ANTERIOR CRUCIATE LIGAMENT...different (4.3% vs 4.1%) No difference in those returning to sports sooner than 6 months compared to those after 6 months Risk 17%

1

ANTERIOR

CRUCIATE

LIGAMENT

Prevalence

1 out of every 3000 people will suffer an

ACL injury per year.

Approximately 100,000 ACL

reconstructions are performed annually.

Miyasaka KC, et al. The incidence of knee ligament injuries in the

general population. Am J Knee Surg 1991;4:3-8.

Cavanaugh J. Anterior Cruciate Ligament Reconstruction. In:

Postsurgical Rehabilitation Guidelines for the Orthopedic

Clinician. Mosby, St. Louis, 2006.

Prevalence

Disrupted more than any other ligament in

the body

Johnson R. Prevention of cruciate ligament injuries. In: Feagin JJ

(ed). The Crucial Ligaments: Diagnosis and Treatment of

Ligamentous Injuries about the Knee. New York, 1988. Churchill

Livingstone.

http://www.answers.com/main/Record2?a=NR&url=http%3A%2F%2Fcommons.wikimedia.org%2Fwiki%2FImage%3AGray347.png

http://www.answers.com/main/Record2?a=NR&url=http%3A%2F%2Fcommons.wikimedia.org%2Fwiki%2FImage%3AGray347.png

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ACL Reconstruction Cost

Variance

Archibald-Seiffer N, et al. Review of anterior cruciate ligament reconstruction cost variance

within a regional health care system. Am J Sports Med. 2015;43(6):1408-1412.

Archibald-Seiffer N, et al. Review of anterior cruciate ligament reconstruction cost variance

within a regional health care system. Am J Sports Med. 2015;43(6):1408-1412.

Function of the ACL

Primary restraint to anterior displacement of

tibia relative to the femur

Secondary stabilizer of rotation, mainly

with internal and external tibial rotation

Cruciates cross with tibial internal rotation

3

Ligament Restraints

ACL provides 85% of restraint to anterior displacement of

tibia between 30-90 degrees of knee flexion

Secondary Restraints – remaining 15%

ITB 25%

Mid 1/3 medial capsule 22%

Mid 1/3 lateral capsule 20%

MCL 16%: LCL 12%

Butler DL, Noyes FR, Grood ES: Ligamentous restraints to anterior-posterior drawer in the

human knee: a biomechanical study, J Bone Joint Surg Am 62:259-270, 1980.

Grood ES, Suntay WJ, Noyes FR, Butler DL: Biomechanics of the knee-extension exercise:

effect of cutting the anterior cruciate ligament, J Bone Joint Surg Am 66:725-734, 1984.

Minimum 5 year FU

1820 patients

78% - 1415 patients

75 (5.3%) had injury

to other knee

61 (4.3%) had injury

to reconstructed knee

Shelbourne KD, Gray T, Haro M. Incidence of subsequent injury to either

knee within 5 years after anterior cruciate ligament reconstruction with

patellar tendon autograft. Am J Sports Med 2009;37(2):246-251.

Women suffered more injuries than men to

contralateral knee (7.8% to 3.7%)

Injuries to reconstructed knee not significantly

different (4.3% vs 4.1%)

No difference in those returning to sports

sooner than 6 months compared to those after

6 months

Risk

17%<18

7% 18-25

4% > 25

Shelbourne KD, Gray T, Haro M. Incidence of subsequent injury to either

knee within 5 years after anterior cruciate ligament reconstruction with

patellar tendon autograft. Am J Sports Med 2009;37(2):246-251.

4

Anatomy

Intercondylar notch

A-shaped notch – higher risk for ACL

injury

With ER ACL gets caught against notch

and is cut by LFC

Uhorchak JM, et al. Risk factors associated with non-contact injury of the

anterior cruciate ligament: a prospective four-year evaluation of 859 West

Point cadets. Am J Sports Med 2003;31(6):831-842.

Anatomy

Intercondylar notch

Others though cast doubt that notch size

contributes to ACL injury

Schickendantz MS, Weiker GG. The predictive value radiographs in the

evaluation of unilateral and bilateral anterior cruciate ligament injuries.

Am J Sports Med 1993;21(1):110-113.

Teitz CC, et al. Symmetry of the femoral notch width index. Am J Sports

Med 1997;25(5):687-690.

Intercondylar Notch

615 male professional basketball players

NBA combine workouts between 1992-

1999

NBA league-wide injury database used to

identify injured players

Notch width index did not predict rate of

ACL injury

Lombardo S, Sethi PM, Starkey C. Intercondylar notch stenosis is not a

risk factor for anterior cruciate ligament tears in professional male

basketball players . Am J Sports Med 2005;33(1):29-34.

5

Anatomy

Q-angle

Those who sustained ACL injury

displayed significantly larger Q-angle

than those that did not sustain injury

Shambaugh JP, et al. Structural measures as predictors of injury in

basketball players. Med Sci Sports Exerc 1991;23(5):522-527.

Anatomy

Notchplasty

Before 1988 done only to increase visualization

of intercondylar area

Noticed upon subsequent arthroscopy that the

lateral aspect of graft became frayed

Now routinely take 11 mm for standard 10 mm

graft

Shelbourne KD and Trumper RV. Anterior Cruciate Ligament

Reconstruction: Evolution of Rehabilitation. In: Ellenbecker TS

(ed). Knee Ligament Rehabilitation. Churchill Livingstone 2000.

Anatomy

Absolute Size of ACL

Volume calculated via

MRI scans

27 noninjured knees of

those injured with

noncontact ACL injury

27 age matched controls

Chaudhari AMW, et al. Anterior cruciate ligament injured subjects

have smaller anterior cruciate ligaments than matched controls. A

MRI Study. Am J Sports Med 2009;37(7):1282-1287.

6

Anatomy

Contralateral volume for

injured subjects was

significantly smaller than

non injured subjects

Injured group volume =

1921 mm3

Uninjured group volume =

2151 mm3

Chaudhari AMW, et al. Anterior cruciate ligament injured subjects

have smaller anterior cruciate ligaments than matched controls. A

MRI Study. Am J Sports Med 2009;37(7):1282-1287.

ACL – Where Does It Fail

80% Mid Substance

18% Femur

2% Tibia

Younger patients often have an avulsion of

the tibial spine which is the insertion of the

ACL

ACL

35mm long

Stretches 10-12 mm

(1/3 increase) before it

ruptures

7

ACL

> 50% disruption

> 50% risk of

progression to

complete failure

Noyes FR, et al. Partial tears of anterior cruciate ligament.

Progression to complete ligament deficiency. J Bone Joint Surg.

1989;71B:825-833.

Mechanism of Injury

Combined valgus and

external rotation

applied to the knee

while the the foot is

firmly planted.

Mechanism of Injury

Non contact external

rotation

8

Mechanism of Injury

Excessive internal

rotatory force or

combination of

internal rotation and

hyperextension

Mechanism of Injury

Hyperextension

Perception of knee

“giving out”

Mechanism of Injury

Most injuries are noncontact injuries in

which sudden limb deceleration

accompanied by contraction of the

quadriceps muscle group

Football player planting and cutting

Basketball player catching a pass and

planting to cut toward basket

9

Mechanism of Injury

6 experts visually examined 39 videos of

ACL injury situations

72% did not involve contact

>50% of women injured pushed just before

injury

Perturbation may have influenced injury

Krosshaug T, et al. Mechanisms of anterior cruciate ligament injury in basketball. Am J Sports Med 2007;35(1):359-367.

Mechanism of Injury

Knee flexion angles at injury were higher in

males than females

Females 5.3 times higher risk of sustaining

valgus collapse

Preventive programs should include

distractive elements

Krosshaug T, et al. Mechanisms of anterior cruciate ligament injury in basketball. Am J Sports Med 2007;35(1):559-367.

Injury From External Contact

O’Donoghue “unhappy triad”

Combination of valgus, flexion, and external rotation applied to knee while foot is planted

Injury to ACL, MCL and Medial Meniscus (Lateral meniscus?)

10

Lateral Meniscus!

Shelbourne KD, Nitz PA. The O’Donoghue triad revisited: combined knee injuries involving anterior cruciate and medial collateral ligament tears. Am J Sports Med. 1991;19:474-477.

Barber F. Snow skiing combined anterior cruciate ligament/medial collateral ligament disruptions. Arthroscopy. 1994;10:85-89.

Barber F. Accelerated rehabilitation for meniscus repairs. Arthroscopy. 1994;10:206-210.

Duncan JB, et al. Meniscal injuries associated with acute anterior cruciate ligament tears in alpine skiers. Am J Sports Med. 1995;23:170-172.

Physical Examination

Patient usually feels and hears a “pop”

(80-90%)

Acute hemarthrosis develops within 12

hours

Factors Determining Treatment

Choices Access to rehab facility

4 week lag time

Surgery on acutely injured knee will lead to

decreased ROM and impaired function

One month prior to surgery begin PRE-HAB

Increase strength

Increase ROM

Decrease swelling

11

Surgical Procedures

Ideal Operation:

Fixation:

Screws rather than sutures

Bone-IPT-bone better fixation

Excellent strength

Allows immediate motion

Permits early activity

Prevent recurrence

Primary Repair

Original tissue is repaired back to itself

Poor long term results for intra-substance tears

repaired as an isolated procedure

Rupture affects blood supply

Medial intragenicular artery injured

Tissue becomes necrotic

Decreases integrity of graft

Appropriate only when true avulsion occurs

Indications for Primary Repair

True avulsion

Usually occurs in teens

Ligaments stronger than bones

Epiphyseal growth plate open

Fixation of bony fragment with screw

Sedentary individuals

Older individuals – less active

Partial ACL rupture with minimal instability

12

Primary Repair with Marrow

Stimulation

99 patients

26 treated with

primary repair of

proximal ACL tears

Marrow stimulation

via microfracture at

femoral footprint

Gobbi A, et al. Primary repair combined with bone marrow stimulation in acute

anterior cruciate ligament lesions. Am J Sports Med. 2009;37(3):571-578.

Primary Repair with Marrow Stimulation





13

Primary Repair with Marrow Stimulation

25 month follow up (17-38 mo)

Subjective scales lower (improved)

following procedure

Ligament laxity different

3.5 mm pre - 1.3 mm post



Reconstructive Procedures

Replace original graft

Infrapatellar Tendon (IPT)

Extra-articular structure becomes an intra-

articular structure

Rejection phase

May create a synovitis response

This can lead to decreased blood supply

Different Procedures

Autograft: own tissue

Allograft: from “tissue bank”

Synthetics: man made tissue

14

Ligament Substitutions

Increased tensile strength

Increased fatigue strength

Decreased immunogenicity

Easy to install

Allows early rehab and return to activity

Allows biological ingrowth

Isometricity/Physiometry

Constant tension on ligament throughout

ROM

The ideal placement for intra-articular grafts

Improper placement is most common cause

of surgical failure

Autograft

Patellar tendon

Bone-IPT-bone procedure

Gold standard

Central 1/3 of IPT (10mm) on average

Semitendinosis/gracilis

Double, triple or quadruple looped for reinforcement

Iliotibial band/Quadriceps tendon

Not used very often

15

Patellar Tendon Autograft

Advantages

Readily available

Excellent strength

Best well documented long term results

Allows most aggressive rehab of all biological tissue secondary to strength and bone-bone healing

Patellar Tendon Autograft Disadvantages

Weakens extensor mechanism (?)

Associated risks

Patellar chondrosis

Tendinitis

ROM deficits

Patellar fracture

Tendon rupture

Requires diligent rehabilitation

IPCS may result

Excessive proliferation of scar tissue secondary to vascular supply

Patellar Tendon Autograft

Anatomic/pathologic limitations

Small/narrow tendon

Chronic tendinitis

Reduced performance in some jumping

sports

16

Surgical Technique

Bone-central 1/3 tendon-bone

Free graft, nothing attached

Procedures

Open reconstruction

Arthroscopically assisted procedure: Hole drilled out through femur, screw fixation from outside

Endoscopic technique: Do not drill all the way out of femur, screw fixation from inside

Semi-T, Gracilis

Tendon

Semi-T/Gracilis Autograft

Advantages

Readily available

Double/triple loop gives excellent strength (120-140%)

Doesn’t compromise the extensor mechanism

Biological graft (immunogenicity)

No weakness of hamstrings

Lipscomb AB, et al. Evaluation of hamstring strength following use of

Semitendinosis and gracilis tendons to reconstruct the anterior cruciate ligament.

Am J Sports Med. 1982;10(6):340-342.

17

No Loss of Hamstring Strength

Lipscomb AB, et al. Evaluation of hamstring strength following use of Semitendinosis and

gracilis tendons to reconstruct the anterior cruciate ligament. Am J Sports Med.

1982;10(6):340-342.

Harter RA, et al. Long-term evaluation of knee stability and function following surgical

reconstruction for anterior cruciate ligament insufficiency. Am J Sports Med 1988;16:434-

443.

Shino K, et al. Quantitative evaluation after arthroscopic anterior cruciate ligament

reconstruction: Allograft versus autograft. Am J Sports Med 1993;21:609-616.

Sachs RA, et al. Patellofemoral problems after anterior cruciate ligament reconstruction. Am

J Sports Med 1989;17:760-765.

Conteduca F, et al. LAD augmentation in ACL reconstructions with pes anserius:

Comparison between proximal and distal detachment. Internal-external forces analysis with

Cybex II evaluation. Presented at the IV European LAD Study Club Meeting, Edinburgh,

Scotland, 1990.

Yasuda K, et al. Graft site morbidity with autogenous semitendinosus and gracilis tendons.

Am J Sports Med 1995;23:706-714.

No Loss of Hamstring Strength

Simonian PT, et al. Assessment of morbidity of semitendinosus and gracilis tendon harvest

for ACL reconstruction. Am J Knee Surg 1997;10:54-59.

Carter TR, Edinger S. Isokinetic evaluation of ACL reconstruction. Hamstring versus patellar

tendon. Arthroscopy 1999;15:169-172.

Nakamura N, et al. Evaluation of Active Knee-Flexion and Hamstring Strength After

Anterior Cruciate Ligament Reconstruction Using Hamstring Tendons. Arthroscopy.

18(6):598-602, 2002.


Two possible explanations for maintaining

hamstring strength:

Tendons remain functional

Compensatory hypertrophy of undisturbed knee

flexors.

MRI cross sectional areas of biceps femoris,

semimembranosus and sartorius muscles were not

significantly different

Simonian PT, et al. Assessment of Morbidity of Semitendinosus and Gracilis

Tendon Harvest for ACL Reconstruction. Am J Knee Surg. 10(2):54-59;1997.

18


Distal most insertion of semi-T & Gracillis

tendons after harvest were always more

proximal than the non-op side

Majority of cases demonstrated some but

never complete re-growth or scar formation

of these tendon remnants

Simonian PT, et al. Assessment of Morbidity of Semitendinosus and Gracilis

Tendon Harvest for ACL Reconstruction. Am J Knee Surg. 10(2):54-59;1997.

Semitendinosis/Gracilis Graft

Disadvantages

Limited long-term follow-up studies

Slower rehabilitation

Soft tissue to bone healing

Still requires diligent rehabilitation

Chronic tendonitis of Semimembranosis

Small tendon

Lizard Tail Phenomenon

19

Lizard Tail

Study to evaluate the ability of the native semi -T to

regenerate after harvest for ACL replacement

Rabbit model; All 10 specimens demonstrated regeneration

at 16 and 28 weeks with normal appearing histological and

morphologic characteristics

Biomechanical strength 23% normal at 16 weeks and 62%

normal at 28 weeks

Leis HT, et al. Hamstring Regrowth Following Harvesting for

ACL Reconstruction. J Knee Surg, 2003;16(3):159-164.

Lizard Tail

Patellar tendon harvest site has been shown

to refill with scar tissue

Biomechanically inferior to native patellar

tendon and not suitable for revision ACL

reconstruction

Leis HT, et al. Hamstring Regrowth Following Harvesting for

ACL Reconstruction. J Knee Surg, 2003;16(3):159-164.

Lizard tail in humans

40 patients ; pre-post ultrasonagraphy

Post US @ 2 wks, 1,2,3,6,12,18,24 mo.

2 weeks: site occupied by an area of increased

thickness and decreased echo, suggesting edema

of soft tissue

1 month: irregular hypoechoic structure appeared

in near anatomic position

Papandrea P, et al. Regeneration of the Semiteninosus Tendon

Harvested for Anterior Cruciate Ligament Reconstruction. J

Sports Med, 28(4):556-561, 2000.

20

Lizard tail in humans

2 mo: Thickness, width, and cross-sectional area were significantly greater than pre-operatively

1 yr: Distinct edges and reduction in thickness and width

18 & 24 mo: Echogenicity of structure very similar to that of normal tendon, but approx. 4 cm proximal to pes anserine.

Papandrea P, et al. Regeneration of the Semiteninosus Tendon

Harvested for Anterior Cruciate Ligament Reconstruction. J

Sports Med, 28(4):556-561, 2000.

ACL ALLOGRAFT

Allograft

Indications

Older individual with substantial DJD or

low desire for high impact activities

When short convalescence is important

Accept increased likelihood of graft

failure

21

Allograft

Advantages

Biological graft – cadaveric tissue retrieved

from tissue bank which is capable of

remodeling and repair

Decreased surgical morbidity with endoscopic

placement, no compromise of normal anatomy

May require less intense of rehabilitation

No other options

Allograft

Disadvantages

Transmission of communicable disease

Prolonged remodeling/revascularization time

Expense and availability – graft alone >$2000

Tissue radiation – decreased tensile strength (?)

YUCK effect - GJD

External biological tissue

Greater chance of infection

May create chronic synovitis

Allograft vs Auto in Younger

Systematic review with meta-analysis

Comparative studies of allograft vs autograft in those <25 years of age and high activity level

7 studies – 788 auto; 288 allo

Mean age 21.7 years; follow up time =24-51 months

Wasserstein D, Sheth U, Cabrera A, Spindler KP. A systematic

review of failed ACL reconstruction with autograft compared with

allograft in young patients. Am J Sports Med. 2015;7(3):207-216.

22

Allograft vs Auto in Younger

Pooled failure variance

Autografts = 9.6 (76/788

Allografts = 25% (57/228)

Wasserstein D, Sheth U, Cabrera A, Spindler KP. A systematic

review of failed ACL reconstruction with autograft compared with

allograft in young patients. Am J Sports Med. 2015;7(3):207-216.

Thermal Treatment to Partial

ACL Tears

Thermal energy has been useful in

treatment of shoulder instability for some

time

Recently thermal energy has been used to

treat laxity of the ACL following surgery or

in partially torn ACL’s

BE CAREFUL!

23

Thermal Treatment for ACL’s

A paucity of in vivo, in vitro, and clinical

data are available with regard to this

potential treatment regime.

Lopez and Markel

Monoploar RFE to the normal ACL of one knee in each of 18 dogs with sham treatment of the contralateral ACL.

Results showed rupture of all treated ligaments approximately 55 days after surgery.

Rupture detected by sudden onset of NW status and + drawer sign.

Lopez, MJ, Markel MD. Anterior cruciate ligament rupture after

thermal treatment in a canine model. Am J Sports Med. 2003;

31(2):164-167.

Sekiya JK, Golladay GJ, Wojtys E

Case Study

16 yo female injured L knee playing basketball

ACLR with semi T/Gracilis

5 months after surgery patient re-injured knee.

Arthroscopy revealed irreparable medial meniscus

tear with ACL in continuity but lax

Sekiya JK, et al. Autodigestion of a Hamstring ACL autograft following

thermal shrinkage. J Bone Joint Surg. 82A:1454-1457, 2000.

24

Autodigestion

ACL treated with heat probe 65 degrees C

as recommended by manufacturer

Graft shrinkage was seen. Following

procedure Lachmans revealed no increased

laxity compared to uninvolved side

13 week after 2nd surgery sustained non

contact knee injury



Autodigestion

PE revealed 3+ Lachman’s with no end point

2 weeks later arthroscopy revealed to remnant of previous hamstring graft identifiable in the notch

Revision with BPTB

9 months following surgery no subjective instability and Lachman’s (-)



Autodigestion

23 year old male athlete

Hyperextension injury playing semi professional

football

Tx four weeks after injury with RFE

Operative report detailed ligament treated on

anterior aspect with “good visual shrinkage”

Post treatment “looked like a normal ligament

with no laxity”

Bailie DS, Ellenbecker TS. Case illustrates risk of thermal shrinkage

in knee joint. Biomechanics 10(9):2003.

25





Autodigestion

Braced 3 weeks in full extension

Returned to full activities in 15 weeks

(-) Lachmans, pivot shift and no c/o pain or

instability

6 months later reported to clinic after

sustaining non-contact twisting injury while

playing soccer. Felt “pop” in same knee



26

Autodigestion

Minimal swelling and med joint line pain

2+ Lachman’s, 2+ pivot shift and 8mm side

to side difference laxity with KT-1000

MRI revealed non-visualization of ACL

Absence of ACL noted during surgery



27

Reasons for Autodigestion

Biomechanical alteration of the collagen

may have led to failure of the graft

An immune-mediated response resulted in

autodigestion of the graft.

Sekiya JK, et al. Autodigestion of a hamstring anterior cruciate

ligament autograft following thermal shrinkage: A case report and

sentinel of concern. J Bone J Surg. 2000;82-A(10):1454-1457.

Thermal Shrinkage – 2 Year FU

64 patients

2 centers

Lax ACL from native

or previous reconstructions

> 2 year follow-up

Smith DB, Carter TR, Johnson DH. High failure rate for electrothermal

shrinkage of lax ACL: Multicenter follow-up past 2 years. Arthroscopy.

2008;24:637-641.

Thermal Shrinkage – 2 Year FU

Failure as determined by 5mm increase in

laxity with KT-1000

Overall 50.8%

Previous reconstructions 78.9%

Native ACLs 38.1%

Smith DB, Carter TR, Johnson DH. High failure rate for electrothermal

shrinkage of lax ACL: Multicenter follow-up past 2 years. Arthroscopy.

2008;24:637-641.

28

Surgical Delay

Relationship between ACL reconstruction

delay and incidence of secondary injury

1434 patients

Time to surgery after initial injury

Ralles S, Agel J, Obermeier M, Tompkins M. Incidence of secondary

intra-articular injuries with time to anterior cruciate ligament

reconstruction. Am J Sports Med. 2015;43(6):1373-1379.

Surgical Delay

Time delay

0-3 months

4-12 months

> 12 months

Association noted between time to surgery and

injury

Trochlea, lat fem condyle, med tib plateau,

medial meniscus

Ralles S, Agel J, Obermeier M, Tompkins M. Incidence of secondary

intra-articular injuries with time to anterior cruciate ligament

reconstruction. Am J Sports Med. 2015;43(6):1373-1379.

Early Revision Predictors

32 adolescents – ACL surgery

Mean age 15.2 years

21(91%) followed at 10-20 years after

Clinical, radiographic and QOL data

Mansson O, Sernert N, Rostgard-Christnesen L, Dartus J. Long-term

clincal and radiographic results after delayed anterior cruciate ligament

reconstruction in adolescents. Am J Sports Med. 2014;43:138-145.

29

Early Revision Predictors

Reconstructed knee significantly more OA

compared with non involved knee

Tegner and Lysholm scores not different pre and

post

Strength and stability improved

Subjective scales varied

Mansson O, Sernert N, Rostgard-Christnesen L, Dartus J. Long-term

clinical and radiographic results after delayed anterior cruciate ligament

reconstruction in adolescents. Am J Sports Med. 2014;43:138-145.

Graft Failure

Categorization of Graft Failure

Error in Surgical Technique

Failure of Incorporation

Trauma

Gries PE, Johnson DL, Fu FH: Revision anterior cruciate ligament surgery: Causes of graft failure and technical considerations of revision surgery. Clin Sports Med. 12;839:1993.

30

Error in Surgical Technique

Initially incompletely recognized or

addressed complex ligament injuries

inadequate notch plasties

Improper tunnel placement

Improper graft tensioning

Insufficient fixation

Failure of Incorporation

Failure of graft to mature and remodel

Trauma

Insufficient or excessive rehabilitation

Recurrent injury (knee abuser)

31

Strain on ACL

Running Downhill 125%

Isometric quad contraction, 22° knee flex, 20-lb 62-121%

Isometric quad contraction, 0° knee flex, 20-lb 87-107%

Jog on floor 89%

Leg lift, 22° knee flexion 12-79%

Jog 5 mph on treadmill 62-64%

Isometric quad contraction, 45° knee flexion, 20-lb 50%

Walk without assist device 36%

Half-squat, one leg 21%

Quad set 18%

Walk with crutches, 50-lb weight bearing 7%

Stationary cycle 7%

Isometric hamstring contraction -7%

Strain on ACL Isometric quadriceps contraction 15° 4.4%

Squatting with resistance 4.0%

Active knee flexion with resistance 3.8%

Lachman’s test (150N anterior shear at 30°) 3.7%

Squatting without resistance 3.6%

Active knee flexion without resistance 2.8%

Quadriceps and hamstring co-contraction at 15° 2.7%

Isometric quadriceps contraction at 30° 2.7%

Stair climbing 2.7%

Anterior drawer test (150 N anterior shear at 90°) 1.8%

Stationary bicycle 1.7%

Quadriceps and hamstrings co-contraction at 30° 0.4%

Passive knee range of motion 0.1%

Isometric quadriceps at 60° and 90° 0.0%

Quad and hamstring co-contraction at 60 ° and 90 ° 0.0%

Isometric hamstring contraction at 30°, 60°, 90° 0.0%

Fleming BC, Beynnon BD, Renstrom PA, et al. The strain behaviouir of the

ACL during stair climbing. An in vivo study. Arthroscopy. 1999;15:185-191.

Ligamentization

Necrosis

Revascularization

Cellular proliferation

Collegen formation

32

Necrosis

First 3 weeks following surgery

Graft needs blood supply

Native cells diminish

Graft nourished by synovial fluid and bone

blood supply

Revascularization

Within first 6-8 weeks

Inflammatory response under control

Bone plugs generally incorporate into

tunnels within 12 weeks

Cell proliferation

Tissue begins to become vascularized

Fibroplasia

Fibroblastic activity collagen and elastin

Tensile strength of ligament slowly

increases

33

Collagen formation (Maturation)

Long-term process

Collagen remodeled in lines of stress

according to tensile forces placed on tissue

Tissue gradually assumes normal

appearance

May require over 1 year

Graft Maturity

Comparison of quad

tendon with bone to

hamstring auto

26 patients

12 quad

14 hamstring

1.5 T MRI .5 years

postoperatively

Ma Y, et al. Graft maturity of the reconstructed anterior cruciate ligament 6 months

postoperatively: a magnetic resonance imaging evaluation of quadriceps tendon with

bone block and hamstring tendon autografts. Knee Surg Sports Traumatol Arthrosc.

2014:DOI:10.1007/s00167-014-3302-0.

Signal to noise ratio

Quad tendon =1.74

Hamstring = 2.44

Rehab may require

modifications

Ma Y, et al. Graft maturity of the reconstructed anterior cruciate ligament 6 months

postoperatively: a magnetic resonance imaging evaluation of quadriceps tendon with

bone block and hamstring tendon autografts. Knee Surg Sports Traumatol Arthrosc.

2014:DOI:10.1007/s00167-014-3302-0.

34

Graft Maturity

Comparison of allo

vers auto

52 patients

30 allografts

22 autografts

3.0 T MRI 2 years

postoperatively

Hong L, Tao H, Cho S, Chen S, Yau Z, Chen S. Difference in graft maturity of the

reconstructed anterior cruciate ligament 2 years postoperatively. Am J Sports Med.

2012;40:1519-1526.

Graft Maturity

Outcomes

Subjective

IKDC

Tegner scores

Physical examination

Lachmans test

Anterior drawer



2012;40:1519-1526.

Graft Maturity

All normal function by 2 years

No subjective score difference

No difference in laxity measures

Signal/noise quotient allograft significantly higher

than autograft

Indicating inferior graft maturity



2012;40:1519-1526.

35

Structured Rehab with Surgery

Vs. Structured Rehab and option for surgery

121 young active

adults – acute ACL

tear

Rehab + ACL

repair

Rehab and option

for repair

Frobell RB, et al. A randomized trial of treatment for acute anterior

cruciate ligament tears. N Engl J Med 2010;364(4):331-342.


Vs.

Structured Rehab and option for surgery

2 year follow-up

Change in outcome scales

4 subscales of KOOS

Short Form 36 Survey

Tegner Activity Scale




Vs.

Structured Rehab and option for surgery

Both groups saw improvements

No significant change between two groups

in either primary or secondary outcomes

Early structured rehabilitation with surgery

did not attain better outcomes than

structured rehabilitation



36

Editorial: Arthroscopy

Apples vs. Apples + Oranges

39% of delayed group went ahead to have

surgery

100% of surgery group had surgery, but so

did 39% of conservative

Tegner scores were significantly different

Tegner better at measuring higher demand

activities than KOOS

Richmond JC, Lubowitz JH, Poehling GG. Prompt operative

intervention reduces long-term osteoarthritis after knee anterior

cruciate ligament tear. Arthroscopy. 2011;27(2):149-152

Editorial: Arthroscopy

Surgical group returned to cutting activities

Non surgical group limited to jogging

Surgery group 39 of 60 (65%) sustained

meniscal damage at time of injury, but only

29 (48%) ended up with resections

Delayed surgery group 30 of 59 (51%)

sustained meniscal tears at time of injury,

but in end 41 of 59 (70%) required resection

Richmond JC, Lubowitz JH, Poehling GG. Prompt operative

intervention reduces long-term osteoarthritis after knee anterior

cruciate ligament tear. Arthroscopy. 2011;27(2):149-152

General ACL Rehabilitation

37

Discussion Today

Single-Bundle ACL

Reconstruction

Discussion Tomorrow

Double-Bundle ACL

Reconstruction

Single-Bundle Technique

Used since 1970’s

Geometry of ACL very

complex

Single-bundle technique

does not duplicate normal

anatomy?

Beynnon BD, et al. Treatment of anterior cruciate ligament injuries:

Part 1. Am J Sports Med 2005;33:1579-1602.

Beynnon BD, et al. Treatment of anterior cruciate ligament injuries:

Part 2. Am J Sports Med 2005;33:1751-1767.

38


High level of OA following ACL

reconstructions.

Single-bundle unable to control valgus and

internal rotation force (Pivot Shift)

Woo SL, et al. The effectiveness of reconstruction of the anterior

cruciate ligament with hamstrings and patellar tendon: a cadaveric

study comparing anterior tibial and rotational loads. J Bone Joint

Surg 2002;84A:907-914.

Knee OA following

ACL reconstruction

prevalence rates in

studies may be too

high

Methodological

quality of studies low

Oiestad BE, et al. Knee OA after anterior cruciate ligament injury. A

systematic review. Am J Sports Med 2009;37(7):1434-1443.

Highest rated studies

report OA range of 0-

13% for those with

isolated ACL injury

OA ranges of 21-48%

with combined injuries

Oiestad BE, et al. Knee OA after anterior cruciate ligament injury. A

systematic review. Am J Sports Med 2009;37(7):1434-1443.

39


2007 review

124 papers on double bundle

120 since 2000

Crawford C, Nyland J, Landes S, et al. Anatomic double-bundle ACL

reconstruction: a literature review. Knee Surg Sports Traumatol

Arthrosc 2007;15: 946-964.

Meta-Analysis

Double-bundle restores KT-1000 outcomes

0.52 mm closer than single-bundle (Sig)

Odds of normal pivot shift is higher in

Double-bundle than those in single-bundle

but – (Not Sig).

Meredick RB, et al. Outcomes of single-bundle versus double-bundle

reconstruction of the anterior cruciate ligament. A meta-analysis. Am

J Sports Med 2008;36:1414-1421.

http://www.docjago.com/uch/multiple_instab-Dateien/image004.jpg

40

Single-bundle Double-bundle

www.ceo-ortopedia.com.br/eventos.htm

Single-

bundle

Kondo E, et al. Prospective clinical comparisons of anatomic double-bundle

versus single-bundle anterior cruciate ligament reconstruction procedures in 328

consecutive patients. Am J Sports Med. 2008;36:1675-1687.

ACL Rehabilitation

http://www.ceo-ortopedia.com.br/eventos.htm

41

Randomized

controlled trial

Formal PT

(17 sessions)

Home based

(4 sessions)

88/129 patients

returned at 2 or 4

years

Grant JA, Mohtadi NGH. Two- to 4 – year follow-up to a comparison of home versus

physical therapy – supervised rehabilitation programs after anterior cruciate ligament

reconstruction. Am J Sports Med 2010;38(7):1389-1394.

Outcomes

ACL QOL score

Knee ROM

Knee laxity

IKDC scores

Home based group had

higher mean ACL QOL

scores 38 weeks after

surgery

Both groups improved from

pre-post

Grant JA, Mohtadi NGH. Two- to 4 – year follow-up to a comparison of home versus

physical therapy – supervised rehabilitation programs after anterior cruciate ligament

reconstruction. Am J Sports Med 2010;38(7):1389-1394.

Systematic review

Level 1 & 2

54 appropriate

studies

Wright RW, et al. A systematic review of anterior cruciate ligament reconstruction

rehabilitation. Part I: Continuous passive motion, early weight bearing, postoperative

bracing, and home based rehabilitation. J Knee Surg 2008;21:217-224.

42

CPM Following ACL

6 studies all had some limitations

Potentially caused type II error

No advantage for CPM use

Except for possible decrease in pain




Early Weight Bearing

1 RCT discussed later

Early weight bearing probably justified




Post Operative Bracing

11 studies

No study demonstrated worse outcomes

when bracing was not used

No increase in postop injuries, increased

pain, decreased motion, or increased knee

laxity in controls




43

Home-Based Rehab

4 RCTs

All have some potential bias!

Despite this it is reasonable to conclude

that a minimally supervised physical

therapy –based program can result in

successful ACL rehabilitation




Systematic review

Level 1 & 2

54 appropriate

studies


rehabilitation. Part II: Open versus closed kinetic chain exercises, neuromuscular electrical

stimulation, accelerated rehabilitation, and misc topics. J Knee Surg 2008;21:225-234.

OKC vs CKC

5 RCTs

All have some potential bias!

All short term outcomes (6 weeks)

3 demonstrate lack of power

Need for additional study




44

Neuromuscular Electrical Stim

14 RCTs

For NM ESTM to be successful it must be

applied at high intensity

May help achieve quad strength

But is not a requirement




CPM

Wright RW, et al. Anterior Cruciate Ligament Reconstruction Rehabilitation: MOON

Guidelines. Sports Health. 2015;7(3):239-243.

No long term

benefit

No increased ROM

Insurance not

always approve so

cost issue

Early Weight Bearing



No new studies

45

Postoperative Bracing



6 new studies since

2005

None demonstrated

advantage from

bracing

OCK vs CKC



OKC activity after

6 weeks may

increase strength

without harming

graft

Not sufficient

evidence for OKC

prior to 6 weeks

NMES



No new studies

Some home units

may not be strong

enough to elicit

contraction

46

Accelerated Rehabilitation



2 new studies since

2005

Most return at 6

months

Unknown if shorter

time frames

harmful

Neuromuscular Training



9 new studies since

2005

Most have shown

efficacy

Recommended

some form of

training be included

Home Based Therapy



2 new studies since

2005

Biases and

limitations

Have not been

shown to be

deleterious

47

74 patients – RCT

Neuromuscular program

Strengthening program

Follow-up

6 months

1 year

2 years

Outcomes

Cincinnati knee score

VAS pain; short form 36

Functional tests; strength

Risberg MA, Holm I. The long-term effect of 2 postoperative rehabilitation programs after

anterior cruciate ligament reconstruction. RCT with 2 years follow-up. Am J Sports Med

2009;37(10:1958-1966.

No significant differences between programs at 1 and 2

years for Cincinnati knee scale

At 2 years

NE group significantly improved function and

reduced pain

SE group significantly improved hamstring strength

Both SE and NE type of exercises should be used

following ACL reconstruction

Risberg MA, Holm I. The long-term effect of 2 postoperative rehabilitation programs after

anterior cruciate ligament reconstruction. RCT with 2 years follow-up. Am J Sports Med

2009;37(10:1958-1966.

Postoperative

1-2 decades ago knee placed in 20-30

degrees of flexion for 6-8 weeks with

restricted weight bearing

Recent advances in surgical technique and

understanding of tissue healing have

allowed early p/o ROM and immediate

weight bearing

48

Past vs. Present

PAST PRESENT

Prolonged

Immobilization

Immediate Motion

Non-Weight Bearing Early Weight Bearing

Slow Progression of

Activity

Accelerated Return to

Activity

Immobilization

Generally knee placed in controlled motion brace locked in extension or between 20-0 degrees of flexion

Correct isometric placement allows full ROM without disrupting the autograft

If procedure combined with collateral ligament repair or meniscus repair, ROM may be restricted

Immobilization

Knee is kept immobilized during

ambulation and at night, but removed for

supervised exercises

49

Cryotherapy

Patients utilizing continuous cryotherapy

Required less medication

Converted from injectable to oral meds

sooner

Greater percentage of compliant patients

Cohn BT, et al. The effects of cold therapy in the postoperative

management of pain in patients undergoing anterior cruciate ligament

reconstruction. Am J Sports Med 1989;17:344-349.

Cryotherapy

Patients utilizing continuous cryotherapy

Were out of bed and ambulating sooner

Performed ROM exercises with more

ease.

Cohn BT, et al. The effects of cold therapy in the postoperative

management of pain in patients undergoing anterior cruciate ligament

reconstruction. Am J Sports Med 1989;17:344-349.

Raynor MC, et al. Crotherapy after ACL reconstruction. A meta-

analysis. J Knee Surg. 2005;18:123-129.

Knee Effusion 53 year old male following

bilateral patellar tendon rupture

repair after fall.

Used cryocuff device for 2

weeks straight.

Returned at 4 weeks with

eschars of both knees

Then debridement, dressing

change and wound coverage

Lee CK, et al. Sever frostbite of knees after cryotherapy. Orthopedics.

2007;30:

http://www.healio.com/orthopedics/journals/ORTHO/%7B8F4A824C-BAD6-

4708-8242-DC8B11857CCA%7D/Severe-Frostbite-of-the-Knees-After-

Cryotherapy?full=1

50

Knee Effusion

4 weeks after free tissue skin

graft transplant

Lee CK, et al. Sever frostbite of knees after cryotherapy. Orthopedics.

2007;30:

http://www.healio.com/orthopedics/journals/ORTHO/%7B8F4A824C-BAD6-

4708-8242-DC8B11857CCA%7D/Severe-Frostbite-of-the-Knees-After-

Cryotherapy?full=1

Knee Effusion

188 patients; single surgeon

Effusion, ROM, instability,

MVIC and activation level.

Effusion grade did not correlate

with quadriceps central

activation ratio

People may adapt to effusion?

Experimentally induced

effusion may be different than

natural effusion

Lynch AD, Logerstedt DS, Axe MJ, Snyder-Mackler L.Quadriceps activation

failure after anterior cruciate ligament rupture is not mediated by knee joint

effusion. J Orthop Sports Phys Ther. 2012;42:502-510.

Rate of Exercise Progression

Depend on surgical procedure and graft selection

Can progress most rapidly with bone-tendon -bone

repairs or allograft repairs with bone plugs due to

better fixation

Open procedures, or procedures using semi-T,

Gracilis, quad tendon or iliotibial band may

require slower progression due to soft tissue

fixation

51

Rate of Exercise Progression

Even though early movement will create a

stronger better oriented scar and ligament

healing, too much stress or too rapid

progression can stretch or damage repairs

Graft Strength

Animal studies indicate that graft strength

may reach weakest point at 6-8 weeks

postoperatively

Butler DL, et al. Mechanical properties of primate vascularized vs. non-

vascularized patellar tendon grafts: change over time. J Orthop Res

1989;7:68-79.

Graft Strength

Graft may only reach failure loads of 11 and

50% of native ACL at 1-year post operative.

Ballock RT, et al. Use of patellar tendon autograft for anterior cruciate

ligament reconstruction in the rabbit: a long-term histologic and

biomechanical study. J Orthop Res 1989;7:474-485.

52

Graft Strength

Most studies done on animal models

Makes determining optimal load and

optimal timing of load in humans difficult

to determine.

Beynnon BD, et al. The science of anterior cruciate ligament rehabilitation.

Clin Orthop 2002;9-20.

Primary Goal of ACL

Reconstruction

Restoration of knee stability

Safe and expedient return to normal

activities and athletics

Early recognition of complications

Maximum Protection Phase

0-6 weeks: Goals

Protect graft fixation

Minimize effects of immobilization

Control swelling and inflammation

Achieve full extension ASAP

Educate patient on rehab

53

Brace

Dependent on fixation.

Generally:

0-1 week: locked in full extension for ambulation and sleeping

May be longer with soft tissue healing, e.g., hamstring, quad tendon

1-4 weeks: Unlocked for ambulation, sleeping

Weight Bearing

Generally:

0-4 weeks: weight bearing as tolerated

Emphasis on achieving full knee extension

at heel strike with FWB on involved side

Decrease ambulation with flexed knee

Wean off crutches when good quad control

and able to perform SLR with no lag

54

Bone Mineral Density - ACL

BMD and BMC

15 Subjects

Ages 17-51 Years

Time from surgery 6 to 32 months

BMD < in involved lower extremity

Reiman MP, Rogers ME, Manske RC. Interlimb differences in lower

extremity bone mineral density following ACLR. J Orthop Sports Phys

Ther 2006;36(11):837-844.

Bone Mineral Density - ACL

6.6% < at trochanteric region

4.0% < for entire hip

3.4% < for intertrochanteric region

Reiman MP, Rogers ME, Manske RC. Interlimb differences in lower

extremity bone mineral density following ACLR. J Orthop Sports Phys

Ther 2006;36(11):837-844.

Weight Bearing

24 patients per group

Controls

6-12 weeks

6-7 months

12-15 months

Neitzel HA, Kernozek TW, Davies GJ. Loading response following

ACL reconstruction during parallel squat exercise. Clin Biomech.

2002;17:551-554.

55

Weight Bearing

Smith squat rack

Pedar sensors

3 sets of 9 squats

randomized

3 angles (30,60,90°)

3 weights (40# bar only, 35% BW, 50%

BW)

Neitzel HA, Kernozek TW, Davies GJ. Loading response following ACL

reconstruction during parallel squat exercise. Clin Biomech. 2002;17:551-

554.

Weight Bearing

Do you feel like

equal weight placed through both feet?

Significant differences (p<0.05) between

with group interaction with weight and

angle



2002;17:551-554.

Weight Bearing

6-12 weeks

Unconscioulsy “Unload LE”

6-7 months

Unconsciously “Unload LE”

12-14 months

Do not “Unload”



2002;17:551-554.

56

Weight Bearing

Most patients thought they had

demonstrated equal WB

? Accelerated rehabilitation program

Full sports at 6 months after surgery

Benefit of early single-leg exercise



2002;17:551-554.

Weight Bearing

RCT with 49 patients

Immediate weight bearing vs delayed

weight bearing x 2 weeks

BPTB ACL reconstruction

Follow up 2 weeks and final

Tyler T, et al. The effect of immediate weight bearing after anterior

cruciate ligament reconstruction. Clin Orthop 1998;357:141-148.

Weight Bearing

ROM – NS at 2 weeks or final (6-14 mo)

VMO EMG activity significant increase at

2 weeks in weight bearing group

Final follow up both groups EMG same



57

Weight Bearing

Statistically significant decrease in

anterior knee pain

Pain in 7/20 restricted WB

Pain in 2/25 immediate WB

ROM and KT scores not sig different

between groups




0-6 weeks Control of postoperative

pain, and edema: use cryotherapy, e-stim, elevation and compression

Caution if using Cryocuff and Tube-grip together – may compromise vascular flow

Mindrebo N, Shelbourne KD. Knee pressure dressings and their effect

on lower extremity venous capacitance and venous outflow. Orthop Int

1994;2:273.


0-6 weeks Begin setting exercises

and muscle stimulation to prevent atrophy

Due to closed packed position, little stress placed on graft in full knee extension

58

Quadriceps Atrophy

Atrophy and weakness of quadriceps can

begin immediately following ACL repair

and is the major group that undergoes

atrophic changes.

Sachs R, et al. Patellofemoral problems after ACL reconstruction. Am J Sports

Med 1989;17:760-7655.

Gerber C, et al. The lower extremity musculature in chronic symptomatic

instability of the ACL. J Bone Joint Surg 1985, 67A:1034-1043.

Quad Atrophy

Like to see forceful quadriceps contraction within the 4th post-operative day

If unable to initiate we will begin neuromuscular electrical stimulation to facilitate a contraction

Electrical Stimulation of ThighArvidssoon I, et al. Prevention of quadriceps wasting after immobilization:

an evaluation of the effect of electrical stimulation. Orthopedics.

1986;9:1519-1528.

Delitto A, et al. Electrical stimulation versus voluntary exercise in

strengthening thigh musculature after anterior cruciate ligament surgery.

Phys Ther 1988;68:660-663.

Fitzgerald GK, et al. A modified neuromuscular electrical stimulation

protocol for quadriceps strength training following anterior cruciate ligament

reconstruction. J Orthop Sports Phys Ther 2003;33:492-501.

Lieber RL, et al. Equal effectiveness of electrical and volitional strength

training for quadriceps femoris muscles after anterior cruciate ligament

surgery. J Orthop Res 1996;14:131-138.

Paternostro-Sluga T, et al. Neuromuscular electrical stimulation after

anterior cruciate ligament surgery. Clin Orthop 1999;368:166-175.

59

Electrical Stimulation of ThighRebai H, et al. Effects of two electrical stimulation frequencies in thigh muscles after

knee surgery. Int J Sports Med 2002;23:604-609.

Ross M, The effect of neuromuscular electrical stimulation during closed kinetic chain

exercise on lower extremity performance following anterior cruciate ligament

reconstruction. Sports Med Train Rehabil 2000;9:239-251.

Sisk TD, et al. Effect of electrical stimulation on quadriceps strength after reconstructive

surgery of the anterior cruciate ligament. Am J Sports Med 1987;15:215-220.

Snyder-Mackler L, et al. Electrical stimulation of the thigh muscles after reconstruction

of the anterior cruciate ligament. J Bone Joint Surg 1991;73A:1025-1035.

Snyder-Mackler et al. Strength of quadriceps femoris muscle recovery after

reconstruction of the anterior cruciate ligament. J Bone Joint Surg 1995; 77A:1166-1173.

Wigerstad-Lossing I, et al. Effects of electrical muscle stimulation combined with

voluntary contractions after knee ligament surgery. Med Sci Sports Exerc 1988;20:93-98.

Range of Motion

Regain full extension ASAP!

What is normal motion?

Both men and women have hyper-

extension

Men = 5° while Women = 6°

DeCarlo M, Sell K.E. Normative data for range of motion and single-leg hop

in high school athletes. J Sport Rehabil 1997;6:246-255.

60

502 patients

14.1 years PO

Regression analysis

Most important factor

in subjective scores

Knee motion

Shelbourne KD, Gray T. Minimum 10- year results after anterior cruciate

ligament reconstruction. How the loss of normal knee motion compounds

other factors related to the development of OA after surgery. Am J Sports Med

2009;37(3):471-480.

Shelbourne KD, Gray T. Minimum 10- year results after anterior cruciate ligament

reconstruction. How the loss of normal knee motion compounds other factors related

to the development of OA after surgery. Am J Sports Med 2009;37(3):471-480.

98% of patients with normal motion,

normal articular cartilage and intact

menisci had normal radiographs

Even a 3-5° loss of extension motion

compared to opposite knee affected

outcomes

Shelbourne KD, Gray T. Minimum 10- year results after anterior cruciate

ligament reconstruction. How the loss of normal knee motion compounds

other factors related to the development of OA after surgery. Am J Sports Med

2009;37(3):471-480.

61

Study to determine factors related to

motion loss after ACL reconst.

217 consecutive patients

ROM recorded at:

Day of surgery

6 weeks

3 months

Quelard B, et al. Preoperative factors correlating with prolonged range of motion

deficit after anterior cruciate ligament reconstruction. Am J Sports Med

2010;38(10):2034-2039.

Significant correlations

with motion loss and:

Pre-op ROM

Lat comp bone

contusion

Operative delay < 45

days

Female sex

Quelard B, et al. Preoperative factors correlating with prolonged range of motion

deficit after anterior cruciate ligament reconstruction. Am J Sports Med

2010;38(10):2034-2039.


Regain full extension ASAP

Passive knee extension with heel block,

prone knee hangs

62


Immediate motion to decrease risk of

complications related to loss of motion

Complication rates range from 9-74%

Noyes FR, et al. Early knee motion after open and arthroscopic

anterior cruciate ligament reconstruction. Am J Sports Med

1984;15:149-160.

Dodds JA, et al. Results of knee manipulation after anterior cruciate

ligament reconstruction Am J Sports Med 1991; 19:283-287.

Graf B, Uhr F. Complications of intra-articular anterior cruciate

reconstruction Clin Sports Med 1988;7:835.

Wojtys EM, et al. Patella baja syndrome. Presented at the annual

meeting of the AAOS. New Orleans, LA, 1986.

Cyclops lesion 15-year old

Hamstring ACL 16 weeks PO


Knee “Thunks”

Knee is bent slightly and gently allowed to

“thunk” down into extension

May be hard for patient to understand or

tolerate so may want to do on uninvolved

side first

Shelbourne KD, et al. Rehabilitation after anterior cruciate ligament

reconstruction with a contralateral patellar tendon graft: Philosophy, protocol,

and addressing problems. In: Manske RC (ed). Post Surgical Sports

Orthopedic Rehabilitation: Knee and Shoulder, Mosby, 2006.

63


Flexion will generally return in time.


If hamstring repair may hold active heel

slides for up to 3 weeks.

Some allograft procedures require lifting of

pes – hold active hamstring contraction x 3

weeks


Generous patellar mobilizations to decrease risk of

IPCS, arthrofibrosis, knee flexion contracture

Wall slides and heel slides to increase knee flexion

64


Precaution:

By 4-6 weeks bone plugs should be adequately healed

Suppose 8-12 weeks before soft tissue healed into tunnels with hamstrings

At 4-6 weeks the graft itself is at its weakest point in the rehab process

West RV, Harner CD. Graft selection in anterior cruciate ligament

reconstruction. J Am Acad Orthop Surg 2005;13(3): 197-207.


Stretching

If hamstring may hold

stretching of gastroc

and hamstrings for up

to 3-4 weeks


4-6 weeks graft weak and actually necrotic

Avoid resisted OCK activities in the range

of 30-0 degrees of flexion

65


Total Leg Strength

(TLS)

SLR x 4

Multi-hip

Moderate Protection Phase

6-12 weeks

Normalize gait

Maintain full extension

Protect fixation

Full flexion ROM

Improve strength, endurance, and

proprioception of lower extremity


6-12 weeks This phase is characterized by exercises utilized to

increase strength and ROM

Muscles require increased intensity to allow adaptation for sport-specific demands

By 9-12 weeks graft is becoming more vascularized

Progressive exercises to work on strengthening not only quads and hams, but TLS should be emphasized

120º of knee flexion and extension should easily be obtained during this time frame

66


6-12 weeks Precaution:

Avoid CKC exercises

between 60-90º of

knee flexion (PF) and

OKC between 30-0º of

knee flexion as

anterior tibial

translation may stretch

graft?

Minimal Protection Phase

12-24 weeks OKC isotonic exercise

from 90 - 45° safe

Advanced CKC exercises

Single leg squats

Leg press 0 - 45°

Step-up progression

Balance and proprioception


12-24 weeks

Bilateral squats level

ground

Progress with

weighted balls or

dumb bells

67


12-24 weeks Advanced CKC

exercises

Squats on labile

surface

Watch for proper

form!

Balance and

proprioception


12-24 weeks

Advanced CKC

exercises

Balance and

proprioception


12-24 weeks Advanced CKC

exercises

Balance and

proprioception

68


12-24 weeks Single-leg exercises important

Athletes in competition spend

tremendous amounts of time in

a single-leg position

Single-leg landing training


12-24 weeks

Single-leg landing

training

Good Landings!


12-24 weeks

Single-leg landing

training

Poor Landings!

Be careful of

excessive rotation in

the transverse plane

upon landing.

69


12-24 weeks Lunges

Lunge onto labile

surface

Lunge with

perturbation

Sports specific tasks


12-24 weeks

Emphasis placed on light functional

activities such as jogging, stepping,

footwork and agility drills

These activities can be initiated if strength

assessment reveals 75-80% of uninvolved

side and arthrometer reveals stable graft


12-24 weeks Plyometrics and

velocity spectrum

isokinetics can be

begun

By 6 months most

return to full pre-

injury activity level

70

Return to Sport Phase 6-9

Months

Goals

Progress:

Strength

Power

Proprioception


Months Continue

strengthening and

flexibility as previous

Walk/jog progression

Forward/backward

running

Cutting/crossover

Sports specific drills

Return to Sport Phase 6-9 Months

Double leg squat on BOSU

Labile surface

71


Months Plyometrics

Double leg jumps

Labile surface


Months Plyometrics

Single leg jumps

Labile surface

72

Deficits in Quad Strength

Literature review

Side to side strength differences

6 months =23% (3-40%)

12 months = 14% (3-28%)

Self reported function deficits

6 months = 14%

12 months = 13%

Hop tests

6 months = 11%

12 months = 1.3%

Lepley LK. Deficits in quadriceps strength and patient-oriented

outcomes at return to activity after ACL reconstruction: A review of

the current literature. Sports Health. 2015;7(3):231-238.

Survival of Graft

All patients – one

surgeon 1993-1994

Telephone or email

Minimum 15 years

after surgery

Bourke HE, et al. Survivial of the anterior cruciate ligament graft and

the contralateral ACL at a minimum of 15 years. Am J Sports Med.

2012;40:1985-1992.

Survival of Graft

775 patients met criteria

BPTB = 314; Ham = 359

673 (89%) responded

23% had suffered graft rupture or contralateral

ACL tear

Graft survival not different between groups

Ham = 88%; BPTB 91%

Bourke HE, et al. Survival of the anterior cruciate ligament graft and


2012;40:1985-1992.

73

Survival of Graft

Contralateral rupture 2x as frequent as graft

rupture in BPTB group

Positive family history of ACL injury doubled

odds of having injury to graft or contralateral

ACL

Men less favorable survival rate of graft than

women.

Bourke HE, et al. Survival of the anterior cruciate ligament graft and


2012;40:1985-1992.

Smoking and ACL Reconstruction

ACL reconstruction in patients who use tobacco

associated with increased rates of

Infection

VTE

Subsequent ACL reconstruction

Cancienne JM, et al. Tobacco use is associated with increased

complications after anterior cruciate ligament reconstruction. Am J

Sports Med. 2016;44(1):99-104.


66 smokers – FU 5.67 years

238 non-smokers – FU 6.61 years

Similar in age, gender, graft type, fixation

and associated meniscal and chondral

pathology

Karim A, et al. Smoking and reconstruction of the anterior cruciate

ligament. J Bone Joint Surg 2006;88B:1027-1031.

74


Assessment

IKDC scores

Cruciometer

readings




SS Poor outcomes in

smokers

IKDC scores

Frequency of pain

Intensity of pain

Laxity




Less likely to return to their original level of

pre-injury sport

Well-known negative effects of smoking on

tissue healing affects ACL reconstruction

patients also!



http://images.google.com/imgres?imgurl=http://stellargraffiti.com/My%2520Pictures/Cn%2520Smoking.jpg&imgrefurl=http://stellargraffiti.com/My%2520Pictures/&h=411&w=373&sz=32&hl=en&start=26&tbnid=1MFQZs7NpdHsuM:&tbnh=125&tbnw=113&prev=/images%3Fq%3DSmoking%26start%3D20%26ndsp%3D20%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DN

http://images.google.com/imgres?imgurl=http://stellargraffiti.com/My%2520Pictures/Cn%2520Smoking.jpg&imgrefurl=http://stellargraffiti.com/My%2520Pictures/&h=411&w=373&sz=32&hl=en&start=26&tbnid=1MFQZs7NpdHsuM:&tbnh=125&tbnw=113&prev=/images%3Fq%3DSmoking%26start%3D20%26ndsp%3D20%26svnum%3D10%26hl%3Den%26lr%3D%26sa%3DN

75


14 studies

8 smoking and

ligaments

6 smoking and articular

cartilage

Negative association of

smoking

Kanneganti P, et al. The effect of smoking on ligament and cartilage

surgery in the knee. A systematic review. Am J Sports Med.

2012;40:2872-2878.


Negative effects from

various perspectives

Molecularly

Biomechanically

Clinically

Kanneganti P, et al. The effect of smoking on ligament and cartilage

surgery in the knee. A systematic review. Am J Sports Med.

2012;40:2872-2878.

Documents

ANTERIOR CRUCIATE LIGAMENT...different (4.3% vs 4.1%) No difference in those returning to sports sooner than 6 months compared to those after 6 months Risk 17%