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ACL Reconstruction

Information for Patients

Delivering
Excellence
Hip and Knee service

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Contents

Page

The classic injury

Why does the anterior cruciate

ligament fail to heal?

Rationale for treatment

Treatment options

What is involved for you as a

patient?

Complications

10

After the operation

12

Prehabilitation/rehabilitation

13

Alternative language/s

22

Notes

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A Patients guide to
ACL RECONSTRUCTION
The anterior cruciate ligament (ACL) is a 3-4cm
long band of fibrous tissue that connects the
femur (thigh bone) to the tibia (shin bone). It
helps stabilise the knee joint when performing
twisting actions. The cruciate ligament is usually
not required for normal daily living activities,
however, it is essential in controlling the rotation
forces developed during side stepping, pivoting
and landing from a jump.

Intra-operative arthroscopic (keyhole surgery) view

showing a normal ACL in the knee
THE CLASSIC INJURY
The ACL is commonly injured whilst playing running ball sports or skiing. Whilst playing ball sports
momentum is developed and upon attempting a
pivot, landing from a jump or side step manoeuvre, the knee gives way. When skiing, rupture may

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occur at low or high speeds. Commonly the binding

fails to release as the ski twists the leg resulting in a
tearing sensation. Patients frequently hear or feel a
snap, or crack accompanied by pain. Swelling
commonly occurs within the hour, but is modified
by ice or compression. Frequently pain is felt on the
outer aspect of the knee as the joint dislocates. This
dislocation may be felt to reduce with a clunk.
Initial treatment of any knee ligament injury should
consist of ice packs, compression bandages and
crutches. It is difficult to weight bear for several
days, however, after seven to ten days the swelling
settles and walking is possible with the joint
gradually returning to full movement.
By four weeks following injury the knee becomes
almost normal. Patients who return to sport
following injury usually notice a weakness or
instability.
Further episodes of instability result in multiple
injuries to the cartilages and the joint surfaces.
Damage to these structures eventually leads to osteoarthritis.
WHY DOES THE ANTERIOR CRUCIATE LIGAMENT
FAIL TO HEAL?
Unlike other ligaments about the joint, the ACL
passes through the joint and is surrounded by joint
fluid. Other ligaments heal by scar formation,
however due to the unique location of the ACL the
bleeding is uncontained, filling the joint, causing

pain and swelling. The blood irritates the knee

joints lining to produce synovial fluid. This fluid is
designed to dissolve and prevent blood clotting
within the joint. Without blood clot, scar tissue does
not form. The result is that the ACL rarely heals in
continuity.
RATIONALE FOR TREATMENT
The goal of treatment of an injured knee is to
return the patient to their desired level of activity
without risk of further injury to the joint. Each
patients functional requirements are different.
Treatment may be without surgery (conservative
treatment) or with surgery (surgical treatment).
Those patients who have a ruptured ACL and are
content with activities that require little in the way
of side stepping (running in straight lines, cycling
and swimming) may opt for conservative treatment.
Those patients who wish to pursue competitive ball
sports, or who are involved in an occupation that
demands a stable knee are at risk of repeated injury
resulting in tears to the menisci, damage to the
articular surface leading to degenerative arthritis
and further disability. In these patients, surgical
reconstruction is recommended.
TREATMENT OPTIONS
Conservative Treatment
Conservative treatment is by physical therapy aimed

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at reducing swelling, restoring the range of motion

of the knee joint and restoring full muscle power.
Proprioceptive training to develop the necessary
protective reflexes are required to protect the joint
for normal daily living activities.
As the cruciate ligament controls the joint during
changes of direction, it is important to alter your
sports to the ones involving straight line activity
only. Social (non-competitive) sport may still be
possible without instability as long as one does not
change direction suddenly.
Surgical Treatment
Patients who are unable (generally young adults) or
those unwilling to lower their level of activity, are
at risk of causing further damage to their knee
should they return to sporting activity and are
advised to undergo surgical reconstruction.
Reconstruction involves placing a graft inside the
knee by arthroscopic surgery (keyhole). A
>90% success rate is normal with some
deterioration over time depending upon other
damage within the joint.
Although ACL reconstruction surgery has a high
probability of returning the knee joint to near
normal stability and function, the end result for the
patient depends largely upon a satisfactory

rehabilitation and the presence of other damage

within the joint.
Advice will be given regarding the return to sporting activity, dependant on the amount of joint damage found at the time of reconstructive surgery.
It is important to preserve damaged joint surfaces
by restricting impact loading activity to delay the
onset of degenerative osteoarthritis later in life.
In the surgery a graft will be harvested to use to
reconstruct the torn ligament. Usually two of the
hamstring tendons are taken, but sometimes other
suitable graft choices
are used. This will be
discussed with you
prior to the
operation. The remnants of the torn
ACL are removed
with keyhole surgery
and tunnels are
made in the tibia
(shin bone) and femur (thigh bone) to allow the graft to be positioned
across the knee. The new reconstructed ligament is
then fixed at both ends to secure it in place.
WHAT IS INVOLVED FOR YOU AS THE
PATIENT?
Prehabilitation. Before surgery your knee must

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have a nearly normal comfortable range of movement. For the weeks leading up to the surgery you
should start some exercises
that will help with your
recovery. These are explained in more detail in
the prehabilitation/ rehabilitation section.
Healthy patients are admitted on the morning of their surgery. You should
inform your surgeon and anaesthetist, of any medical conditions or previous medical treatment as this
may affect your
operation.
It is extremely important that there are no cuts,
scratches or pimples on your lower limb as this
greatly increases the risk of infection. Your surgery
will be postponed until the skin lesions have healed.
You should not shave or wax your legs for one week
prior to surgery.
Patients should cease smoking and taking the oral
contraceptive pill 6 weeks prior to surgery as this
increases the risk of thrombo-embolism (life
threatening blood clots).
After the operation you will normally be required
to stay in hospital for one night.
Physiotherapy is commenced immediately post-

operatively and should continue for 4-6 weeks. By

7-10 days following surgery you should be able to
walk without crutches. Sedentary and office
workers may return to work approximately 3-5 days
following surgery. Most patients should be walking
normally 14 days following surgery although there
is considerable patient to patient variation.
Should the left knee be involved then driving an
automatic car is possible as soon as pain allows. You
must not drive a motor vehicle whilst taking severe
pain killing medications. Should the right knee be
involved driving is permitted when you are able to
walk without crutches.
Rehabilitation exercises should be continued
intensively until 4 to 6 weeks when jogging under
controlled conditions is commenced.
Solo sport as part of a comprehensive
rehabilitation programme commences at
approximately 6-10 weeks. Ideal solo sports are
shooting basket balls, solo squash or hitting a tennis
ball against a wall.
Playing sport non-competitively or training is
possible at 4 to 6 months. Training may commence
when an adequate rehabilitation of the thigh
musculature has occurred. A return to competitive
sport is permitted at 9-12 months following surgery,
again provided that there has been a complete
rehabilitation and the joint is demonstrated to be
stable.

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COMPLICATIONS
General complications related to surgery
Deep vein thrombosis and pulmonary embolus:
Although this complication is rare following
arthroscopic surgery, a combination of knee injury,
prolonged transport and immobilisation of the limb,
smoking and the oral contraceptive pill or hormonal
replacement therapy all multiply to increase the
risk. Any past history of thrombosis should be
brought to the attention of the surgeon prior to
your operation. The oral contraceptive pill,
hormonal replacement therapy and smoking should
cease 6 weeks prior to surgery.
Pneumonia: Patients with a viral respiratory tract
infection (common cold or flu) should inform the
surgeon as soon as possible and will have their surgery postponed until their chest is clear. Patients
with a history of asthma should bring their inhalers
to hospital.
Complications specifically related to your knee
reconstruction surgery.
Infection is a serious but rare complication. Surgery
is carried out under strict germ free conditions in an
operating theatre. Antibiotics are administered
intravenously at the time of your surgery.
Any allergy to known antibiotics should be brought
to the attention of your surgeon or anaesthetist.

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Despite these measures, following arthroscopic ACL

reconstructive surgery there is about a 0.5% chance
of developing an infection within the joint. This
may require treatment with antibiotics or may
require hospitalisation and arthroscopic wash-out of
the joint. Subsequent to such procedures prolonged
periods of antibiotics are required and the post
operative recovery is slowed.
Postoperative bleeding and marrow exuding from
the bony tunnel may track down the shin causing
red inflamed painful areas. Characteristically when
standing up the blood rushes to the inflamed area
causing throbbing this should ease with elevation
and ice packs. This may end with a bruise and slight
swelling around the ankle usually lasting about one
week. This is a normal postoperative reaction and
only delays short term recovery. Excessive bleeding
resulting in a haematoma is known to occur with
patients taking aspirin or on steroidal antiinflammatory drugs. They should be stopped at
least one week prior to surgery and probably should
not be taken all all.
Nerve injury. Due to the skin incision, patients may
notice a numb patch on the outer aspect of their leg
past the skin incision. This is of no functional significance and is unavoidable. The numb patch tends to
shrink with the passage of time and does not affect
the result of the reconstructed ligament.
Hamstring tears. Your hamstring musculature will
recover quickly and tendon regrowth may be felt at
14 days following surgery. However scar tissue

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forms around the reformed tendons. This may tear

and is felt as a pop or tear behind the knee on the
inner side. This will usually set your rehabilitation
back a few days only. Scar tissue may tear more
than once but does not usually occur after 6-8
weeks post operative.
Graft failure due to poorly understood biologic
reasons occurs in approximately 1% of grafts and a
further 1% of grafts rupture during the
rehabilitation programme. After two years if you
return to normal activities the risk of further ACL
injury returns to near normal (about 1% each year
for patients returning to high intensity sports), the
risk of rupturing the reconstruction is similar to that
of rupturing the ACL in the other knee.
Pain and stiffness. Rarely patients develop pain
and stiffness in the knee after ACL reconstruction.
This can normally be resolved with intensive
physiotherapy. Occasionally further surgery may be
required.
AFTER THE OPERATION
You will wake up in recovery with the knee
bandaged. You may have a small drain coming from
the knee to help drain any excess bleeding and
reduce the swelling. You will be given pain
medications if required. It is safe to move the knee,
but you will be encouraged when resting to keep
the knee straight.
It is safe to fully weight bear through the knee

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straight away, but often it is more comfortable to

start walking with some elbow crutches. Most
patients will only use these for the first few days.
By one to two weeks you should be walking
normally. It is normally safe to drive when you are
walking normally and putting all your weight
through the leg (you can perform an emergency
stop). Please check with your insurance company
that you are covered before starting to drive again.
The knee will have a tendency to swell in the first
six weeks. It is important to ice the knee between
exercises and when resting to keep it elevated.
You will be given some exercises to help rehabilitate
the knee. The rehabilitation is split into three
phases
PREHABILITATION / REHABILITATION
Pre-operative exercises
Before the operation it is important that you have
as near to full pain free movement as possible.
Ideally a few weeks before the surgery you should
start exercises building up your quadriceps and
hamstring strength. This trains the muscles up and
makes it easier to get going after the surgery.
Phase1. (0-1weeks following surgery)
This phase involves regaining a full range of
movement (especially full extension).

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It is important that these exercises are performed

for short periods but regularly (rather than one
longer period)
Calf exercises

Move the foot up and down from the ankle to

maintain good circulation
Extension exercises
Sit on a firm surface
and fully straighten
your knee. To help
the knee go
straighter tighten
the front thigh
muscles
(quadriceps).
Pull your toes up towards your face and at the same
time push your knee back into the floor.
Hold for 10 seconds and repeat.

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knee bends
Slide your
heel up and
down a firm
surface bending and
straightening
your knee.

static hamstrings
PICTURE NOT AVAILABLE

With the knee bent to about 30 from fully straight

push the heel into the floor and hold for 10 seconds.
knee bends in standing
Standing upright bend
your operated knee
bringing your heel to
your bottom. Lower the
foot slowly back into a
straight position.

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Phase 2 (1-8weeks following surgery)

This phase is about improving muscle strength and
continuing to improve movement back to full.
It is important to perform these exercises regularly
and we recommend at least twice a day. The more
effort that is put into the rehabilitation the better
the recovery and quicker the return to full activities.
Straight leg raise
Lie on your front. Lift
the leg straight up in
the air and lower. Try
and stop the downward fall of the leg by
quickly contracting
your muscles. As you
progress you can add weight to your ankle.
Leg raise in side lying
Lie on your side with
your operated leg
uppermost. Lift and
lower the leg using
your outer thigh muscles. Change sides so
the operated leg is at
the bottom
(lowermost). Lift the operated leg up and down using the
innermost thigh muscles.

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Bridging
With your knees bent
push your heels into
the floor and lift your
bottom clear. Progress to just using
your operated leg.

Sit to Stand
Slowly stand up from a chair.
As you progress put the unoperated leg forward so more
of the work is done by the
operated leg.

One leg balance

Stand on the operated leg
with it slightly bent. Try to balance for 30 seconds. As you
progress try closing your eyes.

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Hamstring catches
Stand on your un-operated leg.
Bring your other heel to your
bottom. Then lower your foot,
try and stop the downward
movement by quickly contracting your hamstring muscles.

Rope walk
Place a skipping rope along the
floor. Walk along it carefully
keeping your
Balance

Calf stretch
Feet pointing forward, operated leg behind you with knee
straight and heel down. Lean
in towards the wall, hold for
20 seconds

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Hamstring stretch
Stand with operated leg straight
out in front of you, heel on the
floor. Bend forwards from the
hips and rest your hands on your
bent un-operated leg keeping
your back straight. Hold for 20
seconds.
Phase 3 (8-16 weeks following surgery)
At this stage phase 2 exercises can be progressed at
increased speed, weight and number of repetitions.
You can now start building in some exercises to help
proprioception (joint stability coordination).
1. Skipping
2. Step-ups and
downs
3. Quadriceps stretch
4. Jogging
5. Cycling
6. Swimming
7. Gym work.
8. Wobble board
9. Single leg squats

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Phase 4 (16 weeks following surgery)

Rehabilitation can now be directed at graded return
to sports.

Solo sports such as hitting a tennis ball against a

wall, or shooting some baskets helps build up
proprioceptive reflexes in a controlled
environment.

When jogging you can

start to build in some
direction changes
initially running long
curves, but as you
progress making the direction changes
more acute.

At 6 months following
surgery if the musculature is sufficient sport specific
training exercises can be started.

We would not recommend return to competitive

sport until at least nine months following surgery.

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As with all operations if at any stage anything

seems amiss it is better to call for advice rather than
wait and worry. A fever, or redness or swelling
around the line of the wound, an unexplained increase in pain should all be brought to the attention
of your doctor.
Useful telephone numbers
NHS Direct

0845 4647

Ward
01865 ______________
(make a note of the number in the space above)
Physiotherapy

01865 738074

Occupational therapy

01865 737551

Rheumatology unit
Occupational therapy

01865 737557

Recovery

01865 738156

Outpatients

01865 738149

Orthotics

01865 227775

Pre-operative
assessment clinic

01865 738237

Your consultants
secretary
01865 ______________
(make a note of the number in the space above)
Patient advice and
liaison service (PALS)

01865 738126

Nuffield Orthopaedic
Centre Switchboard

01865 741155

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Notes

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This booklet can also be

provided in large print on
request.
Please call 01865 738126

Marketing & Communications

Nuffield Orthopaedic Centre
Windmill Road
Headington
Oxford
OX3 7LD
Telephone 01865 737509
www.noc.nhs.uk

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