ACL Reconstruction
If you’ve torn your anterior cruciate ligament (ACL), you may have heard a pop, felt your knee give way, or experienced immediate swelling and instability. ACL injuries can be quite limiting initially with swelling and early instability, but some can be managed non operatively with physiotherapy, wearing a brace and sometimes activity modification.
If you are experiencing ongoing instability despite physiotherapy, or are planning to return to high level pivoting sports, ACL reconstruction surgery may be required. Work, sports and every day activities can be difficult if you have an unstable knee and an ACL reconstruction can allow you to do these activities normally again. If your knee is giving way or unstable it may also cause further damage and increase your risk of needing further surgery and possibly knee replacement later in life.
Understanding your injury
ACL tears often happen without any contact with another player or object. Because we play a lot of sports in Gippsland that put a lot of pressure on the knee, like football, netball and soccer, ACL ruptures are unfortunately relatively common. They typically occur during activities like cutting, pivoting, or landing awkwardly from a jump. Female athletes face a 4-6 times higher risk than males due to anatomical differences and hormonal factors, though ACL tears certainly affect athletes of all genders.
The injury often happens when several risk factors align: poor landing mechanics, muscle imbalances between your quadriceps and hamstrings, weak core and glute muscles, and sometimes just being in the wrong place at the wrong time. Understanding these factors is important because addressing them during your recovery will be crucial for preventing future injuries and may determine whether you have a good chance of non-operative management.
The technical aspects
After your anaesthetic, either a general anaesthetic where you are put to sleep or a spinal anaesthetic which is a needle in your back to numb your legs, Dr Brooker prepares your knee and leg with a sterile wash.
Dr Brooker performs arthroscopic (key hole) ACL reconstruction which is common in modern surgery. Arthroscopic surgery avoids a large cut on your knee and leads to faster recovery and less pain. Dr Brooker routinely performs arthroscopic assessment first, which involves two small cuts on the front of your knee, through which a camera is inserted to look at the cartilage and meniscus as well as the ACL and other ligaments. Any other injuries such as meniscal tears can be fixed if required. Dr Brooker then performs a second incision on the front of your knee and removes two of your hamstring tendons which will form the new ACL (the graft).
Dr Brooker generally uses a hamstring tendon graft although occasionally a patella tendon graft may be chosen. Once the hamstring tendons are removed Dr Brooker drills holes in your femur and tibia in order to thread the graft through the knee where the ACL used to be. Screws and small buttons are then inserted to hold the graft in place, and dissolvable sutures are used to close the wounds.
When additional stabilisation is needed
In certain situations, Dr Brooker may recommend adding a lateral extra-articular tenodesis (LET) to your ACL reconstruction. This involves using a strip of tissue from the outside of your thigh to provide additional rotational stability to your knee.
A LET is considered if you are at a higher risk of re-rupture of your ACL graft. This could be the case if this is revision surgery, if you have generalised joint laxity (you’re naturally “loose-jointed”), if you’re quite young, or if you’re a high-level athlete in a pivoting sport. The LET significantly reduces the risk of graft failure, but it does add some complexity to the surgery and carries a small risk of causing knee stiffness. A LET is becoming a relatively common addition to ACL reconstruction surgery in a select group of patients. It is performed at the same time as your ACL reconstruction (one surgery) and importantly does not change your recovery. Dr Brooker will discuss with you whether a LET is advised prior to your ACL reconstruction.
What to expect in recovery
Most patients go home the same day as surgery. You’ll start on crutches, but the timeline for walking without them depends largely on whether there was other damage in your knee. If it’s just your ACL, you’ll typically use crutches for 3-4 weeks. However, if we also had to repair your meniscus or if there’s significant bone bruising, this period may extend to 6-8 weeks.
Modern ACL reconstruction techniques and rehabilitation protocols have moved away from routine bracing, as it can slow your recovery by preventing normal movement patterns. Dr Brooker recommends prioritising gradual and repetitive range of motion exercises early in your recovery to avoid stiffness.
You won’t be able to drive while you’re on strong pain medications, and if your right leg was operated on, it may be 4-6 weeks before you’re safe to drive again. For your left leg, this might be as little as one week once you’ve stopped strong pain killers and feel confident controlling the pedals.
Your physiotherapist will become one of the most important people in your recovery journey. ACL reconstruction success isn’t determined solely by the surgery; it also requires your commitment to a comprehensive rehabilitation program that typically lasts 9 - 12 months before return to sport.
Realistic timelines and expectations
Return to desk work typically happens within 1-2 weeks, especially if you can work from home. More physically demanding jobs might require 6-12 weeks off work or on modified duties.
Getting back to sports usually takes 9 - 12 months and requires clearance from both your physiotherapist and Dr Brooker.
Recovery from an ACL reconstruction is a long journey and significantly impacts your life. Most patients return to their previous activity levels, though some patients, particularly if you work in a manual job, choose never to return to high level sports and to modify their activities long term to reduce the risk of recurrence or injury to the other knee.
Making the decision
The decision to have surgery on your ACL injury is sometimes straight forward and sometimes difficult, and every patient has different considerations. Dr Brooker believes that it is important that you engage in a period of preoperative physiotherapy and assess the results before you decide whether or not you want or need an ACL reconstruction. Even if you decide to have an ACL reconstruction, physiotherapy before your surgery is also important to improve your recovery and reduce your risk of stiffness. For this reason, engaging in physiotherapy does not delay your time to surgery even if you immediately choose to have an ACL reconstruction, and Dr Brooker recommends it for all patients.
