HAVE YOU BEEN TOLD YOU NEED YOUR ACL RECONSTRUCTED?
DO YOU KNOW WHAT THE PROCEDURE INVOLVES AND THE RECOVERY TIME TO EXPECT?
DO YOU KNOW HOW TO OPTIMISE YOUR RECOVERY?
WHAT IS USED TO RECONSTRUCT THE ACL
When you undergo surgery following an ACL rupture the torn ligament is replaced with a graft. The graft is usually made from a part of a tendon that is taken from another part of your knee for example the hamstrings or the patella tendon. The use of the hamstrings tends to be a more popular option as grafting from the patella tendon can sometimes lead to discomfort around the front of the knee during the recovery period. Another option is use of an allograft which is a tendon that will come from a donor.
The surgeon will discuss the reasoning behind the choice of graft selected for you and this is usually related to your specific functional goals and the structure or your knee joint.
When the graft is fixed within your knee on the day of your surgery it is designed to restore the structural stability of your knee joint. It will act as a scaffold for which a new blood supply will develop and the physical therapy done after surgery is imperative to ensure that this new structure heals optimally and is well supported by the surrounding muscles.
WHAT DOES THE SURGERY INVOLVE AND HOW LONG WILL IT TAKE?
As mentioned in my previous blog, a common reason for ACLR is to reduce further damage to other structures within the knee i.e. the menisci. If other structures are also being repaired the length of surgery and recovery may therefore be slightly longer. This blog will focus on the ACLR alone.
The operation is usually done as a day case and is performed using an arthroscope which is a small fibre-optic TV camera. Most commonly only 3 small incisions are made. The surgery is performed under general anaesthetic and takes around 1 hr. The stages involved are as follows:
1: Constructing the graft:
Two small incisions are made where the arthroscope is placed into the knee and a 3rd incision (in the case of using a hamstring graft), is made on the inside of the knee at the top of the shin. It is from this last incision that the hamstring tendons are located and 3 or 4 strips are taken and stitched together to form the rope like structure that is your new ACL graft.
2: Graft location:
Once the graft has been crafted 2 small holes are drilled. 1 in the tibia (shin bone) and one in a diagonal direction above in the femur (thigh bone). This angle is carefully worked out to ensure maximum stability is gained.
3: Securing the graft:
The graft is then threaded through these 2 holes and screwed or stapled into place and the surgeon will check to ensure the knee feels stable.
4: Tidy up:
The knee is then cleaned up and stiches are applied to the fix the small incision.
Most patients are home within the day after they have seen a physiotherapist. The physio will show you how to use your crutches and how best to tackle stairs as well as giving you some basic exercises to start at home. Most people are often surprised at how quickly they are up and about. Some people suffer with sickness following a general anaesthetic and if this is the case or if any other complications are experienced then you may be kept in over-night.
WHEN SHOULD I START PHYSIOTHERAPY AND WHAT SHOULD I EXPECT FOLLOWING THE SURGERY?
The first 2 weeks following the surgery are focused on you recovering from the operation. You may have to return to hospital to have some stiches removed and the incision sites cleaned but otherwise there is little to do. For those patients that feel well enough to start physiotherapy I would usually recommend starting at around day 10-15 post surgery. The recovery process is split into stages and for this blog I will give you a more focused view on the early stage recovery:
- Wound healing : it is important that you keep the area clean and dry as the wounds heal. If you start to feel unwell and the wound is becoming red and angry then you must contact your surgeon. When the incisions have completely closed your physiotherapist will teach you to do some gentle massage over the scars to ensure they don’t become too sensitive or stiff.
- Managing pain: this is very different with each individual and I always leave it in the patient’s hands. Most people do not like taking pain killers but at this stage it is necessary to enable you to rest and sleep. The knee is going to be a little sore given the surgery, this is very normal. Over time (on average in week 2-4) you will be able to slowly wean yourself off the medication.
- Settling swelling: placing an ice pack or bag of peas over the knee for 10-15 mins 2-3 times a day will help settle swelling. Ensure you don’t put the ice pack directly on your skin as this can cause ice burns. Wrap it in a wet towel. Most patients continue this for 2-4 weeks.
- Range of movement: following your surgery your physio is likely to give you some exercises that focus on you straightening and bending the knee. The straightening part is always the most important at this stage to restore normal mechanics of the knee joint.
- Quadriceps activation: in combination with the range of movement work you will need to start activating your thigh muscles. These are used to straighten the knee and will support it as you start to walk. Initially it will seem like your muscles have gone to sleep. We call this ‘muscle inhibition’ and it occurs because the muscles are not good at contracting when there is pain and swelling around but the more you work on it you will start to see the muscle wake up and this makes everything feel much less painful.
- Gait/ Walking: you will be on 2 elbow crutches when you initially go home and will be taught how to use these properly. The crutches are simply used to reduce the amount of load the knee has to absorb as you start to work on your muscle strength. It is important that you obtain as ‘normal’ a gait pattern as possible as early as possible i.e. heel to toe pattern and allowing your knee to bend through as you take each step. It will feel very strange initially but eventually you will find you can put more and more weight through the leg and when you are walking without a limp you will be able to wean yourself off the crutches.
NOTE: You are always better to walk well on crutches than badly without as it avoids secondary problems. If you are still on crutches as 5 weeks that is ok. Everyone adapts and recovers differently and it is best to do it right.
The following stages of recovery will be outlined in my next blog in detail. Overall an ACL rehabilitation programme takes 12-18 months. The exercises become more challenging and are designed to advance the knee’s strength and control in situations of higher stress and load. This may sound like a long time but the work needed to restore strength, stability and neuromuscular control takes time and unfortunately we can’t make biology happen any faster! You may often see professional footballers back at 6/12 but remember they will have physio every day, often twice a day through that time and there are a large number of other factors that come into consideration in professional sport. You may also have heard of a friend who had the same injury and was back to sport at 6 months but I have every confidence in telling you that I would highlight significant risk factors for future injury if I were to do a full functional assessment of the knee at this stage post surgery.
NOTE: If patients cease physio after a few weeks or months following surgery they often fail to return to sport or go on to have knee issues in the future.
HOW CAN YOU BEST PREPARE FOR SURGERY?
The last point I want to make is about prehab. This is physical therapy prior to your surgery. As mentioned in my previous blog, an ACL rupture can render your knee stiff, swollen and weak. You are therefor best to allow the knee to settle from the acute injury and work with a physiotherapist to restore range of movement and strength prior to the operation. Delaying this only leads to mal- adaptive movement patterns and increased weakness and instability around the knee and makes recovery after surgery more difficult. Those that do 4-6 weeks of prehab tend to have a knee that recovers faster as it is operated on in a much better state.
If you have any questions about any of the above please do not hesitate to drop me an e mail or give me a call to discuss further.