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Anterior cruciate ligament (ACL) repair is a reconstructive procedure used to restore the integrity and function of the ACL after it has been stretched or torn from the skeletal structure of the knee. Unlike other body tissues, the ACL does not heal or repair itself after injury.
The ACL is a powerful ligament extending from the top-front surface of the shinbone (tibia) to the bottom-rear surface of the thighbone (femur). The ligament prevents instability in the front of the knee joint (anterior instability). The ACL lies in the middle of the knee, prevents the tibia from sliding out in front of the femur, and provides rotational stability to the knee. This stability is particularly important to athletes or individuals whose activities include running or kicking.
ACL injury can occur when an individual comes to a quick stop (sudden deceleration); suddenly changes direction while running, pivoting, or landing from a jump; or overextends the knee joint in either direction. The ACL is the most commonly injured major knee ligament. Injury prevention includes hamstring-strengthening exercises and the use of proper techniques when playing sports or exercising.
Many cases of ACL injury occur in conjunction with other knee injuries. Approximately 50% of individuals with ACL injuries also have meniscal tears (Hubbell).
Risk: Risk for ACL injury is higher for athletes in certain sports, such as football, basketball, soccer, and skiing. Female athletes are 2 to 8 times more likely to tear the ACL than male athletes. Studies reveal a two-fold increase among female college soccer players and a four-fold increase among female basketball players compared with their male counterparts. Additional studies are under way to determine why this occurs, but it may be due to variations in training, differing strength-to-weight ratios, joint laxity, or muscle recruitment patterns (Hubbell). Recent studies have discounted the idea that female ACL laxity is due to changes in the menstrual cycle (Belanger).
Some individuals may be more prone to ACL injury for structural reasons (e.g., those with femoral notch stenosis). Incidence and Prevalence: Approximately 100,000 individuals undergo ACL repair in the US each year (Hubbell). |
Source: Medical Disability Advisor
| The purpose of ACL reconstruction is to restore the strength and function of the ACL, thus stabilizing the knee joint. This helps to prevent additional serious damage to the knee and slow the onset of degenerative arthritis. |
Source: Medical Disability Advisor
| ACL reconstruction is usually scheduled at least 3 weeks after the injury to avoid the complication of arthrofibrosis (the formation of dense fibrous scar tissue within the joint). Surgery may be performed as an open procedure or may use a special instrument that is inserted through a small incision (arthroscopic procedure). Most individuals are given general anesthesia, although ACL repair can be performed under spinal or regional anesthesia.
Tendons cannot be repaired by sewing them back together. The ligament is reconstructed by taking a piece of tendon from a different part of the body (autograft) or from a donor (allograft) and connecting it to the shinbone and thighbone. Although there are different methods for ACL reconstruction, they all involve the same basic procedure. An incision is made in the individual's leg, and small tunnels are drilled into the bone. Then the new or harvested ACL is brought through the tunnels and secured with a staple-and-buckle system. Proper tension is crucial, since a lax graft may not restore stability to the knee, whereas a graft that is too tight may fail or limit knee range of motion.
Patellar tendon autograft uses the individual’s own patellar tendon, which connects the kneecap (patella) to the shinbone (tibia). The middle third of the tendon and a small portion of the bone on either end are harvested and used as the new ACL. This method allows a high rate of return to pre-injury levels of activity. However, 10% to 40% of individuals who undergo this procedure have postoperative anterior knee pain (Hubbell).
Another autograft method of ACL reconstruction uses the individual's hamstring tendons (semitendinosus-gracilis), which connect muscles in the back of the thigh to the lower leg. A small portion of these two tendons is removed through an incision in the individual's leg and looped to form a strong new ACL. This method is associated with faster recovery from surgery and less anterior knee pain. Some critics believe this method to be more susceptible to graft stretching (elongation).
A third method of ACL reconstruction, an allograft, uses tendon from an organ and tissue donor (cadaver). This method does not disrupt other structures within the individual’s knee or leg to obtain grafts. However, allografts must be properly sterilized. Synthetic grafts are no longer used due to high rates of complications (Hubbell). |
Source: Medical Disability Advisor
| In general, conservative treatment of an injured ACL has a variable long-term prognosis. Individuals who are sedentary, or who engage only in light manual work and sports that do not require abrupt stops or changes of direction, may benefit from nonoperative treatment of minor instability. The goal of conservative treatment is to return range of motion and strength comparable to those of the uninjured knee. Nonoperative treatment may result in a mildly increased risk for recurrent injury, meniscal damage, and onset and progression of osteoarthritis.
Individuals with major instability or those who do heavy labor or engage in high-demand recreational activities are candidates for ACL reconstruction. The procedure relieves symptoms, improves function, and reduces the risk of osteoarthritis. ACL reconstruction restores activity level and stability in 75% to 95% of cases. The ACL repair failure rate is approximately 8% and is largely attributable to recurrent instability, graft failure, or arthrofibrosis (Hubbell). |
Source: Medical Disability Advisor
| Note on research and authorship Rehabilitation, requiring months of intense exercise, is recommended for successful recovery from a surgical repair of the anterior cruciate ligament. Rehabilitation following anterior cruciate ligament repair follows a structured process beginning immediately after the surgical repair and ending with the individual returning to work and other activities (Ageberg; Mikkelsen). The entire process can take up to 9 months.
Phase 1: Initially in Phase 1, the physical therapist uses modalities, such as cold packs, to decrease postoperative pain. The physician may request very gradual weight-bearing immediately after the anterior cruciate ligament repair. A rehabilitation brace, also called a postoperative brace, is used immediately after surgical repair in an effort to put the joint at rest and help protect it while still allowing appropriate but limited motion. This form of bracing is available in two particular types: a straight immobilizer and a hinged brace. Straight immobilizers are made of foam with two metal rods down the side that are secured with Velcro and prevent all motion. The hinged brace allows range of motion to be set by tightening a screw control.
Once pain and swelling are controlled, range of motion is started in rehabilitation and performed as tolerated, as guided by the surgeon. This phase continues with isometric exercises, such as the quadriceps set. Ankle range of motion of the involved lower extremity should be encouraged intermittently throughout the day to promote blood circulation. By the end of this phase, crutch walking should be easily tolerated.
Phase 2: This phase usually begins at the end of immobilization, when swelling is controlled and pain is minimal. Goals of rehabilitation are to achieve full and pain-free motion of the knee joint along with strengthening of, in particular, the quadriceps and hamstring muscle groups, and all muscles in the involved leg (Liu-Ambrose).
Phase 3: This phase is considered the intermediate stage of rehabilitation. The criteria for beginning Phase 3 is no swelling, minimal to no pain and almost full range of motion. The individual is encouraged to walk, with weight bearing restrictions as indicated by the surgeon, and may be allowed to return to light work. For some individuals, this phase may not be reached for several months longer. More intense exercising, with increased resistance, is called for during this phase. Cycling and proprioceptive exercises may be attempted at this time.
Phase 4: In this phase, resisted exercise is initiated by the therapist. At the completion of Phase 4 of the rehabilitation for anterior cruciate ligament repair, the individual should have full range of motion, no symptoms, and functional stability with the involved limb demonstrating no more than 10% deficit of strength compared to the uninvolved leg.
Phase 5: This phase focuses on the individual's reinstatement to work as exercise is now directed toward work requirements. The physician may prescribe a brace to be worn by the individual at the onset of resuming functional activities, when the individual returns to work, training, or competition.
Generally speaking, rehabilitation of the anterior cruciate ligament will vary depending on the type of surgery that was performed, the location from which the graft was harvested, and whether any associated supporting ligament and cartilage were also injured and/or repaired.
Additional information may provide some insight into the rehabilitation needs of these individuals (Thomson; Wu). |
| FREQUENCY OF REHABILITATION VISITS | | Surgical | |
| Physical Therapist | | Up to 40 visits within 26 weeks | |
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| The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice. |
Source: Medical Disability Advisor
| Associated conditions include injuries to other structures in the knee, such as tears to the crescent-shaped discs of fibrocartilage attached to the superior articular surface of the tibia (menisci), fractures of the patella, and osteoarthritis.
Many ACL reconstructions are successful. Common complications include a decrease in knee range of motion (which can be minimized by early rehabilitation) and anterior knee pain. Less common complications include fractures of the patella and patellar tendon rupture (Hubbell). The quadriceps tendon can also rupture, depending on the site where the graft was harvested.
About 8% of ACL reconstructions fail (Hubbell). These failures are usually due to recurrent instability, ongoing pain, or arthrofibrosis (scar tissue build-up inside the knee joint). Other surgical complications include infection, bleeding, stiffness of the joint, vein inflammation (phlebitis), and complex regional pain syndrome (CRPS). Improper placement of the graft can cause impingement and require additional surgery. Grafts rupture in approximately 2.5% of cases (Hubbell). If symptoms return after surgery, hardware removal may be necessary.
Any type of surgery is associated with potential risks and complications that may include, but are not limited to injury to blood vessels and nerves around the knee (less than 1%); blood clots in the legs (deep vein thrombosis), which may break off and go to the lungs (embolism) (less than 1%); and infection (less than 1%) (Hubbell). Small areas of diminished sensation in the front of the knee are common and usually do not present a problem. |
Source: Medical Disability Advisor
| Limited weight-bearing, use of a knee brace, and rest periods for elevation of the leg would be expected at work during the early stages of recovery. Long-term use of a protective knee brace may be recommended. Individuals should refrain from activities requiring squatting, jumping, and abrupt turning or twisting. Postoperative medications may include nonsteroidal anti-inflammatory drugs (NSAIDs) and prescription painkillers (opioid analgesics). Use of analgesics and other medications can affect dexterity and alertness. Review of drug policies may be required to accommodate this use. |
Source: Medical Disability Advisor
| Adams, Kenneth, and Tarek Souryal. "Anterior Cruciate Ligament Injury." eMedicine. Eds. Robert E. Windsor, et al. 5 Jul. 2002. Medscape. 20 Oct. 2004 <http://emedicine.com/PMR/topic3.htm>.Ageberg, E., et al. "Influence of Supervised and Nonsupervised Training on Postural Control after an Acute Anterior Cruciate Ligament Rupture: A Three-year Longitudinal Prospective Study." Orthopedic and Sports Physical Therapy 31 11 (2001): 632-644. National Center for Biotechnology Information. National Library of Medicine. 25 Sep. 2008 <PMID: 11720296>. Belanger, M. J. "Knee Laxity Does Not Vary with Menstrual Cycle, before or after Exercise." American Journal of Sports Medicine 32 5 (2004): 1150-1157. Hubbell, John D., and Evan Schwartz. "Anterior Cruciate Ligament Injury." eMedicine. Eds. Francisco Talavera, et al. 3 Jul. 2006. Medscape. 6 Jan. 2009 <http://emedicine.com/sports/topic9.htm>. Linko, E., et al. "Surgical Versus Conservative Interventions for Anterior Cruciate Ligament Ruptures in Adults." Cochrane Database of Systematic Reviews 2 (2005): Liu-Ambrose, T., et al. "The Effects of Proprioceptive or Strength Training on the Neuromuscular Function of the ACL Reconstructed Knee: A Randomized Clinical Trial." Scandinavian Journal of Medicine and Science in Sports 13 2 (2003): 115-123. National Center for Biotechnology Information. National Library of Medicine. 25 Sep. 2008 <PMID: 12641643>. Mikkelsen, C., S. Werner, and A. Eriksson. "Closed Kinetic Chain Alone Compared to Combined Open and Closed Kinetic Chain Exercises for Quadriceps Strengthening after Anterior Cruciate Ligament Reconstruction with Respect to Return . . .." Knee Surgery, Sports Traumatology, Arthroscopy 8 6 (2000): 337-342. National Center for Biotechnology Information. National Library of Medicine. 25 Sep. 2008 <PMID: 11147151>. Thomson, L. C., et al. "Physiotherapist-led Programmes and Interventions for Rehabilitation of Anterior Cruciate Ligament, Medial Collateral Ligament and Meniscal Injuries of the Knee in Adults." Cochrane Database System Review 2 (2002): CD001354. National Center for Biotechnology Information. National Library of Medicine. 25 Sep. 2008 <PMID: 12076407>. Wu, G. K., G. Y. Ng, and A. F. Mak. "Effects of Knee Bracing on the Functional Performance of Patients with Anterior Cruciate Ligament Reconstruction." Archives of Physical and Medical Rehabilitation 82 2 (2001): 282-285. National Center for Biotechnology Information. National Library of Medicine. 1 Dec. 2004 <PMID: 11239327>. |
Source: Medical Disability Advisor
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