Accelerated rehabilitation after anterior cruciate ligament reconstruction

228

Abstracts

They had a mean follow-up 53% 21% 26% -

/The

of 42 months

Functional Partially Failure

It is seen from the above study that numerous surgeries have been undertaken in many young patients and this highlights the importance of careful understanding of the problem and how to deal with it. Dealing with the femoral tunnel, then several situations are anticipated. If the tunnel is too anterior, one can attempt to place a new tunnel more posteriorly. If there is no space behind the tunnel and/or removal of the interference screw proves difficult, than an over-thetop technique is used. Whether the previous femoral tunnel is to be drilled again depends on the presence of the interference screw, the case of its extraction and the type of graft previously used i.e. synthetic or not. We would like to present 8 patients who had revision anterior cruciate ligament reconstructive surgery here to highlight some of the associated problems. They have been followed up for a year following the re-injury to the primary reconstruction: Primary reconstruction Re-injury 4 patients

failure 4 patients

References [l] [2]

Johnson DL, Harner CD, Mayday MG, Fu FH, Harner CD, Vince KG, eds. Knee Surgery. Williams & Wilkins, 1994. Noyes FR, Barber-Westin SD, Roberts CS. Use of allografts after failed treatment of the rupture of the anterior cruciate ligament. J Bone Joint Surg 1994:76(A);1019-1031.

Accelerated rehabilitation after anterior cruciate ligament reconstruction K Donald Shelboume Methodist Sports Medicine Center, 1815 North Capitol Avenue, Suite 530, Indianapolis, Indiana 4602, USA Reconstruction of the anterior cruciate ligament (ACL) has received considerable attention during the past 2 decades. Although treatment advances have changed the operative management of this injury, the primary goals of treatment remain constant. These include restoration of knee stability, limiting surgical morbidity, and a successful return to full activities. The mid-third autogenous patellar tendon graft is the most common graft source used for ACL reconstructive surgery. However, a number of surgeons have chosen alternative grafts due to the potential morbidity associated with harvesting of this graft source. The most common of these complications, include knee stiffness, anterior knee pain, and quadriceps weakness. In lieu of searching for a graft source equal to the patellar tendon in restoring knee stability, we have focused on minimising the postoperative morbidity associated with its use. The most significant contribution to this effort has been in the area of perioperative rehabilitation. This began in the 1980s when we observed that patients strictly following our rehabilitation protocol were

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progressing more slowly than those who were advancing their activities as tolerated contrary to our guidelines. These non-compliant patients had fewer complications without an increased incidence of instability. The key differences we observed between these two groups were: (1) patients who regained full hyperextension early did not exhibit increased instability but had fewer complaints of anterior knee pain and stiffness with return to full activities: (2) patients who developed good leg control and were able to ambulate with a normal gait pattern immediately after surgery had better patellar mobility, less patellofemoral pain, and regained their strength much faster; and (3) if a large hemarthrosis developed after reconstruction, this limited progression of rehabilitation with a trend toward recurrent effusions and prolonged strength loss. Since that time, we have continued to critically examine and modify the rehabilitation guidelines with a continued trend toward fewer limitations and an earlier return to full activities. This approach has significantly limited the morbidity commonly associated with autogenous patellar tendon grafts. In addition, we have noted that by critically assessing graft placement and our ability to reproduce this position, we have continued to decrease our KT-1000 and functional instability failures despite allowing a much faster return to full sporting activities. We feel we are now able to offer the patient the ‘gold standard’ in ACL reconstruction without the increased morbidity commonly associated with its use. Basic rehabilitation concepts Achieving optimal results using the accelerated rehabilitation protocol requires an understanding of some key concepts. The most critical of these is full knee extension. It is important to note that most patients exhibit a small amount of hyperextension when the knee is fully extended. The term full knee extension actually refers to hyperextension equal to the contralateral knee. The importance of this can not be overemphasized. Achieving and maintaining full knee extension, simply stated, equates to prevention of surgical morbidity. A stiff knee lacking full extension rarely leads to complaints of instability, but often results in a dissatisfied patient with anterior knee pain, quadriceps weakness, and a poorly functioning knee. These complaints if allowed to develop can often be lessened by postoperative arthroscopic scar resection and restoration of full knee extension. However, it is best to prevent problems by obtaining full extension before and immediately after surgery, rather than treat them once they occur. Patient education is a second major key to a successful postoperative course. With our rehabilitation programme few patients require more than four or five physical therapy visits. These visits are aimed at patient education and rehabilitation guidance with emphasis on avoiding postoperative problems. It is vital for the patient to fully understand the rehabilitation goals and how they can be achieved. A smooth postoperative course is characterised by a patient who takes responsibility for achieving the rehabilitation goals. Finally, organisation of the perioperative protocol is worthy of brief discussion. Our accelerated protocol can be separated into a four-phase programme. These phases are helpful in guiding the patient and physician during the preoperative and postoperative course. However, it may be more appropriate to think of rehabilitation as a step-wise progression. For example, the patient must

Abstracts

/ The Knee 3 (1996)

control swelling before realising a full range of motion (ROM). We have found that motion, and full knee extension in particular, is a prerequisite to a rapid return of quadriceps strength. Quadriceps strength is a must for a successful return to full activities. Failure to proceed in a step-wise fashion results in a frustrating and prolonged postoperative course. This is well demonstrated by the patient who attempts to participate in functional activities before achieving a return of 70% quadriceps strength. The result is often a swollen knee that functions poorly. An outline of the accelerated protocol is given in Table 10. These are merely guidelines and each patient’s progress should be individualised. Although each phase has a general time period assigned to it, very few time constraints are placed on patient progress with the exception of the first 2 postoperative weeks where we focus on limiting swelling and maintaining full knee extension. When the goals of a specific rehabilitation phase are acl-ieved, the patient is ready to proceed to the next phase. Rehabilitation protocol Phase I: Preoperative preparation of the patient is the foundation for a successful postoperative recovery. Delay surgery until the patient has a normal appearing knee with no swelling and normal ROM will limit surgical morbidity. Operating on an acutely injured knee without restoring full knee extension preoperatively is associated with an increased incidence of postoperative knee stiffness. Most patients require 3-6 weeks before their swelling is minimal and motion has returned to normal. Two special circumstances deserve mention. The first involves the patient with a concomitant medial collateral ligament (MCL) injury. These individuals are particularly prone to have motion problems if reconstructed in the acute period. This is particularly true if the MCL injury Table 10 Phzses of rehabilitation

following

ACL

surgery

Phase I

(Preoperative rehabilitation of the injured knee): Regain full ROM Minimise swelling Review postoperative rehabilitation programme Mental preparation for surgery Arrange school, work, family schedule for surgery

Phase II

(O-2 weeks postoperatively: Obtain full knee extension Ailow wound healing Maintain active quadriceps Minimise swelling Achieve 90” of flexion

(hyperextension)

Phn.re III (3-5 weeks postoperatively): Resume a normal gait pattern Improve flexion to 135” Begin closed chain quadriceps

leg control

strengthening

Phase IV (From 5 weeks postoperatively): Isokinetic and KT-1000 stability testing If strength is adequate, start lateral shuffles cariocas, jumping rope, light running programme Start sport specific activities and return to competition as rehabilitation progress allows

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is off the medial femoral condyle. In this setting, 6-10 weeks of peroperative rehabilitation are often required before the knee is ready for the reconstructive procedure. The second circumstance involves the individual with a chronic ACL deficient knee who resents with a locked bucket handle meniscal tear and a flexion contracture greater than 10”. Simultaneous management of the meniscal pathology and ligament instability can result in an increased incidence of postoperative stiffness. We have found that a two-staged approach can effectively eliminate this problem. Our preferred treatment includes initial care of the meniscal tear through outpatient arthroscopic repair followed by a delayed reconstructive procedure when knee motion has returned to normal. This not only serves to minimise the chances of having motion problems after the ACL reconstruction, but allows for an aggressive approach toward meniscal preservation. A second-look arthroscopy at the time of reconstruction will allow for evaluation of the meniscal repair and hopefully encourage us to repair more of these torn menisci. Finally, the patient’s psychological frame of mind is critically important. It is normal to feel depressed and/or angry for a short time after a major knee injury. This frame of mind is not conducive to a smooth postoperative recovery. Patients need to be well informed and mentally prepared for the procedure. This often involves scheduling around school vacations or work. Delaying surgery until the patient and the knee is ready for ACL reconstruction will not compromise ultimate stability. However, it will serve to significantly limit the incidence of postoperative morbidity. Phase II: Phase II consists of the initial 2 weeks after surgery. The goals of this phase include: (1) minimising swelling; (2) establishing and maintaining full knee extension; (3) obtaining knee flexion to 90 degrees; and (4) demonstrating good quadriceps leg control. This period is the most critical and emphasis must be placed on avoiding problems as opposed to solving them once they occur. For this reason, most patients remain in the hospital for approximately 2 days after surgery. During these first 2 days patients begin to understand the rehabilitation process and take responsibility for obtaining the goals outlined for them. Following surgery a @o/Cuff and Tecnol immobiliser are applied to the operative leg. The splint is removed when the patient returns to the room and the leg is placed in a continuous passive motion (CPM) machine with a ROM from 0 to 30”. The CPM machine serves to effectively elevate the knee and aid in keeping the patient comfortable. Extension exercises are started almost immediately by placing the patient’s heels on the end of the bed frame and allowing the knee to relax into full extension as shown in Fig. 11. A 2.5-pound ankle weight may be applied to the proximal tibia to aid in obtaining full knee extension. This is repeated every waking hour for approximately 10 min. The following day the patient continues the extension exercises during the waking hours. In addition, flexion exercises are initiated by allowing the knee to bend over the side of the bed three times a day during meals. Leg control is enhanced by performing short arc quadriceps contractions from 90 to 30”. Prior to discharge a shower is allowed with a plastic bag covering the operative

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Fig. 11. Full knee extension is achieved by placing the patient’s heels on the bed frame and allov+ingthe knee to relax into hyperextension. A 2.5-pound weight may be applied to the proximal tibia to aid in gaining full extension.

extremity. Full weight-bearing is encouraged and serves to facilitate patellar mobility and leg control. We have found that this programme for the first 2 days after surgery allows us to eliminate problems postoperatively and minimises the need for physical therapy to undo problems that may develop. After discharge the patient continues much of the sameat home. The CPM machine is utilised for approximately 1 week and the Cryo/Cuff is used almost continuously except during extension exercises and meals. Full weight-bearing ambulation is allowed but should be kept to a minimum during this initial phase of rehabilitation as it may result in knee swelling, which will slow the rehabilitation. An increase in activity is allowed during the second week. Many patients return to school or work on a part-time basis.Liberal use of the Cryo/Cuff and extension exercisesmust be continued. Knee welling servesas the best guide in determining the amount of activity allowed. The most urgent aspect of this phase is obtaining and maintaining full knee extension. Failure to achieve full extension early often leads to a permanent loss of knee motion and subjective symptomsupon return to activity. If the knee is allowed to remain in the flexed position the patellar tendon graft will not fit snugly in the intercondylar notch. As a result, scar tissue will fill the space and act as a ‘door stop’, preventing terminal extension, which can causeanterior knee pain and crepitus. Flexion has a lower priority during the initial phase of rehabilitation although we obtain near 90” of knee flexion prior to discharge to prevent patellar entrapment. Occassionally patients have difficulty maintaining full knee extension. If this situation develops, it must be recognised and aggressively addressed at this phase of the rehabilitation to prevent it from becoming a more difficult problem later. In most cases,management of this problem includes utilisation of an extension board, as shown in Fig. 12. The patient’s heel is placed on an elevated pad at the end of the board while straps above and below the knee

serve to extend the joint. Liberal use of the board is continued until the patient can easily achieve full knee extension. The

use of an extension

cast also is occasionally

re-

quired. In particular, a cast seemsto be most useful in

Fig. 12. The extension board is useful for patients who have difficulty gaining full knee extension. The heel is elevated while straps above and below the knee joint serve to promote extension.

two circumstances.The first is the patient who returns at the 1 week postoperative visit with 5” or more short of full extension. A full extension cast in this individual during sleep at night can eliminate the flexion contracture and also decrease knee swelling and allow a resumption of the programme. The second involves the patient who reports a very still and bent knee each morning. This situation is best treated by applying an extension case, bivalving it, and having the patient wear it while he or she sleepsat night. Both the extension board and casting are well tolerated and effective methods of limiting knee extension problems. With an understanding of the importance of full knee extension, patients are eager to do whatever is necessaryto achieve this goal. Phase III: Phase III of therapy encompasses the general

period from 2 to 5 weeks following reconstruction. Emphasis is placed on: (1) achieving a normal gait pattern; (2) maintaining

full knee extension;

(3) increasing

knee

flexion; and (4) quadriceps strengthening. By the third week patients should be ambulating without aids and without limping. Flexion exercisessuch as wall slides are continued, but the importance of maintaining full knee extension must be emphasized.Quadriceps strengthening is also an important part of preparing for a return to sport specific activities. The best tolerated strengthening programmes usually include closed chain exercisessuch as a stair-step machine, stationary bicycle, and leg press exercises. Phase Iv: Very few time constraints are placed on a return to full activities. We have found that a 70% return of quadriceps strength seems to be the necessary

level for successfulparticipation in sports specific activities. Any attempt to return before this level of strength is obtained often results in a sore and swollen knee. Rehabilitation should therefore focus on strengthening until this 70% level is achieved. Thereafter, strength will continue to improve with lessemphasison strengthening by resumption of participation in functional activities. It is not uncommon

for patients

to start these activities

as

soon as 5 weeks after surgery. Early involvement in lateral shuffles, cariocas, jumping rope, or shooting baskets is progressedas the patient becomesmore comfortable and confident on the reconstructed knee. It is important to remember 2-3 months of sport specific

that most patients require activities before returning

to a competitive level. Realistically, this means that an

Abstracts

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Knee 3 (1996)

athlete who plans on returning to competition 6 months after reconstruction needs to begin playing full-court basketball or equivalent at 3-4 months after surgery. Although little scientific support exists for functional bracing, we have continued to encourage its use during the first competitive season. Most patients can anticipate bouts of patellar tendon soreness and occasional swelling during the preseason drills. Avoiding severe patellar soreness early in the season, and in particular during two-a-day practices, is important to a successful return as the season progresses. Judicious use of a day off and limiting practice to once a day will often serve to minimise these problems. Very few patients experience the same difficulties the following season. Discussion It is believed that maturation of the reconstructed ligament is preceded by initial weakening as shown by previous animal studies. This graft weakening is accompanied by formation of a vascular sheath and revascularisation by 6-8 weeks after the procedure. A more recent human study has demonstrated that the reconstruction graft is repopulated with new host fibroblast as early as 3 weleks after reconstructive surgery. Amiel et al. have presented evidence that suggest that patellar tendon graft does respond to its environment. In addition, we now know that the healing ligament demonstrates both collagen synthesis and degradation, the balance of which is shifted toward synthesis during the inflammatory stage. Collagen synthesis and organisation is also known to be inlRuenced by applied stress in transplanted connective tissue. These observations would lead us to believe that the reconstructed patellar tendon graft is not a non-viable structure with little adaptive potential, but is actually a living construct with the ability to respond in a positive fashion to applied stress. This concept of ‘ligamentisation’ is central to the accelerated rehabilitation protocol. To date we have been unable to identify any detrimental effects of the accelerated protocol. While using the same surgical technique before accelerated rehabilitation (before 1987) and after accelerated rehabilitation (after 1987) we have seen an improvement in KT-1000 values. At a minimum follow-up of 2 years, the patients prior to 1987 had an average KT-1000 manual maximum difference of 2.8 mm. Patients following the accelerated protocol have had an average KT-1000 manual maximum difference of 2.1 mm. This improvement is most likely the result of our enhanced ability to reproduce the surgical technique with correct positioning and tensioning of the patellar tendon graft. Regardless of the reason, it appears the resumption of full weight-bearing and an early return to functional activities actually serves to strengthen the patellar tendon graft instead of ‘stretching‘ it out as previously hypothesized. The major advantage of the accelerated protocol lies in its ability to limit the incidence of postoperative morbidity. Patients who obtain full knee extension beforme and immediately after surgery rarely exhibit the surgical complications commonly associated with this procedure. Knee stiffness, patellofemoral pain, and quadriceps weakness are rarely encountered. Less than 1% undergo subsequent procedures for flexion contractures. Also, we have discovered that most patients are able to return to full activities much sooner than previously thought with no detrimental effects.

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Suggested Reading Amiel D, Kleiner JB, Akeson WH. The natural history of the anterior cruciate ligament autograft of patellar tendon origin. Am J Sports Med 1986:14;449-462. Andriacci T, Sabiston P, DeHaven K, et al. Ligament: Injury and repair. In: Woo SL, Buckwalter JA, eds. Injury and repair of the musculoskeletal soft tissues. Park Ridge, III: American Academy of Orthopaedic Surgeons, 1987:103. Amoczky SP, Tarvin GB, Marshall JL. Anterior cruciate ligament replacement using patellar tendon. J Bone Joint Surg 1982:64A;217-224. Clancy WG, Narechania RG, Rosenberg TD, et al. Anterior and posterior cruciate ligament reconstruction in rhesus monkeys. J Bone Joint Surg 1981:63A;l270-1284. Fullerton LR, Andrews JR. Mechanical block to extension following augmentation of the anterior cruciate ligament: A case report. Am J Sports Med 1984:12;166-168. Klein L, Lunseth PA, Aadalen RJ. Comparison of functional and non-functional tendon grafts. J Bone Joint Surg 1972:54A;1745-1753. Krippaehne WW, Hunt TK, Jackson DS, Dunphy JE. Studies on the effect of stress on transplants of autologous and homologous connective tissue. Am J Surg 1962:104;267-272. Mohtadi NG, Webster-Bogaert S, Fowler PJ. Limitation of motion following anterior cruciate ligament reconstruction: A case control study. Am J Sports Med 1991:19;620-625. Paulos LE, Rosenberg TD, Drawbert J, et al. Infrapatellar contracture syndrome: An unrecognised cuase of knee stiffness with patella entrapment and patella infera. Am J Sports Med 1987:15;331-341. Rougraff B, Shelboume KD, Gerth PK, et al. Arthroscopic and histologic analysis of human patellar tendon augografts used for anterior cruciate ligament reconstruction. Am J Sports Med 1993:21;277-284. Sachs RA, Daniel DM, Stone ML, et al. Patellofemoral problems after anterior cruciate ligament reconstruction. Am J Sports Med 1989:17;760-765. Shelboume KD, Johnson GE. Locked buckethandle meniscus tears in chronic ACL-deficient knees. Am J Sports Med (in press). Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med 1990:18;292-299. Shelboume KD, W&kens JH, Mollabashy A, et al. Arthrofibrosis in acute anterior cruciate ligament reconstruction: The effect of timing of reconstruction and rehabilitation. Am J Sports Med 1991 :19;332-336.

Preventing complications and minimising morbidy after autogenous bone-patellar tendon-bone anterior cruciate ligament reconstruction K Donald Shelboume Methodist Sports Medicine Center, 1815 North Capitol Avenue, Suite 530, Indianapolis, Indiana 46202, USA In this article we offer our approach to potential problems of anterior cruciate ligament (ACL) reconstruction and provide suggestions on how to minimise, prevent, or avoid them. Graft harvest, particularly with the patellar tendon graft, has concerned surgeons. Range of motion, quadriceps strength (if the patellar tendon is harvested from the ipsilateral knee) anterior knee (Patellofemoral) pain, patellar-tendinitis, and patellar contracture/baja are included in the spectrum of potential