ACL reconstruction surgery in Harrow

Although it doesn’t look it, the knee is a very complex structure compromised of many different elements.

One of these is the ACL. ACL stands for anterior cruciate ligament — a tough band of fibrous tissue that joins the thigh bone to the shin bone at the knee joint, running diagonally inside it and joining your thigh bone (femur) to the front of your shin bone (tibia).

The ACL provides your knee with rotational stability so that you can safely twist and change direction. It also controls the back-and-forth motion of your knee which enables you to bend it.

ACL injuries are one of the most common sporting injuries, particularly during sports that require sudden stops or changes in direction, both of which can put abnormal strain on the knee and cause the ACL to become damaged.

Some of the injuries to the ligament that can occur include:

• A partial tear of the ACL
• A full tear of the ACL
• A stretched ACL (usually referred to as an ACL sprain)
• Detachment of the ACL from the bone (referred to as ACL dislocation)

ACL injuries often don’t occur alone. In fact, Mr El-Tawil states that as many as 50% of patients he sees with an ACL injury also have an injury to another part of their knee, such as their meniscus (an area of cartilage covering the bone).

In the vast majority of cases, ACL injuries most often affect people involved in sports. They are also more common in women than men.

In most instances, an ACL injury will happen when you:

• Quickly change direction when running or walking, causing you to twist your knee and the ligament to stretch, tear or dislocate
• Twist your knee, especially if you do this while keeping your foot stationary. For example, in netball when you must stand still but may twist to throw the ball to one of your team
• Suddenly slow down or stop moving at speed
• Over-extend your knee joint, such as if you skid along a muddy football pitch
• Experience a sudden blunt force trauma to the knee, for example when someone collides with you

However, it isn’t just sports in which these types of injuries can occur. Slipping on a wet floor or a patch of ice could over-extend your knee joint. Being involved in a car accident could also harm your knee and cause damage to your ACL.

Many people who experience an ACL injury during a sporting activity will either hear or feel a ‘pop’ in their knee when the damage occurs. Sometimes they experience both.

The knee may then immediately feel unstable, almost like it could give way if you put weight on it. We recommend that you don’t do this, as it’s unlikely to be able to support you, and putting weight on it could make the damage worse.

Other symptoms of an ACL injury include swelling of the knee, pain and stiffness.

Getting diagnosed with an ACL injury is usually fairly straightforward and requires just two elements.

Firstly, you’ll undergo a physical examination where your doctor will check your knee for swelling and tenderness, comparing it to the uninjured knee. They may ask you to make certain movements to see how stiff the joint is, and how far you can move it. They’ll also ask you about the severity of the discomfort that you are experiencing.

Your physical examination may be followed by an x-ray. While soft tissue injuries won’t show up on the x-ray, it will enable your doctor to rule out a broken bone as the source of your symptoms.

ACL surgery is not recommended for all patients.

“The goal of ACL surgery is restore the stability of the knee to how it was before the injury, and restore the patient’s quality of life,” says Mr El-Tawil.

While a torn ACL won’t heal without surgery, non-surgical treatment techniques may be effective for older patients, or those with a very low level of physical activity. Meanwhile, athletes and younger patients who have very active lifestyles are usually very good candidates for the surgery.

As with any surgery, knowing what to expect before your surgery, and following the pre-operative instructions provided by your orthopaedic team is crucial to the success of your procedure. This will help to minimise the risk of complications during both the surgery and your recovery.

Some of the advice that you may be given for preparing for ACL surgery at The Clementine Churchill Hospital Harrow include:

• Stopping taking any medications as advised by your surgical team
• Preparing your home for your return. This may mean setting up a sleeping area downstairs so that you don’t need to go up and down stairs until you are ready. It may also mean filling your freezer with meals or arranging for someone to come in and help with housework
• Staying as active as you can. This will help keep the muscles around your knee strong, which is vital for your recovery following surgery
• Preparing yourself mentally for time away from certain physical activities. It can take up to a year before you are recovered enough to take part in some types of sports

You will be asked to attend a pre-operative appointment around a week before your surgery.

This is to ensure that you are physically and mentally ready for your surgery. You’ll undergo a physical exam, and a member of your surgical team will speak to you about what to expect on the day of your surgery, and afterwards. They will also be able to answer any questions that you have.

ACL surgery is performed arthroscopically. This is a minimally-invasive technique that involves several small incisions being made, rather than opening up a larger section of the knee. There are a number of benefits of performing surgery arthroscopically, making this the preferred option wherever possible.

There are three incisions made in ACL surgery. The first two are keyhole-sized, around 5mm, and made at the knee. One is used to insert the arthroscope — a long, thin tube with a light and camera at one end and is used to visualise the joint. The second has surgical instruments passed into it, which are then used to perform the ACL reconstruction.

The final incision is around 4/5cm in length and is made into the back of the leg. This is used to take the hamstring. The hamstring is a tendon that attaches your large thigh muscle to the bone — it is the hamstring that is used to reconstruct the anterior cruciate ligament during surgery.

Local anaesthetic is used in ACL reconstruction, meaning that patients are awake for the duration of their surgery. However, it may be possible to sedate you if required.

Once the ACL has been reconstructed, all of the incisions will be closed using sutures and dressed.

The role of the hamstrings in ACL surgery

ACL surgery involves reconstructing the ACL with a donor ligament — a hamstring. Everyone has four hamstrings at the back of each leg.

To reconstruct the ACL, two hamstrings are taken from one leg, with the other two left intact. Many people are concerned that taking the hamstrings could compromise the strength or movement of the affected leg, but Mr El-Tawil assures us that this isn’t the case. “Even professional athletes have difficulty being able to tell that they have two fewer hamstrings in one leg compared to the other”.

Should a patient require further ACL surgery in the future, their surgeon will be able to take two hamstrings from the other leg to perform this. “Your own body tissues are always best, but if you are unlucky enough to require more than two surgeries, donor hamstrings can work just as effectively,” explains Mr El-Tawil.

Just like any other surgery, there are risks associated with ACL surgery. These will be explained to you in detail by your orthopaedic surgeon ahead of your procedure, but could include and may not be limited to:

• Bleeding
• Infection
• Blood clots in the lungs or legs
• Trouble urinating
• Reaction to anaesthesia
• Continued pain or stiffness
• Your graft failing to heal well
• Graft failure

The risks of surgery are always assessed at the consultation stage. This means that your orthopaedic surgeon will have used their knowledge and experience to determine that the risks (which are very low) are considerably outweighed by the benefits of having ACL surgery.

ACL surgery is usually performed as a day case, so you shouldn’t need to stay overnight and will be able to go home the same day. Before you leave the hospital, your surgical team will want to feel confident that you can manage your discomfort and that you know how to change the dressings on your incisions.

It’s normal for the areas around the incisions to be swollen and bruised for up to six weeks following ACL surgery, and it can take up to a fortnight for your wounds to heal after ACL surgery.

Getting back to sports after ACL surgery

In terms of getting back to doing the sports you love, we’re afraid you will have to be patient.

While it will be possible for you to do some types of sport within a few months of your surgery — such as swimming — contact sports, martial arts and any activity where the knee could twist will be strictly off-limits for as long as a year.  Regrettably, there is nothing that can be done to speed up this recovery either.

“One of the most common questions I’m asked is if there’s any tricks or techniques that can be used to accelerate the ligament graft and help patients get back to their sport more quickly,” explains Mr El-Tawil. “Unfortunately, healing after ACL reconstruction is a biological process and nothing any surgeon can do can speed that up”.

It's important that patients don’t try to rush back to their chosen sport, even if they feel ok. It could do further damage, which means even more time being unable to be physically active.

Going back to work after ACL surgery

Most patients with fairly sedentary jobs they perform at home can go back to work within a day or two of their surgery.

However, if you commute or have a more physically-demanding role, you may be advised to wait for up to six weeks before you return to work.

When can I drive after ACL surgery?

Most patients should be able to resume driving between four and six weeks after their ACL surgery.

However, we recommend that you check with your surgical team and your insurance company to make sure that you aren’t in breach of your policy conditions.

Will I be in pain after my ACL surgery?

Unsurprisingly, pain is one of the most common worries of any patient undergoing a surgical procedure. Fortunately, it’s not something that you particularly need to worry about in this case.

“Pain is not a massive feature of ACL surgery,” reassures Mr El-Tawil. “The incision made to harvest the hamstring is nearly always slightly more tender than the knee itself.

Most patients can manage with a combination of ibuprofen and paracetamol and may not even need to take these as quickly as a week after surgery. However, if you do need something stronger, don’t hesitate to ask your surgical team”.

As with most orthopaedic surgeries, all patients will be referred for physical therapy, usually both before and after their procedure. Physical therapy is a very important part of the recovery process and shouldn’t be overlooked. Its role is to build and strengthen the muscles and improve your range of motion, so that you can get back to full function without any long-term adverse effects.

“It’s impossible to understate the importance of physical therapy,” states Mr El-Tawil, who encourages patients to get back on their feet as soon as possible. “In fact, it is just as important as the surgery itself. Without it, the procedure would be ineffective”.

Physical therapy usually starts around a fortnight after your procedure, and how often your appointments will be will depend on the recommendations of your PT and surgeon.

It is essential that you don’t only attend these appointments, but that you also complete any exercises that your PT recommends that you do in between them. Regular PT will help aid your recovery and ensure that when you do get back to your chosen sport, you are able to participate at the best possible level.

ACL surgery is a very common surgery, and rarely anything to be concerned about. 

“Most of my patients are athletes, particularly those performing at a high level, but I’ve been known to perform ACL surgery on patients of all ages and lifestyles,” explains Mr El-Tawil.

Nevertheless, the orthopaedic team at Circle Health Group Hospitals, including The Clementine Churchill Hospital Harrow are always on hand to provide information, advice and reassurance.

If you’ve experienced an ACL injury and would like more information about ACL surgery, don’t hesitate to book your private consultation online or give us a call on 020 8872 3872.