Anterior Cruciate Ligament (ACL) Reconstruction

ACL injuries are common and unfortunately because of this ligament not always being able to withstand the strains that we, as human beings, place on our bodies. Usually, the ACL is ruptured when playing sport that puts high rotational forces on the knee (e.g. football, rugby, skiing), but there are many potential mechanisms of injury.

When Paul Gascoigne ruptured his ACL in the 1991 FA cup final, it was a major news story and patients frequently would talk about the ‘Gascoigne’ ligament. With the rise of ladies’ football, it was major news when Leah Williamson, the England football captain, ruptured her ACL and missed out on the 2023 World Cup competition. The higher incidence of ACL rupture in women is a major problem and the fine tuning of training and warm up routines is an important area of focus in the professional game.

Reconstruction of the ACL was once an operation that had the sole objective of getting sportspeople back onto the pitch or slope. Over time, surgeons have observed that there are many patients who experience instability of their knee during their day-to-day tasks, and these patients often benefit from reconstruction. The younger the age of rupture, the more likely patients are going to feel unstable without their ACL, and the more likely they are to undergo reconstruction.

Many people wonder whether they need ACL reconstruction to protect their knee in the future and to prevent later osteoarthritis. This is a complex question to answer and could occupy hours of discussion. To attempt to simplify things, it is worth knowing that the articular surface of the knee can be damaged at the time of injury. If this has happened, it is thought inevitable that osteoarthritis will ultimately develop and so in this situation the decision to proceed to ACL reconstruction would be to stabilise the knee, but it would not be possible to claim that it would be to reduce the chances of later osteoarthritis. If we take a different situation, where their articular surfaces have not been damaged, then we may be able to make an argument that reconstruction could also have a protective effect against later osteoarthritis. Certainly, if there is a delay to surgery, it is more likely that the knee will suffer a tear of the medial meniscus and lose the meniscus’s function of distributing load evenly over its articular surface.

I carry out ACL reconstruction using arthroscopic (keyhole) techniques. Depending on the situation, I have different options for graft selection, but in almost all cases it would come from yourself (an autograft). During your workup, I will have evaluated you for the possibility of their being additional injuries that may also require attention at the time of surgery. Your procedure is documented with intra-operative photographs and this will include inspection of all the structures within your knee. Good surgery is a great way to start, but good rehabilitation is vital after your surgery and thankfully the team are very experienced in this area.

A 4 strand graft prepared from hamstring tendons

Harvesting a patella tendon graft in the operating theatre

The harvested patella tendon graft

Images from theatre of a hamstring reconstruction of the ACL

Lateral extra-articular tendodesis (LETS)

Prior to the 1990s, an ACL rupture would usually be a career ending injury for many sportspeople. Surgery involved non-anatomical reconstruction with procedures that we now group as LETS procedures (lateral extra-articular tenodesis). This helped to reduce the amount of abnormal rotation the knee may experience and proved helpful to patients. After the development of anatomical ACL reconstruction and the enhancement of this with arthroscopically assisted (keyhole) ACL reconstruction, the use of LETS fell out of favour. I have been performing this procedure as an adjunct to anatomical ACL reconstruction for several years, and now it is becoming increasingly recognised to be an important additional procedure to be performed in the groups of patients who are at higher risk of a re-rupture. This is something that I’m happy to discuss when considering ACL reconstruction.

Other ligament injuries associated with ACL rupture

At the time of injuring the ACL, it is common to injure other structures in knee also. Some of these can be picked up on an MRI scan and they will be addressed in theatre at the same time as the ACL reconstruction. These would include injures to cartilage or a meniscus.

It is possible to injure other ligaments at the same time also, and although these can be picked up on an MRI scan, it is still very important to examine the knee properly to help to detect them, and to determine if they’re also going to require reconstructive surgery.

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