Surgery and Rehabilitation Issues for ACL Injuries

Grafting Techniques

1 Introduction
2 Factors that contribute to arthrofibrosis >
3 Grafting techniques
4 Rehab following contralateral patellar tendon grafting >
5 ACL rupture incidence in females >
6 ACL rehabilitation program >

You have pioneered the use of the contralateral patella tendon as a graft for ACL reconstruction. Why do you prefer this technique over hamstring tendon grafts or allografts?

"In my opinion, ACL reconstruction should be performed using the graft source that has been found to be the most reliable for obtaining good postoperative stability. The patellar tendon graft is the strongest graft available, and it provides quick bone-to-bone healing to allow accelerated rehabilitation. The surgical technique I use involves button fixation, which provides a tight bone-to-bone press fit of the bone plugs, and healing has been evident on MRIs at 1 week after surgery.

"The reason other graft sources have been sought by some surgeons is because of the limited knowledge regarding the means for rehabilitation the donor site. Rehabilitation for ACL reconstruction has always centered upon rehabilitation as it pertains to the ACL graft in the knee, but the donor site has been largely ignored.

"I have always used the contralateral patellar tendon graft for revision ACL reconstruction. In my experience with these patients, I have observed the ease and quickness the patients had with obtaining full range of motion and with returning to activities. At first, it did not make sense to me that patients who were undergoing a revision surgery actually had an easier time with rehabilitation than patients who had primary surgery. I thought the reason was probably because the patients had been through the procedure before, so they knew what to expect. However, range of motion in the contralateral donor knee returned to full essentially on the day of surgery. In addition, the range of motion in the ACL reconstructed knee returned to full quicker also. Furthermore, the attainment of full range of motion seemed to be easy for patients in that they did not have to spend a lot of time each day doing range of motion exercises.

"It was these observations with patients undergoing revision ACL reconstruction that led me to performing primary ACL reconstruction using the contralateral patellar tendon. It took us a couple years to refine the rehabilitation for this approach to surgery. We finally learned that to rehabilitate the donor site, it needed to be done in 3 progressive steps:

Step 1
Get full range of motion in the knee (obtained usually on the day of surgery).
Step 2
Do high repetition, low resistance exercises beginning immediately after surgery to stimulate the patellar tendon to grow back to normal size.
Step 3
Begin heavier strengthening exercises to regain strength back to normal. You cannot begin heavy strengthening until the patellar tendon size has recovered. Heavy strengthening on a smaller than normal tendon makes the tendon extremely sore. The high repetition, low resistance should make the tendon just sore enough so the patient can feel the soreness, but it should resolve quickly after icing the knee.

"Meanwhile, the rehabilitation for the ACL-reconstructed knee can concentrate fully on regaining full range of motion, and there is no immediate concern for strengthening the leg. Full extension should be obtained the day of surgery. Usually flexion will be around 115° at 1 week, 125° at 2 weeks, and full by 1 month postoperatively. By full flexion, I mean the patients should be able to sit on his heels.

"During this first month, the patients should be able to get the patellar tendon size back to normal in the donor knee. So, at 1 month post-op, the patient should be ready to do more aggressive strengthening. By having surgery in both knees, the patient is forced to use both knees equally, which fosters more symmetry between knees. This is an advantage to having just one knee undergo surgery because many times, with 100% strength in one leg and 60% strength in the other leg, the patient continues to favor the stronger leg and the operative leg never recovers to normal. With using the contralateral graft, both knees have symmetrical but lesser than normal strength initially, but by using both legs with every day activities and with strengthening exercises, both will recover to their preoperative normal baseline strength."

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4 Rehab following contralateral patellar tendon grafting >

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