Reconstruction of the Ligaments in the Knee
The knee is a complex joint that depends on bones, ligaments and muscles for its stability. There are four major ligaments in the knee – the medial and lateral collateral ligaments supporting either side of the joint, and two cruciate ligaments situated in the centre of the joint controlling forward and backward glide. All four ligaments work together to control rotation.
The anterior cruciate ligament is the one most commonly requiring surgical reconstruction, but the same general principles apply to all procedures.
It is possible to replace the damaged ligament with an artificial one made of polyester and/or carbon fibre, however these are rarely used now as improved results are obtained using a natural graft taken from the patients own body (an autograft). Most commonly the graft is taken from the either the patellar tendon (on the front of the knee) or the hamstrings tendons (at the back of the knee). Both grafts have been shown to produce excellent results however, nothing is yet perfect and you may find confusing information if you try to research the topic. If you are unsure or wish to discuss the pros and cons in more detail do contact the clinic.
PRIOR TO SURGERY
You may be asked to attend the clinic for tests such as X-rays, an MRI scan, or a KT2000 (ligament laxity evaluation). These are all aids to diagnosis and will help to evaluate the full extent of your problem. The MRI scan shows the ligaments and soft structures around the joint, which do not show up on conventional X-ray. You may also be referred to the clinic physiotherapist prior to surgery, who will explain the operative procedures to you, and will advise you on exercises which are beneficial to practise before surgery. The physiotherapist will also go through the post-operative protocol with you so that appropriate planning can be made. If you have any questions the physiotherapist will be happy to answer them for you.
It is usual to stay in hospital for two nights after your operation, during which time you will gradually become mobile and independent, walking with crutches. Occasionally local patients are able to go home after one night however this would not be until the evening as you need time to become confident walking and to go through your exercise program.
Comfortable loose clothing is recommended – shorts are ideal if you prefer to be dressed.
The Day of your Operation:
You will wake up from the operation with an absorbent dressing and white “T.E.D.” stockings on your legs. The dressing will be changed the next day, but you will continue with the stockings.
The white stockings have a twofold purpose:
- To reduce the risk of post-operative thrombosis.
- To control swelling in the leg and around the joint.
It is advisable to wear the stockings until you are walking normally without crutches, and until the swelling around the joint has settled.
In some cases a small drain is inserted into the wound at the time of operation, to drain away any excess fluid from the knee. This is usually removed the next day, with minimal discomfort.
On return to the ward after surgery, your leg may be placed on a C.P.M. machine, (continuous passive movement). This machine will slowly bend and straighten the knee, most patients find it very comfortable and the movement can be beneficial in reducing swelling and preventing stiffness.
The next morning the physiotherapist will get you out of bed and teach you to walk with crutches. It is important at this early stage to begin to put some weight through the joint, but the crutches will give you confidence and help with balance. You will also be shown exercises which you are expected to practise regularly while in hospital and when you get home. You will be shown how to negotiate stairs before you are discharged.
An appointment will be arranged for you to come for physiotherapy as an out-patient. If you live too far away and cannot attend the clinic, it is advisable to find a reputable chartered physiotherapist nearby before your surgery (your GP will be able to recommend someone or check yellow pages). After your operation, we can forward all the necessary information and instructions. You will come back to the clinic for review at regular intervals and will see the physiotherapist who will check your rehabilitation progress prior to your seeing the consultant.
The reconstruction is performed by “arthroscopic” (keyhole) surgery, which involves inserting a 5mm scope with an attached camera and light source, into the joint. The scope and instruments are introduced through small wounds (or “portals”) and the joint examination and reconstruction is monitored on screen and recorded on video. You are likely to have three or four portals, which will be covered with small adhesive dressings and heal very quickly.
You will also have one or two small incisions through which the graft will have been harvested, these are superficial and do not enter the joint itself. These wounds may be stitched below the skin with soluble thread and the skin closed with steristrips.
It is important to find a balance between activity and rest during the first week at home. You are encouraged to walk and put weight through the leg – you may discard one or both crutches, providing you are safe and not limping. Restrict your exercises to those which the physiotherapist has taught you in hospital, and do rest in between to allow inflammation and swelling to settle down.
After The First Week:
You will normally be expected to attend the physiotherapy department on about the sixth to eighth day. Your dressings and wounds will be checked and, providing the swelling has settled, you will be shown more progressive exercises.
It is important to realise that the role of the physiotherapist is largely advisory and supervisory – it is up to you to practise exercises regularly so that muscle strength and range of movement return quickly.
Everyday activities, such as walking, and going up and down stairs etc., should become easy fairly quickly, but you should not be tempted to return to any strenuous or sporting activity without discussion and advice from the physiotherapist.
Return to work is obviously dependant on your occupation. If you have a sedentary job, you may be able to return after two weeks but, depending on the level of activity, you may require a few weeks or even months if your occupation is strenuous.
There is no reason why you should not be able to drive once the swelling around the knee settles but you must be confident that you are able to move your leg quickly to cope with an emergency stop if necessary. Research shows that it is 2 – 3 weeks before normal reaction time returns. You are advised to check with your insurance company regarding regulations following an anaesthetic, most insurance companies will not cover you for the first 48 hours.
APPROXIMATE TIMETABLE FOR REHABILITATION
The post-operative schedule out-lined below enables strength, mobility and flexibility to be regained as early as possible without compromising the new ligament.
The graft acts as a framework for new natural tissue growth, but this process is gradual. Full maturation of the tissue goes on for about eighteen months or more.
If you are very physically fit before the reconstruction, your progress through the rehabilitation programme will probably be quicker than the average individual.
Progressive weight bearing gradually, discarding the crutches when confident.
Static or isometric exercises (as taught by the physiotherapist).
Simple “closed kinetic chain” exercises, the physiotherapist will explain these to you.
Extension stretch – it is imperative that the knee can straighten to the same extent as your opposite leg as soon as possible. You will be shown how to achieve this and must perform the stretch 5 / 6 times daily at home.
SECOND WEEK INWARDS:
Mobilising exercises to regain full movement as soon as possible.
Progressive closed kinetic chain exercises to strengthen the quadriceps (on the front of the thigh) and hamstrings, (on the back of the thigh), and to improve balance and co-ordination.
We would expect return to normal every day activities within three weeks.
Swimming and cycling are encouraged as soon as the physiotherapist thinks you are ready,(usually by three weeks), these are ideal forms of exercise, as they put little stress the healing tissues.
There is no reason why open chain exercises for the hip should not be commenced. Other open chain exercises, specifically for either the quadriceps or hamstring muscles, should be practised with the physiotherapists advice. The suitability of these exercises will depend on which ligament you have had reconstructed.
Many gymnasium type exercises can be introduced at this stage, but do take advice on the suitability of each piece of apparatus before starting a programme.
When ready, you will be able to start light jogging, initially on a soft surface, and ,at the physiotherapists discretion, will have an isokinetic assessment to test muscle strength, endurance and balance, prior to return to any sporting activity. This is usually between the fourth and sixth months, post-operatively.
Return to sports-specific training,- including running and gymnasium work.
You should not return to full sporting activity until the isokinetic and functional tests show that muscular activity in the affected leg is equivalent to the unaffected side.
Return to non contact sport, and begin gradual introduction of contact sports -specific training
Return to non-contact sport.
Begin contact sports-specific training.
Gradual return to contact sport.
Return to normal sporting activity.
These time scales are a guide only – obviously each patient is different and will progress at varying rates. The physiotherapist will guide you through the various stages and tell you when you are ready to move on to the next stage.
If you have any questions regarding your proposed operation, or the rehabilitation which will follow, please do telephone and speak to the clinic nurse; a physiotherapist; or doctor, who will be happy to help you.