Anterior Cruciate Ligament Reconstruction
Patient Information and Management Guidelines for Hamstring Auto Graft
Produced By Mr. Jeer, Mr. Vinayakam,
Mr. Seneveratne (Physiotherapist)
Background
The Anterior Cruciate Ligament
The anterior cruciate ligament is one of the main restraining ligaments in the knee. It runs from the back of the femur (thigh bone) to the front of the tibia (shin bone) and acts to prevent excessive forward movement of the tibia. Its main function is in stabilising the knee, especially in rotation movements during turning or side stepping (cutting) manoeuvres. The ACL is typically injured in a non contact twisting movement and is often associated with a tearing or popping sensation followed by a rapid onset of swelling due to bleeding from the ruptured ligament. The mechanism may involve rapid deceleration or change of direction movements such as side stepping, pivoting or landing from jump. Associated injury to the joint surface or the meniscus (footballer’s cartilage) can also occur.
In addition, the ACL provides important feedback information to the muscles involved in the reflex control of knee movement. This proprioception is a normal feature of all joints and can be compensated for in the ACL deficient knee by specific rehabilitation exercises for the hamstrings and quadriceps muscles. However, the knee is a complex joint and when exercises are not enough then reconstruction of the ACL may become necessary.
The Operation
The operation to reconstruct the ligament involves replacing it with a graft taken from certain tissues around the knee. The two most common types of operation use the middle third of the patella tendon, which includes a small piece of bone from the patella end and the tibial end, and two of the hamstrings tendons. Both have good results. Post operative rehabilitation is the same for each type of procedure and is essential in regaining both the strength and proprioception required for near normal knee function.
At the QEQMH the preferred technique is to use hamstrings as we feel this allows for speedier rehabilitation and less anterior knee pain.
Surgery is performed under general anaesthesia and takes around 60 minutes. The graft is harvested through a small incision and the inside of the knee is then prepared using instruments under arthroscopic control. A tunnel is made in the tibia and the femur and the graft is passed into the knee. It is then held in place with an interference fit metal screw in the tibia and a device called an endobutton on the femoral side.
Expectations
The aim of the operation is to prevent the knee giving away or buckling. The published results indicate that approximately 85-90% of knees will still be functioning normally or near normally after 5 years. The surgery is designed to allow individuals to return to full contact sport activities but often the sporting aims have changed by the end of rehabilitation.
Problems can occur and these include:
- failure to provide enough stability in the knee to allow return to full sporting activities.
- medical complications such as deep vein thrombosis, pulmonary embolus, wound infection, arthrofibrosis (knee joint stiffness), lack of full extension and flexion, and graft laxity or rupture. The graft can fail and stretch requiring revision surgery.
- proprioception: the ligament is not normal and the operated leg may not feel right for sometime. Using a simple tubigrip sleeve may help to stimulate skin sensation and improve the joint position sense.
- nerve sensitivity / neuroma.
ACL Reconstruction Rehabilitation
The aim of rehabilitation following surgery is to improve range of movement, strength, proprioception (awareness of the position of one's body), to prevent contractures and to optimise the results of the procedure.
The rehabilitation programme is based on the ACL Rehabilitation guidelines produced by Surgeon Commander T. Spalding and has been subdivided into specific milestones which not only ensure that the graft is given sufficient time to heal, but also allow for a graded return to activity therefore reducing the risk of injury.
The guidelines described below are not a strict protocol and can vary for each individual.
During Admission
PRE-OP
Rehabilitation begins before surgery in the pre-operative phase to ensure that you and your knee are ready for the operation.
- You will be asked to attend a pre-assessment clinic
- Ensure full range of movement and keep quadriceps/hamstrings muscles strong before surgery.
- Assessed and examined in pre-assessment clinic, by surgeon, where you will be required to provide consent for surgery.
- Admitted on the day of surgery for general fitness examination for general anaesthetic – opportunity to ask questions.
- You maybe asked to complete outcome measure questionnaires.
Day of Operation
- Light dressing: Mepore + gauze + crepe bandage.
- Analgesia: Intra-operative local anaesthetic into wounds and knee joint. Regular coproxamol tablets and voltarol or Tramadol injections/tablets.
- Cryo-Cuff (iced water compression cuff) may be applied to knee to reduce pain and swelling.
- Start exercises: static quads and hamstring tightening – Quads to force leg straight.
- Aim to stand out of bed on evening of operation with supervision and using crutches for support.
Day 1 and 2 Post-Op
- DAY 1: Dressing removed and long leg tubigrip applied.
- Swelling in knee is normal and controlled by the Cryo-Cuff if required.
- Mobilise weight bearing as tolerated using ctutches.
- Exercise as instructed by physiotherapist to be performed approx. 5 times per day and including:
- Static quads and hamstrings
- Extension exercises “pillow” hangs”: resting ankle on pillow and pushing leg into extension to match normal side to prevent build up of scar tissue around graft.
- Patella mobilisation to prevent tethering of patella in scar tissue.
- Discharge from hospital on DAY 1 if progressing well.
Aims on Discharge
- Full passive extension Comfortable knee flexion 0-90°
- Weight bearing as pain allows
- (You can Fully Weight Bear FWB)
- Pain controlled on tablets
Following Discharge from Hospital
Your rehabilitation within the physiotherapy department will commence approximately two weeks after discharge and once the clips (used to hold wound together) have been removed. The rehabilitation programme provided within the Physiotherapy department aims to safely progress you through the milestones. You will be shown the exercises which will most effectively allow you to achieve these milestones. Most of the exercises require very little equipment and have been developed to allow you to continue your rehabilitation at home. You will be expected to continue the exercises taught to you by the physiotherapist until you are seen in the outpatient physiotherapy department for further rehabilitation. Pain and swelling should be your guide with regards to the amount of exercise you can undertake.
You will have a Consultants review 2 weeks post surgery where your clips will be removed and an x-ray taken on arrival.
PRECAUTIONS:
For the first 6 weeks
DO NOT:
| bend your leg more than 90° |
fully straighten your leg from the last 30° without support of your other leg. |
straighten your knee more than possible with your non-operated leg |
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Exercise Programme
The exercise programme consists of five main phases namely:
Phase 1: Initial phase - first 2 weeks post op
Phase 2: Proprioception phase - weeks 3- 6
Phase 3: Strengthening phase - weeks 6 - 12
Phase 4: Pivoting and cutting (early sport) phase - 3 - 6 months
Phase 5: Advanced strength and endurance (return to sport) phase 6 - 9 months
It is advisable to perform the exercises described below on a daily basis and not only within the physiotherapy department.
Phase 1: Initial Phase - First 2 Weeks Post Op
Aim
The aim of this phase is to regain movement in the knee, allow swelling to settle and to encourage a normal gait pattern.
Week one
Week 2
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(1).Calf Stretch with Towel – 3 x 30secs |
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(2).Calf push-downs against towel – 3 x 10 repetitions |
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(4).Double leg wall squat to 45°. 10 repetitions 3 times a day. |
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(5).Single leg balance with eyes open. Hold for 10 repetitions of 10secs a day. |
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(6).Double leg calf raises. 10 repetitions 3 times a day. |
2 Week Orthopaedic Review
Phase 1 Goals
- Full extension to 90° flexion
- Wound healed
- Minimal swelling
- Normal Gait
Phase 2: Proprioception Phase - Week 3 - 6
Aim
The aim of this phase is to introduce proprioceptive exercises and gradually improve strength and endurance. By the end of 6 weeks your knee should feel normal in activities of daily living.
Week 3
Example exercises
Week 2 exercises including:
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(1). Lateral leg raises with weight |
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(2). Inner leg raises with weight |
Min resistance
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(3). Leg extensions with weight |
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(4). Half circles on stationary bicycle with minimal resistance |
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6 Week Goals
- Full range of movement
- Minimal swelling
- Minimal discomfort
Phase 3: Strength Phase - Weeks 6 - 12
Aim
At this stage the hamstring graft will have become solidly fixated within the femur and tibial tunnels. This allows for more vigorous strength training to commence. There are no specific precautions at this stage, but it is important to avoid too rapid progress as there is a risk of developing complications associated with overloading. The physiotherapist will monitor your strength and control, and progress as appropriate.
Example exercises week 6-12
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(1). Power walking on treadmill |
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(2). Progression of Single leg step work |
 Mini Squats
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(3). Squat work on wobble board |
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(4). Mini trampet balance work |
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(5). Progression of Closed chain exercises (foot in contact with floor) with weight |
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(6). Outdoor cycling on flat ground |
12 Week goals
- No swelling
- Full range of movement
- Increased feeling of stability
Phase 4 - Early Sport Phase - 3 - 6 Months
Aim
The aim of this phase is to introduce pivoting and cutting exercises which play an important role in returning to sporting activities. This stage includes agility and power training starting slowly and progressing to moderate speeds. If your occupation involves manual work it should be possible at this stage depending on the requirements of the occupation.
3-6 Months
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(1). Walk – Jog on treadmill with increased gradient |
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(2). Lunges |
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(3). Double leg skipping
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(3). Hopping on both legs progressing to one leg |
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(4). Lateral shuffle leg to leg |
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(5). Lateral figure of eights |
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(6). Start jogging on flat terrain |
6 Month goals
- Functional and strength tests at 85% of normal side
- Return to non-contact sport/training
Phase 5 - Advanced Strength And Endurance
(Return To Sport Phase) 6 - 9 Months
Aim
This phase is aimed at progressing training to create a foundation for the return to full sporting activity. It is not recommended to return to full contact sport until the functional and strength outcomes are measured at greater than 85% of the normal side. To build up the confidence and regain pre-injury level of skill and performance is variable and can take 3 to 4 months of training and playing. It is recommended that you progress your training within your specific sporting environment. Progress is best achieved in conjunction with a general fitness programme and full contact is best avoided until you are able to tolerate full training sessions and are confident with your fitness and endurance.
No Contact Sports Until After 9 Months
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