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Not all patients with an ACL tear are candidates for surgery. Minor ALC tears (grade I and II) can be healed with conservative treatment. Grade III ACL tears (complete tears) should be treated surgically.

An ACL tear injury is a very common injury. It can be treated surgically and conservatively. In the US alone, over 100,000 ACL reconstructions are performed each year [1]. 

The choice of treatment method depends on a lot of factors. One of the main factors is the type of ACL tear injury and the patient’s physical activity level prior to surgery. Conservative treatment can be the treatment of choice for patients with a low level of activity [2]. 

Most orthopedic surgeons will recommend surgery if the patient is very active or an athlete, and in case of a complete ACL tear (grade III tear). With grade I and grade II ACL tears, meanwhile, there is a chance that conservative treatment might lead to healing. In the case of a complete ACL tear, there is no contact between the two ends of the ACL. The contact between ends is very important in the healing process, so surgery is required in such cases.

When it comes to surgery for an ACL tear injury, there are two types: repair of ACL and reconstruction.

ACL repair

The type of surgery your doctor will recommend depends mostly on the type of ACL injury you have. In case of avulsion of the ACL from the femur or tibia, repair might be the right choice. During repair, the ACL will be returned to its natural position and stabilized. Repair cannot be used in cases of ACL tears which are localized in the middle part of the ACL.

After the surgery, most orthopedic surgeons recommend using a brace after the surgery. Three weeks after the surgery, the patient will be allowed to flex their knee up to 90 degrees of flexion and they will start with isometric exercises. The patient will have to use crutches for six weeks. After eight weeks, the patient should have a full range of motion.

This technique is not that common and the main cause is a high rate of failure [3]. 

ACL Reconstruction

ACL reconstruction is reserved for patients who have an ACL tear localized in the middle part of the ACL. In case of ACL reconstruction, there are a lot of different techniques. All of them replace the ACL with tissues (tendons) or synthetics. 

In most cases, an iliotibial band (a structure located at the lateral side of your leg, near the knee), patellar tendon, or hamstring tendons are used for reconstruction. The patellar tendon provides greater stability and is commonly used for ACL reconstruction in athletes [4]. Lately, there has been an increase in the use of artificial ligaments for ACL reconstruction.

Most patients will end up with a small scar located on the anterior side of their lower leg, right beneath the knee. Recovery after surgery for an ACL tear injury is as important as a successful surgery. Surgery alone won’t help a lot without an aggressive rehabilitation process.

Right after surgery, the knee is placed in a brace in extension. The main goal of a brace is to prevent flexion contracture of the knee. It is very important to restore full knee extension early after the surgery. The patient is encouraged to do knee extension exercises right after the surgery.

The patient should use crutches for three to four weeks after the surgery. Partial weight bearing is allowed right after the surgery. Most professional athletes are allowed to return to their previous activity level six months after the surgery. 

Just like any other surgery, surgery for ACL tear injury carries a risk of complication. Intraoperative complications include different fractures (mostly patella), short grafts, errors in the size of bone plugs and bone tunnel, and errors in tunnel placement. [5].  The most common complication of surgery for an ACL tear injury is anterior knee pain which is more common if the patellar tendon is used [6].

Postoperative Recovery

  • 0-3 Weeks after the surgery

The main goal during this period of recovery is to increase the strength of quadriceps muscle, mobilization of knee joint and increase of range of motion of the knee. The patient uses crutches and should be able to bear weight as tolerated. Cold compresses can be used to reduce the swelling during the first days of the recovery period.

The patient should lie on a bed and flex the foot until they feel the contraction of the quadriceps muscle. This exercise can be repeated multiple times. For the next exercise, the patient can sit on a chair, extend the leg and pull the leg towards the chair while keeping it on the ground.

  • 3-8 weeks after the surgery

The main goal during this period of recovery is to return the full range of motion and to engage in strengthening exercises. Most patients will go through this part of rehabilitation in the rehabilitation center or in some cases at home. The patient can start swimming as part of rehabilitation exercises for ACL tear injury

The patient can start doing proprioceptive exercises by shifting their weight from one leg to the other and by doing squats with up to 75 degrees of flexion in the knees, straight walking on heels and toes, maintaining balance on a board, and performing exercises on a stepper.

  • 8-12 weeks after the surgery

The main goal of exercises is to increase physical shape and increase coordination. The patient is allowed to swim and do the same exercises as mentioned above with the addition of walking with a load and bicycle riding.

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