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ACL Reconstruction

What is the purpose of ACL reconstruction?

ACL reconstruction surgery uses a graft to reconstruct the ligament. The most common grafts are autografts using part of your own body, such as the tendon of the kneecap (patellar tendon) or one of the hamstring tendons. Another choice is allograft tissue, which is taken from a deceased donor.

Repair surgery typically is used only in the case of an avulsion fracture (a separation of the ligament and a piece of the bone from the rest of the bone). In this case, the bone fragment connected to the ACL is reattached to the bone.

Arthroscopic surgery

Many orthopedic surgeons use arthroscopic surgery rather than open surgery for ACL injuries because:

  • It is easy to see and work on the knee structures.
  • It uses smaller incisions than open surgery.
  • It can be done at the same time as diagnostic arthroscopy (using arthroscopy to find out about the injury or damage to the knee).
  • It may have fewer risks than open surgery.

Arthroscopic surgery is done under regional (such as spinal) anesthesia or general anesthesia.

During arthroscopic ACL reconstruction, the surgeon makes several small incisions-usually two or three-around the knee. Sterile saline (salt) solution is pumped into the knee through one incision to expand it and to wash blood from the area. This allows the doctor to see the knee structures more clearly.

The surgeon inserts an arthroscope into one of the other incisions. A camera at the end of the arthroscope transmits pictures from inside the knee to a TV monitor in the operating room.

Surgical drills are inserted through other small incisions. The surgeon drills small holes into the upper and lower leg bones where these bones come close together at the knee joint. The holes form tunnels through which the graft will be anchored.

The surgeon will also make another incision in the knee and take the graft (replacement tissue).

  • A graft taken from the tendon at the front of the knee below the kneecap (patellar tendon) will include two small pieces of bone called “bone blocks” on the ends of the tissue. One piece of bone is taken from the kneecap and the other piece is taken from a part of the lower leg bone near the knee joint. This type of graft allows better healing because the tendon is still attached to its original bone, and the pieces of bone just need to heal into their new locations.
  • If the autograft comes from the hamstring, bone blocks are not taken. This type of graft may allow the knee to look more normal after it heals, because the tendon from the front of the knee is not used. It is also easier to add extra tissue from a deceased donor (allograft) to this type of graft.
  • The whole graft may also be taken from a deceased donor (allograft).

The graft is pulled through the two tunnels that were drilled in the upper and lower leg bones. The surgeon secures the graft with hardware such as screws or staples and will close the incisions with stitches or tape. The knee is bandaged, and you are taken to the recovery room for 2 to 3 hours.

During ACL surgery, the surgeon may repair other injured parts of the knee as well, such as menisci, other knee ligaments, cartilage, or broken bones.

Why It Is Done

The goal of ACL surgery is to restore normal or almost normal stability in the knee and the level of function you had before the knee injury, limit loss of function in the knee, and prevent injury or degeneration to other knee structures.

Not all ACL tears require surgery. You and your doctor will decide whether rehabilitation (rehab) only or surgery plus rehab is right for you.

You may choose to have surgery if you:

  • Have completely torn your ACL or have a partial tear and your knee is very unstable.
  • Have gone through a rehab program and your knee is still unstable.
  • Are very active in sports or have a job that requires knee strength and stability (such as construction work), and you want your knee to be as strong and stable as it was before your injury.
  • Are willing to complete a long and rigorous rehab program.
  • Have chronic ACL deficiency, which is when your knee is unstable and affecting your quality of life.
  • Have injured other parts of your knee, such as the cartilage or meniscus, or other knee ligaments or tendons.

You may choose not to have surgery if you:

  • Have a minor tear in your ACL (a tear that can heal with rest and rehab).
  • Are not very active in sports and your work does not require a stable knee.
  • Are willing to stop doing activities that require a stable knee or stop doing them at the same level of intensity. You may choose to substitute other activities that don’t require a stable knee, such as cycling or swimming.
  • Can complete a rehab program that stabilizes your knee and strengthens your leg muscles to reduce the chances that you will injure your knee again and are willing to live with a small amount of knee instability.
  • Do not feel motivated to complete the long and rigorous rehab program necessary after surgery.
  • You have medical problems that make surgery too risky.

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