Arthroscopic Ligament Surgery
ACL Reconstruction Rehabilitation Protocol
The following is the expected progress of your recovery after ACL, reconstruction:
|Bed rest||:||Only for one day, on the day of surgery.: From 2nd day of the operation, you will be able to go to the he toilet with the support of one crutch|
|Up and about in the house||:||For two weeks after surgery you will be required to be in the house with a crutch|
|Out of house for sitting job||:||From 3rd week with the help of a hinged knee brace.|
|Car driving||:||After 4 weeks.|
|Stair climbing||:||One foot at a time 3 weeks. Normal after 6 weeks|
|Fieldwork||:||After 8 weeks|
|Jogging||:||After 3 months|
|Running||:||After 4 months|
|Light sports||:||After 6 moths|
|Unrestricted sports||:||After 1 year|
Rehabilitation after ACL reconstruction involves a progressive exercise program. We will teach you the exercises on your post- op visits as per the stage of rehabilitation. You would need to do these exercises at home yourself for 3-4 months depending on your requirement. Most patients do well with home therapy program; some need closer supervision by frequently visiting our therapist.
The following are the expected goals of recovery:
- To make the knee completely straight (not even slightly bent) – about 2 week.
- To reduce knee swelling 3 weeks, sometimes aspiration of fluid from the knee may be needed to reduce swelling at 3 weeks.
- To achieve knee bending –up to 90 degrees in 3 weeks, and full in 6 weeks.
- To build up the muscles around the knee joint- takes up 1-6 months
Schedule of visits for surgeon
|1st visit||:||approx 5 days after surgery, for dressing change and retraining of exercise|
|2nd visit||:||2 weeks after surgery, for stitch removal, and retraining exercise|
|3rd visit||:||6 weeks after surgery, monitor progress|
|4th visit||:||months after surgery
|It may be required to come more frequently in some cases.|
Schedule of visits for Therapy
One visit before surgery, for assessment and to understand the rehabilitation protocol. After surgery it is advisable that therapy be done under supervision 3 times per week for the first six weeks, and then once in a week for the next six weeks.
The above information presents an approximate picture of recovery after surgery. Exact progress varies from patient to patient
- PCL Reconstruction
- How often does this ligament get injured??
- The incidence of this injury is relatively less than an ACL tear.
- Do I always require to be operated??
- The PCL has a better propensity to heal than the ACL. However younger age, persistence of feeling unstable and feeling of weakness in the knee is an indication for ligament reconstruction.
How is the operation done?
The surgery is done completely via keyhole technique (arthroscopic surgery). The graft used is the patient's own hamstring tendons (semitendinosus and gracilis) like an ACL reconstruction. The only difference in the two techniques is that a small portal (1cm incision) needs to be made at the back of the knee for the keyhole surgery. The new ligament is fixed with specilaised implants on the thigh and leg bone.
Multiple ligament injuries:
The strength of the knee comes from four ligaments – one on inside of the knee, one on outside, and two in the middle. The one on inside is called MCL (Medial Collateral Ligament), the one on outside is called LCL (Lateral Collateral Ligament), and the two in the middle of the knee are called cruciate ligaments.
Usually, it is only one or sometimes two ligaments which get torn. Rarely, more than two ligaments, and sometimes all the four ligaments are torn. This severe damage occurs in serious road traffic accidents or high velocity sports.The knee often dislocates, or becomes severely unstable. It becomes impossible to even move the leg in one piece. Any attempt at putting load on the leg makes the knee give way. In early stages, there is bluish discolouration of the knee due to the blood seeping out under the skin. In severe injuries, there may occur damage to the nerves and vessels of the leg, and may make this injury limb threatening.In some low demand patients non surgical treatment may be considered. In all other cases the ligaments need reconstruction which are done in a combination of keyhole (arthroscopic) and minimally invasive surgery
What is the PCL?
PCL (posterior cruciate ligament) is a major ligament of the knee. It is situated in the middle of the knee in its posterior (back) part. It is responsible for not allowing the knee to move backward.
How is it injured?
It may be injured if the knee is hit from the front, for example in a head on crash where something from front hits the knee. Injury to this ligament is not as dramatic, and is missed often.
Does it need surgery if torn?
In the past, it was thought that PCL injury can be left as it is, and it does not cause much problem. But, it is now understood that PCL is an important ligament, injury to this ligament needs to be treated by surgical reconstruction in most cases.
How is it done?
This surgery is a keyhole (arthroscopic) surgery. The same hamstring tendons are harvested with an inch incision in front of the knee and fashioned into the new ligaments. This is introduced via an arthroscopic tunneling technique that involves a small 1 cm cut on the back of the knee too. It is fixed with specialized devices on the leg and thigh bones.
What are the results of PCL surgery?
They are excellent with a less than 5% chance of the graft not being accepted by the body. This however requires the right rehabilitation techniques.
What are the complications?
Apart from the standard possible complications associated with ACL surgery there is a possible chance of injury to the vessels at the back of the knee in these operations. However they rarely occur if done in the right hands.
What is the post operative rehabilitation?
Its almost the same as an ACL reconstruction.
The only difference is a support is kept under the back of the leg and the patient needs to wear a long knee brace for 6 weeks while walking.
Flexion and extension exrecises are done in prone position
The restrictions are slightly more than after an ACL reconstruction and near normal walking occurs at about 6 weeks.
Running and jogging at 4-5 months and sports after 6-9 months
MCL (medial collateral ligament) is often injured in a knee bending inward, or when hit from outside. This is one of the easier ligament, as it heals up in most cases by simple rest in brace. When associated with injury to other ligaments such as ACL, or in obese patients, tear of this ligament may also need reconstruction.
Do we always need to operate on it?
This is a rather friendly ligament and heal up in about half the cases when it is torn off from the thigh bone or the middle of its substance. This healing takes about 6 weeks and requires some element of immobilization like a brace.
When do we need to operate?
Surgery is required when the knee continues to open up from the inside after 6 -8 weeks, or if the injury is from the attachment to the leg bone. Sometimes when associated with injuries to multiple ligaments of the knee, early repair may be required.
What kind of operation is done?
There are two types
- Repair: This is done when the ligament has just come out of its attachment at either end. Then the original ligament is just repaired back to its place.
- Reconstruction: This is done when the ligament is completely torn and lacks its original structure. The hamstring tendons (semitendinosus/gracilis) is used to make a new ligament and fixed with specilaised devices.
What is the post op rehabilitation?
Depending if done in isolation or with another concomitant ligament reconstruction.
If in isolation, the patient is kept on a long knee brace for 6 weeks and is allowed to bend the knee out of the brace keeping the knee in a cross legged position. Walking is permitted with the brace using a walker/crutches. However for 6 weeks the patient needs to wear the brace while walking.
If present with other ligament reconstruction the rehabilitation depends on which other ligament is injured.
Posterolateral Corner injuries:
What is the posterolateral corner?
This is a part of the knee on the back of the outer aspect of the knee. It primarily consists of two parts the popliteus tendon and the lateral collateral ligament.
Does it require reconstruction?
More often than not it always requires reconstruction. It is usually never present in isolation and is associated with ACL or PCL tears that are reconstructed at the same time.
How is it reconstructed?
The other legs semitendinosus and gracilis (hamstring tendons) are fashioned into both or one of these ligaments and fixed to the thigh and leg bone at their respective locations
What is the post operative rehabilitation?
The patient is kept on a long knee brace for the first two weeks then a hinge knee brace with crutches or a walker.
Movement is permitted out of the brace but in prone position.