Background
Dr Vertullo has a special interest in anterior cruciate ligament (ACL) reconstruction and has performed thousands of these procedures on the Gold Coast since completing fellowship training in North America.
ACL reconstruction involves placing a new graft into the knee to replace the torn ligament. While ACL injuries are common, not all patients require surgery — some can be successfully managed with rehabilitation alone. Surgical reconstruction is considered when instability persists or patients wish to return to pivoting sports.
For further information, see the Australian Knee Society Position Statement on the Management of ACL Injuries.
How is it Done ?
ACL reconstruction is performed using keyhole (arthroscopic) surgery. Through small incisions, a camera (arthroscope) and fine instruments are inserted into the knee joint.
The first step is graft harvest. A small incision is made to obtain the replacement tissue, most commonly from the quadriceps tendon, hamstrings, or occasionally the patellar tendon. The graft is carefully prepared to the correct size and strength before being reimplanted into the knee.
Two small tunnels or sockets are then created in the femur (thigh bone) and tibia (shin bone). The graft is passed through these tunnels to recreate the torn ACL and is held securely in place with specialised fixation devices such as buttons, screws, or anchors. Over time, the graft heals into the bone and functions like a new ligament.
At the same time, any other damage inside the knee can be addressed:
Meniscal tears may be repaired, trimmed, or left alone depending on their type and healing potential.
Cartilage (chondral) damage may be treated with smoothing, microfracture, or other techniques.
Additional ligament injuries (such as the PCL, MCL, or posterolateral corner) may also be reconstructed or reinforced if needed.
The overall goal is not just to reconstruct the ACL, but to restore stability and protect the long-term health of the knee joint.
What are my Graft Choices ?
Dr Vertullo’s current main choice for ACL reconstruction is the quadriceps tendon graft. This graft has become increasingly popular worldwide because it provides excellent strength and stability, with reliable outcomes and low rates of donor site problems. Hamstring grafts remain widely used and can provide good knee stability with relatively little pain. However, some patients may experience weakness in hamstring strength afterwards. Hamstring grafts can be prepared in 4-, 5- or 6-strand combinations depending on patient size and anatomy.
In the past, many ACL reconstructions were performed using the patellar tendon graft (middle third of the tendon). While this is still an effective graft, it is now used less often because of higher rates of anterior knee pain and stiffness. It may still be chosen in selected situations, such as revision surgery. Allografts (donor tissue from another person) are another option, particularly for revision surgery or in multi-ligament knee injuries. However, they may have slightly higher failure rates in younger, highly active patients. In some cases, Dr Vertullo may also perform a lateral extra-articular tenodesis (LET) alongside ACL reconstruction. This uses a strip of the iliotibial band on the outside of the knee to provide additional stability, especially in patients at high risk of re-injury.
Artificial grafts, such as polyester-based devices (e.g. LARS), have been used in the past. While they may still have a role in certain revision settings, their use in standard ACL reconstruction has declined due to concerns over long-term outcomes.
RECOVERY
It will take over 9 months for he graft to become a living part of you. The graft acts as a scaffold and slowly the body turns the hamstring graft into a living part of you.
Some Common Questions
Q: Why do I need an anterior cruciate ligament reconstruction?
There are two types of patients for whom anterior cruciate ligament reconstruction is recommended:
Group One - Active patients with an acute, i.e. recent anterior cruciate ligament rupture with or without simultaneous meniscal cartilage damage.
Group Two – Patients who have torn their anterior cruciate ligament at some stage in the past and have either gone on to develop ongoing feelings of instability or a meniscal cartilage tear.
If patients are older, less active and with either no feelings of instability or no cartilage damage, the surgery is undertaken on a case by case basis.
Q :What are the benefits of having my anterior cruciate ligament reconstructed?
The main aim is to prevent buckling or pivoting episodes of the knee which often go on to cause medial meniscal cartilage damage. If a patient tears their medial meniscus and loses it, they have a very high rate of osteoarthritis at 10 to 20 years post injury. If a patient doesn’t damage their meniscal cartilage, irrespective of what has been undertaken to the anterior cruciate ligament, they do well long-term . The main reason to have the anterior cruciate ligament reconstruction is to protect the knee from arthritis and knee replacement longer term by preventing meniscal cartilage tearing.
Q: Can I walk after the surgery and do I need crutches?
To prevent patients stumbling or falling post-surgery, a brace and crutches is used for a few days after surgery. At one week post surgery, physiotherapy is commenced.
Q: When can I return to work?
Most patients can return to work utilizing the following guide:
School/university students can usually return at one to two weeks post surgery.
Office workers can usually return at two to three weeks post surgery, depending on their transport requirements.
Heavy manual labourers or tradesman can usually return to work by six weeks but in a suitable duties capacity with expectations of full duties at three months.
Patients who work in very high demand activities such as police officers, roof tilers, merchant seaman, firefighters, armed forces personnel etc often can’t return to work until three months post surgery.
Q: When can I return to sport or other activity?
Most patients are able to return to pivoting sports at eight to nine months. Patients can ride a bike within a few weeks of surgery and most patients can go back and play golf at eight weeks and go back surfing at three or four months. You can drive once you are out of the brace and safely controlling the vehicle.
The restriction on the pivoting activity is because this is the prime stress that leads to stretching out of the anterior cruciate ligament graft. Activities that are also precluded would include touch football, netball, wake boarding, skiing etc.
Q: What do I have to be careful of after the surgery?
As the graft is a scaffold and your body grows into it over the nine months, slipping over on wet tiles is a prime cause of graft injury before it heals.
Post surgery you should notify immediately if you notice any increasing pain or swelling, either in the knee which could be a sign of infection or in the calf which could be a sign of a deep venous thrombosis.
In general, if you are getting better every day, the swelling is reducing and you are able to slowly increase your activities, then your post operative recovery is proceeding as normal.
Q: What are the complications of this surgery?
Dr Vertullo has invented a technique of infection prevention by soaking the anterior cruciate ligament graft intra operatively with antibiotics. This has reduced the infection rate from approximately 1% down to 0% over the last 1,000 anterior cruciate ligament reconstructions he has undertaken. Hence, while infection can occur, it is much less likely using this technique.
Other complications can include thrombosis in the leg, known as a deep venous thrombosis. You will be given a heparin injection while in hospital and then you will be asked to take low dose Aspirin, of 100 mg per day for three weeks after the surgery to decrease the risk of blood clots on the lungs and legs.
In addition, some patients notice numbness around their scars. Usually, if this occurs it is limited to the top end of the calf and it will decrease in time. Occasionally, however, patients always have a small patch of numbness around the wound and sometimes it never completely recovers normal sensation around the wound.
There is a 5% chance of needing a repeat arthroscopy either because the patient gets too much scarring over the graft, known as a Cyclops lesion or a meniscal repair fails. A Cyclops lesion is a lump of scar tissue prevents the knee from straightening properly and patients get a clunking sensation when they attempt to do so. If you have a meniscal repair simultaneously to the surgery, 80% of these heal spontaneously but 20% fail to do so and hence these patients need repeat arthroscopy because of meniscal tearing or non healing.
Very rare complications would include injuries to nerves and arteries.
When can I leave hospital ? Usually the same or next day.
What size scars will I have ?
You will have two 5mm incisions either side of your patella tendon, with a 3cm incision to harvest the hamstring just to the inside of your top of your tibia.
Will I need a Catheter in My Bladder or a Drain in My Knee ?
No