Knee ambulatory rehabilitation after anterior crossed ligament reconstruction

MEDICINA SPORTIVA - Journal of Romanian Sports Medicine Society

"Sport Medicine Journal" No.5 - 2006

ORIGINAL PAPERS

Knee ambulatory rehabilitation after anterior crossed ligament reconstruction

Mirela Lucia Călina¹ , Despina Beer²

¹University of Craiova, Faculty of Phisical Education and Sport,
²Ministery of Justitice

Abstract: Knee is one of most important joint of our body, that presents frequently many traumas. The anterior cruciate ligament (ACL) is the major stabilizing ligament of the knee. This is one of the structures most often injuried by sportsmen. This injury causes internal rotational instability of tibia to the femur when the knee is in flexion. The ACL reconstruction with anatomically bone-tendon-bone graft harvested from the patellae ligament, is accepted today as the “golden standard”. The aim of this study is to evaluate the rehabilitation of knee after ACL reconstruction. We compared two groups of subjects, one with ambulatory rehabilitation by kinetic programme and one with rehabilitation in a rehabilitation hospital services.

Key words.: knee, ACL, ambulatory rehabilitation

Introduction

The achievements in surgical and rehabilitation treatment have helped post-surgical line in patients with surgical reconstruction of anterior cruciate ligament (ACL).

New surgical techniques, first arthroscopy, are less invasive and injuring on articular and periarticular structures offering better stability and faster mobilization and support.

The improvement of functional rehabilitation techniques, such as closed kinetic chain, has permitted a faster rehabilitation, decreasing the solicitation on the knee. These progresses allowed ambulatory rehabilitation to win in the competition with rehabilitation in a rehabilitation hospital service with complete hospitalization.

The aim of this study is to evaluate the efficiency of a program of ambulatory functional rehabilitation of the knee after surgical reconstruction of ACL injury.

We compared the results of two groups of patients: one with ambulatory rehabilitation, one with rehabilitation during three weeks of hospitalization in a rehabilitation hospital service.

Material and method

We studied a number of 24 patients with ACL injuries and bone-tendon-bone graft surgical reconstruction and rehabilitation started first day post-surgery.

After ACL reconstruction we mead 2 lots: group A with ambulatory rehabilitation and group B with reeducation in a rehabilitation and physical medicine center.

Daily rehabilitation activities - walking, climbing, descending - in a period of 4-6 weeks mean walking without support, complete extension of the knee and an active flexion in 120 degrees.

Group A – rehabilitation with a kineto-therapist during 6 weeks, three times in a week- home exercises.

Group B – during hospitalization, two hours/day, two days/week, three weeks, then ambulatory rehabilitation like in group A.

Reeducation period - 6 weeks to 4 months - during this phase kinetotherapy was suspended; home physical exercises; the result: swimming, bike-riding.

Muscular reeducation - 4 to 6 months post-surgery; result: maximal rehabilitation in movement, force and stability of the knee.

Sport rehabilitation - 6 to 12 months post-surgery - progressive sport activities, training and then competition.

The study was made between june 2003 – july 2005, on 24 patiens, 16 males and 8 females, average age - 24 years old, 70% performance sportsmen, 23% freetime-sportsmen, and 7% are not sportsmen (graph 1).

All patients present: ACL injury with or without menisci injury, surgical reconstruction with bone-tendon-bone technique and accepted rehabilitation program.

We did not select patients with other kind of surgery of the knee (excepting exploratory artroscopy), with degenerative joint pathology or important injuries of periarticular structures.

Patients evaluation-3, 6 weeks, 4, 6 months and 1 year post-surgery.

Noticed parameters:

general: age, sex, high, weight
information about the injury
period between the injury and surgical treatment
surgical technique
anterior sport activities.

Each check evaluated:

the liquid level (ultrasound) “0”- without liquid; “1”- minimum; “2”- medium; “3”-important

the amplitude (goniometry) of the flexion and extension of the knee
test Lachmann - Trillat for the ligaments of the knee
functional score of Lysholm (evaluation of the instability, pain, swallowing, articular blocking of the knee)

Results

The 24 patients, 12 group A, 12 group B were 24 +/- 7 years old, high 172 +/-8 cm, weight 69 +/-11 kg.

Pre-surgery Lachmann test was positive in all patients meaning high risk of instability or real instability.

In 75% of patients surgery was performed 1 year after the injury, half of these after 6 months, 1/3 after 3 months.

The frequency of menisci injury was more important in group A (43%) then in group B (19%)

There was no difference in mobility, in flexion and extension of the knee between the two groups (exception: flexion after 3 weeks post-surgery) (table1).

No significant differences in swelling evolution between the two groups.

No differences in Lachmann and Lysholm tests (table 2, 3).

Conclusions

Functional reeducation after surgery for ACL injury can be proceeded in ambulatory from the beginning and it is based on a well-established protocol of easy home kinetic-therapy techniques.Weekly medical supervising during first period of reeducation may improve the results by adjusting kinetic program on each patient and early registration of the complications.

Well relationship patient-physician –kinetic-therapist determined comparable results in ambulatory rehabilitation and hospital rehabilitation in surgical reconstruction of ACL.

Graph 1

Table 1.Evolution of articular mobility

	Extension		Flexion
	Group A	Group B	Group A	Group B
3 weeks	- 3,9 + - 4,8	- 2,2 + - 3,6	96 + - 17	109 + - 13
6 weeks	- 1,6 + - 3,9	- 2,61 + - 5,1	119 + - 17	121 + - 12
4 months	- 0,1 + - 3,3	- 1,3 + - 4,3	136 + - 10	137 + - 9
6 months	0, 5 + - 3,1	0,22 + - 3,7	138 + - 11	142 + - 6
1 year	0,6 + - 1,9	- 0, 16 + - 2,7	141 + - 8	143 + - 6

Table 2.Remaining laxithy 1 yearpost-surgical ACL reconstruction

Manual Lachmann test 1 year post-surgery	Group A	Group B
0 sau + -	61%	60%
+	35%	40%
++	4%	0%

Table 3. Functional results

Functional score of Lysholm	Group A	Group B
6 weeks	78 + - 11	64 + - 15
4 mounths	90 + - 8	82 + - 14
6 mounths	92 + - 6	90 + - 7
1 year	96 + - 5	94 + - 6

Bibliography

Boileau P., Rémi M., Lemaire M., Rousseau P., Desnuelle C., Argenson C., (1999) Plaidoyer pour une rééducation accélérée après ligamentoplastie du genou par un transplant os-tendon rotulien-os, Rev Chir Orthop, 85, pp475-490 ;
Beynnon BD., Johnson RJ., Fleming BC., Stankewich CJ., Renström PA,. Nichols CE., (1997) The strain behavior of the anterior cruciate ligament during squatting and active flexion-extension. Comparison of an open and a closed kinetic chain exercise. Am J Sports Med, 25(6), pp 823-829;
Beynnon BD., Fleming BC., Johnson RJ., Nichols CE., Renström PA., Pope MH., (1995) Anterior cruciate ligament strain behavior during rehabilitation exercises in vivo. Am J Sports Med, 23(1), pp 24-34;
Bynum EB., Barrack RL., Alexander AH., (1995), Open versus closed chain kinetic exercises after anterior cruciate ligament reconstruction. A prospective randomized study. Am J Sports Med, 23(4), pp 401-406;
Shelbourne KD., Nitz P.,(1990) Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med, 18(3), pp 292-299;
Shelbourne KD., Klootwyk TE., Wilckens JH., DeCarlo MS., (1995), Ligament stability two to six years after anterior cruciate ligament reconstruction with autogenous patellar tendon graft and participation in accelerated rehabilitation program. Am J Sports Med, 23(5), pp 575-579;
Shelbourne KD.,Gray T., (1997), Anterior cruciate ligament reconstruction with autogenous patellar tendon graft followed by accelerated rehabilitation. A two to nine years follow-up. Am J Sports Med, 25(6), pp 786-795.

"Sport Medicine Journal" No.5 - 2006