ACL reconstruction surgery is a common surgical procedure. It restores stability to your knee if the ACL is ruptured.

You are most likely to benefit from a reconstruction surgery if:

• You are young and want to remain active
• You want to keep playing sports that involve twisting, pivoting or rapid deceleration
• Your knee is unstable and gives way or feels like it might with normal day-to-day activities
• Your job is very physical or your knee giving way could be dangerous (builders, firefighters, etc.)

The surgery aims to give you a knee that you can trust when active. It lets you to get back to playing your chosen sport while avoiding more damage to the knee.

An ACL reconstruction is not an emergency surgery and if carried out too quickly can lead to a worse result. Operating on a swollen and stiff knee can leave you with a stiff knee long term.

It is vital that you work with your Physiotherapist to regain a full and painless range of motion in your knee which generally takes from 10 days to 3 weeks from the injury.

Sometimes it is necessary to operate on the knee for other injuries such as a ‘Bucket-Handle’ meniscal tear first to allow you to rehab your knee properly  and then come back several weeks later for the ACL reconstruction surgery when the knee is ready..

It is also important to consider the 12 months of rehabilitation and what effect the timing of surgery will have on:

• Family events and holidays
• Work trips or busy periods
• Important exam periods such as HSC or Uni finals

At MTP Health, we take your preparation for surgery very seriously in order to ensure that you get the best outcome  through being psychologically prepared, physically strong and medically safe enough to undergo this procedure.

We may need to get additional tests or specialist referrals.

Finally and importantly, we will help you to get strong:

• Our team of Physiotherapists and Exercise Physiologists can assess your level of function
• We recommend that at the time of confirming your surgical date, you book your first Physiotherapy appointment in the first 2-5 days from surgery.

The hospital will contact you in the week of surgery and they will confirm with you on the day before your surgery, the time you need to arrive and when you need to start fasting.

For our patients, if you are on a morning list you need to stop all food from midnight and stop clear fluids from 0530 or 2 hours before the planned start of the list, whichever comes first.

For afternoon lists that time is 11am.

Acceptable clear fluids include water, ‘see through’ apple juice with no bits or ‘see through’ energy drink such as gatorade. It does not include milk or cloudy juice with bits.

You will arrive at the hospital between 1 and 2 hours before your surgery and can usually go home on that same day (day case surgery). One of our anaesthetists will give you a general anaesthetic, meaning you will be ‘asleep’ for the whole procedure. They may also put local anaesthetic around your leg’s nerves (nerve block) to reduce pain after you wake up.

Once you are asleep, the first step is harvesting the graft material. In most cases, this comes from the hamstring tendons but can also be part of the patella tendon. To access the hamstrings, a 3-5cm incision is made over the inside of your shin bone just below the knee joint. For the patella tendon, an incision is made down the centre of your knee from the kneecap to the tendon attachment – the tibial tuberosity. Once the graft is removed, it is prepared with sutures and sizers to ensure it is the right shape and size for your knee.

The next stage is to inflate a tourniquet around your upper thigh. This reduces blood flow and allows a clear view inside the knee. Your surgeon then makes 2-3 small incisions (1cm) at the front of the knee and fills the joint with sterile saline (salty water).

The telescope (arthroscope) is attached to a camera and inserted into the knee. This is used to assess the torn ACL and check for other injuries such as meniscal tears or cartilage damage. These can be treated with a selection of small instruments.

Your surgeon then measures and marks out the correct spots to drill tunnels into the femur and tibia bones. The graft is passed through these tunnels and fixed at either end with screws, buttons or staples.

At the end of the procedure, the incisions are injected with local anaesthetic, closed with dissolvable sutures, and glued to provide a strong waterproof closure.

The surgery takes 30-90 minutes on average with additional time before for anaesthetics and after for recovery. Relatives or partners will usually need to wait 2-3 hours between leaving the admissions area and getting back to the day stay ward.

Most patients experience little more than mild discomfort after waking up from an ACL reconstruction. It usually involves a fast recovery needing painkillers for only a short period.

After the operation, you wake up in the recovery room, where you are monitored for approximately 1 hour and when stable, you can be transferred to the day stay ward. During this time, your surgeon will call your relative. It is important that they realise that this may be more than 4 hours from the time you were ‘taken into the operating theatres’ due to waiting and preparation times.

WALKING - You will be given crutches to use before leaving hospital for your safety. (If you have your own, feel free to bring them). Following ACL reconstruction, most patients can put all their weight through that leg immediately after surgery and are allowed to bend the knee as much as their pain allows. Most people are walking comfortably by 2 weeks.

BRACING - A brace is used to restrict bending in some cases but usually only when there has been associated meniscal repair or root reconstruction. For those patients, it will be worn for 6 weeks in total

DRESSINGS - The bulky dressings that are wrapped around your leg can be removed the morning after surgery. You will have small, waterproof dressings underneath (insert  picture)  that you should leave on until you have your wound check at 10-14 days. It is common for some of the fluid used inside the knee to ooze out into the dressings over the first 24-48 hours and this can have a faint red colour to it. If this happens, the waterproof dressings may need changing.

You can shower with these dressings but avoid soaking in the bath, a pool or the ocean. If they come loose or get soaked, please replace them.

GAME READY - If you have been supplied with a Game Ready machine, please click here for information on how to set it up. We advise that you use it on program 2 or 3 and for up to 2 hours at a time. You can use it as often as you like in a day as long as you manage to complete your rehabilitation exercises. If your pain and swelling are well controlled then you  don’t need to use it. When supplied by MTP Health you have the Game Ready for 2 weeks. At the end of this time it will be picked up by a courier unless you want to continue to rent it yourself.

LENGTH OF STAY - It is safe for you to go home on the same day of surgery but if the surgery is later in the day, it is sometimes more comfortable to stay overnight and go home the next day.

SURGEON FOLLOW UP

Your first post-operative visit will be with your surgeon at 2 weeks. This appointment is critical for checking your wound healing and to assess the stiffness of the knee as well as to answer any questions you may have.

Further follow up with your surgeon with x-rays at each visit until the bone has healed -

• 6 weeks after surgery
• 12 weeks after surgery
• 6 months after surgery
• 1 year after surgery and annually ongoing

Your recovery starts the minute you are awake from the anaesthetic. You start with the simple exercises including ‘Pumping’ your calf muscles to encourage blood movement through the legs and contracting your thigh muscles to squash the back of your knee into the bed. The Physiotherapist will assist you in getting out of bed and walking.

It is vital to your recovery that you engage with a Physiotherapy to maximize your early recovery from surgery.

At MTP Health we that you book your first post operative appointment with a Physio as soon as we have a confirmed surgical date. This should be between 2 and 5 days from the surgery and we will have communicated the rehab plan with your treating Physio whether that is one of our team or your own Physio.

They will help you manage swelling and stiffness before working on your leg strength and function. Finally they will look to improve your level of function for your chosen sport or activity and develop your program to reduce the risk of further injury.

The ACL rehabilitation protocol we use is based on years of research and experience.

Recommended Rehabilitation visits - 

• First 6 weeks - twice a week Physio
• Second 6 weeks - once a week Physio
• 3 - 12months - 1-2 x weekly Exercise  Physiology for minimum 9 months

The knee may remain swollen for up to 6 weeks and the incision sites are often puffy and firm for up to 3 months.

Recovery to a point that the knee feel relatively normal for day to day activities takes 6 months.

Driving: Returning to driving takes a minimum of 6 weeks for right knee surgery and 2 weeks for left knee surgery in an automatic. Regardless of time, you must be able to safely perform an “emergency stop” and you must have stopped all painkilling medication other than over the counter meds such as panadol or nurofen. There is no specific documentation on this by licencing authorities and it is also recommended to check with your relevant car insurance companies.

Work

Most office workers will be able to return to work after 1-2 weeks.

Heavy manual workers may require 2-3 months before resuming full duties.

Sports: Returning to high risk sports such as netball, soccer, footie and basketball takes a minimum of 9 to 12 months. This involves a consistent dedication to your rehab program under the guidance of Physiotherapy and Exercise Physiology.

Returning to sport earlier than 9 months or before you have achieved the targets our team will set you for strength, balance and function will increase the risk of the  graft failing.

ACL reconstruction surgery is a very safe procedure, but all joint surgeries carry some general risks. The most common side effect is temporary pain and bruising. Other complications can include:

Blood clots in the leg

These are uncommon after ACL surgery but can cause severe swelling and pain. Clots that develop in the calf are called deep vein thrombosis (DVT) – these can travel to the lungs and cause a pulmonary embolism (PE). If a clot develops, you may need to take blood thinners for several months

Pain at the hamstring or patella tendon graft site

You may feel pain or discomfort at the site the donor tendon was taken from. This is generally not too severe and can be managed with painkillers. If it persists or can’t be managed, make sure to notify your doctor.

Infection

This is very uncommon after ACL surgery. If it’s just in the wound, antibiotic tablets or an IV drip may be needed. If the infection gets into the knee joint, further surgery be needed to wash the joint out.

Skin numbness

There are very small nerve fibres in the skin around the knee that are always cut during the surgery. This leaves a small numb patch on the outer part of the leg past the scar. This numb patch tends to shrink over time and permanent nerve damage is rare, especially to the larger nerves that supply muscles.

Joint stiffness

Most patients are stiff following ACL surgery. This usually settles within the first few days to weeks. Even though modern techniques and early joint mobilisation prevents most stiffness, some patients suffer from excessive internal scarring called arthrofibrosis.

Rupture of the graft

The reconstructed ligament is at a greater risk of re-rupture during the first 3 months of rehab (whiles it regains a blood supply). The risk of the graft rupturing is 1-2%, but can be higher if you return to high impact sports. If it does rupture, it can be reconstructed again using a different graft.

Other uncommon complications include:

• Anaesthetic risks
• Allergic reaction to medications
• Heart damage
• Stroke

As always with the health system, the answer is ‘it depends.’

At MTP Health, our aim is to simplify healthcare through a better understanding of the system upfront. Therefore, while you can discuss the options specific to you with the team when you see your specialist -

If you are having surgery using your private health cover, the standard fees for the surgeon, anaesthetist, and assistant usually lead to a total out-of-pocket payment of around $4,500. This is the ‘gap’ that is left after Medicare and your insurance company has given you back their rebates.

Note that the anaesthetist is an independent practitioner and can charge a different gap which could affect this figure. We always provide you with their details and recommend you check their quote before committing to surgery.

The surgeons at MTP Orthopaedics participate in the various reduced gap schemes run by different health insurance providers. However, please check for the availability of surgical time slots first as there is often a wait of many months for this option.

Your insurance may also have an excess to pay, so please check. This is usually $500.

If you are having the operation through the public system, there is no out-of-pocket cost. Unfortunately, you are likely to have to wait up to a year for surgery.