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 The double-bundle ACL reconstruction is a new and innovative technique for replacing an injured ACL or anterior cruciate ligament. It involves using two separate grafts to reconstruct or replace the native ACL, whereas a standard ACL reconstruction uses a single graft. The advantage of the new technique is that it functions much more like the native ligament. Thus, it should allow the patient to have more normal biomechanical function of their knee. This should lead to better function on the field with less chance of further injury to the knee.
The double-bundle ACL reconstruction is a technique that has been utilized widely in Japan with very impressive results. In the United States it is a procedure that has been performed in significant numbers at only a few centers of excellence, one of those at Emory Sports Medicine.
Dr. John W. Xerogeanes and Dr. Karas have been studying and modifying this procedure over the last three years. He has combined his clinical experience and basic science studies to develop both surgical instrumentation and a reproducible technique. He has performed over 50 of the double-bundle ACL reconstructions.
The double-bundle ACL reconstruction in not recommended for everyone. It is especially suited for those who have had a previous reconstruction and for patients who are at high risk for further knee injuries. If you have a patient with an ACL injury, they can be evaluated by Dr. Xerogeanes or Dr. Karas to see if they are a candidate for the double-bundle reconstruction.
Rehabilitation after ACL Reconstruction
- Question: When does rehabilitation start after an ACL reconstruction?
Answer: On the day of surgery. Patients are given a set of exercises to start immediately in the recovery room.
Actually, rehabilitation starts before the surgery in order to allow for complete range of motion, good strength, and decreased swelling before surgery is undertaken
- Question: Will I need to be on crutches after surgery?
Answer: Yes, but only initially and only for comfort. Full weight bearing is gradually increased as tolerated by the patient. It typically takes seven to 10 days after the procedure, until the patient is comfortable without the assistance of a crutch.
An exception to this rule is if the patient also underwent a meniscal repair or other reconstruction of an additional ligament. In these cases, weight bearing may be restricted for several weeks.
- Question: What do I do in the first few weeks after surgery?
Answer: The first two weeks after surgery concentrates on decreasing the swelling in the knee and regaining knee extension, with less concern about knee flexion. This is accomplished by elevating/icing the leg and riding the stationary bike.
At two weeks post-operatively the goal is for patients to achieve and maintain full knee extension and increase quadriceps muscle function. While knee flexion of only 90 degrees is the goal for this stage, obtaining full extension is more of a priority. Loss of extension after ACL surgery is more common, and less tolerated by the patient. Therefore, the early stages of rehabilitation focus on this area.
- Question: When can I drive?
Answer: Usually by two weeks post-operatively patients are off crutches, demonstrating adequate muscle function, mobility, and comfort to allow driving. This is dependent on what leg has been operated on and how fast the patient recovers.
- Question: How is rehabilitation after an ACL reconstruction typically structured?
Answer: Although different surgeons and therapists will have slightly different protocols, the goal for all forms of post-operative ACL rehabilitation is the same.
The goal of rehabilitation is to return the patient to a normal and complete level of function in as short a time possible without compromising the integrity of the surgically reconstructed knee.
In order to achieve this goal, therapy is typically broken down into stages (or phases) of activity with goals for each stage. Here is an example of a standard four-phase protocol:
Phase I - Begins immediately after surgery and extends through approximately two weeks. Emphasis:
Control of inflammation
Range of motion - full extension, and 90 degrees of knee flexion
Achievement of quadriceps control
Education of patient about rehabilitation process
Crutches - usually seven to 10 days until patient is comfortable
Patellar Mobilization - to prevent patellar tendon shortening/contracture and loss of knee motion
Phase II - begins two weeks post-operatively and extends to six weeks. Emphasis:
Strengthening - light weights and sports cords
Full range of motion
Continued protection of the graft from stresses
Improvement of endurance and proprioception - use of treadmill, step machine and elliptical trainer
Phase III - typically starts at six weeks and extends through three to four months. Emphasis:
Improve patient's confidence in the knee
Progression in strength, power, and proprioception - preparing for return to sport
Jogging typically allowed at three months
Straight ahead running
Phase IV - begins at four to six months. Emphasis:
Possible return to sport, depending on type of sporting activity and type of graft
Full pain free range of motion should be present
Sufficient strength and proprioception should be present
Typically, patient is advanced to initiate advanced lifting exercises
Phase is typically customized to the patient's activity level and competition level in sport.
Phase V - begins with return to sport, usually at six months. Emphasis:
Patient must meet all the criteria for return to sports
No soft tissue or range of motion complaints
Physician must clear the patient to resume full activities
The goal is safe return to sports
Education of patient about possible limitations
Maintenance of strength, endurance, and proprioception
Functional bracing may be recommended by some physicians for the first one to two years after surgery for psychological confidence.
- Question: Will I need a brace after my ACL reconstruction?
Answer: Bracing after ACL surgery is purely dependent on patient and surgeon preference. Some surgeons never use bracing, some always use a brace, and others just use a brace during the immediate post-operative or just the rehabilitation phases.
This topic still remains the subject of much debate in sports medicine literature. However, to this date, no long-term benefits have been found with regard to knee laxity, range of motion, or function following ACL surgery.
Bottom line: If you feel more comfortable in a brace, then one will be ordered for you.
- Question: What type of follow-up is done after an ACL reconstruction?
Answer: You will be seen within the first week, at two weeks, six weeks, three months and six to eight months. Specifically the physician will look at and measure:
The presence of continued pain and swelling
Range of motion of the knee
Laxity of the graft
Strength of the leg
Knee function during routine activities of daily living
Return to sports
Several outcome studies at one year post-operatively have demonstrated rates between 90 percent and 95 percent good to excellent results following ACL reconstruction.
- Question: What are the possible complications of ACL surgery?
Answer: As with any invasive surgical procedure, infection and bleeding are always present as surgical risks. Infection rates for arthroscopic ACL reconstructions are among the lowest for surgical procedures with average infection rates typically cited at 0.2 percent. As for bleeding complications, the rates are much less than 1 percent, and consist mostly of isolated case reports.
Loss of motion following ACL reconstruction is the most commonly cited complication. This can range from minor and inconsequential to severe. Prevention is the first and most effective method for treatment of loss of motion. This is why compliance with post-operative rehabilitation is so vital to the outcome of the procedure, and why range of motion is started immediately post-operatively.
Another risk of ACL reconstruction surgery is continued anterior knee pain post-operatively. It is commonly believed that extensor mechanisms, including the patellofemoral joint, surrounding soft tissues, and the patellar and quadriceps tendons, are the source of the pain, with the patellofemoral joint being largely responsible. Anterior knee pain following ACL reconstruction also has been closely associated with loss of motion.
Therefore, range of motion, quadriceps strengthening and patellar mobility are of primary concern during the first two weeks following surgery.
The success of ACL reconstruction is truly dependent on a team effort by the surgeon, therapist and the patient.
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