ACL surgery in amputee athletes: discover how a Paralympian returned to elite sport thanks to a tailored reconstruction technique.
Recovering from an anterior cruciate ligament (ACL) tear is already a complex journey, but what happens when the patient is a Paralympic athlete with a transtibial amputation? This blog article dives into the rare case of ACL reconstruction in a high-level disabled athlete and highlights the surgical strategy, rehabilitation and successful return to competition.
The information presented here comes from the scientific study titled "Management of a rare case of anterior cruciate ligament reconstruction in a Paralympic athlete with a transtibial amputation – a case report" led by Prof. Etienne Cavaignac, Alexandre Le Guen, Thibaut Lucena and Eric Laboute.
To explore more cases and research, browse Professor Cavaignac’s other studies and insights.
ACL surgery in amputees presents unique surgical challenges. In this specific case, the patient, a 34-year-old Paralympic long jumper with a transtibial amputation, sustained an ACL rupture one year before the Paris 2024 Games.
Because of the presence of a prosthesis, the surgeon had to avoid pressure zones critical for prosthetic socket function. Traditional graft choices, such as the patellar or hamstring tendons, were unsuitable due to their location or biomechanical implications. For instance, the hamstrings are essential for propulsion in amputees due to the absence of the calf muscles.
Instead, the team led by Professor Etienne Cavaignac chose to use the ipsilateral quadriceps tendon, harvested through a short suprapatellar incision placed outside of prosthetic pressure zones. This method preserved hamstring function and reduced the risk of complications with prosthetic fitting.
Anterior cruciate ligament surgery in amputees requires tailored strategies to ensure optimal outcomes despite the anatomical and biomechanical challenges. In this unique case, the surgical approach was meticulously adapted to the patient’s needs.
Quadriceps tendon graft was selected for its favourable location and minimal impact on prosthetic comfort. The femoral and tibial tunnels were drilled using an outside-in technique and fixed with BioComposite™ interference screws. No lateral tenodesis was performed, as the athlete participated in linear rather than rotational sports.
The patient was positioned lying on his back (supine position), with the amputated leg left hanging freely. A support was placed under the thigh to slightly elevate the femur, giving the surgeon better access to the knee while preserving full mobility of the stump during the procedure. This set-up was essential to avoid putting pressure on sensitive areas of the residual limb and to allow smooth movement during arthroscopy.
The rehabilitation after the ACL surgery was a coordinated effort between surgeons, physiotherapists, sports doctors and the orthoprosthetist. The orthoprosthetist played a crucial role by adapting the socket of the prosthesis in line with stump volume changes during recovery.
Postoperative protocol included:
Muscle mass loss in the stump was addressed progressively with socket adjustments and targeted strengthening exercises. The patient resumed running after 3.5 months and returned to jumping at the 6-month mark.
This is the first documented case of ACL reconstruction in an amputated knee on the same side, making it a landmark in orthopaedic literature. The athlete achieved an excellent clinical result, with a Self Knee Value (SKV) score rising from 20 pre-op to 95 one year after surgery. He finished fourth in his category at the Paris 2024 Paralympic Games.
The case also highlighted essential principles for ACL surgery in elite athletes, especially those with disabilities:
For the general population or sportspeople without amputations, this case still offers valuable insights:
Professor Cavaignac’s practice routinely incorporates these principles across all his ACL reconstructions, using minimally invasive arthroscopic techniques, patient-specific graft selection and digitally guided rehab via Orthense (a remote monitoring tool).
This unprecedented case of ACL surgery in a transtibial amputee demonstrates that with careful planning, adapted surgical techniques and multidisciplinary rehabilitation, even the most complex knee injuries can be overcome, enabling elite athletes to return to their sport at the highest level.
For any ACL-related concerns, trust in the experience and dedication of Professor Étienne Cavaignac, a leading knee surgeon and sports traumatology expert based in Toulouse.
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