Cruciate ligament reconstruction

Harvested hamstrings tendon being prepared for use as an anterior cruciate ligament reconstruction.

Is cruciate ligament reconstruction a major surgery?

A cruciate ligament tear is a major injury because of the long-term potential for knee instability, subsequent meniscus damage and the development of osteoarthritis.

The reconstruction surgery, however, if expertly performed, can be relatively easy, although rehabilitation may be somewhat arduous. Decisions will need to be made about the choice of graft material, and this will affect the rehabilitation.

• Quote from peer-reviewed paper:

  "Current evidence suggests average long-term outcomes are similar following management of ACL rupture with ACLR [ACL reconstruction] and rehabilitation or with rehabilitation alone...."

  Citation: Filbay SR, Grindem H. Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture. Best Pract Res Clin Rheumatol. 2019 Feb;33(1):33-47. doi: 10.1016/j.berh.2019.01.018. Epub 2019 Feb 21. PMID: 31431274; PMCID: PMC6723618.

• Quote from peer-reviewed paper:

  "....many individuals with an ACL rupture remained symptomatic after rehabilitation and eventually underwent ACL reconstruction surgery...."

  Citation: Rodriguez K, Soni M, Joshi PK, Patel SC, Shreya D, Zamora DI, Patel GS, Grossmann I, Sange I. Anterior Cruciate Ligament Injury: Conservative Versus Surgical Treatment. Cureus. 2021 Dec 6;13(12):e20206. doi: 10.7759/cureus.20206. PMID: 35004026; PMCID: PMC8730351.

• Quote from peer-reviewed paper:

  "For some patients, not returning to sport can negatively impact long-term [quality of life], but returning to pivoting sport increases the risk of subsequent knee injury...To reduce the risk for subsequent injury, pivoting sport athletes with [anterior cruciate ligament reconstruction] should pass functional criteria for return to sport and delay full participation for at least nine months after surgery"

  Citation: Filbay SR, Grindem H. Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture. Best Pract Res Clin Rheumatol. 2019 Feb;33(1):33-47. doi: 10.1016/j.berh.2019.01.018. Epub 2019 Feb 21. PMID: 31431274; PMCID: PMC6723618.

Back to top

How is cruciate ligament reconstruction performed?

In adults, cruciate reconstruction involves obtaining graft material from the patient (autograft) or a tissue laboratory (allograft), drilling holes in both the tibial and the femur, pulling the prepared graft material through, and fixing the ends.

The exact procedure will depend upon the choice of graft material. Synthetic grafts are now seldom used.

In children the surgical technique is usually rather different, as there are always concerns about any drill holes damaging the growth plate at the ends of the tibia and femur, and other techniques are likely to be chosen.

Back to top

What governs the choice of cruciate graft material?

Before proceeding to a reconstruction, the surgeon and patient have to make decisions about where the graft material will be sourced from.

Harvesting the new ligament from the patient's own tendons (eg autograft hamstrings tendon) is likely to lead to a good result for the new cruciate, but may give problems at the donor site. The good result is because the material is genetically identical and also fresh.

An allograft from a tissue bank has been taken from a cadaver, and then treated and stored. The results are often good, but less favourable that an autograft. However, there are no donor site issues for the patient.

• Quote from peer-reviewed paper:

  "....Autografts are more commonly used than allografts or synthetic grafts. Three autograft options that are commonly used are [bone-patellar tendon-bone], [hamstrings tendons] and bone quadriceps tendon...."

  Citation: Dhammi IK, Rehan-Ul-Haq, Kumar S. Graft choices for anterior cruciate ligament reconstruction. Indian J Orthop. 2015 Mar-Apr;49(2):127-8. doi: 10.4103/0019-5413.152393. PMID: 26015598; PMCID: PMC4436475.

Back to top

Is cruciate ligament reconstruction successful?

If the procedure is expertly done, and rehabilitation followed diligently, then this is usually a very successful procedure.

Unfortunately is is often the ambitious sportsperson who gets this injury in the first place, and their goal is often return to sport at the same level. This may result in re-rupture, resulting in revision surgery which is more complex.

Back to top

Forum discussions

• The rebuild process - ACL No. 5 - the Polyfilla story

  When things go wrong with ACL reconstruction...and the long road back.

Back to top