- Prehabbing and Graft choice
Prehabbing your knee basically helps get full motion back in the knee, prevents muscle shrinking, decreases swelling, and improves overall comfort of your knee after surgery. Everyone is not comfortable after having their ACL reconstructed, but with prehabbing your knee, you will be more comfortable and will gain independence back faster after surgery.
Graft choice is one of the most important decisions with all of the choices having pros and cons with them. As I write this the gold standard is BTB or bone patellar tendon bone autograft. If you are a high school, college, or professional athlete, this is the graft to get as it has the lowest retear rate. Next best are really 2a and 2b. They are the hamstring autograft and quad tendon autograft. If you are a weekend warrior (in your late 20’s/30’s/40’s) these are the grafts for you. Lastly the least stable graft is the cadaver allograft. If you are in your 50’s and active or just want to be functional, this is the graft for you.
- Time based criteria vs. objective-based criteria.
Time based criteria is how long it has been since you have had surgery. Objective-based criteria are measurements on the patient. This is important that the patient meets both criteria prior to certain activities. Time based criteria is important as it takes a certain amount of time for the tissues to heal to be able to withstand the next level of activity in therapy. One of the most common questions I get are “When can I Run?” Generally speaking, if you had an autograft (graft was harvested from your own body) the ligament and bone plugs are able to withstand the forces of running at 12 weeks after surgery. However, objectively you must pass isolated and functional strength testing, have near full motion in your knee, and have little to no pain. If the patient is not able to meet both criteria, then moving onto running puts the patient at risk of injuring themselves again.
- What to do once you are cleared for your sport?
Once you are discharged from physical therapy and you are wanting to return to a sport like soccer, football, basketball, ECT, then you should start with individual drills in practice in a closed environment (basically it is a predicable environment) for 1-2 weeks. Next, you return to full contact and participate in practice for 1-2 weeks. Finally, if you have had no issues with reintegrating into practice for a week or two, it’s time to return to competition.
Andrew Kupper PT DPT SCS
I just tore my ACL what do I need to know before surgery?
If you are reading this and you tore your ACL, you have my deepest condolences. You are in for a long journey to get back to doing everything you want to do.
However, there is good news!
Your outcome is ultimately in your hands. Picking your surgeon (I have one that I highly recommend), picking your therapist (I also know of a great PT), and then prepping yourself before surgery all play a big part in your short- and long-term outcome. Then there is prehabiliating your knee for surgery. Nowadays surgeons want patients to wait a few weeks to have surgery, therefore there are things you can do to set yourself up for success early on. Properly prehabbing your knee includes decreasing swelling in your joint, getting the quadriceps (thigh) muscle to fire, regaining range of motion, and if possible get to be able to walk normal.
First, you need to work on decreasing swelling in your knee joint. This can be done many ways. The RICE method is used. RICE stand for Rest Ice Compress and Elevate. Lay on your back prop your leg up above your heart, have some compression on the joint and ice it down. 20′ at a time multiple times a day if possible. Next, is getting your thigh muscle to be able to squeeze again. This is pretty simple, sit with your knee straight and start squeezing your thigh. Try to hold for 5 s and do 30 or more repetitions. This needs to be done several times a day. After that regaining full motion (if possible) is a must. If you have the motion walking into surgery, it will be easier getting it after surgery. You can work on bending your knee by riding a stationary bike and then doing heel slides. (insert picture of heel slide) Getting the knee straight is important too. you can do this by stretching your hamstrings and calf (insert picture here). Lastly being able to walk normal is important before surgery as it will be easier to relearn how to walk after surgery.
This was just a brief overview of prehabbing a knee before surgery. I discussed the most general ways I do prehab. If you have questions or have anxiety about doing these recommendations on your own, I recommend you call and get an appointment with us. This way your interventions will be specifically tailored to you.
The next biggest piece of information you need to know is graft selection. Each graft has pros and cons to them. I’m going to discuss those next.
Bone Patellar Tendon Bone Autograft (BTB)
As I am writing this blog post the BTB Autograft is the best graft if you are wanting to return to competitive high level sports. This is because the graft becomes stable faster than the other grafts. This is due to how the graft is harvested and then prepared and put into the knee. Both ends of the graft have bone on them and that heals faster with the bone tunnel that is made in your knee. There are some cons to this graft type. The 1st is quad strength takes a little longer to return and the other is potential of discomfort with kneeling onto the knee.
Hamstring Autograft
The hamstring autograft is great for individuals who are still active but are also not looking to return to high level sports quickly. The surgeon harvests the semitendinosus muscle of the involved knee. The pros of this graft type is that the patient is able to get quad strength back faster and there is much less risk of pain in the front of the knee. There is also less scars on the front of the knee with this approach. How this graft is prepared by the surgical staff also plays a factor in long term stability of the knee. A double bundled graft provides more stability than a single bundled graft. The cons of this type of graft are that there is more muscle pain in the hamstring earlier on, there will always be weakness in the hamstring that was harvested by the surgeon.
Quad Tendon Autograft (QT)
The QT autograft is the new kid on the block. Because of that there is overall less data on it. However, what is out is quite promising. From a stability standpoint this graft provides the same amount as the BTB autograft with less donor site pain. (Donor site is where the surgeon harvests the graft). Also, it gets better functional outcomes than the hamstring autograft. It also has a larger graft diameter. If you are looking to get back into high level sports, this is a solid option as well.
Cadaver allograft
These are used in patients usually older than 35 and are more sedentary. The pro of this graft is that there are no donor site pains you have to worry about. Cons include risk of body rejection, slower graft healing, If you are wanting to become more active or return to a high level of physical activity, I do not recommend getting this graft.
Ultimately the best graft for you depends on your age, activity level you want to return to, and other issues in the knee. Generally speaking, if you are young and want to get back to a high level of activity, I’d go with a BTB or QT autograft. If you are a little older in age and want to stay fit for general health, then a HS graft is a good choice. Lastly if you want to just have function on a day-to-day basis and don’t care about running or jumping then a cadaver is probably your best bet.
As a patient you must be well informed to make the best decision for your future health. Not every surgeon or physical therapist is created equal. If you want to get a different graft than what the surgeon is recommending based on YOUR activity goals, I would hear their reasoning for their choice first. Then I would recommend reiterating what your goals are and then see if they change their mind. Again, you get to choose who operates on you.
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