Rehabilitation following Dacron Graft Reconstruction of the Anterior Cruciate Ligament of the Knee WENDY M SUART MCSP

MELANIE A PATRICK MCSP

HEATHER J BETTS MCSP

ANNE MURRAY MCSP

JILLIAN A POPE MCSP Senior Physiotherdpi\ts. Broddgrern Ho~pitdl. Liverpool

words: Anterior cruciate ligament. Dacron. rehabilitation, dynamic stabilisation, home exercise programme.

Summary: Dacron graft reconstruction surgery of the anterior ligarnent has been performed at Broadgreen Hospital since January 1985. When trying to establish a rehabilitation programme we found little recorded information on this subject (The only work then available is listed in the bibliography at the end of this paper.) The purpose of this study. therefore. was to review the post-operative progress of patients who have undergone reconstructive surgery of the anterior cruciate ligament using Dacron. and to establish a post-operative rehabilitation programme.

Biography: Wendy M Suart trained from 1974-78 at Mancheater Royal Infirmary School of Physiotherapy. She has a particular interest in knee surgery. and at present holds a senior post in in-patient orthopaedica.

Melanie A Fatrick trained 1979-82 at the Royal Liveqkol Hospital School of Physiotherapy. She has a particular interest in sports injuries and currently holds a senior post, gymnasium.

Heather J Betts trained 1978-81 at the Royal Liverpool Hospital School of Physiotherapy. With a particular interest in PNF. she is a part-time senior physiotherapist on orthopaedic rotation.

Jillian A Pope trained 1972-75 at the United Liverpool Hospitala School of Physiotherapy. She has a particular interest in mobilisation and manipulation and is a pad-time senior physiotherapist on orthopaedic rotation.

Anne Murray trained 1972-75 at the United Liverpool Hospitals School of Physiotherapy. Having a particular interest in recent injuries, at present she holds a senior post with GP access.

OVER a 15-month period, 17 patients were operated on using the Dacron graft technique. Half these patients attended other hospitals for their out-patient treatment. Survey forms were sent out to the relevant hospitals and all but one were returned. Our statistics therefore relate to 16 patients.

Table 1 indicates the age of patients, origin of injury and the time between injury and reconstructive surgery. Previous surgery varied from diagnostic arthroscopy to one or more ligament repairs. The main indication for surgery is chronic instability of the knee joint and therefore the aim of reconstructive surgery is to provide a stable knee joint. The aim of post-operative rehabilitation is to restore full mobility and power.

Pre-operative Regime

On admission it is explained to the patient that post- operatively the leg will be in a thigh-to-toe plaster of Paris w i th 4 5 O of knee flexion and loo of external rotation. To assist general mobility the leg will be supported in slings.

Table 1: Data on patients and their injuries

Patient Age Sex Sport Other Previous Time between

surgery (years) injury injury surgery injury and

A 24 M J X J 3

B 35 M X J X 3

C 31 M J X J 5 %

D 29 M J X J 3

E 22 M J X

F 21 M J X

G 19 M J X

H 34 M J X

I 25 M J X

J 34 M J X

K 20 F X J L 26 F J X

M 20 F J X

N 39 M J X

0 23 M J X

P 24 M J X

J X

X

X

J X

J J J J J ?

3

3

3

6

%

4 1 % 3

4%

4

Y3

?

? Information not available J Affirmative X Negative

Static quadriceps, hamstring and hip abduction and adduction exercises are taught, as well as the usual bed maintenance exercises.

Surgery

The knee is flexed at 90°. A medial parapatellar incision is made and the knee joint is exposed.

The patella is dislocated mcdially. Drill holes are made through the tibia1 condyle (near the intercondylar area), medial aspect and the lateral femoral condyle roughly in the anatomical line of the natural anterior cruciate ligament.

The Dacron graft is introduced and secured to the bone using staples. It is the length necessary to be taut in full extension, the capsule soft tissue and skin sutured and plaster of Paris applied.

Post-operative Regime

Day 1-4: The patient remains on bed rest in sling suspension and is encouraged to continue with the exercises as taught pre-operative1 y. Day 5: Mobilisation begins - non-weight-bearing wi th crutches. Day 7: The patient is shown how to manage the stairs and is allowed home when safe. The importance of continuing with the exercises at home is emphasised, while limiting the amount of time that the patient walks wi th crutches. Day 14: The patient attends for a day to have sutures removed and plaster replaced with Scotchcast or alternative lightweight material. Six weeks: The cast is removed and the patient is referred for out-patient physiotherapy.

Physiotherapy, October 1988, vol74, no 10 528

Out-patient Rehabilitation

The initial aims of treatment are to reduce swelling and pain, increase knee flexion and increase power within the available range.

Work to increase flexion may include active and passive techniques but extension is only performed actively - ie passive techniques are never used in the early stages.

First attendance (as soon as possible following removal of plaster): 0 Initial assessment of the knee. 0 Start of appropriate treatments to reduce swelling and pain. 0 The patient is taught a quadriceps and hamstring regime and hip abduction and adduction exercises in side-lying. 0 Instruction is given regarding the regime at home. (It is recommended that this be carried out t w o or three times d a i I y.) 0 The patient must continue non-weight-bearing.

Subsequent treatments: For at least t w o weeks the patient attends daily and thereafter three times a week.

Treatment of pain and swelling is continued using ice, electrotherapy and so on, and home icing is advised if necessary.

The following techniques are used to increase knee flexion, and the muscle power of flexion and extension: 1. Mobilisations. 2. PNF - rhythmical stabilisations.

(i) At the limits of range with a rotational emphasis. (ii) At mid range with a flexion/extension emphasis. Slow reversals. Repeated contractions. Hold /re1 ax.

Patterns are used for both the knee and the hip working,

A good, well-organised and progressive home exercise especially biceps femoris and tensor fascia lata.

Table 2: Follow-up findings

Patient

A

B

C

D

E

F

G H

I

J

K

L

M N

0 P

16

Three months after operation

Full Full Partial Full flexion extension weight- weight-

bearing bearing

X

X

X

?

J X

X

X

J X

X

X

J X

X

J

X

X

X

?

J X

J J

J X

X

X

X

J J

X

J J

J ?

J J J X

X

J J

J J J J

J

X

X

X

?

X

X

X

J J X

X

X

X

X

X

X

4 6 13 2

programme is essential throughout the rehabilitation period and includes the following: 0 Quadriceps exercises w i th increasing weights - emphasis is placed on inner range work. 0 Hamstring exercises. 0 Hip abduction, adduction and extension and exercises using repetition work and adding weights to progress. 0 Muscle stretching techniques.

Once 90' flexion has been obtained and there is no quadriceps lag, the patient may begin partial weight-bearing. Once full flexion has been obtained, extension can be treated passive I y.

Work on the quadriceps bench can begin at approximately eight weeks. This has been found to be the average time when the patients have sufficient power, range of movement and co-ordination to cope with this activity. Work on the static bike can be started when there is approximately 110' knee flexion. Work on the Westminster pulleys can begin when there is good muscle power and stability (approximately ten weeks).

Progression to full weight-beariig is established at approximately three months, fo l lowing consul tant assessment of knee stability. Once the patient is full weight- bearing it is important t o increase proprioception using balanceko-ordination work, for example wi th a wobble board, Trampette and so on.

Final Rehabilitation

At approximately three to four months the patient begins circuit activities that are worked out individually depending on his sport.

The aim of the circuit is to improve weight-bearing strength and proprioception and balance. The circuit is built up to a full programme which is performed three times weekly.

It is important that good 'warm up' and 'warm down' sessions are included within the circuit and the following

Six months after operation

flexion extension weight- contact Full Full Full Nan-

bearing sport

J J X

X

J X

J J J X

J

J

J J

J J

J J J

J J

J J J J

J J X

X

J

J X

J J J

J J

J J J J

J J

J

J J

J J

X

X

J

J X

J J ?

J J ?

X

X

X

J J

12 13 16 8

One year after operation

flexion extension contact sport Full Full Non- Contact

sport

X

X

J X

J X

J

J

J J J

J J

J

J J

J

J

J J J J J

J

J J J

J X

J

J X

J

J

J J J J

J J

J J ?

X

?

J

J

J

J X

X

X

J X

?

J

J X

?

X

?

X

J

J

12 14 13 6

? Inforrna+ion not available owing to patients attendinG other hospitals J Affirmative X Negative

j fiysiotherapy, October 1988, voi 74, no io 529

are some of the activit ies tha t are used at Broadgreen Hospital: 0 Stretches of all relevant muscle groups. 0 Step-ups. 0 Sit t o stand with medicine ball. 0 Static bike.

Full squat thrusts are avoided. At six months the patient may begin skipping and light

running. At eight months, with the doctor's permission, the patient

may start gentle track training. At one year, with the doctor 's permission, contact sports

may b e resumed. The maintenance of the dynamic stabilisation of the knee

is so important t ha t the athlete is encouraged to continue with his home exercise programme to prevent re-injury.

Table 2 records the results of our fol low-up a t three months, six mon ths and one year.

It can be seen tha t a t one year after surgery, 13 patients had returned t o non-contact sport (including squash) including six w h o had also returned to contact sport. It does n o t appear to be relevant t o the long-term results whether or n o t t he patient had undergone previous surgery. Neither does there seem t o be any correlation between the rate of progress throughout the rehabilitation period and the results a t one year.

BIBLIOGRAPHY

Blackburn, A (1985). 'Rehabilitation of anterior cruciate ligament injuries', Symposium on the Anterior Cruciate Ligament, Part I / ,

Hinko, P J (1981). 'The use of a prosthetic ligament in repair of the torn anterior cruciate ligament in the dog', Journalof the American Animal Hospital Association, 17, July/August.

Turner, R J, Hoffman, H L and Weenberg, S L (1982). 'Knitted Dacron double velour grafts', in: Stanley, J C (ed) Biologic and Synthetic Vascular Prosthesis, Grune and Stratton, New York, 509- 520.

241 - 269.

Consumer Protection Act l987 - Update FOLLOWING the article in the April issue of Physiotherapy (page 175). further information has been received and members have contacted the Society indicating some problems. These were discussed at the last meeting of the Professional Practice Committee and it was agreed that updates of information and guidance relating to the Consumer Protection Act 1987 will be published as necessary in Physiotherapy.

The Department of Health and Social Security in March of this year published a Health Notice HN(8813 'Procurement Product Liability'. This draws attention to the main implication for Health Authorities of the Consumer Protection Act and offers guidance to help minimise NHS liability for defective products. It is a very clear document setting out the role of the N H S a supplier, as owner of equipment (as a keeper) and as a producer.

In the paragraph discussing the role of the NHS as producer, there is an acknowledgment of the need for 'experimental and development' work on existing products and stresses the need to conform to relevant standards for 'constituents and components' and the maintenance of records to demonstrate conformity and traceability.

There is also a detailed paragraph on record keeping w h i c h states: 'To avoid liability . . . will depend substantially on the

maintenance of clear, accurate and comprehensive records relating to the procurement, use, modification and supply of products. And, since an obligation arising from liability is extinguished only after a period of ten years and up to one year is allowed for the serving of a writ, such records should be retained for a period of 11 years.' This paragraph also highlights the existing implications of maintaining more detailed records in the likelihood of claims; and increased costing to be met by health authorities, from existing funding.

District and Superintendent physio- therapists are strongly advised to obtain a copy of this Health Notice, if they do not already have one, and to implement a record- keeping policy regarding this Act as soon as possible.

The Society has also received a copy of the British Medical Association New Guidance Note to general practitioners (EEC 31, Newsletter) which was issued in June of this year; this also contains much useful information but particularly the following sentences: 'The liability will generally fall upon the manufacturer or the importer of the finished product into the country. However, in order to give the claimant a clear route of action, liability will fall on any supplier who cannot identify someone further up the chain of supply.' 'Records should be made of the manufacturer or supplier of products which are supplied or

loaned to patients without a label.' Although this applies to all physiotherapists, private practitioners can find themselves in a particular vulnerable position as they have nobody such as the NHS, to stand vicariously liable.

For the physiotherapists employed within the private sector, it is impor tant that they ensure that their employees are aware of the Consumer Protection Act 1987 and its implications, and ensure that their employer will stand vicariously liable if, in the unlikely event of litigation, no supplier can be found.

Several members have raised the problem of dealing with small items such as ferrules, etc. In paragraph 3(a) of HN(88)3, there is a reference to 'practical limitations to such record keeping' and with all small items, a note of a batch number is probably sufficient.

Instructions in the use of various pieces of equipment is important and to avoid the overloading of record systems it is important to build up a departmental policy of custom and practice so that exceptions only need be recorded.

It has been suggested that the profession should be urging manufacturers not only to label their equipment clearly, but also state the date of manufactureisupply.

The Professional Practice Committee would be interested to hear of any further suggestions, comments or information on this important subject.

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