Most surgeons will delay the operation until the pain and swelling has decreased and the range of motion of the knee has improved. There is no definite time frame for this to occur. Some patients are ready in 1 week and others take 6 weeks. If there is a loss of extension, then imaging must be done to determine if this is the stump of the ligament or a displaced bucket handle meniscal tear. The meniscal tear should be reduced and repaired early. The knee is then rehabilitated to regain the range of motion, and the anterior cruciate ligament reconstruction can be carried out at a second stage.
The operative procedure should be done on a compliant patient.
The abnormally lax patient will also present problems in achieving stability.
The conventional wisdom is that the young pivotal contact sport athlete should have a patellar tendon reconstruction. Patients with pre-existing patellofemoral symptoms or who are only involved in recreational activities should undergo a semi-tendinosus reconstruction.
The current trend is to do less notchplasty.The notch only has to be large enough to accomadate the graft. In most cases only the soft tissue needs to be removed to visualize the over the top position.
This has become less of an issue since we have moved to the interference screw fixation of the semi-tendinosus. The fixation is near the tunnel entrance and reduces the bungee effect of periosteal fixation.
The graft should be tensioned with about 10-15 pounds of tension at 20* of knee flexion.
The fixation of grafts with the bioabsorbable screw is evolving to the preferred method of fixation. The blunt metal screw has become the standard, and the bioabsorbable screw has advantages over the metal screw, so it should become the standard of the future.
The most important advance in ACL reconstruction in the past decade has been the concept of accelerated rehabiliation as proposed by Don Shelbourne. This has reduced the problems of limited range of motion, patellofemoral pain and had increased the return to sports participation. It has also reduced the time of return to sports from 12 months to 4 months.
Recently in the popular press, we are hearing of early return to sport in 6-8 weeks. In my opinion, we may be able to rehab the athlete, but have we given the biology of soft tissue healing a chance to incoporate the graft. Most surgeons feel that it takes 4-6 months for the athlete to recover after autogenous ACL graft reconstruction.
The use of a functional brace after ACL reconstruction is still a debatable issue. I feel that if a patient undergoes a reconstruction, then he does not need to wear a brace to return to sport. If the patient elects to undergo conservative treatment, the functional brace is a mainstay of that treatment.
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