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Post Op Care of ACL Reconstructions

 - Radiographic Evaluation:
    - hyper-extension lateral view:
           - allows assessment of percentage of impingement by intercondylar roof;
           - a line is drawn thru the center of the tibial tunnel and a line is drawn tangential to the slope of the intercondylar roof;
           - note where these lines intersect in relation to to the tibial plateau;
           - ideally, the anterior border of the tibial tunnel should be just posterior to the intersection of the intercondylar
                    roof with the tibial plateau;

- Complications of ACL Reconstruction

- Rehab of ACL Tears/Reconstructions: test
    - in the report by Barber-Westin SD, et al. (1999) the authors studied the effect of rehabilitation strength training
           and return to activities on AP knee displacements after ACL reconstruction using a bone patellar bone technique);
           - rehabilitation included immediate knee motion and early weightbearing, light sports at 6 months, and competitive sports at 8 months or later;
           - assisted ambulatory phase was length of time the patient spent using crutch or cane support, and it lasted until approximately 4th to
                     8th week after surgery;
           - during this phase, range of motion exercises, straight leg raises (extension, flexion, abduction, adduction), quadriceps muscle isometrics,
                     electrical muscle stimulation, and closed-chain exercises (minisquats, toe raises);
           - at a minimum of 2 years after surgery, 121 patients (85%) had normal displacements (less than 3 mm of increase at 134 N), 14 (10%) had
                     3 to 5.5 mm of increase (partial function), and 7 (5%) had more than 5.5 mm of increase (failed);
           - there was no association found between the initial onset of the abnormal displacements in 21 knees and either the amount of time after
                     surgery or the rehabilitation program;
    - range of motion:
           - patients should be able to obtain 0 deg of extension (or equal to other side) by 2 weeks, and 90 deg of flexion by 4 weeks;
           - references: 
                  - The effect of exercise and rehabilitation on anterior-posterior knee displacements after anterior cruciate ligament autograft reconstruction
                  - The efficacy of continuous passive motion in the rehabilitation of anterior cruciate ligament reconstructions.
                  - Effect on knee stability if full hyperextension is restored immediately after autogenous bone-patellar tendon-bone anterior cruciate ligament reconstruction.
    - active extension:
           - closed chain exercises (foot is maintained on the ground or a platform) is more physiologic and less stressful on the ACL than open chain exercises;
                  - closed chain exercises, reduce shear stress across the joint and permit muscular co-contraction;
                  - perhaps most important rehab consideration is to avoid open chain excerises (limb not bearing wt), especially those which are
                          performed near full extension;
                  - in their report, Kvist J and Gillquist J measured tibial translation and muscle activation in 12 patients with unilateral anterior cruciate              
                          ligament injury and in 12 control subjects;
                          - in the uninjured subjects, tibial translation increased with increasing load except during the squat with the center of gravity
                                 behind the feet, which produced the smallest translation;
                          - for the active extension exercises, translation was greater during eccentric activity.
                          - in the anterior cruciate ligament-injured knees, all squats resulted in similar translation, which was smaller than that during
                                    the active extension exercise;
                          - highest muscle activation was seen during squats;
                          - increased static laxity in the ACL-deficient knee can be controlled during closed but not during open kinetic chain exercises;
                          - ref: Sagittal Plane Knee Translation and EMG Activity During Closed and Open Kinetic Chain Exercises in ACL Deficient Patients and Controls 
           - contraction of the quadriceps muscle can markedly increase strain on ACL, and this increase is most marked between 0 deg & 45 deg of knee flexion;
                  - knee-extension exercises should be performed with the knee in flexion in order to avoid putting excess strain on anterior cruciate ligament;
                  - resistive exercises performed between 0 deg & 45 deg of flexion are avoided during first 3-6 months after injury or reconstruction of ACL;
                  - active extension of knee between limits of 50 and 110 deg does not strain the ACL, therefore, this activity presents minimal risk of overstraining ACL;
           - references:
                  - Comparison of closed and open kinetic chain exercises in the anterior cruciate ligament deficient knee
                  - Intra-articular cruciate reconstruction. I: Perspectives on graft strength, vascularization, and immediate motion after replacement.
                  - Exercise after anterior cruciate ligament recontruction. The force exerted on the tibia by the separate isometric contractions of the quadriceps or the hamstrings.
                  - Comparison of tibiofemoral joint forces during open-kinetic-chain and closed-kinetic-chain exercises.  
                  - Muscle exercise after anterior cruciate ligament reconstruction. Biomechanics of the simultaneous isometric contraction method of the quadriceps and the hamstrings.
                  - Accelerated rehabilitation after anterior cruciate ligament reconstruction

    - gait and resumption of activities:
           - there is no good evidence to show that brace wear improves the outcome following surgery;
           - reliable patients can be allowed to wt bear as tolerated, when they feel able;
           - running and any activity that involves excessive knee rotation (cutting) is discouraged for the first several months;
           - patients over 40 years of age: (from Plancher KD, et al (1998))
                 - average time to bicycling was 4 months, jogging resumed at 9 months, and sking resumed at 10 months; 
                 - Reconstruction of the anterior cruciate ligament in patients who are at least forty years old. A long-term follow-up and outcome study

    - patella mobility:
           - patient is taught to mobilize the patella in all directions;
- ACL Braces:
    - inherent problems w/ ACL braces include the following:
           - excessive limitation of internal and external rotation of the knee;
           - poor control of anterior translation especially at 30 deg flexion;
    - in the report by Risberg MA, et al (1999), the authors performed a prospective, randomized, clinical trial to evaluate the effect of knee
           bracing after ACL reconstruction;
           - 60 patients were randomized into one of two groups: Patients in the braced group wore rehabilitative braces for 2 weeks, followed
                    by functional braces for 10 weeks, and patients in the nonbraced group did not wear braces;
           - at all follow-up times there were no significant differences between the two groups with regard to knee joint laxity, range of motion,
                    muscle strength, functional knee tests, or pain.
     - references:
           - Use of a knee brace for control of tibial translation and rotation.  
           - The effect of functional knee bracing on strain on the anterior cruciate ligament in vivo.  
           - The Effect of Knee Bracing After Anterior Cruciate Ligament Reconstruction.  A Prospective, Randomized Study with Two Years' Follow-up 

 - Prevention of DVT:
      - Extended-Duration Thromboprophylaxis With Enoxaparin After Arthroscopic Surgery of the Anterior Cruciate Ligament: A Prospective, Randomized, Placebo-Controlled Study 
      - The Incidence of Deep Venous Thrombosis After Arthroscopically Assisted Anterior Cruciate Ligament Reconstruction

Reflex Inhibition of the Quadriceps Femoris Muscle After Injury or Reconstruction of the Anterior Cruciate Ligament.
The effect of early versus late return to vigorous activities on the outcome of anterior cruciate ligament reconstruction.

Ligament stability two to six years after anterior cruciate ligament reconstruction with autogenous patellar tendon graft and participation in accelerated rehabilitation program.

Muscle coordination following rupture of the anterior cruciate ligament. Electromyographic studies of 14 patients.

Can muscle co-contraction protect knee ligaments after injury or repair?

Comparison of tibiofemoral joint forces during open-kinetic-chain and closed-kinetic-chain exercises.     

- references:
      The Effect of Exercise and Rehabilitation on Anterior-Posterior Knee Displacements After Anterior Cruciate Ligament Autograft Reconstruction 
      Effects of Early Progressive Eccentric Exercise on Muscle Structure After Anterior Cruciate Ligament Reconstruction: a 1-year follow-up study of a randomized clinical trial. 
      The role and implementation of eccentric training in athletic rehabilitation: tendinopathy, hamstring strains, and acl reconstruction.

Septic Arthritis After Arthroscopic Anterior Cruciate Ligament Reconstruction 

Septic Arthritis of the Knee After Anterior Cruciate Ligament Surgery. A Stage-Adapted Treatment Regimen

Risk and Outcome of Infection After Different Arthroscopic Anterior Cruciate Ligament Reconstruction Techniques  

The effect of early motion on tibial tunnel widening after anterior cruciate ligament replacement using hamstring tendon grafts.