in water.
    • Be sure to follow your doctor’s instructions.

    Call Your Doctor

    After you leave the hospital, call your doctor if any of the following occurs:
    • Redness, swelling, increasing pain, excessive bleeding, or any discharge from the incision site
    • Signs of infection, including fever and chills
    • Pain cannot be controlled with medicines given
    • Numbness in the knee area
    • Nausea or vomiting
    • Trouble urinating
    • Inability to eat or drink
    • Any other concerns

    Call for Medical Help Right Away If Any of the Following Occurs

    Call for medical help or go to the emergency room right away if any of the following occurs:
    • Shortness of breath, or chest pain
    • Swelling, pain, or heat in your calves
    If you think you have an emergency, call for medical help right away.

    RESOURCES

    American Academy of Orthopaedic Surgeons http://www.aaos.org/

    American Orthopaedic Society for Sports Medicine http://www.aossm.org/tabs/Index.aspx/

    CANADIAN RESOURCES

    Canadian Orthopaedic Association http://www.coa-aco.org/

    Canadian Orthopaedic Foundation http://www.canorth.org/

    References

    Agency for Healthcare Research and Quality. Knee & leg (acute & chronic). Agency for Healthcare Research and Quality, National Guideline Clearinghouse website. Available at: http://www.guideline.gov/content.aspx?id=12673&search=acl+surgery . Published February 2, 2004. Accessed on August 26, 2010.

    American Academy of Orthopedic Surgeons. ACL Injury: does it require surgery? American Academy of Orthopedic Surgeons website. Available at: http://orthoinfo.aaos.org/topic.cfm?topic=a00297 . Updated September 2009. Accessed August 26, 2010.

    American Orthopaedic Society for Sports Medicine. The injured ACL. American Orthopaedic Society for Sports Medicine website. Available at: http://www.sportsmed.org/secure/reveal/admin/uploads/documents/ST%20Injured%20ACL%2008.pdf . Published 2008. Accessed August 26, 2010.

    Canadian Orthopaedic Foundation. Anterior cruciate ligament (ACL) surgery. Canadian Orthopaedic Foundation website. Available at: http://www.canorth.org/en/patienteducation/Default.aspx?pagename=Anterior%20Cruciate%20Ligament%20Repair . Accessed August 26, 2010.

    DynaMed Editorial Team. Anterior cruciate ligament (ACL) injury. EBSCO DynaMed website. Available at:  http://www.ebscohost.com/dynamed/what.php . Updated August 4, 2010. Accessed August 26, 2010.

    Smith CM, Leach RE. Anterior cruciate ligament (ACL) injury. EBSCO Patient Education Reference Center website. Available at: http://www.ebscohost.com/thisTopic.php?marketID=16&topicID=1034 . Updated January 11, 2010. Accessed August 26, 2010.

    6/6/2011 DynaMed's Systematic Literature Surveillance DynaMed's Systematic Literature Surveillance : Mills E, Eyawo O, Lockhart I, Kelly S, Wu P, Ebbert JO. Smoking cessation reduces postoperative complications: a systematic review and meta-analysis. Am J Med. 2011;124(2):144-154.e8.

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