Surgical Considerations - ACL Flashcards
What is the typical MOI for ACL tears?
Non-contact mechanism during pivoting, cutting, jumping with the knee slightly flexed in valgus postion. Also forced knee hyperextension
Those patients that have partial and full-thickness tears that manage conservatively with PT are known as what?
Copers
- They manage with activity modifications, and/or PRP injections
When conservative treatment fails over a reasonable time frame, this is typcially dependent on…?
- Response from PT
- Patient’s particiapation requirements
- Effectiveness of other treatments
-Biologics (PRP, Stem Cells, etc) - Severity of tear
- Concomitant injuries
What are the indications for surgery?
- Disabaling instability
- Frequent episode of the knee giving away during ADLs
- Concomitant injuries to the MCL and Meniscus
What takes place during ACL Reconstruction surgery?
The Torn ACL is removed and replaced with a graft
- Autograft (This is perferred. Harvested tissue from the body. The most common are bone, patellar tendon bone, hamstring, and quad tendon that utilizes bone from the superior portion of the patella)
- Allograft (cadaveric tissue. This is typcially utilized with older, less active individuals)
The graft is threaded through tunnels drilled into the tibia and femur
Screws or pins are used to anchor each end of the graft within the tunnel
Post-ACL Reconstruction, what should the Subjective Exam focus on?
- Red/Yellow flag screening (intake and OM
- Understanding of the full scope of the surgery
-What are the restrictions from the surgen?
-Graft type
-Parameters of wearing the T-ROM brace
-WB precautions and progression off crutches
-ROM restrictions - Will they be going to work or school while rehabbing?
- Will they be doing any other training while rehabbing?
- What level of activity do they need to get back to?
(What sport do they particiapte in?)
What are the structure(s) affected by surgery?
Primary, secondary, tertiary
- Primary: Graft Tissue
- Secondary: Bone of Tibia and femur where the tunnels were drilled for the ACL graft
- Tertiary: Surrounding tissues disrupted by surgery to access the primary tissues
Post-ACL surgery, what is an important education piece in the first 2-3 weeks and during weeks 6 to 8?
- During the first 2-3 weeks, the graft goes through a necrotizing process
- The revascularization process then weakens the graft again weeks 6-8.
Extra care must be taken during these time frames to avoid reinjury and/or stretch in the graft
Post-ACL Reconstruction, What does the Physical Examination entail?
- Integumentary Exam
- Knee ROM
- Joint Integ
- Muscle Performance Testing
- Palpation
Post-ACL surgery, with the Physical Examination, when should an Integumentary Exam take place and what is expected?
- Before and after treament
- We expect to find redness, erythema and maybe eccymosis around incision.
- Signs to look out for are signs of necrosis, excessive tenderness or edema, increased heat and drainage; which indicated infection and/or delayed healing
The most common complication from surgery is infection and/or wound complications
Post-ACL surgery, with the Physical Examination, what is done during Knee ROM?
We expect limited motion in both Flexion and Extension
- AROM and PROM should be tested to patients tolerance to get baseline measurements
- ROM should be assessed at each visit to ensure progress, especially during extension
Post-ACL surgery, with the Physical Examination, what is done during Joint Intergrity?
- Testing for patella mobility in all directions may be done if the patient can tolerate it.
- Patella mobility will most likely be limited in all four directions (superior, inferior, medial and lateral)
Post-ACL surgery, with the Physical Examination, what takes place during Muscle Performance Testing?
We expect to see poor to fair quad activation during a quad set
- Quad activation
- Other muscle perfromance testing may be deferred based on patient tolerance
Post-ACL surgery, with the Physical Examination, What is expected during palpation?
- TTP of quads, hamstrings, and gastroc/soleus
Due to trauma of surgery and/or muscle guarding
What is the Prognosis for an ACL Reconstruction surgery?
This will vary based on:
- Natural History (The bodys ability to heal its self over time)
- Primary tissue healing times (Bone and graft tissue)
- Social determinants of health (SDOH)
Full maturation of the graft can take up to 18 months, but research has shown that the graft tissue is matured enough at around 9 months to withstand the forces of cutting, pivoting and jumping. Full rehab can take as long as 12 months to return to sport activity, especially sports that involve high amounts ot cutting, pivoting and jumping
What are the Phases of Rehab for ACL Reconstruction?
With the 1st phase of rehab what is the rehab focus?
- Phase 1, pts typically begin PT 3 days post-op, and they’ll be in the Acute SOH with nocicpetive pain. This phase aims to protect the surgical procedure, control pain and swelling, slowly increase knee ROM, increase quad activation, and normalize gait pattern
With the 2nd phase of rehab what is the rehab focus?
Pt will be in the subacute SOH with nociceptive pain but with less severity and irritability. This phase aims to regain full knee AROM and PROM, increased quad and hamstring strength, increased tolerance to activity and prepare for jogging around week 12
With the 3rd phase of rehab what is the rehab focus?
Pt should not have any pain symptoms, pt will be in the chronic SOH. This phase aims will be to continue to strengthen the quads, hamstrings and core. Pt will be able to begin impact exercises during this phase, such as jogging and light jumping
With the 4th phase of rehab what is the rehab focus?
This is the return to sport phase, but due to the typical time frame of 9 months to return to full participation. This phase will last at least 5 months in duration, this includes jumping, running, agility, cutting and sports specific drills to prepare them to return to participation safely
With Phase 1, What are the Precautions, Goals, and Interventions?
Treatment approach is to control pain, modulate post-op symptoms and regain ROM
Precautions
- Avoid activities that increase pain and effusion
- If Hamstring graft used: avoid any hamstring exercises
- Crutches until gait is normalized
- Use of T-ROM brace as directed by surgeon
Goals
- Full knee extension
- Knee flexion to > 100°
- Normalize gait pattern
- Voluntary quad control
Interventions
- Manual Therapy
-Flex/Ext PROM
-Patella mobilizations
-Soft-tissue massage - Exercises:
-Quad activiation with and without NMES
-Flex/Ext ROM
-Gait training - HEP/Education
-Emphasis should be on quad activation, patella mobility and knee extension ROM
With Post-Op ACL Reconstruction, what is the Critera to Progress from Phase 1 to Phase 2?
- Minimal swelling and effusion
- Normal patella mobility
- Knee extension at least at 0°
- Knee flexion to at least 120°
- Normal gait pattern without crutches
With Phase 2, What are the Precautions, Goals, and Interventions?
Treatment approach is to increase LE strength through progressive loading and to prepare the knee for higher level exercises and impact
Precautions
- Avoid activities that increase pain and swelling
- If autograft: slowly load the tissue to avoid tendinopathies
Goals
- Full ROM
- Progressive strength and load tolerance
- Prepare for running in the next phase
Interventions
- Manual Therapy: As needed
- Exercises:
-Quad based exercises
-Focus on single-limb exercises both strength and motor control
-Glute, hamstring, gastroc and core exercises - HEP should be gym-based to increase loading for increased strength and tolerance
With Post-Op ACL Reconstruction, what is the Critera to Progress from Phase 2 to Phase 3?
- No pain and swelling
- Full knee ROM
- Good Quad strength
