What is the anterior cruciate ligament (ACL)?

The ACL is one of the major internal ligaments in your knee. It is located in the centre of your knee joint and functions, with other structures, to provide you with a stable knee joint, rotationally, front to back, and side to side.

The ACL may be ruptured in knee trauma sustained in sports or other accidents. This often results in rapid pain and swelling, and a feeling that that knee joint is unstable, to the point that patients may lose the confidence to participate in running or pivoting activities/sports.

Can the ACL heal without surgery?

There is evidence in the literature that some cruciate ligament ruptures have healed spontaneously, but this generally took many months and it is difficult to predict which ones will heal or not. Furthermore the dysfunction and limitations  that occur while one is waiting for healing affect day to day activities, and for active individuals this often makes the faster rehabilitation that goes with reconstruction surgery preferable.

How is ACL rupture managed?

If you suspect you have an ACL injury it is important to be referred to the orthopaedic surgeon for further management.

Dr Ihsheish will examine you clinically to diagnose your injury and any associated problems. It is common to use imaging studies such as MRI scan of the knee prior to deciding on any treatment plan.

You initial management should include the following -

• pain relief and crutches to help you mobilise
• ice to minimise the amount of swelling
• physiotherapy to minimise early onset of stiffness in your injured joint.
• a temporary light knee splint or compression bandage is found to be helpful by some patients in pain relief and reducing swelling

Following the initial assessment and management Dr Ihsheish will discuss in detail with you the subsequent treatment options, including the details of reconstructive knee surgery, non surgical options, and the expected outcomes. The decision to operate is made by the surgeon and patient together.

Does everyone with a ruptured ACL require surgery?

The aim of ACL reconstruction surgery is to allow the patient to function with a stable knee joint in your day-to-day activities (at home, work, or sports) and prevent falls and injuries to other parts of your knee.

It is important to know that not all patients need surgery, and not all patients are able to have surgery safely. The details can be complex, and Dr Ihsheish can discuss your specific details with you.

In general, if you are skeletally mature (ie your bones have stopped growing), and physically active with a well preserved joint you may benefit from reconstruction of this ruptured ligament. Again, Dr Ihsheish will be able to discuss your specific case with you.

How is ACL reconstruction surgery done?

The surgery aims to reconstruct the damaged ligament in your knee, Dr Ihsheish often uses your own tissue to form an ACL graft. The graft is placed in the site of the torn ligament, and is designed to fill the stabilising role of the native ACL.

Dr Ihsheish will most commonly use some of your own tendons, namely tendons from your hamstrings, to reconstruct the ACL. In other circumstances your surgeon can use other types of graft such as your patella ligament, donor tissue, or synthetic graft material. Hamstring graft has an excellent track record and very little chance of causing you any reaction is it is your own tissue. Dr Ihsheish can discuss the merits of the different graft options, and the most suitable graft for your case.

The graft is fixed firmly inside your knee joint in a position that mimics the native ACL.

The surgery is ‘arthroscopic’, meaning it is done through small incisions in the skin. The knee is swollen and tense after the operation, and although crutches are used for a few days after the operation for support, Dr Ihsheish generally does not place a splint on your knee after the operation.

Patients may go home the same day of surgery or stay for one night in order to be assessed by the physiotherapist the next day.

There is a rehabilitation protocol available through our clinic which you will be encouraged to follow over the following weeks.

What follow-up will I have?

Dr Ihsheish, nurses, and physiotherapists will see you during your hospital stay.

As outlined in our protocol, a vital part of your post-operative follow-up is guided physiotherapy, which will begin in the first week after surgery and continue for 3-6 months.

Your surgeon will see you at two weeks after the surgery to review your wounds and early progress, and thereafter appropriate arrangements will be made accordingly. There will be restrictions on your physical activities which Dr Ihsheish will discuss with you specifically, and these are outlined on our protocol in general also.The restrictions are aimed at protecting the new graft while is re-establishing blood supply and gaining strength.

What should I look out for following the surgery?

It is normal to experience swelling and warmth in the area of the operation.

Some of the dressings may have some dry blood on them.

Your knee will be a little stiff in the first 1-2 weeks after the surgery, this should improve gradually, as should the swelling and pain in your knee and leg.

Look out for anything different to the above, or temperatures/fevers or feeling generally unwell and bring it our attention please.

It is not unusual for your knee to feel weak or unstable early after the surgery, this should improve with ongoing physiotherapy.

Please note that physiotherapy is the most important aspect of your recovery after the surgery, and make sure your have the protocol when you visit your physiotherapist.