Process, Not Procedure: ACL Postop

The cannula, shaver, and burr have been deployed, the graft is in place, and the patient is brought to postop. The procedure—ACL reconstruction—is done, but the process continues.

Dr. Donald Shelbourne, founder of the Shelbourne Knee Center in Indianapolis, has performed more than 6, 000 ACL reconstructions. In his view,

The way we are undertaking ACL surgery is misguided. Doctors look at the surgery as an event and not a process. After surgery, patients are usually assigned to a PT location that may be independent of the doctor’s facility. And often, the surgeon feels that his or her ‘problem’ is gone because the patient is gone. A shift in thinking is in order so that we surgeons are part of the patient’s entire experience, start to finish.

And he has the numbers to show what exactly should be included in this process. “I deal primarily with knee problems in athletes, more than half of whom are under 18. Over the last 28 years my colleagues and I have amassed the world’s largest collection of data on ACL reconstructions…data indicating that traditional postoperative rehabilitation is overly restrictive and problematic. In the late '80s I began presenting data on 400 patients showing that no braces, splints, or crutches were needed postoperatively. You can imagine the pushback.”

Providing some background, Dr. Shelbourne explains, “In the 1980s a third-party researcher interviewed our patients to determine if compliance to our rehab program actually contributed to better results. We wanted to know if patients that did what we asked them to do did better postop than the ones that didn't follow our instructions. We learned a lot from this. The researcher found that many people were not following the instructions and yet they did not have worse results. Often, the patients were more comfortable and were doing better with their rehabilitation. We began to study what patients could do and what they should not do post-operatively to effectuate a smooth rehab. We learned that the first week of rehab should be focused on preventing a hemarthrosis (the patient has to recline with the leg elevated above the heart and keep the cold/compression device on at all times except for when he/she is performing ROM [range of motion] and leg control exercises). If the patient returns one week post-op without swelling, good ROM and leg control, the rehab is relatively simple from that point forward.”

How a surgeon guides rehabilitation depends much on expectations…those of the doctor and patient. Dr. Shelbourne: “We initially thought that the patient’s goal of undergoing surgery was to have a stable knee. The problem is that if you don’t give patients a normal knee with symmetrical motion and full flexibility then they are not satisfied. But few doctors have that goal for their patients…most tell patients that their knee will never be normal again. In 90% of my cases, though, we return the knees to normal functioning. Stability is a nice goal, but if the patient lacks significant range of motion (ROM) 15 years later then that puts them at increased risk for osteoarthritis. So, my ultimate goal of this data collection is to learn why certain patients get back to normal ROM and how we can get everyone to that point.”

From the first handshake, Dr. Shelbourne is thinking about what exactly he can do to help this person have an exceptional outcome. “Orthopedists should focus on perfecting our preoperative strategies in order to obtain the best postoperative result. If patients go into surgery without full ROM then the chance of them having less ROM postoperatively is higher. Our patients must undergo preoperative conditioning in order to prepare their knees for surgery.”

As for the timing of surgery, he adds,

We used to operate right after the injury and found that the patient was having problems with ROM after surgery. ‘Something is broken…let’s fix it’ is the orthopedist’s mindset. But it’s best to slow down and see what needs to be done before we open up the patient. Fortunately, I have physical therapists on staff who see the patients with me before surgery.

In ACL rehabilitation the tools that therapists employ may be ordinary, but the results certainly are not. By using such mundane items as the edge of a chair or a towel, patients can eventually achieve full ROM. “First, patients focus on obtaining full extension, then full flexion, with the goal being that they will have symmetric knees at four weeks. Years ago we found that patients who get a symmetrical range of motion come back at a year and their knees are normal.”

And, says Dr. Shelbourne, the patient’s mental state prior to undergoing surgery is critical. “Patients should approach surgery with a ‘can do’ attitude toward rehabilitation, and without a fear of the unknown (which is why we spend so much time on pre-op patient education). There is a clear advantage for those patients who are undergoing a second ACL surgery, i.e., their rehabilitation is easier. We do our best to give patients all the information they need, including educational materials, a slideshow, and discussions with their families. This process is hard for some patients, for example young athletes who are seeking a scholarship. They often feel angry and depressed, and may be in denial. That is when the doctor and the therapist collaborate to act as ‘pregame coaches.’ We tell them about the positive results our other patients have had; the fact that we can be specific and support our claims with data is helpful. So often athletes go to a doctor and ask, ‘How many of these surgeries have you done?’ and ‘What are your results?’ and are met with, ‘Quite a few’ and ‘Pretty good.’”

Dr. Stephen Howell, an orthopedic surgeon in Sacramento, California, and the designer of the OtisKnee, is a proponent of a laissez faire approach regarding ACL rehabilitation.

I am an advocate of self-administered rehab; I give the patients guidelines and they go to the gym and do the exercises. Brace wear is not helpful because it gives the patient a sense that the knee is fragile (and slows them down). I don’t like to put someone in a brace for two months and tell them they can’t do sports for a year. If you take the necessary precautions during surgery, you can take an aggressive approach to physical therapy. My colleagues and I have a paper appearing soon in the American Journal of Sports Medicine showing that the use of a self-administered, brace-free, rehabilitation program designed to encourage an early return of motion and function did not result in a clinically important increase in anterior laxity and slippage at one year after ACL reconstruction with a soft tissue graft.

As for how the mechanics of the operation in the OR affect the biomechanics of rehabilitation, Dr. Howell states, “There is a paper from the UK by Khan et al showing that the ACL graft can stretch after surgery. If patients are moving the knee soon after surgery and you want to prevent an increase in laxity, then you have to fashion the bone tunnels so that the graft is free from impingement and fasten the graft mechanically so it doesn’t slip during post-op exercise. During the first month the graft heals quickly to bone—after which mechanical fastening is unnecessary. The trick is to get the tunnels in the right spot so that the graft doesn’t stretch from impinging against the intercondular roof when exercising the knee in extension and against the posterior cruciate ligament (PCL) when exercising the knee in flexion. If you don’t do these steps, and put the graft in with roof and PCL impingement, fasten the graft insecurely, etc., then the rehabilitation will be prolonged, motion will be difficult to regain, and the knee could become unstable again.”

While Dr. Howell is directive about how physical therapy should proceed, he lets patients choose the exercises that feels best to them within a set of guidelines. “Before surgery patients review the detailed rehabilitation guidelines on our website and have ample opportunities to ask questions. During the first two weeks postop, I have them focus on straightening and bending the knee and walking on the leg. I want patients off crutches, and I want the knee bending at least 90 to 100 degrees and straightening all the way by two weeks. I remind patients that it is normal for their leg to swell, bruise, and be sore. If you set realistic expectations and the patient experiences them, then they will learn to trust you.”

So what are Dr. Howell’s empowered patients doing? “The initial goal is to regain motion, not strengthen the knee. Once motion is regained then it’s time to work on strength. I encourage cycling because the patient can adjust the duration of the ride and the resistance on the wheel so that they get fatigued muscles, but not a sore knee. I encourage them to begin riding for 10 or 15 minutes. When they are comfortable then they can increase the duration of the ride and the resistance on the wheel. Once they master the cycling they can use any exercise machine as long as they start off easy with low weight and high repetitions. If the knee hurts during a particular exercise I suggest they skip it; but if a muscle hurts then that means this is a good exercise for the patient.”

After thousands of ACL reconstructions and numerous studies, these experts agree: think “process”…not “procedure.”