ACL reconstruction: an OR 101 guide
Reviewed by Rodnie Oro, cath lab charge nurse · Last reviewed: October 2026 · Education only, not medical advice
ACL reconstruction in one minute
What it is: keyhole surgery to replace a torn ACL (a key knee ligament) with a tendon graft.
Who it is for: people with an unstable knee after an ACL tear, especially if active in sport or work.
Main risks: infection, stiffness, graft failure or re-tear, numbness near the cuts, blood clots.
Usually: under general anaesthetic with a nerve block, 1–2 hours, often home the same day.
On this page: What is ACL reconstruction? · Who is it for? · When is it done? · Step by step · Recovery · Risks · Kit list · First time in theatre? · FAQ
What is ACL reconstruction?
The anterior cruciate ligament (ACL) runs through the middle of the knee and stops the shin bone sliding forward. It is often torn in twisting injuries.
In ACL reconstruction the surgeon:
- harvests a tendon graft, often from the hamstrings or the patellar tendon, or uses a donor graft, per surgeon
- drills tunnels in the thigh and shin bones
- passes the graft through and fixes it with screws, buttons or other devices, per device and operator
Other injuries such as meniscus tears may be treated at the same time. Rehabilitation takes many months.
New to the acronyms? See the Cath Lab Abbreviations A–Z.
Who is it for?
It may be considered for people with:
- a torn ACL with the knee giving way
- people wanting to return to pivoting sports or demanding work
- an ACL tear with other repairable injuries
The decision is made by your surgical team, who will talk through the reasons, the alternatives and the risks with you.
When is it done?
Most operations are planned; some are urgent. Before it, you usually have:
- an examination and X-rays, and sometimes a CT or MRI scan
- blood tests and, for bigger operations, an ECG
- a review of your medicines, especially blood thinners, as per centre protocol
- fasting instructions
- a chance to ask questions and give consent
Step by step
1. Getting ready
Team brief and WHO checklist first, including the implant check and confirming the site and side marking. The anaesthetic team and ODP give the anaesthetic (general, often with a nerve block, as per centre protocol); antibiotics and blood-clot prevention are given as per centre protocol. The circulating practitioner checks positioning and pressure areas, the diathermy plate, warming, the tourniquet, and radiation protection if X-ray is used. The scrub practitioner checks implant and instrument trays are complete and sterile, and does the first count. Theatre traffic is kept to a minimum, especially in laminar-flow theatres. The arthroscopy stack (camera, light, fluid pump and shaver) is checked.
2. Access
The patient lies on their back with the leg in a holder and a tourniquet. Two or three small arthroscopy ports are made around the kneecap, plus a cut for the graft harvest.
3. Reconstructing the ligament
- A. Knee inspected. The camera checks the torn ACL and other structures.
- B. Graft prepared. The tendon graft is harvested and prepared on the back table.
- C. Tunnels drilled. Tunnels are drilled in the thigh and shin bones with guides.
- D. Graft fixed. The graft is passed through and fixed at both ends.
4. Finishing
The ports and graft site are closed. A dressing and sometimes a brace are applied. Final counts are confirmed, implant details recorded, and the patient goes to recovery with a full handover, including limb checks (circulation and nerves), as per centre protocol.
Recovery and aftercare
- First hours: in recovery; ice, elevation and pain relief.
- Going home: often the same day.
- Crutches: for a few weeks, as advised.
- Rehabilitation: a structured physiotherapy programme for 6–12 months.
- Return to sport: often 9–12 months, guided by your team.
- Follow-up: as per centre protocol.
Call 999 if you have chest pain or sudden breathlessness. Contact your team if you have increasing pain, a cold, numb or very swollen limb, calf pain, fever, or a wound that becomes red, hot or leaky.
Risks and complications
Your team will explain the risks that apply to you. Possible problems include:
- infection
- stiffness
- graft failure or re-tear
- numbness around the cuts
- ongoing knee pain or swelling
- blood clots in the legs or lungs
Theatre kit list (printable)
Example kit list
Every theatre has its own protocol, and sizes and doses vary.
- arthroscopy stack: camera, scope, light, fluid pump and shaver
- ACL instrument set with drill guides
- graft harvest instruments and graft preparation board
- fixation devices, sizes per device and operator
- power drill and reamers
- tourniquet and leg holder
- closure sutures, dressings and brace if used
Procedural steps
- Team brief, WHO sign in; side marked; implant check; anaesthesia and block
- Supine; leg holder; tourniquet; prep and drape; count
- Ports; diagnostic arthroscopy
- Graft harvest and preparation
- Tunnels drilled; graft passed and fixed
- Final check; closure; counts; implant log; sign out and handover
First time in theatre?
đź’ˇ First-time tip
- Implant check. Read back the implant type, side and size before opening, and record it in the implant log.
- Site and side. Check the marking at sign in and again before the cut.
- Counts matter. Swabs, needles, instruments and small implant parts are counted; speak up if one is missing.
- Tourniquet time. Note when the tourniquet goes up and call out times as per centre protocol.
- Fluid and camera. Keep the fluid bags topped up and check the camera is white-balanced and focused.
FAQ
Can an ACL be repaired instead?
Usually it is replaced with a graft. Your surgeon will advise.
How long is recovery?
Return to sport often takes 9–12 months.
Will I need a brace?
Sometimes, per surgeon.
Related guides
Sources
All checked on 14 October 2026. Each page's own date is shown where it gives one.
- NHS. Knee ligament surgery. nhs.uk/conditions/knee-ligament-surgery
- StatPearls (NCBI Bookshelf), search: anterior cruciate ligament reconstruction. ncbi.nlm.nih.gov/books
- StatPearls (NCBI Bookshelf), search: anterior cruciate ligament injury. ncbi.nlm.nih.gov/books
- World Health Organization. Surgical Safety Checklist. who.int
Disclaimer
Education only. This page is for general education for healthcare students, theatre staff and curious readers. It isn't medical advice and doesn't replace advice from your own doctor, surgical team or local unit protocols. Equipment and medicines are described generically. No product or manufacturer is recommended. If you think someone is having a medical emergency, call 999.
Disclosure: I work in the medical device industry. This page is independent education and isn't sponsored or reviewed by any company.
All diagrams on this page are original illustrations created for rodnieoro.com.
