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Specialties: ACL Reconstruction Procedure Overview

What happens during the operation?

Most surgeons perform this surgery using an arthroscope, a small fiber-optic TV camera that is used to see and operate inside the joint. Only small incisions are needed during arthroscopy for this procedure. The surgery doesn't require the surgeon to open the knee joint.

Before surgery you will be placed under either general anesthesia or a type of spinal anesthesia. The surgeon begins the operation by making two small openings into the knee, called portals. These portals are where the arthroscope and surgical tools are placed into the knee. Care is taken to protect the nearby nerves and blood vessels.

If you decide to have a Allograft (donor graft) the next step is not done. But, if you decide to get and Autograft (you own tendon) then the next step applies.

Hamstring Tendon Graft (the Gracilis and Semitendinosus Tendons)

The hamstring tendon graft is usually the preferred graft choice for a number of reasons. It does not disrupt the mechanism by which the knee is straightened. It has been shown to result in less pain post-operatively, less discomfort when kneeling post-operatively and a reduced loss of full extension (straightening) of your knee. Longer term a Hamstring ACL reconstruction at 5 years is associated with only a 4% back of kneecap arthritis rate compared to 40% at 7 years with the traditional patella tendon graft. The hamstring graft also more closely reproduces the forces of an intact ACL. The hamstring tendons can be felt on the inner aspect of the thigh at the back of the knee. You will manage perfectly well without them and in fact research now shows that they grow back to some extent. Surgery to reconstruct the ACL is carried out via arthroscopy and a small incision on the inner aspect of your lower leg just below your knee. The arthroscopy allows additional surgery (i.e. trimming of meniscal “cartilage” tears) to be performed at the same time. Most ACL reconstructions are performed under general anesthetic although the procedure can be undertaken under “regional” anesthesia.

An incision is also made along the inside edge of the knee, just over where the hamstring tendons attach to the tibia. Working through this incision, the surgeon takes out the semitendinosus and gracilis tendons. Some surgeons prefer to use only the semitendinosus tendon and do not disrupt the gracilis tendon.

The tendons are arranged into three or four strips, which increases the strength of the graft. The surgeon stitches the strips together to hold them in place. Next, the surgeon prepares the knee to place the graft. The remnants of the original ligament are removed. The intercondylar notch (mentioned earlier) is enlarged so that nothing will rub on the graft. This part of the surgery is referred to as a notchplasty.

Once this is done, holes are drilled in the tibia and the femur to place the graft. These holes are placed so that the graft will run between the tibia and femur in the same direction as the original ACL.

The graft is then pulled into position through the drill holes. Screws or staples are used to hold the graft inside the drill holes.

The portals and skin incisions are then stitched together, completing the surgery.

Complications: What can go wrong?

As with all major surgical procedures, complications can occur. This document doesn't provide a complete list of the possible complications, but it does highlight some of the most common problems. Some of the most common complications following hamstring tendon graft reconstruction of the ACL are:

Anesthesia Complications

Most surgical procedures require that some type of anesthesia be done before surgery. A very small number of patients have problems with anesthesia. These problems can be reactions to the drugs used, problems related to other medical complications, and problems due to the anesthesia. Be sure to discuss the risks and your concerns with your anesthesiologist.

Thrombophlebitis (Blood Clots)

Thrombophlebitis, sometimes called deep venous thrombosis (DVT), can occur after any operation, but is more likely to occur following surgery on the hip, pelvis, or knee. DVT occurs when blood clots form in the large veins of the leg. This may cause the leg to swell and become warm to the touch and painful. If the blood clots in the veins break apart, they can travel to the lung, where they lodge in the capillaries and cut off the blood supply to a portion of the lung. This is called a pulmonary embolism. (Pulmonary means lung, and embolism refers to a fragment of something traveling through the vascular system.) Most surgeons take preventing DVT very seriously. There are many ways to reduce the risk of DVT, but probably the most effective is getting you moving as soon as possible after surgery. Two other commonly used preventative measures include:


Following surgery, it is possible that the surgical incision can become infected. This will require antibiotics and possibly another surgical procedure to drain the infection.

Problems with the Graft

After surgery, the body attempts to develop a network of blood vessels in the new graft. This process, called revascularization, takes about 12 weeks. The graft is weakest during this time, which means it has a greater chance of stretching or rupturing. A stretched or torn graft can occur if you push yourself too hard during this period of recovery. When revascularization is complete, strength in the graft gradually builds. A second surgery may be needed to replace the graft if it is stretched or torn.

Problems at the Donor Site

Problems can occur at the donor site (the area behind the leg where the hamstring graft was taken from the thigh). A potential drawback of taking out a piece of the hamstring tendon is a loss of hamstring muscle strength.

The main function of the hamstrings is to bend the knee (knee flexion). This motion may be slightly weaker in people who have had a hamstring tendon graft to reconstruct a torn ACL. Some studies, however, indicate that overall strength is not lost because the rest of the hamstring muscle takes over for the weakened area. Even the portion of muscle where the tendon was removed works harder to make up for the loss.

The hamstring muscles sometimes atrophy (shrink) near the spot where the tendon was removed. This may explain why some studies find weakness when the hamstring muscles are tested after this kind of ACL repair. However, the changes seem to mainly occur if both the semitendinosus and gracilis tendons were used. And the weakness is mostly noticed by athletes involved in sports that require deep knee bending. This may include participants in judo, wrestling, and gymnastics. These athletes may want to choose a different method of repair for ACL tears.

The body attempts to heal the donor site by forming scar tissue. This new tissue is not as strong as the original hamstring tendon. Because of this, there is a small chance of tearing the healing tendon, especially if the hamstrings are worked too hard in the early weeks of rehabilitation following surgery.

After Surgery: What should I expect after surgery?

You will be placed in a bulky dressing and a hinged post operative knee brace with a form of cold treatment that circulates cold water through hoses and pads around your knee.

Most ACL surgeries are now done on an outpatient basis. Many patients go home the same day as the surgery.

Your surgeon may also have you wear a protective knee brace for a few weeks after surgery. You'll use crutches for two to four weeks in order to keep your knee safe, but you'll probably be allowed to put a comfortable amount of weight down while you're up and walking.

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Last Modified: April 20, 2018