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Knee Ligament Surgery

Knee Ligament Surgery

Knee injuries are incredibly common among athletes. One of the most common knee injuries is the ACL tear. The ACL, or anterior cruciate ligament, is a band of tissue that attaches the thigh bone to the shin bone and helps to provide stability to the knee joint. In the UK alone, there are 30 people who suffer from ACL injuries out of every 100,000 people in the population.

If you suffer from cruciate ligament damage, you should seek medical advice immediately. Cruciate ligament damage is common among martial artists, footballers, tennis players and other athletes who do a lot of jumping, are required to change direction suddenly or engage in contact sports. These knee injuries usually occur because the athlete landed awkwardly, twisted suddenly or had something land on their knee. Minor injuries can be managed by wearing a knee support, but more serious injuries may require surgery.

If your cruciate ligament damage is severe, you will find that your knee becomes weak and unstable and you no longer have full range of motion. Many athletes find that they can still walk and do day-to-day tasks on a damaged knee, but their chosen sport is almost impossible to play while the injury remains untreated.

Detailed Overview

Deciding to have surgery

The severity of a knee injury will be the deciding factor as to whether a patient needs to be operated on. If the injury affects quality of life or the damage to the anterior cruciate ligament cannot be repaired in any other way, surgery may be the only option.

When considering knee ligament surgery it is important to note that if you choose not to proceed with an operation the damage to your knee may worsen over time. A study on those who suffered from ligament damage showed that the risks of causing increased damage to the knee rose by one per cent every month. A small, but significant, percentage.

If the injury is not too bad many patients opt for a knee support or brace to keep weight off the knee and promote healing, and this can be an effective way of avoiding knee ligament surgery. For those who don't have an active lifestyle or if the knee seems to feel stable surgery may be decided against, and a knee support worn to ensure the damage does not worsen dramatically.

Pre-surgery considerations

Other considerations that need to be addressed when deciding whether or not to have surgery include:

How regularly you enjoy sporting activities. For those who are fit and exercise, or play sports on a regular basis, surgery may be a necessity in order to continue participating in these activities.

If other injuries are present having ACL surgery may be essential as it can aid in the healing process of more than just the ligament. For example, if your menisci is torn it could be repaired during ligament reconstruction, ensuring that corrects more than just one issue.

If the knee is unstable and walking is difficult surgery should be recommended, especially as the patient is at an increased risk of further damaging the knee due to the instability.

Age and lifestyle are also huge considerations when deciding whether to proceed with surgery, as an older person who is not very active may not be a candidate, nor would someone who would be unable to complete the rehabilitation program post-surgery.

Occupation is also taken into account, especially if the surgery candidate works in an industry where manual labour or being on their feet all day is a requirement.

All of these factors are considered when doctors and patients are determining whether surgery is the right choice for them.

Children are also occasionally candidates for surgery if their ligament damage is severe enough, however due to the fact that their bodies are still growing the surgical procedure is adapted to avoid the growth areas. The operation to repair cruciate ligament damage in a child is far more complicated than one performed on an adult and a specialist surgeon would be required to complete the procedure. This type of surgery for cruciate ligament damage is usually only undertaken after every other avenue, including knee support options and other treatment plans have been attempted.

Waiting for Surgery

Any reconstructive operation cannot happen straight away. You will need to allow the swelling to subside and your knee ligament to move fully again before the surgery can take place. You should also allow the thigh muscles (quadriceps and hamstrings) to strengthen, as these will all make the recovery process considerably easier. The initial stages of recovery for cruciate ligament damage can take around three weeks. During this time, your GP may recommend physiotherapy to help prepare your joints for surgery.

The Benefits of Physiotherapy

If your GP refers you to a physiotherapist for your cruciate ligament damage, they can help with the recovery process and ensure you are fully prepared for the surgery. A physiotherapist can provide the right exercises to allow the knee to begin working correctly again. This includes stretching exercises to improve flexibility and low-impact activities such as cycling and swimming. These will build up the strength in your muscles without putting too much stress on the injured ligament.

Before Surgery

Before you go in for surgery you will have to attend a pre-admission appointment. At this meeting the medical team will carry out assessments, including a physical exam, take details of your medical history and carry out any tests needed, such as x-rays. They will also look at any medication you’re currently taking and talk through previous problems you may have encountered with anaesthetic. At this meeting you will have the opportunity to ask the doctor any questions.

It’s important to find out about the operation you’ll be having on your cruciate ligament damage, as then you’ll understand exactly what is happening. Before you go into hospital, check that any of your other medical conditions, such as high blood pressure, are under control. Just before you’re admitted, you should have a bath or shower to reduce the risk of bacteria being present. Make sure you remember when to stop eating and arrange transport to and from the hospital. You should ensure that you have enough food, magazines and medical supplies, such as a knee support, for when you return home and that you’ve organised any help you’ll require.

How it is performed?

Anterior Cruciate Ligament, or ACL, reconstruction surgery rebuilds the knees central ligament in order to keep the tibia in place and prevent the knee giving way during physical activity. There are a number of different reconstruction methods used when performing this surgery, with the most common being the use of a tendon from elsewhere in your body to replace the torn ACL

Cruciate ligament damage is particularly common in sportsmen who perform strenuous physical activities. In many cases cruciate ligament damage is caused by the lack of adequate knee support or bracing and tendons tear due to over exertion. Many athletes opt for knee support in the form of a brace and avoid anterior cruciate ligament damage by strengthening their bodies and not pushing themselves. For those who have damaged their ACL and require an operation, the procedure is done under general or spinal anaesthetic as the reconstruction process can be lengthy.

Surgeon examination

Post anaesthetisation a surgeon uses a scalpel to open a patient’s knee and examine the tendon using an arthroscope (a thin, flexible, fibre optic tube that is both a camera and a light). The surgeon will determine whether the ligament is torn and check to see if there is other damage to the knee that will need to be surgically repaired. Once a surgeon has confirmed there are torn knee ligaments, the graft tissue is removed and prepped for relocation.

Replacement graft tissue

Tendons can be replaced using a number of different tissues and the use of own tissue is termed an autograft. Donor or allograft tissue can be used if your body does not have a suitable supply. Prior to your operation a surgeon will discuss what tissue would be your best option and the types of tissue used to replace a ligament are as follows:

Quadriceps tissue

Hamstring tendon tissue

Patellar tendon tissue

Allograft tissue that consists of patellar tendon or achilles tendon

Synthetic graft of manmade fibres designed to replace a torn ligament

All graft tissue is cut to the correct size before use and attached to the femur and tibia during the operation.

Knee arthoscopy

The technique used for surgery is known as arthoscopy, or keyhole surgery. A small incision is made for the arthoscope and a visual sent to a TV monitor to give the surgeon a clear view. Additional incisions accommodate medical instruments used to remove damaged ligament and new ligament is grafted by making a tunnel through your bone and affixing it in the same place as the damaged tendon. Permanent staples or screws keep the new ligament in place and prevent the tendon from slipping.

Final surgical examination

Once the graft tissue is secure a surgeon tests the tension, range of motion and strength of the graft. Once the ligament is deemed strong enough the small incisions are stitched up and post op dressings applied. After the procedure is complete you will be moved to a general ward for a few days.

Risks

In more than 80% of patients, surgery to repair cruciate ligament damage completely restores the functionality of the knee. The surgery will help the knee’s stability, and prevent it from giving way.

All surgery carries risks - these include infection (less than 1 in 100), a blood clot (around 1 in 1000) and pain or knee stiffness and weakness which can in some cases be long term. After surgery, there is also a slight chance (less than 10 in 100) that your freshly grafted ligament will not work properly, meaning that the instability in the knee will remain.

Many patients report that they are able to return to their chosen sport after six months, although many choose to wear a knee support for added confidence. However, in some cases of cruciate ligament damage, it is not possible to completely repair the knee, and you may notice some swelling and pain in the replacement ligament. A further operation may rectify this, but subsequent surgery tends to be more complicated and the success rate is not as high. If you are at particular risk from surgery your surgeon will of course discuss this with you before you make a final decision.

Caring for the wound

The wound will be closed with stitches. Dissolvable stitches will disappear within a month, but a healthcare professional will need to remove stitches which aren’t dissolvable. You should receive advice about the stitches and how to wash and care for the wound from your surgeon at the time of the surgery. It is very important to avoid infection whilst the wound is healing.

The affected knee will need to be bandaged to keep it clean and to reduce swelling. You may also be provided with a cryocuff - a waterproof dressing which contains iced water - which will help to further reduce swelling. Painkillers may also be prescribed to control any pain. Swelling and inflammation may spread to the shin and ankle. This is normal and is caused by synovial fluid leaking from the knee joint down the lower leg. Such swelling will reduce after seven to ten days.

Rehabilitation

The physiotherapist or surgeon will advise you on a rehabilitation programme. Following this programme is paramount if you are to make a successful recovery from your surgery for cruciate ligament damage. You can start some of the exercises whilst you are still in hospital, almost immediately after surgery. The exercises prescribed will include movements which involve raising, straightening and bending the joint. Don’t be afraid to ask for further instruction if you are unsure how to do any of the movements or are experiencing particular pain when undertaking the exercises.

Crutches will be required for approximately the first two weeks following surgery for cruciate ligament damage. Allow the injury to only take as much weight as you can comfortably handle.

Weeks 1-2: The knee is likely to be stiff and swollen. Painkillers and anti-inflammatory medication may be required. Elevating the leg and applying ice will also help to reduce the swelling and subsequently the pain.

Weeks 2-6: It’s likely that your exercise programme will be changed as the swelling and pain settle down. You will be encouraged to fully bend and extend your knee, and exercises which strengthen your leg muscles and improve your balance will be introduced. Swimming and cycling may also be recommended.

Weeks 6-24: During this time, you will gradually return to a normal level of activity. However, any sport which involves jumping, turning and twisting should still be avoided. The grafted tissue won’t yet be sufficiently healed to resist such movements.

In most cases, cruciate ligament damage will require surgery and a period of rehabilitation, which could be as long as 12 months in some patients. It is important that the patient follows the rehabilitation programme prescribed. A knee support may help to reduce swelling and provide support during the prolonged rehabilitation process.