The anterior cruciate ligament (ACL) provides stability in the knee,
particularly during pivoting. Injury to this ligament is common in athletes.
For many, this injury does not require surgery, if the knee only gives way
during sports. Bracing can be quite effective in this scenario. If the
knee gives way without warning during normal, day-to-day activities,
bracing is less practical because this would require ongoing, continuous
brace wearing. Furthermore, not all athletes find a brace effective,
acceptable or satisfactory.
A torn ACL is typically not repairable as the ligament ends are
typically shredded. Instead, a new ligament substitute is created, using a
tendon construct. I usually harvest two hamstring tendons. Two tunnels are
then created, one entering the knee joint through the tibia (lower leg),
one tunnel extends into the femur (thighbone). The placement of these
tunnels is under arthroscopic control. Usually, rigid fixation is
obtained by looping the tendons over a fixation device in the femoral tunnel,
followed by fixation with another fixation device on the tibia. Currently, this
fixation appears to allow the fastest rehabilitation. it takes about
six weeks for some biological fixation through on-growth of bone onto the
tendons in the tunnels. This often necessitates some restrictions in
activity during the first six weeks with alternative fixation methods.
ACL reconstruction requires usually 60 - 90 minutes of surgery. The
aim is to create a construct strong enough to allow immediate weight bearing
and full range of motion. By six weeks, full range of motion is expected, as
well as comfortable stationary bike riding. Gentle running on a treadmill can
be initiated at 6 weeks. At three months, outdoor running can be started, as
well as progressive agility training, aiming for return to sports at 4-6 months
after surgery. Bracing is not utilized during rehabilitation.
Decision-making regarding the management of an individual's ACL injury requires
careful evaluation of the functional impact of this injury, thorough discussion
of the options available, non-surgical and surgical. If surgical treatment is
sought, the benefits and risks of this procedure should be carefully explored
with the surgeon, to tailor the options to the individual situation.
More information can be found in our Frequently Asked Questions.