Anterior Cruciate ligament reconstruction - Galway Clinic

Paraic Murray
MSc, MCh(Orth), FRCSEd(Orth)
Consultant Orthopaedic Surgeon
Patient Information
Booklet Following
A.C.L.
Anterior Cruciate
ligament reconstruction
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The practice Contents
Consultant Orthopaedic Surgeon: Paraic Murray
Secretary: Linda Moylan
Physiotherapist / Research Assistant: Jane Campbell
Typist: Fiona Walsh
What is the ACL and what does it do? 4
The Meniscus. What is it and what does it do? 5
How an ACL Injury Occurs 5
Diagnosing a torn ACL 6
Pre-surgery preparation 6
Prehabilitation exercise programme 7–10
Surgery 11
How do I prepare? 12
What happens the day of surgery? 12
After the procedure 12
Physiotherapy and cryotherapy 13
Wound Care 14
When can I leave the hospital? 14
What happens when I go home? 14
When do I return to the Clinic? 14
Physiotherapy/Rehabilitation 14–16
Isokinetic Testing 16
Notes 17
References 18
Useful Telephone Numbers 18

What is the Anterior Cruciate Ligament and what does it do?
The knee contains four ligaments that connect the thighbone (femur) to the shinbone (tibia).
These ligaments hold the knee in proper alignment and control its movement.
There are two ligaments on either side of the knee the medial collateral ligament and the
lateral collateral ligament. These two ligaments control side to side movement.
The other two ligaments are on the inside of the knee and cross each other (hence the name
cruciate) as they cross from the bottom of the thigh bone to the top of the shin.
The posterior Cruciate Ligament (PCL) runs from the front of the thigh bone to the back of
the shin and provides front to back stability. This ligament is rarely injured.
The Anterior Cruciate Ligament (ACL) runs from the back of the thigh bone to near the
front of the shin. It limits the side-to-side rotation of the lower leg and prevents the shin from
moving too far forward in relation to the thighbone. It prevents the knee from buckling on
twisting, sudden stopping, jumping and landing and in contact sports.
Femur (thighbone)
Anterior Cruciate Ligament
Lateral Femoral Condyle
Lateral meniscus
Lateral Collateral
Ligament
Fibula
Frontal View of Right Knee
Patella (underside)
Trochlea
(patellofemoral groove)
Posterior Cruciate
Ligament
Medial Collateral
Ligament
Tibial Plateau
Tibia (shinbone)
Tibial Tuberosity
Medial Meniscus
The Meniscus. What is it and what does it do?
The Meniscus or menisci (plural) is commonly referred to as cartilage. This is not to be
confused with the cartilage which covers the joint surfaces called articular cartilage.
There are two menisci in your knee each rest between the thigh bone and shin bone (see
diagram). One meniscus is on the inside of your knee; this is the medial meniscus. The other
meniscus rests on the outside of your knee, the lateral meniscus. They spread the weight of
the body across the knee surface and reduce friction during movement.
How an ACL Injury Occurs
Typically ACL injuries occur during sports or fitness activities such as basketball, football, soccer
or skiing. Most often they occur when you slow down or cut or pivot with your foot fixed on
the ground. Landing awkwardly from a jump is also a common cause of ACL tears.
It is not uncommon for the meniscus (cartilage) to tear along side with the ACL . If this injury
includes the medial collateral ligament (MCL) it is known as the Ó Donoghues triad or ‘unhappy
triad’. This is seen in sports such as football, when the player is hit on the outside of the knee.
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Diagnosing a torn ACL
Firstly the surgeon will ask about how you injured the knee. How did it feel and did you hear or
feel a ‘pop’? Did the knee swell immediately after? Were you unable to be physically active after?
The surgeon will then examine your knee. The most commonly used exams are the Lachman’s
test and the pivot shift test.
If the movement in your knee is restricted by swelling or contraction of the muscles in the
back of your upper thigh (hamstrings) the surgeon might not be able to detect an ACL tear
with these tests. If this is the case a magnetic resonance image (MRI) may be requested.
An MRI can also help identify if there is any damage to the cartilage (cushioning structures) or to the
other ligaments. It must be noted that an MRI is not 100% accurate and is not always necessary.
An arthroscopy may be necessary in some cases if there is a question about what is causing
the knee problem (see also patient information booklet following knee arthroscopy)
Pre-Surgery Preparation
It is important prior to surgery to have reduced all swelling and have regained full range of
motion. This is to decrease the likelihood of post-operative complications and the development
of excess scar tissue. To this end Mr Murray will not operate until a minimum of six weeks
after your injury.
There are many different types of exercises which can be done prior to surgery with the aim of:
• Restoring range of motion
• Decreasing swelling
• Decreasing pain
• Increasing strength
• Preparing you for your post-operative rehabilitation
Using ice and elevating the leg will also help decrease the swelling. You may carry out your
“pre-habilitation” even if you have torn your medial ligament.
Avoid:
• Jumping and landing
• Sudden Stops
• Twisting and turning
• Contact sports
Pre-habilitation Exercise Programme
The following are some examples of exercises you may carry out prior to surgery. Your own
Physiotherapist may suggest some additional exercises.
Cycling
Cycling is good for increasing range of motion and decreasing swelling.
Swimming
Avoid breaststroke leg kicks. A good non-weight bearing exercise.
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Assisted knee flexion/heel slides
Lie/sit on the floor or bed. Put a sliding board or plastic bag under your heel to
decrease friction. Hook a towel around your heel. Pull on the towel and slide your heel
towards your buttocks. Pull it to the point of mild discomfort and tightness. Hold this
point for a few seconds, then straighten your leg out. Repeat this 10 times
Static Quadriceps
With your leg straight out in front of you, push the back of your knee down
onto the bed or floor . You will feel your quads (thigh muscles) tighten. Hold
this for 10 seconds. Repeat 10-15 times
Straight leg Raises
Lie on the bed or floor. Bend the ‘good knee’ on the injured side tighten your quads
as above. Now lift your leg 10cms off the floor. Hold 10 seconds. Do 10-15
Hamstring stretches
Sit with your leg elevated as shown. Keeping both your knee and your back
straight. Lean forward from your hips until you feel a strong stretch. Hold 30
seconds. Repeat 3 times
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Calf stretch
Stand as shown with both feet and hips pointing forward. ‘Good leg’ to the front. Keeping
your back knee straight lean forward taking your weight onto your font foot until you feel
a stretch in the calf muscle on the back foot. Hold 30 seconds. Repeat 3 times.
Surgery
The aim of the ACL reconstruction is to give you the most stable knee possible so that you can
resume your previous level of activity and minimise the risk of future knee damage.
You may choose this option if:
• Your knee gives way during typical daily activities
• You are unable to participate in sporting activities which are important to you
• In people with ACL tears whom we know will have instability
The surgery is done with the aid of an arthroscope. Incision are required around the knee but
the surgery doesnít require the surgeon to open the joint.
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3
2
4
1
5 6 7
1. Femur
2. Patella
3. Lateral meniscus
8
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4. Cruciate ligaments
5. Fibula
6. Medical meniscus
In the majority of cases, the new ACL is made
using a graft taken from the hamstrings tendons
(the muscles which run down the back of the
thigh). Their tendons cross the knee joint and
attach to either side of the tibia (shin bone). The
graft used in the ACL is usually taken from the
semitendinousus and gracilis tendons which run
along the inside part of the thigh and knee.
In some cases or revision surgery (if you have had
an ACL reconstruction before), the hamstring
graft may be taken from the opposite knee.
7. Tibia
8. Collateral ligament
9. Irrigation cannula
Hamstring Muscle Group
Stab incisions are
made into the knee
through which
a scope and an
irrigation cannula
will be inserted.
The arthroscope
allows the surgeon
to view the joint in
its entirety in order
to make a diagnosis
of its condition
The other grafts which can be used for ACL
reconstruction are the patella tendon or a donor
tissue (allograft). Back view Side view

How do I prepare?
If you are taking medication ask the surgeon if you need to stop taking it before or after
surgery. Remove any nail polish and leave your valuables at home. It is important that you have
an outpatient physiotherapy appointment organized for when you go home, usually about a
week after the operation.
You will be admitted into the hospital the night before the procedure. To avoid the risk of
infection you will be asked to take 3 shower using a chlorohexidine scrub. This is a pink liquid
like shower gel, which you wash thoroughly with, paying special attention to the foot and leg
of the affected side. You will take two of these showers the night before your surgery. To avoid
any damage to the skin do not shave your leg, this will be done in theatre. You must also be
fasting from midnight the night before surgery.
Certain circumstances can complicate the procedure.
Before surgery, tell the surgeon if:
• You are pregnant
• You are allergic to any medication including anaesthetic
• You have a skin infection or an infected wound near the affected joint
• You or any family members have had an adverse reaction to anaesthesia in the past
What happens the day of surgery?
You will take the last of your 3 showers this morning. You will be taken to the operating
theatre on your bed where you will meet Mr Murray. Various checks will take place including
checking the correct side for operation. The anesthetist will then give you a general
anesthetic which will put you asleep.
After the procedure
Once the surgery is complete the joint is washed out and injected with a local anaesthetic. The
incisions are then closed with paper stitches, covered with white dressings and surrounded
with a wool and crepe pressure bandage. A rolled up towel will be placed under your ankle to
insure that you keep your knee
straight while you are inactive
and an x-ray will be taken. You
will have an intervenous drip in
your arm to give you any fluid or
drugs you may require. Once you
have woken from the general
anaesthetic and are comfortable
you will be taken back to the
ward again in your bed.
Physiotherapy
You will be encouraged to lift your leg up straight as soon as possible after your surgery. This is
to encourage the muscles at the front of your thigh to work (see diagram below).
The physiotherapist may assist you to get up the evening of your operation or else the morning
after. You will walk normally with the aid of elbow crutches. Please dress appropriately for
Physiotherapy. Loose track suit
bottoms or shorts and non-slip
foot wear with heel support.
The Physiotherapist will take you to
the physiotherapy department where
you will be instructed in exercises
to carry out for the first couple of
weeks after your operation.
You will also be instructed how to
use the stairs.
Cryotherapy (ice-therapy)
The Physiotherapist will put a cryocuff on your knee after your physiotherapy session. Ice is
helpful to reduce pain and swelling in your knee which may slow your progress. You may use
two bags of frozen peas on your knee, one on top and one underneath, when you return home.
Leave the ice packs on for up to 20 minutes, three times a day for the first week and after
exercises or when particularly swollen for the next few weeks thereafter.
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Wound Care
The large wool and crepe bandage is taken off the morning after your operation. Underneath
these, there are small square white dressings covering the little wounds, which are closed using
a paper stitch.
In order to let these wounds heal properly you will need to keep them clean
and dry so you cannot soak in a bath but you may take a shower if you cut the
end off a plastic bag, pull it over your knee and tape it above the knee to keep
the wounds dry, acting like an umbrella over the wounds.
After ten days you can let them come off in the shower or soak off, but you don’t have to
remove them immediately.
When can I leave the hospital?
Once the Physiotherapist is satisfied that you can walk independently and safely on the elbow
crutches, can climb the stairs and are able to do a straight leg raise, you will be able to go home.
This is normally on the morning after the operation.
What happens when I go home?
You will be on the crutches for 7-10 days. You should wear your anti-DVT (deep vein thrombosis)
stocking for 1-2 weeks while you are less active and on the crutches. You should attend a
follow-up with your physiotherapist within the week of returning home. This may be either the
physiotherapist who referred you, your local physiotherapist or the physiotherapy department in
The Galway Clinic.
When do I return to the clinic?
Your first appointment is usually 6 weeks after surgery. This appointment is given to you either
at your initial appointment or on discharge from the hospital.
Physiotherapy/Rehabilitation
It typically takes 6-9 months of Physiotherapy and strengthening exercises before you will be
able to return to your previous level of activity. It will be a full 6 months before you may start
jumping, landing or pivoting type sports (the same activities that tore the ACL initially)
Your rehabilitation occurs in 5 phases. Progression from one phase to the next will depend on
how well you master the goals within each stage.
Phase 1
The first phase of post-operative rehabilitation begins on the first day after surgery and
continues until the 2nd post-operative week. It consists of controlling the pain and swelling,
maintaining good quadriceps (front of thigh) control, maintaining full knee extension and
normalising your walking pattern. The hamstring is quite fragile at this time so it is important
that you do not carry out any hamstring/heel curls in this phase.
Phase 2
The second phase typically lasts from the 2nd to the 6th post-operative week. During this phase
you focus on gaining full range of movement (ROM), decreasing swelling, improving your muscle
strength and retraining your balance. Care needs to be taken with your hamstrings within the
first 6 post-operative weeks to avoid straining them. Avoid doing leg straightening or bending
exercises with a weight on the foot or ankle until you have passed the 12th post-operative week.
This includes again hamstring/heel curls.
Phase 3
This phase lasts from approximately 7 to 12 weeks. The goals for this phase are to maintain full
ROM, run in a straight line without pain or swelling, Hop without pain or swelling and increase
the strength of the hamstring muscles.
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Phase 4
The 4th phase goes from week 13 to week 16 post-op. At this point running drills may be
introduced. By the end of this phase you should be able to carry out running drills at 70% speed
without difficulty, jump without difficulty and hop 75% the distance of your ‘good’ knee.
Phase 5
The final phase of post-operative rehab lasts several months after surgery, and consists of a
gradual return to full activity. You will continue with stability, balance and strength training as
well as exercises specific to your sport or training. Your Physiotherapist will guide in these. You
may also decide to have Isokinetic muscle strength testing.
Isokinetic Testing
Isokinetic testing is used for muscle strength testing.
The machine measures the leg at three different
resistance and speed levels, after measuring the
range of motion in your knee.
It compares the strength of the Quadriceps and
Hamstrings on affected leg to the ‘good’ leg. It
also compares the ratio of the Hamstrings to the
Quadriceps on the same leg i.e. the hamstrings
should be approximately 60% the strength of the
Quadriceps on the same leg.
It also looks at how quickly the muscles fatigue or tire depending on the speed and resistance
they are working at. Isokinetic testing is available in the Physiotherapy Department of the Galway
Clinic or ask your Physiotherapist where the nearest isokinetic facility to you is.
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Notes

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Useful Phone Numbers
Admissions 091 785800 / 785801
Freyer Unit (Orthopaedic ward) 091 785251 / 785252
Hospital Switch 091 785000
MRI 091 785554
Physiotherapy Department 091 785450
X-Ray 091 785600 / 785601
References
www.galwayclinic.com
Multicenter Orthopaedics Outcomes Network (MOON) group
www.mayoclinic.com
www.eorthopod.com
Authors:
Jane Campbell – Chartered Physiotherapist
Paraic Murray – Consultant Orthopaedic Surgeon

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Mr Murray’s suite is situated on the second floor of
the Galway Clinic. On entering the main hospital
entrance, the lifts to the suites are on your left.
Once exiting the lifts on the second floor, suite 32
is straight ahead and second suite on the right.
GALWAY CLINIC
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