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Effects of an Accelerated Rehabilitation

Program after Anterior Cruciate LigamentReconstruction with CombinedSemitendinosus-Gracilis Autograft and aLigament Augmentation Device

Peter B. MacDonald,* MD, FRCSC, David Hedden, MD, Ondrej Pacin,and David Huebert, MD

From The University Of Manitoba, Section Of Orthopaedics, St. Boniface General Hospital,Winnipeg, Manitoba, Canada

ABSTRACT

Forty patients with anterior cruciate reconstructions

using semitendinosus and gracilis autografts and a liga-ment augmentation device were reviewed at a minimumof 20 months postoperatively to determine if an accel-erated rehabilitation program was detrimental to inter-mediate follow-up results. The rehabilitation programincluded immediate full weightbearing, using crutchesas aids for 2 weeks only, and a Generation II rehabili-tation brace set at full range of motion for 2 weeks fol-lowed at 2 weeks by bicycle riding and strengtheningexercises. Return to sports was allowed at 4 months fornonpivoting sports and at 6 months for level 1 sportsinvolving pivoting. Thirty-seven patients were availablefor followup. At followup, three grafts were determinedto be nonfunctional (KT-1000 arthrometer testing indi-cating >4 mm of side-to-side difference). The other 34patients had good or excellent results, with all returningto their preinjury levels of sport with a brace. Early ac-celerated rehabilitation after anterior cruciate ligamentreconstruction with semitendinosus and gracilis tendonautograft and a ligament augmentation device does notseem to affect the results adversely. Results in this se-ries were as good as or better than other series usingthe same reconstructive technique.

During the past 15 years, there has been a dramatic changein the management of the ACL-deficient knee. As surgeons,

the biggest change that we have witnessed has been in therehabilitation of these injuries after surgery. We have pro-gressed from operating on knees with this injury within 72hours of injury followed by prolonged cast immobilizationto delaying surgery and prescribing early aggressive re-habilitation. Studies analyzing so-called accelerated reha-bilitation techniques have been performed on knees recon-structed with patellar tendon autografts.’One of the theoretical disadvantages of the semitendinosus

and gracilis tendon graft has been the lack of bony healing (nobone blocks on the ends of graft as in the bone-patellartendon-bone graft) in the first 6 weeks, apparently makingaccelerated rehabilitation less attractive.3 The purpose of thisstudy was to document the results of early accelerated reha-bilitation in patients with ACL reconstructions who hadsemitendinosus and gracilis tendon autografts and ligamentaugmentation devices and to show that accelerated rehabili-tation does not lead to early graft failure.

MATERIALS AND METHODS

Between November 1991 and August 1992, the senior au-thor (PBM) analyzed 40 consecutive ACL reconstructionswhere a semitendinosus and gracilis tendon autograft anda ligament augmentation device (3M, St. Paul, Minnesota)were used. The average age of the patients was 23.5 years.There were 34 men and 6 women who were treated sur-

gically an average of 1.2 years after injury; 18 knees weretreated within 4 months of injury. The most commonmechanisms of injury were passive (collision) hockey in-juries (8) and active (noncollision) basketball injuries (8).Less common mechanisms included baseball (5), rugby (3),soccer (2), and skiing (2). There were 12 passive injuriesand 28 active injuries. Twenty-four patients regularly par-ticipated in level 1 activities (based on the International

*Address correspondence and repnnt requests to Peter MacDonald, MD,305-400 Tache Avenue Winnipeg, MB R2H 3C3, Canada

No author or related institution has received any financial benefit from re-search m this study.

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Knee Documentation Committee Knee Ligament StandardEvaluation Form) before surgery, with the remainder be-

ing level 2 athletes. Ten of the 24 patients who participatedin level 1 activities had to curtail severely their participa-tion before surgery. None of the level 2 athletes had to cur-tail their athletic participation.

All patients underwent a preoperative history and physi-cal examination by the senior author, who documented dis-ability and physical findings on the International Knee Docu-mentation Committee (IKDC) scoring system. No

preoperative KT-1000 arthrometer (MEDMetric Corp., SanDiego, California) testing was done, but the patients weretested at the 6-month and final follow-up visits. Eighteen pa-tients were experiencing giving way of the knee with sportson a regular basis. Only five patients experienced giving waywith everyday activity. The remainder of the patients hadacute or subacute injuries and had not returned to sports par-ticipation between the injury and surgery.

All patients had at least a 90° arc of motion before surgery,with 29 patients demonstrating a full range of motion. Sevenpatients had knees that were considered locked preopera-tively in that they were unable to attain full extension, evenwith the aid of vigorous physical therapy. Of these seven pa-tients, only three had meniscal tears requiring surgery, andonly one had a displaced bucket-handle tear.Associated injuries were present in 26 patients. Twenty-

two patients had associated meniscal tears; none had mul-tiple meniscal tears. There were 11 medial meniscal tears and11 lateral meniscal tears. Three of the lateral tears werestable and were left untreated. Among the remaining 19tears, which were treated, there were 7 meniscal repairs and12 excisions. One of the three meniscal repairs failed and asecond repair was performed. When the second repair failed,the meniscus was excised at 1 year after the initial surgery.This patient resumed sports earlier than the protocol allowed.However, his ACL graft was functional and the final resultwas good. All but four of the meniscal tears were produced byan active injury mechanism.There were eight associated ligamentous injuries. All of

these were medial collateral ligament injuries, three ofwhich were complete with no apparent end point to valgusstressing with the knee flexed 30°. None of the associatedligamentous injuries were surgically repaired, and, at fol-lowup, there were no cases of more than grade I medialcollateral ligament laxity.

Surgical Technique

The arthroscopic surgical technique was similar to thatpreviously described by Fowler.~ Twenty-two of the pa-tients who were treated in the latter part of the series hadsurgery on an outpatient basis, the remainder were ad-mitted to the hospital overnight.A longitudinal incision was made more than 3 cm medial

to the tibial tuberosity, at the pes anserinus insertion. Thesuperficial fascia of the sartorius muscle was identified andincised in line with its fibers to expose the underlying in-sertion of the semitendinosus and gracilis tendons. Afterthese tendons were carefully freed, particularly from theirattachments to the medial head of gastrocnemius muscle,they were stripped from their musculotendinous junctions

with a standard subcutaneous tendon stripper. The inser-tions of these tendons were dissected free and left intact.The tendons were then sutured to a ligament augmen-

tation device in a sandwich fashion, after applying oneleading suture of polyglactin 910 (Vicryl, Ethicon Inc.,Somerville, New Jersey). A tubing suture of 2-0 Vicryl wasused and great effort was made to bury the ligament aug-mentation device. Interrupted 2-0 Prolene nonabsorbablesuture material (Ethicon Inc.) was used for the tibial tun-nel portion of the graft, where the suture fixation of theligament augmentation device to the graft was thought tobe crucial. A tendon leader was applied, and the graft wasset aside in a moist environment.A 4-cm longitudinal incision was made just proximal to

the lateral epicondyle of the femur. The iliotibial band wasincised longitudinally and the lateral intermuscular sep-tum was incised to develop an over-the-top position.The notch was then inspected and the ACL tear was con-

firmed. Meniscal surgery, if necessary, was done at thistime. A modified notchplasty was performed, but effortswere made to preserve the tibial stump of the ACL for pos-sible later ingrowth into the graft. The preservation of pro-prioceptive function of the ACL’ was also a considerationin this regard.A groove was developed in the over-the-top position with

special rasps to move this position approximately 6 mmanteriorly. If the notch was considered exceedingly small,a high-speed burr was used to enlarge it by burring thelateral wall. Any ridges were carefully removed to avoidlater impingement. Most of the notch work was done withthe instruments entering through an accessory anterome-dial portal about 2 cm medial to the viewing portal.The surgeon drilled at a 35° angle to the horizontal, with

the guide wire exiting the tibia through the midportion ofthe ACL stump. The tunnel was reamed to an average 8mm in diameter. A rasp was again used to remove sharpedges from the tunnel.The graft was then brought through the knee to the over-

the-top position, where it was pretensioned by flexing andextending the knee about 10 times. Any impingement of thegraft was noted at this time. The graft was then stapledusing barbed staples with 20 pounds of tension and withthe knee in full extension. The belt-buckle stapling tech-nique was used whenever graft length permitted.

Rehabilitation Protocol

After surgery, the patients wore a Generation II rehabili-tation brace (Generation II, Richmond, British Columbia,Canada) (not to be confused with the Generation II de-rotation brace). They were allowed full weightbearing am-bulation with crutches (protected full weightbearing).There were no initial range of motion restrictions. Duringthe first 2 weeks after surgery, a program of active knee

range of motion exercises, as well as hip and ankle main-tenance exercises, was instituted. Passive knee extensionexercises were done using a roll under the heel four timesa day for 1 hour at a time. Passive flexion with end rangestretching was also done. The patients were taught iso-metric quadriceps muscle exercises with the leg in full ex-tension. This was followed by straight leg raises as soon as

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the patient could tolerate them. These exercises were doneby the patient at home, without formal physical therapy,for the first 2 weeks after surgery.At the 2-week follow-up visit, the patients should have

reached at least 90° of flexion. Formal physical therapy wasthen instituted. Stationary bicycle exercises were com-menced initially, with the seat set to prevent extension past45°. For the first 2 weeks, patients performed backwardpedaling and oscillating peddling with no resistance. If wedetected early signs of a stiff knee, gentle mobilizations ofthe patellofemoral and tibiofemoral joints were started.At the 4-week point, strengthening exercises were com-

menced. Isometric and active quadriceps muscle exerciseswere continued. Closed-chain exercises (leg presses and 30°squats) were emphasized. Progressive resisted exercises ofthe hip abductor, adductor, and extensor muscles wereadded. The hamstring muscles were strengthened withfree weights on the ankle and isotonic and eccentric exer-cises in the standing position. Calf raises were done at bothslow and fast speeds. Ambulation without crutches wasallowed when a near full range of motion was present(maximum, -5° extension) with no quadriceps muscle lag,the patient had no limp, and the patient could do a straightleg raise with 15 pounds of weight on the tibial tubercle.At the 8-week point, biking exercises were continued,

now avoiding extension past 30°. Daily progressive resistedhamstring muscles exercises using free weights were com-menced. Strengthening of the hamstring and quadricepsmuscles on an isokinetic dynamometer with a 30° blockwere also done. Isotonic hip girdle exercises were continuedalong with calf raises and gait education exercises. Swim-ming was allowed, avoiding the whip kick, and outdoor cy-cling could be done avoiding hills and extension past 30°.Jogging was commenced at 10 weeks. This was restricted

to straight-ahead level ground running with no pivoting.Skating could also be commenced at this time. Use of a de-rotation brace was encouraged for these activities. Skatingwas confined to slow speeds with no explosive or suddenmovements. Isokinetic exercises of the quadriceps and ham-string muscles were continued with an extension block of 15°.At 14 weeks after surgery, isokinetic exercises were con-

tinued with no extension block. Jogging and skating werealso continued. Return to hockey and nonpivoting sportswas allowed at 4 months if the patient showed a full rangeof motion and quadriceps muscle strength 85% that thecontralateral limb on Cybex dynamometer testing (LumexInc., Ronkonkoma, New York). Figure-of-8 and agilitytraining with a brace were commenced at Week 20, andpivoting sports were allowed at 6 months. A derotationbrace was recommended for at least the lst year after re-turn to sports.

RESULTS

Thirty-seven patients had adequate follow-up data. Lengthof followup ranged from 20 to 33 months. At the most recentfollow-up examination, 10 patients were considered to havea grade 1 Lachman result; 3 patients, a grade 2 Lachmanresult; and the remainder, a negative Lachman result. Twopatients had a grade 2 drawer sign; two patients, a grade

1 drawer sign; and the remainder, a negative drawer sign.Three patients had a grade 2 pivot shift result; seven pa-tients, a grade 1 pivot shift result; and the remainder, anegative pivot shift result (Fig. 1).

All patients had a full range of motion at final followup,with the exception of two (both acute reconstruction pa-tients). Both of these patients had full extension with alimitation of flexion of 6° to 15° (Fig. 2).At final followup, three grafts were considered nonfunc-

tional (defined as KT-1000 arthrometer side-to-side differ-ence of 4 mm or a 2+ pivot shift) (Fig. 3). Two of thesefailures occurred with significant sports-related injuries(rugby and baseball) more than 1 year postoperatively. Theother failure was an early one that occurred in a construc-tion worker who returned to strenuous activity against ouradvice at only 8 weeks postoperatively. One patient playedball hockey several times from 6 to 8 weeks postoperativelywithout adverse effects.

The remaining 34 patients were all rated as having goodor excellent results based on complete or near-completesatisfaction, within 5° of full motion, and no complaints ofpain, swelling, locking, or giving way. Thirty-two of these34 patients returned to their preinjury activity levels, in-cluding 22 who returned to level 1 sports. One patient re-turned to professional hockey and one to professional wres-tling.Of the chronic ACL injury cases, 2 patients rated their

knees as abnormal (failures), 7 rated their knees as nearlynormal, and 10 as normal (Fig. 4).Two patients had subsequent staple irritation necessi-

tating removal of the staple more than 6 months postop-eratively. Three of the seven meniscal repairs developed

Figure 1. Postoperative pivot shift test results at most recentfollow-up examination.

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Figure 2. Range of motion loss in patients with acute ACLtears (preoperative compared with postoperative).

Figure 3. Anterior translation as measured with the KT-1000arthrometer (side-to-side difference) at 25° of flexion at themost recent follow-up examination.

mild superficial wound infections; all responded to oral an-tibiotics. There were no serious deep infections. Two pa-tients had transient postoperative saphenous paresthesiathat resolved. There were no other complications. Of noteis that there were no cases of persistent synovitis secondaryto the ligament augmentation device. There were six casesof transitory patellofemoral pain that resolved with reha-bilitation. No patients were thought to have significantpatellofemoral crepitus.

Figure 4. Patient subjective assessment among chronicACL cases (preoperative compared with postoperative).

DISCUSSION _

Anterior cruciate ligament reconstruction with a semiten-dinosus and gracilis tendon graft has been proposed as analternative to a bone-patellar tendon-bone graft recon-struction because of less morbidity and perhaps a de-creased incidence of patellofemoral pain.’ In addition,problems of stiffness as well as unusual problems of pa-tellar fracture and quadriceps muscle weakness seem tobe lower with the semitendinosus and gracilis graft recon-struction. A study by Marder et al.’ suggests similar resultswith both types of grafts. Recent studies have questionedwhether the use of the ligament augmentation device isnecessary (M. D. Santi et al., unpublished data, 1993).With an accelerated rehabilitation program being pro-

posed after a patellar tendon graft reconstruction,~ thepurpose of this study was to examine whether a similarprogram would cause early failure of a semitendinosusand gracilis tendon graft. Our findings suggest that anaccelerated program does not adversely affect results.The one early failure was in a patient who returned to ademanding construction job at 8 weeks postoperatively,against medical advice. The remaining two failures oc-curred more than 1 year after surgery and were the re-sult of violent injury.Although this study was not controlled, the specific focus

was on adverse occurrences of early rehabilitation, whichcan be examined without a control group. Whether the liga-ment augmentation device contributed to the success inthis group cannot be answered in this study. The lack ofserious complications, including stiffness or significantpatellofemoral pain, as well as the high rate of patient sat-isfaction support the use of this type of reconstruction.

CONCLUSIONS

Early aggressive rehabilitation in patients with ACL re-construction using semitendinosus and gracilis tendon

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autograft and a ligament augmentation device does notseem to adversely affect results in terms of early graftfailure. This type of ACL reconstruction continues to bea viable alternative to the bone-patellar tendon-boneACL graft. Serious complications were not present inthis series.

REFERENCES

1 Barrack RL, Skinner HB, Buckley SL Proprioception in the anterior cru-ciate deficient knee Am J Sports Med 17 I-6, 1989

2 Fowler PJ. Semitendinosus tendon anterior cruciate ligament reconstruc-tion with LAD augmentation Orthopedics 16 449-453, 1993

3 Klootwyk T, Shelbourne KD, Decarlo MS Perioperative rehabilitation con-siderations Oper Techn Sports Med 1 22-25, 1993

4 Marder RA, Raskind JR, Carroll M Prospective evaluation of arthroscopi-cally assisted anterior cruciate ligament reconstruction Am J Sports Med19 478-484, 1991

5 Rosenberg TD, Franklin JL, Baldwin GN, et al Extensor mechanism func-tion after patellar tendon graft harvest for anterior cruciate reconstructionAm J Sports Med 20 519-526, 1992

6 Shelbourne KD, Nitz P Accelerated rehabilitation after anterior cruciate

ligament reconstruction Am J Sports Med 18 292-299, 19907 Warner JJP, Warren RF, Cooper DE Management of acute anterior cru-

ciate ligament injury Instr Course Lect 40 219-232, 1991