After an Acute ACL Injury in a Competitive Athlete, How Do You Manage the Patient in Preparation for Surgery?
In a competitive athlete, an anterior cruciate ligament (ACL) rupture can be a devastating injury. The anterior cruciate ligament is essential for knee stability in most athletic endeavors, specifically those that require cutting, pivoting, and jumping. It is important to reconstruct the ligament as soon as possible in order to minimize the time to return to play and maximize results. However, reconstruction of the ACL immediately following rupture has been shown to be associated with an increase in postoperative arthrofibrosis, slower return of quadriceps function, and range of motion loss1,2 (Figure 9-1). These problems can be detrimental to the competitive athlete. To prevent this loss, Shelbourne and Faulk,2 as well as Harner et al,1 recommended waiting 21 to 28 days before reconstruction of a ruptured ACL. This waiting period allows for the subsidence of the inflammation, swelling, and resultant loss of motion. Using these principles, reoperation for motion loss after ACL surgery has gone from 12% to 14% to now less than 1%.
Figure 9-1. Sixteen-year-old female with 22-degree flexion contracture 6 months after early ACL reconstruction performed 7 days postinjury. Patient required extensive arthroscopic lysis of adhesion to regain full extension.
Rather than specifically mandate a time period prior to surgery, I prefer to look at the following parameters. It is imperative that the athlete regains full symmetric extension and 120 degrees of flexion prior to reconstruction. The knee should have little to no effusion. The patient should have strong quadriceps activity with normal or near normal gait pattern. Most times, I will send the patient shortly after injury to physical therapy to help maximize this effort. The therapist will utilize modalities such as cryotherapy, compression, and anti-inflammatory medications to reduce pain and swelling. In addition, attention must be focused on relieving the quadriceps inhibition that is present following this injury. Techniques such as closed-chain quadriceps exercises, straight leg raises, and electrical muscle stimulation can aid to recondition the quadriceps musculature. Restrictions must be reinforced and maintained during this preoperative period, such as avoiding cutting, pivoting, and jumping to prevent any instability events that could damage articular cartilage or menisci.
Once these parameters are achieved, I feel comfortable proceeding with ACL reconstruction. In some cases, this may occur rapidly within 1 to 2 weeks or it may take up to 6 to 8 weeks. However, I prefer to use this clinical criteria rather than a specific time frame when determining the timing of surgery.
In occasional rare instances in which patients are unable to regain full extension, the physician is responsible for ensuring that there is no mechanical cause such as a displaced meniscal tear or entrapped ligament stump. In those cases, the physician may proceed with arthroscopic debridement or meniscal repair and defer ACL reconstruction until motion improves.
1. Harner CD, Irrgang JJ, Paul J, Dearwater S, Fu FH. Loss of motion after anterior cruciate ligament reconstruction. Am J Sports Med. 1992;20:499-506.
2. Shelbourne KD, Foulk AD. Timing of surgery in anterior cruciate ligament tears on the return of quadriceps muscle strength after reconstruction using an autogenous patellar tendon graft. Am J Sport Med. 1995;23:686-689.