Arthroscopic ACL Reconstruction Surgery: An Effective Treatment with Small Incisions and Quicker Recovery
- Once the anterior cruciate ligament (ACL) tears, it cannot heal on its own. Treatment therefore requires arthroscopic ACL reconstruction surgery to create a new ligament — not to repair the original one.
- Arthroscopic ACL reconstruction surgery creates small incisions for the treatment: one incision of approximately 2–3 cm for the surgical equipment, and two 1 cm incisions for camera ports. Patients typically stay in hospital for only 2 days, and the procedure carries a success rate of 90–95%.
- Beyond surgical efficiency, the most important factor affecting recovery outcomes is the patient’s consistency in completing post-operative physical therapy.
The anterior cruciate ligament (ACL) is one of four key ligaments in the knee joint. Each ligament serves a different function — some can heal on their own after injury, but the ACL cannot. A torn ACL leads to knee instability, making it impossible to play sports that require directional changes effectively. ACL injuries don’t only happen during sports; they can also result from everyday accidents such as missteps, falls, or sudden twisting of the knee. When an injury occurs, the question that often follows is: “Do I need surgery?” This article addresses common questions about ACL reconstruction surgery and what patients can expect.
Table of Contents
ToggleWhat Is ACL Reconstruction Surgery and What Does It Take to Treat?
Surgical treatment for ACL tears is not a repair of the original ligament, but rather a reconstruction — the creation of a new ACL using tendon tissue taken from another part of the body. Because once the ACL tears, it cannot simply be sutured back together.
The procedure begins by removing all remnants of the torn ligament, then replacing it with a tendon graft harvested from the patient’s own body (autograft). This approach reduces the risk of infection and the body can better adapt to the new ligament. There are three main graft options:
1. Hamstring Tendon
With this most widely used graft currently, ACL reconstruction surgery using hamstring tendon causes fewer postoperative complications and is suitable for general patients and non-professional athletes. Some research suggests it may slightly reduce sprinting speed in professional athletes.
2. Patellar Tendon
Patellar tendon is a strong graft option as it includes bone plugs at each end that allow bone-to-bone healing, which occurs faster than soft tissue integration. However, patients may experience anterior knee pain when kneeling and some numbness around the front of the knee after surgery.
3. Quadriceps Tendon
Growing in popularity due to its large size and strength, quadriceps tendon is well-suited for use in ACL reconstruction surgery for athletes who require high levels of knee stability. This option does leave a small additional scar just above the kneecap.
Signs That Your Anterior Cruciate Ligament (ACL) May Be Torn
- A knee-twisting injury, whether from sport or everyday activities such as tripping or falling
- A distinct “pop sound” inside the knee at the moment of injury, a significant indicator that the ACL may have been torn
- Swelling, inability to fully straighten the knee, and difficulty standing or walking normally due to bleeding inside the joint. Swelling typically develops within 1–3 hours of injury and gradually subsides over 2–4 weeks.
If left untreated, the swelling will resolve and the patient may walk and straighten the knee normally again. However, upon returning to activity, a sense of knee instability (loose knee) or giving way becomes apparent, particularly during sudden direction changes such as walking down the stairs or any movement requiring the knee to bear weight at varying angles. These symptoms indicate that the ACL can no longer perform its normal function.
How are ACL Tears Diagnosed?
History taking and physical examination
The doctor begins with taking a detailed history of the injury — including the mechanism of injury, symptoms experienced, the patient’s activity demands, and the impact on daily life.
Knee stability tests
A physical examination is performed to assess laxity in the knee joint using specific tests, including
- Lachman Test
- Anterior Drawer Test
- Pivot shift test
Together with history taking and physical examination, the information can allow an experienced specialist to make a preliminary diagnosis at this stage.
MRI scan
MRI serves as the confirmatory diagnostic tool, providing clear images of the bone structure, tissues, ligaments, menisci, and cartilage within the knee. It confirms the diagnosis and guides treatment or surgical planning.
Do ACL Tears Always Require Surgery?
Patients who are recommended for surgery
ACL reconstruction surgery is typically recommended for:
- Patients with functional instability — such as knee buckling — in daily life or while playing sports
- Younger patients with high activity demands (Active lifestyle), such as playing sports involving frequent direction changes or jumping
- Patients with associated injuries within the knee joint, such as a simultaneous meniscal tear alongside the ACL tears
- Patients who have completed a full course of conservative treatment but continue to experience knee instability (failed conservative treatment) that affects daily function
Patients who are recommended for non-surgical treatment
- Patients playing low-intensity sports
- Older patients
Non-surgical treatment may be appropriate for older patients, those with low activity levels, or those who do not experience knee instability in daily life. Treatment focuses on strengthening the muscles around the knee through physical therapy. However, patients must accept an increased risk of knee osteoarthritis.
Arthroscopic ACL Reconstruction Surgery
Today, ACL reconstruction surgery is performed with an arthroscope as standard in every patient. The surgeon creates two 1 cm. portal incisions around the knee to insert the camera and surgical equipment, along with a small 2–3 cm. incision to harvest the graft. This minimally invasive approach means less pain, faster recovery, and a shorter hospital stay for patients.
Preparing for ACL Reconstruction Surgery
Pre-surgery ACL rehabilitation
Before surgery, the doctor will recommend physical therapy to strengthen the quadriceps muscles and restore full range of motion in the knee. In patients whose muscle strength is insufficient, physiotherapy may be recommended for approximately 1–2 months prior to surgery, as muscle strength is one of the key factors influencing ACL reconstruction outcomes.
Health screening and fasting
Prior to surgery, patients undergo a general health assessment to confirm they are fit for the procedure and must fast — avoiding food and water — for at least 8 hours before the scheduled operation.
Steps in Arthroscopic ACL Reconstruction Surgery
Step 1: Anesthesia
The anesthesiologist performs a spinal block combined with a targeted nerve block. The spinal block prevents pain during surgery, while the targeted nerve block extends pain relief for 24–36 hours post-operatively, allowing patients to stand and begin walking with minimal discomfort in the early recovery period.
Step 2: Arthroscopic knee assessment
The surgeon makes small incisions, introduces saline solution to expand the joint space, and inserts a high-magnification camera to assess the extent of damage to the ligament, menisci, and surrounding structures.
Step 3: Graft preparation
The surgeon harvests the chosen tendon and prepares it into a graft of appropriate size and strength for implantation.
Step 4: Graft placement and fixation
The surgeon drills tunnels in both the upper and lower bones of the knee joint, threads the prepared graft through, and secures it using a suspensory fixation button. This method offers advantages over traditional screws — it protects the graft from damage, reduces the risk of displacement, and provides superior stability.
Step 5: Final verification
The surgeon tests graft tension and knee flexion-extension to confirm correct positioning and function before closing the incisions. The entire procedure takes approximately 1–2 hours.
Advantages of Arthroscopic ACL Reconstruction Surgery
- Creates small incisions with significantly less pain compared to open surgery.
- Restores knee stability, allowing the patient’s knee to safely bear weight and change direction.
- Protects the menisci and cartilage from further damage caused by an unstable knee.
- Has a high success rate of 90–95%, with the ability to return to playing sports.
- Recovers faster, with just 2 days of hospital stays and a quick readiness for physiotherapy.
Recovery and Success Rates
Hospital stay
After anterior cruciate ligament reconstruction surgery, patients remain in hospital for up to 2 days for monitoring and initial physiotherapy. During the first 1–2 days, the targeted nerve block continues to manage pain effectively, allowing patients to stand and practice walking with minimal discomfort.
Overall recovery timeline
- Week 1–2: Walking with crutches with partial weight-bearing; keeping the wound dry until suture removal; focusing on reducing swelling and regaining full knee extension.
- Week 3 to Month 3: Walking normally without crutches; beginning closed chain quadriceps exercises such as wall squats and leg press.
- Month 3: Graft has healed sufficiently to begin open chain quadriceps exercises such as cycling and leg extension machine work.
- Month 5–6: Returning to jogging.
- Month 9–12: Returning to sports involving direction changes, such as football and basketball.
Surgery success rate
ACL reconstruction carries a success rate of 90–97%. However, outcomes are strongly influenced by the patient’s discipline for physical therapy and rehabilitation. Even if the surgery is performed correctly, inconsistent physiotherapy will clearly affect the recovery result.
Returning to Daily Life After ACL Reconstruction Surgery
Returning to full activity postoperatively depends primarily on physical therapy and rehabilitation discipline and muscle strength. Most patients can walk normally and perform daily activities within 3–4 weeks, cycle within 3 months, and return to sports involving direction changes — such as basketball and football — within 9–12 months post-surgery. Each patient’s recovery timeline may vary depending on postoperative physical therapy and rehabilitation consistency.
Can ACL Reconstruction Surgery Prevent Knee Osteoarthritis?
This is an important fact for patients to understand: ACL reconstruction surgery does not prevent long-term knee osteoarthritis. The risk of knee degeneration begins at the moment of the original injury, regardless of whether surgery is performed. The primary goal of surgery is to restore knee stability, allow the patients to return to exercises and sports, and protect the menisci and cartilage from further damage caused by a loose knee.
Frequently Asked Questions About ACL Reconstruction Surgery
Is ACL reconstruction surgery painful?
With modern arthroscopic techniques and advanced pain management including spinal and targeted nerve blocks, patients experience significantly less pain. Post-operative discomfort is generally manageable with general pain medication.
Can ACL tears be treated without surgery?
Yes, in patients with low activity levels or those whose instability does not affect daily life. However, patients must accept the associated risk of further meniscal or cartilage damage if the knee continues to give way repeatedly.
How long will I need crutches after surgery?
Typically 2–4 weeks following ACL reconstruction surgery alone.
An article by Korakot Thamphongsri, M.D., Experienced Sports Medicine and Shoulder Surgeon, Foot and Ankle Surgeon
Reference:
https://pmc.ncbi.nlm.nih.gov/articles/PMC4628627/
https://www.mayoclinic.org/diseases-conditions/acl-injury/diagnosis-treatment/drc-20350744
https://my.clevelandclinic.org/health/diseases/16576-acl-tear
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