Surgical treatment is most frequently recommended for individuals with ACL tears accompanied with other injuries. The most likely candidates for surgical treatment are active individuals in sports or jobs with heavy manual work that requires pivoting or pushing off with the knee. Surgery is also recommended for people with unstable knees or injuries combined with damage to the menisci, articular cartilage, joint capsule, or ligaments.
Prior to surgery, most people participate in physical therapy. Swelling can make the knee stiff. Immobility can cause the muscles and ligaments to shorten. Your physical therapist will help you stretch your knee to regain full movement. If your collateral ligaments are involved, you may need to wear a brace to allow them to heal prior to your surgery. These steps will help you prepare for a successful recovery after your surgery.
The goal of ACL repair is to reconstruct your knee joint to restore its function and stability, and prevent further injury. During surgery, your doctor will replace your damaged ACL with a healthy tendon, called a graft. There are several options for acquiring grafts. They may be taken from an area near your knee or from a donor cadaver.
A patellar tendon autograft uses the middle third of the patellar tendon and bone plugs from the shin and kneecap. This type of reconstruction is most often recommended for high-demand athletes and individuals that do not have to perform a lot of kneeling activities. This grafting procedure has been considered the “gold standard” for ACL repair.
A hamstring tendon autograft uses one or two tendons from the hamstring muscles at the inner side of the knee. The hamstring tendon autograft is most appropriate for lighter-weight individuals with a small patella bone and a history of pain. This method can be associated with a faster recovery.
A quadriceps tendon autograft uses the middle third of the quadricep tendon and a bone plug from the upper end of the kneecap. The quadricep graft is large. It is most appropriate for taller and heavier individuals. It is also used for individuals with prior failed ACL reconstructions. Because it is a large graft, this method uses a larger incision.
Allografts are tendon grafts taken from cadavers. Allografts are most appropriate for older individuals that are moderately active or those with a history of pain. It is also used for individuals with prior failed ACL reconstructions, those attempting to return to sports more quickly, and those that need more than one ligament reconstructed. Because the graft is not taken from the individual, this method is associated with less pain, smaller incisions, and a shorter surgery time.
Many ACL reconstructions are performed as outpatient procedures. You can be anesthetized for surgery or receive a nerve block to numb your knee and leg area. After you have received your anesthesia and your leg is relaxed, your doctor will examine your knee by performing similar tests that were done in your clinical examination. This provides your doctor with more information about your knee and helps to formulate the surgical plan.
Your surgeon will make one or more small incisions, about ¼” to ½” in length, near your joint. Your surgeon will fill the joint space with a sterile saline (salt-water) solution. Expansion of the space allows your surgeon to have a better view of your joint structures. Your surgeon will insert an arthroscope and will reposition it to see your joint from different angles.
An arthroscope is a very small surgical instrument. It is about the size of a pencil. An arthroscope contains a lens and lighting system that allows a surgeon to see inside of a joint. The surgeon only needs to make small incisions and the joint does not have to be opened up fully. The arthroscope is attached to a miniature camera. The camera allows the surgeon to view the magnified images on a video screen or take photographs and record videotape.
Your surgeon may make additional small incisions and use other slender surgical instruments if you are having your meniscus, cartilage, or ligaments repaired or removed. Your new graft will be attached using surgical hardware. Your surgeon will test the new graft and your knee function. Again, your doctor will examine your knee by performing similar muscle tests that were done in your clinical examination. This is to ensure that your knee is stable and has full range of motion. In addition to bandages, some surgeons apply a knee brace or a cold therapy device to help reduce swelling at the completion of your surgery.