Anterior Cruciate Ligament Surgery

Is Instability in Your Knee Restricting Your Movement?

What Is Anterior Cruciate Ligament Surgery?

Anterior Cruciate Ligament Surgery is a surgical treatment applied following the tearing or rupture of the anterior cruciate ligament (ACL), which is located within the knee joint and controls forward sliding and rotational movements of the knee. The primary aim of this surgery is to restore knee stability, reduce pain and enable the patient to safely return to daily activities or sporting activities.

The anterior cruciate ligament has very low potential for self-healing. Therefore, particularly in active individuals and athletes, surgery after rupture is considered the most permanent and effective treatment method.

Safe Movement with Anterior Cruciate Ligament Surgery

Instability in the knee joint resulting from anterior cruciate ligament tearing can be managed with appropriate treatment approaches. In cases where conservative methods do not provide benefit, anterior cruciate ligament surgery is an effective surgical treatment option aimed at restoring knee stability and enabling safe movement.

"With appropriate treatment for anterior cruciate ligament problems, safe and balanced movement can be restored."

Effective Solution for Knee Stability: Anterior Cruciate Ligament Surgery

Anterior cruciate ligament surgery is a surgical treatment method applied in patients with instability and loss of function resulting from ligament tearing in the knee joint. This condition leads to a feeling of the knee giving way, insecurity, pain and restricted movement, which can significantly reduce quality of life. Rest, medication and physiotherapy are initially preferred. When adequate benefit cannot be obtained from these methods, anterior cruciate ligament reconstruction is applied as an effective surgical treatment option aimed at restoring knee stability, enabling safe movement and supporting return to active life. Dr. Atakan Güvendiren

What Is the Anterior Cruciate Ligament (ACL) and What Does It Do?

The anterior cruciate ligament (Anterior Cruciate Ligament – ACL) is one of the most important ligaments located within the knee joint that connects the thigh bone (femur) and the shin bone (tibia) to each other. It provides knee stability by controlling forward sliding of the knee joint, sudden rotational movements and uneven loading.

The ACL is a fundamental structure that enables the knee to function safely, particularly during movements such as running, sudden stopping, changing direction and jumping.

What Are the Primary Roles of the Anterior Cruciate Ligament?

The primary roles of the anterior cruciate ligament are as follows:

• To prevent forward sliding of the shin bone

• To control rotational movements of the knee joint

• To provide knee stability during sport and daily activities

• To prevent excessive loading of the meniscus and cartilage structures

Thanks to these roles, the knee joint functions both with mobility and in a secure manner.

How Is the Knee Affected Without the Anterior Cruciate Ligament?

When the anterior cruciate ligament is damaged or completely ruptured, the following occur in the knee:

• A giving-way sensation

• Insecurity and loss of balance

• Recurrent swelling

• Sudden pain when playing sport

such complaints arise. Untreated ACL injuries significantly increase the risk of meniscus tearing and knee osteoarthritis over time.

During Which Movements Is the Anterior Cruciate Ligament More Active?

The anterior cruciate ligament is particularly active:

• During contact sports and sports involving sudden turns such as football, basketball and skiing

• When climbing and descending stairs

• During sudden stopping and changing direction

under load. For this reason, anterior cruciate ligament injuries are more common in athletes.

What Causes Anterior Cruciate Ligament Rupture?

Anterior cruciate ligament (ACL) rupture is a serious ligament injury that results from sudden and uncontrolled strain to the knee joint. Although it is most commonly seen during sport, trauma occurring in everyday life can also lead to anterior cruciate ligament rupture.

The basic cause of ACL rupture is sudden rotation, excessive stretching or forward forcing of the knee.

Anterior Cruciate Ligament Rupture Related to Sports Injuries

A large proportion of anterior cruciate ligament ruptures occur during sporting activities. In particular:

• Sudden change of direction

• Unbalanced landing after jumping

• Sudden stopping whilst running

• Strain to the knee during contact sports

increase ACL rupture risk in sports such as football, basketball, volleyball and skiing.

Anterior Cruciate Ligament Rupture Related to Trauma

Causes other than sport can also lead to anterior cruciate ligament rupture:

• Traffic accidents

• Falls

• Direct impact to the knee

• Incorrect stepping on stairs

In such trauma, the ligament can be torn or completely ruptured by sudden and high force.

Why Is Anterior Cruciate Ligament Rupture More Commonly Seen in Women?

Anterior cruciate ligament rupture is seen more frequently in women than in men. The reasons include:

• Anatomical differences (wider pelvic structure)

• Hormonal effects

• Muscle strength imbalances

• Differences in knee biomechanics

are involved. For this reason, ACL injuries are more prevalent in female athletes.

Muscle Weakness and Balance Problems

Weakness of the thigh and hip muscles reduces knee stability. In particular:

• Imbalance between quadriceps and hamstring muscles

• Core (central) muscle weakness

• Lack of balance and proprioception

are important factors that increase anterior cruciate ligament rupture risk.

Inappropriate Surface and Footwear Use

Slippery or hard surfaces and inappropriate sports shoes:

• Cause the foot to catch on the surface

• Increase sudden rotational forces on the knee

contribute to anterior cruciate ligament injuries.

Can Anterior Cruciate Ligament Rupture Be Prevented?

Although it cannot always be completely prevented, the risk of anterior cruciate ligament rupture can be reduced with the following measures:

• Regular muscle strengthening exercises

• Balance and coordination training

• Correct sports technique training

• Appropriate footwear and surface selection

What Are the Signs of Anterior Cruciate Ligament Rupture?

Anterior cruciate ligament (ACL) rupture is a serious knee injury that typically develops suddenly and presents with distinct signs. The signs may vary depending on the severity of the injury and any accompanying meniscus or cartilage damage.

Sudden Tearing Sensation and "Popping" Sound

During anterior cruciate ligament rupture, many patients report experiencing:

• A sudden tearing sensation

• A "popping" or "cracking" sound

in the knee. This is a quite typical finding for ACL injuries.

Rapid Swelling in the Knee (Haemarthrosis)

Within the first few hours after rupture, the knee develops:

• Rapidly developing swelling

• Sensation of tension

occurs. This is due to bleeding inside the joint caused by tearing of the ligament.

Knee Giving Way and Feeling of Instability

In anterior cruciate ligament damage, the knee:

• feels like it is giving way when walking or turning

• provides no confidence, particularly during sudden movements

This condition leads patients to stop playing sports or to hesitate in daily activities.

Pain and Restricted Movement

After ACL rupture:

• moderate to severe pain in the knee

• inability to fully bend or straighten the knee

• difficulty in bearing weight on it

can be observed. Pain is more pronounced in the first few days.

Loss of Performance During Sport

Particularly in athletes:

• difficulty during acceleration and change of direction

• instability during jumping and landing

• marked decrease in performance

are among the important symptoms of anterior cruciate ligament rupture.

Symptoms Appearing Over Time

In untreated anterior cruciate ligament ruptures, the condition may progress:

• recurrent knee swelling

• meniscal tears

• knee arthrosis (osteoarthritis)

risk of developing increases.

What Is the Difference Between Anterior Cruciate Ligament Rupture and Partial Tear?

• In complete ruptures, knee stability is significantly impaired.

• In partial tears, there may be pain but the sensation of giving way may not always be present.

Definitive differentiation is made by clinical examination and MRI imaging.

How Is Anterior Cruciate Ligament Rupture Diagnosed?

Anterior cruciate ligament (ACL) rupture is diagnosed by evaluating the patient's complaints together with detailed physical examination and imaging methods. Accurate diagnosis is critical for determining the treatment plan.

Patient History (Anamnesis)

The first step in diagnosis is a detailed evaluation of the moment of injury experienced by the patient. In particular:

• sudden twisting or stopping movement

• unbalanced landing after jumping

• hearing a "popping" sound

• rapid knee swelling

are strong indicators of anterior cruciate ligament rupture.

Physical Examination Tests

Special tests performed by an experienced orthopaedic specialist are very important in the evaluation of ACL rupture.

Lachman Test

It is the most reliable clinical test for anterior cruciate ligament injuries. The amount of forward displacement of the tibia is assessed.

Anterior Drawer Test

By fixing the knee at a specific angle, forward displacement of the tibia is checked.

Pivot Shift Test

Rotational stability of the knee is assessed. It is generally positive in advanced ruptures.

Magnetic Resonance (MRI) Imaging

MRI is the gold standard imaging method for diagnosing anterior cruciate ligament rupture. With MRI:

• whether the ligament is partially or completely ruptured

• meniscal and cartilage damage

• associated bone edema

can be clearly assessed.

When Is X-ray Necessary?

X-ray does not show the anterior cruciate ligament itself but:

• bone fractures

• abnormalities in joint structure

• accompanying other injuries

provides complementary information.

Importance of Early Diagnosis

Early recognition of anterior cruciate ligament rupture:

• prevents improper loading

• reduces meniscal and cartilage damage

• improves treatment success

ensures.

What Happens After Diagnosis?

After diagnosis, the patient's:

• age

• Activity level

• sports goals

• additional injuries in the knee

are evaluated and surgical or non-surgical treatment options are planned individually.

Who Needs Anterior Cruciate Ligament Surgery?

Anterior cruciate ligament (ACL) surgery is not automatically applied to every patient with an anterior cruciate ligament injury. The surgical decision is made individually, taking into account the patient's age, lifestyle, sports level, knee instability, and associated injuries.

Active and Athletic Individuals

Anterior cruciate ligament surgery is particularly:

• recommended for those who play football, basketball, volleyball, skiing and similar sports

• recommended for those who perform activities requiring sudden direction changes and jumping

• recommended for those who experience knee giving way during sports

is generally the required and recommended treatment method.

Patients with Knee Instability in Daily Life

Those who do not play sports but in daily life:

• Difficulty walking down stairs

• Experiencing a sense of the knee giving way when walking

• Restricting their movements due to lack of confidence in their knee

surgery may become necessary.

Those Whose Symptoms Continue Despite Non-Surgical Treatment

Despite physiotherapy and muscle strengthening programmes:

• If knee stability cannot be achieved

• If recurrent swelling and pain develop

anterior cruciate ligament surgery becomes necessary.

Patients with Meniscus and Cartilage Damage

Accompanying anterior cruciate ligament rupture:

• meniscal tears

• Cartilage lesions

surgery is important in protecting the knee joint and preventing osteoarthritis that may develop in the future.

Young Patients and Those with Sport Goals

Young individuals who:

• Wish to maintain an active lifestyle

• Aim to return to sport

often have anterior cruciate ligament surgery for long-term knee health.

When May Anterior Cruciate Ligament Surgery Not Be Necessary?

In some patients, surgery is not mandatory:

• Those with low activity levels

• Those without complaints of knee instability

• Patients with partial tears and good muscle control

in this group, non-surgical treatment options may be considered.

How is the Decision for Surgery Made?

The decision for surgery:

• Clinical examination

• MRI findings

• Patient expectations

are evaluated together by the orthopaedic specialist.

How Is Anterior Cruciate Ligament Surgery Performed?

Anterior cruciate ligament (ACL) surgery is nowadays largely performed using arthroscopic (minimally invasive) technique, aimed at restoring knee stability. The fundamental principle of the surgery is not to repair the torn ligament, but to create a new ligament in its place.

Preparation Before Anterior Cruciate Ligament Surgery

Before surgery:

• Detailed orthopaedic examination is performed

• MRI images are evaluated

• Swelling and movement restriction in the knee are reduced as much as possible

This preparation period directly affects the success of post-operative recovery.

Arthroscopic (Minimally Invasive) Anterior Cruciate Ligament Surgery

The surgery is usually performed using a minimally invasive approach. Several small incisions are made around the knee:

• The knee interior is visualised using a camera (arthroscope)

• The torn anterior cruciate ligament is debrided

• The meniscus and cartilage structures in the knee joint are evaluated

Thanks to this technique, tissue damage is kept to a minimum.

Creating a Graft (New Ligament) in Anterior Cruciate Ligament Surgery

The new ligament is usually prepared from the patient's own tissues. The most frequently used grafts are:

• Hamstring tendon graft

• Patellar tendon graft

In some special cases, a ready-made graft (allograft) may also be preferred. Graft selection is determined according to the patient's age, sport level and expectations.

Placement of the New Ligament

The prepared graft:

• Is passed through special channels created in the thighbone (femur) and shinbone (tibia)

• Is positioned anatomically correctly

• Is fixed with special screws or anchoring systems

This stage is critical in restoring the knee's natural biomechanics.

How Long Does Anterior Cruciate Ligament Surgery Take?

The operation usually takes between 1–2 hours. The duration may vary depending on accompanying meniscus repair or additional procedures.

The Immediate Post-Operative Period

After surgery:

• Patients are usually discharged on the same day or the next day

• Walking with crutches is begun

• An early physiotherapy programme is planned

Following successful surgery, the rehabilitation process is as important as the surgery itself.

What Does the Success of Anterior Cruciate Ligament Surgery Depend On?

• Correct surgical technique

• Appropriate graft selection

• Patient compliance with physiotherapy

• Controlled progression of return to sport

determine the long-term success of the surgery.

What Types of Grafts Are Used in Anterior Cruciate Ligament Surgery?

In anterior cruciate ligament (ACL) surgery, the torn ligament is not repaired; instead, a new ligament (graft) is created to restore knee stability. Graft selection is one of the most important factors directly affecting the success of the surgery and the return-to-sport process.

Graft type is determined individually based on the patient's age, activity level, sport goals and knee structure.

Hamstring Tendon Graft

One of the most frequently used graft types. It is taken from the tendons of the hamstring muscles at the back of the knee.

Advantages:

• Post-operative pain is generally lower

• Risk of anterior knee pain is lower

• Return to daily activities is more comfortable

Disadvantages:

• Rarely, loss of strength in the hamstring muscles may be observed

Hamstring graft is frequently preferred, particularly in recreational athletes and active individuals.

Patellar Tendon Graft (Bone–Tendon–Bone Graft)

A portion of the patellar tendon below the kneecap is taken together with bone fragments.

Advantages:

• It is a very strong and durable graft

• Provides high stability on return to sport

• Frequently preferred in professional athletes

Disadvantages:

• Risk of front knee pain

• Discomfort when climbing stairs or squatting

Accepted as the gold standard in high-performance sports.

Allograft (Pre-prepared Graft)

It is tendon tissue taken from another person and processed through special procedures.

Advantages:

• Does not require an additional incision or tissue harvesting

• Operation time is shorter

• Post-operative pain may be less

Disadvantages:

• In young and highly active patients, the risk of graft failure may be higher

• Not recommended for every patient

Generally preferred in older patients or during revision surgery.

Quadriceps Tendon Graft

Harvested from the quadriceps tendon at the front of the thigh.

Advantages:

• It is a thick and strong graft

• The risk of front knee pain is lower than with patellar graft

Disadvantages:

• Not routinely used by every surgeon

It is an effective alternative, especially in certain special cases.

Which Graft Is Better?

The concept of an "ideal graft" varies from patient to patient. What matters is:

• The patient's level of sport

• Age and weight status

• Previous knee surgeries

and similar factors to be considered together.

Does Graft Selection Affect Surgical Success?

Yes. Appropriate graft selection:

• Increases knee stability

• Reduces the risk of graft re-rupture

• Supports safe return to sport

How Is the Recovery Process After ACL Surgery?

The recovery process after anterior cruciate ligament (ACL) surgery is directly related to surgical success and the patient's compliance with the rehabilitation programme. Through a properly planned recovery process, patients can safely return to their daily activities and sports.

First Days After Surgery (0–2 Weeks)

The primary aim during this period is to control pain and swelling.

• There may be swelling and tenderness in the knee

• Partial weight-bearing with crutches

• Gentle exercises to maintain knee range of motion are started

• Ice application and elevation are recommended

Early Rehabilitation Period (2–6 Weeks)

During this period, knee control and muscle activation are the targets.

• Crutches are gradually discontinued

• Full knee extension and flexion are worked on

• Quadriceps and hamstring muscles are strengthened

• Daily walks are increased

Mid-term Recovery (6–12 weeks)

Functional strength gain is the focus during this period.

• Balance and coordination exercises are added

• Climbing and descending stairs becomes easier

• Daily activities can be performed without pain

Sport Preparation Period (3–6 months)

Preparation for return to sport takes place during this period.

• Running and direction-change exercises are started

• Muscle strength and knee stability are tested

• Sport-specific training is undertaken

Return to Sport (6–9 months)

• Return to sport is possible in most patients between 6 and 9 months

• This period may be longer in professional athletes

• Return to sport must be done under the supervision of a doctor and physiotherapist

Factors Affecting the Recovery Process

• Type of graft

• Regular participation in physiotherapy

• Patient's weight and muscle composition

• Smoking and comorbidities

directly affect the recovery time.

What Should Be Observed After Surgery?

• The rehabilitation programme must not be interrupted

• The knee must be protected from sudden forceful movements

• Early return to sport should be avoided

Following these rules reduces the risk of re-rupture.

What If I Do Not Have ACL Surgery?

If anterior cruciate ligament (ACL) rupture is left untreated, it can lead to serious and permanent problems in the knee joint over time. Although the need for surgery varies from patient to patient, especially in active individuals, avoiding surgery may negatively affect long-term knee health.

Knee Instability and Giving Way Persist

The anterior cruciate ligament is one of the fundamental structures for knee stability. If surgery is not performed:

• The knee gives way during sudden movements

• A feeling of instability occurs when walking or turning

• Sports and daily activities are restricted

This condition reduces the patient's quality of life.

Risk of Meniscus Tear Increases

Because stability is compromised in a knee with ACL rupture:

• The menisci bear more load than normal

• Over time, meniscus tears may develop

Meniscus damage makes it difficult to protect the knee joint and complicates treatment.

Early Osteoarthritis of the Knee May Develop

Untreated anterior cruciate ligament tears:

• Cartilage wear in the joint

• to early osteoarthritis of the knee

can lead to this. This condition can cause persistent pain and restricted movement in the years ahead.

Negative Impact on Sporting Life

Particularly in individuals who play sports:

• Performance decreases

• Risk of re-injury increases

• Sport may need to be abandoned completely

Non-surgical Management Is Not Always Appropriate

Non-surgical management may be possible in some patients:

• Those with low activity levels

• Those without complaints of knee instability

• Patients with partial tears and good muscular control

However, these patients must also be under regular supervision.

Is It Always Risky Not to Have Surgery?

No. The surgical decision should be made after evaluating:

• Patient age

• Activity level

• Knee stability

• expectations

However, surgery is generally not recommended for active and young patients who choose not to have it.