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ACL Reconstruction Surgery


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Repairing a torn anterior cruciate ligament (ACL) is nearly impossible, except in some specific cases. Instead of repairing, a new ligament is constructed through an ACL reconstruction surgery.


In some specific cases, an ACL repair surgery is performed. To read the details about the ACL repair surgery, you can click on this:


How is Anterior Cruciate Ligament (ACL) Surgery Performed?

The procedure is performed arthroscopically, which means it is a minimally invasive surgery. Two small incisions are made in front of the knee. An arthroscopy camera is inserted through one of these incisions to visualize the inside of the knee. The other incision is used to insert specialized tools (arthroscopic instruments) suitable for minimally invasive surgery.

As an Orthopedic and Traumatology specialist surgeon, I, Dr. Utku Erdem Özer, will explain in detail the ACL reconstruction surgery method I most frequently perform, which involves using hamstring tendons and the elevator technique. You can find other ACL surgery methods later in the article.

As soon as the camera is placed inside the knee, the condition of the injury to the anterior cruciate ligament is assessed. In addition, any accompanying damage to the meniscus, cartilage, and other ligaments is checked. In a way, a damage assessment is carried out.

If the tendon (graft) to be placed instead of the ACL is to be taken from the patient and will be obtained from the hamstring tendons, a small incision is made above the attachment point of the hamstring tendons on the inner and lower side of the knee to the tibia.

These tendons are the Gracilis and Semitendinosus tendons. After preparing these two tendons, they are folded in half. This creates a quadrupled tendon graft. Then, special sutures are passed through one end of the graft, as shown in Figure 1, and a device containing a button-like titanium material is placed on one end of these sutures.

Figure 1

The procedure then continues within the knee joint. First, a tunnel is opened in the thigh bone (lateral femoral condyle) where the upper part of the graft will be placed. Then, using the location where the tendons were taken, a second tunnel is opened from the tibia (medial tibial plateau) beneath the knee.


A guide wire is inserted into the tunnels, followed by a suture. With the help of this suture, the prepared graft is passed through the tunnel in the tibia, the joint, and the tunnel in the thigh bone. As soon as the metal structure at the end of the graft (Toggleloc Zimmer Biomed) is passed through the tunnel in the thigh bone, it is flipped and secured to the corner of the bone. Then, by pulling the sutures in the opposite direction, the upper part of the graft is placed in the tunnel in the thigh bone. This method is called the elevator technique. The elevator technique allows for excellent tension control of the graft. Achieving proper tension is crucial in ACL surgeries.


The connection of the graft to the knee bone is made by placing one screw into the end of a screw tunnel. After the procedure, the graft is controlled with the camera.


What does the graft used in Anterior Cruciate Ligament Surgery mean?

The structure placed in the place of the torn anterior cruciate ligament is called the graft, which is the reconstructed anterior cruciate ligament.


Where is the newly created anterior cruciate ligament taken from in Anterior Cruciate Ligament Surgery?

In anterior cruciate ligament surgery, the newly created ligament can be obtained in two different methods.

1. Tendon taken from the tissue bank: (Allograft)

The tendon graft obtained from the tissue bank is prepared and placed in the opened tunnels. And it is detected in detail as described above. The most important advantage is that no tendon needs to be taken from any part of the patient's body.


2. Tendon taken from the patient's own body: (Autograft) The most frequently used grafts taken from the patient's own body are:

  • Bone-Tendon-Bone Graft: two pieces of bone are taken from the front of the knee cap and tibia. There is a patellar tendon between the two pieces of bone.

  • Graft made from Hamstring Tendons: Two of the hamstring tendons (semitendinosus and Gracilis tendons) attached to the bottom and inside of the knee are taken and prepared. Each tendon is folded in two. A total of 4 tendons are created. Currently, the most commonly used graft is made from hamstring tendons.

  • Graft made from Quadriceps Tendon: Approximately 8-9 mm thick and long tendon piece is taken from the quadriceps tendon attached to the upper part of the knee cap and used as the replaced anterior cruciate ligament.


Why is a Drain Placed into the Knee after Anterior Cruciate Ligament Surgery?

It is important to safely remove the blood that leaks into the surgical site after surgery. A small tube is placed in the surgical area after most surgeries to remove the blood.

A drain is also left in place for approximately 24 hours after anterior cruciate ligament surgery. If the bleeding stops, it is removed. The drain is placed inside the knee joint in anterior cruciate ligament surgery. The presence of the drain in the knee joint does not prevent walking.


When Can I Start Running after Anterior Cruciate Ligament Surgery?

We allow jogging-style running as early as the end of the third month after surgery if the muscle strength is sufficient. We can measure the sufficiency of the muscle strength with the single leg squat test. If the patient is able to perform the single leg squat test in a regulated and desired manner, we know that there will be no problem with running, so we can start running training.


Why Does a Sound Come from My Knee after Anterior Cruciate Ligament Surgery, Is This an Abnormal Situation?

It is normal to hear a sound from the knee in the first months after anterior cruciate ligament surgery. However, if there is pain along with the sound, this situation should be illuminated. The presence of pain along with the sound suggests that there may be a problem in the joint.

The reason for the sound from the knee after anterior cruciate ligament surgery is primarily due to loss of quadriceps muscle. Loss of quadriceps muscle causes a change in the biomechanics of the knee cap, leading to the sound. The sound will disappear when muscle strength is regained.

Another reason for the sound is a change in the properties of the joint fluid after surgery. A decrease in the density of the joint fluid causes abnormal sounds from the knee cap when it contacts the surface. This situation returns to normal and disappears over time.


What Can I Do to Recover Quickly after Anterior Cruciate Ligament Surgery?

1. Tip

Make sure to learn quadriceps activation with the help of a physiotherapist before the surgery. In the early postoperative period, start by making quadriceps activation while walking, getting out of bed, or stepping on it. The most important benefit of this is that the load bearing on the graft decreases in the early period, swelling and edema in the knee are almost minimal. This means that you will go through a high-quality and fast rehabilitation process.

2. Tip

Rehabilitation will take a long time. Being patient and going through the rehabilitation process step by step is very important. This process is normal in the nature of the surgery. Returning to play (return to play) before waiting for the tendon graft to unite with the bone is very risky. At this time, we allow a return to play, competition as early as 9 months later.

3. Tip

It is very important to straighten your knee completely after the surgery. Placing a pillow under the knee to relieve knee pain is especially helpful after an anterior cruciate ligament surgery using hamstring tendons. However, this movement will lead to loss of motion and will prolong the rehabilitation process. Therefore, you should place the cushion under your toes to straighten your knee completely. If your pain is very severe, you can briefly place the cushion under the knee.


Why Can Some Athletes Return to Sports Competitions in Time, While Others Return Late?

There may be several reasons for this. The most important reason is related to whether there is any other injury in the knee when the anterior cruciate ligament tears. Anterior cruciate ligament injury is not a simple ligament injury. During the injury, the knee joint slips out of place in the joint fluid and returns to its place. Depending on the severity of the trauma, meniscal tears, internal and external posterior cruciate ligament injuries, cartilage damage and even joint fractures can occur.

For example, let's say that an external meniscus tear requiring stitching is accompanied by an anterior cruciate ligament injury. When stitching is applied to the meniscus, weight must not be placed on the meniscus for it to heal. For this reason, on average, we provide the patient with a pair of crutches for 1 month, and do not place weight on it. Only for this reason, situations such as muscle loss, loss of proprioception sense, and angle loss in the joint may arise. All of these can be improved towards the pre-injury status with appropriate rehabilitation, but the athlete will need a longer rehabilitation period to regain what they lost. The return to sports will be delayed and along with the athlete being negatively affected psychologically, financial loss will also result from the loss of time. Remember that most sports clubs have agreed on the match start when the athletes make their contract.

The second important issue is a good rehabilitation process that will be followed after the surgery. In professional athletes, this process is managed by working with a physical therapist for 2-3 or even 4 hours a day in some cases.


When Should I Have Anterior Cruciate Ligament Surgery?

There is no full agreement on this in the literature. In my experience, it is appropriate for patients who have regained joint motion that is close to normal and have learned and can apply quadriceps activation to have surgery 1-2 days after the injury.


How Long Does Anterior Cruciate Ligament Surgery Last?

If there is no other pathology that requires intervention, such as an accompanying meniscus tear or cartilage damage, the surgery lasts approximately 1 hour.


What Kind of Anesthesia is Given in Anterior Cruciate Ligament Surgery?

In anterior cruciate ligament surgery, general or spinal (local anesthesia) is performed.

Under general anesthesia, the patient is completely unconscious and doesn't feel any pain during the surgery. The patient's breathing is maintained through a tube connected to the airway.

In spinal anesthesia (spinal block), a needle is made at the lower back, and the patient doesn't feel anything below the waist. The patient also does not feel any pain during surgery. Additionally, sedatives are given during surgery to eliminate any stress for the patient.

Which anesthesia method to choose is a matter that the anesthesiologist, surgeon and patient must decide together.


Is Meniscus Surgery Done During Anterior Cruciate Ligament Surgery If There is a Meniscus Tear?

Before starting the anterior cruciate ligament surgery, the damage is detected and it is checked if there is another injury. If there is another injury, it must be intervened. If a meniscus repair or a cartilage intervention is necessary, these procedures are essential.

If another injury that needs to be intervened is not intervened besides the anterior cruciate ligament injury, this problem will arise during the rehabilitation process and a second surgery will be needed. Naturally, the recovery time will be longer.


If you want to get detailed information about the treatment of meniscus injuries, you can open this link: https://www.utkuerdemozer.com/post/disaridan-iceriye-meniskus-dikisi

If you want to get detailed information about the treatment of cartilage injuries, you can open this link: https://www.utkuerdemozer.com/post/kikirdak-yaralanmalari


What is the Recovery Process After Anterior Cruciate Ligament Surgery, When Will I Heal, When Will I Start Sports, When Will I Play a Match?

If there is no other injury in the patient's knee and only anterior cruciate ligament surgery was performed, the patient walks with crutches after 1 hour after the surgery, waiting for the effect of the anesthesia to pass.

  • After the surgery, if the patient wishes, he/she can go to the toilet with the help of a doctor, nurse or physiotherapist, by standing up with crutches after the effect of the anesthesia has passed.

  • Patients can take a shower after the surgery, covering their wounds with waterproof dressings. Another method is to wrap the dressing area with food stretch film in 3-4 layers, rolled.

  • Most patients become able to walk with a single crutch one day after the surgery, after the drain has been removed from their knee. The presence of a drain in the knee joint does not prevent walking, but patients can walk more comfortably after the drain has been removed.

  • One dressing is sufficient after the drain has been removed.

  • The surgical wounds heal approximately 7-10 days after the surgery, and there is no need for dressing after that. The surgical areas are left open.

  • Physical therapy-physiotherapy can start from the 2nd day of the surgery, and can be done 5 days a week. The physiotherapy process can last approximately 2-3 months, and in some cases it can last up to 6 months. The aim of physiotherapy is to restore joint mobility, regain the muscle strength of the knee area, and regain skills such as balance and agility.

  • Patients who receive physical therapy regularly can walk smoothly enough not to be noticed from the outside after 2-3 weeks of surgery.

  • After an anterior cruciate ligament surgery, if the patient works at a desk, he or she can return to work on the 10th day. If they do a job that requires physical labor, it will be appropriate to wait for the 1st month.

  • Running is one of the questions that athletes ask frequently, when can I start running? The answer to this question is quite simple. It depends on the strength of the knee circumference muscles at the end of the 2nd month. A single leg squat test is performed on the patient to make this decision. If the patient can perform the single leg squat correctly, then a short-term start is made with jog-style running. Running times are gradually increased over time.

  • Specific exercises for sports are started at the end of the 4th month.

  • Returning to sports, returning to play should not be before 9 months. This is because of the healing time for the newly formed anterior cruciate ligament to fuse with the bone.

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