ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION, A PATIENT GUIDE.

Transcription

1 ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION, A PATIENT GUIDE. Anatomy of the Right Knee Lateral Condyle of Femur Intercondylar notch Tibial Condyle Knee Straight Knee Bent KEY: Patella Kneecap Femur Thigh bone Articular cartilage Protective coating covering the end of a bone. ACL Anterior Cruciate Ligament Meniscus Crescent shaped washer often referred to as cartilage. Collateral ligaments Tough fibrous bands of tissue situated on either side of the knee. Fibula Bone at the outside of shin. Tibia Shin bone Lateral femoral condyle Outer knuckle part of thigh bone. The back, top attachment of the ACL Intercondylar notch Area/ gap between the femoral condyles. Tibial condyle shinbone. Bony prominence at the top of The front, lower attachment of the ACL. 1 the

2 GENERAL INFORMATION The knee joint has the ability to bend, straighten and twist. There are two ligaments that cross each other inside the knee joint; THE ANTERIOR CRUCIATE LIGAMENT (ACL) THE POSTERIOR CRUCIATE LIGAMENT (PCL) These help to control the movement of the knee joint by connecting the bones and bracing the joint against abnormal movements and forces. The ACL attaches to the front part of the shinbone (tibial condyle) and passes upward, backwards and out to the side (laterally) and attaches to the thigh bone (lateral condyle of the femur). The average length of the ACL is 4cm. However, the ACL can stretch by approximately 15% before it ruptures. The ACL acts like a very thick rubber band and can return to its normal shape after stretching, within certain limits. The ACL is composed of two main bundles of fibres. Various aspects of the knee joint, including the ACL contain nerve fibres that sense joint position and therefore play an important role in balance. The term used to describe this function is proprioception. FUNCTIONS OF THE ACL 1. Resists the forward movement of the tibia under the femur. 2. Resists rotation of the femur on the tibia, especially when the knee is slightly bent. For example, during twisting, turning and cutting manoeuvres. 3. Resists sideways movements of the knee joint. For example, when tackled from the side. 4. Provides proprioceptive feedback from the nerve fibres within the ligament, therefore aiding balance. For example, running on uneven surfaces. MECHANISM OF INJURY There are many ways in which the ACL can be injured. A tear of the ACL can occur with a surprisingly small amount of force and is often associated with hearing a pop or crack as it ruptures. ACL injuries can occur as a result of direct trauma (contact), or more often an indirect incident (non-contact). Two possible mechanisms of injury are: a) ROTATIONAL STRESS E.g. sudden change of direction, side stepping (cutting), pivoting on a fixed foot or landing awkwardly from a jump. b) HYPEREXTENSION 2

3 When the knee is forced into an over-straightened position. E.g. landing awkwardly from a fall, during a challenge or an uncontrolled follow through of a kick. SYMPTOMS SWELLING In most cases the knee joint swells almost immediately at the time of injury. The ACL is situated within the joint capsule, therefore if it tears the bleeding caused is held inside the joint capsule. This is referred to as a HAEMARTHROSIS. GIVING WAY The knee may feel loose and unstable. Mechanically the knee may give way when changing direction or during twisting and turning manoeuvres. PAIN Pain may be experienced at the time of injury, due to the swelling and/ or damage to other structures. However the ACL is not a structure that produces pain. TREATMENT CONSIDERATIONS CONSERVATIVE TREATMENT Following an injury to the ACL there are ways of rehabilitating the knee to compensate for the associated instability. This involves a programme of intensive rehabilitation, including exercises to strengthen the hamstring muscle group (muscles at the back of the thigh). The hamstrings help control the gliding movements between the femur and tibia. Your physiotherapist will guide you through the progressive rehabilitation, hopefully leading to a gradual return to sport. However, if after following this comprehensive programme, your knee is not stable enough to cope with your chosen sport/ daily activities, surgery may be required. If this is the case this period of prehabilitation will enable a smooth transition into the post-operative rehabilitation. SURGICAL TREATMENT Unfortunately, the ACL has little healing capacity and will often require surgical reconstruction. The material used to reconstruct the ligament is referred to as a graft. It can either be an autograft (from your own body) or an allograft (from a donor). 3

4 Three possible methods are; 1) PATELLA TENDON GRAFT. VIEW: FRONT OF KNEE Femur Bone block Patella Patella Tendon Middle 1/3 of tendon used for graft Bone block Tibia This involves replacing the torn ligament with the middle one third of the patella tendon. The patella tendon merges from the quadriceps (muscle group at the front of the thigh) and attaches to the front of the tibia. The middle third of the patella tendon is cut vertically with a bony block at either end; one from the lower end of the patella and the other from the upper end of the tibia. Often the cut to extract the graft results in some degree of numbness on the outer side of the knee. This usually diminishes within twelve months and in no way hinders the function of the knee. Keyhole surgery (arthroscope/ arthroscopy), involves two to three small incisions, allowing the surgeon to drill two small tunnels into the tibia and the femur, allowing the final position of the graft to mimic that of the ACL. The patella tendon graft is brought through the tunnels and the bone blocks are fixed into place. 2) HAMSTRING GRAFT. This method uses two of the hamstring tendons (semitendinosis and gracilis). These are removed via a small incision to the side of the knee. They are then braided together to form the strong new ligament. 4

5 VIEW: FRONT RIGHT THIGH VEIW: BACK OF THIGH Hip Hip Femur GRACILIS Femur SEMITENDINOSUS Knee Knee Harvested Tendons. Braided Tendons Then as just like the patella tendon graft the surgeon to drill two small tunnels into the tibia and the femur, allowing the final position of the graft to mimic that of the ACL. The hamstring tendon graft is brought through the tunnels and fixed into place. 3) SYNTHETIC GRAFT. This involves the use of a manmade polyester ligament. This form of reconstruction is usually the preferred choice in the more mature patient or those who do not wish to participate in high levels of sport. 5

6 Following a synthetic graft reconstruction you may rehabilitate and progress as your comfort allows, there is no limitation to your activity at all and the following DO s and DO NOT s will not apply to you. If you are offered one of the afore-mentioned operations the type graft chosen will be catered to your individual requirements and the implications will be discussed fully. GENERAL DO S AND DON TS FROM DAY 1 DO X DO NOT Do consult your physiotherapist if X Do not drive until you can perform you are unsure about anything an effective emergency stop, which is concerning your rehabilitation. usually about two to three weeks following your operation. It is advisable to check with your insurer Do check with your physiotherapist before you resume driving. before progressing any form of exercise or training. X Do not bend and straighten the affected leg whilst in a sitting position, Do expect to work your whole eg. Leg extension exercise body within your rehabilitation regime. Do follow the exercises within your own limits. X Do not perform any twisting, turning or pivoting manoeuvres on your affected leg Do use elbow crutches for comfort X Do not attempt to run/ jog when walking and gradually discontinue use when you feel capable, under the supervision of X Do not use a breaststroke leg kick your physiotherapist. (The aid of when swimming crutches are usually required for one week following surgery.) Do return to work when you feel capable of doing so. Check with your physiotherapist beforehand with respect to specific postures, positions and manoeuvres your job entails. Apply ice to the knee after exercise. (See instructions below). 6

7 FROM 3 MONTHS DO X DO NOT Commence leg extension exercises, X Perform any high speed twist, turns bending and straightening the leg or pivots. whilst in an upright sitting position. Gradually introduce jogging on a sprung surface, progressing duration and speed under supervision. Allow breaststroke leg kick. FROM 4 MONTHS DO X DO NOT Introduce predictable twists, turns X Attempt any unpredictable twist, and pivots, e.g. shuttle runs. turns or pivots. Ensure your training is specific FROM 5 MONTHS DO X DO NOT Progress to include unpredictable X Do not begin contact sport. twist, turns and pivots. Commence non-contact sport training. FROM 6 MONTHS ONWARDS DO X DO NOT Gradually return to full sporting X Do not progress to full sporting activity with no restrictions, as guided by your physiotherapist. activity unless you are advised to do so by your surgeon or physiotherapist. EVERYONE RECOVERS AT DIFFERENT RATES AND THE ABOVE LIMITS ARE ONLY A GUIDELINE TO YOUR RECOVERY. 7

8 ICE If you do not have any circulatory disorders, you may benefit from applying an ice pack to your knee following the exercises. A good ice pack to use at home is an ice cube bag (available from supermarkets) wrapped in a damp towel. Before applying the ice pack, if the wound is still at the stage where it is to be kept dry, wrap the knee with cling film. Keep the ice pack in place for approximately twenty minutes, with the leg supported in an elevated position. Ice application can be repeated every two hours during the day. If you are unsure whether you should apply ice, consult your physiotherapist beforehand. EXERCISE GUIDELINE FROM DAY 1 POST SURGERY TO FIRST OUT PATIENT PHYSIOTHERAPY APPOINTMENT The following exercises are a guideline to be performed within the limits of comfort, as directed by your physiotherapist in the first instance. Certain exercises may be deleted others may be added to cater for you as an individual. The order in which the exercises are to be performed may be altered to include a warm-up and cool-down phase when appropriate. If you are in any doubt over certain exercises or if a specific exercise results in severe pain stop and consult your physiotherapist immediately. When the physiotherapist is satisfied with your ability to perform these exercises safely, you may follow them independently. The exercises will be progressed with respect to the healing of the graft and your individual recovery. Within the first three months following your operation you will be expected to attend physiotherapy for a minimum of one to two sessions per week, (allowing for some flexibility), in order to optimise your recovery. An outpatient physiotherapy appointment will be organised for you before you are discharged home. 8

9 1. Sitting as below, ensuring the non-affected leg is bent, lean forwards from your hips, reaching towards your toes. Feel the stretch at the back of the thigh/ knee. HOLD sec 2. Sitting as below, with the thigh muscles of the affected leg relaxed move your kneecap side to side and up and down. each direction. 3. Sitting as below, pull your foot toward you from the ankle. Tighten the thigh muscles, bracing your knee back straight. HOLD sec 9

10 4. Seated as below, place the heel of your affected leg onto a slippery surface (e.g. A tray sprinkled with talcum powder). Keep the heel in contact with the surface as you pull the heel toward your buttock, and then allow the weight of your leg, assisted by the slippery surface to return to the straightened position. 5. Lying on your front, allow the lower leg and kneecap to over hang the end of the bed. Let the weight of the leg stretch the knee out straight. HOLD sec. 6. Lying on your front, bend and straighten your affected leg within a comfortable range. 7. As above, pausing at various points within your available range. 8. Lying as below, hook your non-affected leg under your affected leg and over press the bend as comfort allows. 10

11 HOLD sec 9. Sitting with your legs out straight or bent, place a ball or rolled towel between your knees and squeeze your knees together, working the muscles on the inside of the thigh. HOLD sec 10. Lying on your back with both legs bent to the same angle, lift your pelvis off the bed, tightening your buttocks as you do so. HOLD sec 11. Lying on your front maintaining your knee bend at 90, lift and lower 11

12 your thigh about 1-2. (Ensure you do not twist at the lower back). 12. Lying as below, lift and lower your straight leg approximately 1-2. (Ensure you do not twist at the lower back). 13. Lying on your non-affected side with the hips stacked, ensure the affected leg is straight and rotated, allowing the heel to lead the movement. Lift and lower the affected leg, working the outer thigh and buttock region. HOLD 14. Standing with your affected leg placed behind you, heel down, foot 12

13 facing forwards lean your body weight forwards. Feel the stretch at the back of your calf/ knee. HOLD sec 15. Standing as below, transfer your body weight side to side. 16. Standing with even weight through both feet lift and lower your heels. 13

14 Standing with feet shoulder width apart and even weight through both feet, bend the knees to approximately 30 and straighten. Try to ensure that the centre of the kneecap is inline with the second toe as you do so March on the spot. 19. Standing, supported if necessary stand on the affected leg, try to keep your balance. 14

15 Stand with your affected leg placed in front and transfer your body weight forwards and backwards. Note the heel toe movement. REPEAT X As above with your affected leg behind you, transfer your body weight forwards and backwards, pushing off with your back affected leg. Note toe off movement. 22. Using a shallow step, step touch with your affected leg. Ensure you do not hip hitch as you perform the exercise. 23. Sit on a chair with the heel of the affected leg placed on another chair in front, allowing the knee to be unsupported. Place your hands on the thigh bone just above the kneecap and push down into some resistance and release PULSE X 15

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