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Circle Health Group

ACL Reconstruction Surgery Q&A

Three of our leading orthopaedic specialists answer common questions on ACL reconstruction surgery including what's involved in the procedure and recovery, possible side effects and alternative options.

The Consultants

Mr Richard Boden, a Consultant Trauma & Orthopaedic Surgeon from BMI The Beardwood Hospital

Mr Julian Flynn, Consultant Orthopaedic Surgeon from BMI The Saxon Clinic

Mr Wiqqas Jamil, Consultant Orthopaedic Knee Surgeon from BMI The Highfield Hospital and BMI The Alexandra Hospital

What is the ACL (anterior cruciate ligament)?

Mr Richard Boden
The anterior cruciate ligament is a band of tissue, approximately 3cm in length within the knee. It connects the tibia (shin bone) to the femur (thigh bone) and is the primary stabiliser of the knee, mainly in sporting activities including rotation and side stepping.

Mr Julian Flynn
The anterior cruciate ligament (ACL) is one of the “crucial” ligaments running through the centre of the knee. There are four main ligaments around the knee, one on either side of the joint – called the collateral ligaments, and two centrally called the posterior and anterior cruciate ligaments. The ACL is the main restraint to the tibia (shin bone) slipping forward on the femur (thigh bone). The ACL also has the important function in controlling rotation of the shin bone on the femur to maintain stability of the knee when performing sports or activities with twisting movements of the knee. It is one of the commonest ligaments to be injured, usually with a severe twist of the knee with the foot fixed, or with a force to the outside of the knee.

Mr Wiqqas Jamil
The ACL is a fibrous band of tissue that is just under 4cm in length and links the thigh bone (femur) with the shin bone (tibia). The ACL functions as stabiliser of the knee and is the primary restraint to limit forward translation of the tibia on the femur. It is also the main proprioceptor in the knee telling the brain where the knee is in space and time.

What are the reasons for ACL reconstruction surgery and how can you avoid injury to it?

Mr Richard Boden
The ACL is mainly injured during sports involving jumping, turning and side stepping. Skiing and ball sports are commonly associated with ACL injury. Patients frequently hear or feel a snap within the knee and are unable to continue their activity, the injury is usually associated with rapid swelling of the knee, initially eased by rest, ice and compression. As the swelling settles however, pain or instability, particularly on turning may be noted.

ACL injury is difficult to avoid due to its occurrence during sporting activities, but maintaining fitness and generalised muscle tone around the knee, along with warming up prior to activities will help.

Mr Julian Flynn
The main reason for reconstructing the ACL is to try and restore normal stability, range of motion and strength of the knee. The decision to undergo reconstruction is based on clinical grounds if a patient has a feeling of instability on the knee, or cannot trust the knee when turning or twisting. After reconstruction it is vital to follow a rehabilitation protocol overseen by a Physiotherapy Team to ensure that the new cruciate ligament graft is protected and allowed to heal. At the same time, objectives include regaining a full range of motion in the knee and thus allowing restoration of muscle strength and proprioception – the ability of the body to know where the joint is in space, and the ability of muscles to control the joint.

Mr Wiqqas Jamil
ACL reconstruction is performed to stabilise the knee and in doing so allowing return to sports that involve pivoting movements and protecting other structures in the knee as well as the joint surfaces. ACL injury is caused by contact and non-contact mechanisms. There are a number of risk factors (including hormonal, anatomical and biomechanical) that are associated with increased risk of ACL injury. Preventing injury altogether is not always possible but the risks can be reduced through biomechanical musculoskeletal conditioning and injury prevention programs.

What does the procedure involve?

Mr Richard Boden
You will be admitted on the day of surgery and discharged either that evening or the following morning. The surgery is performed arthroscopically (keyhole surgery) using hamstring autograft (your own tendons from the same knee). This technique involves a general anaesthetic and local anaesthetic block (extra pain killing anaesthetic placed in the area of the knee to aid rapid recovery).

A full examination and diagnostic arthroscopy are performed and the hamstring graft is harvested, usually two of the hamstrings are taken, preserving the remaining hamstring tendons and muscles to maintain knee function. Tunnels are drilled in the tibia and femur and the tendon grafts are passed across the knee, securely fixing them to reconstruct the torn ACL. You will have the wounds dressed and a bandage placed which will be taken down after 24hours. Physiotherapy will start immediately. You will be on crutches for approximately 7 days (or less if possible) with no brace or immobilisation of the knee.

Mr Julian Flynn
The operation involves taking either a graft from the patient (usually either their hamstring tendons, or part of the patella tendon) or using a cadaveric graft in some instances. Bony tunnels are drilled through the tibia and femur, and the graft is then taken across the joint and fixed in the bony tunnels to try and reproduce the anatomy of the old ACL. This should restore much of the stability of the knee, but it is important to note that it is not possible to produce a normal knee in all cases. Additional procedures such as meniscal repair may be required at the same time, as meniscal injuries or injuries to the surface cartilage frequently occur at the same time as the ACL injury.

Mr Wiqqas Jamil
An MRI scan is often performed to assess the ACL and surrounding structures. Occasionally arthroscopic evaluation prior to reconstruction may be required. Physiotherapy may also be required before ACL reconstruction. The procedure involved can be performed through a number of techniques including open and arthroscopic (keyhole) with a variety of tissues that can be used as a graft to substitute for the torn ACL.

What are the alternatives to ACL reconstruction surgery?

Mr Richard Boden
Conservative treatment mainly involves physiotherapy to strengthen the knee and improve proprioception (the body’s awareness of the position of the knee). This treatment will usually give a stable knee to linear movements (those in a straight line), but instability can still be felt on turning and side stepping. A proportion of patients can get back to competitive sports with this treatment, but most find the knee to be unstable and at risk of further injury. Most sporting patients elect for an ACL reconstruction.

Mr Julian Flynn
Not all patients with a rupture or partial rupture of the ACL actually require a full reconstruction. Those individuals with a sedentary lifestyle or whose sporting aspirations do not include twisting and pivoting, may be able to cope with a rehabilitation protocol which strengthens their quadriceps and hamstring muscles and may regain sufficient proprioception to avoid surgery. The use of a brace after an ACL injury or after ACL reconstruction is controversial and should be based on an individual’s requirements and degree of laxity in their knee.

Mr Wiqqas Jamil
Alternatives to surgery depend on an individual's functional requirements and recreational needs. Conservative management can be through certain activity avoidance, conditioning of knee musculature, proprioceptive conditioning and on occasions bracing.

Are there any risks or side effects to the procedure?

Mr Richard Boden
90% of patients gain a successful outcome after ACL reconstruction with some deterioration of the knee over time. The risks of surgery are those of general complications seen in many procedures including blood clots, infection, bleeding or nerve injury. Specific risks of graft failure (2% initially then 1% per year thereafter), hamstring tears and knee stiffness are also present.

Mr Julian Flynn
ACL reconstruction is a significant operation and the main obvious risks are the possibility of infection, swelling and stiffness. Subsequent risks include the possibility of the graft stretching and, therefore, becoming non-functional, or completely re-rupturing once an individual returns to sport. However, after an ACL reconstruction the main risk on returning to sport is sustaining a similar injury to the other knee. In the ten years after an ACL reconstruction there is around a 25 percent chance of requiring further arthroscopic surgery for damage to other structures including the meniscus.

Mr Wiqqas Jamil
Yes – there are risks involved with any surgery. In ACL reconstruction they include overall general risks of up to 5% but the risk of serious complications is in between 1 - 2%.

How long does it take to recover from ACL reconstruction surgery?

Mr Richard Boden
Most patients are off crutches at about a week, walking normally and driving at about 2 weeks. Return to sports can occur gradually, solo sports at about 3 months, non-contact at 6 months and contact sports at 1 year (this will be led by your physio team)

Mr Julian Flynn
ACL reconstruction surgery is now generally performed on a day case basis although patients may need to stay in overnight for pain relief if required. In general, time frames depend on the specific recovery of each individual but it commonly takes twelve months to return to contact sports. Short-term recovery is guided by physiotherapy rehabilitation with an emphasis on reducing swelling, improving pain and therefore improving range of motion which will allow muscles to recover. During this time the graft will initially lose strength before healing with new cells and blood vessels to form new living tissue.

Mr Wiqqas Jamil
You will be walking on crutches the same day and discharged either the same or the following day. Wound healing takes 2-3 weeks. Post-operative physiotherapy is started within 7-14 days of the reconstruction and return to contact sports is between 9 - 12 months.

What made you want to be a consultant?

Mr Julian Flynn
I have been interested in how the body works, and was fascinated by the structure of the body, since school. This led me down the path of wanting to study medicine and then subsequently have an interest in orthopaedics which is very much based on anatomy. Ultimately the specialisation of knee surgery is a natural progression as it is a joint with a complex interplay of bony surfaces, ligaments, muscles and mechanics. Becoming a consultant is the reward for completing training, but the start of being able to develop ideas and perform surgery independently and drive patient care are key factors as well.

Mr Wiqqas Jamil
I wanted to be a doctor from a very young age. The influence of a competitive sporty background led to my fascination with movement of the body and thus specialising in Trauma & Orthopaedic Surgery was a natural progression for me.

Becoming a specialist Consultant in my field has allowed me improve function and pain, reduce disability and improve quality of life in my patients. With so much of medicine involving the delivery of bad news to people I find it satisfying to be able to specialise in a field within which most of the time we can improve or remove people's symptoms.

What has been your career highlight to date?

Mr Richard Boden
I love what I do, with many highlights to date. Seeing patients return to a full active life is the reason I work as a surgeon.

Mr Julian Flynn
In general, it has been a pleasure to meet and interact with very many team members and colleagues who are enthusiastic, dedicated and stimulated to perform at the best of their ability. More specifically, I have been fortunate during my Consultant career to be involved with a number of stuntmen and women, actors and film directors who have injured their knees during the course of filming blockbuster movies. I have been able to reconstruct their various knee injuries to get them back to their intense, high demand activities, and their appreciation for getting them back to their careers has been immensely satisfying.

Mr Wiqqas Jamil
My career highlights revolve around the various changes I have instigated in enhancing patient recovery and care as a Consultant and my research projects.

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