What is the anterior cruciate ligament?The anterior cruciate ligament (ACL) is one of the important ligaments that stabilise your knee. If you have torn (ruptured) this ligament, the knee can collapse or ‘give way’ when making twisting or turning movements.
How does an ACL rupture happen?An ACL rupture happens as a result of a twisting injury to your knee. The common causes are contact sports and skiing injuries. You can injure other parts of your knee at the same time such as tearing a cartilage or damaging the joint surface.
It is currently recommended that ACL rupture in active patients be treated by reconstruction surgery since it is menisci-protective. Surgical techniques for ACL reconstruction have improved dramatically during the past ten years. Recovery is much faster and complications are rare.
Are there any alternatives to surgery?Not everyone with an ACL injury may require surgery. Conservative and non-surgical management may be an option in older non-active patients’ as it is possible to compensate for the injured ligament with strengthening exercises or a brace.
What does the operation involve?The surgery is performed arthroscopically. Both traditional ACL reconstruction surgery and All-Inside ACL reconstruction surgery involve replacing the ACL with a tendon graft. The ruptured ligament is removed and the bone prepared in order for it to accept the new graft which replaces the old ACL. Options for the tendon graft are outlined below. The difference between traditional ACL surgery and All-Inside ACL surgery is the approach taken, in particular the drilling of a tibial tunnel. Traditional ACL reconstruction techniques involve drilling a tunnel from the outer tibial cortex into the proximal tibia and knee joint. Through this tunnel the ACL graft is inserted and securely fixed onto the tibia. This tibial tunnel is a significant source of pain following ACL surgery.
However, with All-Inside ACL reconstruction such a tibial tunnel is not created. Instead a specialised tool called a reamer is used to create a tibial socket, which does not violate the tibial cortex as it does in traditional ACL surgery. All-Inside ACL surgery also doesn’t involve any formal incisions, only three to four small arthroscopy incisions. The advantages of All-Inside ACL surgery include less pain and a faster recovery time than traditional techniques. Due to the specialised instrumentation used All-Inside ACL surgery can also help to create a more anatomic ACL reconstruction.
ACL GraftsThere are a number of different surgical options that can be used to reconstruct the ACL ligament. These include the use of autologous hamstring or patellar tendon graft, cadaveric donor grafts and synthetic graft (LARS). From the literature there is no overall significant difference between any of the options; but each method has its own advantages and disadvantages. The best option is the one that is most suited to both the individual patient and their injury. The graft of choice is then prepared in order to take the form of a new tendon and is passed through into the bone.
The new tendon is then fixed into the bone with various devices to hold it into place while the ligament heals into the bone (this usually takes about six months).
Dr Kinzel will discuss with you the pros and cons for each graft option at your appointment.
How soon will I recover?You should be able to go home the same day or the day after. You might have to wear a knee brace for a few weeks. Once your knee is settling down you will need to start intensive physiotherapy treatment, which may continue for as long as 6 months. Regular exercise should help you to return to normal activities as soon as possible.