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.
Patient Information and Management Guidelines for Hamstring Auto Graft.
Produced By Mr Jeer, Mr Vinayakam, Mr Seneveratne (Physiotherapist)
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 a 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 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.
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 sports 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 a 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 some time. Using a simple Tubigrip sleeve may help to stimulate skin sensation and improve the joint position sense.
- nerve sensitivity / neuroma.