What is ACL Reconstruction?
Arthroscopic anterior cruciate ligament (ACL) reconstruction is a surgical treatment for a torn ACL. The ACL is a critical ligament in the center of the knee that is responsible for providing stability to the knee. When an ACL tear occurs, one experiences immediate pain, swelling, and instability. Many patients report hearing or feeling a pop in the knee. This injury typically results in the inability to have normal use of the knee without experiencing giving way episodes.
Commonly, an ACL tear occurs when:
- There is a sudden, high energy stop
- When the foot is firmly planted and the body turns while suddenly changing direction
- Landing awkwardly from a jump
These events often occur during sports activities, such as skiing, soccer, football, and basketball.
For patients diagnosed with a torn ACL who wish to resume an active lifestyle, ACL surgery is indicated. In this procedure, the torn ligament is removed and a tendon is used to replace the torn ACL. The tendon that is used to reconstruct the ACL may be harvested from the patient (autograft) or from a deceased donor (allograft). In most cases, Dr. Cunningham recommends an autograft, as you incorporate your own tissue into your knee much better than you incorporate a donor tendon. Given this, there is a significantly higher retear rate when using a donor tendon to reconstruct the ACL.
Dr. Cunningham commonly uses a portion of the quadriceps tendon to reconstruct a torn ACL, as the quad graft is the biggest and the strongest compared to hamstring or a patellar tendon graft, and it also does not cause long term pain at the harvest site as is quite common with a patellar tendon graft. ACL surgery is typically performed arthroscopically. It is an outpatient procedure, with no requirement for an overnight hospital stay. Dr. Cunningham is an ACL surgeon at Vail Summit Orthopedics and Neurosurgery. He is an expert at diagnosing and treating ACL injuries for patients in Vail, Summit County, Aspen, and Denver, CO.
When is ACL Surgery Needed?
ACL surgery is indicated for patients with ACL tears who have knee instability, and who wish to resume cutting and pivoting sports. Patients who tear their ACL who resume cutting and pivoting sports with a torn ACL almost universally will have further giving way episodes in the knee. These instability events cause further cartilage damage in the knee, leading to early arthritis. Furthermore, people without an intact ACL are unable to function at their peak performance, as the knee will continue to feel unstable and give way.
ACL surgery should be considered if you have torn your ACL and have:
- Buckling of the knee with sports and/or daily activity
- Wish to resume an active sports lifestyle involving pivoting, cutting, and jumping
- Work a physical job, walking on uneven ground, carrying heavy objects at work
- Injured other knee ligaments in addition to the ACL
- Completed a course of physical therapy but still have ongoing knee instability
- Experience chronic instability of the knee–a sense of the knee giving away repeatedly
In order to avoid further injury to the knee immediately after sustaining an ACL tear, one should avoid cutting and pivoting sports. Early range of motion exercises and gentle strength maintaining exercises are recommended. When the initial pain, swelling, and stiffness in the knee has mostly resolved and when people are able to put full weight on the knee, ACL reconstructive surgery can be undertaken. However, it may take a few weeks of home exercises or physical therapy to get the knee in optimal condition to be ready to have surgery.
How is ACL Reconstruction Performed?
ACL surgery is performed arthroscopically on an outpatient basis. An anesthesiologist performs a nerve block to help limit pain during and after the surgery. A light general anesthestic is also administered. Small incisions are made to create viewing portals for the procedure. An arthroscope–a small medical camera the size of a pencil—is inserted into the knee and displays a comprehensive view of the knee on a screen. A tendon graft is harvested from the affected leg and the size of the harvested tendon graft is precisely measured. The torn ACL is removed form the knee, as tears in the mid portion of the ACL will not heal if an attempt is made to sew the ligament back together. A small socket is made in the bottom end of the femur bone and the top end of the tibia bone, exactly where the native ACL once attached to these bones. The tendon graft is then passed into the knee and secured to these bone sockets with small, strong fixation devices, such that the tendon graft will slowly grow into the bone sockets over time.
The patient’s knee is put through a full range of motion in surgery to be sure that the tendon graft is in the proper position and allows full knee range of motion of the knee. The knee is stressed to confirm that stability has been restored. Sterile dressings and a knee brace are applied to the knee. Patients are then moved to the recovery room, where a nurse monitors you while you awake from anesthesia. Most patients are released and allowed to travel home within 2 hours of completing the surgery. At home, patients are encouraged to ice, elevate and compress the knee and leg. Gentle range of motion exercises can be started immediately. Physical therapy is started within days.
ACL Reconstruction vs. ACL Repair
Current research supports arthroscopic ACL surgery over an ACL repair for patients with a complete tear of the midportion of the ACL, which is where most patients tear. However, Dr. Cunningham is one of the few surgeons in the country to also do ACL repair surgery. ACL repair surgery can be successful in cases where the ACL tears away from its bone attachment, but is not done for ACL tears that occur in the midportion of the ligament. When the ACL tears away from its bone attachment site, Dr. Cunningham can arthroscopically reattach the torn ACL back to the bone so that the ACL can heal itself and be preserved. Unfortunately, only about 1 in 20 ACL tears are amenable to ACL repair, where the ligament is torn off the bone attachment and can be reattached successfully.
In older patients or in those who are willing to give up cutting and pivoting sports, ACL surgery is not usually required. If the knee continues to give way with everyday activities however, then this may lead one to elect to have surgery to stabilize the knee.
How Long is the Recovery After ACL Reconstruction?
Range of motion exercises are started immediately after ACL reconstruction surgery. Formal physical therapy (PT) is started within days of the surgery. PT is prescribed approximately twice per week for 3-4 months. Patients are usually able to spin on an exercise bike within the first 7-10 days. it usually takes about 2 weeks for a patient to be able to put full weight on the knee and to have adequate muscle control such that one can discontinue the use of the knee brace and crutches. It may take 10-12 weeks to regain full range of motion but most patients have the majority of their knee motion within 6 weeks. By 3 months from surgery, patients can be riding a bike outdoors. By 4 months from surgery, patients can be jogging or playing golf. It takes 8 months or more for patients to regain full strength and to be able to return to all sports. Patients are fitted for a sports knee brace and use it for one year once cleared for cutting and pivoting sports.
Patient compliance to the recovery program is essential for an optimal recovery. Patients report a high degree of satisfaction following arthroscopic ACL surgery. Dr. Cunningham is one of the highest volume ACL surgeons in the country. He is an ACL surgeon at Vail Summit Orthopedics and Neurosurgery. He is an expert at diagnosing and treating ACL injuries for patients in Vail, Summit County, Aspen, and Denver, CO.