Type
Description
No. of patients
I
Anteromedial bundle partial lesion (<100%)
20
II
Posterolateral bundle partial lesion (<100%)
4
II
Both bundles partially torn
12
IV
Complete tear
0
25.3 Surgical Technique
The patient is positioned supine under spinal anesthesia. The typical preparation and draping for arthroscopically assisted ACL reconstruction is used. A routine arthroscopic evaluation of the knee by standard anteromedial and anterolateral portals is performed and partial tearing of the ACL is confirmed (Fig. 25.1a). Associated pathologies of other intra-articular structures are addressed prior to ACL repair. ACL repair is performed by passing No. 1 Polydioxanone (PDS) sutures (Ethicon, Piscataway, New Jersey), using a Clever Hook or other suture passing device (Fig. 25.1b), and the torn portions of ACL are secured together using a Duncan loop (Fig. 25.2). Using a 45° microfracture awl, several holes (1.5 mm in diameter, 3–4 mm apart, and 3 mm deep) are made around the anatomic femoral insertion of the ACL (Fig. 25.1c). PRP glue is prepared using a commercially available system (Arthrex Angel System, Naples, FL, US). Approximately 3 mL of PRP is isolated and activated with Batroxobin enzyme (Plateltex® act-S.R.O., Bratislava, SK) to produce a sticky PRP gel, which is injected at the repaired site to biologically augment the healing process. More recently, our preferred technique is to augment all ACL repairs with activated bone marrow aspirate concentrate in order to provide the healing ligament with MSCs as well as growth factors (Fig. 25.1d). Batroxobin or autologous thrombin may be used to activate the bone marrow aspirate concentrate, although the use of autologous thrombin requires an additional 15 min of centrifugation time.
Fig. 25.1
(a) Partial rupture of the ACL involving the anteromedial bundle. (b) Arthroscopic suture passage to reapproximate torn ligamentous fibers. (c) Marrow stimulation about ACL footprint within the intercondylar notch using microfracture awl. (d) Application of activated bone marrow aspirate concentrate to repaired ACL
25.4 Rehabilitation
The rehabilitation protocol was based on functional rather than temporal criteria; the progression of the recovery was related to the achievement of specific criteria that allow the patient to proceed to the next rehabilitative phase.
Five fundamental steps were identified in the rehabilitation program that were achieved in a sequential manner [28]:
- 1.
Resolution of pain, swelling, and inflammation.
- 2.
Recovery of range of motion (ROM) of joints and muscle flexibility.
- 3.
Recovery of muscle strength.
- 4.
Recovery of motor patterns and coordination.
- 5.
Recovery of athletic gesture.
From a functional perspective, we identified three phases in our protocol that were characterized by micro-objectives, and ended with the achievement of specific functional criteria.
The first several weeks after surgery are important for the healing process of the repaired ACL, so the repair was protected by bracing the knee in extension for 3 weeks, and exercises that may stress the ligament were avoided [29]. Continuous passive motion within a limited ROM was prescribed 4–6 h a day to reduce the risk of arthrofibrosis. There was a gradual increase in knee ROM, up to 90° by 2–3 weeks, followed by progression to full ROM. Partial weight bearing with crutches was prescribed for the first 3 weeks, followed by weight bearing as tolerated. The protocol emphasizes recovery of strength and proprioception. Low-impact exercises and comfortable performance of activities of daily living were restored by the end of phase 2, while the objective of phase 3 was complete functional recovery and return to sport. This was achieved through a progression of exercises that consisted of musculoskeletal and neurological components, and which proceeded from general movement patterns to sport-specific functions. Recovery of walking, running, and sport-specific activities were allowed according to predefined clinical parameters and functional objectives (Table 25.2). Greater detail of exercises performed in the pool, gym, and on field during the rehabilitation program is presented in Table 25.3.
Table 25.2
Criteria for progression of rehabilitation phases
Functional phases | Micro-objectives | Criteria of progression |
|---|---|---|
• Phase 1: Recovery of gait and autonomy in daily life (0–8 weeks) | − Protection of the ligament, avoidance of shear forces − Pain, swelling, and inflammation control − Full extension recovery − Gradual flexion recovery − Quadriceps neuromuscular control recovery − Adequate walk-pattern recovery | 1. Full extension, flexion >120° 2. Absent or minimal pain and swelling 3. Full weight bearing ambulation with normalized gait pattern 4. Adequate quadriceps recruitment, restoration of muscle tone, and trophism |
• Phase 2: Recovery of inline running (8–16 weeks) | − Recovery of full range of motion − Further recovery of knee extensor-flexor muscle tone, trophism, and flexibility − Functional progression and introduction of open kinetic chain exercises with resistance − Good functionality and autonomy in daily activities − Absence of pain and swelling | 1. Complete movement recovery 2. Absence of pain and swelling 3. Absence of complications 4. Good running-pattern without pain 5. Appropriate muscular tone and proprioceptive control (Isokinetic strength approximately 80% of contralateral limb) 6. Single leg hop test approximately 80% of contralateral limb |
• Phase 3: Recovery of sport-specific patterns (16–24 weeks) | − Complete recovery of muscular tone and trophism − Adequate basic sport gesture recovery − Proper neuromuscular control in dynamic proprioceptive exercises − Continued absence of pain, swelling, and complications − Gradual recovery of specific sport patterns − Recovery of general athletic condition | 1. Return to high-impact sport activity is allowed at the completion of the rehabilitation protocol if: − Normalization of running and sport-specific patterns without pain or sensation of instability − Isokinetic strength >90% of contralateral limb − Functional testing >90% contralateral limb (e.g., single leg hop test) |
Table 25.3
Rehabilitation program
Phase 1 | Phase 2 | Phase 3 | |
|---|---|---|---|
Brace: | • Brace locked in extension during ambulation and overnight for 3 weeks. The brace is removed during the day at rest, and for rehabilitation exercises and mobility with Kinetec® • From 4 to 6 weeks post-op, brace unlocked and ROM as tolerated until full weight bearing and adequate gait pattern restored | – | – |
Weight bearing: | • Partial weight bearing for 3 weeks (begin toe-touch ambulation and increase to 10% of body weight) with the aid of 2 crutches and brace in extension. Subsequently, progressive weight bearing as tolerated with use of articulated brace | • Full weight bearing | – |
Swelling and inflammation control: | • Continuous cooling system (i.e., Cryo-cuff, AirCast® USA) in immediate postoperative phase • Nonsteroidal anti-inflammatory drugs and anticoagulants as prescribed • Antithrombotic socks until recovery of full weight bearing • Elevated limb at rest with active mobility of the ankle • Ultrasound, HeNe laser therapy, and transcutaneous electrotherapy (TENS) as needed | • Ice room for 20 min after the rehabilitative exercises as needed to control swelling • Ultrasound, HeNe laser therapy, and transcutaneous electrotherapy (TENS) as needed | – |
Range of motion: | • Passive mobilization (degrees of flexion-extension): − First week: 10–60°. Subsequent increases of 5° per day until a range of 0–90° after 2–3 weeks, 0–120° at 6 weeks, and full range by 8 weeks postoperatively • Use Kinetec® for 6–8 h a day during first 3 weeks • Extension exercises for recovery of full passive extension after the first 2 weeks. Avoid hyperextension • Active and passive flexion. • Active extension is avoided for the first 3 weeks − After the 3rd week, begin active extension without resistance between 90° and 40° − After the 6th week, begin active flexion-extension without resistance | • Progressive recovery of full ROM • Active and passive full flexion and extension • Kinetec® not necessary | – |
Muscle strengthening: | • Postoperative day 1, recruitment exercises (flash contractions) and isometric contraction of the quadriceps with knee in extension and foot in neutral position • Subsequently, the following exercises are introduced, depending on presence of pain, swelling, and the level of mobility: − Straight leg raise − Co-contraction exercises (quadriceps and hamstrings) − Electrical stimulation of the quadriceps muscle − Active flexion-extension of the ankle with elastic resistance − Strengthening exercises of the adductor, abductors, and gluteal muscles, with knee in extension − Closed kinetic chain submaximal strengthening exercises within a limited range of motion (0–40°, e.g., mini-squat, elastic leg press) by weeks 3–4 − Submaximal strengthening exercises for knee flexors • After restoration of steady gait without the use of crutches, the following exercises are introduced: − Reinforcement of muscular recruitment and improved control of knee motion (e.g., leg press, wall slide) − Concentric–eccentric plantar flexion in full weight bearing − Core stabilization exercises • PRECAUTIONS: Avoid open kinetic chain exercises for quadriceps against resistance for the first 6–8 weeks, then begin with proximal resistance and limited ROM | • Closed kinetic chain strengthening exercises (e.g., leg press, squat) in concentric and eccentric modalities • Open kinetic chain strengthening exercises (e.g., leg extension) progressing from 90° to 40° to full extension, using gradually increasing concentric and eccentric distal resistance • Isokinetic strengthening beginning with high angular speed and limited ROM • Strengthening exercises of hip adductor, abductor, and gluteal muscles • Concentric and eccentric knee flexor exercises (e.g., leg curl) • Proceed with exercises to reinforce muscular recruitment and optimize control of knee motion (e.g., leg press, wall slide) • Strengthening and proprioceptive ankle exercises • Progress core strengthening exercises | • Progression of open and closed kinetic chain strengthening exercises, particularly for quadriceps and knee flexors • Isokinetic training at low angular speed full ROM • Plyometric exercises |
Muscles stretching | • Muscle stretching (hamstrings, triceps surae, posterior muscular chain, ilieopsoas, tensor fascia latae, and quadriceps) once 130° of knee flexion has been restored | • Continue muscular stretching | • Continue muscular stretching |
Proprioceptive exercises | • Bi- and monopodalic proprioceptive exercises in partial weight bearing (seated) from the 2nd to 3rd week, and full weight bearing by 4th–5th week. • Subsequently: − Small proprioceptive paths − Simple exercises on bouncer | • Bi- and monopodalic proprioceptive exercises with full weight bearing • Complex proprioceptive pathways • Running and jumps on bouncer | • Advanced proprioceptive exercises with dynamic control motion (bi- and monopodalic) |
Manual therapy | • Soft massage of the knee and calf
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