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Anterior Cruciate Ligament (ACL) Reconstruction

Anterior cruciate ligament injuries occur most often in the sporting population. A torn anterior
cruciate ligament is a common outcome from a major knee injury. The anterior cruciate ligament
is the primary stabiliser of the knee joint. Thigh and calf muscles are secondary stabilisers of the
knee joint.

If you have torn your anterior cruciate ligament you usually have a sudden twisting movement with
your leg fixed on the ground. A snap or pop may be heard and the knee usually swells up within a
few hours. The ligament either snaps in half or is pulled from the femoral or tibial surfaces. Once completely torn the ligament cannot repair itself. Partial tears may heal but the tendon is often
stretched causing the knee to give way. The anterior cruciate ligament rupture will cause the knee
to become unstable in certain movements. This occurs usually when one pivots such as a sudden
change in direction. The knee feels like it is going to give way.

At the time of injury the other ligaments and cartilages in the knee may be damaged. Most
commonly the medial collateral ligament may tear and either the medial or lateral meniscus
may tear. This may result in locking of the knee joint.

Initial treatment is important to reduce swelling and improve range of motion by appropriate
exercises. An x-ray is taken to exclude a fracture and occasionally an MRI scan is arranged to
further assess the knee joint. It is quite common to see bone bruising on the MRI scan.

An anterior cruciate ligament reconstruction is recommended in patients whose knees give way
on repeated occasions. If you have built up your thigh muscles and your knee does not give way
then an anterior cruciate ligament reconstruction may not be necessary. There is a theoretical
argument to do an anterior cruciate ligament reconstruction in order to preserve the knee for the
future. It has been proven that torn cartilages result in long-term osteoarthritis. It is yet to be
proven that a torn anterior cruciate ligament results in osteoarthritis but a torn anterior cruciate
ligament with an unstable knee may lead to a torn cartilage and therefore in the end, an arthritic
knee. Reconstructing the anterior cruciate ligament may not prevent long-term arthritic changes.

The surgery:

Two methods of anterior cruciate ligament reconstruction are available. The first method uses the
central third of the patellar tendon and the second method uses the hamstring tendons from
behind the knee. Both methods have advantages and disadvantages and you should discuss
with your surgeon his preferred method.

The following steps outline the surgical procedure in anterior cruciate ligament surgery:

  1. General anaesthetic.
  2. Hamstring or patellar tendon harvesting and preparation.
  3. Arthroscopy to clean up the knee joint, trim or repair any torn cartilages and prepare the
    femoral and tibial bone tunnels.
  4. The graft is passed through the tunnels and secured either with screws or staples.

Following anterior cruciate ligament reconstruction it is important to have a regular physiotherapy
exercise programme in order to rehabilitate the knee and regain motion. It is most important to
regain full extension.

Risks and complications:

General anaesthetic risks.

As anybody undergoes general or regional anesthesia (epidural anesthesia) there are always
risks associated with it. The risks of course are magnified if you have abnormal general medical conditions, which may have affected the functions of your vital organs such as heart, lungs and kidneys. Therefore a complete evaluation of those systems has to be performed before you are taken to the Operating theatre.

Specific risks:

  1. Infection.
  2. Deep vein thrombosis.
  3. Numbness just to the side of the incision.
  4. Stiffness.
  5. Reflex sympathetic dystrophy.
  6. Rupture of the graft.
  7. Damage to vessels and nerves.
  8. Ongoing instability and pain.
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