The Expert Guide to ACL Reconstruction Surgery

The anterior cruciate ligament, or ACL, is an important ligament that helps to stabilise the knee. It’s a strong, thick piece of tissue but it can become torn if you land on your leg awkwardly, sustain a blow to the knee or suddenly change direction, stop or twist your leg.

A torn ACL is a common knee injury, most often seen in people who play sports that require a twisting of the knee and lower leg, such as football, rugby, skiing, netball, tennis and other racquet sports.

ACL reconstruction surgery is a common surgical procedure that replaces a torn ACL, helping to restore normal movement and stability to the knee joint.

What happens during ACL reconstruction surgery?

The anterior cruciate ligament is one of four major ligaments providing stability to the knee joint. Ligaments are tough bands of tissue that attach bones to bones – the ACL is found in the middle of the knee and connects the thigh bone to the shin bone. It supports the knee from front to back and when performing pivotal and rotational movements.

In some patients, it’s possible to repair a torn or damaged ACL, but when this isn’t possible, ACL reconstruction surgery is recommended. The damaged ligament is replaced using tissue from a patient’s own body, most often from the hamstring or quadricep, donated tissue or an artificial graft.

When performing a quadriceps tendon graft, your surgeon will make two small surgical cuts on the outside of your knee and a long, thin camera called an arthroscope is then passed through these cuts in order to give your surgeon a good look at the inside of your knee.

They will then make a small cut, between 2 to 3cm, over the front of the knee just above the kneecap. This enables your surgeon to take a strip of graft tissue from the quadricep. This piece of tissue is then grafted into the knee joint using long, thin surgical instruments.

ACL reconstruction surgery is performed under a general anaesthetic and takes around an hour and a half. Most patients require an overnight stay in hospital following surgery.

What should I expect after ACL reconstruction surgery?

When you wake from surgery, your wounds will have been dressed and your medical team will be on hand to advise you on your next steps for recovery.

It’s normal to experience pain and swelling following ACL surgery and you will be provided with pain relief medications. You will also be advised to begin physiotherapy within the first week following surgery.

After 24 hours, you can remove the outer bandaging, but the sticky, waterproof dressings underneath should remain in place for two weeks. During this time, you can shower, but you should avoid getting your dressings too wet. You will normally see your surgeon for a review after two weeks, when they will remove your dressings and check how well your wounds are healing.

You should use crutches for as long as you feel you need to, this is usually around two weeks, and you can put as much weight on your leg as you feel comfortable with during this time. You should be able to put some weight on your leg after 24 hours. Pain relief medications can also be taken for as long as you feel you need them, often also around two weeks.

How should I prepare for ACL reconstruction surgery?

It’s advisable to seek advice from a physiotherapist soon after an ACL injury to help strengthen the muscles in the area, reduce swelling and improve your range of movement as much as possible before surgery.

This will support maximum recovery from ACL reconstruction surgery and is known as prehabilitation. You can continue to exercise as long as it’s comfortable to do so. Cross training and indoor cycling are both a good idea. It’s also a good idea to practice using crutches correctly as you’ll need them for a time following surgery.

Prior to any surgery, the advice is to be as healthy as possible to help aid your recovery. This involves eating a healthy diet, avoiding alcohol, quitting smoking and taking steps to lose weight if you need to.

It’s also a good idea to prepare your home for your recovery, such as making sure that your floors are clear and essential items are accessible.

How long will it take before I can resume normal activities following surgery?

How long it may take you to return to normal activities will depend on your individual procedure, how active and healthy you are and what your normal activities entail.

Recovery should be goal focussed and your physiotherapy team will set goals and targets for you based on your unique circumstances. You shouldn’t progress onto the next stage of recovery until you’ve met your goals.

It takes around six months for an ACL graft to bond to the bones of the knee joint and Mr Webb would strongly encourage patients not to plan to return to full sports until 12 months has passed. Prior to this, once there is minimal swelling and your range of motion has returned, using a cross trainer and stationary bike can be helpful for recovery.

Work-wise, if you can work from home, you can expect to be able to return to work after a couple of weeks. If you’re a manual worker, you can normally return to light duties after three months. Heavier manual work such as carrying heavy loads and using ladders will take longer – usually between six and 12 months.

Your return to driving will normally take six weeks. Legally, you can drive once you can safely perform an emergency stop. Therefore, if your right knee has been operated on, it may take longer. If your left knee has been operated on, you may be able to return to driving sooner.

Taking part in sexual activity will depend on your individual surgery and other factors but Mr Webb advises using comfort and common sense as a guide.

What can I do to reduce my risk of further issues following surgery?

After your rehabilitation programme and beyond, your rehabilitation exercises should form part of your normal exercise regime. You should also perform prehabilitation exercises on your non-injured leg to help keep the muscles strong and maintain a good range of movement.

Finally, Mr Webb advises that he performs ACL surgery with the aim to get his patients back to as close to the level they were at when they injured their knee as possible. He therefore advises patients to use comfort and common sense as a guide to returning to or starting a new activity.

ACL surgery is only a small part of the process and will only be successful if patients have a good rehabilitation programme that’s followed diligently. Patients who don’t engage in rehabilitation exercises don’t do well. Equally, patients who try to push their rehabilitation and get back to exercise and duties too soon will also struggle to rehabilitate.

More information

• If you have knee pain and think you may have damaged your ACL, please see your GP or consultant. (Don’t have a GP?)
• Mr Mark Webb is an expert in sports injuries and ACL reconstruction and is part of the King Edward VII’s Hospital Orthopaedic Surgery department, a world-renowned centre of excellence staffed by dedicated doctors, nurses and physiotherapists. Make an enquiry.
• Read a patient story of an ACL reconstruction at King Edward VII’s Hospital.