ANTERIOR CRUCIATE LIGAMENT (ACL) RECONSTRUCTION

What Is an Anterior Cruciate Ligament Reconstruction?
The Anterior Cruciate Ligament (ACL) of the knee is one of the most important ligaments providing rotatory stability to the knee. It provides essential stability for sporting activites where there is cutting or pivoting movements, such as dodging and opponent in football. Without this support, the knee will tend to “give way” or collapse resulting in pain, and recurrent injury. An ACL reconstruction aims to restore this function by replacing the ligament with a substitute. This will most commonly be from the patients own hamstring tendon or the middle 1/3 of the patella tendon. There are numerous other grafts, which can be used depending on the individual circumstances.

Who Should Have an ACL Reconstruction?
Not everyone who tears their ACL requires a reconstruction. Around 90% of people will have no or minimal symptoms on a day to day basis if they undergo a rehabilitation program to strengthen the muscles around the knee. Unfortunately 10% of people will still have symptoms of instability and risk further damage with repeat episodes of giving way. Most people who are active in sport require a reconstruction for “predictive” instability- where the activity involved requires pivoting or cutting movements, and lacking an ACL will result in the knee collapsing.

When there are more complex injuries, such as multi-ligament injuries, when menisci are repaired and cartilage defects are regenerated, an ACL reconstruction will be required.

Why Do People Have ACL reconstruction Surgery?
For the majority of people who have an ACL reconstruction, the procedure results in:

• Stability of the knee
• Ability to return to an active sporting life
• improvements in activities of daily living
• improved quality of life.

What Are Alternatives to ACL Reconstruction Surgery?
Often the knee injury can be the trigger for someone “retiring” from their chosen sport. Avoiding risky sports and movements can prevent further injury and instability.

A gym/ physiotherapy based strengthening programme can help overcome many of the symptoms experienced on a day to day basis from an ACL tear. If there is still a desire to participate in sport, but you wish to avoid surgery, then customised hinged knee braces can be made to support the knee.

What Are Possible Complications of ACL Reconstruction Surgery?
All surgery carries the risk of something not working or going “wrong”. Importantly, over 90% of people undergoing an isolated ACL reconstruction will have the capacity to return to their chosen sport. However nothing can potentially prevent you from having a repeat injury. Grafts can fail or re-rupture, particularly in the first 12 months following surgery as the graft matures. Early mobilisation is critical to avoid the risk of DVT or blood clots, and to minimise the chance of stiffness. Keeping the wounds clean and covered help prevent infection.

To minimise the risk of complications, it’s important to know how to prevent problems and to recognise signs of potential problems early and contact your doctor. For example, tenderness; redness and swelling of your calf; or swelling of your thigh, ankle, or foot could be warning signs of a possible blood clot. Warning signs of infection include fever, chills, tenderness and swelling, or drainage from the wound. You should call your doctor if you experience any of these symptoms.

When Is Revision Surgery Necessary?
Occasionally someone can reinjure their knee, and re-rupture the graft. This is something that needs to be discussed further with Mr Richardson.

ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION
CARE OF YUR KNEE AFTER SURGERY

SURGERY
After your surgery you will have a pressure bandage on your knee, and your leg with be splinted in a Zimmer Knee Splint. The morning after your surgery your will be seen by the physiotherapist who will mobilise you and ensure you are safe to be discharged. Prior to discharge your nurse will remove the pressure dressing and change it to a tubigrip compression stocking. The waterproof dressings underneath this are to be left intact until your 2-week post-operative visit with Mr Richardson.

You are allowed to fully weight bear on your knee when in the knee splint, but you will be given crutches to make this easier whilst your knee is painful. At rest, the splint can be removed to allow full range of motion exercises, and for ice to be applied to the knee.

On discharge, you should be provided with:

• Post-operative instructions
• Analgesia
• Review appointment (this will normally have been made for you prior to your surgery and referenced in your information pack)
• DVD of your surgery
• Xrays

CARE OF YOUR KNEE AFTER SURGERY
Swelling and discomfort is normal after surgery. This is most apparent in the first 3 days, after which, most of the discomfort should start to settle. Even if you have minimal pain or swelling in the first 3 days you should really rest and not “over do it”.

Unless otherwise instructed, Mr Richardson wants you to walk short distances only in the first 2 weeks.

After your 2-week review with Mr Richardson you will no longer require the splint.

ICING YOUR KNEE
Ice has the effect of controlling pain and inflammation and swelling in your knee after surgery. It is most effective in the first 3 days after surgery and should be used regularly in the post-operative period.

Please have an ice pack ready at home for when you are discharged, so it can be applied immediately when you get home. Always use a thin cloth between ice and your skin (Ice can burn if left on your skin). You can use a commercial ice pack, bag of frozen vegetables or crushed ice.

For the first 3 days, ice your knee regularly during waking hours. Apply the ice for 20 minutes, and then remove for an hour before reapplying. Thereafter, apply after exercising or when the knee becomes sore or tight from swelling.

BANDAGE
You will leave hospital with a tubigrip bandage applied to your knee. This is designed to protect your wounds and apply pressure to stop bleeding and swelling in your knee. The dressings underneath are waterproof, and should cope with small splashes of water from the shower. The waterproof dressings are to be left intact until your review appointment in 2 weeks. You can shower over the top of these dressings, but they are not to be soaked in a bath or pool. If they become loose they can be replaced simply with a Band-Aid.

If you experience significant bleeding from the wounds it will nearly always settle with the reapplication of the PRESSURE DRESSING, ELEVATION of the knee and application of an ICE PACK.

If at any stage you are worried, please call Mr Richardson’s rooms for further advice.
In an emergency situation Mr Richardson can be contacted on his mobile telephone.

CRUTCHES
Crutches are used to help rest your knee in the first few days after surgery. They are used to assist you mobilise whilst resting your knee. You do NOT have to remain non-weight bearing. You can wean yourself off the crutches as you recover your confidence and regain your muscle strength.

ANALGESIA
You will be discharged with oral analgesia to help with any pain you might experience.

It is recommended that you have a stronger pain killer the first evening, but from then on, icing, elevation and simple paracetamol and anti-inflammatories will often be adequate.

Do not take the strong analgesics if you are not in a lot of pain.
If you require more than what has been supplied upon discharge then please attend to you GP for further prescriptions.

If you develop uncontrolled pain, or become unwell, then please contact Mr Richardson’s rooms for more advice.

PHYSIOTHERAPY
Physiotherapy rehabilitation is an essential part of the recovery following ACL surgery. You will be given exercises to follow when you leave hospital. You should make an appointment with your physio to coincide to follow the review appointment with Mr Richardson. If you do not have a physiotherapist, Mr Richardson will refer you to one.