ARTHROSCOPIC ASSISTED ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION SURGERY

Knee ligament injuries have become an epidemic in today’s active society. The demands that activities, in both the workplace and sports, place upon the knee, subjects the knee to significant risk.

The anterior cruciate ligament is one of two central supporting the knee joint. It, along with the posterior cruciate ligament, is responsible for coordinating the femur (thigh bone) as it rotates on the tibia (shin bone).

One function of the ACL is to guard against excessive forward movement of the tibia on the femur. The other central ligament of the knee is the posterior cruciate ligament which is responsible for keeping the tibia from shifting posteriorally, or backwards. The anterior and posterior cruciate ligaments are both suspended within the central part of the knee joint and therefore, when these structures tear, the ends usually fall apart, not allowing primary healing to occur.

The other two ligaments of the knee are the medial (inside) and the lateral (outside) collateral ligaments which guard against side-to-side motion of the knee. These ligaments can be torn either independently, or more commonly, in combination with the anterior and posterior ligaments.


Sitting between the tibia and fibula are two disc-shaped structures called the menisci. The menisci, often referred to as “cartilages,” are important as shock absorbers. Their job is to protect the white gliding surface that is on the ends of the bones called the articular cartilage.

Ligament Injury

The mechanism of injury to the anterior cruciate ligament may or may not result from direct contact. More frequently, particularly in sports that require quick deceleration and pivoting such as football, basketball, and soccer, we are finding higher incidents of non-contact anterior cruciate ligament tears. In skiing, because of advances in boot design and bindings, the anterior cruciate ligament has been placed at higher risk and now makes up almost 50% of all major skiing injuries.

If the anterior cruciate ligament is torn, one may experience episodes of giving away of shifting of the knee. This giving away, or buckling, usually occurs when the foot is planted and twisting, or pivoting activities away from the affected side occur.

Shifting may occur, however, even with normal activities of daily living such as walking on uneven ground, turning a corner, or getting out of a car. It is these giving way episodes that lead to further stretching of the secondary restraints or surrounding structures of the knee and potentially to further tears of the menisci. Repeated episodes of knee instability also may lead to damage of the joint surfaces.
Although some patients are extremely dependent on their anterior cruciate ligaments for stability of the joint, others, with absent ACL’s may do very well with minimal episodes of giving away. Cutting sports are more dependent on the functioning anterior cruciate than are sports such as jogging or straight-ahead skiing. Approximately 70% of all individuals who tear their anterior cruciate ligament end up needing further surgery or
anterior ligament reconstruction.

ACL Surgery

Surgical reconstruction performed at Coordinated Health is done one of two ways:

* The torn anterior cruciate ligament is replaced with the central third of the patella (knee cap) tendon and a portion of the bone attached to this tendon at both ends. The reason for using the patella tendon is that the central third of the graft is approximately 1-1/2 times the strength of the original anterior cruciate ligament. This has the longest track record and can be reharvested after the graft deficit heals in case a re-injury occurs.


* The hamstring ACL procedure involves harvesting two of the smaller hamstring tendons which come down the leg on the inner side of the knee. Arthroscopically these tendons are then channeled through drill holes which are made in both the tibia and the femur. New techniques involving the way the graft is doubled over itself and then fixed into the bone has greatly improved the results. This repair technique offers advantages related to quicken rehab time with less discomfort. Short-term results appear promising, however, long-term results such as with the bone-patella-bone graft are not yet available.

Although other tissues have been used for ACL reconstruction, these have fallen into disfavor for several reasons:
bicyclist.jpg (19522 bytes)Synthetic ligaments, to date, have problems with fatigue failure and therefore, are not currently recommended for use in primary ACL reconstruction surgery.
The incidence of success, allowing the patient to return to full activities without further episodes of shifting of giving away, using the arthroscopically-assisted anterior cruciate ligament reconstruction autograft technique approaches 90-95%.

Meniscal Tears

When forces are present enough to tear the ACL, often times associated structures will be injured. Anywhere from 50-70% of the time an associated meniscsal tear will be present.
In the past, before the advent of arthroscopy, the menisci were not appreciated as being important structures and therefore, were freely removed for any size tear. It became evident 10-15 years down the road that this led to an accelerated arthritis.
We now attempt to save as much meniscal tissue as possible. Most meniscal tears occur in areas that have no blood supply. In cases where the tear extends to the portion of the menisci with the blood supply, a repair will be performed arthroscopically.
In individuals who have a repairable meniscus tear, it is important to reconstruct the anterior cruciate ligament at the same time as the meniscus repair or else the repair has a higher chance of failure.

Surgical Procedure
After examination of the knee under anesthesia, an arthroscopy of the entire knee is performed to determine the extent of any damage to the joint surfaces, the menisci, and the cruciate ligaments. Any meniscus surgery is done at this time.

The use of the arthroscope allows direct observation of the previous insertion sites of the anterior cruciate ligament both on the tibia and the femur. Under arthroscopic guidance two tunnels are drilled, one for the tibia and the femur, in the anatomic location of the original anterior cruciate ligament. The central one-third of the patella tendon and the respective bone from both the tibial tubercle and patella are then harvested, and sutures are placed through both ends of the bone blocks.

The graft is then placed through the femoral tunnel into the tibial tunnel until the bone blocks are seated within their respective tunnels. The graft is then pulled tight and anchored by using screws or staples.

Preparation For The Hospital Stay And Your Surgery
The hospital will be contacting you 7 to 14 days prior to the date of your admission for pre-admission testing. At the time of your testing you will be told where and what time to report the morning of surgery.
Please fast- NOTHING to eat or drink NOT EVEN WATER after midnight the night before your operation. If you are taking any daily medicine please speak to the Physician Assistant at the time of your physical examination to see what you should do.
Please leave any valuable at home and remove any nail polish and make-up before going to the hospital.
If you have crutches, please take them to the hospital since you will need them post-operatively. If not, a pair will be provided for you at the hospital.

Post-Operative Instructions
Ice: The use of ice following surgery can decrease pain and swelling. Apply ice for 20-30 minutes every hour.

Elevate: Elevate your legs as much as possible, using two pillows, above the level of your chest. Wiggle your toes frequently as this also helps to decrease swelling.

Pain Control: You will receive prescriptions to help control your pain. Follow the instructions written on the prescription bottle. When the prescription pain medication is no longer necessary, you make take Tylenol, two tablets every four hours as needed for pain.

Dressings: An ace bandage is kept in place during the first seven days except when exercises are performed as instructed by the physical therapist. Ace wraps should be loosened at night while sleeping to insure no disruption of circulation. Steri-strips will be kept in place until the second week follow-up visit with the physician. Steri-strips and other dressings must be kept dry to insure proper healing of incisions and sterile conditions to decrease the chance of infection.

Bathing: It is necessary that you cover your incision with an occlusive dressing or saran wrap and tape, when showering until your first post-operative visit in the office. When you are seen in the office your would will be checked and you will be allowed to shower without the occlusive dressing. The skin adjacent to the incision can be carefully cleaned with soap and water thereafter.

Infection: If you begin to run a fever (101 degrees or above), your knee becomes swollen and red, or you have yellow drainage from your wound, call the office immediately.

Driving: You may feel fee to ride in the car when you feel comfortable doing so. You are not permitted to drive a car until you are cleared by your doctor to do so.

Ambulation: You will ambulate with the use of standard crutches and the knee immobilizer. Weight will be placed as tolerated to the surgical leg. This pattern will continue for the first few weeks at which time crutches may be discontinued and he brace may be opened if good quad set is attained with review of the physical therapist and in accordance with your surgeon.

EMS Unit: Electrical stimulation, used to reeducate the quadriceps muscle following surgery, will be used 3 to 6 times each day for the first few weeks. The unit will run 20 minutes each session. When using this unit, a towel roll or Ace wrap is placed under the surgical leg to insure full extension. Remember to contract with the EMS and relax when it is off. The unit will be disconnected when you can attain good quad set on your own as per review of the physical therapist.
Rehabilitation: Your physical therapy will begin the first post-operative day. Plan to be in the clinic for approximately one (1) hour. Coordinated Health’s entire ACL Protocol is outlined in this document. Please enter the “B” side of the building.

One Week Post-Op
Brace:
Worn 24 hours per day, except the 3-4 times exercises are performed.
Ambulation:
Weightbearing as tolerated with the use of extension brace locked at 0 degrees and standard crutches.
Exercises:
1. Quad sets with and without the EMS unit.
2. Ankle pumps and circles
3. Straight leg raises with brace
4. Adductor sets
5. Thera-band all ankle motions
6. Patellar mobilizations
7. Balance, single limb in brace
8. Prone extension hang
9. ROM knee flexion
10. Ice
Goals:
1. Attain full passive knee extension
2. Knee flexion to 90 degrees
3. Full weightbearing with brace and standard crutches
4. Able to perform straight leg raise, in brace, without assist
5. Identify problems:
o Less than 90-degree flexion.
o Lack of full extension.
o Inappropriate amount of swelling and/or pain.





1-2 Weeks Post-Op
Brace:
Worn 24 hours per day, except the 3-4 times exercises are performed.
Ambulation:
Weightbearing as tolerated with the use of extension brace locked at 0 degrees and standard crutches.
Exercises:
1. As above 0-1 week
2. Straight leg raises without brace (if calf touch present)
3. MRE’s all ankle
4. Double toe raises
5. Standing hamstring curls
6. 1⁄4 squats
7. Bike for range of motion
8. Stairmaster (brace set at available range)
9. Balance (progress from brace as indicated)
10. ROM knee flexion and extension
11. Ice
Goals:
1. Maintain full active knee extension
2. Knee flexion to 100 degrees
3. Able to perform straight leg raise, without brace, and achieve a calf touch
4. Quad set with terminal extension without EMS unit
5. Independent with home program
6. Identify problems:
o Less than 90 degrees knee flexion.
o Lack of full knee extension.
o Inability to perform straight leg raise with a calf touch.
o Inappropriate amount of swelling and/or pain.


2-4 Weeks Post-Op

Brace: Worn 24 hours per day, opened to available range of motion.
Ambulation: Weightbearing as tolerated with brace open to available range and standard crutches.
Exercises:
1. As above 1-2 weeks
2. Progress weight as tolerated with exercises
3. MRE’s hamstrings
4. PNF diagonals
5. Hydrotherapy
6. Thera-band press backs (band above knee joint)
7. Lateral step-ups
8. Balance inline/trampoline/Thera-band
9. Body masters (leg press, calf press, leg curl, multi-hip)
10. Treadmill (gait)
11. Biodex- hamstrings (concentric/eccentric)
12. ROM knee flexion and extension
13. Ice
Goals:
1. Maintain full knee extension
2. Knee flexion to 120 degrees
3. Ambulate with normal gait pattern on treadmill
4. Independent and compliant with program
5. Identify problems:
o Less that 120 degree of knee flexion at 4 weeks post-op.
o Lack of full extension.
o Ambulates with abnormal gait pattern on treadmill.
o Inappropriate amount of pain and/or swelling


4-6 Weeks Post-Op

Brace: Place in functional brace (if pain-free, good quad set, and full active extension). Discontinue brace at night.
Ambulation: Brace open to available range and standard crutches. Discontinue crutches indoors.
Exercises:
1. As above 2- weeks
2. Progress weight as tolerated with exercises
3. Short arc quads (using small towel roll)
4. Thera-band- heel to toe extension exercise
5. Proprioceptives (walk-through heel walking, toe walking, side-stepping, front cross-overs, kariochas, backward walking)
6. ROM knee flexion and extension
7. Ice
Goals:
1. Maintain full knee extension
2. Knee flexion to 135 degrees (or more)
3. Ambulate with normal gait pattern indoors and without crutches
4. Identify problems:
* Lack of full knee extension.
* Less than 120 degrees of knee flexion at 6 weeks post-op.
* Ambulates with abnormal gait pattern.
* Inappropriate amount of pain and/or swelling.

6-10 Weeks Post-Op

Brace: As above.
Ambulation: Discontinue crutches.
Exercises:
1. As above 4-6 weeks
2. Progress weight as tolerated with exercises
3. Discontinue hydrotherapy, unless desires CV workout in 7’ pool
4. Slideboard
5. MRE’s quads
6. Short arc quads with bolster, 0-45 degrees
7. Body Masters (leg extension)
8. Biodex- quads and hamstrings (concentric/concentric). Speeds 180, 210, 240 degrees/ sec
9. Treadmill (jogging)
10. Lower extremity stretching
11. ROM knee flexion and extension
12. Ice
Goals:
1. Maintain full knee flexion and extension
2. Exhibits normal gait pattern, walking and/or jogging
3. Independent and compliant with program
4. Identify problems:
* Lack of full knee flexion and/or extension.
* Ambulates with abnormal gait pattern.
* Inappropriate amount of pain and/or swelling.

10-16 Week Post-Op

Brace: As above.
Ambulation: As above.
Exercises:
1. As above 6-10 weeks
2. Progress weight as tolerated with exercises
3. Increase pace of proprioceptive exercises
4. Lunges, box drills
5. Two-legged hopping, jump rope
6. ROM
7. Ice
Goals:
1. Maintain full knee flexion and extension
2. Exhibits normal gait pattern with walking, jogging, and functional activities
3. Strength of quadriceps and hamstrings with 75% of opposite lower extremity according to isokinetic testing
4. Independent and compliant with program
5. Identify problems:
* Lack of full extension and/or flexion.
* Exhibits abnormal gait pattern(s)
Progress to independent fitness program
May progress into an independent fitness program after 12 th week of the above goals are met, and at the discretion of the physical therapist/operating surgeon. The patient will return to physical therapy at 16 weeks for a Biodex test and every 4 weeks thereafter as needed.


16 Weeks Post-Op

Brace: Worn with higher level activities, exercise, etc.
Ambulation: As above.
Exercises:
1. As above 10-16 weeks
2. Progress weight as tolerated with exercises
3. Plyometrics, sport specific activities, agility
Goals:
1. Maintain full knee extension/flexion
2. Exhibit normal gait with all activites
3. Strengthen within 90-95% of opposite lower extremity according to isokinetic testing
4. Prepare for full return to sport
5. Independent with full flexibility, strength, and fuctional program
6. Biodex test performed at 16 weeks. Speeds of 120, 180, 240 degrees/sec.

Criteria for Return:
* Greater than 90% quad and hamstring strength compared bilaterally with isokinetic testing
* Complete and pass functional agility program
* Brace worn for first year of return to full sporting activities
* You will be returned to competition as per the operating surgeon and completion of the above criteria.
* KT-1000 test