ACL RECONSTRUCTION

Figure 7: Fixed flexion deformity fol- lowing early ACL reconstruction employing a patellar tendon graft hence the visible scar. Most notably the knee was not straight prior to the operation.

Although not widely understood by surgeons fixed flexion is not only a big cause of morbidity, but it can be prevented by good surgery and postoperative physio- therapy, and, if established, treated.

Numbness Numbness following ACL surgery is very common. If a long

longitudinal midline scar is employed to harvest a patellar tendon graft then skin lateral to this will inevitably be numb. This can be improved by dividing the scar into two small incisions especially if they are placed transversely. Although the scar for hamstring harvest is relatively small, it does run the risk of damaging the infrapatellar branch of the saphenous nerve with resultant numbness across the front of the upper shin. This almost always resolves but not in all cases.

Graft failure Re-rupture of a well undertaken ACL reconstruction is uncommon. Statistically it is more likely that the patient will re-present with a rupture of their native ACL in the opposite knee than return with a re-rupture of the reconstruction the surgeon has undertaken. Unfortunately most revision ACL reconstructions undertaken are due to malplacement of the ACL graft by surgical error. This will predispose it to failure.

At three months or so from surgery the graft is almost certainly strong enough to undertake almost all activity. The reason it is not safe to do so is because the neuromuscular control of the joint is compromised. The final phase of physiotherapy/rehabilitation puts this right.

CONCLUSION Contemporary optimal treatment of ACL rupture is surgical reconstruction plus good rehabilitation. This should be the norm and non-surgical treatment, whilst genuinely indicated for a few, the exception. The future will depend on better training of sur- geons, improvement of operative techniques, and one day the development of tissue engineering options.

THE AUTHOR Dr Andy Williams, FRCS (orth) - for full author biography, please see page 9.

POST OPERATIVE REHABILITATION

My usual post-operative rehabilitation following ACL reconstruction is described on the next page. Assuming progress is uncomplicated, clinic visits are at 2-3 weeks, 12 weeks, and 6-9 months.

I do not change this protocol even if meniscal suture is undertaken but will adapt it if other ligaments require reconstruction.

The early rehabilitation phase emphasises minimising the inflammatory response to the injury of surgery and most importantly obtaining full knee extension as soon as possible. If this is not achieved then fat pad contracture can occur and this leads to significant trouble. I strongly believe that the most common cause of problems following soft tissue knee surgery is related to fat pad scarring/contracture. This can be countered by achieving full early extension, and also patellar mobilisations. I do not use knee braces in simple cases nor do I like the prolonged use of crutches. There is something 'magical' about restoration of normal limb function. Although hard to prove this is related to restoration of the muscle pump to help reduce swelling and the maintenance of normal neuromuscular co- ordination and neural pathways. I am very happy for a patient to be full weight bearing and off crutches from day one if they have good quadriceps control and gait pattern. Paradoxically these patients usually have less swelling at two to three weeks post-operation in the clinic than those who have a much slower recovery. Of course if a patient struggles to have a decent gait pattern I would rather they were protected by crutches.

The middle term of rehabilitation occurs whilst the graft healing is maturing and the final stages emphasise restoration of agility (neuromuscular control) and strength.

For most professional athletes such as in soccer and rugby, I aim for a return to sport around six months from surgery although I warn the players that they will require another year to reach their peak.

I firmly believe in early supervision from physiotherapists and like my patients to have outpatient physiotherapy within a week of their surgery. Sadly the funding of physiotherapy is being neglected both by the NHS and the private insurance companies in my opinion. The private insurance companies are hiding behind the perception that physiotherapy is not particularly use- ful after a number of knee-related operations. Of course, failing to fund physiotherapy will reduce costs. I am firmly of the opin- ion that good quality physiotherapy makes all the difference.

RECOMMENDED READING

The following reference is excellent for discussing the pro- tective effect of ACL reconstruction. Dunn WR, Lyman S, Lincoln AE, Amoroso PJ, Wickiewicz T, Marx RG. The effect of anterior cruciate ligament recon- struction on the risk of knee reinjury. American Journal of Sports Medicine 2004;32(8):1906-1914

There has been an unfortunate tendency to use the word ‘aggressive’ when talking about rehabilitation following ACL reconstruction. I support the use of 'intensive' physiotherapy but never 'aggressive' physiotherapy. Aggressive has all the wrong overtones. An angry knee will not do well if it is brutalised and will require a slower approach than a knee that is quiet. The quality of the surgery can make a big difference to how much inflammation occurs.

14 sportex medicine 2007:33(Jul):10-15