13 Aug Questions you should ask before having ACL surgery
All things ACL – the questions every patient should ask their surgeon before undergoing ACL reconstruction
An ACL injury is a significant event for any Individual. Despite advances in surgical treatment and rehab practices, 1 in 5 athletes who have elected to have ACL reconstruction will suffer an ACL re-injury (graft rupture) or ACL injury on the opposite leg (Barber-Westin, Noyes., 2020). When faced with the possibility of surgery, it’s crucial to gather as much information as possible to make informed decisions about your treatment, rehabilitation and long-term knee health. Here are five key questions to discuss with your surgeon before proceeding with ACL surgery.
1) If I need surgery, do I need to get it straight away or should I wait before having it?
Understanding the timing of your surgery is vital and is greatly nuanced within different individual presentations and scenarios. Some patients benefit from, and absolutely need, early intervention. This is especially the case if they have other injuries that require immediate attention such as unstable or expansive meniscus tears, or high-grade injuries to other ligaments such as the MCL, LCL or posterolateral corner. Other subsequent injuries such as fractures will also require urgent intervention.
In the case of an isolated ACL tear or one with some minor concomitant injuries that aren’t deemed serious enough to require immediate surgical attention, the evidence-base tells us that most people should be offered at least a 6-12 week period of Prehabilitation before undergoing the surgery. This serves as valuable time to gain greater neuromuscular control of the knee, increase strength and range of motion of the knee, eliminate swelling and to decrease pain.
Not only does the evidence tell us that there are better long- and short-term outcomes after surgery in individuals that have had extensive prehab, but usually surgeons don’t like operating on a knee with high amounts of swelling, pain and even bony bruising as the surgery itself is more difficult and the post-operative pain can be a lot higher, making rehab a lot harder. In my clinical experience, I have seen that individuals that undergo a period of prehabilitation do much better in the early days after surgery and tend to progress through the process a fair bit quicker. Discussing this with your surgeon can help you understand the pros and cons of immediate versus delayed surgery based on your specific condition.
2) Which graft are you thinking of using and why?
There are different types of grafts used for ACL reconstruction, including autografts (tissue taken from your own body) and allografts (donor tissue). Usually, autografts are the graft type of choice as they are less likely to be rejected by the body, causing all sorts of issues. In some cases however, a donor graft is absolutely necessary, particularly in those undergoing a second or third reconstruction.
As well as deciding whether to use the autograft or allograft, there is a second decision to make regarding where to take the graft from. The most common graft choice within Australian surgeons in particular is that of a hamstring graft (Semitendinosus-gracillis graft/STG). The other common graft types are that of the quadriceps tendon (QT) graft or the bone-patellar tendon-bone (BPTB) graft. Each of these types has its own set of benefits and potential drawbacks. Your surgeon’s recommendation will depend on various factors, such as your age, activity level, prior injury history, knee stability, post-operative impacts and even personal preferences. Some common reasons why a quads tendon may be chosen over a hamstring graft for example might be a substantial history of hamstring injuries, or some medial joint laxity in the case of a concomitant MCL injury. In this case, the hamstring tendons would be required to aid in medial knee stability. Understanding the rationale behind your surgeon’s choice can help you feel more confident in the surgical plan.
Watch this space for a more in depth look at the pro’s and con’s of graft types and potential reasons for their choice.
3) Will you be performing a Lateral Extra-Articular Tenodesis during the operation? If not, why?
The Lateral Extra-Articular Tenodesis (LET) is an additional procedure that can be performed alongside ACL reconstruction (within the same surgery) to help stabilise the knee further. Think of this as giving the ACL graft a bit of reinforcement and help to do its job. This procedure includes the harvesting of a small portion (~8cm worth) of the bottom part of the iliotibial band (ITB) and passing it underneath the lateral collateral ligament before attaching it to the outer aspects of the knee with small staples.
This procedure may be recommended for patients who have high-risk factors for re-injury. Additionally, the evidence-base tells us that those at higher-risk of reinjury (younger age and even some generalised ligamentous laxity) who undergo ACL reconstruction + LET (4% re-rupture rates) have >50% decreased risk of graft re-rupture when compared to those who have ACL reconstruction alone (11% re-rupture rates) at 2 year follow-up (Getgood et al., 2020). These stats are extremely important to know.
However, the LET does have the rather slight consequence of adding to the surgery, requiring slightly more ‘slicing and dicing’ than normal. This means that there will likely be some slightly higher post-operative pain. However, the benefits seem to far-outweigh this small negative in the long run.
To further understand how the LET can help, Figure 2 shows the normal anatomy of the lateral knee and ITB (multiple muscles, tendons and ligaments not included) vs simplistic representation of what the LET looks like (right). Can see the portion of the ITB passing underneath the LCL, which is stapled onto the lateral femur and tibia. From a side-on view like this, we could also envision the ACL graft looking incredibly similar from an orientation perspective, but it would be situated deep inside the knee. This LET is trying to ‘help out’ the ACL graft in performing its function of stabilising the knee.
I have personally seen a couple of LET procedures performed within a ‘standard’ ACL reconstruction in the operating room and was blown away by how minimally invasive it was. So much so, that it added no more than 10 minutes (at most) to the total surgery time. However, this will likely change from surgeon-to-surgeon.
Asking your surgeon whether LET is necessary for your case, and understanding their reasoning, can provide insight into the comprehensiveness of your treatment plan and the measures being taken to minimise the risk of future injuries.
4) Will you be operating on anything else apart from my ACL reconstruction? Will that impact my recovery and will there be any changes to my early post-op rehab?
ACL injuries often occur alongside other knee injuries, such as meniscus tears or damage to other ligaments. In fact, it’s relatively uncommon to have an isolated ACL tear. If your surgeon plans to address these issues during the same operation, it’s essential to know why and how this will affect your recovery timeline and rehabilitation process.
For example, in the case of an ACL tear with a meniscus injury that may be suitable for repair (suturing), the post-operative rehab looks COMPLETELY different to that of an isolated ACL reconstruction or even an ACL reconstruction alongside a meniscectomy (trimming/removal of damaged meniscus).
There are a lot of factors that go into the decision making process of a meniscus repair vs a trim but that’s for a different blog. If a meniscal repair has been performed, we expect that there will be a 6-12 week period of bracing with limited range of motion allowance and even weight bearing restrictions – this is to protect the surgical site as it heals, making sure we don’t undo the surgeon’s good work! As you can imagine, this has massive implications for rehab which generally makes rehab take that bit longer.
This is in complete contrast to that of an isolated ACL reconstruction or ACL reconstruction with a meniscectomy. In these cases there’s almost never a post-operative brace given unless purely for comfort and confidence. This means that rehab can be further accelerated quite quickly, meaning a quicker return to day-to-day function. Because of this, you should NEVER compare your ACL recovery to others. Seeing someone running at 4 months post-op can be very flattening and have you questioning your rehab plan when you’re still working on the ‘basic’ foundational exercises. Having this information upfront can help you set realistic expectations for your recovery – knowing where you’re supposed to be at and when during your recovery is very important!
5) Given my goals and injuries, do you think that I absolutely need the surgery? Could I be a candidate for bracing and/or non-operative management? If not, why not?
Not every ACL injury necessitates surgery. Yes you read that correctly. Let me repeat. NOT EVERY ACL INJURY NECESSITATES SURGERY.
As you could imagine, these statements need to have some very serious nuance attached to them. Some patients, particularly those with lower activity levels or specific goals, might manage well with non-surgical treatments such as bracing and rehab or rehab alone. We’re even beginning to find that particular bracing protocols can even stimulate normal healing of the ACL tear, leading to better outcomes. Discussing your long-term goals with your surgeon can help determine whether surgery is the best option for you or if non-operative management could be equally effective. Understanding why surgery might be necessary (or not) based on your unique situation is crucial for making an informed decision.
Watch this space for a blog about the operative vs non-operative debate and decision making… More to come on this.
Wrapping things up
Being well-informed and proactive in your discussions with your surgeon can significantly impact your surgical and recovery experience. By asking these key questions, you can ensure that you understand the specifics of your treatment plan, the reasons behind certain recommendations, and what to expect throughout your recovery journey. Additionally, you may even potentially halve your risk of re-injury! Remember, your health and well-being are the priority, and having open, clear communication with your healthcare provider is essential for achieving the best possible outcome.
Todd Grbac
Physiotherapist (Special Interest in ACL injury)
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