Accelerated rehabilitation after anterior cruciate ligament reconstruction * K. DONALD

SHELBOURNE,† MD,

AND PAUL

From the Methodist Sports Medicine Center,

strength while maintaining terior knee pain.

ABSTRACT To overcome many of the complications after ACL reconstruction (prolonged knee stiffness, limitation of complete extension, delay in strength recovery, anterior knee pain), yet still maintain knee stability, we developed a rehabilitation protocol that emphasizes full knee extension on the first postoperative day and immediate weightbearing according to the patient’s tolerance. Of 800 patients who underwent intraarticular ACL patellar tendon-bone graft reconstruction, performed by the same surgeon, the last 450 patients have followed the accelerated rehabilitation schedule as outlined in the protocol. A longer than 2 year followup is recorded for 73 of the patients in the accelerated rehabilitation group. On the 1 st postoperative day, we encouraged these patients to walk with full weightbearing and full knee extension. By the 2nd postoperative week, the patients with a 100° range of motion participated in a guided exercise and strengthening program. By the 4th week, patients were permitted unlimited activities of daily living and were allowed to return to light sports activities as early as the 8th week if the Cybex strength scores of the involved extremity exceeded 70% of the scores of the noninvolved extremity and the patient had completed a sport-specific functional/agility program. The patient database was compiled from fre-

NITZ, MD

Indianapolis, Indiana

stability

and

preventing

an-

Rehabilitation after ACL reconstruction plays a major role in the functional outcome of the extremity. 3,6,9, 16, 23 Protocols for rehabilitation programs2, 3, 5,6 locus on range of motion, weightbearing, strength recovery, and functional return to activities. The protocols that have been published2, ~’ 6, ~’ 16, ~~ vary as far as prescribed length of rehabilitation and expected rate of recovery. Within the last several years, there has been a trend toward earlier range of motion and muscle strengthening exercises,4, 16, 25, 26 despite adverse conclusions obtained from laboratory studies with animals and cadaver specimens.7, 17 Clinical rehabilitation protocols have been tempered by constraints advocating postoperative immobilization followed by a gradual progression in range of motion and strengthening exercises before return to full activities. The lengthy rehabilitation, along with the technical intricacies of intraarticular reconstruction and its potential complications has caused both surgeons and patients to be hesitant in choosing this form of treat-

ment.10, 11,13,20 In 1982, we began to treat ACL deficient knees selected for surgical management with a modified Jones patellar tendon-bone graft procedure, followed by immobilization. Full weightbearing without braces was not permitted for 6

quent clinical examinations, periodic knee questionnaires, and objective information, such as range of motion measurements, KT-1000 values, and Cybex

to 8 weeks. In

1983, the program of rigid immobilization was

discarded in favor of immediate continuous passive motion.&dquo; For the next 2 years we used a rehabilitation protocol slightly modified from that used by Noyes et al.1’ and Paulos et all When comparing the patients’ results to compliance with rehabilitation protocol, we found that patients who were noncompliant (in that they progressed as they desired and obtained full extension earlier than instructed) returned to normal function (without developing instability) sooner

strength scores. A series of graft biopsies obtained at various times have revealed no adverse histologic reaction. The evidence indicates that in this population, the accelerated rehabilitation program has been more effective than our initial program in reducing limitations of motion (particularly knee extension) and loss of

than patients who complied with the regimen. To ensure that no adverse effects were occurring as a result of early full extension and weightbearing, we carefully followed noncompliant patients and found they had no adverse sequelae. From that point, we gradually advanced the rehabilitation

’Presented at the 15th annual meeting of the AOSSM, Traverse City, Michigan, July 1989 t Address correspondence and reprnt requests to. K Donald Shelbourne, MD, Methodist Sports Medicine Center, 1815 North Capitol Avenue, Suite 600, Indianapolis, IN 46202

292

293

schedule, maintaining the objective and subjective databases for comparison with previously obtained data. Based on the continued and long-term success of the accelerated rehabilitation protocol, we discontinued use of the orthosis, allowed early weightbearing to tolerance, and permitted return to activities at the time the patient felt he or she was ready (if objective goals other than time since surgery were met). Over the next several years, analysis of subjective and objective data confirmed clinical impressions that full range of motion was obtained more quickly and more completely, severe muscle atrophy was prevented or reversed sooner, and patellofemoral joint symptoms occurred less frequently

TABLE 1 Rehabilitation

protocol,

1984

through

1985

under the accelerated program than under the initial program of rehabilitation that was used in the group of patients treated in the early 1980s. By the end of 1986, the rehabilitation protocol for all patients surgically treated for ACL reconstruction was changed to the program advocated in this paper, i.e., the accelerated rehabilitation protocol. To document clinical impressions of the effect of the accelerated rehabilitation, we devised a comparative study where the subjective and objective data gathered from patients who followed the initial form of rehabilitation were compared to the data obtained from patients who followed the accelerated protocol of rehabilitation. The results of this study indicate that after ACL reconstruction, full knee motion and leg strength can return more quickly than previously thought, without adverse effects on stability. The advantages of the accelerated rehabilitation protocol include 1) increased patient cooperation and compliance, 2) earlier return to normal function and athletic activities, 3) decrease in incidence of patellofemoral joint symptoms, and 4) marked decrease in the number of procedures required to obtain full knee extension.

MATERIALS AND METHODS Patient

population

were treated by the (KDS), were assigned to groups based on the rehabilitation protocol they followed. The time frames 1984 through 1985 and 1987 through 1988 were chosen because the rehabilitation within each period was relatively consistent, and the differences between the initial (Table 1) and the accelerated rehabilitation protocol (Table 2) are exem-

The two groups of patients, all of whom same

surgeon

plified. The athletic involvement of the groups was diversefrom recreational to varsity athletics. Figure 1 illustrates the age ranges for the patients in the groups. Group 1 consisted of 138 patients (90 men, 48

women)

who underwent ACL reconstruction in 1984 and 1985. Group II consisted of all 247 patients (174 men, 73 women) who were treated by ACL reconstruction by one surgeon (KDS) during 1987 and part of 1988 (January to June). Ninety-two percent of the patients in Group I were followed throughout the entire course of the study. Ninety-eight percent of the population in Group II were followed for varying lengths of time (range, 12 to 30 months; 73 patients longer than 24 months). All clinical and subjective data were stored and

analyzed in an IBM computer utilizing dBase III, Lotus 123, and Minitab.

Surgical procedure The knees of all

patients

in both groups

were

arthroscopi-

294

TABLE 2 Accelerated rehabilitation program, 1987

through

1988

Figure 1. by age.

Distribution of

patient population (GroupsI and II)

surface with the concave surface of the button facing the so that the graft could self-adjust. An additional 3 cm longitudinal incision was required over the distal lateral femoral surface to permit fixation of the graft on the proximal side. After fixation of the graft, the knee was put through a full range of motion to ensure proper tightness of the graft and to guarantee that the graft was not impinged in the

bone

intercondylar notch. Additional notchplasty and/or retightening of the graft at one of the ends was performed if indicated. Rehabilitation Rehabilitation protocol, 1984 and 1985. Group I patients underwent the rehabilitation protocol used at that time (Table 1). The involved leg was splinted in slight flexion. The patient was allowed to bear partial weight with crutches during the first 6 weeks. The agility program began 7 to 8 months after the ACL reconstruction. By 9 months, a return to all activities with a knee brace was permitted it Cybex strength results were greater than 80% of the noninvolved extremity, range of motion was near normal, and the functional progression had been completed. Most patients, however, were unable to return to their preinjury activity levels at 9 months and expressed their dissatisfaction with the

cally evaluated and any internal lesions arthroscopically managed (for example, repair or partial excision of the meniscus, depending on the nature of the tear) before ACL reconstruction was performed using the modified Jones technique. 14 A 6 cm anteromedial arthrotomy incision was used to expose the intercondylar notch and to place the tibial and femoral bone tunnels-both of which were drilled with cannulated reamers free-handed over a guide pin. A 10 mm wide central portion of patellar tendon with 2.5 cm of patellar and tibial bone at each end of the tendon graft was secured with three #2 Polydec (Deknatel, Inc., Floral Park, NY) sutures in the bone at each end of the graft. These sutures were tied over a convex 19 mm button (Biomet, Inc., Warsaw, IN) that was snugly interfaced to the recipient bone

delay. Rehabilitation protocol, 1987 and 1988. Group II patients followed the accelerated schedule of rehabilitation (Table 2), which was notable for the comparatively rapid achievement of various goals, particularly full extension equal to the opposite knee. The patient’s leg was not immobilized after the procedure; continuous passive motion and weightbearing began on Day 1, and the patient usually returned to light sports activities by 2 months and full activity 4 to 6 months after the reconstruction. Frequent follow-up examinations

were performed on all patients by the surgeon (KDS) during the first 4 weeks; we feel this is the critical time for obtaining full extension. Initial Cybex assessment along with the initial KT-1000 evaluations was accom-

295

5 to 6 weeks postoperation. Similar testing was scheduled at 10 weeks, 16 weeks, 6 months, 8 to 10 months, 1 year, and yearly thereafter. KT-1000 measurements were routinely performed on each patient by the same therapist in order to avoid interobserver discrepancies for any one patient’s clinical course. To facilitate the return of kinesthetic sense about the knee while improving patient compliance with the protocol, athletic activities, such as shooting basketballs and hitting a tennis ball, were permitted as soon as they could be tolerated by the patient. Return to full competition, however, was generally not condoned until at least 4 to 6 months after surgery. Permission to return to sports was contingent upon achieving near normal strength in the involved extremity, full knee extension, no knee effusion, and completion of a running program. A functional knee brace (Indiana Knee Orthosis, Indiana Brace Company, Indianapolis, IN) was recommended during participation in athletic competition for the lst postoperative year.

plished

Clinical

follow-up evaluation and analysis

The clinical examinations for both groups included range of motion assessment and stability tests (Lachman and pivot shift). Objective assessment included KT-1000 measurements, range of motion measurements, and Cybex strength evaluations. The difference between the KT-1000 scores of the involved and noninvolved knees at 20 pounds of force was recorded for analysis. Although Cybex evaluations were performed at 60, 180, and 240 deg/sec, only the quadriceps strength of the index extremity at 180 deg/sec was analyzed for this study. Subjective assessment of the knee was done periodically during the postoperative course using a modified Noyes’ knee rating scale (Fig. 2), with overall activity level (20 points walking, 10 points running, 10 points stairs, 5 points jumping, and 5 points twisting) accounting for 50 of the 100 points. The remaining 50 points were assigned to

pain (20 points), stability (20 points), and swelling (10 points). For comparison, the questionnaire was also administered to 140 competitive athletes with normal knees (Table 1). The data from the two groups of patients were compared corresponding time intervals. Also, the incidence of postoperative complications requiring additional treatment was recorded, and comparisons were made between subgroups. Unpaired t-tests were completed on all data from the two at

groups.

RESULTS The average range of motion values for each group are listed in Table 3. Compared to the averages for Group I, Group II average scores indicate an earlier and more complete achievement of extension equal to the opposite knee, which was maintained throughout the 2 year follow-up period. Final average flexion was reached earlier by Group II than Group I. The Cybex average scores for quadriceps strength at 180 deg/sec appear in Table 4. At the early testing times, the

Group II mean percentage was higher than in Group I, but by 1 year there was, as expected, no difference between Group I and II. The average KT-1000 arthrometer measurements of the tibiofemoral excursion at a 20 pound force appear in Table 5, Figure 3, and Figure 4. The average subjective scores on the questionnaire show only a few points difference in the results as perceived by the patients in both groups (Table 6). However, the results cannot reflect the number of noncompliant patients in Group I. The percentage of patients with a self-rated stability of 20 out of a possible 20 was 95% in Group I and 98% in II. The subjective ratings of 140 athletes (from a Division I NCAA school) with normal knees (Table 7) are in the same range as the average scores of the patients who had ACL reconstructions.

Complications Patients who had persistent difficulty in achieving full knee extension equal to the noninvolved knee in spite of the accelerated rehabilitation and who also had associated anterior knee pain were offered surgical intervention. Arthroscopy was performed to excise the scar tissue at the base of the ACL graft and to enlarge the notch anteriorly and laterally if necessary (Table 8). This procedure, which allowed for complete extension and required casting for a few days to ensure maintenance of full extension, was required in 12% of Group I patients and 4% of Group II patients.

DISCUSSION The purpose of this retrospective study was to evaluate from a clinical perspective the results obtained in two patient populations-one group who followed an accelerated rehabilitation program and another who followed our initial rehabilitation program after being treated by ACL reconstruction with the same technique by the same surgeon (KDS). We compared objective and subjective data from both groups of patients. We have followed patients from our initial regimen (Group I) for 4 to 5 years, and of the patients in the accelerated program (Group II), we have followed 73 for more than 2 years, and 174 patients for 1 year or more. The rehabilitation was not changed in cases of concomitant meniscal repair, and since January of 1987, only one of the 87 repaired menisci have clinically retorn. We sought answers regarding the range of motion achieved, quadriceps strength, stability, and patient satisfaction. We questioned our data: Were there any adverse effects or contraindications of the accelerated program? Were there any advantages, and did the combination of surgical procedure and rehabilitation program accomplish the goal of obtaining a functional knee, sufficiently stable for competitive athletics and free of anterior pain? To the best of our knowledge, this is the first clinical study to compare two different rehabilitation protocols in two groups of men and women treated by the same technique by the same

surgeon.

296

Figure 2. Postoperative questionnaire (Noyes, reproduced by permission). In comparing the objective data, we observed that knee extension returned much more quickly in Group II patients than in Group I patients. The accelerated rehabilitation protocol emphasizes extension, in contrast to the immobilization in flexion and restrictions on extension outlined in the past. We intentionally made this change because we had observed through the years that after the patient returns to sports participation, extension loss frequently resulted in patient dissatisfaction secondary to extremity pain and fatigue. The benefit of obtaining early full extension is reflected in the significant decline in the number of patients in Group II (compared to Group I) who required surgical management for symptomatic extensor loss. Closed kinetic exercises are emphasized in the accelerated

rehabilitation protocol, and open kinetic quadriceps exercises are avoided. Closed kinetic chain exercises are performed with the foot placed on a surface (floor, step, pedal, etc.) and the entire limb bearing a load. This causes all of the joints in the extremity to be compressed by the load. In open kinetic chain exercises (i.e., leg extensions) where the foot is free, a relatively larger shear stress is applied to the joint with less joint compression. In closed kinetic exercises (generally performed nearer full extension), patellofemoral joint forces are markedly decreased compared to those forces generated when the open kinetic exercises are performed in the zone of 30° to 90° of knee flexion. 3,15,27,28 In addition, closed kinetic chain activities place functional stresses on the joint and the extremity in ways that are similar to normal

297

TABLE 3

Range

of motion

(average) results

for each group by time after reconstruction

Significantly different from Group I, P < 0.01. Significantly different from Group I, P < 0.05. ‘ ROM measurements; a/b/c: a is degrees of hyperextension past 0, b is degrees short of 0° of extension, and c is degrees of flexion. °

6

TABLE 4

Cybex quadriceps percentages

at 180

4. Distribution of differences (average) in KT-1000 measurements of injured knee compared to noninjured knee at 20 pounds.

Figure

deg/sec

-

-

TABLE 6

Postoperative subjective ratings&dquo; (average)

Q

Significantly different from Group I, P
0.1

‘ No. of questionnaires

averaged. TABLE 7

Subjective ratings of normal knees in

° P > 0.1

140 athletes

at each time.

°

Scale

=

1 to 100.

TABLE 8 Scar resections to obtain full extension

a

Figure 3. Differences (average) in KT-1000 measurements of injured knee compared to noninjured knee at 20 pounds. activities. We reasoned that the joint compression that occurs when the extremity is loaded by body weight provides inherent joint stability and allows more strenuous strengthening workouts without the degree of shearing forces that occur with conventional open kinetic exercises. Group II patients began closed kinetic exercises

weightbearing

No. of questionnaires

averaged.

on the involved We have noted that the closed kinetic exercises used in the accelerated program help decrease postoperative anterior knee pain as well as increase subjective stability of the involved knee and the patient’s confidence in ambulation. Group II averaged a quicker return of quadriceps muscle strength than Group I. However, return of quadriceps strength appeared to depend more on the individual’s moas soon as

full, unsupported weightbearing

extremity

was

possible.

298

tivation than any other variable. The patient’s pain tolerance and control of postoperative knee effusion seemed to interplay with the motivational factor. Some of the competitive athletes in Group II regained 85% to 90% of quadriceps strength as early as 10 weeks postoperation. These highly motivated athletes were followed closely to determine if there are any adverse effects resulting from allowing the patient to proceed at his or her own pace under our guidance. To date, we have seen no complications as a result of the accelerated program. Perhaps programs such as the one we used from 1984 through 1985 (Table 1) are excessively restrictive, and activity limitations should be determined for each patient individually. In this population, it appeared that graft strength was sufficient to allow earlier activities than previously believed without causing failure from early return to

sports.

Analysis of the KT-1000 results (Figs. 3 and 4, Table 5) indicated that, as a whole, Group II patients had average values equal to or better than those in Group I at corresponding postoperative dates. There was no tendency in either group to demonstrate increasing displacement of the tibia on the femur with advancing time from date of reconstruction. Furthermore, out of 20 possible points on the subjective stability scale, 95% of Group I patients and 98% of Group II patients scored 20 on their most recent semiannual survey. These data confirm clinical impressions of improved recovery and thus provide further support for the safety of the accelerated rehabilitation protocol. Subjective knee evaluations were comparable for both groups, except that in the early postoperative course, patients in Group I indicated discontent and discomfort. Many patients in Group I had difficulty with protocol compliance, meaning they wanted to progress more rapidly than allowed by the protocol. We realized that a number of them were noncompliant, yet they showed no adverse effects from their increased activity. Hence, with the revision of the protocol, Group II patients were, by the 3rd to 4th postoperative week, allowed to reti-irn to normal 1 Rrtivitip~ nf daily living. fred of encumbering braces and walking aids, and (usually) had a normal gait. We believe that these factors had much to do with their satisfaction with the reconstruction. With our last 450 patients having followed this protocol, we now feel confident that the accelerated rehabilitation program will not necessarily cause graft weakening and subsequent failure at a later time. We performed a histologic analysis (unpublished data) of graft tissue from patients in Groups I and II who required arthroscopic procedures subsequent to the ACL reconstruction with autogenous patellar tendon. Twelve graft biopsies were obtained from 12 patients. These were longitudinal tissue samples of the graft obtained from 6 weeks to 4 3~4 years after implantation. The transplanted tissue had remained consistently viable, attaining maximum fibroblast size and number by the 6th postoperative month and proceeding in maturation to &dquo;ligamentization.&dquo;’, 1 24 None of the biopsy samples demonstrated more than a partial central necrosis. These findings support our theory that grafts can match physical stresses inherent

in the accelerated rehabilitation after ACL reconstruction without deleterious sequelae. The evidence from this retrospective study comparing the objective and subjective findings in both groups shows that an accelerated rehabilitation program, individually paced,

with patients undergoing regular follow-up evaluations, offers advantages over conventional rehabilitation programs in terms of patient compliance and satisfaction and graft viability. Patients in the accelerated program returned to normal function and athletic activities sooner than patients in the conventional rehabilitation program. We detected fewer problems with patellofemoral joint symptoms in these patients, and the number of procedures required to obtain full knee extension was reduced from 12% (Group I) to 4% (Group II). Furthermore, comparative data from the two groups in this study population demonstrate that range of motion, strength, and function can be achieved by an accelerated rehabilitation regimen without compromising stability or putting the graft at risk.

REFERENCES D, Ing D, Kleiner JB, et al The natural history of the anterior cruciate ligament autograft of patellar tendon origin Am J Sports Med 14 449-

1. Amiel

462, 1986 2 Antich TB, Brewster CE. Rehabilitation of the nonreconstructed anterior cruciate ligament-deficient knee Clin Sports Med 7 813-826, 1988 3. Arms SW, Pope MH, Johnson RJ, et al The biomechanics of anterior cruciate ligament rehabilitation and reconstruction. Am J Sports Med 12.

8-18, 1984 4 Bilko TE, Paulos LE, Feagin JA, et al. Current trends in repair and rehabilitation of complete (acute) anterior cruciate ligament injuries. Analysis of 1984 questionnaire completed by ACL study group Am J Sports Med 14. 143-147, 1986 5 Blackburn TA Rehabilitation of anterior cruciate ligament injuries. Orthop Clin North Am 16. 241-269, 1985 6 Brewster CE, Moyens DR, Jobe FR Rehabilitation for anterior cruciate reconstruction J Orthop Sports Phys Ther 5 121-126, 1983 7 Clancy WG Jr, Narechania RG, Rosenberg TF, et al Anterior and posterior cruciate ligament reconstruction in Rhesus monkeys A histological, microangiographic and biochemical analysis. J Bone Joint Surg 63A. 1270-

1284, 1981 8

Clancy WG Jr, Ray M, Zoltan DJ: Acute tears ligament Surgical versus conservative treatment

9.

Feagin

of the anterior cruciate J Bone Joint Surg 70A.

1483-1488, 1988 JA. The syndrome of the torn anterior cruciate ligament Orthop Clin North Am 10 81-90, 1979 10 Fullerton LR Jr, Andrews JR: Mechanical block to extension following augmentation of the anterior cruciate ligament A case report. Am J Sports Med 12 : 166-168, 1984 11 Graf B, Uhr F Complications of intraarticular anterior cruciate reconstruction Clin Sports Med 7. 835-848, 1988 12 Hughston JC. Complications of anterior cruciate ligament surgery. Orthop Clin North Am 16 : 237-240, 1985 13. Jones KG. Reconstruction of the anterior cruciate ligament A technique using the central one-third of the patellar ligament J Bone Joint Surg 45A:

925-932, 1963 14 Junst KA, Otis JC Anteropostenor tibiofemoral displacements during isometric extension efforts The roles of external load and knee flexion angle Am J Sports Med 13. 254-258, 1985 15. King S, Butterwick DJ, Cuerrier JP: The anterior cruciate ligament: A review of recent concepts J Orthop Sports Phys Ther 8 110-122, 1986 16. Noyes FR, Butler DL, Grood ES, et al: Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions J Bone

Joint Surg 66A 344-352, 1984 Noyes FR, Mangine RE, Barber S Early knee motion after open and arthroscopic anterior cruciate ligament reconstruction. Am J Sports Med :149-160, 1987 15 18 Paulos L, Noyes FR, Grood ES, et al. Knee rehabilitation after anterior cruciate ligament reconstruction and repair. Am J Sports Med 9 140-149, 17

1981

299

Rosenberg TD, Drawbert J, et al: Infrapatellar contracture unrecognized cause of knee stiffness with patella entrap: 331-341, 1987 ment and patella infera Am J Sports Med 15 20 Shelbourne KD, Whitaker HJ, McCarroll JR, et al. Anterior cruciate ligament 19 Paulos LE,

syndrome

21

An

injury Evaluation of intraarticular reconstruction of acute tears without repair Am J Sports Med, in press, 1990 Skyhar MJ, Danzig LA, Hargens AR, et al: Nutrition of the anterior cruciate ligament Effects of continuous passive motion Am J Sports Med 13 415-

418,1985 22 Thomee R, Renstrom P, Grimby G, et al Slow or fast isokinetic training after knee ligament surgery J Orthop Sports Phys Ther 8 475-479, 1987 23. Walla DJ, Albright JP, McAuley E, et al Hamstnng control and the unstable anterior cruciate ligament-deficient knee Am J Sports Med 13 34-39, 1985 24 Yasuda K, Sasaki T. Muscle exercise after anterior cruciate ligament reconstruction Biomechanics of the simultaneous isometric contraction method of the quadriceps and the hamstrings. Clin Orthop 220: 266-274, 1987 25 Yasuda K, Sasaki T Exercise after anterior cruciate ligament reconstruction The force exerted on the tibia by separate isometric contractions of the quadriceps or the hamstrings Clin Orthop 220 : 275-283, 1987

DISCUSSION Frank R. Noyes, MD, Cincinatti, Ohio: It is a pleasure to discuss this very important paper. I fully agree with the authors after bone-patellar tendon-bone ACL reconstruction that full extension can be obtained, even right after surgery and certainly by 3 to 4 weeks. I also agree that the early return of flexion is possible, certainly by 6 weeks. Early progressive weightbearing, protected functional exercises (mini-squats, etc., rather than weighted, flexed heavy resistance exercises) are also areas of agreement. The serial arthrometer measurements taken postoperatively to follow AP displacement are another good part of the authors’ program. We have also reported the success of a similar program, although there is one exception in protocol. The results of this study probably apply only to bone-ligament-bone grafts; we do not know to what extent we can apply the results to other grafts. For this program, the authors performed a subsequent arthroscopic lysis of adhesions and contracture on only 11 of 247 patients. We recorded only 3 of 227 patients who required a subsequent arthroscopic lysis for adhesions. The most frequent and common complication of ACL surgery is joint stiffness and contracture, which then cascades into further atrophy. Articular cartilage degeneration and a symptomatic knee are entirely avoidable. Surgeons should look critically at their complication rates and see how they may wish to modify their postoperative programs.

There is one aspect of this study with which I do have to disagree, and that is that the authors allow at 5 to 6 weeks after surgery, jump roping, agility drills, and stairclimbers. In my own series, I have seen graft stretchout and patellofemoral crepitus develop in a small and I will emphasize, small, but important group of patients. I think this need not occur. I also caution against full sports as early as 4 months after surgery. We have seen arthroscopic and MRI evidence of delayed graft maturation, again, in a small group, but why risk it? The authors really do not present how many of their patients actually got involved in these early exercises or

returned to sports at 4 months. Were there any that showed a stretchout? In the 20% of the patients with a KT-1000 over 3 mm, they report a very slight stretchout. When did this occur? And if this did occur (documented by the serial KT-1000 measurement), did they modify the program? We need more data on this one controversial point. Aside from this objection, the early protected motion and early use of the leg with weightbearing as these authors have presented should be one of the mainstays after ACL surgery. Authors’ Reply: I would like to reiterate what Dr. Noyes has said, in that this program has only been used in autogenous bone-patellar tendon-bone ACL reconstructions. The question as to whether a similar program can be used with other graft sources is unanswered by this study. By obtaining full extension immediately after surgery, we attempt to prevent anterior scar formation and flexion contractures. We feel that flexion contractures give falsely &dquo;tight&dquo; KT-1000 results. In following our patients we have found no tendency for the KT-1000 to change with time (unpublished data). Perhaps KT-1000 changes with time are seen with graft sources other than autogenous patellar tendon, or as patients regain their range of motion. Once full motion is achieved, KT-1000 results have not changed. Most of our rehabilitation is based on guidelines and not actual enforced protocol. If patients develop any problems during the rehabilitation, we adjust our guidelines appropriately. With the large number of closely followed patients treated by all of the doctors in our clinic in a similar fashion, we can now confidently allow our patients to follow this rehabilitation protocol with a high degree of success and patient satisfaction.

Accelerated rehabilitation after anterior cruciate ligament reconstruction.

To overcome many of the complications after ACL reconstruction (prolonged knee stiffness, limitation of complete extension, delay in strength recovery...
798KB Sizes 0 Downloads 0 Views