Anterior Cruciate Ligament (ACL)

Have you been told you have an ACL tear or a cruciate injury of the knee? If you’ve torn your cruciate, this page is designed to help you understand what has happened to your ligament, what your treatment options are and how to decide on a surgeon if ACL surgery is the path you choose.

Meet Your ACL Expert

Everything you read here comes from the extensive knowledge and experience of Mr Declan Bowler. Mr Bowler is one of Ireland’s leading Consultant Sport Surgeons. He works out of the Bon Secours, Ireland’s largest private hospital, and is the surgeon who typically serves the Cork City Football Team. A Consultant Orthopaedic and Sports Surgeon since 2007, he specialises in getting athletes back to play after a cruciate tear and performs a high volume of ACL surgeries, over 150 a year.

“I’ve been told I’ve torn my cruciate…”

In order to make an informed choice about how to treat your cruciate tear, you first need to understand what you have damaged and how. A ‘cruciate injury’ will normally refer to a tear in your anterior cruciate ligament (ACL). The ACL is a tough band of tissue that links your thigh bone (femur) to your shin bone (tibia)at the knee joint. The purpose of this ligament is to:
– connect the two halves of your leg at the knee joint.
– stabilise the knee.
– prevent your shin bone from sliding forward or rotating too much.

Tears typically occur during pivoting movements, like ones you would do when playing soccer, rugby, hurling or Gaelic football. ACL tears might result from a tough tackle, but they are more likely to happen in non-contact situations such as an awkward landing from a jump, a quick change of direction, stopping suddenly or other twisting motions where the joint is put under serious strain.

Approximately half of all ACL tears are isolated. This means your anterior cruciate ligament is the only thing that’s been damaged during your injury. The other half involve varying levels and types of injury to other parts of the knee, such cartilage or other ligaments.

ACL Surgery & Treatment Guide

Now that you understand what happened, it’s time to think about how to recover from your cruciate injury. There is no one size fits all approach to treating an ACL tear. This is because your body, your injury, your lifestyle, your future goals, and your appetite for risk, when taken in combination, are completely unique to you.

Any good surgeon has three main objectives when treating your ACL tear. They want to:
– get you back doing the things you love, like playing sport at the level you want.
– minimise the risk of re-injuring your knee and cruciate.
– minimise your chance of developing arthritis associated with the injury in the long term.
Your surgeon should be able to clearly explain to you how they’re going to manage the risks. They should also let you know what the impact of any change from the recommended treatment might have on those risks.

Here are some of the considerations that the surgeon should step through with you when supporting you in making your decision.

What do you plan to do after you recover from your ACL tear?

If you are not planning on returning to sports or performing activities that will strain your injury such as jumping from tractors or trucks, conservative treatment using only physiotherapy is a viable option. Your recovery time will typically be shorter, and you avoid having to have surgery.

If you are planning on returning to the same or similar sports or activities where you were injured, surgery will reduce your risk of getting injured again and likely doing more damage to the knee the second time around. What we really want to avoid is a patient choosing to have months of physiotherapy, only to tear the ACL again the first time they go back to their normal activities. Then they may need surgery to fix an even more severe injury and they will need to start the recovery cycle all over again.

What’s your risk of re-rupture?

A typical re-rupture rate (where you tear your cruciate again) for ACL surgery should be around 2 to 5%. But this figure doesn’t really capture the full picture and your surgeon needs to inform you of your personal risk profile and how they propose to manage that.

The younger you are, the greater the risk of re-rupture. This is because your knee joint has more wear and tear ahead of it at the age of 15 than it does at 25 or 35 years old. Another factor that should be considered is the level you plan to play at, generally the higher the level of pivoting involved in the sport, the greater the risk.
If you have soft tissue laxity (looseness) and you are hypermobile (very flexible joints or double-jointed) by nature, that increases your risk of tearing again.
The slope of your shin bone needs to be considered, as a greater than 10-12 degree angle increases your risk.
If you tear more than one ligament, your risk is higher.
Many of these risk factors can be at least partially reduced by performing a lateral ligament repair called ‘lateral tenodesis’ along with the ACL graft. This involves a second incision (surgical cut) at the side of the knee during surgery. It is especially effective in reducing the risk of re-rupture of ACL repairs which used hamstring tendons if there is a lot of rotational instability after the injury. The results of the STABILITY study (Getgood et al. AJSM 48:285) showed that this lateral tenodesis can reduce the risks of re-rupture of hamstring grafts from 11% to 4% in younger patients. Further study in the future with the STABILITY 2 trial will determine if a lateral tenodesis is needed with quadriceps or patellar tendon grafts.


Choosing A Good ACL Surgeon

There are two areas you should carefully check when choosing an ACL surgeon. The first is their level of current experience. To be competent in ACL surgery, a surgeon should be performing at least 30 ACL operations a year. That doesn’t make them good, just competent enough to be performing the procedure. You will be in better hands with a surgeon who does a high number of ACL surgeries, this bracket starts at about 50 cruciate surgeries a year and the level of expertise increases with the more they do.

The second is the level of detail they apply to the consultation before surgery and most importantly, to the surgery itself. Any good surgeon should cover all the topics outlined above in detail and be able to calculate all your risk factors, along with the surgical options to reduce those risks. This is to make sure you are fully informed before committing to your ACL surgery. The surgeon’s operating day should be specialised and contain mostly ACL and sport injury surgeries. It is important that time is given to each case to ensure all injuries found within the knee are addressed and repaired.

Mr. Bowler specialises in ACL reconstructions and takes time to carry out a detailed pre-surgical consultation. He creates a personalised treatment plan that factor in every aspect of each individual patient, working collaboratively with you to find the best path back to health.

Mr. Bowler recently pioneered the use of innovative techniques in the treatment of ACL injuries. He was the first surgeon in Ireland to use ACL repair (rather than graft replacement) in 2017. He was also the first in the country to start using all soft tissue quadriceps tendon graft in 2020. His methods continually evolve to achieve the best possible results.
If you have a cruciate tear and would like to make an appointment with Mr. Bowler, contact us today.

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