ACL Surgery

ACL Surgery vs Non-Operative Management

Each case should be assessed individually and a discussion should be had between the patient, physical therapist and doctor as to the best course of action required.

If you tear the anterior cruciate ligament (ACL) in your knee, you may need to have surgery or not. Several factors come into consideration when deciding between operative or conservative management. The decision to have knee surgery will depend on the extent of damage to your ACL, if there is other knee damage and if your quality of life is affected. If your knee feels stable and you do not have an active lifestyle, you may decide not to have ACL surgery. Not all ACL injuries require an ACL reconstruction. We know that many people can cope without an ACL at all.

Your doctor will discuss options with you and assess if you need surgery, once swelling goes down and if rest and physical therapist has helped to treat your symptoms.

Grading ACL Tears

ACL sprains are graded based on how much the ligament is damaged.

• A Grade 1 sprain is a minor stretching to the ligament and your knee is still fairly stable.
  • The fibers of the ligament are stretched, but there is no tear.
  • There is a little tenderness and swelling.
  • The knee does not feel unstable or give out during activity.
  • No increased laxity and there is a firm end feel.
• A Grade 2 is a partial ACL tear, with the ligament stretched so much that it is loose and damaged. These are relatively rare.
  • The fibers of the ligament are partially torn or incomplete tear with hemorrhage
  • There is a little tenderness and moderate swelling with some loss of function
  • The joint may feel unstable or give out during activity.
  • Increased anterior translation yet there is still a firm end point.
  • Painful and pain increase with Lachman’s and anterior drawer stress tests.
• A Grade 3 sprain, there is a complete tear of the ACL, with the knee joint becoming unstable and surgery almost inevitable if it is to be corrected.
  • The fibers of the ligament are completely torn (ruptured); the ligament itself is torn completely into two parts.
  • There is tenderness, but limited pain, especially when compared to the seriousness of the injury.
  • There may be a little swelling or a lot of swelling.
  • The ligament cannot control knee movements. The knee feels unstable or gives out at certain times.
  • There is also rotational instability as indicated by a positive pivot shift test.
  • No end point is evident.
  • Haemarthrosis occurs within 1-2 hours.

ACL Reconstruction

What is ACL Reconstruction?

A torn ACL usually is treated with a procedure called an ACL reconstruction. Surgeons replace the damaged ligament with new ACL graft tissue — either taken from the patient’s own body (tissue from the main patellar tendon, quadriceps tendon or the hamstring) or donated from someone else (called an allograft).

ACL reconstruction is the current standard-of-care surgical treatment for ACL tears. This procedure typically uses a graft, or a piece of tissue, placed in the knee in a minimally invasive surgery that uses small incisions. Most ACL surgeries performed at HSS are ACL reconstructions.

ACL Repair

What is ACL Repair?

ACL repair is an older technique that involved sewing the torn ACL tissue back together with sutures, rather than rebuilding it with a graft. ACL repair was performed in the 1970s at select institutions, including Hospital for Special Surgery, but was abandoned due to unacceptably high failure rates of up to 50%. Today, ACL repair has been modernized and can be performed through a minimally invasive approach. Some surgeons feel that modern ACL repair techniques may be performed safely and may lead to a quicker recovery than ACL reconstruction. However, the data on outcomes is limited, and failure rates for ACL repair appear to be between 5 and 10 times higher than those for ACL reconstruction in people of all ages.

Considerations of ACL Repair

Not all patients will be a candidate for the procedure due to tissue quality and where the tear is located, along with other factors, and only your surgeon can determine the most appropriate treatment. As with other sports medicine procedures, patient age, activity level, and everyday demand on the knee are taken into consideration prior to surgery; speak to your surgeon to see if ACL repair might be right for you. ACL repair is an innovative procedure that not all sports medicine surgeons perform

ACL Revision

What Is ACL Revision?

When ACL surgery fails, surgeons must do a revision surgery (a second operation) to fix any problems that were not successfully addressed the first time. If a repaired ACL fails, it can only be revised with an ACL reconstruction. Having to redo any kind of ACL surgery may result in higher rates of failure, lower rates of successful return to sports activity, and increased risk of developing osteoarthritis in the knee. It is important for patients of all ages to have a successful surgery the first time, but it is particularly important for young athletes. For them, a failed surgery can be devastating: In the short term, it can mean that they lose years away from their chosen sport. In the longer term, it can lead to chronic pain and loss of knee function.

Pre-injury

Before having surgery

Before having ACL surgery, you may need to wait for any swelling to go down and for the full range of movement to return to your knee. You may also need to wait until the muscles at the front of your thigh (quadriceps) and back of your thigh (hamstrings) are as strong as possible. If you do not have the full range of movement in your knee before having surgery, your recovery will be more difficult.

Before having surgery, you may be referred for physiotherapy to help you regain the full range of movement in your knee.