The anterior cruciate ligament (ACL) attaches the shinbone to the thigh bone. Tearing this ligament is common among athletes, especially those engaged in cutting sports like soccer, football, basketball, rugby and lacrosse. ACL surgery is usually recommended and appears to provide the greatest long-term solution for many athletes.

In an ACL reconstruction, a new ligament is built from a graft that is provided from either a donor or from the patient themself. Surgery is often performed four to six weeks after a torn ACL. This gives time for a preoperative exercise program to work on quadriceps activation and strength, full knee range of motion and swelling reduction. ACL surgery lasts about one and a half hours, and patients usually recover two hours after surgery before heading home.

Before Surgery

Before ACL Surgery

Before ACL Surgery

The Surgery

The Surgery

Plan to be at the hospital for at least six hours.

Upon arrival, you will be taken to the preoperative holding area. The nurse will have you change into a hospital gown and will take you to your assigned bed. An intravenous line (IV) will be placed in your arm to deliver fluids and medications during and after the surgery.

After a review of your health history, an anesthesiologist will meet with you. Most patients undergo a general anesthetic (i.e., “go to sleep”). The anesthesiologist may discuss the option of a postoperative pain block or catheter where a local anesthetic is injected to numb the top of your thigh.

Your surgeon will recheck your surgical consent, mark your operative site and see if you have any last minute questions before your procedure.

What To Expect During The Surgery

ACL Prep

The Operating Room

The anesthesiology team and your circulating nurse will take you to the operating room. You and your care team will complete a sign-in procedure to verify the correct patient, consent, surgical site marking, medication allergies and the surgery to be performed.

Once those steps have been completed, anesthesia is administered through your IV. Heart and brain wave electrodes monitor how you are responding to anesthesia. Once you are fully asleep, your legs are positioned and padded. The skin on the operative knee is prepped with a sterile surgical cleansing scrub from the mid-thigh to the ankle. Sterile drapes are applied.

Before beginning, the surgeon verifies your name, on which side your surgery is being done, the type of surgical procedure(s), your medical allergies and any other special considerations or needs for your case.
ACL Graft

Obtaining the graft

The first step in ACL reconstruction is obtaining the graft that will be used to reconstruct the torn ACL. An autograft is a graft that is harvested from your own body. In most cases, a portion of hamstring tendon (autograft) is harvested from the same knee or, in some cases, the opposite knee. A 4-centimeter incision is made just below the knee on the inside and top portion of the shin bone or sometimes on the back side of the knee, depending on surgeon preference. A special instrument is used to harvest one or two hamstring tendons (the semitendinosus and the gracilis).
ACL Graft Prep

Preparation of the graft

After it has been harvested, the surgeon prepares the hamstring graft by trimming and cleaning the tissue and tagging the ends with suture. The graft is then folded over to determine its diameter and length. If the graft is too small in diameter, the surgeon may elect to add to the hamstring with a donor/cadaver graft (allograft).The use of allograft tissue is patient-specific and depends on several factors, such as the patient’s age and condition of the knee. The allograft is stored in a designated tissue freezer and has been screened and sterilized. The preparation of the allograft is the same as the hamstring autograft. If you receive an allograft for your knee, you will NOT need to take anti-rejection medications.
ACL Arthro Eval

Arthroscopic evaluation

After the graft has been prepared and sized, the surgeon performs an arthroscopic evaluation of your knee. Two or three small incisions (portals) are made around the knee. Sterile fluid is pumped into the joint to help the surgeon see inside the knee and to control bleeding. A small camera is introduced into one portal and the instruments through the other(s) to fully evaluate the knee, looking at the meniscus (cartilage pads), ligaments, bony surfaces and other soft tissues. It will be used to photograph the anatomy and conditions of the knee.
ACL Surgery

Addressing the injury

The surgeon will address any meniscus tears and other injuries and then turn his or her attention to the ACL reconstruction. The torn ACL stump is removed with a motorized shaver. The torn stump of the ACL is removed to allow room for the new graft. Using specific guides, two tunnels are created: one in the femur (thighbone) and the other in the tibia (shin bone). These tunnels are in the anatomic footprint of the old ACL. The bone marrow at the end of both bones provides nutrients and helps with healing of the new graft.

ACL Close Incision

Wrapping up the surgery

Once satisfactory bone tunnels have been created, the graft is passed through the femur and tibia tunnels and secured. The devices used to secure the graft can be a metallic button, bio-absorbable screw or other device. The surgeon then bends and straightens the knee several times to check for the correct amount of tension and graft placement and stability and to look for any impingement (pressure) on the graft. After final inspection, the instruments are removed from the knee and the incisions closed. A sterile dressing is applied with a compression wrap and a cold pack.

After surgery, you will be brought out of anesthesia and transported to the post-anesthesia care unit (PACU). Your family will be allowed back to the recovery room. The nurse will review instructions regarding weight bearing, activities and medications with you and the person driving you home. A physical therapist will meet with you regarding crutch training and home exercises. Once you have recovered enough and are stable, you will be discharged.

The effects of anesthesia may remain for 24 hours or longer. Do not drive, operate equipment or make important decisions during this time.

Post-Surgical Care

Recovery from ACL Surgery

Ensure that you have follow-up physician and physical therapy appointments scheduled. Follow these instructions for your care at home:

Protect your knee

  • You are encouraged to bear as much weight as you are able on your surgery leg. Since your thigh may be numb for a day or two, you may be at risk of falling. Use crutches as needed for support and balance.
  • Do not bend your knee more than 90 degrees if you have had a meniscus repair.
  • Elevate your leg for comfort and to limit swelling.

Cold therapy

  • Use your cold therapy unit (Cryocuff) for the first 48 hours after surgery. After that, use it for 20 minutes four to six times during the day. After the bulky dressing is removed (three days after surgery), do not apply the cold pad directly to the skin – place a soft cloth between your skin and the pad.
  • Do not leave the temperature set to maximal coldness. If the temperature reads into the red area, unplug and restart it.
  • If blisters or redness appears, discontinue cold therapy on the affected area.

Incision care

  • Keep the dressing clean and dry for 72 hours. Remove the bulky dressing after 72 hours. Leave the tape strips (called Steri-Strips) in place, even if they are bloody. You may want to use small gauze pads or adhesive bandages over the incisions to keep the stitches from catching on your Ace wrap.
  • Use an Ace wrap to control swelling or for comfort. Start the wrap at the lower leg and work your way up above the knee. Do not wear the Ace wrap at night unless you are told otherwise.
  • Do not apply any ointment or cream to the incisions.

Bathing

  • Keep the incisions dry for three days. You may sponge bathe around the incisions.
  • After three days, you may shower, but do not let the water spray hit your incisions. Only let the water gently run over the incisions. Gently pat the incisions dry with a clean towel or gauze pad.
  • Do not soak the incisions in a tub bath, pool or hot tub until 24 hours after your stitches are removed.

Medicine

  • If you were given a prescription for an anti-inflammatory medicine, be sure to take it as directed until it is gone.
  • Your prescription pain medication may cause constipation. You may take an over-the-counter stool softener.

Exercise

  • Complete all exercises as you are instructed, even if it feels uncomfortable. You should start your exercises the day of surgery if you are able. You will not cause any damage to your knee.
  • Do 200 leg raises each day. Do not put a pillow under the knee, but use a towel roll under your heel.
  • Work on both getting your leg straight and bending your knee to 90 degrees.
  • Your surgeon will determine if you will need a knee brace or continuous passive motion (CPM) machine after ACL reconstruction.
  • You will be given more exercises at the first physical therapy appointment five to 10 days after surgery.

Call your doctor right away

  • If you have signs of infection at the incisions:
    • Redness, swelling or warmth of the skin
    • Pus or changes in the amount or color of the drainage
    • Fever or temperature over 101 degrees F
  • Signs of blood clot (which could indicate deep vein thrombosis):
    • Pale/cool or red/swollen extremity
    • Chest pain
    • Shortness of breath
  • Uncontrolled pain, swelling, nausea or vomiting
  • Bleeding that is not controlled with direct pressure. Some oozing is normal during the first two days after surgery.

Returning to Activity

Returning to Activity

If you are an athlete who is returning to sport after ACL reconstruction surgery, here are important considerations:

Stay involved with your team; you can still be learning, observing or maintaining fitness on the sideline even though you are injured. Helping track team stats and/or documenting the practice plans can help you achieve mental engagement with the team.

Core work, stationary cycling, upper extremity strengthening and rehab exercises are all options to discuss with your physical therapist or athletic trainer. Be certain that you are protected from any plays, passes or equipment that could cause injury to your knee. If your knee begins to bother you at any time, stop activity and apply ice.

Every athlete recovers at a different pace. You might feel fit and ready to return (starting with sideline/weight room activity) around 4-6 weeks after surgery, but you should verify the plan with your physician, physical therapist or athletic trainer. Be sure to keep your coach involved in the rehabilitation process as well.

Learn more about what to expect during your orthopedic procedure