Physio and the therapist – Clutch

You will hear this along the way many times, the surgery is the easy part of reconstructing your ACL, the tough part is the Physiotherapy. Well, from experience, this is absolutely true.

I have stated this many times during my previous posts, but ensure that your physiotherapy program no later than a week after surgery.  During my first ACL tear, my physiotherapy started a few weeks after surgery and that contributed a lot towards my lack of extension and leg strength, which probably were supplemental reasons behind my second tear.

Having experience this first hand, the first thing I did was arrange my physiotherapy. Wherever you are in the world, make sure that you do enough homework on this. Ask people, physicians or people who have first hand experience. In addition, its vital that they the PT you work with has experience in ACL recoveries  and successful ones at that. ACL physio is very practical and changes from person to person, so you need to have someone who is informed, aware of the limitations that could hinder your physio and able to develop an improvised plan according to your pace in recovery. I have worked with my many PTs, so if this is concerning you, please leave me a comment.

Wherever you conduct your surgery, you will be handed a protocol checklist that the doctor uses to measure your progress. I recommend you carry that with you and give it to your PT, so that he or she are able to cross check your progress according to the checklist prescribed by your doctor.

During physio and depending on the person you work with, there will be different approaches. There will be some basics shared across some of the fundementals, but the improvisation will differ. For instance, so I was getting flexion quite rapidly, my PT was dedicated most of the time firing back my extension and it might be the same or vice versa for you. Whatever it may be, this is time is crucial, so don’t lose your focus.

Over the next four weeks, I recommend 2-3 sessions with your PT, on top of that, you should be repeating the exercise drills you learn there 2-3 daily. This is all you have to do over the next month. I have attached a video that I thought was encouraging for me, watching professional athletes get injured and recovering well enough to pursue their careers. One thing being common, determination.

Oh, build a close relationship with this PT, cause you are going to be in lots of pain and most possibly crying during the first week, so I recommend you get comfortable 🙂

Good luck!

Once you leave the attentive care of nurses…

Pat yourself at the back, you have come a long way. People try to tone down the aggressiveness of an ACL operation, but don’t be fooled, even though its routine, the knee suffers A LOT of trauma and you were a few days not able to stand and now you already are. This is an achievement and an overwhelming feeling.

In the past few days, you were not able to move, so you had a lot of time to think to yourself. Being in surgery is an experience. Your body and mind are not aligned. You want to get up and continue your life, but my dear friend, your physically NOT able to. So you are left with a brain that is offsetting the lack of motion in your body in the depth of thinking. I encourage you to dwell into it, find out more about yourself, ponder, be mesmerized by your body recovery, think of who was there for your during this hardship and who wasn’t, fill your heart with positive energy, there is a new page of life waiting to be scripted the minute you walk out of the hospital door. I know this is slightly off course, but I thought I should open your eyes to any positiveness available to you when your movement is limited.

Once you leave the hospital, you are now more in charge of the tempo of your recovery. That being said, you are not being babysat by nurses anymore, you need to be disciplined and you need to initiate this state of mind immediately, as your next 6 months are going to depend on it. You have certain protocols to achieve in the first week.

One of the most common complications following ACL reconstruction is loss
of range of motion, especially loss of extension. Loss of knee extension has been shown to result in a limp,quadriceps muscle weakness, and anterior knee pain. EXTENSION is your holy word here, frame it on your wall if you had to.
 
Range of motion – One of the most common postoperative complications following ACL reconstruction is loss of range of motion, particularly loss of knee extension. 

Biomechanically, loss of knee extension range of motion has some fairly serious implications.  In addition to increased patellofemoral issues and potential wear and tear to the articular cartilage, loss of knee extension creates an environment that does not allow the knee to lock into the “screw home” mechanism.  In turn, you can’t lock out your knee and your quadriceps has to fire at all times to stabilize the knee.  Over time, these patients tend to struggle with quadriceps strength gains and return to functional activities.

My thoughts on the below:

Crutches – Stick to your crutches. You need to minimize any pressure on your injured knee. USE BOTH CRUTCHES!

 
Knee brace –  depending on your doctor, you might be advised on wearing one. Some believe in it and some don’t. If you do get, make sure you buy a very good brace, so don’t be stingy on this investment, its worth comforting yourself knowing you have a stable knee.
 
Your goals Week 1:
 
* Control pain and swelling – Ice your knee as much as possible. The cold effect might annoy you at first, but trust me, you will start to enjoy it. Do it while watching TV so you are distracted. I would recommend 3 times, for 20mins each time.
 
* Care for the knee and dressing – The most annoying element to watch out. Sadly, you can’t freely shower as you need to keep the dressing on your stitches dry. I used to shower by wrapping plastic bags around my knee and if they got soggy, I immediately changed them. You can’t take the chance of causing an infection to your wound, so becareful and don’t be careless.
 
* Early range of motion exercises  and Achieve and maintain full passive extension – This is all going to be done during physio in different aggressive ways, but while at home , you should do the following, so please check the link below
Hope this is useful. Please remember, the first week is very important, so don’t get lazy on it and make sure you hit your protcols. Leave me a comment if you have any questions.

The first few days after surgery

It is safe to say that once you open your eyes after surgery, you will feel a sense of victory. Before that sensation arrives, prepare yourself to answer some common questions. Right after surgery, you will be carried away to the recovery room where there are plenty of people waking up from the effects of anesthesia. To make sure your sobering up, you will be asked your name,age and other general question.

The drugs in your system will be dragging your head back every time you feel like you got your sensors activated again. I for one, enjoy that feeling and I’m sure you have heard endless stories about how fantastic morphine feels 🙂 If you are one of them, enjoy the ride and stay away from people who will be looking to get the truth from you, you are the perfect victim!

For the ones not comfortable with the feeling of being light headed, don’t panic, it will fade away shortly. As the drugs star wearing off, you will start feeling the aftermath of the surgical instruments that invaded your leg. This feeling is not pain, rather discomfort either caused by the tight dressing covering your thigh all the way to your ankle or by sensation of the cutting/drilling that took place. Distract yourself and don’t think of it, as they will remove the dressing first thing the next morning and the general feeling of the post surgery will disappear day by day. To make this easier, you will be provided with painkillers throughout the day and most of the time, they work.

Usually after surgery, you will have trouble going to the toilet. Your bladder is going to be full that it feels like your going to explode. Again, don’t panic if you are not able to release yourself cause your mentally not comfortable urinating in a empty bottle. My advice here is call someone and ask them to open the water taps, the sound of water rushing down will help you psychologically. Believe me, it works!

You should be sleeping as much as possible during the first few days, but during the time your awake, make sure your still. First thing in the morning the nurses will be coming in to open up your dressing which will be a relief. The doctors will come in to ensure everything is in order and will explain to you the surgery and what took place. They will declare their satisfaction with the tunnels created, the graft being double band vs triple band, etc. Ask as many questions here cause you will mostly likely see them the next day.

Good doctors will ensure physiotherapy is instant and I strongly recommend that. The objective here is for the leg to start getting active again. The PT(physiotherapist) will start extending/flexing the leg and as much as it may seem impossible, please be assured that this necessary to maximize your chance in gaining both aspects of extension and flexion as soon as possible. In fact, during the surgery, the doctors will fully extend and flex the leg to ensure success.

To ensure extension, the doctors placed a device that was elevated and by placing your leg there you are forced to extend your leg for long hours, which is the best way to achieve  it.  2013-05-23 19.31.51

Attached is also a photo of what the dressing might look like. 2013-05-23 13.03.58

I wish you the best of luck and before you know it, you will have your freedom and you will love it!

K.

The Surgery

So now, as you have progressed through this blog, you have come to understand the following:

1. How an ACL can possibly tear and is having the surgery a suitable option for you

2. The characteristics of the doctor you choose to consult

3. The type of graft you are going to choose and the pros and cons of each and the importance of graft positioning.

Now that we have covered these areas, the next discussion will revolve around familiarizing you with the surgery and what is expected to take place.

If you have opted to pursue the surgical option, its normal to be nervous and stressed, the most important thing to do is try and relax. ACL reconsruction is now considered routine surgery with some procedures being wrapped up within a couple of hours and sometimes as an out-patient.

That being said, its never nice to be in surgery. Even though this is my second time, I was still anxious. This feeling was compounded on the day of the surgery because I was told the day before that my surgery will be at 11am. So when I reached at 7am to check in(giving myself time to prepare mentally), I imagined I was going to listen to something soothing, crack jokes with some friends and get some parental support before surgery. This did not happen. At 7:10,  and in that stereotypical German efficiency, I had a few nurses come into my room and placed the dreadful surgery clothing on the bed and told me to get ready, as ” we are ready for your downstairs”. I tried to fightback with the fact that I was told it was at 11, but that debate didn’t last long, cause since I was physically there, there is no reason to wait.

Being in a rush rush, I never got the time to sooth myself and didnt get time in with my supportive family who were still on their way to the hospital, I had no option but to take my mind of things by opening conversations with nurses and medical team preparing me for the surgery. My advice here, whether you were able to relax before the surgery or not, befriend every person you meet until you are put under the anasthesia. I found their calmness  very soothing, especially how composed they were considering they are about to perform surgery. If your curious like me, then you will be extremely impressed and you will be wishing one of your children will one day be a surgeon for it is truly a remarkable skill.

The day of, or the day before the surgery you will speak to your Doctors again. You will probably be having another look at the MRI, CT, X ray and any other possible scan already requested. They will ask you for blood samples and go through a series of questions to ensure that the anaesthesia is not a risk to you.

Below there are links of the surgery, both patellar and hamstring graft(animation) of you are interested. It will give you an idea of what mostly takes place. Please do not be phased, its really not that gruesome 🙂

Patellar graft animation surgery

Hamstring graft animination surgery

Until the next post, good luck.

Graft Positioning and how crucial it is.

Now that you are aware of what kind of graft you are going to be using, whether it is hamstring, patellar or an allograft, the next important thing to highlight is the positioning of the graft.

This is an issue that I was completely unaware of when I conducted my first surgery and the poor positioning of the graft is the main reason behind my second rupture. Based on endless conversations with Doctors and reading plenty of material online, its seems to me that the main culprit behind a revision ACL surgery is caused by the misplacement of the chosen graft.

Naturally, your ACL is at an angle and looks like this. Where as, in the case of many, an ACL graft can be misplaced with the tunnels created being more vertical.

During my first year post op, and even after my intensive 6 month rehab, I was lacking confidence in the well being of my modified knee. Sometimes it was a matter of stability, sometimes it was joint pain and sometimes I would subconsciously catch myself brushing my teeth and all my pressure is on my better leg.  As a result of this insecurity, I decided to visit another doctor, different than the one that operated on me. Upon his request of performing MRI scans, he was able to see that the reconstructed ligament is intact and looks good enough, but his recommendation was to see X rays as well.At first, I thought that was unusual, thinking that MRI scans show everything, but to my ignorance, it turned out that the X ray are more crucial after performing surgery and here’s why.  The x rays will be able to image the actual tunnels that were created after drilling your femur and tibia. These tunnels act as your poles that hold the new ligament between your knee.

It seemed after all, that even though the doctor who performed my surgery did a decent job, the positioning was too vertical( outdated method) which is not the direction your ligament is born in you. You are born with a ligament that is positioned with an angle, which gives it that range of motion, fixation and flexbility needed to recover the maximum possible from your operated knee.

Now that I have brought some light to this issue, please ensure to have this discussion with surgeon to understand the graft positioning and the size of the tunnels being drilled.

ACL Reconstruction – What are they doing to me exactly?

In my previous post, I highlighted the importance of doing your own research in the essence of making the best of your consultation with your doctor, which will the only assessment you have before choosing the doctor you are going to go with.

If this is your first ACL reconstruction operation, you might be wondering what exactly does reconstruction actually mean. My sesame street description of this as follows:

When you tear your ACL completely( and I say completely cause there are some cases when the ligament can be 50% torn and the surgeon might have other options), naturally, you  cannot stitch these loose ends together again. The only option is to completely replace it with another ‘wannabe’ ligament called a graft, which either can come from your own body or from a donor. There are 3 options that you could choose from, all with their own set of pros and cons.

The choices you will have, in accordance with your doctor’s advice, will depend on factors such as your record in physical setbacks, age, and activity participation level going forward. These are your options:

Hamstring Graft – The hamstring muscles are the group of muscles on the back of your thigh. When the hamstring tendons are used in ACL surgery, two of the tendons of these muscles are removed, and “bundled” together to create a new AC.

Pros

–       Hamstring autografts generally have the least post-operative pain associated with it.

–       Easier rehabilitation in regards to quadriceps activation occurs.

–       Most patients have a quicker return to Activities of Daily Living (ADLs).

–       The incision used to harvest the hamstring graft(s) is the same incision used to drill and place the fixation hardware.

Cons

–       The fixation is not as strong initially so caution is advised with rehabilitation.

–       General hamstring weakness is noted.

–       Return to full athletic participation is generally slower, usually 6-7 months.

–       There is no hamstring activation for at least the first four weeks in order to allow the harvest site to scar and heal down.

–       There is an increase incidence of hamstring strain / tenderness.

Pateller Tendon Graft – The patellar tendon is the structure on the front of your knee that connects the kneecap (patella) to the shin bone (tibia). The patellar tendon averages between 25 to 30 mm in width. When a patellar tendon graft is taken, the central 1/3 of the patellar tendon is removed (about 9 or 10 mm) along with a block of bone at the sites of attachment on the kneecap and tibia.

Pros

–       A bone-patellar tendon-bone autograft is one of the strongest grafts concerning the initial fixation.  This is due to the fact that there is bone on each end of the graft that is going into a tunnel in the bone.

–       Physicians have the most experience with using this type of graft.

–       Return to full athletic participation is typically quicker, usually within 5-6 months

Cons

–       B-PT-B autografts are generally the most painful of the grafts post-operatively because harvesting the middle third of the patellar tendon along with a bone fragment from the distal pole of the patella and the tibia tubercle.

–       Has an increased chance for patellar tendonitis.

–       Because of the bone fragment harvested from the distal pole of the patella, there is an increased chance for a patella fracture.

–       Initial rehabilitation / activation of quadriceps is more difficult because one third of the connective tissue allowing for quadriceps activation is removed and used.

–       There is an increased incidence of patellar tendon pain and discomfort with kneeling.

–       There is an extra incision where the graft is harvested from.

Allograft –  Most commonly used in lower demand patients, or patients who are undergoing revision ACL surgery (when an ACL reconstruction fails). Biomechanical studies show that allograft (donor tissue from a cadaver) is not as strong as a patient’s own tissue (auto graft). For many patients, however, the strength of the reconstructed ACL using an allograft is sufficient for their demands. Therefore this may be an excellent option for patients not planning to participate in high-demand sports (e.g. soccer, basketball, etc.).

Pros

–       No harvest morbidity occurs because the graft is donor tissue.

–       Allow for the fastest return to Activities of Daily Living (ADLs).

–       Allografts are the least painful post-operatively.

–       Allows for a smaller incision on the medial tibia.

Cons

–       Potential risk of viral transmission (HIV, hepatitis).  The chance of HIV infection from donor graft tissue is 1 in 1.8 million.

–       Return to full athletic activities is generally within 6-7 months.

–       Though small, there is a chance for some type viral transmission.  As with any surgical procedure, that chance is there.  There are also other risks involved with any surgical procedure.  Dr. Lowe or his representative will discuss those risks with you.

In 2010, after my first encounter with ACL tears, I honestly was not given an option from the doctor, but also because I was not educated enough on the injury for me to realize what other choices I may have had.  In any case, my first surgery was performed using a hamstring tendon. It survived for two years. I was back to my normal sports activity and I felt secured with it. Since they take a piece of your hamstrings tendon, you must be sure that you need to strengthen your hamstring after your operation cause it’s now minus some artillery.  I felt some pain in it sometimes, if I was performing hamstring focused exercises but nothing out of the ordinary.

Now that I have summarized your options on your graft selection, there are still a lot of bits of pieces that you need to know, regarding the graft positioning and the complications that may arise in your surgery if this is indeed a revision surgery.

See you in the next post.

Adios.