ACL surgery involves the reconstruction of a torn anterior cruciate ligament (ACL) with a new ligament. The procedure is performed arthroscopically, commonly referred to as minimally invasive surgery. Over the last 20 years, significant advancements have been made in ACL surgery techniques.
One of the most impactful advancements in ACL surgery is the anatomical ACL reconstruction technique. This method aims to replicate the exact structure and location of the original ligament, ensuring optimal function and stability.
In ACL surgery, the structure used to replace the torn ligament is called a graft. There are several graft options available. The most commonly used grafts are autografts—taken from the patient’s own body. Among these, the most frequently used include:
Hamstring tendon
Quadriceps tendon
Bone-patellar tendon-bone graft (harvested from the front of the knee).
Additionally, allografts (donor tissue from a tissue bank) can also be used when appropriate.
In this article, you will find detailed information about ACL surgery, types of procedures, and the recovery process.
How Is ACL Surgery Performed?
ACL surgery is performed arthroscopically, also known as minimally invasive surgery. Two small incisions are made at the front of the knee. Through one of these incisions, an arthroscopic camera is inserted to visualize the inside of the knee. Through the other incision, arthroscopic surgical instruments specifically designed for minimally invasive procedures are used to perform the surgery.
As an Orthopedic Surgeon, Dr. Utku Erdem Özer, I frequently perform ACL reconstruction surgeries using the hamstring tendons and the "elevator technique." Below, I will explain this technique in detail. You can also find other ACL surgery methods further in the article.
Once the camera is inserted into the knee, the extent of the ACL injury is assessed. Additionally, the surgeon evaluates for accompanying injuries such as meniscus tears, cartilage damage, or other ligament injuries. This step acts as a comprehensive damage assessment.
If the tendon (graft) to replace the ACL is to be harvested from the patient and hamstring tendons are to be used, a small incision is made over the connection point of the hamstring tendons to the shinbone (tibia) at the lower inner part of the knee. The gracilis and semitendinosus tendons are then extracted.
After preparing these two tendons, they are folded in half, creating a quadruple tendon graft. One end of the graft is secured with special sutures, as shown in Figure 1, and attached to a titanium button-like device.
The next step in the ACL surgery is to create tunnels in the bones to position the graft. First, a tunnel is drilled into the femur (lateral femoral condyle) where the upper part of the graft will be secured. Then, a second tunnel is drilled into the tibia (medial tibial plateau) using the area where the tendons were harvested.
A guidewire is used to pass a thread through these tunnels. Using this thread, the prepared graft is pulled through the tibial tunnel, the knee joint, and finally, the femoral tunnel. Once the metal component at the end of the graft passes through the femoral tunnel, it is flipped and anchored to the edge of the femoral bone. The graft is then tensioned in the opposite direction using the threads to ensure its upper end is securely positioned within the femoral tunnel. This technique is known as the "elevator technique", which ensures optimal graft tension. Proper tensioning is critical for the success of ACL reconstruction.
The graft is further secured to the tibia using a screw placed at the end of the tibial tunnel. Once the procedure is complete, the graft is checked for proper placement and tension using the arthroscopic camera.
You can watch an example of an ACL surgery I performed by clicking this link: https://www.youtube.com/watch?v=k3KCtsji-CA
Figure 1
Steps of ACL Surgery
Preparation: Pre-operative evaluation and preparation are conducted to assess the patient’s overall health condition.
Anesthesia: General or spinal anesthesia is administered to prepare the patient for surgery.
Arthroscopy: Small incisions are made to insert a camera and surgical instruments into the joint.
Graft Placement: A graft, typically harvested from the patient’s tendons, is positioned to replace the damaged ligament.
Final Inspection: The graft is checked to ensure it is properly positioned and stable.
Closure: The incisions are closed, and the surgery is completed.
Where Is the New ACL Taken From in ACL
Surgery?
In ACL surgery, the reconstructed ligament can be obtained using two different methods:
Tendon Taken from a Tissue Bank (Allograft):
A sterile tendon graft, ready for use, is obtained from a tissue bank. This graft is prepared and placed into the drilled tunnels as described in detail earlier. The biggest advantage of this method is that there is no need to harvest a tendon from the patient's body.
Tendon Taken from the Patient’s Own Body (Autograft):
The most common types of autografts harvested from the patient’s body are:
Bone-Tendon-Bone Graft:
This graft is harvested from the front of the knee, including a bone segment from the kneecap (patella) and the shinbone (tibia), with the patellar tendon in between.
Hamstring Tendon Graft:
Two hamstring tendons (semitendinosus and gracilis) are harvested from the lower and inner part of the knee. Each tendon is folded in half to create a total of four tendon strands. Today, hamstring tendon grafts are the most commonly used in ACL reconstruction.
Quadriceps Tendon Graft:
A tendon piece, approximately 8-9 mm thick and long, is harvested from the quadriceps tendon, located just above the kneecap, to replace the torn ACL.
Why Is a Drain Inserted Into the Knee After ACL Surgery?
After surgery, it is crucial to safely remove any blood leaking into the surgical area. In most surgeries, a small tube (drain) is inserted to allow blood to be drained from the surgical site.
In ACL surgery, a drain is left inside the knee joint for about 24 hours. Once blood flow through the drain stops, it is removed. The presence of a drain in the knee does not prevent the patient from walking.
When Can I Start Walking After ACL Surgery?
If only ACL surgery is performed (without meniscus repair or cartilage surgery), the patient can start walking just a few hours after the operation. Pain management is the key factor in this process.
When Can I Start Running After ACL Surgery?
Jogging can be permitted as early as the third month after surgery, provided the patient’s muscle strength is adequate. Muscle strength is evaluated using the single-leg squat test. If the patient can perform this test correctly and with the required repetitions, they are deemed ready to begin running exercises without issues.
Why Does My Knee Make Sounds After ACL Surgery? Is This Normal?
It is normal for the knee to make sounds during the first few months after ACL surgery. However, if the sounds are accompanied by pain, this issue should be evaluated further. Pain along with sounds may indicate a potential problem within the joint.
The primary reason for knee sounds after ACL surgery is quadriceps muscle loss. Weak quadriceps muscles alter the biomechanics of the kneecap, causing sounds to be heard. Once muscle strength is restored, these sounds usually disappear.
Another reason for the sounds is the change in the properties of the synovial fluid inside the joint after surgery. A decrease in the viscosity of this fluid can cause abnormal sounds from the surfaces the kneecap contacts. This condition typically resolves over time as the fluid returns to normal.
What Can I Do to Recover Quickly After ACL Surgery?
A quick and efficient recovery after ACL surgery requires careful attention to a few key factors. Regular participation in physiotherapy and rehabilitation programs, following your doctor’s recommended exercises, and avoiding excessive activity are critical. Here are some tips:
Tip 1:
Before the surgery, learn how to activate your quadriceps muscles under the guidance of a physiotherapist. In the early post-operative period, activate your quadriceps while walking, getting out of bed, or bearing weight. The benefit of this is significant—it reduces the load on the graft during the early stages, minimizes swelling and edema, and ensures a smoother and faster rehabilitation process.
Tip 2:
Rehabilitation is a long process, and patience is essential. Progressing step by step through the rehabilitation stages is crucial. This timeline is natural for the recovery process. Attempting to return to competitive play or matches (return to play) before the tendon graft has fully fused with the bone is extremely risky. Currently, the earliest recommended time to return to sports is after the 9th month.
Tip 3:
Achieving full knee extension after surgery is extremely important. Particularly after ACL reconstruction using hamstring tendons, placing a pillow under the knee to reduce pain may feel comfortable. However, this can lead to a loss of movement and delay the rehabilitation process. Instead, place the pillow under your heel to ensure your knee is fully extended. If pain is severe, the pillow can remain under the knee for short periods, but avoid prolonged use in this position.
Why Do Some Athletes Return to Sports on Time After ACL Surgery While Others Are Delayed?
There are several reasons for this. The most significant factor is whether other injuries occurred in the knee alongside the ACL tear. An ACL injury is not a simple ligament injury—it often involves the knee joint temporarily dislocating and then relocating within milliseconds during the trauma. Depending on the severity of the trauma, meniscus tears, collateral ligament injuries, posterior cruciate ligament damage, cartilage damage, or even intra-articular fractures can occur.
For example, let’s assume an ACL tear is accompanied by a lateral meniscus tear that requires sutures. In this case, weight-bearing on the meniscus must be avoided during its healing process. This typically requires the patient to use two crutches and avoid weight-bearing for approximately one month. This delay can lead to muscle loss, loss of proprioception, and limited range of motion in the joint.
All these issues can be addressed and improved through proper rehabilitation, but the athlete will need a longer rehabilitation period to regain what was lost. This extends the timeline for returning to sports, causing psychological distress for the athlete and potential financial loss due to the delay. It’s important to remember that many professional athletes have contracts based on their match participation.
Another critical factor is the quality of rehabilitation after surgery. For professional athletes, this process often involves working with a physiotherapist one-on-one for 2-3 hours, sometimes even 4 hours a day, every day.
When Should I Have ACL Surgery?
There is no definitive consensus in the medical literature on this topic. Based on my experience, patients who have regained nearly full range of motion and learned to activate their quadriceps muscles can safely undergo surgery as early as 1-2 days after the injury.
How Long Does ACL Surgery Take?
If there are no additional issues, such as a meniscus tear or cartilage damage that require intervention, the surgery typically lasts about one hour.
What Type of Anesthesia Is Used in ACL Surgery?
In ACL surgery, either general anesthesia or spinal (regional) anesthesia is administered.
General Anesthesia:
The patient is completely unconscious and does not feel any pain during the procedure. In this type of anesthesia, the patient’s breathing is supported through a tube placed in the windpipe.
Spinal Anesthesia:
The patient is numbed from the waist down via an injection in the lower back. This method also ensures no pain is felt during the procedure. Additionally, sedative medications can be given to alleviate stress during the surgery.
The choice of anesthesia is a decision made collectively by the anesthesiologist, surgeon, and patient.
If a Meniscus Tear Is Present During ACL Surgery, Is Meniscus Repair Performed in the Same Operation?
During ACL surgery, a damage assessment is conducted at the very beginning to check for other injuries. If other injuries are present, they must be addressed during the same operation.
If meniscus repair or cartilage intervention is required, these procedures are essential. Ignoring such injuries during ACL surgery may lead to complications during rehabilitation, necessitating a second surgery, and further delaying the return to sports.
For detailed information about meniscus injuries and their treatments, click this link: [https://www.utkuerdemozer.com/en/page/meniscal-tears-and-treatments].
Recovery Process After ACL Surgery
Questions such as "What is the recovery process after ACL surgery?" "When will I recover?" "When can I start playing sports?" and "When can I return to games?" are among the most frequently asked by patients.
Below, you can read about the recovery process from immediately after ACL surgery until returning to sports.
If there are no additional injuries to the knee and only ACL surgery was performed, the patient can begin walking with crutches a few hours after surgery, once the effects of anesthesia wear off. Here is a detailed outline of the recovery process after ACL surgery:
Key Milestones in the Recovery Process
Immediately After Surgery:
Once the anesthesia wears off, the patient can use crutches to go to the restroom with the assistance of a doctor, nurse, or physiotherapist.
Waterproof dressing materials allow patients to shower after surgery. Alternatively, the dressing area can be wrapped with 3-4 layers of plastic wrap.
Most patients can walk with one crutch a day after surgery, following the removal of the drain. The drain does not prevent walking but is removed for added comfort.
A single dressing change is sufficient after the drain is removed.
Surgical wounds heal within 7-10 days, after which dressings are no longer necessary, and the wounds can remain exposed.
Physiotherapy:
Physiotherapy begins on the second day after surgery, with sessions held 5 days a week. The duration of physiotherapy varies from 2-3 months to, in some cases, up to 6 months.
The goals are to restore joint range of motion, regain muscle strength around the knee, and improve balance and agility.
Patients who follow a regular physiotherapy program can walk almost normally within 2-3 weeks after surgery.
Returning to Work:
Patients with desk jobs can return to work around the 10th day after surgery.
Those with physically demanding jobs should wait until the 1-month mark.
Running:
Running is a common concern, especially for athletes. Patients can begin jogging at the end of the second month, depending on their muscle strength. A single-leg squat test is used to assess readiness. If the test is performed correctly, short jogging sessions can begin and gradually increase in duration.
Sports-Specific Training:
At the end of the 4th month, sports-specific exercises can begin.
Full return to sports, including team practices and games, should not occur before the 9th month. This is to allow the reconstructed ACL sufficient time to integrate with the bone.
Recovery Timeline Overview
First 20 Days Post-Surgery
Control of swelling and inflammation.
Restoring knee range of motion: achieving full knee extension and limiting flexion to 90 degrees.
Quadriceps activation exercises to regain muscle control.
Learning to use crutches: single crutch use is ideal for the first 7-10 days.
Patella mobilization by a physiotherapist to prevent adhesions.
Learning isometric exercises like straight leg raises.
Weeks 3-6 Post-Surgery
If initial goals are met, progression to Phase 2 begins.
Knee flexion increases from 90 degrees to 120 degrees.
Strengthening exercises like leg presses and mini squats are introduced.
Proprioception exercises are initiated.
Month 3 Post-Surgery
Focus shifts to advanced strengthening exercises, particularly quadriceps development through deeper squats.
Step-down programs and agility exercises begin.
Leg presses and lunges are incorporated into the routine.
Weeks 14-22 Post-Surgery
Jogging begins.
Strength and flexibility programs continue.
Sports-specific agility exercises are added.
Plyometric exercises are introduced.
22 Weeks and Beyond
Advanced plyometric exercises are started.
Athletes return to sports under the supervision of a doctor or experienced sports physiotherapist.
When Does Pain Subside After ACL Surgery?
Pain is most pronounced during the first 24 hours post-surgery. This is managed with intravenous painkillers and intensive ice application. By the 5th to 7th day, pain significantly subsides.
Activating the quadriceps during movements such as walking, sitting, and standing can also help reduce pain and swelling.
Is Metal Hardware Used in ACL Surgery?
Yes, metal hardware is used to secure the graft inside the bone tunnels. These components are very small and do not need to be removed.
Do the Implants Need to Be Removed?
The implants used in ACL surgery pose no harm to the body and can remain permanently. There is no need for removal.
I Can't Bend My Knee After ACL Surgery. How Can I Bend It?
Difficulty bending the knee after ACL surgery is a common and usually temporary issue. The primary causes are post-surgical swelling and pain.
Regaining knee mobility after ACL surgery is crucial. Follow your doctor's and physiotherapist's instructions carefully, and avoid attempting to increase your knee's range of motion on your own.
The knee has two primary movements: extension (straightening the knee) and flexion (bending the knee). Achieving full extension early after surgery is critical. If this is delayed, addressing the issue becomes more challenging. To prevent this, place a pillow under your heel, not under your knee, while resting or sleeping.
Many patients find placing a pillow under the knee relieves pain, but this can keep the knee in a bent position, leading to long-term issues. Always ensure the pillow is placed under your heel to keep the knee straight.
Restoring knee flexion is generally easier but should be guided by an experienced physiotherapist.
Knee Flexion Goals:
By the end of the first 2 weeks: achieve 90 degrees of knee flexion.
By weeks 2-4: achieve 120 degrees of knee flexion.
Exercises to Improve Knee Flexibility
Heel Slides: Lie on your back and slowly pull your heel toward you.
Straight Leg Raise: While lying on your back, lift your straight leg upward.
Wall Push: Stand and push against a wall with your hands while extending your leg backward.
Knee Bends: While holding onto a chair, bend your knee backward.
Balance Exercises: Stand on one leg and maintain your balance.
Possible Complications After ACL Surgery
Swelling in the Knee: Swelling is the most common issue after ACL surgery. Although temporary, it can delay recovery. Teaching the patient quadriceps activation exercises is essential to reduce swelling. Engaging the quadriceps during activities like sitting, standing, walking, and lifting the leg significantly reduces swelling. Applying ice can also help manage swelling. If swelling becomes severe, consult your surgeon immediately.
Difficulty Achieving Full Knee Extension: Inability to fully straighten the knee after ACL surgery is a serious issue that must be addressed promptly. The most common cause is incorrect pillow placement under the knee during recovery. Placing a pillow under the heel while resting ensures the knee remains straight, preventing this problem.
Restricted Mobility: The success of the physiotherapy process is as important as the surgery itself. An inappropriate rehabilitation process can lead to muscle weakness, limited mobility, inability to bear weight, and fear of movement. Close follow-up by the surgeon on the physiotherapy program is crucial to avoid these issues. In rare cases, a condition called arthrofibrosis may develop.
Infection: Although rare, there is a slight risk of infection after ACL surgery. Preventive measures are taken to minimize this risk. Early detection of infection is critical. Signs of infection include a sudden increase in pain (similar to the pain felt immediately after surgery), redness around the knee, and fever. If you notice any of these symptoms, consult your doctor immediately.
Patient Experiences After ACL Surgery
Patient experiences provide valuable insights into the recovery process after ACL surgery. Sharing these experiences can encourage and inform other patients.
Patient Feedback:
"When I underwent ACL surgery with Dr. Utku Erdem Özer, I was deeply grateful for his expertise and care. I was well-informed before the surgery and guided step by step through the recovery process. Thanks to his knowledge and experience, I had a smooth recovery without any concerns."
How Many Days of Rest Are Needed After ACL Surgery?
Typically, 3-4 weeks of medical leave is provided after ACL surgery. Resting during the first week is essential to reduce swelling. Gradual return to daily activities is possible after this initial recovery period.
Differences Between ACL and Meniscus Surgery
ACL surgery involves reconstructing the damaged ligament with a graft (usually from the patient's own tendons) to restore and maintain knee stability. This procedure is typically performed arthroscopically.
Meniscus surgery, on the other hand, addresses tears in the shock-absorbing cartilage of the knee. It involves repairing or removing the damaged meniscus and is also performed arthroscopically.
ACL Surgery Cost in 2025
The cost of ACL surgery in 2025 varies depending on several factors, including the techniques used and the patient's condition. For this reason, we recommend that patients planning ACL surgery contact us through our communication channels to obtain detailed information about the cost and the procedure.
Conclusion
With advancements in technology in recent years, the success rate of ACL surgery has significantly improved, and the return-to-play rate for athletes has increased.
ACL surgery is a highly technical procedure, and it is essential to place the reconstructed ligament in the exact same position as the original torn ACL. The most common cause of failed ACL surgery is incorrectly positioned bone tunnels.
The post-operative physiotherapy process is just as important as the success of the surgery itself. During this period, patients should be closely monitored by both the orthopedic surgeon and the physiotherapist.
For football players who undergo ACL surgery, returning to team training and matches typically takes 9-12 months. It is crucial for patients to remain patient and committed to their treatment during this recovery period.
Thank you for reading our article. Feel free to visit our homepage at utkuerdemozer.com for more information.
