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ACL Reconstruction

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Michael Hua

on 25 October 2013

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Transcript of ACL Reconstruction

ACL Reconstruction - Rehabilitation Protocol
To optimze the patient for surgery and early stages of post-operative rehab program
Reduce swelling
Restore ROM
Ensure the patient has mastered the simple post-op exercises
Stage I - Acute Recovery (day 1 - day 10-14)

Educate patient on time frame of rehab, scheduled targets and clinical outcomes
Relieve post-surgical pain and manage soft tissue trauma
Progress off crutches and normal gait
Wound healing, decrease joint swelling
Restore full extension (including hyperextension)
Establish muscle control
Aim for 90 degrees of knee flexion

Stage VI - Return to Sports 12+ months

Return to sports safely
Minimize the risk of further injury or reinjury
Treatment Guidelines
This is varied due to the nature of the patient’s ability to cope with the injury.
Light knee flexion and extension exercises
Operate on pain free mobile joints

Stage II Hamstring and Quadriceps Control (2-6 weeks)
Stage III Proprioception (6-12 weeks)
Stage IV Neuromuscular (12 weeks - 5 months)
Stage V - Sports Specific (6-12 months)
Treatment Guidelines
Decrease swelling and pain
Full weight bearing as pain allows
Active and passive ROM exercises with patella mobilizations
Gait retraining - with full extension at heel strike
Estabilsh of co-ordination muscle function
Bike exercises 3 days post operation
Gentle hamstring stretch minimizing adhesions
Active hamstring strengthening (static) --> proceed to active free contractions by day 14

*Resisted hamstring strengthening should be avoided for at least 6-8 weeks*
Return the patient to normal function
Further progress muscle control and initiate proprioceptive skills
Muscle control particular aimed at hamstrings and quadriceps
Normalise gait patterns
Continue to reduce effusion that may be recurrent or persistent.
Treatment Guidelines
Increase repetitions, length of contraction and more dynamic positions
Gradually introduce gym equipment
Increase complexity and reps of hamstring strengthening co-contractions - open chained exercises
(low resistance, high reps aim to increase endurance)
Continue with ice and pressure pump if swelling is still present

Improve neuromuscular control and proprioception
Continue to improve total leg strength
Improve endurance capacity of muscles
Improve patient confidence
Improve confidence

Proprioceptive exercises more dynamic (e.g. slide board)
Begin jogging in straight lines on flat surfaces
Progress resistance on gym equipment (increase power and speed of contraction)

Preparation for specific sports
Introduce sports specific activities
Implement agility and reaction time into proprioceptive work
Increase total leg strength
Develop patient confidence

Treatment Guidelines
Progression of strength work
Proprioceptive activities should emphasize good landing technique e.g. hopping, jumping, low impact step aerobics; incorporating lateral movements
Proprioceptive agility work e.g. shuttle runs, skipping
Sport specific activities
Emphasize glut max training (strong hip extensors and external rotators while in flexed hip posture)
Commence PEP program
Restoration of strength and neuromuscluar function
Improve confidence and skill level
Return to training
Treatment Guidelines
Continue progression of plyometrics and sport specific drills
Return to training and skill exercises
Progression of power and endurance
Implement an neuromuscular program for warm up decreasing further ACL injury

Treatment Guidelines
Neuromuscular program should be implemented as a warm up before training and games
Advice must be given to patients dependent on their sport to reduce chances of reinjury.
ACL Role in Knee Stability
Prevention of anterior translation of tibia on femur
Resists excessive rotation at knee joint
Resists varus and valgus forces applied to knee
Provides information on joint space orientation, via proprioceptive inputs

ACL Injuries
Commonly occur via a non-contact mechanism during sports that involve movements such as jumping, cutting and pivoting.
Injuries can affect the ACL in isolation, however in up to 50% of cases, further knee pathologies are experienced.
Usually involves damage to meniscus and MCL.
Frequently presents with heamarthrosis

Incidence of ACL Ruptures
High as 1 in 3000 people
Large percentage result in reconstructive surgery.
Annual estimates range from 70,000-200 000 operations per year in the US.
Surgical intervention not only mechanism of treatment.
Some ACL ruptures involve minimal impairment to individual allowing participation in strenuous activities with few functional limitations.

Indications for Surgery
The key indication for when considering if a patient should require surgery is symptomatic instability.
If stability can be maintained by surrounding musculature, conservative treatment regime can be trialled.
If patient wishes to return to pivoting sports or a physically demanding occupation, then reconstructive surgery is recommended.

Reconstructive surgery
Replacement of ACL ligament in full by an orthopaedic surgeon.
Grafts made from either hamstring or patellar tendons of injured patient.
Common sources of replacements used to reconstruct the ACL include:
of hamstring or patellar tendons; using tissue taken from patient’s own body

LARS graft:
Artificially developed piece of material utilised as new ligament.
Utilization of donated tissue (commonly Achilles tendon) from a cadaver.

Autograft is the most commonly used and is current gold standard.
Limited evidence of the effectiveness of LARs grafts, along with Poor patient outcomes associated with graft failure, tunnel osteolysis, synovitis, and early arthritis.
Allograft can present with complications of infection and graft laxity
Hamstring Tendon Autograft
Involves harvesting approximately 20cm of gracillis hamstring and semitendinosus tendons.
They are doubled over producing a 4-strand graft
A tunnel through the femur and tibia is made for placement of graft.
Graft is secured onto tibia and femur
Full ROM of patient’s knee needs to be achieved prior to tibial fixation.
The reconstruction is usually a day surgery procedure
Most reliable and safest option; increased laxity and decreased chance of post surgical rupture

Patellar Tendon Autograft
Involves a small incision below patella to expose the middle portion of patellar tendon and bone attachments of tibia and patella.
The graft is secured onto holes that are drilled through femur and tibia.

Comparing Hamstring Tendon and Patellar Tendon Autografts
No significant clinical improvement between using hamstring or patellar tendon grafts for:
• Muscle strength,
• Knee stability
• Return to sport.
However, studies show an increased risk in patellar fracture, tendon rupture and graft re-repture following the patellar tendon graft.

Comparing Re-rupture rates between hamstring tendon (HT) and patella-tendon (PT) autografts.
Inclusion criteria
Studies published in English
Intervention: ACL repair post-surgery
Comparison: types of treatment and therapies
Outcome: Relieving symptoms and restoring function
Exclusion Criteria
Articles: without adequate sequence generation, concealed allocation, incomplete outcome data, trials free f selective reporting and evidence bias
Cochrane 2010 guidlines were used by 8 members of the group to assess bais

Lachmans Test
The gold standard for diagnosing an ACL rupture is a MRI, this will visualize the tear and assess the quality of the surrounding structures that are commonly co-damaged with the ACL (MCL and Medial Meniscus)
To assess for anterolateralrotary instability
Anterior Pivot Shift Test
To test for single plane anterior instability
Knee flexion (135 º) & extension (0º )
Supported bilateral calf raises
Hip abduction and extension
Hamstring stretches
Week 6

Eccentric hamstring strengthening e.g. hamstring curl
Consider beyond the knee joint for any deficits e.g. ITB, gastroc soleus
Increase and develop total leg strength

Co-contraction muscular exercises should be progressed further to more dynamic movements (e.g. side lunge, half squat)
Improve overall endurance capacity of musculoskeletal system

Individual sports or activities usually permitted with little or no restrictions
Start cycling bicycle, jogging and swimming
Consider pelvic and ankle control and cardio fitness
Introduce open chain exercises (if no patellofemoral symptoms) 40-90 degrees progression to 10-90 degrees by 12 weeks
Pool work - using flippers to maintain fitness and build further leg strength
Low impact aerobic classes - increased proprioception and confidence
Introduce agility and reaction time - incorporate speed work and and faster movement within controlled environment
Further increase leg strength
Prevention and Enhanced Performance Program (PEP)
1. Warm-up
Running in all planes of motion
2. Stretching
30 secs / 2 reps each eg
Calf, quad, hamstring, adductors, hip flexors
3. Strengthening
Walking lunges (20m x 2sets)
Russian hamstring (10reps x 3sets)
Single toe raises (30reps on each side)
4. Plyometrics
20 reps each
Hop overs
Single leg vertical jump
Scissor jump
5. Agilities
Shuttle run
Diagonal runs
Bounding or leaping runs
Post surgical Rehabilitation Protocols
The implementation of this post-surgical ACL reconstruction rehabilitation program should allow patients to resume the level of activity prior to their injury.
By following the preposed steps and developing patient specific outcome measures that will be assed at each visit, the program can safely be utilised within a clinical setting.
Special mention should be made for safety, in that each step of the program will require careful evaluation of the patient’s current progression and compliance to the program and specific exercises.
Thank you
Specific Exercises
Achieve full ROM
Strengthen muscles
Lengthen short muscles
Specific exercises
Redevelop ROM
Stretching to reduce adhesion's
Develop muscular
MRI findings
Common Mechanism of Injury
Orthopeadic Testing
Lachmanns test
Anterior Pivot Shift Test
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