Once we have decided together that a reconstruction is the right step, the next few weeks are not a waiting room. What you do with them affects the result more than almost anything that happens in theatre.
First, a quiet knee
An ACL reconstruction is not an emergency, and operating on a hot, swollen, stiff knee is the classic recipe for a stiff knee afterwards. Before surgery the knee needs to meet four targets:
- Fully straight. Full extension, equal to the other side. This is the one that matters most and the one people neglect, because a slightly bent knee feels more comfortable.
- Swelling down. A quiet knee, not a puffy one.
- Quadriceps working. Able to lift the straight leg without a lag, and to tense the thigh muscle on command.
- Walking normally. No limp.
A physiotherapist takes you through this, usually over three to six weeks from the injury. In a comparison of two large groups of patients, those who had a structured program before surgery had meaningfully better knee function two years after it. The program is the same one you will use afterwards, so you learn it before the knee is sore.
Timing
Once the knee is quiet, timing is about your life: your season, your exams, your work, your travel. Weeks or a few months of delay in a knee that is not giving way do not harm the result. What does harm it is a knee that keeps giving way while you wait. Each episode of instability can tear the meniscus or bruise the cartilage, and those injuries are what decide the long-term health of the knee. If the knee is unstable in daily life, surgery should not wait long. If it is stable with the brace of a good quadriceps, there is time to choose the date well. Surgery or rehabilitation? covers how that decision is made.
Consent, understanding the operation
Dr Broadhead will go through the operation with you: which graft and why, whether the meniscus is likely to need repair, whether an additional lateral procedure is planned, the risks that matter, and what the first year asks of you. You will sign a consent form, but the point is that you can explain the operation and the recovery in your own words before you agree to it. Bring your questions written down. Bring a parent or partner if you like; for a teenager, a parent is part of the conversation.
Costs, in writing
You will receive a written quotation before the procedure, setting out any out-of-pocket expenses for the surgeon, assistant, anaesthetist and hospital. In a public hospital there is no out-of-pocket cost. If the injury happened at work or in organised sport, workers compensation or a sports insurer may cover it; tell the rooms early, because the approvals take time.
Tests before surgery
The MRI that made the diagnosis is usually all the imaging needed, together with X-rays. For a younger patient whose growth plates may still be open, an X-ray of the knee and sometimes of the hand is taken to judge how much growth is left, which changes the technique. Routine blood tests and a heart tracing are arranged only where your health needs them.
The anaesthetic
Almost all reconstructions are done under a general anaesthetic, with local anaesthetic placed in and around the knee at the end of the operation so that you wake comfortable. Some anaesthetists add a nerve block; where one is used, it is the kind that spares the thigh muscle, because a quadriceps that will not switch on is the one thing the first fortnight cannot afford. The anaesthetist assesses you before surgery, at a pre-admission clinic or by phone.
What you can do yourself
- Do the prehabilitation. Every session.
- Sort the logistics. You will be on crutches for a week or two, you will not drive a right-knee reconstruction for four to six weeks, and you will need lifts to physiotherapy. Arrange them now.
- If you smoke, stop. Smoking impairs graft healing and wound healing.
- Deal with infections early. A skin wound, an ingrown toenail, a bad tooth or a bladder infection near the time of surgery can seed infection in the knee. See your GP about any of these.
- Medicines. Anti-inflammatories are usually stopped in the week before surgery; the oral contraceptive pill is a small clot risk and is discussed with the anaesthetist; supplements are stopped two weeks before. You will be told exactly what to do with each medicine.
The day itself
Most isolated reconstructions are done as a day case or with one night in hospital. The hospital will contact you the day before with an arrival time and fasting instructions; follow them exactly. Bring your medicines or a list, your crutches if you already have them, loose shorts or trousers that go over a bandaged knee, and your health fund or Medicare details. You will walk out on the leg, on crutches, with a written program, ice at home, and a physiotherapy appointment already made for the first week.