Introduction


The ACL Surgery: Inside the Operating Theatre Masterclass, taught by Professor Julian Feller and Randall Cooper provides a complete overview of ACL Surgery. This Executive Summary provides clinically relevant, actionable information that may be useful to health professionals.

Part 1 - View from the Operating Theatre


Observing ACL surgery in the operating theatre provides valuable insight into surgical technique and the key considerations that shape post operative rehabilitation. Examination under anaesthesia allows accurate assessment of ligament stability using tests such as Lachman’s and pivot shift, free from muscle guarding. Arthroscopy follows a structured checklist, including portal placement and fat pad considerations. Grafts, whether hamstring, quadriceps or patella tendon, are harvested and inserted with careful attention to tunnel preparation, graft length and growth plates. A Lateral Extra Articular Tendodesis may be added to enhance rotational stability. Post operative bruising is expected, grafts are strong on leaving theatre, and early knee motion must be closely monitored and communicated with the medical team.

  • Escalate concerns if active knee extension or flexion remains limited for a prolonged period.
  • Reassure patients about graft strength while guiding safe early movement.
  • Use knowledge of graft choice and LET to inform clear rehabilitation planning and education.
  • Monitor bruising and pain to appropriately adjust early stage rehabilitation.
  • Maintain consistent communication with the surgical team regarding any unexpected findings.

Masterclass Preview

Enjoy this free preview of Julian demonstrating a knee arthroscopy.

Part 2 - Current Concepts


Contemporary ACL management focuses on identifying patients at higher risk of graft rupture and individualising surgical and rehabilitation decisions. A Lateral Extra Articular Tendodesis may be considered in younger athletes, those returning to pivoting sports, or individuals with risk factors such as increased tibial slope, strong family history, or lower psychological readiness. Its primary role is to reduce graft rupture risk rather than simply improve stability, although it may increase challenges with regaining extension or contribute to quadriceps inhibition. Emerging options such as internal bracing and repair techniques including BEAR exist, but long term data in high level sport remain limited. Non-operative management requires informed consent, shared decision making and consideration of financial implications and meniscal risk. Regardless of pathway, rehabilitation fundamentals remain central: restoring extension, managing swelling, building capacity and addressing psychological readiness for return to sport.

  • Use identified risk factors and the ACL-RSI to guide surgical discussions and return to sport planning.
  • Prioritise early restoration of full knee extension and avoid running on a swollen knee.
  • Correlate MRI findings with objective examination before progressing rehabilitation.
  • Discuss long term implications and financial considerations when exploring non operative options.
  • Communicate clearly about potential LET trade offs, including extension loss and quadriceps inhibition.