Hamstring Tendon Graft for Anterior Cruciate Ligament Reconstruction

OCTOBER 2002, VOL 76, NO 4

Home Study Program HARJlSTRING TENDON GRAFT H)R

ANeLRlOR CRUCIATE LIGAMENT RECONSTRUCTBON

T he article “Hamstring tendon graft for anterior cruciate ligament reconstruction” is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, edu-

cation program professional, Center for Perioperative Education. A minimum score of 70% on the multiple-choice examination is

necessary to earn 2.5 contact hours for this independent study. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of comple- tion. The deadline for submitting this study is Oct 31,2005.

Send the completed application form, multiple-choice examination, learner evaluation, and appropriate fee to

AORN Customer Service c/o Home Study Program

2170 S Parker Rd, Suite 300 Denver, CO 80231-5711

or fax the information with a credit card number to (303) 750-3212.

BEHAyloRAL OBJECllvm After reading and studying the article on anterior cruciate ligament

(ACL) reconstruction, the nurse will be able to (1) identify the normal anatomy of the knee, (2) discuss common tests used to confirm ACL injury, (3) explain the surgical setup for ACL reconstruction with hamstring

tendon graft, (4) describe the perioperative nurse’s role when caring for patients

undergoing ACL reconstruction with hamstring graft, and (5) discuss the importance of early rehabilitation to optimize surgical

results.

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

610 AORN JOURNAL

Hamstring Tendon Graft for Anterior Cruciate Ligament Reconstruction

he incidence 01' sports iiijnries is on the rise as more teenagers and adults become involved with sports activities. Anterior cruciate ligament (ACL) tears are becoming more common among adults and female

teenagers because of their increased participation in contact sports, especially with the increase in female soccer players. Although the medial collateral ligament (MCL) is the most commonly injured ligament of the knee, the ACL is the most commonly itijured ligament that causes abnorinal knee joint laxity.' Injury to the ACL without iiijury to other ligaments occurs in approximately 60% of ACL injuries. The classic history o f a n ACL tear is a sudden twisting of the kncc at which time the patient hears a pop or snap. The patient also may complain o fa fccling that the knee is giving away. During the initial injury, the ACL may not be the only stability structure torn. For

example, a common triad of iiijiiries includes the torn ACL, a medial meniscus tear, and a partial or complete MCL tear.

NORMAL ANATOMY The knee joint is one of the largest and most

complex joints in the body. It consists of the femur, which meets the tibia to forin the main knee joint; the patella, a triangular-shaped bone cinbeclded in the tendon of the quadriceps muscle, which is anterior to the knee joint in the intercondylar groove of the distal femur; and the patellol'emoral joint, which is where the fern ur joins t he pate I la.

The main knee joint has a medial and lateral coin- partrnent surrounded by a joint capsule that is attached proxiinallv to the femoral condvles and dis-

A B S T R A C T In an age of increasing emphasis on sports, the most common

contact injury of the lower extremity is anterior cruciate ligament (ACL) rupture. The classic history of an ACL injury is a sudden twisting of the knee accompanied by a popping or snapping sound. The patient usually complains of a feeling of hesitation, instability, or giving way of the knee. By the end of the day, the patient's knee will be swollen and unstable. There are many ways that the ACL can rupture, but a common method is a contact injury in which a valgus force is applied to the flexed, rotated externally knee. This can produce tears to the ACL, medial collateral ligament, and menisci. Noncontact injuries, such as those incurred while skiing or jumping, occur when the knee is extended and the tibia is internally rotated on the femur. There are several methods of repairing a ruptured ACL, such as using an allograft or autograft of the patella tendon or a hamstring tendon graft for the repair. This article focuses on the use of a hamstring tendon graft for ACL reconstruction and how to care for patients undergoing this procedure. AORN J 76 (Oct 2002) 61 2-624.

tally to the tibia1 condyles and upper end ofthc libula.

L ig am e n t s a re b ti n d I es o f collagen tibers that provide stability and strength to the knee joint. The collateral ligaments (ie, medial, lateral) strap the outside of the joint and cruciate ligaments (ie, anterior. posterior) cross within the joint. The term cruciate conies li-om the word C J ~ Z L Y or CFO.Y.\ and the word uw c id . The cruciate ligaments con- sist of two fibrous bands that extend fi-om the i n t ercond y I ar l'ossa of the femur to attachments anteriorly and posteriorly in the intercondylar eminence of the tibia. They crisscross over one another to form an "X" inside the

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knee. The ACL connects the anterior surface of the tibia to the posterior surface of the femur and is cru- cial for preventing the knee from sliding forward. The posterior cruciate ligament (PCL) provides opposing support by passing anteriorly and medially (Figure 1). The capsule also is reinforced in fi-ont by the patellar and quadriceps tendons and posteriorly by the popliteus and gastrocnemius muscles.

The menisci (ie, thickened cartilage pads) are inserted between the femoral and tibial condyles and attached to the joint capsule. Menisci are almost total- ly avascular; therefore, degenerative changes usually are permanent. The suprapatellar bursa is situated between the tendon of the quadriceps femoris muscle and the anterior surface of the lower segment of the femoral portion of the knee joint. Synovial membrane (ie, a sheet of flattened connective tissue cells) lines the capsule of the joint and covers the infrapatellar fat pad, parts of the cruciate ligaments, and portions of the femur and tibia.’

RllycllolwLAMAToIIIy Normally, the knee flexes to a maximum of 135

degrees and extends to zero degrees. The two joints formed by the femur and tibia have a meniscus between them that acts as a smooth surface on which the joint can move. Bursa (ie, fluid-filled sacs) surround the knee joint to provide a gliding surface to reduce friction of the tendons, such as friction of the patellar tendon that attaches to the front of the tibia below the kneecap. Large blood vessels pass through the popliteal space behind the knee. The quadriceps muscle extends the knee joint, and the hamstring muscle flexes the knee joint.

The average adult ACL is approximately 3.5 cm long. It has a semicircular attachment at the posterior portion of the medial aspect of the lateral femoral condyle. The ACL lies in an anteromedial and distal direction, making an outward spiral and inserting near the anterior spine of the tibial plateau. The tibial attachment usually is 1.5 cm posterior to the anterior articular surface of the tibial plateau. The ACL, like the PCL, is an extrasynovial structure, and yet it

restraint to anterior tibial translation on the femur and acts as the major secondary restraint to medial tibial displacement. It provides stabilization to valgus and varus opening, as well as to internal and external rotation.

MECHAMISM OF INJURY The most common method of injuring the ACL

happens without the knee coming in cbntact with another object. This kind of noncontact injury usually happens when the person changes direction rapid- ly so that, with the knee in 111 extension, the femur is rotated externally on a fixed tibia. Landing on a straight leg or attempting to make an abrupt stop also can torque the knee in this manner, causing an ACL injury. These kinds of injuries are common in basket- ball, football, volleyball, and soccer. Skiers and snow boarders also can experience this kind of injury because the foot and ankle is locked into a boot preventing the person fi-om relieving the sudden torque on the knee. Also, the ACL often is injured by a direct blow of excessive lateral force to the knee. This valgus stress forces the knee into an abnormal position, tearing the ACL and other knee structures.

I N m A L ~ ~ ~ ~ When the patient presents for evaluation, he or

she usually complains of knee instability. The patient most often describes having heard a pop or having felt a tearing sensation inside the knee. Moderate to severe pain was felt at the time of injury, and the patient was unable to continue the causative activity because of the pain, The knee joint became swollen within 24 hours of injury, but

is located intra-articularly. Figure 1 Anatomy of the knee in extension (u) and flexion (6). (4// \//us- trotions by Kurt Jones, Denver) The ACL provides a primary

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many patients state that the swelling occurred within three hours. Some patients report that the knee seemed to recover but became unstable and now feels as though it is giving out, especially during activities that require lateral movement of the knee, such as cutting or pivoting. Many patients, however, deny knee pain with straight ahead activities, such as running or jogging. Symptoms may be vague in nature and often require more definitive testing. Clinical evaluation includes the Lachman test, anterior drawer test, and pivot-shift maneuver. The ACL may be imaged, if necessary, by obtaining a mag- netic resonance imaging (MRI) scan.

In the Lachman test, the patient lies supine on the table with the involved leg beside the health care provider performing the examination. The examiner holds the patient’s knee at 30 degrees of flexion (Figure 2). The examiner stabilizes the patient’s femur with one hand while anteriorly translating the proximal aspect of the tibia with the other hand. “A positive sign is indicated by a mushy, soft, end-feel when the tibia is moved forward.”’ A positive sign also may indicate that other structures, including the anterior capsule, are i n j ~ r e d . ~ The Lachman test is the most sensitive test for detecting ACL deficiency.

For the anterior drawer test, the patient lies supine on the examination table with his or her knees flexed 90 degrees and both feet flat on the table (Figure 3). The health care provider examining the patient cups his or her hands around the patient’s knee, placing his or her fingers on the medial and lateral hamstring insertion points and thumbs on the medial and lateral joint lines. The examiner then

draws the tibia forward. The ACL may be torn if the tibia slides forward from under the femur (ie, positive anterior draw sign).s

The last definitive test for an ACL tear is the pivot-shift maneuver. The patient lies supine with his or her hip flexed 20 degrees and relaxed in slight medial rotation. The examiner holds the patient’s foot with one hand, using the other hand to flex the patient’s knee slightly. The examiner flexes the patient’s knee by placing the heel of the hand behind the patient’s fibula, over the lateral head of the gastrocnemius muscle, and medially rotating the patient’s tibia, which causes the tibia to sublux anteriorly.

An MRI usually is obtained if two out of three of the previously mentioned tests are positive .for an

Figure 2 The Lachman test is the most sensitive test for detecting anterior cruciate ligament deficiency. The arrow indicates direction of movement.

Figure 3 The anterior drawer test demonstrates that the anterior cruciate ligament may be torn if the tibia slides forward from under the femur as the examiner pulls the tibia forward gently (u), more forcefully (b), and then moves it backward (c).

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ACL tear. An MRI also may be performed to evalu- ate for additional or associated injuries. Recon- structive surgery is considered depending on how active the patient currently is and plans to be in the future, whether there are associated injuries, and the amount of abnormal knee laxity demonstrated.

PREOPERATIVE mTlENT CARE. The day before surgery, the patient is instructed

to see the preoperative nurse. This visit is vital to the patient’s surgical experience. The preoperative nurse makes any additional appointments for the patient, such as laboratory tests if the patient is older than 40 years of age or if the patient has any ongoing, chronic illnesses. These laboratory tests should be reviewed by an internal medicine physician. The preoperative nurse provides the patient with written and oral instructions to ensure that he or she clearly understands preoperative and postoperative instructions. If the patient is going home the day of surgery, the nurse ensures that someone is available to drive the patient home and care for him or her postoperatively. The preoperative nurse assesses the patient’s home status by asking questions regarding the patient’s home situation. The following questions should be asked.

Is the patient a single parent? If the patient is a parent, is there adequate child- care for the first three postoperative days? Is there anything that would hinder the patient’s recovery (eg, need for help with pet care during the postoperative recovery period)?

The patient may be concerned about returning to his or her previous lifestyle and how long it will take to do so. The physician should have discussed this issue during the first diagnostic appointment. If the question should arise during the preoperative appointment, the nurse should reassure the patient that chances are very good that he or she can return to his or her previous lifestyle but that the patient should check with his or her physician. The patient should understand that rehabilitation is a long process, and he or she may need to wear a brace for six months or more when participating in sport activities. The nurse also should emphasize that the patient must use crutches for approximately two weeks. The nurse suggests that the patient wear loose clothing to fit over the brace. The nurse makes a physical therapy appointment for the patient during which a therapist will ensure that the patient can maneuver with crutches skillfully and safely. Toward the end of the preoperative visit, the patient may be asked to sign and date the informed consent form. The surgeon may have the patient sign the informed consent upon arrival in the preoperative

area of the hospital. The form should specifL the surgical leg, type of procedure to be performed, and grafting technique to be used (ie, hamstring, patella tendon, or both). The nurse witnesses the patient signing the form, but this does not indicate the nurse witnessed the surgeon educating the patient about the risks of the procedure or other options available.

Day of surgery. When the patient is brought to the OR holding area, the circulating nurse follows the facility policy for correct site surgery by verifLing the surgical site with the patient and ensuring that the patient places his or her initials or an “X’ on the correct surgical leg. The nurse also checks the consent form for completeness (eg, site is specified, all signa- tures have been obtained) and has the patient state what procedure is being performed. The circulating nurse then checks the chart for laboratory results and any other tests that were ordered preoperatively. The nurse shows any abnormal laboratory or test results to both the anesthesia care provider and surgeon. The OR holding nurse or anesthesia care provider inserts an IV catheter, starts an IV of lactated Ringer’s solution, and infuses prophylactic antibiotics, if ordered by the surgeon. The circulating nurse develops and initiates a care plan specific for the patient (Table 1). The patient now is ready to enter the OR.

OPERATING ROOM PREPARATION Nursing staff members work cooperatively with

the surgeon and anesthesia care provider to ensure efficient and complete OR setup so the patient has a positive surgical outcome. The nurse also interfaces with sales representatives to ensure availability of specialty supplies, if needed. The scrub person verifies that all supplies and instruments have been obtained and hnction correctly, The circulating nurse verifies that all videotaping equipment, including the printer for arthroscopic images, is in working order before the patient enters the room. The OR suite also should have a pneumatic tourniquet preset at 300 mm Hg or 10 mm Hg higher than the patient’s systolic pressure. A well-padded leg holder for the nonsurgical leg, such as a low lithotomy stirrup, is needed to prevent unnecessary pressure on muscles and bony prominences.

A fluid infusion pump is used to provide dis- tention of the surgical knee during the procedure. Two 3-L bags of normal saline solution are hung from the fluid pump. A large back table is used for basic orthopedic and arthroscopic instruments (Table 2). The grafting instruments, such as the graft preparation board, endoscopic ligament button holder, and vein strippers are placed on a separate, small back table that the surgeon or assistant uses to pre- pare the hamstring tendon graft.

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Table 1 NURSING CARE PLAN FOR mnENTs UNDERGOING ANTERIOR CRUCIATE LIGAMENT RECONSCRUCTWMI

Interim oufcome outcome criteria statement The patient's skin

Nursing diagnosis Intervention Risk of infection Assesses DreoDerativelV for susceptibility to infection. The patient is free related to length . and type of procedure and tissue manipula- tion during procedure 8 . .

8 . Risk for acute and chronic pain .

8

Risk of anxiety related to knowledge . deficit and stress of surgery .

Risk for injury due to positioning and intraop- . erative manipu- lation of the surgical leg .

.

I .

Implements, monitors, and maintains aseptic technique.

Administers prescribed antibiotic therapy at appropriate times.

Initiates traffic control.

Performs skin preparations.

Helps minimize length of the intraoperative phase of surgery by planning and anticipating care.

Prevents cross infection.

Administers wound site care and applies sterile, dry surgical dressing after wound closure.

Provides pain management instruction and describes pain management options.

Identifies desired level of pain control preoperatively.

Identifies cultural and value components related to pain and pain control.

Implements pain guidelines.

Collaborates in initiating patient-controlled analgesia.

Evaluates response to pain management interventions.

Determines knowledge level and assesses coping mechanisms and readiness to learn.

Explains expected sequence of events, including family members in perioperative teaching when appropriate.

Evaluates response to instruction.

Identifies baseline tissue perfusion and preoperative neurovascular status of lower extremities

Assesses factors related to risk for ineffective tissue perfusion (eg, chronic diseases, immunosuppression)

Positions the patient neutrally and anatomically correct and pads pressure points

Evaluates for signs and symptoms of positioning injury by comparing the patient's bilateral lower extremities neurovascular status with preoperative status and checks for signs and symptoms of injury as a result of positioning

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remains intact from the signs and nonreddened, and symptoms wound is dry, and temperature remains normothermic throughout the perioperative period

of infection

The patient The patient's vital demonstrates and signs and other reports adequate nonverbal symp- pain management toms remain throughout the stable post- perioperative operatively period indicating

adequate pain control

The patient demonstrates decreased anxiety and increased ability to cope before induction

The patient verba- lizes understanding of the procedure and expected out comes before induction

The patient participates in decisions affecting the plan of care.

The patient demonstrates knowledge of psychological response to the procedure and potential side effects.

The patient's func- The patient is tion and sensation free from signs is maintained or and symptoms of improved from injury related to baseline levels positioning throughout the peri operative period

The patient's pedal pulses are present and equal bilaterally throughout the perioperative period

INTRAOPERATIVE PATIENT CARE After the circulating nurse checks the patient

into the OR suite. OR team iiieinbers cooperatively double check the informed consent form and eiisLirc tha t the patient has identified the surgical knee by initialing it. When all team members are in agree- ment, the anesthesia care provider administers the anesthetic agent. The anesthesia care provider either anesthetizes tlie patient using an endotracheal tube and general anesthesia or places an epidural catheter and administers a regional anesthetic. The circiilat- ing iiiirsc, anesthesia care provider, and surgeon reposition the patient so that tlie popliteal space is approxiiiiately 2 inches beyond the break in the OR bed. The foot ofthe bed then is lowered. The surgeon applics a tourniquet ciifl‘ to the upper thigh of the

arthroscopic leg holder. The circulating iitirse places the nonsurgical leg in a well padded low lithotomy stirrup, ensuring that there is no undue pressure on the calf and peroneal nerve. After the circulating nurse pads and secures the patient’s nonsurgical leg. he or she assesses the patient’s pedal pulses.

While the circulating nurse, surgeon, ant1 assistant arc positioning the patient, the scrub person prepares the larger back table for the arthroscopic and reconstriiction portions of the proccdurc and the hamstring tendon harvest and a smaller back table I’or assembly and preparatioii of the hamstring tendon. Thc circtilating nurse shaves the patient’s surgical leg from 3 inches to 4 inches above tlie knee to 4 inches below the patella, laterally and medially. The circulating iiiii-se cleanses the patient’s leg with povidone- iodine scrub and paint solutions circiimfrentially l‘rom the thigh to the toes. Alter the sui-geon scrubs, gowns, and gloves, he o r she and the scruh person drape the patient Ihr a standard knee arthroscopy. The drapes include a plastic U-shaped drape that is placed aroiind the patient’s surgical leg and a lower extremity drape. A smaller drape, such as a hall‘ sheet, may be placed over the nonsurgical leg.

Placenient .J‘ incisions. To achievc cleaner synovial penetration in the knee, the surgeon dis- tends the patient’s knee with saline before making the initial stab incision. The surgeon places his or her thiimb i n the angle between the patellar tendon and the joint line o f the flexed knee and makes the incision above his o r her thumb. The next sLab incision is anteroniedial. The point of entry should be slightly higher than that of the lateral incision to I‘acilitate access to the region of the posterior horn oi’ the 111 en i sc us.

Repair of rissocirited injuries. Before the stir- geon makes an incision to harvest the tendon graft, he

patient’s surgical leg and places the surgical leg ’ I l l ’ an

or she asscsscs tlie knee arthroscopically for signs ot’ meniscal tears and other associated iii.juries or to coii- iirni the ACL niptiire. If a meniscal tear is present, the surgeon either repairs it with 2-0 meniscal stittires or perforins ;I partial meniscectoiny using an aggressive arthroscopic blade and suctioidsliaver. After tlie surgeon assesses the knee and verilies an ACL r i p turc, he or she makes the incision to harvest the gmft. Depending on surgeon preference. the tourniquet may be inflated to 300 mm Hg o r I0 mm Hg higher than the patient’s systolic presstire to provide a blood- less lield. If the surgeon believes that the procedure may last longer than two hours, he o r she may opt not to inflate the touriiiqiiet.

Obtuining the tuidmi grufi. An oblique o r loti-

gitudinal incision approximately 4 cm to 7 cm long is made 2 cm t o 3 cm medial to the tibia1 tubercle. and blunt dissection is carried through tlie subcutancotis fat to expose the sartorius muscle (Figure 4). The stir- geon identities by linger palpation the pes anserine t cndons. \v li i c h are the t i na I corn in on tend i no us in ser- tion of tlie sartorius. gracilis, and semitendinosiis tendons along the proximal-medial aspect of the tibia (Figure 5). These muscles serve as tlexors and internal rotators and help protect the knee irom rotary as well as valgus stress.“ The surgeon incises the skin

INSTRUMENTS #HI ANTERIOR CRUClATE UGAMENT RECONSTRUCTION

Arthroscopic suction/shaver

Arthroscopic instruments

Cannulated drill bits, sizes 7 mm to 12 mm

Cannulated screw driver

Depth gauge

Drill guide

Graft preparation block

Graft preparation board

Guide wires

Large drill

Probe

Rasps, various sizes

Reamer

Tibia1 guide, right and lefl

Tunnel notcher

Vein stripper

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and bluntly dissects through the subcutaneous fat to expose the sartorius. The gracilis and semitendinosus tendons can be seen and palpated as two small bumps lying under sartorial fascia.’ After the surgeon sepa- rates the gracilis and semitendinosus tendons, he or she harvests them with a closed or slotted tendon stripper (Figure 6). The surgeon places a whip stitch on the tendon end with a #2 polyester braided nonabsorbable suture so that traction can be applied to each tendon. The surgeon pushes the tendon stripper in an upward direction along the course of the gracilis tendon until it is separated from its muscle belly.8 The scrub person wraps the tendon graft in a moist laparo- tomy sponge and places it on the small back table. The surgeon harvests the semitendinosus tendon in the same manner. The tendons should measure approximately 100 mm to 150 mm in length when folded in half.

Preparing the grafi The assistant prepares the tendons using the graft preparation board. The graft preparation board is flat with a ruler along its edge to measure the length of the graft. A post at each end with removable clamps is used to hold the tendon securely. The assistant extracts muscle fibers from the tendon using a knife blade or periosteal elevator. After the tendon is free from muscle fibers, the assistant places a whip stitch on the proximal end of the tendon using a #2 polyester braided nonabsorbable suture. He or she folds the graft to half its original length and sizes the diameter using the tubular sizers ranging from 7 mm to 12 mm. The average graft size

Figure 4 tendon graft.

Skin incisions for harvesting the hamstring

is between 8 mm and 9 mm in diameter (Figure 7). After sizing the graft, the assistant unfolds the graft to its original length and slips a button with a loop on

Figure 5 Identification of key structures for obtaining a tendon graft.

the tendon. He or she again folds the graft in half and places it back on the graft master using the button holder attachment. The graft now is ready for later placement. The surgeon must create the tibial and femoral tunnels before the graft can be placed.

Creating the tibial tunneL The surgeon creates the first of the two tunnels (ie, the tibial tunnel) approximately 30 mm in length, which enables proper placement of the graft. The size of the cannulated drill bit must match the size of the graft. The surgeon starts the tunnel halfway between the tibial tubercle and the posteromedial edge of the tibia. He or she uses landmarks (eg, the inner edge of the anterior horn of the lateral meniscus, the medial-tibia1 spine, the PCL, the ACL stump) to ensure correct placement of the tibial tunnel and proper placement of the graft. The purpose of these landmarks is to recreate

Figure 6 * Passing a tendon stripper to obtain the hamstring graft.

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Figure 7 Preparing the graft using an 8-mm tubular sizer.

Figure 8 Securing the graft in the femoral tunnel.

the normal anatomical position of the original ACL tendon and prevent impingement of the graft.

Preparing the intercondylar notch. The surgeon shapes the top of the intercondylar notch to prevent impingement of the ACL graft when the patient’s leg is in full extension. The graft eventually will erode if it is impinged upon. Using a suctiodshaver with a round or an oval-shaped burr, the surgeon resects bone along the inner aspect of the lateral femoral condyle.

Creating the femoral tunnel The assistant holds the patient’s knee at a 90-degree angle to facil- itate best placement of the guide pin. The surgeon places a femoral drill guide in the notch at the 11 o’clock position when working on the right knee and at the one o’clock position when working on the left knee. After the drill guide is positioned properly, the

surgeon uses a 2.7-mm guide pin to drill through the lateral femoral cortex of the lateral thigh. He or she uses a cannulated drill bit to create the femoral tunnel using the pin as a guide. Using a biodegradable screw or a metal interference screw, the surgeon secures the graft in the femoral tunnel (Figure 8). The surgeon may choose to stretch the graft by holding the distal end of the graft under tension while cycling the knee through flexion and extension (Figure 9). With the graft under tension, the surgeon then anchors it to the tibia with a staple, 4.5-mm cor- tical screw and spiked washer, or both.

Closing. The surgeon and assistant close the incisions with absorbable, interrupted, subcutaneous sutures and self-adhesive wound approximat- ing strips. They cover the incisions with 4-inch by 8-inch gauze dressings and elastic bandage wrap. The surgeon applies a range of motion brace and locks it in zero-degree flexion. The surgical team transfers the patient to a stretcher, and the circulating nurse elevates the patient’s surgical extremity on a pillow placed under the patient’s leg from the calf to the heel. The circulating nurse checks the patient’s pedal pulses bilaterally before leaving the OR suite. The circulating nurse and anesthesia care provider then transport the patient to the postanes- thesia care unit (PACU) with supplementary oxy- gen, if needed.

POSTOPERATIVE wmmi CARE The PACU nurse provides the patient with oxy-

gen by face mask and continues cardiac and pulse oximetry monitoring. The PACU nurse ensures that a pillow is supporting the patient’s surgical lower leg and places an ice bag on the patient’s knee to minimize swelling and reduce pain. Some surgeons prefer using an ice water-filled soft compression brace for the first 24 to 48 hours. The circulating nurse gives a brief report to the PACU nurse, including the patient’s history, allergies, antibiotics and local anesthesia administered intraoperatively, and any special needs the patient may have. The PACU nurse checks the patient’s vital signs every five minutes along with bilateral checks of the patient’s pedal pulses, circulation, and sensation. If the patient complains of pain, the PACU nurse uses the one to 10 pain scale, with 10 being the worst possible pain, and administers pain medications according to the patient’s response. The patient usually is in the recovery room for approximately 45 minutes before being transferred to the postoperative medical-surgical unit.

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Many patients who undergo ACL reconstruction are excellent candidates for patient controlled analgesia for 24 to 48 hours postoperatively. Oral pain medication usually is effective after this time.

Upon arrival in the medical-surgical unit, the assigned nurse measures the patient’s vital signs and peripheral circulation every 15 minutes for one hour. The nurse continues to monitor the patient every hour until discharged.

Discharge instructions. The nurse explains possible adverse reactions that may occur, including swelling, burning, tingling, loss of sensation, and excessive bleeding. He or she also tells the patient who, when, and what numbers to call during both normal and after office hours in the event that the patient has questions or concerns. The nurse also instructs the patient to

elevate the surgical leg and use ice for 48 hours to minimize swelling and pain; use crutches to avoid weight bearing on the surgical leg for approximately two weeks; not stand for long periods of time; bathe by placing a dry towel around the surgical limb covered by a clean garbage bag taped just above the dressing; and not drive for 72 hours.

Physical therapy. Before the patient is discharged, a physical therapist fits the patient with crutches and gives instructions regarding their correct use. If the patient must use stairs, the physical therapist instructs him or her on a safe method of climbing and descending stairs using crutches. The therapist instructs the patient regarding early quadriceps muscle strengthening exercises to be performed for the first two postoperative weeks. These exercises include

straight leg raises, quadriceps sets in which the patient locks the quadriceps muscle until the back of his or her knee touches the bed, and heel slides in which the knee is flexed to 90 degrees.

The physical therapist also instructs the patient to maintain the brace at zero degrees flexion while ambulating during the ftrst two weeks.

Follow-up physiciaB visit. The patient returns to the surgeon’s office two weeks after surgery for a wound check. The surgeon then instructs the patient to continue wearing the brace while beginning to bear full weight on the surgical leg.

Figure 9 Stretching the graft by holding the graft under tension and cycling the knee through flexlon and extension.

CONCLUSION This article discusses the use of hamstring ten-

don graft for ACL reconstruction. Several research studies have been performed comparing the use of a hamstring tendon graft verses a patella tendon graft. These studies demonstrate that even though both techniques result in a stable, functional knee, patients on whom hamstring grafts were used had less postoperative pain and a quicker return of quadriceps muscle function. One such study demonstrates that the advantages of using the hamstring tendon graft include

the graft is larger and stronger than a patellar tendon graft, morbidity of the harvest technique donor site is less than that of patellar tendon grafts, there is little quadriceps inhibition after quadriceps harvest, and there is quicker return to sports activities after aggressive rehabilitati~n.~

Deborah M. Boni, RN, BSN, MAJ, US Air Force, was an rwfirst assistant and the operations officer for surgical services at MacDill Air Force Base, Fla, a f the time this article was written.

George E. Herrioit, MLI, MAJ, US Air Force, is an orthopedic surgeon at MacDill Air Force Base, Fla.

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NOTES

l%e Knee Fom, Function, Patholow, and Treatment (Philadelphia: W B Saunders Co, 1993).

2. M H Meeker, J C Rothrock, Alexander k Care of the Patient in SurgeT, 1 Ith ed (St Louis: Mosby, Inc, 1999).

3. R C Evans, Illustrated Essentials in Orthopedic Physical Assessment, second ed (St Louis: Mosby-Year Book, 1994) 802.

1. R L Larson, W A Grana, eds, 4. Ibid, 783. 5. S Hoppenfeld, R Hutton,

Physical Examination of the Spine and Extremities (Philadelphia: Appleton and Lange, 1976).

Wheeled Textbook of Orthopaedics, http://www.ortho- u.net/ol2/30.htm (accessed 12 Aug 2002).

6. “Anterior cruciate ligament,”

7. C H Brown, J H Sklar, “Endoscopic anterior cruciate ligament reconstruction using quadru- pled hamstring tendons and endobut-

Fewer Physicians Taking New Nearly 22% percent of family physicians surveyed report that they can no longer accept new patients who receive Medicare, according to a July 24,2002, news release from the American Academy of Family Physicians. The annual survey conducted in June 2002 includes data from 1,664 randomly selected academy members active in patient care. In last year’s survey, 17% of physicians reported they no longer were accepting patients who receive Medicare.

reductions in reimbursements have resulted in According to the physicians surveyed, recent

ton femoral fixation,” Techniques in Orthopaedics 13 (1 993) 28 1-298.

W Carson, “The use of hamstring tendons for anterior cruciate ligament reconstruction: Technique and results,” Clinical Sports Medicine 12 (October 1993) 723-756.

9. C H Chen, W J Chen, C H Shih, “Arthroscopic anterior cruciate ligament reconstruction with quadriceps tendon-patellar bone autograft,” Journal of Trauma 46 (April 1999)

8. C H Brown, Jr, M E Steiner, E

678-682.

Medicare Patients Medicare payments that do not cover the cost of health care services for older adults. The formula used to calculate the Medicare physician fee sched- ule resulted in a 5.4% reduction in reimbursement payments to physicians and other health care providers in January 2002, according to the release.

Number of Physicians Turning Away New Medicare Patients Jumps 28 Percent (news re/ease, Washington, Dc: American Academy of Family Physicians, July 24, 2002) h t t p : / W . a@. orghorvIe~mlPress?press- id=850 (accessed 23 Aug 2002).

A Low-Fat Diet Can Reduce Risk of Alzheimer’s Disease Eating lean meats (eg, fish, poultry) and plenty of fruits and vegetables during midlife may reduce the risk of Alzheimer’s disease compared to eating large amounts of red meats, processed meats, fats, and sugars, according to a July 22,2002, news release from the Alzheimer’s Association. This information was announced by researchers at the association’s eighth international conference on Alzheimer’s disease and related disorders July 23,2002, in Stockholm.

Researchers asked participants, or a surrogate respondent for those with Alzheimer’s, how often they consumed various foods during different times in their lives (ie, 20 to 39 years of age, 40 to 59 years of age, age 60 and older). When the data were analyzed, researchers discovered two distinct dietary patterns for consumption of 29 food groups within

the 40 to 59 years of age bracket. One pattern consisted of red and processed meats, eggs, fXed chick- en, high-fat dairy products, beverages with high sugar content, french fries, refrned grains, mar- garine, snacks, nuts, sweets, and desserts. The other pattern consisted of yellow and green vegetables, fish, seafood, fruits, homemade and readymade soups, whole grains, and vegetables.

with regard to these high-fat and low-fat diet patterns. This calculation led researchers to the conclusion that a low-fat diet is associated with a reduced risk for Alzheimer’s.

The odds ratio for Alzheimer’s was calculated

High Antioxidant, Low-Fat Diet May Protect Against Alzheimer‘s (news release, Stockholm: Alzheimefs Association, July 22, 2002).

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Documents

Hamstring Tendon Graft for Anterior Cruciate Ligament Reconstruction