ACL Reconstruction – Hamstring Autograft With or Without Meniscus Repair

Recovery after knee surgery entails controlling swelling and discomfort, healing, return of range-of-motion of the knee joint, regaining strength in the muscles around the knee joint, and a gradual return to activities. The following instructions are intended as a guide to help you achieve these individual goals and recover as quickly as possible after your knee surgery.

COMFORT
- Elevation
  - Elevate your knee and ankle above the level of your heart. The best position is lying down with two pillows lengthwise under your entire leg. This should be done for the first several days after surgery.
- Cold Therapy
  - If you elected to receive the circulating cooling device, this can be used continuously for the first 3 days, (while the initial post-op dressing is on). After 3 days, the cooling device should be applied 3 times a day for 20-30 minute intervals.
  - If you elected to receive the gel wrap, this may be applied for 20 minutes on, 20 minutes off as needed. You may apply this over the post-op dressing. Once the dressing is removed, be sure to place a barrier (shirt, towel, cloth, etc.) between your skin and the gel wrap.
  - If you elected to use regular ice, this may be applied for 20 minutes on, 20 minutes off as needed. You may apply this over the post-op dressing. Once the dressing is removed, be sure to place a barrier (shirt, towel, cloth, etc.) between your skin and the ice.
- Medication
  - Pain Medication-Take medications as prescribed, but only as often as necessary. Avoid alcohol and driving if you are taking pain medication.
    - You have been provided a narcotic prescription postoperatively. Use this medication sparingly for moderate to severe pain.
    - You are allowed two (2) refills of your narcotic prescription if necessary.
    - When refilling pain medication, weaning down to a lower potency or non-narcotic prescription is recommended as soon as possible.
    - Extra strength Tylenol may be used for mild pain.
    - Over the counter anti-inflammatories (Ibuprofen, Aleve, Motrin, etc.) shoulder be avoided for the first 4 weeks following surgery.
  - Anti-coagulation medication: A medication to prevent post-operative blood clots has been prescribed (Aspirin, Lovenox, etc.) This is the only medication that MUST be taken as prescribed until directed to stop by Dr. Forsythe.
  - Nausea Medication – Zofran (Odansetron) has been prescribed for nausea. You may take this as needed per the prescription instructions.
  - Constipation Medication -Colace has been prescribed for constipation. Both your pain medication and the anesthesia can cause constipation. Take this as needed.

ACTIVITIES
- Range-of-Motion – Move your knee through range of motion as tolerated. This must be done while sitting or lying down.
  - Note: If you underwent a meniscal repair, you may have range of motion restrictions.
- Locking Knee Brace – The brace is to be worn for up to 4-6 weeks following surgery. It will be locked straight until bone healing and good knee strength have been achieved (usually 5-6 weeks after surgery). At that time your doctor will determine if your leg has enough strength to allow your brace to be unlocked. You may unlock the brace while sitting but lock the brace before standing. Sleep with the brace on until directed by Dr. Forsythe.
- Exercises – These help prevent complications such as blood clotting in your legs. Point and flex your foot and wiggle your toes. Thigh muscle tightening exercises should begin the day of surgery and should be done for 10 to 15 minutes, 3 times a day, for the first few weeks after surgery.
- CPM – (Continuous Passive Motion Machine) – A Continuous Passive Motion (CPM) machine maybe started the day after your surgery. This machine will be set at 30°. Motion on the machine should be increased at 10-15° per day or as much as tolerated, to a maximum of 90° in one week. The machine should be used 6 hours per day (i.e. 2 hours in the morning, 2 hours in the afternoon and 2 hours in the evening). Use of the machine will continue for 1-2 weeks, or until maximum flexion of the machine is reached (110°).
  - DO NOT WEAR LEG BRACE OR COOLING DEVICE WHILE USING CPM MACHINE.
- Weightbearing – You are allowed to put all of your weight on your operative leg using your brace in the lockedstraight Do this within the limits of pain. Two crutches should be used until directed to discontinue by Dr. Forsythe.
  - Note: If you underwent a meniscus repair (not a debridement), you will NOT be allowed to put full weight on your operative leg for 1 week.
- Physical Therapy– PT is usually started a day after surgery. You should call the physical therapist of your choice for an appointment as soon as possible after surgery. A prescription for physical therapy, along with physical therapy instructions (included in this packet) must be taken to the therapist at your first visit.
  - Note: If you underwent a meniscus repair, or if you have had multiple ACL reconstructions, you may not start PT immediately.
- Athletic Activities– Athletic activities, such as swimming, bicycling, jogging, running and stop-and-go sports, should be avoided until allowed by your doctor.
- Return to Work– Return to work as soon as possible. Your ability to work depends on a number of factors – your level of discomfort and how much demand your job puts on your knees. If you have any questions, please call your doctor.

WOUND CARE
- Bathing - Tub bathing, swimming, and soaking of the knee should be avoided until allowed by your doctor - Usually 4-6 weeks after your surgery. Keep the dressing on, clean and dry for the first 3 days after surgery.
  - You may shower 3 days after surgery with WATERPROOF band-aids on. Apply new band-aids after showering.
- Dressings - Remove the dressing 3 days after surgery. Your stitches will be removed about 1 week after your surgery. You may apply band-aids to the small incisions around your knee

EATING
- Your first few meals, after surgery, should include light, easily digestible foods and plenty of liquids, since some people experience slight nausea as a temporary reaction to anesthesia

CALL YOUR PHYSICIAN IF:
- Pain in your knee persists or worsens in the first few days after surgery.
- Excessive redness or drainage of cloudy or bloody material from the wounds (Clear red tinted fluid and some mild drainage should be expected). Drainage of any kind 5 days after surgery should be reported to the doctor.
- You have a temperature elevation greater than 101°
- You have pain, swelling or redness in your calf.
- You have numbness or weakness in your leg or foot.

RETURN TO THE OFFICE
- Your first return to our office should be within the first 1-2 weeks after your surgery. Call your physician’s office to make an appointment for this first post-operative visit.

REHABILITATION PROGRAM:

Anterior Cruciate Ligament Reconstruction

Hamstring Autograft

NOTE: The following instructions are intended for your physical therapist and should be brought to your first physical therapy visit.

INTRODUCTION
Presuppose 8 weeks for complete graft re-vascularization
CPM not commonly used unless meniscus is repaired
ACL reconstruction performed with meniscal repair or transplant follows the ACL protocol. For semitendinosus/gracilis autografts, isolated hamstring strengthening for 6 weeks. Physician may extend time frames for use of brace or crutches.
Supervised physical therapy takes place for 3-9 months

GENERAL PROGRESSION OF ACTIVITIES OF DAILY LIVING

Patients may begin the following activities at the dates indicated (unless otherwise specified by the physician):

Bathing/showering without bracer after suture removal
Sleep with brace locked in extension for 1 week
Driving: 1 week for automatic cars; left leg surgery

4-6 weeks for standard cars; right leg surgery

Brace locked in extension for 6 weeks for ambulation
Use of crutches, brace for ambulation for 6 weeks
Weightbearing as tolerated immediately post op

PHYSICAL THERAPY ATTENDANCE

The following is an approximate schedule for supervised physical therapy visits:

Phase I (0-6 weeks) 1 visit/week
Phase II (2-3 weeks) 2-3 visits/week
Phase III (2-6 months) 2-3 visits/week
Phase IV (6-9 months) 1 visit/1-2 weeks

REHABILITATION PROGRESSION

The following is a general guideline for progression of rehabilitation following ACL semitendinosus/gracilis autograft reconstruction. Progression through each phase should take into account patient status (e.g., healing, function) and physician advisement. Please consult the physician if there is any uncertainty concerning advancement of a patient to the next phase of rehabilitation.

PHASE I

Begins immediately post-op through approximately 6 weeks

Goals:

Protect graft fixation (assume 8 weeks fixation time)
Minimize effects of immobilization
Control inflammation
Full extension range-of-motion
Educate patient on rehabilitation progression
ROM as tolerated
- limit to 90 degrees the first 4 weeks if meniscus repair performed

Brace:

0-1 week: Locked in full extension for ambulation, sleeping
1-6 weeks: Locked for ambulation and sleeping. May unlock when patient has

achieved no lag with straight leg raise

Weightbearing Status:

0-6 weeks: Weightbearing as tolerated with twocrutches as needed

Therapeutic Exercises:

Heel slides
Quad sets
Patellar mobilization
Non-weightbearing gastroc/soleus, begin hamstring stretches at 4 weeks
SLR, all planes, with brace in full extension until quadriceps strength is sufficient to prevent extension lag
Quadriceps isometrics at 60° and 90°

PHASE II

Begins approximately 6 weeks post-op and extends to approximately 8 weeks.

Criteria for advancement to Phase II:

Good quad set, SLR without extension lag
Approximately 90° of flexion
Full extension
No signs of active inflammation

Goals:

Restore normal gait
Maintain full extension (especially hip extension), progress flexion range-of-motion
Protect graft fixation
Initiate open kinetic chain hamstring exercises

Brace/Weightbearing Status:

Discontinue use of brace and crutches as allowed by physician when the patient has full extension and can SLR without extension lag.
Patient must exhibit non-antalgic gait pattern, consider using single crutch or cane until gait is normalized.

Therapeutic Exercises:

Wall slides 0°-45°, progressing to mini-squats
4-way hip
Stationary bike (begin with high seat, low tension to promote ROM, progress to single leg)
Closed chain terminal extension with resistive tubing or weight machine
Toe raises
Balance exercises (e.g., single-leg balance, KAT)
Hamstring curls
Aquatic therapy with emphasis on normalization of gait
Continue hamstring stretches, progress to weightbearing gastroc/soleus stretches

PHASE III

Begins at approximately 8 weeks and extends through approximately 6 months.

Goals:

Full range-of-motion
Improve strength, endurance and proprioception of the lower extremity to prepare for functional activities
Avoid overstressing the graft fixation
Protect the patellofemoral joint

Therapeutic Exercises:

Continue flexibility exercises as appropriate for patient
Stairmaster (begin with short steps, avoid hyperextension)
Nordic Trac
Knee extensions: 90°-45°, progress to eccentrics
Advance closed kinetic chain strengthening (one-leg squats, leg press 0°-45°, step-ups begin at 2” and progress to 8”, etc.)
Progress proprioception activities (slide board, use of ball, racquet with balance activities, etc.)
Progress aquatic program to include pool running, swimming (no breaststroke)

AT 4 MONTHS: May begin supervised jogging

PHASE IV

Begins at approximately 6 months and extends through approximately 9 months.

Criteria for advancement to Phase IV:

Full, pain free ROM
No evidence of patellofemoral joint irritation
Strength and proprioception approximately 70% of uninvolved leg
Physician clearance to initiate advanced closed kinetic chain exercises and functional progression

Goals:

Progress strength, power, proprioception to prepare for return to functional activities

Therapeutic Exercises:

Continue and progress flexibility and strengthening program

Initiate plyometric program as appropriate for patient’s functional goals
Functional progression including, but not limited to:
- Walk/jog progression
- Forward backward running, ½, ¾, full speed
- Cutting, crossover, carioca, etc.
Initiate sport-specific drills as appropriate for patient

PHASE V

Begins at approximately 9 months post-op

Criteria for advancement to Phase V:

No patellofemoral or soft tissue complaints
Necessary joint ROM, strength, endurance, and proprioception to safely return to work or athletics
Physician clearance to resume partial or full activity

Goals:

Safe return to athletics
Maintenance of strength, endurance, proprioception (continue to work on hip extension)
Patient education with regard to any possible limitations

Therapeutic Exercises: