Anterior cruciate ligament (ACL) reconstruction

If you are considering anterior cruciate ligament (ACL) reconstruction or have an operation planned, it is important to know all you can about it. This includes:

• why you need this operation

• what it will be like

• how it will affect you

• what risks are involved

• any alternatives.

The information here is a guide to common medical practice. Each hospital and doctor will have slightly different ways of doing things, so you should follow their guidance where it is different from the information given here. Because all patients, conditions and treatments vary it cannot cover everything. Use this information when making your anterior cruciate ligament reconstruction treatment choices with your doctors. You should mention any worries you have. Remember that you can ask for more information at any time.

What is the problem?

You have torn the anterior cruciate ligament. This ligament is often referred to as the ACL for short.

What is the knee joint?

The knee is quite a complex hinge joint formed by the ends of the femur and the tibia. The femur has 2 smooth rounded joint surfaces, which move on the nearby flat joint surfaces of the tibia.

Between the 2 sets of joint surfaces there are two ligaments. These ligaments make a cross, and are called the cruciate ligaments. One ligament starts at the front of the knee and is called the anterior cruciate ligament or ACL. The other starts at the back and is called the posterior cruciate ligament or PCL. These cruciate ligaments keep the femur and the tibia properly aligned as you bend and straighten your knee.

The patella is the bone at the front of the knee. It is embedded in the tendon in the front of your knee joint, called the patella tendon. The patellar tendon runs from your thigh muscles, called the quadriceps, to the front of your tibia. Part of this tendon below the patella may be used to replace your cruciate ligament.

Finally, the tendons of your hamstring muscles run behind your knee. You can feel them on each side of your knee, where they are fixed onto your tibia. The tendons on the inner side may also be used to replace your cruciate ligament.

What has gone wrong?

You have torn your anterior cruciate ligament, probably due to a fall or a sports injury. This will make your knee give way or feel as if it will give way; this is called an unstable knee. It may stop you doing your normal work and sports. The ligament will not heal if it is torn. It cannot be repaired but may be reconstructed.

The aims

The aim of the operation is to reconstruct the torn ligament with one or more tendons taken from your knee. There is a choice as to which tendons can be used to reconstruct the ligament. These are a graft of patellar tendon with bone at either end, or one or two of the hamstring tendons. Both work well, but they do have their own problems.

Patellar tendon - Taking the patellar tendon graft may leave you with tenderness on kneeling after your operation. If your work, sport or religion involves kneeling, or you have had pain in the front of your knee, a hamstring graft may be better.

Hamstring tendon - The hamstring tendon graft may weaken the remaining hamstring muscles.  You may have numbness on the inner side of the leg. The graft may pull out of place. The graft may not be as strong as a patellar tendon graft. 

Artificial tendons - These nearly always break if used on their own but they may be useful in reinforcing a tendon graft.

The benefits

The operation should make your knee feel stable again. Your knee will not feel as if it is going to give way. Reconstructing your ligament may also reduce the chance of arthritis in your knee when you are older.

Are there any alternatives?

If your knee does not feel too unstable, and you do a lot of therapy to build up the muscles around your knee, it may become stable enough for your needs. You may not then need to have an operation.

Some surgeons use an arthroscope to see where the new ligament needs to go. The majority make a slightly larger incision and do not use an arthroscope for this part of the procedure. There is no difference in the result between open and arthroscopic surgery.

What if you do nothing?

Without an operation, your ligament will not repair itself. Your knee may become more unstable with time and suffer further damage, perhaps leading to arthritis. 

Who should have it done?

You should have the ACL reconstruction if your ligament is completely torn and:

• you participate in vigorous sports, such as football or skiing or
• your knee feels unstable during day-to-day activities, even after undergoing a course of physiotherapy.

Who should not have it done?

You should not undergo ACL reconstruction if either of the following apply to you:

• you already have significant arthritis in your knee
• you are not prepared to go through the rehabilitation that follows the operation.

The above information is © Dumas Ltd 2006.

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