ACL Surgery: What to Expect on the Day of Surgery

Surgeons working

Thierry Dosogne / Getty Images

In This Article

Anterior cruciate ligament (ACL) tears are a common sports injury that often require surgical treatment. ACL surgery involves reconstructing the injured ligament using a tendon graft. The surgery is performed by an orthopedic surgeon under general anesthesia in a hospital or surgical center.

Before the Surgery

On the day of your surgery, you will arrive at the hospital or surgical center and go to a pre-operative room.

Here, you can expect the following:

  • You will change into a hospital gown.
  • A nurse will record your vitals and place an intravenous (IV) line into your vein for administering fluids and medications.
  • Your orthopedic surgeon and anesthesiologist will come to say hello and briefly review the surgery with you.

When the surgical team is ready, you will be taken into the operating room where you will lie on an operating table. You will then be given anesthesia medication to put you to sleep.

During the Surgery

Once you are asleep, the anesthesiologist will insert a breathing tube, which is connected to a ventilator. During the entire surgery, which will last less than two hours, the anesthesiologist will remain in the operating room to adjust your anesthesia medications and keep track of your vitals.

Your ACL surgery, which is most commonly performed arthroscopically, will typically proceed then with the following steps:

Confirming the ACL Tear Diagnosis

In order to visualize and confirm the diagnosis of an ACL tear, your surgeon will make two to three small incisions (cuts) around the knee and insert an arthroscope into the knee joint to inspect the ligament injury. In addition to the ACL, the knee meniscus, cartilage, and other ligaments may be inspected for damage.

It is common to treat meniscus tears and cartilage injuries at the same time as performing ACL reconstruction.

'Harvest' and Prepare the ACL Graft

Once the ACL tear is confirmed, a graft must be obtained—a process called "harvesting" the graft.

There are three types of ACL grafts most commonly used. These include:

  • The patellar tendon
  • The hamstring tendon
  • An allograft—a tendon from a deceased donor

The fourth type of graft less commonly used is the quadriceps tendon graft.

In the case of a donor graft, the tissue must be thawed. In cases where the graft is coming from the patient having the ACL reconstruction (called an autograft), an incision will be made to obtain the tissue.

After obtaining the graft, the tissue being used to create a new ACL is cleaned and trimmed to be the proper length and width. The graft is then set aside and stored in a special tissue freezer until the knee is ready for the new ACL.

Creating a Tibial (Shin) Tunnel

The next step is to create a place for the new ACL to sit within the knee. The ACL is right in the center of the knee joint and needs to be attached to the bone above and below the joint. Therefore, the new ligament must start within the end of the thigh bone and end within the top of the shin bone.

A drill is used to make a tunnel in the shin bone. The end of this tunnel in the knee joint is directly where the ACL should attach to the shin bone.

Creating a Femoral (Thigh) Tunnel

Through the tibial tunnel just created, a drill is passed directly through the middle of the knee joint. A second bone tunnel is made from inside the knee up into the end of the femur. This bone tunnel will hold one end of the new ACL, and the tibial tunnel will hold the other.

Passing the Graft

With two bone tunnels (one at the end of the femur, and another in the top of the tibia), the new ACL graft must be passed into position. A large pin is passed through both bone tunnels, and attached to the end of the pin is the new ACL.

The new ACL is pulled up into the femoral tunnel so one end can be secured into the femur. The other end is now in the tibial tunnel, and the central portion of the graft is in the center of the knee joint taking the place of the old ACL.

Securing the Femoral Side of the Graft

With the ACL graft in position, the graft must be solidly fixed in its new position. There are several ways to secure the graft. One common way to do so is to use a screw to hold the graft end within the tunnel. The screw can be made of metal, a plastic-dissolvable material, or a calcium-based substance that turns into bone. Your doctor may recommend a particular type of material, although none has been shown to be "better" at securing the graft.

Securing the Tibial Side of the Graft

Once the graft is solidly fixed on the femoral side, tension is placed on the end of the graft so the new ACL will be tight. The tibial side of the new ligament is then fixed, similarly to the femoral side. Again, different materials may be used to fix the graft into position.

Over time, the graft will heal to the surrounding bone, making the fixation devices unnecessary. Occasionally, a prominent screw or staple that was used to hold the graft in the position may be removed after about a year. If not causing problems, these materials are usually left in place.

Closing the Incision Sites

After the graft is secured, the surgeon will close the incision sites with stitches or tape strips. A bandage will be placed over the knee. Anesthesia medication will be stopped, the breathing tube will be removed, and you will be taken to a recovery room where you will wake up.

After the Surgery

After ACL surgery, you can expect to be in the recovery room for about two to three hours. During this time a nurse will do the following:

  • Monitor your vital signs.
  • Ask you about pain—often using a standard pain scale of zero (no pain) to ten (the worse pain ever)—and give you medication, as needed.

If your vitals are stable and your pain is under control, you will be discharged. A friend or family member will need to drive you home.

Upon discharge, your surgeon will give you various post-operative instructions.

Some of these instructions may include:

  • Applying ice and elevating your knee regularly to reduce swelling.
  • Taking pain medication, usually an opioid and nonsteroidal anti-inflammatory drug (NSAID), for short-term pain relief.
  • Performing various knee exercises and moving around with crutches.
  • Keeping the incision site dry until the stitches are removed.
  • Following-up with your surgeon (within a few days) to remove stitches and monitor for complications (e.g., infection or knee stiffness/loss of motion).
  • Attending physical therapy appointments, which will begin immediately after surgery.

A Word From Verywell

ACL surgery can successfully restore knee function and range of motion, but this does require work on your part as the patient. During your recovery and healing process, be sure to follow-up with your surgeon as advised and remain steadfast and committed to your knee rehabilitation program.

Was this page helpful?
Article Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. The Ohio State Wexner Medical Center. ACL Reconstruction Surgery.

  2. American Academy of Orthopaedic Surgeons. Knee arthroscopy. Updated September 2016.

  3. Feucht MJ, Bigdon S, Bode G, et al. Associated tears of the lateral meniscus in anterior cruciate ligament injuries: risk factors for different tear patterns. J Orthop Surg Res. 2015;10:34. doi:10.1186/s13018-015-0184-x

  4. Widner M, Dunleavy M, Lynch S. Outcomes following ACL reconstruction based on graft type: are all grafts equivalent? Curr Rev Musculoskelet Med. 2019;12(4):460-465. doi:10.1007/s12178-019-09588-w

  5. Fritsch B, Figueroa F, Semay B. Graft preparation technique to optimize hamstring graft diameter for anterior cruciate ligament reconstruction. Arthrosc Tech. 2017;6(6):e2169-e2175. doi:10.1016/j.eats.2017.08.011

  6. U.S. National Library of Medicine, MedlinePlus. ACL reconstruction. Updated April 21, 2019.

  7. Chahla J, Moatshe G, Cinque ME, Godin J, Mannava S, Laprade RF. Arthroscopic anatomic single-bundle anterior cruciate ligament reconstruction using bone-patellar tendon-bone autograft: pearls for an accurate reconstruction. Arthrosc Tech. 2017;6(4):e1159-e1167. doi:10.1016/j.eats.2017.04.001

  8. Debieux P, Franciozi CE, Lenza M, et al. Bioabsorbable versus metallic interference screws for graft fixation in anterior cruciate ligament reconstruction. Cochrane Database Syst Rev. 2016;7:CD009772. doi:10.1002/14651858.CD009772.pub2

  9. Almeida A, Roveda G, Valin MR, Almeida NC, Sartor V, Alves SM. Complications of the screw/washer tibial fixation technique for knee ligament reconstruction. Rev Bras Ortop. 2010;45(5):409-414. doi:10.1016/S2255-4971(15)30428-6

  10. University of Michigan. (June 2019). Anterior Cruciate Ligament (ACL) Surgery.

  11. American Academy of Orthopedic Surgeons. ACL Injury: Does It Require Surgery?

Additional Reading