Update on Accelerated Rehabilitation after ~nterior Cruciate Ligament Reconstruction

Transcription

1 A C L S U R G E R Y & R E H A B I L I T A T I O N Update on Accelerated Rehabilitation after ~nterior Cruciate Ligament Reconstruction K. Donald Shelbourne, MD, Thomas E. Klootwyk, MD, Mark S. DeCarlo, PT, SCS, ATC K. Donald Shelbourne Thomas E. Klootwyk Mark S. DeCarlo P revious rehabilitation of the ACL reconstructed knee focused on protection of the new ligament with blocking of full extension (9, 13, 17) and avoidance of active quadriceps function in the terminal degrees of extension (3). This approach led to numerous postoperative complications, including stiffness, weakness, and patellofemoral problems (8, 18, 20). With the recognition of complications, modification in the postoperative rehabilitation was developed. An accelerated rehabilitation protocol after ACL reconstruction, using a central onethird bone patellar tendon bone Rehabilitation of the anterior cruciate ligament (ACL) reconstructed knee continues to be a topic of intense interest among surgeons and therapists. Since 1987, over 880 patients who have undergone ACL reconstruction using the central one-third of the bone patellar tendon bone graft have followed our accelerated rehabilitation protocol. Follow-up of the patients reveals early return to athletic activity and maintenance of long-term stability. Our 1987 accelerated rehabilitation program continues to be modified, with less constraints placed on the postoperative patient in our present rehabilitation protocol. These recent changes are once again prompted by noncompliant patients who, with close follow-up evaluation, continue to yield excellent results. Our present accelerated rehabilitation protocol is divided into four phases. The initial phase encompasses the preoperative period. The second phase involves the initial 2 weeks post ACL reconstruction. The third phase dates from 2-5 weeks postoperation, and the final phase (greater than 5 weeks) involves a safe return to athletic play. Our goal with the accelerated rehabilitation protocol remains to decrease postoperative complications without jeopardizing the long term stability of the ACL reconstructed knee. Key Words: anterior cruciate ligament reconstruction, rehabilitation, clinical outcome ' Methodist Sports Medicine Center, Indianapolis, IN graft was presented in 1989 and published in early 1990 (2 1). An u p dated version of the rehabilitation program was also published in late 1990 (22). As discussed in these two papers, the development of the accelerated rehabilitation protocol during the mid 1980s arose out of observation that patients who failed to comply with the restrictions dictated by the rehabilitation protocol did better than patients who were totally compliant. These noncompliant patients did not develop instability and had a lower incidence of postoperative complications (stiffness, anterior knee pain) (2 1). The focus and hall- mark of the accelerated rehabilitation protocol remains the early obtainment and long-term maintenance of full knee extension. Two areas of the accelerated rehabilitation protocol warrant clarification. The first is the concept of "fullw knee extension. Most normal knees will exhibit some degree of hyperextension (Figure 1). The ability of the ACL reconstructed knee to hyperextend equal to the opposite normal knee is referred to as "fullw extension. The goal of the rehabilitation program is to ensure that the patient is able to "fully hyperextend" his or her reconstructed knee to the same degree that his or her normal JOSPT Volume 15 Number 6 June 1992

2 knee hyperextends. Grasp of the concept of full extension is the key to success in the use of the accelerated rehabilitation protocol. The second area of the protocol that deserves clarification is the initial two weeks after the reconstructive procedure. Although the term "accelerated" certainly applies to the rehabilitation program in regard to early full extension, quadriceps activity, and early return to athletic play, it does not apply to the initial 14 days after surgery. During these first 2 weeks of postoperative rehabilitation, the patient is given five goals to obtain. Full extension, wound healing, good quadriceps leg control, minimal swelling, and flexion to 90" are emphasized. The patient is allowed to bear weight as tolerated with the aid of crutches but is encouraged to be up and about only for bathroom privileges and meals. During the remainder of this time the patient is to rest, limit walking, and elevate the operated extremity. This initial 2 weeks of rest greatly reduces postoperative swelling, and therefore, during the following weeks, the patient can quickly advance toward normal activities of daily living and an earlier return to athletic play. A brief description of the four phases of our acelerated rehabilitation protocol appears in Table 1. PHASE I The process of postoperative rehabilitation of the ACL recon- FIGURE 1. Normal knee hyperextension. Phase I: Phase 11: Phase Ill: Phase IV: Regain full ROM Resolve swelling Review postoperative rehabilitation program Mental preparation for surgery Arrange school, work, family schedule for elective reconstruction Obtain full hyperextension Allow wound healing Maintain active quadriceps leg control Minimize swelling Achieve 90" of flexion Resume a normal gait pattern Improve flexion to 135' Increase knee bends, step-ups, calf raises, leg press, Stairmaster, bicycle If strength is adequate, start lateral shuffles, cariocas, jumping rope, light running program Start sport-specific activities and return to competition as rehabilitation progress allows TABLE 1. four phases of our accelerated rehabilitation program. structed knee begins shortly after the acute knee injury and weeks before the actual operation. Previous belief that there was an emergent need to reconstruct an acutely injured knee has been dispelled (1 2, 23). It is now realized that an unac- Most normal knees will exhibit some degree of hyperextension* ceptable incidence of arthrofibrosis was associated with acute ligament reconstruction. With a delay in surgery, there is a decline in postoperative complications and an early return of postoperative strength (23). Instead of immediate surgery, the patient with an acutely torn ACL begins a rehabilitation process to prepare the injured knee and to ready the patient mentally for reconstructive surgery. The initial focus is on regaining full ROM and decreasing swelling, which is aided by the use of the knee Cryo/Cuff (Aircast, Summit, NJ). Range of motion of the injured knee is considered to be full when it equals the opposite normal knee. Also, patients work on resumption of a normal gait pattern. Once swelling and discomfort are minimal and full knee motion is restored, strengthening of the injured extremity can be undertaken. It is important to maintain minimal swelling and "full" motion during the preoperative time period. The second area of importance in the preoperative phase is the mental preparation of the patient. Details of the operative procedure, in addition to the process of hospital admission, are discussed. An indepth explanation and demonstration of the postoperative rehabilitation program is carried out by the physician and the therapist. It is extremely important the patient fully understand the rehabilitation process and approach the operation with a positive mental outlook. A "let's just get it over with" attitude is not acceptable. The goals of Phase I are to have a patient looking forward to the ACL reconstruction. A full understanding of the operative procedure and postoperative rehabilitation and an ACL deficient knee that has no swelling and full ROM are prerequisites for surgery. 304 Volume 15 Number 6 June 1992 JOSPT

3 PHASE II The second phase of the accelerated rehabilitation program encompasses the initial 2 weeks after surgery. The five goals of this phase are to I) obtain full extension, 2) allow wound healing, 3) maintain adequate quadriceps leg control, 4) minimize swelling, and 5) achieve flexion of 90". Phase I1 starts in the operating room prior to closure of the surgical wounds. At this time, the reconstructed knee's ability to be placed through full passive ROM (full extension to flexion of 145" without retightening of the graft) must be confirmed. At the completion of the operative procedure, a postoperative dressing using the knee Cryo/Cuff and a straight leg immobilizer (Techno1 splint, Technol, Inc., Fort Worth, TX) is applied to the leg. Upon arriving in the hospital room, the reconstructed knee is taken out of the immobilizer and placed in a CPM machine (Figure 2). The CPM machine has two functions. One is to gently bend and extend the knee over short arc of motion. Secondly, it provides a comfortable and predictable means of elevation of the operative knee. The Cryo/Cuff and elevation both work effectively in the early phase of rehabilitation to control swelling. The patient begins work on extension on the evening of the operative day. Early guidelines are for the patient to spend 10 minutes every hour during the day and early evening with the Cryo/Cuff removed and the heel of the operative extremity propped on pillows to allow the knee to relax into "full" extension. A 2%-lb ankle weight is added to the anterior portion of the proximal tibia1 to aid in achieving full extension. Extension of the operated knee is compared to the opposite knee. Full extension allows the correctly placed reconstructed ligament to fit perfectly into the intercondylar notch. Failure to achieve full extension within the first few weeks after surgery will allow this "potential" notch space to fill with scar tissue and become a permanent block to extension (8). Leg control is also emphasized during the early postoperative period. During the initial 2day hospital stay, it is confirmed that with active quadriceps contraction, the patient can lift the operative extremity. An active quadriceps contraction mobilizes the patella and places the patellar tendon at length. It is felt that this early quadriceps activity If is extremely important for the pa fien f to fully understand the rehabilifafion process and approach fhe operation with a positive mental outlook minimizes the potential problem of infrapatellar contracture. In addition to full extension and leg control, the patient will flex the knee to 90". This is started on the first postoperative day and is performed 3 times a day during the initial 2-week period. The flexion activity is usually coordinated with meals. Also during this time the patient will perform short quadriceps contractions in the range of motion of 90-30". Patients are usually discharged from the hospital on postoperative day number 2. Prior to discharge, it is confirmed that they can ambulate weight bearing as tolerated with crutches. While at home during the FIGURE 2. A is applied in the operating room and the leg is placed in a CPM machine upon arrival to the hospital room. FIGURE 3. Prone hangs with an ankle weight are applied to the operated extremiw. initial week, patients are encouraged to be up only for meals and bathroom privileges. Otherwise, it is recommended that patients rest, minimize walking, and continue to use the Cryo/Cuff and elevation to minimize knee swelling. During the second week of this 2-week phase, patients are allowed some increase in activity, guided by the amount of swelling. This usually involves students returning to classes and office personnel returning to jobs on a part-time basis. Patients continue to work each hour on extension of the knee and maintain active quadriceps leg control. During the second postoperative week, prone hangs are added as an additional means of achieving full extension (Figure 3). Three times a day, patients work on maintaining flexion of 90". Although patients are able to be up and about full-time during this time period, this will only lead to in- JOSPT * Volume 15 * Number 6 * June 1992

4 creased swelling, which can impede wound healing, increase patient discomfort, limit flexion, and delay rapid progression of the later rehabilitation phases. With regard to postoperative brace use, patients use the straight leg immobilizer during the initial 2- week period after surgery. It is recommended that the immobilizer be worn during the transport home and when out of the house. It need not be worn when up and ambulating at home. The initial follow-up evaluation is at 7 days postsurgery. At this visit, the patient sees the physician and a physical therapist. It is the goal of the rehabilitation protocol to avoid po'stoperative problems rather than have the therapist undo problems that are allowed to occur. The therapist's role should be to educate the patient on how to maintain minimal swelling and full extension instead of reducing extensive swelling or obtaining the terminal degrees of extension. All parameters of the early rehabilitation process are evaluated, with most attention directed at obtaining full extension. At this time, patients are measured for a postoperative brace that they will pick up the following week at their second postoperative visit. The brace is double-hinged without blocks to extension or flexion. This brace replaces the postoperative immobilizer and, after the 2-week period of time, is worn as a protective device during inclement weather and when the patient is returning to athletic activity. PHASE Ill Phase I11 of the rehabilitation usually encompasses weeks 3-5 postoperatively. During this phase, patients are encouraged to develop a normal gait pattern and gradually resume normal activities of daily living. Walking without aids and without a limp probably does more to encourage early quadriceps return than any specific exercise. It is im- perative that the patient maintain full extension with minimal swelling. While 90" of flexion is the goal of the initial postoperative phase, phase I11 is a time period when patients work on improving flexion. Most patients achieve full ROM (full extension to 135O of flexion) 5 weeks after reconstruction. The patient starts doing lateral knee bends, stepups, and calf raises at 2 weeks postoperatively. At 2-3 weeks, patients begin Stairmaster, bicycle, and leg press exercises. PHASE IV We also know that applied stress is important in the formation of new collagen and reorganization of transplanted connective tissue. The final phase of the rehabilitation process starts 5 weeks postoperatively. If strength testing shows that the operated extremity has reached 70 percent of the strength of the unaffected leg, then a running program is instituted. Also, lateral shuffles, cariocas, and rope jumping are added. In addition, some sports specific activities are also started. Throughout this phase, aggressive activity is tempered by the control of swelling and the maintenance of motion. If the patient does not desire a rapid return to sport, it has been noted that through normal activities of daily living, over a 1-2 year period of time, the patient will be able to regain a near normal level of strength in the now stable operated knee. If a patient does desire a rapid return to the field of play, then strength training can be intensified in this final phase of rehabilitation. Patients are counseled that although they can return safely to light athletic competition as early as 2 months postoperatively, it takes an additional 3-4 months of sports-specific play for the patient to regain full confidence in his or her reconstructed knee. During these steps of the rehabilitation process, physician followup and therapy visits are coordinated. Patients are followed at 1, 2, 5, 9, and 15 weeks postoperatively. It is at these visits that the patient is guided by the therapist in progression of exercises and activity. Patients can perform most of the rehabilitation on their own. Additional postoperative visits are at 6 and 12 months. Patients are followed longterm at 2-year intervals. DISCUSSION It has been written that the study of knee ligaments starts with the patient, migrates to the lab seeking solutions, and then returns to the patient (6). The problem we have in the study of patients is the lack of basic science information on in vivo human ligaments and grafted human ligaments. The development of the accelerated rehabilitation protocol of the ACL reconstruction was based on clinical observation of patients who were noncompliant with proposed rehabilitation guidelines and the finding that these noncompliant patients did better than compliant patients. We continue to modify the rehabilitation program based on clinical findings. At present, answers to numerous questions remain unknown. Animal research studies have documented an initial weakening of the reconstructed ligament before complete maturation (4, 5). These studies show the formation of a vas- Volume 15 Number 6 June 1992 JOSPT

5 ACL SURGERY 1G REHABILITATION cular sheath and revasculari7ation at 6-8 weeks after reconstructive procedures have been performed. In recent work, it is noted that as early as 3 weeks postoperation a grafted patellar tendon ligament has new host fibroblast cells present (1 9). The concept of "ligamenti7ationn was discussed by Amiel et al (1) in regard to autogenous patellar tendon grafts in rabbit ACL reconstructions. This study suggests that the graft is responding to its environment. We know that in the early stages of repair, a healing ligament will show both active collagen synthesis and degradation. Collagen synthesis is slightly greater than degradation during this inflammatory stage (2). We also know that applied stress is important in the formation of new collagen and reorganization of transplanted connective tissue (1 0, 1 1). In human autograft ACL reconstruction using a patellar tendon graft, it is unknown if the process of early synthesis outweighs early degradation like it does in animal grafted tissue. If it does exist, then does an appropriate level of stress applied early through normal activities guide the graft to an earlier and more functional cellularity and, therefore, allow the ligament to undergo the process of "ligamentbation" in a shorter time frame postop eratively? All of our strengthening activities are closed chain exercises. Open chained exercises are avoided. As noted in the original accelerated rehabilitation article, a proposed advantage of closed chain exercises is less patellofemoral stress (2 1). Additional proposed advantages are that closed chain activities place functional stresses on the joint and extremity in ways similar to normal weight bearing activities. It was previously reasoned that "the extremity loaded by body weight provides inherent stability and allows more strenuous strengthening workouts without the degree of shearing forces that occur with conventional exercises" (21). A recent article has examined the biomechanical aspects of closed chain rehabilitation and supports its use in early rehabilitation after ACL reconstructions (I 6). At the present time we do not have any basic science documentation that a "Wolffs law" of soft tissues applies to the autograft patellar tendon in ACL reconstruction. We do know that in a review of KT arthrometer (Medmetric, Inc., San Diego, CA) values before accelerated rehabilitation (before 1987) and after accelerated rehabilitation (after 1987), we see an improvement in scores. Using an identical surgical technique during this time frame, the patients following the accelerated rehabilitation, at two year follow-up, had an average KT maximum manual value of 2.1 mm. Patients before 1987 who did not follow an accelerated rehabilitation protocol were noted to have a KT maximum manual value of 2.8 mm at 2-3 year follow-up. It is our opinion that this does reflect a process of "early ligamentiiration" of the patellar tendon graft. We feel that the use of early normal activities guides the graft to a more functional cellularity. Therefore, weight bearing as tolerated with early quadriceps activity and a quick resumption of a normal gait pattern actually strengthen the properly placed graft instead of "stretching" the graft. The accelerated rehabilitation protocol continues to be evaluated and modified. The protocol functions as an outline and patients are guided through the rehabilitation process using the parameters of swelling and ROM to control the speed at which they are allowed to proceed through the various phases of the rehabilitation process. CONCLUSION With knowledge of the natural history of an ACL deficient knee well established (7, 14, I ti), the oper- ative procedure of ACL reconstruction has been well accepted. The goal of a postoperative rehabilitation program should be to ensure success of the procedure and to eliminate the potential complications that result from the surgical reconstruction. The accelerated rehabilitation protocol has been shown to significantly decrease postoperative complications (21). At present this rehabilitation program has been applied to reconstructions using a central one-third patellar tendon autograft. It is a protocol that emphasizes what patients can do, instead of what they are not allowed to do. This protocol continues to stress the importance of early full extension, an initial postoperative period of rest and elevation, early weight bearing as tolerated, emphasis on closed chain and functional activities, and a swift and safe return to athletic competition, all without sacrificing ultimate knee stability. We continue to scrutinize our results and progress our rehabilitation protocol guided by our patients and on-going follow-up evaluations. REFERENCES I. Amiel D, Kleiner lb, Akeson WH: The natural history of the anterior cruciate ligament autograft of patellar tendon origin. Am I Sports Med 14: , Andriacci 7, Sabiston P, DeHaven K, Dahners L, Woo S, Frank C, Oakes B, Brand R, Lewis I: Ligament: Injury and repair. 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6 1284, Daniel DM: Diagnosis of a ligament injury. In: Daniel DM, Akeson WH, O'Connor I1 (eds), Knee Ligament: Structure, Function, Injury, and Repair, pp New York, NY: Raven Press, Fetto IF, Marshall ll: The natural history and diagnosis of anterior cruciate ligament insufficiency. Clin Orthop 147:29-38, Fullerton LR, Andrews jr: Mechanical block to extension following augmentation of the anterior cruciate ligament: A case report. Am / Sports Med 12: , Crood 5, Suntay WI, Noyes FR, Butler DL: Biomechanics of the knee-extension exercise. I Bone joint Surg 66: , Klein L, Lunseth PA, Aadalen RI: Comparison of functional and non-functional tendon grafts. I Bone loint Surg 54: , I. Krippaehne WW, Hunt TK, lackson DS, Dunphy le: Studies on the effect of stress on transplants of autologous and homologous connective tissue. Am I Surg 104: , Mohtadi NC, Bogaert SW, Fowler PI: Limitation of motion following anterior cruciate ligament reconstruction: A case control study. Am I Sports Med l9: , Noyes FR, Mangine RE, Barber S: Early knee motion after open and arthroscopic anterior cruciate ligament reconstruction. Am I Sports Med 15: , Noyes FR, Matthews DS, Mooar PA, Crood ES: The symptomatic anterior cruciate-deficient knee. Part 11: The results of rehabilitation, activity modification, and counseling on functional disability. I Bone loint Surg 65: , Noyes FR, Mooar PA, Matthews DS, Butler DL: The symptomatic anterior cruciate-deficient knee. Part I: The long-term functional disability in athletically active individuals. 1 Bone loint Surg 65: , Ohkoshi Y, Yasuda K, Kaneda K, Wada T, Yamanaka M: Biomechanical analysis of rehabilitation in the standing position. Am I Sports Med 19:605-6 l 1, Paulos L, Noyes FR, Crood E, Butler DL: Knee rehabilitation after anterior cruciate ligament reconstruction and repair. Am 1 Sports Med 9: , Paulos LE, Rosenberg TD, Drawbert I, Manningl, Abbott P: lnfrapatellar contracture syndrome: An unrecognized cause of knee stiffness with patella entrapment and patella infera. Am I Sports Med 15: , Rougraff B, Shelbourne KD, Certh PK, Warner I: Arthroscopic and histologic analysis of human patellar tendon autografts used for anterior cruciate ligament reconstruction. Am Sports Med (in press) 20. Sachs RA, Daniel DM, Stone ML, Carfein RF: Patellofemoral problems after anterior cruciate ligament reconstruction. Am 1 Sports Med 17: , Shelbourne KD, Nitz P: Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am I Sports Med 18: , Shelbourne KD, Wilckens /H: Current concepts in anterior cruciate limment reconstruction. Orthop Rev jb: , Shelbourne KD, Wilckens IH, Mollabashy A, DeCarlo M: Arthrofibrosis in acute anterior cruciate ligament reconstruction: The effect of timing of reconstruction and rehabilitation. Am I Sports Med 19: , 1991 Volume 15 l Number 60June 1992 l JOSPT