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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

A Patient’s Guide - UW Orthopaedics and Sports Medicine · University of Washington Department of Orthopaedics & Sports Medicine Page 7 of 8 Postoperative Care After surgery you

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Page 1: A Patient’s Guide - UW Orthopaedics and Sports Medicine · University of Washington Department of Orthopaedics & Sports Medicine Page 7 of 8 Postoperative Care After surgery you

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.