I just tore my ACL what do I need to know before surgery?

If you are reading this and you tore your ACL, you have my deepest condolences. You are in for a long journey to get back to doing everything you want to do.

However, there is good news!

Your outcome is ultimately in your hands. Picking your surgeon (I have one that I highly recommend), picking your therapist (I also know of a great PT), and then prepping yourself before surgery all play a big part in your short- and long-term outcome. Then there is prehabiliating your knee for surgery. Nowadays surgeons want patients to wait a few weeks to have surgery, therefore there are things you can do to set yourself up for success early on. Properly prehabbing your knee includes decreasing swelling in your joint, getting the quadriceps (thigh) muscle to fire, regaining range of motion, and if possible get to be able to walk normal.

First, you need to work on decreasing swelling in your knee joint. This can be done many ways. The RICE method is used. RICE stand for Rest Ice Compress and Elevate. Lay on your back prop your leg up above your heart, have some compression on the joint and ice it down. 20' at a time multiple times a day if possible. Next, is getting your thigh muscle to be able to squeeze again. This is pretty simple, sit with your knee straight and start squeezing your thigh. Try to hold for 5 s and do 30 or more repetitions. This needs to be done several times a day. After that regaining full motion (if possible) is a must. If you have the motion walking into surgery, it will be easier getting it after surgery. You can work on bending your knee by riding a stationary bike and then doing heel slides. (insert picture of heel slide) Getting the knee straight is important too. you can do this by stretching your hamstrings and calf (insert picture here). Lastly being able to walk normal is important before surgery as it will be easier to relearn how to walk after surgery.

This was just a brief overview of prehabbing a knee before surgery. I discussed the most general ways I do prehab. If you have questions or have anxiety about doing these recommendations on your own, I recommend you call and get an appointment with us. This way your interventions will be specifically tailored to you.

The next biggest piece of information you need to know is graft selection. Each graft has pros and cons to them. I'm going to discuss those next.

Bone Patellar Tendon Bone Autograft (BTB)

As I am writing this blog post the BTB Autograft is the best graft if you are wanting to return to competitive high level sports. This is because the graft becomes stable faster than the other grafts. This is due to how the graft is harvested and then prepared and put into the knee. Both ends of the graft have bone on them and that heals faster with the bone tunnel that is made in your knee. There are some cons to this graft type. The 1st is quad strength takes a little longer to return and the other is potential of discomfort with kneeling onto the knee.

Hamstring Autograft

The hamstring autograft is great for individuals who are still active but are also not looking to return to high level sports quickly. The surgeon harvests the semitendinosus muscle of the involved knee. The pros of this graft type is that the patient is able to get quad strength back faster and there is much less risk of pain in the front of the knee. There is also less scars on the front of the knee with this approach. How this graft is prepared by the surgical staff also plays a factor in long term stability of the knee. A double bundled graft provides more stability than a single bundled graft. The cons of this type of graft are that there is more muscle pain in the hamstring earlier on, there will always be weakness in the hamstring that was harvested by the surgeon.

Quad Tendon Autograft (QT)

The QT autograft is the new kid on the block. Because of that there is overall less data on it. However, what is out is quite promising. From a stability standpoint this graft provides the same amount as the BTB autograft with less donor site pain. (Donor site is where the surgeon harvests the graft). Also, it gets better functional outcomes than the hamstring autograft. It also has a larger graft diameter. If you are looking to get back into high level sports, this is a solid option as well.

Cadaver allograft

These are used in patients usually older than 35 and are more sedentary. The pro of this graft is that there are no donor site pains you have to worry about. Cons include risk of body rejection, slower graft healing, If you are wanting to become more active or return to a high level of physical activity, I do not recommend getting this graft.

Ultimately the best graft for you depends on your age, activity level you want to return to, and other issues in the knee. Generally speaking, if you are young and want to get back to a high level of activity, I’d go with a BTB or QT autograft. If you are a little older in age and want to stay fit for general health, then a HS graft is a good choice. Lastly if you want to just have function on a day-to-day basis and don’t care about running or jumping then a cadaver is probably your best bet.

As a patient you must be well informed to make the best decision for your future health. Not every surgeon or physical therapist is created equal. If you want to get a different graft than what the surgeon is recommending based on YOUR activity goals, I would hear their reasoning for their choice first. Then I would recommend reiterating what your goals are and then see if they change their mind. Again, you get to choose who operates on you.

Anderson AF, Snyder RB, Lipscomb AB Jr. Anterior cruciate ligament reconstruction. A prospective randomized study of three surgical methods. Am J Sports Med. 2001 May-Jun;29(3):272-9. doi: 10.1177/03635465010290030201. PMID: 11394593.

Mouarbes D, Menetrey J, Marot V, Courtot L, Berard E, Cavaignac E. Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Outcomes for Quadriceps Tendon Autograft Versus Bone-Patellar Tendon-Bone and Hamstring-Tendon Autografts. Am J Sports Med. 2019 Dec;47(14):3531-3540. doi: 10.1177/0363546518825340. Epub 2019 Feb 21. PMID: 30790526.

Nyland J, Collis P, Huffstutler A, Sachdeva S, Spears JR, Greene J, Caborn DNM. Quadriceps tendon autograft ACL reconstruction has less pivot shift laxity and lower failure rates than hamstring tendon autografts. Knee Surg Sports Traumatol Arthrosc. 2020 Feb;28(2):509-518. doi: 10.1007/s00167-019-05720-y. Epub 2019 Sep 19. PMID: 31538227.

Mo Z, Li D, Yang B, Tang S. Comparative Efficacy of Graft Options in Anterior Cruciate Ligament Reconstruction: A Systematic Review and Network Meta-Analysis. Arthrosc Sports Med Rehabil. 2020 Sep 25;2(5):e645-e654. doi: 10.1016/j.asmr.2020.05.007. PMID: 33135006; PMCID: PMC7588648.

Thaunat M, Fayard JM, Sonnery-Cottet B. Hamstring tendons or bone-patellar tendon-bone graft for anterior cruciate ligament reconstruction? Orthop Traumatol Surg Res. 2019 Feb;105(1S):S89-S94. doi: 10.1016/j.otsr.2018.05.014. Epub 2018 Aug 18. PMID: 30130660.