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ACL Reconstruction

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ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION PATIENT INFORMATION LEAFLET This information booklet will give you and your family a basic understanding of what is involved when you require an Anterior Cruciate Ligament ACL reconstruction your goals for rehabilitation and to guide you back to your normal activities It is important for you to understand the advantages but also the possible issues which may occur after this surgery During your stay in Beacon Hospital you will receive advice and support from a number of members of the orthopaedic multidisciplinary team What is an Anterior Cruciate Reconstruction Anterior Cruciate ligament injury or rupture is a common sporting injury It can also occur in other situations where the knee is subject to significant force in certain positions Thighbone Femur Patella Posterior cruciate ligament PCL Articular cartilage Meniscus Patellar tendon Shinbone Tibia Anterior cruciate ligament ACL SIDE VIEW OF THE KNEE

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The knee is quite a complex hinge joint formed by the ends of the femur and the tibia The femur has two smooth rounded joint surfaces These move on the nearby flat joint surfaces of the tibia Between the two sets of joint surfaces there are two ligaments These ligaments make a cross and are therefore called the cruciate ligaments One ligament starts at the front of the knee and is called the Anterior Cruciate Ligament ACL The other starts at the back and is called the Posterior Cruciate Ligament PCL These cruciate ligaments help to keep the femur and the tibia properly aligned as you bend and straighten your knee Often repair of a damaged ACL is not possible Where this is the case the torn ligament is removed and replaced with a graft from another tissue generally one of your tendons To reconstruct the torn ligament a piece of healthy tendon called an autograft is harvested from another area in your leg and used for reconstruction Commonly used techniques include hamstring tendon quadriceps tendon and bone patellar tendon bone The choice is dependent on the Surgeon s preference and the patient s knee injury history Sometimes the graft used may be supplemented with an extra articular augmentation This is further grafting that happens on the outside of the knee to create added stability Preparing for your Admission Smoking It is advisable to give up smoking or at least to reduce the number of cigarettes you smoke as smoking interferes with healing Smoking also impairs bone growth and repair and will delay healing after your surgery If you smoke and want help reducing or quitting or need a nicotine patch please inform the admitting nurse Clothing Day time attire of loose comfortable clothing is advised e g long shorts tracksuits bottoms or loose three quarter length trousers Footwear Comfortable lace up or slip on shoes with a low heel are recommended when in hospital Please ensure there is a back to these shoes

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Fasting pre operatively The scheduling department will phone you prior to admission and they will advise you on how long to fast As a rule you should fast from food drink for six hours and still tap water for 2 hours before your surgery Planning your discharge ACL Reconstruction surgery can be done as a day procedure or may require an overnight stay It is important to discuss with the Physiotherapist you see in the hospital your plans for physiotherapy going forward This may mean attending Beacon Hospital s Physiotherapy Department or continuing physiotherapy in your locality It is important that the correct information is passed on to you to give to your own Physiotherapist if you are to attend elsewhere General Safety Advice for Home Being aware of hazards in your home will make your recovery easier and safer Move electrical cords phone lines and ensure clear pathways exist Store items within easy reach specifically in the kitchen and bathroom areas Remove rugs including bath mats and entrance mats Be careful around pets and young children Be aware of water spills slippery floors and always think before you move Manage your Pain Pain is a common occurrence following any injury or surgical procedure Pain will naturally reduce as your knee heals Medications and ice will also be given to you regularly to manage pain You can ask your nurse for extra painkillers if you need them before your exercises It is important to report pain to the nursing staff who will help you to keep your pain well controlled so you can mobilise comfortably perform your physiotherapy exercises and resume normal activities after surgery You will be asked to rate or score your pain regularly before and after your surgery You will be asked to give a number between 0 and 10 where 0 represents no pain and 10 represents the worst pain you can imagine The score will depend on how your pain feels to you

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Use of Ice Your knee may be hot red and swollen before or after surgery Ice may be used during your hospital stay and at home to help reduce the pain and swelling Dry ice should not be used Place ice on your knee for 15 20 minutes every two hours and after exercising avoiding direct contact with the skin Use a layer of cloth between the ice and your skin to avoid skin damage You may continue to ice regularly as an in patient and on discharge home in order to help control swelling pain and also encourage healing You should elevate your affected leg regularly to aid the reduction of swelling in your limb General Recommendations for Immediate Post Operative Phase Call Bells Use the call bell to ask for assistance with any transfers in out of bed on off toilet Do not attempt to transfer until you have been taught how to transfer safely and have been cleared by the nurse or Physiotherapist to do so Use the call bell when the side rails of your bed are raised Nausea Some of the medications you could be prescribed may cause nausea Please inform the nursing staff if you feel sick or are vomiting Your medications may need to be adjusted or you may need additional medications to prevent or treat nausea Nutrition Aim to follow a well balanced diet which includes protein fats and carbohydrates It is important to be well nourished to promote wound healing so eat well during your post op recovery Protein is particularly important for wound healing It is found in meat fish eggs milk cheese yoghurt beans and pulses We usually advise against trying to lose weight during the first few weeks of your post op recovery If you have any specific dietary requirements please discuss these with a nurse or catering staff at the time of your admission Bowel Care Try to include sources of fibre in your diet brown bread high fibre cereals fruit vegetables and drink plenty of fluids A high fibre diet is recommended after surgery

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After Discharge from Hospital Walking and Crutch Use Crutches are generally required for 2 3 weeks post surgery You may wean from two crutches to one crutch as you improve It is important to restore a normal gait pattern post surgery If stopping crutch use results in an abnormal gait pattern you may not yet be ready to stop using these Your Physiotherapist will assess your gait at your first Outpatient appointment and will be able to further advise Pain Medication On discharge from hospital you will be prescribed medications some of which will be for pain Plan to do your exercises 30 minutes after taking pain medication as preventing pain is easier than chasing pain If these medications are not relieving your pain you cannot take the medications due to side effects or you require a repeat prescription contact your local GP Swelling and Bruising Expect to experience bruising and swelling in the knee after surgery This is a normal part of the recovery phase Bruising can occur up into your thigh or down to your calf The swelling can cause pain in your knee and may restrict the amount of movement you have in the joint To reduce this take the medications that are prescribed for you and ice your knee The swelling can persist for 6 weeks and sometimes longer Car Transfers When travelling in the car you should sit in the front passenger seat A plastic bag on the seat can assist with maneuvering in and out of the car If you intend to go on a long car journey please include regular safe stops Driving In order to be safe driving a motor vehicle you must be in control of the pedals effectively It is recommended that you do not drive a motor vehicle until you have complete control over your leg or are advised by your consultant It is not recommended that you drive while you are still reliant on crutches which is usually around 2 3 weeks When you do become capable of handling a motor vehicle a trial period in an empty car park is recommended Travel Prolonged periods of sitting on airlines may predispose you to leg swelling and deep venous thrombosis It is recommended that you avoid air travel until 6 weeks after your surgery If you must travel wear elasticated stockings and keep your leg elevated as much as possible Please discuss any imminent travel arrangements with your Consultant

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Showering A shower usually has a small step and so care should be taken getting in and out If you only have a bath it is not recommended to use this until a safe period after the removal of the stitches staples Wound Care You will leave the hospital with a simple surgical wound Before leaving the hospital your dressing will be changed and the wound site checked Keep the wound dressing clean and leave the dressing in place for 7 10 days unless indicated otherwise by the nursing staff or consultant When changing the dressing it can be removed after showering Use a clean towel to dry the skin around the wound gently and apply a fresh dressing Ensure your knee is bent as the fresh dressing is applied Signs of Infection Infection may occur despite your best efforts If any of the symptoms below occur then you will need to see your GP or liaise with the Beacon Centre for Orthopaedics for advice and possibly a course of antibiotics The signs of infection include Redness around the wound site Increased pain in the wound Swelling around the wound Heat at the wound site Discharge of fluid may be green or yellow Odour or smell from the wound Feeling of being generally unwell Fever or temperature Most people will have sutures stitches or staples that will need to be removed approximately 10 14 days after surgery This may be done by the GP or in Beacon Centre for Orthopaedics Make sure you receive a copy of the Patient Wound Care Discharge Instructions prior to your discharge Discharge Instructions You will be discharged from hospital on the same day or one day post operatively When you leave the hospital you will be given an appointment to see the consultant usually 2 6 weeks after the operation You will be advised to attend outpatient physiotherapy within one week of discharge as stated above You can either attend a Physiotherapist at Beacon Hospital or a Physiotherapist more local to your home The phone number for Beacon Hospital Physiotherapy Department on 01 293 6692

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Physiotherapy PRE OP PHASE Early injury recovery preparation for surgery It is usually recommended that you take some time to allow your knee injury to settle before undergoing ACL reconstruction This time is important to reduce swelling and regain your knee s range of motion and strength Research has shown that those who achieve full range of motion symmetrical quadriceps and hamstring strength injured vs non injured leg and minimal swelling have better outcomes post surgery than those who don t This phase post injury and pre surgery is termed the Pre op Phase Included in this phase is regular ice application to the knee range of motion exercises low impact activities such as cycling and progressive strengthening exercises As your knee improves clinically your Physiotherapist may progress your exercise regime to include weighted exercises in the gym and even hopping and landing drills The frequency of your exercises will be guided by your Physiotherapist Sports or physical activities requiring running and change of direction type movements should be avoided during this time Important goals for this phase are Eliminate swelling Regain full range of motion in particular knee extension Regain 90 strength in the quadriceps and hamstring muscles compared to uninjured side Achieve 90 of the uninjured leg on functional testing Post operative Physiotherapy Post operative physiotherapy can begin the day of your surgery Depending on your rehabilitation goals it may continue up to and beyond 12 months On the day of your ACL reconstruction your Physiotherapist will teach you how to use crutches and complete the recommended exercises for the first phase of your rehab You can start these the day of your surgery Your Physiotherapist will advise you of how often you should do your exercises In order to continue to strengthen and progress regular ACL focused exercise is required Your Physiotherapist can guide you through this In addition regular reviews at Beacon Hospital are recommended throughout your rehabilitation journey Your exercise program will be ever changing to continue to challenge your knee and whole body in line with your specific goals As you progress through your rehab journey use knee pain and swelling as a guide If either or both are increasing your knee or body may not be ready for what you are asking it to do

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Depending on the nature of your ACL reconstruction you may be required to wear a hinged knee brace for a period of time after surgery Braces are worn to give added protection to the reconstructed ACL after surgery ACL reconstructions may require brace protection if there has been a Meniscal Cartilage repair completed during surgery or if your Consultant has decided to use a particular method of ACL reconstruction that requires brace protection Your Consultant will discuss this with you prior to your surgery Wearing a hinged knee brace may alter your post operative rehabilitation in the short term Your post operative Physiotherapy can be altered to suit and will be guided by your Physiotherapist IMMEDIATE POST OPERATIVE PHASE Frequency You will need to perform a specific therapeutic exercise programme at least three times a day to ensure you reach your rehabilitation goals These exercises see below will be shown to you during your inpatient stay at Beacon Hospital These should be continued at the frequency outlined until your first Outpatient Physiotherapy appointment We recommend that you see a Chartered Physiotherapist within one week of surgery to check your progress and to progress your exercises Please be sure to read the exercises carefully and ask your Physiotherapist any questions that you may have before you leave the hospital 1 Ankle Pumps Lie on your back bend and straighten your ankles Repeat 20 times 2 Static Quads Lie on your back with your legs straight Bend your ankle towards you and push your knees down firmly against the bed Hold for 5 seconds and then relax fully Repeat 10 15 times

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3 Straight Leg Raise Lie on your back with the operated leg straight Pull your toes up towards you straighten the knee and lift the leg 20cm off the bed Hold for 5 seconds then relax and slowly lower the leg to the start position Repeat 10 15 times 4 Knee Bends Lie on your back Bend and straighten your operated leg when keeping your heel on the bed Aim to increase the range daily Repeat 15 times To progress use a band to assist the stretch Hold for 5 seconds x 10 times This exercise may be amended excluded if a hinged knee brace is fitted after surgery 5 Static Hamstring Contraction Lie with your affected leg bent to 20 degrees Push your heel down into the bed contracting your hamstring muscle hold for 5 seconds before relaxing fully Repeat 10 15 reps This exercise may be amended excluded if a hinged knee brace is fitted after surgery

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6 Seated Calf Stretch Lie with your leg straight out in front of you and place a band around your foot Pull your toes up towards you use the band to increase the stretch in your calf muscle Hold for 30 seconds repeat x 1 repetition 7 Knee Cap Patellar Mobilisations Lie with a pillow under your knee and the leg relaxed Move the knee cap from side to side gently for 2 3 minutes Move the knee cap up and down gently for 2 3 minutes

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Stairs Lead with your non operated limb good leg when climbing stairs Step up with the operated leg then bring crutches up onto the step Go one step at a time until instructed otherwise by your Physiotherapist Below is a rough recommendation of when you should be attending your Physiotherapist This can be with your own Physiotherapist or here at Beacon Hospital Where Isokinetic and appropriate Strength Power testing are not available locally we recommend attending Beacon Physiotherapy in order to perform these tests at the time points stated below This provides very valuable information on your progression and areas of weakness that will need to be improved upon in your rehabilitation It is important to realise that return to sport after ACL reconstruction should be criteria based rather than time based That means that you should be meeting the specific goals of a given phase of rehabilitation before progressing to the next phase regardless of the time since surgery Your Rehabilitation Goals Post Surgery PHASE 1 WEEK 0 2 APPROXIMATELY Following your surgery it is best to let your knee settle down for the first 1 2 weeks You can apply ice and compression complete basic activation and range of movement drills which your Physiotherapist will go through with you during your inpatient stay as above The main goals are to decrease your swelling and pain regain range of movement a normal walking pattern and achieve good quadriceps activation Research has shown that swelling and pain can limit quadriceps activation and that asymmetrical walking pattern may be associated with quadriceps weakness Important goals of this phase are Knee range of motion 0 110 degrees Minimal swelling effusion less than 1 cm in the difference between knees Being able to lift your leg straight off the bed and hold it for 5 seconds Comfortable walking without crutches at 2 3 weeks post surgery PHASE 2 WEEK 2 6 APPROXIMATELY As you progress through the next phases of your rehabilitation your knee and body will be challenged more You will begin to build muscle strength and focus on balance Developing good technique and movement patterns are essential in these phases Again it is important to use pain and swelling as a guide Your Physiotherapist will help you monitor performance and the quality of your rehabilitation program as you progress

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Important goals of this phase are Full Knee Range of Motion Normal Stairs walking Normal gait pattern Restore Functional Movement Patterns e g squat lunge PHASE 3 WEEK 6 12 APPROXIMATELY As your knee leg and body gets stronger you may be able to progress to higher level single leg strength exercises This changes the focus somewhat toward the injured leg exclusively particularly aiming to improve its strength and movement patterns to prepare for more advanced rehabilitation in later phases Important goals of this phase are Quadriceps Strength 4 5 Oxford Scale Single leg Press your body weight Star Excursion Balance Test 95 of opposite side PHASE 4 WEEK 12 24 APPROXIMATELY During this phase of rehabilitation exercises generally become more dynamic and begin to include plyometrics provided you meet the criteria required These are high level strength power exercises which focus on fast activation of the leg muscles and explosive movements It is fundamentally important that you have built up enough strength to commence these exercises as higher level exercises such as plyometrics do present more risk if you are not adequately prepared During this phase we can assess your lower limb strength accurately at Beacon Physiotherapy using Isokinetic testing to determine your suitability for plyometric training This is a strength test which uses dynamometry to quantify the level of strength of your quadriceps and hamstrings at different speeds of movement and allows side to side comparisons We can also begin to look at your lower limb power through functional tests such as single leg hop or counter movement jump At this stage you may be able to return to jogging and straight line running if testing suggests that you are ready to do so Important goals of this phase are Isokinetic strength 75 80 of uninjured leg minimum required for jogging Single leg Press 1 5 times your body weight Pain free hopping Functional test scores 75 of uninjured side PHASE 5 END STAGE REHABILITATION 6 MONTHS ONWARDS End stage rehabilitation and return to sport rehabilitation focuses mainly on moving from restricted to unrestricted training and match play It should incorporate high level exercises that may include ongoing neuromuscular retraining and movement pattern training i e retraining how you move In this phase rehabilitation moves away from the injured knee and focuses on the whole body By implementing progressive return to play

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programs and repeating the positions required of you in your sport with good technique you can regain the confidence to participate as you did before Return to play rehabilitation usually happens between 9 12 months post surgery You should be guided by your Surgeon and Physiotherapist here as different advice may be given The evidence suggests that the ACL graft does not reach full maturity or strength until at least 12 months post surgery So returning to play after 12 months can significantly reduce your re injury risk However the most important thing at this stage of your rehabilitation is to fulfil the rehabilitation criteria fully see below not the amount of time passed since surgery Important Goals of this Phase are 90 of uninjured leg Displaying sound landing mechanics This is ensuring that your knee moves well when you land and avoids moving into positions which may increase the risk of re injury Displaying good agility which can be tested using field based tests

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PHASE 6 MAINTENANCE PREVENTION OF RE INJURY Once you have satisfied the criteria laid out by your Physiotherapist a neuromuscular re training and injury prevention program should be implemented and adhered to for you to maintain the gains you have made in rehabilitation This should include a 10 15 minute program including strength balance and plyometric exercises which should be implemented prior to all training and matches It is recommended that athletes continue with this on their return to sport in order to prevent risk of re injury Some well researched injury prevention programs are available online such as the FIFA 11 Warm up GAA 15 Warm up Your Rehabilitation Goals Post Surgery Below is a brief summary of your potential rehabilitation pathway This will vary from patient to patient and will depend on where you are attending for Physiotherapy Pre op 1 2 Reviews with Beacon Hospital Physiotherapy or your local Physiotherapist Phase 1 week 0 2 Review with Beacon Hospital Physiotherapy or your local Physiotherapist within 1 week of surgery Consultant Nurse review for removal of sutures Phase 2 week 2 6 1 2 Physiotherapy reviews during this time Phase 3 week 6 12 1 2 Physiotherapy Reviews during this time Phase 4 week 12 24 Consultant review approximately 16 18 weeks post surgery with Isokinetic Functional Strength testing at Beacon Hospital once cleared by Consultant 2 3 Physiotherapy Reviews during this time Phase 5 Week 24 52 3 6 Physiotherapy Reviews during this time Possible Consultant Review at 8 9 months post surgery to assess progress Isokinetic Functional Strength testing at Beacon Hospital recommended at approximately 8 9 months post surgery and again prior to return to sport at approximately 12 months post surgery if required

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ACL RSI Cincinnati Knee Score 10 5 Test Lateral Hop Single Leg Hop Unilateral CMJ CMJ Q H Ratio Hamstrings 300 s Quadriceps 300 s Hamstrings 180 s Quadriceps 180 s Hamstrings 60 s Quadriceps 60 s RIGHT LEFT TEST 1 4 MONTHS RIGHT LEFT TEST 2 8 MONTHS RIGHT LEFT TEST 3 12 MONTHS COMMENT

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CONTACT Orthopaedic Unit 01 293 8687 01 293 6602 Beacon Centre for Orthopaedics 01 293 7575 Physiotherapy Department 01 293 6692 Beacon Hospital Sandyford Dublin 18 D18 AK68 Tel 01 293 6600 www beaconhospital ie Version 1 03 2021