a patient’s guide - uw orthopaedics and sports medicine · university of washington department of...
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ACL Injury:
A Patient’s Guide
Ø Frequently asked questions on injury, surgery and recovery
Ø Preoperative and postoperative guidelines
Mia S. Hagen, M.D. Assistant Professor Department of Orthopaedics & Sports Medicine University of Washington
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WhatisanACLTear?
TheACL(anteriorcruciateligament)isoneofthemainstabilizersoftheknee.Itisastrongligamentinsidethekneethatallowsyoutoturn,cut,twist,andpivot.TheremaybeotherstructuresinyourkneethatareinjuredatthesametimeasyourACL.Theseincludeyourmeniscus(acartilagecushioninsideyourknee),otherligaments,orthesmootharticularcartilagecoveringtheendsofthebone.Yourtreatmentplanwillbeinfluencedbythecombinationofstructuresinvolved,yourcurrentactivitylevel,andyouractivitygoals.Thefinalplanofcarewillbedecidedbyyouandyourhealthcareteam.
WhatarethesymptomsofanACLinjury?
ThemajorityofACLtearsarecompletetearsorrupturesthatoccurwhenanindividualmakesasuddencutorturnwithfeetplantedinsports.HyperextensionofthekneecanalsocauseruptureoftheACL.Themostfrequentsymptomsare:hear/feelpopintheknee,cannotreturntogame,swellingintheknee,painwithbendingtheknee,feelingunstableinthekneelikeitwillgiveway.
KneeAnatomy
Thekneeislikeafrictionlesshinge.Thishingeisheldtogetherby4ligaments.Thesmoothglidingsurfaceisthearticularcartilageontheendsofthebone(likerubberonatire).Themeniscusorbushingsaredesignedtodecreasetheforceorloadonthearticularcartilage.Injuriesthatareeffectivelytreatedbyarthroscopicsurgeryincludemeniscustears,loosebodies,ligamentinjuries,andsmallcartilageinjuries.Yourphysiciancandiscussinmoredetailyourfindingsandtreatmentstrategy.Pleasenotethatdebridementofarthritisoftheknee(frayingofthetirerubber)isbyitselfnotaneffectivesurgicaltreatmentstrategy.
Medialmeniscus
Lateralmeniscus
Articularcartilage
Imagecredit:http://orthoinfo.aaos.org/topic.cfm?topic=a00550
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TreatmentOptionsforACLTear
Non-OperativeApproach
TheimmediategoalafteranACLtearisthesameregardlessoftreatmentoptions:normalwalking,nearfullmotionandstrength,andreducedswelling.
SomepeoplewhoteartheirACLinanoccasionalrecreationalactivitymaychoosetohaveonlyphysicaltherapywithoutsurgery.Peoplewhodecidenottohavesurgeryusuallydon’thaveaveryactivelifestyleorparticipateinsportsthatrequirealotofcutting/pivoting.MostpeoplewiththistypeoflifestylewillbeabletofunctionnormallywithouthavingsurgerytoreconstructtheirACL.
Activeindividualsoftenquestionwhethertheyshouldhavesurgeryorwearakneebrace.Researchhasshownthatcustomandoff-the-shelfbracesdonotprotectagainstfurtherkneeinjuryinathletes.Ifyouchoosetowearabrace,pleasediscusswithDr.Hagentherisksofadditionalkneeinjuriesandthetypeofbracetobeworn.
OperativeApproach
Patientsthatparticipateincuttingandpivotingsportslikefootball,soccer,basketball,etc.--especiallyatacompetitivelevel--usualelectACLreconstruction.ACLreconstructionhasbeenshowntopreventre-injuryortearingofyourmeniscuscartilageandarticularcartilage.Thisisespeciallyimportantifyouareyoungandactive.AsmallpercentageofathleticpatientswithguidedphysicaltherapycanparticipateinsportswithoutACLsurgery,buthowtoidentifytheseindividualsisunknown.
SurgicalTechniques
Ascurrenttechniquestorepair(suturetogether)thetornACLfibersarenoteffective,anotherpieceoftissue(graft)ischosenbyyouandyourdoctortoplacewithinyourkneeasthenewACL.Autograftmeansyourowntissue.Thesechoicesincludedyourpatellartendon(thecentral1/3ofthetendonfromyourkneecaptoyourlegbone[tibia],includingasmallpieceofbonefromboththekneecapandtibia),or2ofyourhamstringtendons.Allografttissuecomesfromadonor.Thesetissuescanbeeitherpatellartendonorothersofttissue(mostcommonlyhamstringorAchillestendon).
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Inyoungermoreactivepatients,especiallythoseincompetitivesports,eitherautograft(patellartendonorhamstring)isthebestchoice.Allograftsshouldbeavoidedbecauseofa3-foldhigherfailurerateinthesepatients.Asapatientisolder,thereislessofadifferenceinfailureandallograftcanprovideabenefitoflesspainaftersurgery(becausethereisnopainfromwherethegrafttissuewouldbetaken).Researchonpatellarautograftversushamstringautografthasfoundnodifferenceinoutcomes–rather,thesurgicaltechniqueandpatient’srehabilitationaremostimportanttooptimizeresults.Dr.Hagenwillperformtheoperationthroughanarthroscope.Theskinincisionsareonlyfortheharvestofthegraft,ortodrilltunnelsatthesiteoftheACL.Thegraftisplacedwithinthetunnelsandfixedbyavarietyofchoicestoprovideimmediatestabilitypriortohealing.
Whatarethepossiblecomplicationsofsurgery?TheriskofcomplicationsafterACLsurgeryisverylow.However,withanyarthroscopicsurgerytherearerisksincluding,butnotlimitedto: -bleeding -infection -nerveinjury
-bloodvesselinjuryorbloodclot -jointstiffness -cartilagedamagefromsurgery -brokenbone -complicationsfromanesthesia
SpecificallyforACLsurgery,therecanbenumbnessinthefrontofthekneeneartheincisions.Thisnumbnessmaybepermanent.Thereisalessthan0.5%riskofaseriouscomplication(bloodclot,brokenbone,deathfromanesthesia).
CanItearmyACLagainaftersurgery?
Theriskofgraftre-teardependsonyourageandactivitylevel.Overall,thisriskisabout5%in2years.Thisriskincreasesifyoudonotfollowthetherapyguidelinesaftersurgery.
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HowdoIprepareforACLsurgery?
Ifyouwillbehavingsurgery,youshouldhaveapreoperativeevaluationwithaphysicaltherapist(PT)whowillbeamemberofthetreatmentteamresponsibleforyourcareaftersurgery.Duringthepreoperativerehabilitationyouwillbeinstructedonhowtowalkasnormallyaspossible,decreaseswellinginyourknee,getyourkneestraightalltheway,andbendyourkneeasfarbackaspossible.Ifyoucanalreadydothesethingsyoumaynotneedtoseeatherapistbeforehand,althoughwerecommendfindingsomeoneyoulikebeforesurgerysothatyoucanhaveyourpostoperativePTappointmentalreadyarranged.
GoalsofpreoperativePT:
1) Decreaseswelling2) Increaserangeofmotion3) Improvegaitsoyoucanwalkwithoutalimp4) Increasestrengthintheleg5) Educateyouonpostoperativeexercises6) Educateyouoncrutchwalking.
YourPTteamwilldiscussthesethingswithyouandshowyouexercisesthatwillhelpyougetreadyforsurgeryandmakeyourpostoperativetherapyeasier.
PreoperativeRequirements
Priortoyoursurgeryyoumaybeinstructedtoperformaseriesofexercisesinordertobuildyourstrengthandmaintainnormalmotion.Thiswillgreatlyhelpyourrecoveryprocessaftersurgery.Pleaseperformallthefollowing1-2timesperday,and3setsof10repetitionsforeachexercise.Ideallybeforesurgeryyoucan:
1) Walkwithoutalimp.(UnlessyouhavebeeninstructedbyDr.Hagentostayoncrutchesduetotheextentofyourkneeinjury.)
2) Beabletobendthekneeatleast120degrees.3) Haveminimalswelling.Thiscanbeachievedwithfrequentelevationoftheleganduse
ofanicepackfor15-20minutes3-5timesperday.
TheTreatmentTeamconsistsof:Ø YourphysicaltherapistØ Thephysicianassistant
(TravisFann,PA-C)Ø Thesurgeon(Dr.Hagen)Ø Possiblyanathletictrainer
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Exercisestohelpyouachieveyourmotion:
HeelSlides Seatedflexion
Exercisestohelpyoustaystrong:
Quadsets StraightLegRaise
Adduction Abduction
OtherPreoperativeInstructions
Beforesurgeryyouwillneedaphysicalexamination,usuallyperformedbyourphysicianassistant,Travis.Wemayalsoorderbloodwork,chestx-ray,orheartEKGtomakesureyouarehealthyenoughforsurgery.Ifyouareawomanofchildbearingagewemayrecommendaurinepregnancytestbeforesurgeryasanesthesiacancausehealthproblemsinanunbornchild.Youwillalsomeetwiththenursingstaffattheclinictogooveryourpreoperativeinstructions.Thisincludesmedicinestoavoidbeforesurgery,fastingguidelines,showerinstructions,andtransportation.Theycanalsohelpyouwithshorttermdisabilityforms,insuranceforms,andreturntoworkforms.
Slideheelbackasfaraspossible
Slideheelback,bendingtheknee
Tightenquad,pushkneedown
Liftlegasdemonstrated
Liftlegasdemonstrated
Liftlegasdemonstrated
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PostoperativeCare
Aftersurgeryyouwillbegivenawritteninstructionsheet,picturesofyoursurgery,aprescriptionfortherapy,andacopyofphysicaltherapyguidelines.Thisinformationshouldanswermostofthequestionsyoumayhaveduringyourrecovery.YouwillbegoingtoPTafteryoursurgery.Thiscanbeassoonasduringtheweekaftersurgery.Duringthisvisityouwillbeinstructedon“Phase1”exercises,woundcare,andhowmuchweightyoushouldplaceonyouroperatedleg.Inaddition,yourtherapistwillaskyoutohelpsetyourgoalsforrehabilitation.
IfyouhaveanACLreconstructionwithoutmeniscusrepair,youwillbeallowedtoweightbearwhenyouareabletofeelyourlegagainaftersurgery.IfyouhaveameniscalrepairorcartilageworkalongwithyourACLreconstructionyouwillbeoncrutcheslongerandmayreceiveakneebrace,asguidedbyDr.Hagen.
Theentirerehabilitationprocesswilltakeatleast6months(ifyouhavearevisionACLsurgeryormeniscus/cartilagerepair,expecttherehabilitationtogoevenslower).Duringtheearlyphaseofyourrehabilitationyouwillbecloselymonitored.Asyouprogress,youwillbeabletodomoreexercisesonyourown.Ifyouhaveanyquestionsconcerningyourrehabilitationprocess,theyshouldbedirectedtoyourtreatmentteam.
Follow-up:
YouwillbeseenbyTravis,ourphysicianassistant,at1-2weeksaftersurgeryforawoundcheckandremovalortrimmingofstitches.YouwillbeseenbyDr.Hagenat6weeksaftersurgery.Timingandlengthofadditionalfollow-upswillbedeterminedbyyourprogress.
FREQUENTLYASKEDQUESTIONS
WhencanIdrive?
Youshouldnotdrivewhileyouareusingnarcoticmedications.Ifyoursurgeryisontheleftsideandyourcarhasanautomatictransmission,youmaydriveinabout1-2weeks.Ifyoursurgeryisontherightside(orifyourcarismanualtransmission),itmaybe4-6weeksbeforeyouareabletodrive.Thiswillbetailoredforeachindividual–youmustbeoffofyourcrutchesandhavegoodcontrolofyourlegbeforeyoucandrive.
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WhencanIgoonanairplane?
Thereisariskofbloodclotafteranylowerextremitysurgeryandthisisincreasedduringairtravel.Itcanalsobeuncomfortabletositonanairplaneaftersurgery.Werecommendwaitinguntilatleast2weeksaftersurgeryforanyflight.Ifyouhavenecessarytravel,pleaseinformDr.Hagen.IfyouareabletotakeAspirin(325mg),wemayrecommendtakingonetablettwiceadayonthedaybefore,thedayof,andthedayafteryourflight.Whileontheplaneyoushouldgetupandwalkaroundeveryhourtokeepabloodclotfromforming.
WhencanIreturntonormalactivities?
Work/School:Mostpatientsreturntodeskworkorschoolinabout1-2weeks.Ifyourjobrequiresphysicalactivity,itmaytakemuchlonger(weeksormonths)dependingonthenatureofyourjobandtypeofsurgery.Evenifyouhaveadeskjob,thefirstfewweeksaftersurgerymaybeuncomfortableforprolongedsitting.
Sports:Thelengthoftimetoreturntosportwillgreatlyvarybetweeneachindividual.Yourphysicaltherapyexercisesandactivitymodificationswillbereviewedandadjustedateachpostoperativevisit.Controlledrunningusuallybeginsaround3months.Donotexpecttoreturntoyoursportbefore6months.
Generalrecovery:Arehabilitationprogramcanstartassoonasthedayafteryoursurgery.Expectedrecoverytimelineswillbemademorespecific,dependingonwhatexactlywasseenanddoneduringsurgery.Ittakes6monthsormoreforyourkneeto“completely”recoverandforthegrafttohealsolidly.ListentoyourPTanddon’ttrytorushthebiologyofhealing.
HowdoIschedulesurgery?WhatifIhaveadditionalquestions?
Pleasecalloursurgeryscheduler,KirstenHalloran,at(206)598-3484.
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