Anterior Cruciate Ligament Reconstruction
Introduction
Now that you have suffered an injury to your anterior cruciate ligament (ACL) and the diagnosis has been confirmed, you have decided to have an operation to repair it. The information in this leaflet should answer any further questions you may have. If anything is not covered, please ask your surgeon or physiotherapist.
Will I be seen before my operation?
You will be seen about 1 – 2 weeks before your operation in the pre-operative assessment clinic. This is to ensure that you still need the operation and are fit enough to have it performed. The procedure will be explained again and a consent form will be signed. You will be seen again on the ward before going to the operating theatre, where the final details will be checked and the knee being operated on will be marked.
How will my operation be done?
Most patients will have a reconstruction using two of the hamstring tendons taken from behind the knee and thigh. It is surprising how little their removal affects the knee. The tendons are then fastened into the knee using a system of screws and pins by a keyhole technique (arthroscopy). The new ligament is placed in the centre of the knee exactly where the original was. Any repair or removal of torn cartilage will be done at the same time.
Will there be many scars?
The graft is removed through a 4cm wound over the top of the shin just below the knee. The keyhole part is done through two 0.5cm wounds over the front of the knee. An additional 1cm wound is made on the outer side of the knee for placement of one of the graft fixing pins.
Are there any alternatives?
Some patients are not suitable for a hamstring graft. The alternative is the use a strip of the tendon from below the patella (kneecap) instead. The wound is longer, the recovery is a little slower and it can be difficult to kneel afterwards, but the end result is the same. In very rare instances, graft may be taken from the other leg.
Will I be asleep?
Yes. The operation is done under a general anaesthetic for most people, but it is possible under a spinal anaesthetic that just makes the legs numb.
How long does it take?
The operation takes about 1½ to 2 hours.
What will it feel like afterwards?
As the operation is done by a keyhole technique it is not particularly uncomfortable. Any pain you may feel is easily controlled with painkillers.
How long will I be in hospital?
Most people come in on the day of surgery and go home the next day.
What will I be able to do when I go home?
When you go home you may have a splint on the knee to hold it straight, but you can walk on the leg. The physiotherapist will give you a thorough briefing on what to do.
What physiotherapy will I need?
After this type of surgery, rehabilitation is very important. You will start your physiotherapy one week after the operation when any splint is removed. Rehabilitation is done following a set routine and will be explained by the physiotherapist before you go home (see also the Information leaflet: "Guide to Rehabilitation Following Anterior Cruciate Ligament (ACL) Injury and Reconstruction").
Will I be seen after my operation?
Yes. You will be seen after your operation by one of the surgeons. After discharge you will be seen again 2 – 4 weeks. This is in addition to the physiotherapy course outlined above.
In the long term (after 1 year) you will not need to come to hospital for follow up unless there are any problems. However, we are keen to find out how our patients are progressing. You may therefore be contacted to complete a postal questionnaire some time after your operation. Any information returned would be handled sensitively and confidentially, it may be stored on a secure computer register.
When can I drive?
Most people are fit to drive 10 to 14 days after surgery, however ideally you should wait until 6 weeks if possible. You can discuss this further with your surgeon. You are also advised to contact your car insurance company before you start to drive again.
When can I go back to work?
This depends on your job. If it is an office job, you can go back after 2 weeks - sometimes even quicker. If you have a manual job, especially if it involves kneeling or climbing you will need longer.
When can I play sport again?
It is very important that you do not risk damaging the new ligament too soon after the operation. It is easy to snap or loosen the repair in the first 3 or 4 months if you are not careful. Your surgeon or physiotherapist will give you appropriate individual advice, but we advise against non-contact sport for 6 months and contact sport such as football for at least 10 months.
How soon after my operation can I fly or go on holiday?
You should be able to go away within the UK after 48 hours, providing any long journey is appropriately broken. However, you should ensure that you do not miss any of your physiotherapy appointments. Flying immediately after lower limb surgery is associated with an increased risk of deep vein thrombosis (see below). Although no fixed guidelines exist we recommend that you should not fly for 2 weeks following an ACL reconstruction.
What can go wrong?
This type of surgery is generally very safe, but there are a few possible problems you should know about.
- Anaesthetic: Rarely problems can occur related to your general health and the anaesthetic. The majority of potential problems should be picked up at the pre-assessment clinic. Your anaesthetist will be able to discuss this further with you.
- Swelling: Some swelling is common afterwards but usually disappears after a few weeks.
- Bleeding: This can make the knee stiff and swollen. The blood can easily be removed through a needle in hospital.
- Infection: Some redness around one of the wounds is treated with antibiotics. Very rarely, infection develops inside the knee. This needs further surgery to drain and wash it out as well as antibiotics.
- Stiffness: Early physiotherapy gives a good range of movement, but some people find their knee remains stiff. A further keyhole operation is occasionally needed to free it up.
- Giving-way: After the operation the knee feels weak. As the muscles regain strength this improves quickly. Very rarely the graft comes apart either due to another injury or because it simply stretches. Another operation may be needed if this happens. Overall we obtain a stable knee without complications in 95% of patients.
- Deep vein thrombosis: This can occur to any one under going lower limb surgery. The risk is greater if you have had one before or are on the oral contraceptive pill/hormone replacement therapy (which should be stopped 6 weeks before operation). They rarely cause direct problems, but can potentially be serious because of the risk of spread to the lungs (pulmonary embolism). Treatment usually involves taking warfarin (to make the blood clot less easily) for a 3 month period.
Can it be done again if I injure my knee?
Yes, but it is much more difficult and you are less likely to get a stable knee.
Will I get arthritis later?
We know that patients with an unstable knee are more likely to get arthritis. Even though the operation may seem successful in giving you a stable knee that works well, there is still an increased risk of arthritis later in life.
What do I do if I have a problem after my operation?
During the daytime you can contact the ward where you stayed for your operation for initial advice. Out of hours you should contact your GP or attend the Accident and Emergency department.
