Overview
A torn ACL does not reliably heal on its own. ACL reconstruction replaces the damaged ligament with a tendon graft to restore stability and protect the knee during normal activities as well as cutting, pivoting, and athletic activity.
Who Is ACL Reconstruction Recommended For?
ACL reconstruction is recommended for the vast majority of patients with a complete ACL tear who wish to maintain a normal, active lifestyle. The goal is not simply to return an athlete to cutting or pivoting sports. A stable ACL is important for normal work, recreational activities, and everyday function.
Another major reason for reconstruction is to protect the knee over the long term. An ACL-deficient knee remains susceptible to recurrent instability and progressive damage to the meniscus and articular cartilage. Over time, this can accelerate degenerative changes and the development of arthritis. Nonoperative treatment is generally reserved for selected older or low-demand patients with limited functional goals.
How ACL Reconstruction Is Performed
ACL reconstruction is performed arthroscopically. The torn ligament is replaced with a tendon graft that is positioned through tunnels in the femur and tibia to recreate the native ACL. Associated problems such as meniscus tears or cartilage injuries can often be treated during the same procedure.
Graft Choice
My preferred graft is a bone-patellar tendon-bone (BTB) graft using either the patient's own tissue or donor tissue. Graft selection is individualized based on the patient's age, activity level, sport, anatomy, and goals.
Recovery
ACL reconstruction is typically an outpatient procedure. Patients begin weight-bearing with the knee protected in a brace and start physical therapy early. Walking comfortably without a brace commonly occurs around six weeks, jogging around three months, and return to sports generally between six and nine months.
Return to Sports
Return to sports is based on more than time alone. Strength, motion, neuromuscular control, functional testing, confidence, and the demands of the patient's sport all factor into determining when the knee is ready.
Risks and Complications
Potential complications include stiffness, blood clots, infection, persistent instability, graft re-tear, and progression of arthritis. Infection following ACL reconstruction is uncommon.
Revision ACL Reconstruction
Revision ACL reconstruction is a more complex procedure for patients whose previous ACL reconstruction has failed. Failure may result from a new injury, recurrent instability, graft failure or stretching, tunnel problems, or other technical factors.
Successful revision surgery often requires more advanced planning as well as substantial experience and expertise in complex ACL reconstruction. Careful evaluation of the previous reconstruction, graft choice, tunnel position, associated meniscus and cartilage damage, and overall knee stability is essential to developing the appropriate surgical plan.