How I Perform all-inside ACL Reconstruction
In this video, I walk you through the anterior cruciate ligament (ACL) reconstruction you'll be undergoing.
Before we start
By this point, we've already confirmed the torn ACL on MRI. On the day of surgery, once you're asleep, I examine your knee once more — checking just how loose it truly is. This exam under anaesthesia often shows more laxity than what's felt in clinic, since you're fully relaxed and there's no guarding.
Confirming the tear
I then put a camera into the knee joint — arthroscopy — to confirm directly what the MRI and exam have already told us: the ACL is gone.
Harvesting the graft
With the tear confirmed, the next step is harvesting the graft that will become your new ACL. This is most commonly taken from the hamstrings, though the rectus femoris or quadriceps tendon are other options I use — each with its own pros and cons depending on your knee, your activity demands, and the specifics of the tear.
All of these are autografts — taken from your own body rather than a donor. The graft is removed, devascularised (its blood supply is cut off once harvested), and prepared on a side table while the rest of the joint work continues, ready to be reinserted once the tunnels are drilled.
Drilling the tunnels
Reconstruction means building a new ACL along the path of the old one, anchored into bone on both sides of the joint.
I start by drilling the femoral tunnel, into your thigh bone (femur), using specialised instruments to make sure the tunnel sits in the precise, anatomically correct position. Tunnel placement is one of the details that most affects how a reconstructed ACL performs long-term, so this step is unhurried.
I then move to the tibial tunnel, drilled into your shin bone (tibia) with the same precision.
Passing the graft
Sutures are shuttled across both tunnels to guide the graft through. The graft — your new ACL — is then passed across the knee joint: first seated into the femoral socket, then into the tibial socket, restoring the ligament's original path across the joint.
Checking the work
A side-by-side comparison of the knee before and after reconstruction shows the difference plainly — an empty joint restored to one with a ligament back in place. After surgery, an X-ray is taken to confirm the tunnels and implants are exactly where they should be.
"Fear thou not; for I am with thee... I will strengthen thee" (Isaiah 41:10) — a verse I return to often before operating, because that's the goal of this surgery in plain terms: to strengthen a knee that has lost its ligament.
If you have any other questions before your surgery, feel free to ask me.