Surgery and Rehabilitation Issues for ACL Injuries

ACL Rehabilitation Program

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

How has your ACL rehabilitation program evolved over the years?

"Since 1982, I have performed over 4000 ACL reconstructions. What is important to note is that I have used the same surgical technique since I began practice. This technique has always been reliable for obtaining predictable stability. Because I have not changed my method for surgery, I have been able to observe how changes in rehabilitation have affected the results. I have kept a database for ACL-reconstruction patients, which includes information regarding surgical factors, physical measurements, radiographic findings, and objective and subjective results. By keeping this database and by continually analyzing the results, I have been able to make observations regarding complications and rehabilitation problems through the years. With each problem encountered, we were able to analyze the many factors associated with the patient to determine what common variable might be responsible for the problem. Subsequently, we made changes in the rehabilitation program to improve our results.

"Initially, changes in rehabilitation have been made as an attempt to prevent the most common complication observed from ACL reconstruction surgery, knee stiffness. In the early 1980's, the rate of arthrofibrosis was 19%. Since 1996, the percentage of patients who have required a scar resection for symptomatic loss of extension has been <1%.

"The major changes made in our approach to surgery and rehabilitation from 1982 through 1996 were as follows:

1 No immobilization
The initial change in rehabilitation was to incorporate the use of a CPM machine and progress to a removable 0° splint. Once I realized that patients were not using the splint, I stopped using it.
2 Nonsurgical treatment of ACL/MCL injuries
I found that patients with ACL/MCL injuries had a higher incidence of knee stiffness than patients with ACL injuries alone. Given that MCL injuries can heal without surgical treatment, we stopped performing surgery for the MCL. Instead, I began using cast immobilization for a short period to allow the MCL to heal. Then patients underwent rehabilitation to regain full range of motion and good leg control before undergoing ACL reconstruction.
3 Noncompliant patients
In 1986, I had an independent investigator interview my patients to determine how compliant patients were with the restrictions regarding weight bearing and doing sports activities. We found that patients were bearing weight soon after surgery and that some begin doing sporting activities around 2 months after surgery. When comparing the results of patients who were compliant and those who were noncompliant, we found there was no difference in stability between the groups, and patients who were noncompliant had better range of motion, more strength, and better confidence in their knees. These findings led to our development of the "accelerated rehabilitation" program that we began in 1987.
4 Timing of Surgery
Patients who underwent ACL surgery after an acute injury versus chronic instability had a higher rate of knee stiffness after surgery. An initial study found that patients who underwent surgery within 3 weeks of injury had a 12.5 % incidence of requiring a scar resection versus 4.2% for patients who underwent surgery at >3 weeks after injury. Subsequently, we determined that it was not necessarily the time from injury but the condition of the knee that was most important. Once a patient has no swelling, full hyperextension and flexion and good leg control, ACL reconstruction can be performed. In addition, the patient should be mentally prepared for surgery. The surgery is an elective procedure and should be performed at a time when it is convenient for the patient's schedule with school and work.
5 Locked bucket-handle meniscus tears
Another group of patients who we found had a high incidence arthrofibrosis was that patients who had chronic ACL-deficiency and who sought treatment because they had a locked bucket-handle meniscus tear. When these patients underwent meniscus treatment and ACL reconstruction at the same time, they had a higher incidence of arthrofibrosis than those patients who underwent 2-staged procedures of meniscus treatment followed by an ACL reconstruction at an elective time once the knee regained full range of motion.
6 Early postoperative rehabilitation
The first 2 weeks after surgery are the most important with regard to rehabilitation. The key to success is to prevent a hemarthrosis. This is accomplished with the use of a Cryo/Cuff for compression and cold, CPM machine for elevation, and bed rest during the first 5 days after surgery. By preventing a hermarthrosis, the patient has an easier time of obtaining full range of motion and has less pain. Without a hemarthrosis, the patient does not have a problem with shut-down of the quadriceps muscle, so leg control exercises can be performed. During this time, patients can perform their range of motion exercises. Obtaining full hyperextension equal to the opposite normal knee is accomplished on the day of surgery and is monitored and maintained throughout the rehabilitation process. Flexion to about 100° should be accomplished by 1 week postoperative and flexion should be around 135° by 1 month. Aggressive leg strengthening exercises can begin once full range of motion has been achieved.
7 Use of patellar tendon graft from the contralateral knee
Because of my observation of the ease of rehabilitation for patients who underwent revision ACL reconstruction with a contralateral patellar tendon graft, I began using the contralateral graft source for primary ACL reconstruction in select patients 1994. Initially, I used the contralateral graft for patients who were involved in athletics and who desired to have a quick return to sports. However, because of the ease of regaining full range of motion, I began to use the contralateral graft source for other patients as well. I found that adult patients whose initial goal was to be able to comfortable return to work and daily activities, that using the contralateral graft allowed patients to attain these goals by 2 weeks after surgery. Because the patients were forced to use both legs equally, the return of strength and function was possible just by patients using both knees normally with every day activities. More advanced goals of returning to sporting activities could be achieved by specific donor site rehabilitation exercises to regain size and strength. Knee symmetry to the preoperative level has been the ultimate goal with surgery, and symmetry can be accomplished easier with using the contralateral graft.

"The peroperative rehabilitation program used for my patients has been one that has evolved and is still evolving. By continual data collection and analysis, I still strive to identify specific problem patients and we work to find solutions to those problems. I believe that a successful outcome in ACL reconstruction is based on the avoidance of any complications. Regardless of the graft site chosen, the ultimate goal with all patients should be to reconstruct the ACL-deficient knee with one surgery at the appropriate time and rehabilitate the knee so that it is symmetrical in motion, strength, and stability to the opposite knee."

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