Anterior Cruciate Ligament (ACL) Reconstruction

Procedures

ACL Reconstruction

Overview

ACL reconstruction is a common surgical procedure performed to restore stability and function to a knee that has suffered an anterior cruciate ligament (ACL) tear. The ACL is a critical ligament that helps stabilize the knee joint, especially during pivoting, cutting, and sudden directional changes. When torn, it can cause pain, instability, and limitations in athletic performance and daily activities. Surgical reconstruction is often recommended for active individuals who wish to return to sports or physically demanding activities.

What is ACL Reconstruction?

ACL reconstruction involves replacing the torn ligament with a graft, which may be harvested from the patient (autograft) or from a donor (allograft). Using minimally invasive arthroscopic techniques, the surgeon guides the graft into position and secures it to the bones with fixation devices, allowing the ligament to heal and eventually function like a natural ACL.

Conditions Treated with ACL Reconstruction

  • Complete or partial ACL tears causing knee instability

  • Knee instability that interferes with sports or daily activities

  • Associated injuries such as meniscus tears or cartilage damage

Long-Term Consequences of ACL Deficiency

Untreated ACL tears can lead to long-term consequences, including an increased risk of developing meniscal tears and cartilage wear. These secondary injuries can accelerate the onset of osteoarthritis and result in chronic knee pain, instability, and functional limitations.

Graft Choices for ACL Reconstruction

The choice of graft for ACL reconstruction is an important decision that can impact outcomes and recovery. The bone-patellar tendon-bone (BTB) graft is considered the gold standard, particularly for high-demand athletes, due to its strong fixation and reliable results. Quadriceps tendon grafts have gained popularity in recent years, showing promising outcomes. Hamstring tendon grafts, though commonly used in Europe, have been associated with higher failure rates, particularly in younger, more active populations. The decision regarding graft type should be individualized based on patient age, activity level, and specific anatomical considerations.

ACL Repair: Historical Challenges and Emerging Techniques

Historically, ACL repair had high failure rates, which led to its decline in favor of reconstruction techniques. However, recent advancements in surgical methods have shown promising results, particularly for proximal avulsion tears. These techniques are primarily recommended for lower-activity individuals, where the native ligament can be preserved, potentially allowing for quicker recovery and more natural knee biomechanics.

Lateral Extra-Articular Tenodesis (LET)

Lateral extra-articular tenodesis may be recommended as an adjunct to ACL reconstruction in certain high-risk patients. This procedure involves reinforcing the lateral structures of the knee to reduce rotational instability. Candidates for LET include individuals with young age, ligamentous laxity, high-grade pivot shift examination, more than 10 degrees of knee hyperextension, or an elevated posterior tibial slope on x-ray. When performed in appropriate cases, LET has been shown to reduce the risk of graft failure.

The Procedure

ACL reconstruction is typically performed under spinal anesthesia with the assistance of a nerve block for pain control. Small incisions are made around the knee to insert the arthroscope and surgical instruments. The surgeon removes the damaged ACL, prepares the bone tunnels, and positions the graft securely within the knee joint. The procedure generally takes about 60 to 90 minutes.

Advantages of ACL Reconstruction

  • Restored Stability: Reestablishes knee stability, reducing the risk of further injury.

  • Return to Sports: Enables athletes to safely resume high-level activity.

  • Minimally Invasive: Smaller incisions result in less pain and faster recovery.

  • Improved Long-Term Joint Health: Reduces the risk of secondary damage to cartilage or menisci.

Recovery Process

Recovery from ACL reconstruction involves a structured rehabilitation program focused on restoring range of motion, strength, and proprioception. Patients typically wear a brace initially and use crutches for support. Physical therapy starts within days of surgery and continues for several months. Most patients can resume non-contact activities around 4-6 months and return to sports within 9-12 months, depending on their progress and the demands of their activity.

Risks and Considerations

While ACL reconstruction is generally safe, potential risks include infection, blood clots, graft failure, and knee stiffness. Adhering to post-operative guidelines and rehabilitation protocols significantly reduces these risks.

Conclusion

ACL reconstruction is a well-established procedure that helps restore knee function and stability after an ACL tear. If you have experienced a knee injury or are dealing with ongoing instability, contact our office to learn more about your treatment options and whether ACL reconstruction may be right for you.