This is a general description of the average course of events before, during and after surgery. Reading this carefully may help answer many of your questions, allay some of your fears, and in general, allow you to be a better-informed participant in your care and rehabilitation. Your actual experience may differ slightly depending on your particular injury, physical capabilities, the time of your surgery, and other such circumstances. We do strive to continually update our techniques and protocols, so as to provide you with the safest, most effective and reliable treatment available.
The Week(s) Before Surgery
If you have recently injured your knee (in the past 3 weeks) then this time will be used to allow any swelling or inflammation in your knee to decrease prior to the surgery. An anti-inflammatory medication may be prescribed to help accomplish this. Exercises and/or physical therapy can assist you in regaining full motion in your knee, which is a prerequisite to surgery.
The Night Before Surgery
Arthroscopic surgical reconstruction of the anterior cruciate ligament (ACL) is considered a major surgery. As is standard for all such surgeries, you should have nothing to eat or drink after midnight prior to your surgery. However, if you are required to take a daily prescribed medication, we may have you take the medication with sips of water on the morning of your surgery. If you are on diabetic or heart medication, you should obtain specific instructions from you doctor as to how you should take your medication before and after the surgery. If you smoke cigarettes, we ask you to refrain from smoking, at the very least the night prior to your surgery. Smoking does increase the risks of anesthesia, and can increase complications after surgery. If you routinely drink more than two alcoholic beverages a day, please let us know, as this can affect the amount of medication you may require both during and after your surgery.
The Day of Surgery
The Anesthesiologist and his or her assistant will meet with you to discuss your anesthesia. The surgery is usually done under General Anesthesia (with you "asleep"), however, in some cases Epidural Anesthesia (with you "awake", but sedated) may be offered to you as an alternative. This involves numbing you from the waist down through a needle-thin catheter inserted into your spinal canal in the operating room. Both types of anesthesia work well with this type of surgery and are equally safe and effective.
After the surgery, you will awaken from your anesthesia (if you have had general anesthesia) in the Recovery Room. You will find an Ace bandage on your knee, and a brace on your leg consisting of foam padding, aluminum supports, and Velcro straps. This is designed to keep your knee fully extended (straight). The pillows or blankets used to elevate your leg should be kept under your calf and heel, and not under your knee, to prevent your knee from resting in a bent or flexed position. A specialized cooling wrap will be placed around your knee connected by tubes to a cooler. A small motor circulates ice water through the wrap to cool your knee, helping to decrease pain, swelling and bleeding in the knee. There is a temperature gauge and control attached to the unit that should be adjusted to keep the temperature at about 45 degrees Fahrenheit (between 40 and 50). If your insurance approves it, a pain pump catheter will be placed into your knee. This will allow for numbing medicine to be automatically introduced into your knee.
On the day of surgery, you will be able to walk with crutches, bearing weight as tolerated on your affected leg. If you have crutches, please bring them with you on the day of surgery. Do not be alarmed if you experience some throbbing or bleeding in your knee as you stand. This is normal and can be expected.
Once you have recovered from your anesthesia, you may be discharged home. There are three exercises we would like you to do, every hour on the hour while you are awake. First, take ten deep, slow breaths, expanding your lungs fully. On the tenth breath, give a good, hearty cough. This will keep your lungs fully inflated, and help prevent lung problems and fevers. The second exercise is pumping both of your feet up and down, as if stepping on a gas pedal, again ten times. This is to help circulate the blood in your legs and prevent blood clots from developing in your veins.
Finally, you should try to contract and tighten your quadriceps muscles (thigh muscles) ten times. This is called a "quad set" and is designed to allow you to regain control over these muscles. When you are able to do this with good strength and control, you may attempt straight leg raises, lifting your heel off the bed 6-12 inches for 2 or 3 seconds at a time, while keeping your knee straight.
You may be given an anti-inflammatory pain reliever, such as Vioxx, Celebrex, or Ibuprofen. If the ice and antiinflammatory are not enough pain relief, you will also be given a narcotic pain pill, (Lortab, Vicodin or equivalent) to further relieve your pain. The narcotic pain pill is to be taken every 4-6 hours as needed for pain relief, in addition to the anti-inflammatory. If any of these medications cause nausea, vomiting or stomach distress, stop taking the medication and contact my nurse at 748 7550.
During the First Week
Range of motion exercises should be started when you get home. These will involve removing your brace and lying prone (on your chest) while hanging your knee and leg off the end of the bed. Your "good" leg may then be used to both extend and flex your reconstructed knee. These should consist of slow, gentle stretches, held for 5 seconds at a time in either direction and repeated 10 times. Do this 2 or 3 times a day and continue them until you have a full range of motion.
Once you are home, a CPM (Continuous Passive Motion) device may be delivered to you and you will be instructed on its use. While using the CPM, make sure you unlock the hinges on your brace or, better yet, remove the brace while you are in the CPM. With the help of the technician, find a speed and range of motion that is comfortable for you, then gradually increase the flexion on a daily basis, while leaving the extension at 0 to –5. We recommend you try to use the machine at least 6 hours a day. The more you use it, the quicker you will regain motion in your knee. A good goal is to reach 90 degrees of flexion within the first week and 120 degrees flexion by two weeks. Once you have achieved 120 degrees of flexion, call the technician so that the machine can be returned.
A few days following your surgery, you will return for your 1st post-operative visit. Some or all of your sutures may be removed, with the remainder, if any, to be removed at the next visit. You will then be referred to a Physical Therapist who will guide you through the most critical portion of your rehabilitation. They will design a rehabilitation program based on your personal needs, capabilities, and goals, within the general framework I have given them. They will see you two or three times each week, and monitor your progress. You are encouraged to work closely with them, and discuss any questions or problems that arise during your rehabilitation.
During the first week at home there are two possible post-operative complications, which although rare, are considered emergencies and require urgent evaluation and treatment. The first is wound infection. Infections generally arise during the first week and are accompanied by increased swelling, redness, warmth, and pain in the knee, whereas pain and swelling should normally be decreasing during this time. Additionally, you may develop drainage from the knee and/or a recurring ("spiking") fever above 101.5 F. The second possible complication is the development of blood clots in the veins of your leg. This would be accompanied by increased pain and swelling in your calf and foot rather than the knee, which are not relieved by loosening your knee bandage and elevating your leg. The calf muscles may be tender to touch and painful to use, and you may develop a fever. If a clot dislodges and goes into your lungs (a "pulmonary embolus"), you may develop chest pain, a cough and possibly some shortness of breath. If either of these scenarios develop, contact my office at 748 7550.
During the First Month
During the first month, we are most concerned that your knee is able to fully straighten (extend). A common cause of a less than optimal outcome from ACL surgery is the development of scar tissue which prevents the knee from fully extending. This is called a "flexion contracture," and may require additional surgery and delay your rehabilitation. All attempts are therefore made to prevent its occurrence. This is one reason we have you wear the knee brace at all times, except when showering, exercising or using the CPM device.
After 3 or 4 weeks, you should return for your 2nd post-op visit. If you have full extension of your knee (it straightens completely) and you have adequate muscle strength for walking, we will allow you to discard your brace.
6 – 8 Weeks After Surgery
You will continue training under the guidance of your physical therapist or athletic trainer, using a stationary bicycle, stair machine, or other "closed chain kinetic" exercise in which resistance against the sole of the foot is maintained throughout the exercise. These would include partial squats or leg presses with low weights, an exercise bike, stair machine or Nordic track. Leg extensions, heavy weights and power lifting are not allowed for the first six months.
3 Months After Surgery
In general, most patients will be allowed (but not required) to start jogging on a treadmill or cushioned level surface and do most of their rehab on their own. Remember, it will have been 3 months or longer since you last ran, so start slowly at short distances and gradually build your mileage and speed. Additionally, proprioception exercises can be started by your physical therapist. Some knee cap discomfort is not unusual, but if this persists you may need to cut back on your activities. Proprioception is an important joint function. It is a feedback system that allows you to subconsciously and continually sense what position a joint is in, and respond in reflex to sudden changes in position and weight to avoid undue stresses to the joint. In significant joint injuries, such as a torn ACL, this joint function is lost and in general is one of the last functions to return during rehabilitation. Specific exercises can help restore it. You should also continue with your other strengthening exercises.
4 – 6 Months After Surgery
If you have done well at jogging, then sprinting, cutting, figure-of-8, and jumping drills can be started if these are required by your sport (football, basketball, baseball, etc.). These "sports-specific" drills must be done prior to actually returning to your particular sport, and should be done under the guidance of your trainer or therapist. You should also continue with your other strengthening exercises. If all is going well, you will be fitted with a functional, custom-made sports brace. Once you feel comfortable doing drills, you may return to your pre-injury sport or activity, if so desired, (approximately 6 months).
12 Months After Surgery
This will probably be your final follow up visit, to see how your knee and brace are performing in your actual sport. We recommend wearing the new brace for the first year of sports participation. You should also continue on a regular knee strengthening and conditioning program for the next 12 months. The goal of the surgery is to restore the stability of your knee, providing you with a knee that is as strong and reliable as it was before your injury. In general, once your rehabilitation is completed and you have regained your pre-injury strength and proprioception, the risk of re-injury or tearing your new ligament is about the same as if you had your original ligament. Use of the brace beyond 2 years, therefore is optional, and not necessarily required. It may afford some added protection to your knee, but cannot completely protect your knee from re-injury.
5 Common Questions:
- How long will I be on Crutches?
About 1 to 2 weeks.
- When can I Shower?
Your incisions must be healing well and without any drainage before you can get them wet (about 7 days). If you want to shower before this time, cover your knee bandage with a towel and a plastic wrap, such as Saran Wrap, taping the edges of the plastic to your skin to keep the dressing dry. If they get very wet, you should change the dressing with 4" x 4" sterile gauze pads over the incisions, and a clean 4" or 6" elastic (Ace) bandage. All the sutures should be removed before you can actually submerse your knee in water.
- When can I Start Jogging?
Usually around 3 months.
- When can I return to Work or School?
This depends on your job or school. A desk job or regular classes can be returned to in about 1 week. You should be comfortable on your feet for 20-30 minutes at a time. Patients with jobs demanding physical labor, like athletes, must be individually evaluated before returning to their job or sport and may require 3 to 6 months before returning to their jobs. This depends on your job requirements and general physical condition.
- When can I safely return to my Sport?
This depends on your sport. Sports which require cutting and sudden changes in speed and direction require a well-healed graft and normal knee strength and proprioception. This generally requires about 6 months. There are exceptions to this rule, however, returning to your sport sooner than 6 months might increase the risk of re-injuring your knee and damaging your graft. You will have to weigh this increased risk against your desire for an earlier return to your sport. If you have any other questions, please feel free to contact me at the above phone number.