The aim of this information is to improve your understanding of thereconstruction of your Anterior Cruciate Ligament (ACL) and Postero-LateralCorner(PLC)andtherehabilitationinvolved.

Thekneejointliesbetweenyourfemur(thighbone)andtibia(shinbone).Therearefourmainligamentsaroundtheknee:

§ MedialCollateralLigament(MCL)ontheinsideofyourkneeandLateralCollateral Ligament (LCL) on the outside of your knee both preventexcessivesidewaysmovementoftheknee.

§ The Anterior Cruciate Ligament (ACL) and Posterior Cruciate Ligament

(PCL) lie deep inside the knee and limit excessive forwards andbackwardsmovement of the knee. Themain function is to stabilise theknee during rotational movements such as, twisting, turning andsidestepping.

PatientInformationAndRehabilitationGuidelinesFollowingAnteriorCruciateLigamentReconstructionandPostero-LateralCornerReconstruction

Anatomy

OutofalltheligamentsinthekneetheACLismostlikelytobeinjuredinanon-contacttwistingmovement.A tearingorpoppingsensation is frequentlyreportedat the timeof injuryandimmediateswellingiscommon.TheACLplaysanimportantroleinbalance.Whenitistorn,itisunabletohealandtheinformationitcarriesislost.Researchhasfoundthatbalancecanbeimprovedwithspecificexercises.However,whenthese exercises are inadequate, reconstruction of the ACL may becomenecessary.Thereare2smaller ligamentousstructureswhichactas reinforcements to thejointcapsuleandrestrictrotationalforces.Theseare:

§ Thepostero-lateralcorner(PLC)§ Thepostero-medialcorner(PMC)

ThePLC ismadeupofmultiple ligamentswhichhelp tostabilise thekneeandstopexcessiverotation.Injuries to the PLC are often associated with other knee ligament injuries,especiallytheposteriorcruciateligamentoranteriorcruciateligament(ACL).Themost commonway of injuring the PLC is from either twisting or a directblowfromthe frontof theknee. Insomecases,damagetothenerve(CommonPeronealNerve)mayoccurasaresultoftheinjury(16%-40%inliterature).Injuries to the joint surfaces (articular cartilage) or menisci (footballer’scartilage/shockabsorbers)canalsohappenatthesametime.

Whilst it is very common to injure one of the four major ligaments, it is lesscommontoinjuremultipleligamentsduringthesameincident.Whenthisoccursitiscalledkneedislocationandmayrequireextensivesurgerytoreconstructthedamagedligaments.

The surgery is designed to help patients return to their normal functionalactivitiesand,possibly,sportingactivities.Itshouldhelptostabiliseyourkneeandstoptheknee frombucklingorgivingway.However,resultscanbeunpredictable,especiallywhenmoreligamentsareinvolved.A recently published report showed all patients returned to pre-injuryemploymentand23outof25(92%)returnedtosports,althoughnotnecessarilytothesamelevel.Reconstructedligamentscannevertotallyreplacethefullfunctionoftheoriginalligament, and therefore, approximately 12 months of rehabilitation is neededfollowingsurgerytogetthebestpossibleoutcome.‘Wear and tear’ arthritis is associated with ligament injuries and is notnecessarilypreventedbyreconstructionsurgery.

Theoperationtoreconstruct the ligaments involvesreplacingthemwithgraftstakenfromtissuesaroundtheknee.Inseverecases,graftsfrombothlegsmayberequired.Theonescommonlyusedarethepatellatendonand/orthehamstringtendons.Bothsetsoftendonsareequallystrongandgivesimilarlong-termresults.Theincisionswillbeeither5cmatthefrontontheinsideofthekneeand10cmatthebackontheoutsideofthekneeor15cmatthefrontoftheknee.Ascarontheoppositekneemaybemadeifgraftsareneededfromthatsidealso.Thesurgeryisdoneundergeneralanaestheticandcantakebetween1.5-2hours.Ifanyotherstructureshavebeendamaged,forexample,meniscalcartilage,thenitisusuallydealtwithatthesametime.Thismayhowever,onlybeapparentatthetimeofsurgery.

AimoftheOperation

TheProcedure

Tunnelsaremadeinthetibiaandfemurandthegraftsarepassedintotheknee.Theyaresecuredwithscrewsorbuttons.Thesematerialsdonotusuallyneedtobe removed unless causing problems. This could be done at aminimumof 12monthsaftersurgery.If the knee is very inflamed during examination in theatre, the ligamentreconstructionmayneed tobedelayed toavoidexcessive stiffnessafterwards.Thiswouldmeanasecondsurgerywouldberequiredwhen thekneewas lessinflamed.

Complications can occur. Some are minor but others may require furthersurgery.Itisimportantyouunderstandtherisksbeforeundertakingthesurgery.Examplesinclude:Complication Recordedin

literatureProfessorMcNicholas’cases

DeepVeinThrombosis(clotinthecalf)

10%

1.5%

GraftfailureofthePLC

Notrecorded 1%

GraftfailureoftheACL

Notrecorded 2.5%

Septicarthritis(infectioninjoint)

5-7% 0%

Superficialwoundinfection 5-17% 8% Complexregionalpainsyndrome(anabnormalpainreactiontosurgery)

0% 3%

Arthrofibrosis(kneejointstiffness)

5-15% 5%

Furthersurgerytocartilage

6% 8%

Removalofmetalwork

15-18% 16%

Othersurgery 4.5% 8%

Jointreplacement

Notrecorded 3%

Patellafracture

Notrecorded 1.5%

Heterotopicossification(abnormalbonegrowth) 17% 0%

Nerveinjuryduringsurgery(commonperoneal) 6% 0%

Skinflapnecrosis Notrecorded 1%

Complications

Any surgical intervention can theoretically result in mortality (death), it isextremelyrareforthistohappenforthisprocedurebutrecentlegalrulingshavemandatedthisbementioned.

Rehabilitation can begin before surgery. It is important you have full range ofmovementandgoodquadricepsandhamstringstrength.Itisimportantyouworkalongsidethephysiotherapisttorehabilitateyourknee.The surgery will be unsuccessful without a properly supervised exerciseprogramme.Itisimportantyouareawareofyourcontributiontorehabilitationandpreparedtofollowaprogrammeupto12monthsafterthesurgeryinordertoobtainthebestresults.Itmaytakeupto12monthstoreturntosport.Therearerestrictionsintheamountofweightthatcanbeputthroughyourlegand a degree of bend and straightening you can perform after the operation.Initially, exerciseswill aim togradually increase the rangeofmovement in thekneejointandreducepainandswelling.Thisprogressestotrainingmuscularendurance,functionalstrengthandbalance.The exercises are designed to maintain muscle strength as much as possiblewithoutplacingunnecessarystressesonthehealinggraftswhichrequiretimetoheal.Lateronintheprogramme,theexercisesaretailoredtowardsareturntoyourchosensport(s).Timescales0-6weeksAfter surgery your legwill be placed in a long lever bracewhich needs to beworn 24 hours a day. It is only to be removed for bathing (when thewoundshavehealed).Whenbathing,asupportmustbeplacedunderthekneetostopitfromfullystraightening.Greatcaremustbetakenwhengettinginandoutofthebathandthebracemustbethelastthingtobetakenoffandthefirstthingtobeputbackonafteryourbath.Thisbracewillrestrictyourlegbendbetween10and90degrees.Youwillnotbeabletostraightenyourkneefully.Thiswillhelptheligamentshealandreducesthestressonthemetalworkthatisholdingthegraftsinplace.Forthesamereasons,youarenotallowedtoputanyweightthroughtheleg.6-12weeks

Rehabilitation

Thebracewillbeopenedto0°-120°.Yourkneewillbestiffanditishardworktogetthekneetofullybendandstraighten.Thebracemuststillbeworn24hoursadaybutcanberemovedforexercises,onlywhenitstartstolimitthekneebending.Itisthenreplacedforallotherkneeexercises.You are now allowed to put some, but not all, of yourweight through the legwhilstusingthecrutches.12weeksonwardsYour legwillprobably look thinnerwhencomparedwith theother leg.This isduetothelackofusewhichcausesmusclewasting.Youcannowwalkwithoutthecrutchesbutyoumuststillwearthebraceuntilyourmusclesgetstronger.Atnight,thebracedoesnotneedtobewornandyoucanslowlyweanyourselfoffthebraceoverthecomingweeks.Thiswillhappengraduallyasyourleggetsstrongerandyoubecomemoreconfidentwithyourdailyactivities.

Anassessmentof your fitness toundergo surgery includingadetailedmedicalhistory, height, weight, blood pressure and pulse will be performed beforesurgery.Bloodtestsandahearttrace(ECG)mayalsobeneeded.

You are asked not to drink or eat anything for at least 6 hours before youroperation.YouwillbeseenbyyourAnaesthetistandamemberofthesurgicalteambeforeyouroperation.In the anaesthetic room, youwill have aneedleput into your armandwill beplacedonananaestheticmachine.Surgeryusuallytakesaround1.5-2hours.Youwillwake-upinthetheatrerecoveryroom.Onreturntothewardyouwillhavethefollowing:

§ Dressings–woolandcrepebandageonthekneeandabracetolimitknee

Pre-operativeAssessment

TheDayoftheOperation

movement.§ Dripsanddrains–theremaybesmalltubesinthebackofyourhand.You

mightalsohaveatubeintoyourbladder(catheter).§ Analgesia– thismaybeoralmedicationorpatient controlled analgesia

(PCA),whichlookssimilartoadrip.

Exercisesaretocommenceassoonasyouareabletoasthisaidscirculationandhelpsreducebloodclotformation.Exercises include vigorous movement of toes and ankles, quadriceps andhamstringtighteningandgentlekneebends.Post-op–Day1

§ Dressingsremovedandcleanonesapplied§ Drainsremoved§ Bloodthinninginjection(Clexane,Deltaparinorother)for14days§ Yourlegmaybeplacedonamachinewhichhelpstobendandstraighten

yourknee(CPM)§ Continuewith exercises and increase kneebendingwithin thebraceby

usingaslideboard/towelandabandaroundfoot.Addstraightlegraiseandkneestraighteningasbraceallows

§ Mobilisewithcrutchestakingnoweightthroughtheoperatedleg§ Youmustavoidactiveexerciseswith the legoff the floor from30°knee

bendtofullystraightforthefirst6weeks§ Youshouldbegivenaphysiotherapyoutpatientappointment§ You can be discharged from hospital if progressing well, managing the

exercises,followingtheprecautionsandsafeonthestairsDischargeInstructions

§ Thewoundmust be keptdryuntil healed and thedressing is not to bedisturbedunlesssoiledandacleanoneapplied

§ You will be given pain relieving medications to take home with you.Pleasetaketheseasprescribedtopreventpainbuildinguptoalevelthatishardtocontrol

§ Regulariceapplication(10-15minutesevery1-2hours).Placetheiceinacold,wetflanneltoreducetheriskofskinirritation

§ Physiotherapyappointmentisarranged§ Expectbruisinginthethighandlowerleg§ Remember your scar is highly susceptible to the sun, and use of high

factorsunblockisadvised

Return toworkwilldependgreatlyonthejobthatyoudo(desk-basedjobs6weeks;manualjobs6months;jobsrequiringladdersetc.9-12months).Returntodrivingat12-16weeksformanualgearedcarsandautomaticcarsifit is the right leg that has been operated on. If it is the left leg that has beenoperatedon,youmaydriveanautomatic caronce thewoundsarehealedat2weeks.You should notify your insurance company of the procedure that has beenundertakentoensurethatyourcoverisvalid.Forfurtherinformationfollowthisweblink:https://www.gov.uk/driving-medical-conditionsFlying is not permitted for 8weeks following surgery due to a higher risk ofdevelopingabloodclot.Forfurtherinformationfollowtheweblinkbelow:http://www.nhs.uk/chq/Pages/2615.aspx?C%20ategoryID=69

You will be seen regularly post-operatively (3, 6, 12 months, 2, 5, 10 and 15years).Yourkneewillbeexaminedandquestionnairescompleted.ThisdatawillbeprovidedtotheNationalLigamentRegistry:http://www.uknlr.co.uk/patient-information/Wemonitorresultsofthissurgerytoprovideinformationonourperformance.Wewouldbegratefulforyourco-operationtoenableustofurtherimproveourkneeservice.If you changeaddress in the future couldyouplease informus so thatwe cancontinueyourpostsurgeryfollow-up.

Day 1 post-operatively, youwill be given a physiotherapy appointmentwhichyoushouldattendinordertogetthebestpossibleoutcomeandalistofexercisesthatcanbedoneinthefirst6weeks.Afterattendingyour individualphysiotherapy trainingprogramme,youwillbetransferred to the Lower Limb Gym. This usually takes place between 8-12weeks post-operatively depending on your progression. The gym sessions areindividuallytailoredandwillbehardwork.

GeneralAdvice

Long-termfollowup

Rehabilitation(Physiotherapy)Programme

Mostoftheexercisesgiventoyoucanbeperformedathome.Youwillattendthegym session once a week but it is important you continue with these dailyexercises.Itcanbeusefultoputiceonyourkneefor10-15minutesattheendofexercisesessions.The following exercises are to be performed daily. They have been split intostagesdependingonthe lengthof timesinceyouroperation.Whenperformed,allexercisesshouldbepainfreeoruncomfortable(atthemost).Unless instructed by your physiotherapist, all exercises should be performedwith the knee brace in place. If you have any problems, please consult yourphysiotherapist.0-6WeeksTheaimofthisphaseistoregainrangeofmovementasthebraceallows.Kneeswellingshouldstarttoreducealittlebutcanremainuntilthebraceisnolongerrequired.Pain and swelling can be used as a guide to howmuch activity the knee cantolerate.Continuewithpainmedicationasrequiredandkeepthelegelevatedathome.Do not spend toomuch time on your crutches as this canmake the leg swellwhichmakesbendingandstraighteningmoredifficult.Youshouldattendyourphysiotherapyappointmentsregularly.Allexercisesatthisstageshouldbedonenon-weightbearing(bedorchairexercises).Exercises0-6weeks1. Lying on your side supporting yourself on yourelbow. Roll top hip slightly forward, use top arm tosupportyourself infront.Keepingtoplegstraight liftit up towards the ceiling.Make sure the leg stays inlinewith your body and toes point forwards.Repeat20times.

2.Lyingonyoursidewithtoplegbentinfrontof lower legandthe footon the floor.Roll tophip slightly forwards, use top arm to supportyou in front. Lift lower leg cm from the floorkeeping toes pointed forwards. Return to

startingposition.Repeat20times.

3.Sitting,putabandaroundyourfoot.Bendyourkneeas faras possible. Gently pull the band to bend your knee a littlemore. Aim to reach the 90°allowed by the brace. Hold 5seconds.Repeat10times

4.Sitwithlegstraightandrelaxed.Pushyourkneecapfromsidetoside.Hold5seconds.Repeat10times.

5. Lying. Tense your thigh muscles within your brace(quads and hamstrings). Hold for 10 seconds. Repeat 10times.

6.Lyingwithnon-operatedlegbent.Straightenyouroperatedlegasmuchaspossiblewithinthebrace.Raisethe leg10cmandholdfor5-10secs.Repeat10times.

Goalsthatyoushouldaimtoachieve:

§ Improveswelling§ Pain-freerangeofmovementwithinthebrace§ Post-operativepainsettling§ Safelywalkwiththeappropriatewalkingaid,obeyingtherecommended

weightbearingstatus§ Understandyourself-management/monitoringe.g.skincolour,swelling,

temperature§ Managehomeexerciseprogrammeindependently

6-12weeksTheaimofthisstageistograduallystartweightbearingandstrengtheningthewhole leg.Balanceexerciseswill alsobe started.Expectyour leg to lookmuchthinnerandbeveryweak.You should still be wearing the knee brace which will be restricting yourmovementsbetween0-120degrees.

7.Standwiththelegtobestretchedonastool.Flexyourankleandpushtheheeltowardsthestoolkeepingyourkneestraight.Holdfor30 seconds. Then bend your upper body forwards from your hipskeeping your back straight. You should feel the stretching behindyourkneeandthigh.Repeat5times.

8.Sittingonachair,withthelegtobeexercisedsupportedonachair.With brace on, let your leg straighten in this position.Hold10seconds.Repeatx5.

9. Lying on your back with knees bent andfeet on the floor. Lift your pelvis and lowerback off the floor. Hold the position. Lowerdown slowly returning to starting position.Repeat20times.

10. Lying face down with your hips straight and kneestogether.Bendyour kneekeeping your ankle flexed. Youcan do this with an exercise band around your ankle.Repeat20times.

11.Standwithachairforsupport.Pushuponyourtoes.Repeat20times.

12.Standing.Bendonekneeandtakeholdoftheankle.Donotlock the knee of the leg you are standing on. Draw your heeltowardsyourbuttock.Tiltyourhipforwardssothatyourkneepoints towards the floor. Feel the stretch in the front of yourthigh. The brace will allow 120°of bend which should beenough to allow this thigh stretch.Hold30 seconds.Repeat5times.

13.Standinawalkingpositionwithyouroperatedlegstraightbehind you and resting on the floor. The other leg is bent infrontofyouandtakesalltheweight.Takesupportfromawallorchair.Leanyourbodyforwardsanddownuntilyoufeelthestretchinginthecalfofthestraightleg.Holdapproximately30seconds.Repeat5times.

14.Sittingwithyourarmsatyourhips.Standupandthensitdownslowlyonachair.Repeat10-20times.

15. Stand leaning with your back against a wall and your feetabout20cm from thewall. Slowly slidedown thewalluntil yourhips and knees are at right angles. Return to starting position.Repeat10times.

16.Standonyouroperated legusing light fingertipsupport ifneeded.Aimtoholdyourbalancefor30-60seconds.

17.Standinfrontofa20-40cmstep.Stepup10timeswiththeoperatedlegleading.Repeatfor3sets.Thegoalsthatyoushouldaimtoachievebytheendof12weeks(3months)include:

§ Kneebendingandstraighteninggettingclosertotheotherleg§ Muscletonereturningandswellingless§ Fullyweightbearascomfortableonoperatedleg§ Mobilisewithappropriatewalkingaidobeyingtherecommendedweight-

bearingstatus§ Reciprocalpatternwhenusingthestairs

3-6MonthsDuring this phase, muscle strengthening becomes very important, as well asbalance and control activities. Your muscles will get bigger and stronger themoreyouuseitandthekneebraceisgraduallyreduced.You can use the following cardiovascular machines at the gym: Rower, bike,stepperandcross-trainer.Swimmingisallowed,butavoidbreaststrokeinitially.

18.Lyingfacedownonabedwithyourfeetoverthe edge. Let the weight of your feet straightenyourknees.Hold10seconds.Repeat5times.

19.Lyingonyourbackwithoperatedkneebent,otherlegstraight.Liftyourhipsupandhold.Repeat5-10times.

20.Standsidewaysonastepwithonefoothangingovertheedgeofthestep.Slowlybendyourkneeallowingyourotherfoottobrushthefloor.Repeat5timesandrepeatfor3sets.

21.Standononelegonastepfacingdown.Slowlyloweryourselfbybendingyourkneeto30degrees.Returntostartingposition.Repeat5timesfor3sets. Thegoalstoachievebytheendofthe6monthsinclude:

§ Mobilisewithouttheuseofthebrace§ Equalstrengthinalllegmuscles§ Weanedoffbraceasbalanceimprovesandallowequalkneecontrol

6-12monthsAimsRunningandtwistingmovementsareintroducedgradually,buildinguptolightsports if appropriate. Attendance at a gym is encouraged until leg strength isequal.Manualworkshouldbepossibleinthelimitationsoftheoccupation–checkonthisinyourclinicalappointment.Thegoalsthatyoushouldaimtoachievebytheendofthe12monthsare:

§ Legnowreturnedtonearnormalfunction§ Returntonon-contactsport/trainingifappropriate

§ Sport training is progressed to provide a baseline of strength andenduranceforreturntofullsportingactivities

Return to contact sport is recommended when the leg is at least 85% thestrengthoftheother.Thismaytakeaslongas12monthsaftersurgery.

VTEisacollectivetermfortwoconditions:

§ DVT (deepveinthrombosis)–thisisabloodclotmostcommonlyfoundinadeepveinthatblockstheflowofblood.

§ PE(pulmonaryembolism)–apotentialfatalcomplicationwhereabloodclotbreaksfreeandtravelstothelungs.

Whilstyouarelessmobile,especiallyduringthefirstfewweeksfollowingyourprocedure,theriskofVTEishigherbecauseofyourimmobility.ProfessorMcNicholasmayprescribeyouadailyinjectionofClexanetohelpthinyourbloodand these should last approximately14days. If this isneeded, youwillbeshownhowtoinjectthisdrugyourself.Symptoms:

§ Swelling – youwill have some swelling due to your surgery but if youhaveanyconcernspleasecallforadvice

§ Pain–anynewpainwewanttoknowabout§ Calftenderness§ Heatandrednesscomparedwiththeotherleg§ Shortnessofbreath§ Chestpainwhenbreathingin

ThingsyoucandotopreventVTE

§ Movearoundasmuchaspossible.Besensiblethough,shortandregularmovementisbest

§ Drinkplentyofwatertokeepyourselfhydrated§ Westronglyadviseyounot to smoke– thiswillhavebeendiscussed in

preopbutwecanalsoreferyoutooursmokingcessationteamwithintheHospital.

§ Move your ankle around asmuch as possible to keep your calfmusclepumping

Smallpreventativemeasurescanhaveahugeimpactonyourrecovery.

VTE(bloodclots)

Writtenby: MsAHatcher,OrthopaedicPhysiotherapistSpecialist

MrPEllison,OrthopaedicPhysiotherapistSpecialistMrRichardNorris,OrthopaedicPhysiotherapistSpecialistProfessorMJMcNicholas,ConsultantOrthopaedicSurgeon

Editedby: MissFRashid,OrthopaedicRegistrarDatelastreviewed: April2016