Knee ACL Reconstruction
A Comprehensive Guide to ACL Reconstruction
Anterior Cruciate Ligament (ACL) injury
The ACL is an important ligament that gives stability to the knee. It is often injured during a violent twisting movement when the body moves awkwardly against a firmly planted foot. The knee joint is held together by many ligaments, and depending on the direction of force and the nature of the twist, a combination of different ligaments and cartilage can be injured. Occasionally the meniscal cartilage, the surface cartilage of the knee, or the bone can also be injured.
Many patients with an ACL injury will complain of the knee giving way and instability. Once the initial swelling and pain phase has settled, patients may be able to run in a straight line without a functioning ACL, but twisting and turning often leads to repeated giving way.
The ACL reconstruction procedure
ACL reconstructive surgery is often done through an arthroscopic (keyhole) technique where instruments and a telescopic camera are passed through small incisions in the knee. Various different materials can be used to reconstruct the anterior cruciate ligament, the most common being the hamstring graft. The procedure is mostly done as a day case procedure and patients are usually able to leave hospital within 6 hours of surgery.
Patients are typically under a short general anaesthetic with infiltration of local anaesthetic around the small cuts that are made. Occasionally nerve blocks are used to give additional pain relief.
Getting the diagnosis right
At the initial consultation, your consultant knee surgeon will confirm your diagnosis. He or she will take a detailed medical history, perform a careful clinical examination and review radiological imaging. Patients with a soft tissue injury such as an ACL rupture will typically have an MRI scan rather than an X-ray.
Once the diagnosis is confirmed a treatment plan can be discussed and agreed with you. Please note: if recent enough, previous imaging can also be requested and transferred to your new surgeon.
Preparing for surgery
Once scheduled for surgery, it is often recommended that patients prepare by undertaking a course of prehabilitation in the few weeks before - as directed by your surgeon. The aim of this is to reduce any swelling, maximise your range of motion and strengthen muscles to promote a better outcome post-surgery.
Questions you may want to ask your surgeon
What tissue or 'material' is used to reconstruct an ACL rupture?
Popular graft choices include hamstring graft, patella tendon, quadriceps tendon, iliotibial band tissue, allografts (from a donor/cadaver) or synthetic ligaments. Of these, the hamstring ACL reconstruction remains the most popular, with the patella tendon graft being the second most frequently used tissue.
Is an ACL injury often associated with other injuries?
An ACL is often ruptured when a knee partially dislocates or twists. Other structures can also be damaged at the same time including the meniscus, other ligaments around the knee such as the medial collateral ligament and the articular surface (cartilage surface) of the knee. Fractures can also occur.
Is ACL reconstruction always a minimally invasive or keyhole procedure?
The modern method of reconstructing an ACL rupture is to use an arthroscopic technique (ie keyhole). There is a slightly more old fashioned open patella tendon reconstruction but it is rarely performed these days.
When would I need an additional procedure such as an extra articular tenodesis?
Occasionally in a very unstable knee or in a revision ACL reconstruction, your surgeon may recommend an additional stabilisation procedure called a lateral tenodesis, otherwise known as an extra articular tenodesis. This adds an additional layer of stabilisation to an unstable knee but does involve an extra scar on the outside of the knee.
Recovery from surgery
Almost as important as the surgery is the post-operative rehabilitation you will have after surgery. Please discuss the detailed physiotherapy and outpatient rehabilitation packages with your surgeon and treating hospital. Adherence to your programme will optimise recovery and the long term outcome of your surgery.
In the initial recovery phase, your surgeon will advise you about rest and elevation of the leg. Recovery is dependent on many factors including the commitment to physical therapy, age and fitness but generally, a full return to normality and strength can take anywhere between 6 and 12 months.
What are the potential complications of ACL reconstruction surgery?
The possible complications include infection, re-rupture of the graft (approximately 1% per year in a patient returning to sport), stiffness, ongoing pain, and complications associated with general anaesthetic.
Should complications relating to your surgery occur which require you to have further treatment in theatre (another operation within 12 months), our Protect my Care insurance policy will refund the cost of your original care. This policy is included in your care at no extra cost to you.
How to judge the best surgeon and hospital for you
Surgeon and hospital performance
You should discuss our surgeon’s results openly with him or her at your first consultation. Your surgeon will be able to tell you about their experience and how many ACL reconstructions they perform each year.
In the UK, the National Ligament Registry collects some data on ACL reconstructions, but it is not mandatory. Whilst we acknowledge that excellent care can be provided by many clinicians, we would recommend that you see a fellowship-trained soft tissue knee surgeon, exclusively doing knee surgery and undertaking at least 50 ACL reconstructions each year - some surgeons recommending over 100 per year.
Evidence suggests that the best hospitals for ACL reconstruction are those carrying out large volumes of the procedure, with experienced surgeons, specialist orthopaedic nurses and physiotherapists. A dedicated orthopaedic ward (with only screened elective orthopaedic patients), senior resident doctors and a dedicated pain control team are desirable to carefully manage your post-operative care and pain, and identify potential complications early.
Paying for treatment
The price of ACL surgery ranges from £5,500 to nearly £10,000 with the biggest difference factor being the hospital you select. This figure generally consists of hospital costs, surgeons fees, anaesthetic fees and occasionally extra imaging and implant costs. Variations in ACL reconstruction costs can relate to diagnostic imaging - the potential need for MRI.
Variations in ACL reconstruction costs can also occur as a result of additional procedures such as a meniscal repair, meniscectomy, second ligament reconstruction or an extra articular tenodesis being required around a standard reconstruction. Please note: it is advisable that you ask your surgeon whether additional procedures will be required and obtain a quote that covers all of the procedures so you can understand the details.
Typically prices won't include other aspects of your treatment such as the initial diagnostic work-up. Compare my Care aims to provide you with a fixed price for the standard procedure, hospital stay and surgeon follow up.
How Compare my Care works for you
Compare my Care works by analysing consultant and hospital volume and performance data, each hospital's facilities and the available patient experience information to help you make the appropriate choice for your care.
Our medical specialist concierge team will work with you to arrange an initial consultation with an experienced, specialist soft tissue knee surgeon with a high level of relevant expertise at your selected hospital.
Please note: Compare my Care does everything possible to secure a fixed price for each procedure, but individual medical needs may result in diagnostic and treatment variation which can impact costs.
Introducing Protect my Care
‘Protect my Care’ is a unique ‘cash-back' insurance policy provided by Compare my Care. It was created to give patients additional protection and peace of mind when paying for their own surgery - and comes at no extra cost to the patient.
All surgeries come with risks but in the hands of a super-specialist surgeon these can be reduced further. However, in the rare event that a repeat surgery is needed within 12 months, patients will be refunded the cost of their original procedure - to spend as they see fit.