Download The Patient`s Guidebook for Knee Surgery

ELMSLIE TRILLAT SURGERY
Thomas E. Klootwyk, M.D.-Methodist Sports Medicine-Indianapolis,Indiana
The Patient’s
Guidebook for
Knee
Surgery
Copyright 2002 Peter I. Sallay
Rev 9/10/13
CONTENTS
Table of
Section 1
How does your knee work?.............................................................................................. 1
Section 2
What’s wrong with your knee?......................................................................................... 3
Section 3
How does surgery correct my knee problem...................................................................... 4
Section 4
Potential risks of surgery ........................................................................... 6
Peri-operative risks ............................................................................................ 6
Post-operatvie risks ........................................................................................... 7
Section 5
Pre-operative planning....................................................................................................8
Special tests ..................................................................................................... 8
Pre-operative Physical Therapy............................................................................ 8
General medical check-up .................................................................................. 8
Section 6
Phase I: Pre-operative ................................................................................................... 9
Pre-operative Goals ........................................................................................... 9
Exercise ........................................................................................................... 9
Strengthening ................................................................................................. 10
Section 7
The day of surgery.........................................................................................................11
Check-in......................................................................................................... 11
Anesthesia...................................................................................................... 11
Surgery........................................................................................................... 12
Post-operative recovery unit.............................................................................. 12
Section 8
Your hospital stay .........................................................................................................14
Nursing duties................................................................................................. 14
Pain management ........................................................................................... 14
Control of Swelling .......................................................................................... 15
Physical therapy .............................................................................................. 15
Discharge from the hospital.............................................................................. 15
Section 9
Limitations after surgery ............................................................................................... 13
Table of
CONTENTS
Section 10
Section 11
Section 12
Section 13
Section 14
What to expect at home ................................................................................................17
Rehabilitation ................................................................................................. 17
Physical therapy exercises ................................................................................ 18
Medications and pain management .................................................................. 18
Cryotherapy .................................................................................................... 19
Assistive Devices ............................................................................................. 20
Wound care/Bathing ....................................................................................... 20
Activity ........................................................................................................... 21
Driving………………………………………………………………………………...………………… 21
Exercise......................................................................................................... 21
Sexual activity ................................................................................................. 21
Phase II: 1 to 6 Days .............................................................................. 22
Hospital Discharge Goals ................................................................................. 22
Exercises ........................................................................................................ 22
Phase II: 7 to 14 Days ............................................................................ 24
Goals ............................................................................................................. 24
Exercises ........................................................................................................ 24
Phase III: 1 to 3 Weeks........................................................................... 26
Goals ............................................................................................................. 26
Exercises ........................................................................................................ 26
Phase IV: 3 to 6 Weeks............................................................................28
Goals ..............................................................................................................28
Exercises.........................................................................................................28
Table of
CONTENTS
Section 15
Phase II: 1 to 6 Days .............................................................................. 29
Early Phase Goals ............................................................................................ 29
Exercises ........................................................................................................ 29
Agility ............................................................................................................. 30
Final Goals...................................................................................................... 30
Final Exercise Progression ................................................................................ 30
Section 16
Common Problems ................................................................................ 31
Pain ...............................................................................................................33
Nausea...........................................................................................................33
Itching…………………………………………………………………………………..………… …….33
Change in appetite and bowel habits ................................................................33
Stiffness .........................................................................................................32
Bruising/swelling ............................................................................................34
Numbness and tingling……………………………………………………………….……..………34
Section 17
When to call the doctor ........................................................................... 33
Section 18
Important telephone numbers/office hours ............................................... 34
Section 19
Return to work (school) and sports ............................................................ 35
Follow-up visits ............................................................................................... 35
Work .............................................................................................................. 35
Sports ............................................................................................................ 35
Section 1
How Does Your Knee Work?
Trochlea
Femur
Fibula
Tibia
Figure 1: Bones of the knee joint
The knee is an important link in an elegant mechanism that allows
humans to walk upright. The knee provides the leg with the necessary
flexibility to allow locomotion. The knee also functions as sort of a shock
absorber. As the foot hits the ground during walking the knee
automatically bends to gently cushion the blow.
The knee joint is made up of four bones: The femur (thigh bone),
patella (knee cap– not in figure), tibia (shin bone), and fibula (figure 1).
When you bend and straighten your leg your knee cap glides against a
part of the thigh bone called the trochlea (figure 1).
Movement is promoted by a series of powerful muscles that
surround the knee. The major muscles include the quadriceps,
adductors, hamstrings, and gastrocnemius (figure 2). The strength and
endurance of these muscles are critical to the performance of the knee.
Although the muscles are important in maintaining stability the
ligaments are the primary stabilizers in the knee joint.
The patellofemoral joint derives its name from the
“kneecap” (patella) sitting on the rounded ends of the “thigh
Quadriceps
Hamstrings
Patella
Gastrocnemi-
Patellar Tendon
Figure 2: The extensor mechanism as viewed from the side
How does your knee work?
1
bone” ( femur). The lateral surface of the patella is the widest and
therefore covers more area when it rests on the femur. The patella
contains the thickest layer of cartilage in the body. The “cracking” or
crepitus that is felt when the knee is moved in certain positions is a result
of this articular cartilage wearing down.
The rounded ends of the femur are called condyles. During
movement of the knee from flexion (bending) to extension (straightening),
different parts of the patella come in contact with the femoral condyles.
Incorrect alignment, or malalignment, of the patella moving over the
condyles can lead to patellofemoral pain.
The patella functions as a guide for the quadriceps tendon,
decreases friction on the tendon, acts as a shield for the femoral
condyles, and improves appearance for the knee. Different loads are
placed on the patella, depending on activity. In walking, the pressure
placed on the patella is 1/3 of your body weight. Stairclimbing increases
this load to 3 times your weight, and squatting increases the pressure
load to seven times your body weight.
Movement of the patella is influenced and controlled by the
following factors:
 Quadriceps muscle group, especially vastus medialis oblique (VMO).








2
Medial retinaculum, which helps to stabilize the medial border
of the patella.
Shape of the patella; depending on the shape, the patella may move
laterally more or less
Height of the patella; with a patella that sits too high on the femoral
condyles, the VMO loses some of its stabilizing effect.
Vastus lateralis muscle; if the vastus lateralis is stronger than the
VMO, the patella has a tendency to be pulled laterally.
Lateral retinaculum; if this tissue is too tight, the patella can be
pulled laterally and cause increased pressure between the patella
and the condyles.
Location of the tibial tubercle; positioned laterally, the result can be
an increased Q angle.
Q angle; this is the line formed from the hip to the mid-point of the
patella to the tibial tubercle.
Position of the foot; does the foot roll in (pronation) or roll
out (supination)?
How does your knee work?
Section 2
What’s wrong with your knee?
If one or more of these factors contribute to the overall function of
the patella, the resultis a patella that does not track correctly(Figure3),
thus causing increased pressure when in contact with the femoral
condyles or a patella that can have excessive movement causing
recurrent subluxing or dislocation of the patella (Figure 4—2a&b)).
Normal
Abnormal
Figure 3 The tendon from your knee
lies too far to the side causing your
knee cap to track off center when you
bend your knee
SYMPTOMS
The typical sufferer of patellar pain is usually in their teens or early
twenties. They are active and involved in sports at the onset of
symptoms. Some research shows that the symptoms may resolve
spontaneously; in our experience, symptoms do not resolve without
changing the amount or type of activity and without attempting some
form of rehabilitation (exercise, bracing, etc.). The patient may present
with pain in one or both knees. Some common symptoms follow:


Pain when going up or down stairs.
Aching with prolonged sitting with the knee bent at 90 degrees.


Catching, clicking, grating, or feeling of giving way
Mild swelling

Pain during and after activity
Figure 4: X-rays showing 1) how the knee cap sits in the center of the trochlea
normally, and: 2) how the knee cap looks when it subluxes or dislocates and does
not sit properly, but lies to the side in the trochlea.
1
A
B
A
B
2
What’s Wrong With Your Knee?
3
Section 3
How does surgery correct my knee problem?
Elmslie surgery will begin with an arthroscopic procedure. This
involves three tiny incisions to insert an irrigation tube, tiny camera
with a light, and a surgical instrument (Figure 5). After the instruments are inserted into the knee, a TV screen displays the image and
your knee can be evaluated for any arthritis changes or abnormalities
(Figure 6). Sometimes it is necessary to shave the joint surfaces to
make them more smooth and thus improve comfort level. This part of
the procedure will be videotaped and you are encouraged to watch it
at your first office visit after surgery.
Figure 5: The arthroscope, which is used to
examine the inside of your knee
After the arthroscopy, a 1.5 to 2 inch incision is made from the
bottom of the kneecap (patella) to the elevation in the surface of the
shinbone (tibia) where the patellar tendon attaches (tibial tuberosity).
The rest of the procedure is done through this opening into your knee.
First, a lateral release (incision) is done to free your patella. This involves making an incision under the skin. The tissue along the outside of your patella is cut or released to allow more freedom of movement as your patella glides up and down with normal knee motion.
(Figure 7) This will help decrease the irritation, pain, and friction under the patella as well as help decrease the chances of the patella
sliding out (dislocating).
Figure 6: The operating room with the TV
that is used to “see” the inside of your knee
Figure 7: Releasing the retinaculum to allow the patella to slide over.
4
Attention is then focused on the tiabial tuberosity where the bulk
of the surgery will take place. Tiny holes are drilled underneath the
elevation of the tuberosity to make repositioning easier. A chisel frees
the bone bump from its original attachment while maintaining an envelope of soft tissue (patellar tendon) around the edges. The bone
piece is still attached to the patella tendon and as it is moved to the
inside, will slide the tendon and the patella.
The X-rays are used to preplan the desired placement of the tuberosity. The tuberosity is then moved to the inside and measured.
Once the desired position is obtained, two holes are drilled through
the tuberosity. The screws are then inserted to secure the new attachment in place. The new position of the tuberosity allows for better
alignment of the patellar-femoral joint (Figure 8b).
The incision is closed with stitches. Dressings, compression
hose, and a Cryo/Cuff are placed on your leg. The anesthesiologist
will wake you and you will go to the recovery room before going to the
hospital room where you will spend the night.
A
B
Figure 8: Realigning the extensor mechanism A) The bony
prominence of the shin bone is partially detached.
B) It is then slightly rotated and reattached with 2 screws.
What Kind of Surgery is Performed?
5
Section 4
Potential Risks of Your Surgery
Any surgery that we perform has certain documented risks. These
potential problems can arise even if the surgery is carefully planned and
performed. The most notable risks are outlined below. Fortunately the
incidence of such complications with elective knee surgery is very low.
Certain factors may slightly increase your potential risk such as previous
operations on the same knee or coexisting medical conditions such as
diabetes, heart ailments, etc. Our surgical team will discuss any such
condition prior to surgery if it may have a potential impact on your
recovery.The following risks appear in the order of frequency:
Peri-operative risks
1 Anesthetic complications
Sore throat- only occurs in patients who undergo general anesthetic
and is due to the breathing tube used to provide airflow to your
lungs.
Nausea- occurs from the various drugs that are used during
anesthesia. The newer drugs have a lower risk and several antinausea medications are available to minimize the symptoms.
Herbal Supplements/Weight Loss Products- The use of any weight loss
products or herbal supplements must be discontinued 2 weeks prior to
surgery. These products can interfere with bleeding control and
anesthetic medications.
Serious complications- More worrisome complications such as severe
drug reactions and death are fortunately extremely rare. The risk of
death or serious injury as a result of anesthesia is said to be lower than
the chance of being hit by a car!
6
Potential Risks of Your Surgery
2 Operative Risks
Bleeding- Bleeding is expected during surgery because of the
generous blood supply to the knee. We use special instruments to
cauterize small blood vessels which therefore minimizes bleeding.
Blood loss during most knee surgeries is less than 1 to 2 ounces.
Infection- rarely occurs. The risk has been estimated at roughly 1 in
300 surgeries. If an infection does occur then further surgery and
antibiotics may be necessary to treat the problem.
Nerve damage- to the major nerves of the knee and leg is extremely
rare. Damage to the small skin nerves around the incision is expected.
This typically leaves patients with a half-dollar sized area of numbness
next to their incision. There are no functional consequences because of
the numbness.
Post-operative risks
1.
2.
3.
4.
Potential Risks of Your Surgery
Stiffness-This can be a result of poor effort during rehabilitation or in
some cases occurs for no obvious reason. In most cases the
condition is temporary and resolves with diligent rehabilitation. In
less than 2% the condition is persistent and requires further surgery.
Re-injury– If you are undergoing a reparative or reconstructive
procedure bear in mind that we can’t make your knee better than
new! If you should fail to comply with your rehab program or sustain
a significant injury after surgery the result may be compromised.
Failure of graft healing - in rare cases the graft tissue fails to heal
properly leading to recurrent instability.
Hardware failure - in rare cases the hardware may fail due to screw
migration of material failure.
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Section 5
Planning Before Your Surgery
Special Tests
It is most likely you have already had knee X-rays by your family
doctor or in our clinic. If necessary you may have to undergo other tests
such as an MRI (magnetic resonance imaging ), although, in the
majority of cases an MRI is not needed to make the diagnosis. Shortly
before surgery the therapist will test your knee’s stability and strength.
The purpose of this is to have a baseline for comparison after surgery.
Pre-operative Physical Therapy
Preparing your knee and body for surgery is one of the most
important steps to ensuring a good result from your operation. It is
important to understand that this operation is not an emergency
procedure. In fact many times the time between injury and surgery
ranges from 3 weeks to several months. Several studies have clearly
shown that the better your knee looks going into surgery the easier it
is to achieve a rapid and full recovery. The therapist will give you
some simple but effective home exercises designed to decrease
swelling, recover range of motion and strength.
General Medical Check-up
This is only required for individuals who have a history of certain
medical conditions ( eg- heart ailments, lung disease, etc ). In some
cases surgery needs to be postponed while further testing or treatment
is initiated.
Herbal Supplements/Weight Loss Products- The use of any weight loss
products or herbal supplements must be discontinued 2 weeks prior to
surgery. These products can interfere with bleeding control and
anesthetic medications.
8
Planning before your surgery
Section 6
Phase I: Pre-operative
This phase should be started as soon as possible after the injury
and is important even if you choose not to have surgery. These exercises prepare your knee for surgery or normal daily life by reducing swelling, increasing range of motion, and restoring a normal walk. You will
be educated about the surgery procedure and what you can expect following the surgery. A physical therapist or athletic trainer will instruct
you on the exercises. Your determination and compliance with the
home exercise program is the key to a successful recovery.
Please understand that all of the following exercises will be instructed by a Physical Therapist or Certified Athletic Trainer. This packet should be used only as a guide. Each therapist will individualize your
rehabilitation and you should follow his/her instructions.
Pre-operative goals:
1.
2.
3.
4.
Regain full range of motion (ROM).
Regain adequate strength.
Control swelling.
Surgical procedure education.
Exercises:
Fig. 9: Heel props.
Phase I: Pre-operative
1. Heel props (Fig. 9): This is used to regain extension. Prop your
heel on a firm object (Ex: pillow or armrest). Make sure your knee
is relaxed and let gravity do the work. This should be done for 10
minutes each time.
9
Fig. 10: Prone hangs.
2. Prone hangs (Fig. 10): This is also to regain extension. It can be performed on the edge of a bed, table, or stairs with your knee caps hanging off the end. Relax for 10 minutes each time.
3. Heel slides (Fig. 11a & 11b) : This is performed to regain your flexion
(bend). It may initially require the use of a towel (Fig. 11a) to pull your
foot closer to you. Once you gain enough motion you can use your
hands (Fig. 11b) to pull your leg closer. Hold your leg in the position
that you feel a good, tolerable stretch for 5 seconds then straighten
your knee out.
Fig. 11a: Towel slides.
Fig. 11b: Heel slides.
Fig. 13a:
Lateral step-downs
Starting point.
Fig. 13b:
Lateral step-downs
Heel taps the floor.
Fig. 13c
Front step-downs
Starting point.
Fig. 13d
Front step-downs
Heel taps the floor.
Strengthening:
Fig. 12: Quarter squats.
1. Leg press
2. Quarter squats Pre-operative goals: (Fig. 12): This picture demonstrates how low the squat should be when performed correctly. When
looking down at your feet while performing the squat, your knees
should not go beyond your toes.
3. Step-downs (Fig. 13a-d): This exercise can be done two different
ways. Your therapist will direct you on which exercise you should do.
4. Stationary Bike
5. Stairmaster (Fig. 14): This exercise helps to build endurance and leg
strength in a functional weight bearing position.
These exercises are performed as tolerated. Not all exercises will be able
to be completed, depending on the status of your knee before surgery.
Fig. 14: Stairmaster.
10
Phase I: Pre-operative
Section 7
The Day of Surgery
Guidelines
1. Do not eat or drink anything after midnight the day before your surgery.
2. Please bring crutches and Cryocuff to the hospital the day of surgery. If
you do not have these items, you will receive them at the hospital.
Check-in
Figure 15: Room in the surgical holding
area where you will wait for your surgery
You will have to register at the hospital on the day of surgery. The
specific time and location will be given to you during your office visit
or by mail. Please be prompt! Failure to arrive on time unnecessarily
delays not only your surgery but those who are having surgery after
you. If you are significantly late your surgery will be canceled. You
will be asked to arrive at least 2 hours before the actual surgery
time. This is to allow for the registration process and pre-operative
consultation with the anesthesiologist. After you have registered a
nurse will check you into the surgical holding area (figure 15) for a
physical evaluation, surgical site preparation and to change clothes
into a hospital gown. If you have not shaved your leg, it will be done
at this time.
Anesthesia
The nurse will start an intravenous ( I.V. ) line which will be used
to deliver medications to your bloodstream during and after surgery.
Immediately before surgery the anesthesiologist will discuss the
details of your anesthetic. Any questions you have regarding
anesthesia should be addressed to the anesthesiologist at this time.
The day of surgery
11
Surgery
After you have been prepared the nurse from the operating room will
take you to the surgery area. You will be asked to wear a surgical cap to
cover your hair. After being checked in a second time you will be
wheeled into the operating room (figure 14) ( please note that you will
be asked many of the same questions on several occasions. This is
merely to prevent any important information from “slipping through the
cracks” . We appreciate your patience). The surgical team is composed
of the surgeon, his assistant(s), 2 to 3 nurses or surgical technicians and
the anesthesiologists. The temperature in the room is typically lower
than normal and warm blankets will be provided. Once the
anesthesiologist is prepared he will administer medicine which will
make you feel relaxed. Afterward more medicine will cause you to fall
asleep. Surgical time varies from case to case but we will make a time
estimate for your family so they can plan appropriately. After surgery Dr.
Klootwyk will talk to family members to update them on your surgery.
Please make sure that family members are available at this time.
Post-Anesthesia Recovery Unit (PACU)
When you awaken from the anesthetic you will be in the PACU. A
nurse will be assigned to monitor your progress and address your
needs. Dr. Klootwyk will talk with your family or friends to update
them on your condition and discuss the procedure. After you have
stabilized you will be transferred to your room. It is only at this time
that your family members will be able to see you. Family members are
not allowed in the main recovery area because of need to maintain
the privacy of the other patients.
12
The day of surgery
You will have a wound dressing, T.E.D. (compression hose), Cryo/
Cuff or Vascutherm, , and drainage tubes on your knee. When you are
coherent and sufficiently comfortable, the nurses will send you to your
overnight hospital room. Shortly upon arrival to your room you will be
instructed on use of your CPM (continuous passive motion) machine,
Cryo/Cuff or Vascutherm, and rehabilitation exercises.
If you are at a Methodist facility the rehabilitation exercises will
begin very shortly after arriving to your room. Please be sure you understand the exercises as they are a crucial beginning to your recovery
process. You will receive a rehabilitation chart and follow the same
daily routine for the first week.
If you are at a St. Vincent facility your rehabilitation instruction will
be done by a member of Dr. Klootwyk’s staff the morning after surgery.
You will receive your rehabilitation chart at that time. Please be sure
you understand the exercises as they are a crucial beginning to your
recovery process.
Each patient will receive a visit from Dr. Klootwyk or one of his
assistants the morning after surgery. Dressings will be changed and
further post-operative instructions will be given. You will get up for the
first time since surgery and be given instructions on crutch use. You
will be given discharge instructions at that time and will be discharged
to go home.
The day of surgery
13
Section 8
Your Hospital Stay
Nursing Duties
A nurse will be assigned to you for your stay in the hospital.
Occasionally one nurse may be responsible for several patients. The
nurse is responsible for monitoring your progress, measuring your vital
signs, aiding with hygiene and administering your medications. If you
are experiencing any difficulties or if there are any questions the nurse
can communicate with Dr. Klootwyk or the anesthesiologist.
Pain Managment
Remember for the first 24 to 48 hours it is wise to stay ahead of your
pain. Don’t be too timid or proud to take your medication regularly during
this time. The following is a list of the common medications prescribed:
Norco - is a narcotic pain medication. It should be used as needed.
It should be taken 1-2 tablets every 4-6 hours as needed with food. This
medication may make you drowsy and may cause stomach irritation.
Keflex- is an antibiotic that you will use for 4-7 days. One tablet will be
taken 4 times per day. Once this medication is finished, there is no refill.
Ibuprofen (Advil)- two (2) 200mg tablets can be taken with the Norco.
This is best accomplished by taking the Ibuprofen 2 hours after the last
Norco dose. EXAMPLE: If you take a Norco tablet at 8:00, you can take 2
ibuprofen at 10:00.
After the first or second post-operative week, Norco is usually discontinued. If you do not need to use the Norco immediately after surgery, but
want some pain/inflammation control, you can use the
following guideline:
Aleve: take two (2) tablets in the morning and two(2) tablets in the evening (12 hours apart).
Tylenol ES: take two (2) tablets every 8 hours..
The Aleve and Tylenol can be taken in conjunction as outlined above.
DO NOT take Ibuprofen with the Aleve.
14
Your Hospital Stay
Control of Swelling
All patients will experience some degree of swelling after surgery.
Swelling is minimized by staying in bed with your leg elevated and by using
the CryoCuff. The CryoCuff is a vinyl bladder filled with ice water that wraps
around the knee (figure 16). You will continue wearing the CryoCuff even
at home for the first week after surgery.
Figure 16: CryoCuff
Physical Therapy
The morning following surgery the physical therapist will visit with
you. They will review or teach the necessary exercises to begin your
rehabilitation. These exercises are critical in the success of your
operation. Pay careful attention to the therapist and perform all of the
exercises as instructed.
Discharge from the Hospital
If you were admitted after surgery you will be seen by our surgical team
the next morning. You will be discharged after the following conditions
are met:
 Your pain is under control with oral medications
 You are able to eat and drink
 You are able to go the bathroom
 You have been visited by the surgical team
 You have seen the therapist and have learned your rehab exercises
Your Hospital Stay
15
Section 9
Limitations after Surgery
Activity
One of the most important goals after your surgery is to limit
swelling in your knee. Although the CryoCuff helps to minimize
swelling, your activity, being up on your feet, has the most impact on
swelling. For the first week after surgery you should minimize the
amount of time you are on your feet. You should only get up to go to
the bathroom or to shower. At all other times you should be laying
down with your leg propped up in the CPM machine or performing
your exercises. Our experience has shown that those patients who are
on their feet too much experience more swelling and then struggle
more with rehab.
Work/School
In general it is ideal to be off work for two weeks. In some cases it
is appropriate to return to a part-time schedule the second week
after surgery. For students who are in school surgery is typically
postponed until a natural break in the semester (ie- spring break,
etc). Delaying surgery is not detrimental as long as the patient avoids
high risk activities.
Driving
You should not drive for at least one week after surgery. If you had
surgery on your right knee it may take up to 2 weeks to drive comfortably
and safely.
16
Limitations after surgery
Section 10
What to Expect at Home
Rehabilitation
Rehabilitation after the Elmslie Procedure focuses on surgical
site protection, swelling control, range of motion, strength, and return to activity. The program allows for full weight-bearing with normal gait, early range of motion, and strengthening to allow a quicker
return to normal lifestyle activity.
The rehabilitation program requires you to take responsibility for
your progress by following a home exercise program. A physical
therapist or athletic trainer will outline your program and teach the
exercises that will aid in your recovery. These exercises set the path
for a complete recovery. Rehabilitation goals will be established
prior to surgery. If any problems occur throughout the program, or if
the goals are not being met, regular therapy visits will be required
for a successful outcome.
The program has five phases through which you will progress
during the rehabilitation process. Everyone will progress at a different rate, so the phases may actually overlap. The program is personalized for each individual.
What to expect at home
17
Medications and Pain Management
You will be given a prescription for pain and anti-inflammatory
medications. You should stop on your way home to fill your prescription
so that you don’t have to rush out to get them when you are already in
pain. Please let us know if you have any allergies or side effects to any
pain medications or anti-inflammatory medications (ie: ibuprofen,
motrin, aspirin ). Stay ahead of your pain. Take the medicine regularly
for the first 48 hours after surgery, then slowly wean yourself off of the
pain medicine and substitute with an over-the-counter medication.
Make sure to take your medicines with food.
Narcotic pain relievers alter your perception of pain. These
medications can make you feel sleepy therefore you should not drink
alcohol, drive, or operate machinery while taking them. Narcotic pain
relievers can cause nausea, particularly if taken without food.
Additionally some patients will notice constipation. To minimize this
be sure to drink plenty of fluids, especially fruit juices.
Anti-inflammatory medications will help with swelling, stiffness,
and pain. These medications can cause stomach upset and rarely,
ulcers. They too should be taken with food. If stomach irritation occurs
Pepcid AC can be taken in conjunction with the medication. If stomach
irritation persists or if you notice blood in your stools, immediately
discontinue the medication and call our office.
18
What to expect at home
Cryotherapy
Figure 16 CryoCuff
Cryotherapy ( cold therapy ) is just as important in your pain
management as the medications. The cold helps to decrease
inflammation and therefore swelling and pain in the knee. You should
apply the CryoCuff (figure 16) to your knee at all times except when you
are up walking, doing your exercises, or showering. You should keep
the CryoCuff on even when you are in the CPM machine, however, you
may need to loosen the bottom straps when you begin to get to the
higher degrees of flexion. Apply the CryoCuff at night before you go to
bed. You do not have to recharge it at night. Simply leave it in place
and recharge it in the morning. When using the CryoCuff, please have
a thin cloth between the skin and the CryoCuff.
Assistive Device
Figure 17: Heel prop exercise
Following surgery you will initially be required to use an assistive
device such as crutches or a walker. You are encouraged to put as
much weight on your leg as you can tolerate immediately following surgery. This is called partial weight bearing (Figure 17). The crutches are
used to allow you to take some pressure off your knee in order to walk
as normally as possible and maintain balance. Walking as normally as
possible is very important for gaining your strength and not developing
a bad habit of limping. Progress to full weight bearing when you can
walk without a limp and don’t need your crutches. You should expect to
be off your crutches between 1 to 2 weeks after surgery.
Fig. 17: Partial weight
bearing with crutches.
What to expect at home
19
Wound Care
This scar was from a patient
who was 2 months postop.
20
1. Dressing changes should be done every other day. This consists
of changing the gauze pads and applying clean T.E.D. hose. It is
extremely important that you do not remove your steri-strips
across your incisions. At the one week post-op visit your steristrips will be changed. The T.E.D. hose should remain on your
surgical leg until you return to the clinic. You can remove the
T.E.D. hose from your non-operative leg 48 hours after surgery. It
is a good idea to use the tubigrip sleeve that you will receive at
your one week visit for compression until swelling resolves. This
is only necessary when you are up and about.
2. Showering should be done carefully until the stitches are removed. You must keep your incision dry. You should remove your
T.E.D hose and put plastic wrap around your knee from mid-thigh
to mid-calf and a piece of tape around the top. If your knee does
get moist, allow it to fully dry before replacing the T.E.D. hose and
gauze dressings.
3. Sun exposure will alter your scar healing and color. It is recommended that if you are going to be in the sun you cover your
scars with something such as a Band-Aid or use at least 30 SPF
sunscreen for a full year following surgery.
4. Vitamin E can be used on your incisions after the stitches have
been removed. This may help the incision be less noticeable.
5. Cross-friction massage should be started after your stitches are
removed. Use your fingers to lightly rub in a perpendicular motion
over your scar two to three times per day for up to 5 minutes.
What to expect at home
Activity
One of the most important goals after your surgery is to limit swelling
in your knee. Although the cryocuff helps to minimize swelling, your
activity, being up on your feet, has the most impact on swelling. For the
first week after surgery you should minimize the amount of time you are
on your feet. You should only get up to go to the bathroom or to shower.
At all other times you should be laying down with your leg propped up in
the CPM machine or performing your exercises (figure 18). Our
experience has shown that those patients who are on their feet too much
experience more swelling and then struggle more with rehab.
Figure 18. CPM Machine
Driving
You should not drive for at least one week after surgery. If you had
surgery on your right knee it may take up to 2 weeks to drive comfortably.
Exercise
You may begin upper body exercises ( free weights, weight
machines ) two weeks after surgery. You should not resume any lower
body exercise (except physical therapy ) until you have consulted with
Dr. Klootwyk.
Sexual Activity
You may resume sexual activity as soon as you are comfortable.
Avoid direct pressure on your wound (ie kneeling).
What to expect at home
21
Section 11
Phase II: 1 to 6 Days
Hospital Discharge Goals:
Fig. 9: Heel prop.
1. Full easy knee extension in heel prop (Fig. 9) position and 110º of
flexion in CPM machine (Fig. 18 on page 21).
2. Ability to pick up leg on your own (Figure 19).
3. Weight bearing as tolerated with crutches (Figure 17).
Fig. 19: Leg raise.
Exercises:
1. You will begin using the CPM machine (Fig. 18) the day of surgery.
This will remain on your leg at all times except when performing
ROM exercises or when you are up for restroom use. It should be
set at –5º of hyperextension and 30º of flexion.
Fig. 17: Partial weight
bearing with crutches.
22
2. You will wake up with a Cryo Cuff or Vascutherm Device on your
knee. This will provide cold and compression to help decrease
your pain and swelling. The Cryo/Cuff or Vascutherm should remain on your knee at all times except when performing your exercises or walking. The water should be changed hourly during the
day and can be left alone through the night unless you wake up.
Phase II: 1 to 6 Days
3. Heel prop exercise: a) Extension (Fig. 9) should be done for 10
minutes 3x per day. Use the exercise log to keep track of each
exercise ( sample log is enclosed at end of packet). This exercise is crucial to the success of your rehabilitation program.
4. Knee flexion exercise: a) Secure your knee in the CPM machine
(Fig. 20). Set the machine to 110º of flexion. When it reaches
110º (top) shut it off and stretch in that position for 10 min.
This should be done 3 times per day.
5. Leg control: a) Quad sets: Do this on your involved leg each
time you do heel props. Contract your thigh muscle, hold it for
6 seconds and relax.
6. During the first week you should stay down as much as possible and use your CPM and Cryo/Cuff or Vascutherm to control
swelling. When it is necessary to get up you should weight bear
as tolerated with crutches .
Fig. 20: CPM machine set at 110º.
Phase II: 1 to 6 Days
23
Phase II: 7-14 Days
Section 12
Goals:
1. Full knee extension and flexion to 110º.
2. Minimal swelling.
3. Walk without a limp using a normal heel to toe gait (Fig. 21a & 21b).
Fig. 21a: Heel strike. Fig. 21b: Toe off.
Fig. 22: Towel extensions.
Fig. 23: Wall slides.
24
Exercises:
1. Full knee extension is still important in this phase. You
should be able to maintain your extension by performing the
following exercises: a) Towel extensions (Fig. 22): Place a
towel around the ball of your foot. Hold each end of the towel
with your hands and lean back. You should feel a stretch/
pull in the back of your knee. Your knee should be as straight
as your normal knee. b.) Prone hangs (Fig. 10). c.) Heel
props (Fig. 9).
2. Heel slides (Fig. 11b) and wall slides (Fig. 23) are the best
way to gain full knee flexion. Wall slides should be performed on the floor or bed next to a wall. Place your uninjured leg on top and use it to assist your ACL leg with bending
as it slides down the wall. When you feel a good, tolerable
stretch then hold it there for 5 seconds and then relax.
3. When you stand, full weight should be on your ACL leg with
your knee locked back into full extension.
4. You should begin full weight bearing without crutches. As
this becomes tolerable, discontinue use of crutches. It is very
important to use crutches until you can walk without a limp.
Phase II: 7-14 Days
Fig. 24a: Single leg
extension in the mid-range.
5. The following exercises may be included for strength: a) Quarter
squats (Fig. 12) a) Single leg extensions (Fig. 24a & 24b): This
exercise can be performed with or without weights. You can
place a cuff weight around your ankle to add resistance. As you
straighten your leg out, hold the contraction at the top for five
seconds and lower your leg slowly. c) Heel raises (Fig. 25a):
Double leg heel raises are used to strengthen your calf muscle.
(Fig. 25b): Single leg heel raises are performed after you can do
3 sets of 25 repetitions of double leg heel raises.
Fig. 24b: Single leg extension at
the end range.
Fig. 25a: Double leg
heel raises.
Phase II: 7-14 Days
Fig. 25b: Single leg
heel raises.
25
Section 13
Phase III: 1 to 3 Weeks
Goals:
Fig. 26 Quad Set.
1.
2.
3.
4.
Strong quad set (Figure 26) and ability to lift leg.
Minimal swelling.
Full weight bearing with immobilizer and without crutches.
Increased knee flexion.
Exercises:
Fig. 21a: Heel strike.
Fig. 21b: Toe off.
1. Full knee extension is still important in this phase. You should be
able to maintain your extension by performing the following exercises:
a. Towel extensions (Fig. 22): Place a towel around the ball of
your foot. Hold each end of the towel with your hands and
lean back. You should feel a stretch/ pull in the back of your
knee. Your knee should be as straight as your normal knee.
b. Prone hangs (Fig. 10).
c. Heel props (Fig. 9).
2. Heel slides (Fig. 11b) are the best way to gain full knee flexion.
3. You should begin full weight bearing without crutches. As this becomes tolerable, discontinue use of crutches. It is very important to
use crutches until you can walk without a limp.
Fig. 22: Towel extensions.
26
Phase III: 1 to 3 Weeks
4. The following exercises may be included for strength:
a. Quarter squats (Fig. 12)
b. Single leg extensions (Fig. 22a & 22b): This exercise can
be performed with or without weights. You can place a
cuff weight around your ankle to add resistance. As you
straighten your leg out, hold the contraction at the top for
five seconds and lower your leg slowly.
c. Heel raises (Fig. 25a): Double leg heel raises are used to
strengthen your calf muscle. (Fig. 25b): Single leg heel
raises are performed after you can do 3 sets of 25 repetitions of double leg heel raises.
Fig. 24a: Single leg extension in
the mid-range.
Fig. 25a: Double leg heel raises.
Phase III: 1 to 3 Weeks
Fig. 25b: Single leg heel raises.
27
Section 14
Phase IV: 3 to 6 Weeks
End of Phase Goals:
1.
2.
3.
4.
Normal gait.
Increase to full flexion .
Maintain full extension.
Increase strengthening
Exercises:
1. Continue with heel props, towel extensions, and prone hangs as needed to
maintain full easy extension.
2. Once you are able to demonstrate a single leg knee bend (Fig. 27) without
difficulty, weight room activities can begin:
a. Quarter squats (Fig. 12)
b. Unilateral leg press
c. Single leg heel raises (Fig. 25b)
d. Stairmaster at greater intensity levels (Fig. 14)
e. Single leg step-downs (Fig. 13a-d)
f. Single leg extensions (Fig. 24a & 24b)
g. Bicycle workouts can begin as long as you have at least 120º of
flexion. Use it for moderate speed strengthening workouts.
Agility:
Fig. 27: Single leg knee bend.
1. If you have full ROM and other necessary goals have been met, then sport
specific activities and agility drills can be initiated.
28
Phase IV: 3 to 6 Weeks
Section 15
Phase V: 6 Weeks on
Early Phase Goals:
1.
2.
3.
4.
Full ROM.
Consistent strength workouts.
Begin return to sport/ activity.
Strength .to 75-80% of non-involved leg with Cybex testing.
Exercises:
1.
2.
3.
4.
5.
6.
Fig. 28: 90º squat.
Greater than or equal to a 90º squat (Fig. 28) as tolerated.
Unilateral leg press
Single leg step-downs (Fig. 13a-d)
Stairmaster (Fig. 14)
Bicycle
Once the incisions (Figure 29) have healed (4 weeks), swimming and pool workouts are great for endurance and strength
training without added stress to your knee joint.
Need picture here
Fig. 29: Surgical incision
Phase V: 6 Weeks on
29
Agility:
1. Your ability to return to controlled agility training and sport specific activity is determined by your strength testing.
2. A gradual progression of agility and sports participation will help you to
regain fast speed strength and to build your confidence with athletic
activities. The following drills may be included in your program:
a. Jumping rope.
b. Lateral slides (defensive slides).
c. Backward running.
d. Shooting baskets, dribbling a soccer ball and other sport specific drills.
Final Goals:
1. Return to prior activity level.
2. Achieve full strength.
Final Exercise Progression:
1. Strengthening will continue in areas where weakness resides. Your
therapist will advise you on those exercises.
2. Endurance and agility can progress as tolerated.
30
Phase V: 6 Weeks on
Section 16
Common Problems
Pain
Pain is normal after surgery. This surgery is traumatic and you should
expect some discomfort. The pain medication should be utilized to keep
you as comfortable as possible.
Nausea
Nausea may be experienced following surgery. This can be caused
from the anesthesia and should be out of your system in about 24 hours.
If you experience this in the hospital, medication can be administered
through your IV to alleviate symptoms. As described earlier, your medications can also make you nauseated. Food will help prevent problems.
Call the office if the nausea continues more than 48 hours. Never take
your pain medicine on an empty stomach. Once you become nauseated
you may not be able to take your medicines and it may be necessary to
take rectal suppository anti-nausea medicine.
Itching
Norco and Percocet can cause itching over the entire body. In most cases
over-the-counter benadryl, 25mg tablets, every 4-6 hours will relieve the
symptoms. If you still experience itching after 12-24 hours call the office.
Change in appetite/bowel habits
Bowel movements may change due to medication and inactivity. Try to eat
fruit and drink lots of fluids the first post-op week. Over-the-counter stool
softeners such as Colace may be used as needed. As you are able to get
more active during the second week the problem should resolve.
Common Problems
31
Stiffness
Most patients notice that their knee feels stiff after surgery, especially
when they first get up in the morning. This is normal and should
improve rapidly within the first several weeks after surgery.
Bruising/swelling
Bruising may occur around your knee and shin area. An ice bag on
your shin may minimize bruising and help with discomfort. Swelling is
also a normal process following surgery. Excessive swelling can increase your pain and slow down your recovery. You can minimize swelling by staying down, using the T.E.D. hose and the Cryo/Cuff Vascutherm , and staying in the CPM machine.
Numbness and tingling
Lateral (outside of knee) numbness in your knee should be expected following ACL reconstruction. This is a result of the front surgical incision. It will slowly improve with time and you may always have a
dime-size area that has decreased sensation or a funny feeling to the
touch. This is only sensory and will not affect any part of your knee or leg
function. Numbness in the foot may be due to swelling or an over
tightened CryoCuff. Try to control swelling (see above) and loosen the
CryoCuff if you feel it may be too tight.
If you have questions about the above symptoms, contact the office
@ (317)817-1294 .
Or, if after hours, call (317)817-1200 and ask the answering service to page the office.
32
Common Problems
Section 17
When to Call the Doctor
If you experience any of the following problems, call our office:
Fever
A low grade fever below 100° F is common. A temperature above 101°
F, especially if it persists after the first 48 hours after surgery should be
reported.
Pain
Pain is expected after surgery. Your pain can be aggravated if you fail
to take your medicine as directed or if you are overactive with your
knee after surgery. If your pain is steadily increasing over
consecutive days despite all of the normal pain control measures
( see section 1 ) call our office.
Wound Problems
You should expect some minor bloody drainage to be visible on the
dressing. The dressing acts as a wick, therefore, a small amount of
blood can make moderate sized spot on the dressing. If your
dressing becomes soaked with blood or if you notice any pus
drainage call our office.
When to Call the Doctor
33
Section 18
Important Telephone Numbers and Office
Hours
Methodist Sports Medicine Center office hours are from
8:00am to 5:00pm Monday through Friday and 8:00am to
10:00am Saturday. The clinic is closed for official holidays.
General clinic telephone number:
Indianapolis: 317-817-1200
Toll Free: 800-867-9250
FAX number: 317-819-1217
Answering Service: 317-817-1200 - After hours emergency post-operative
questions call the answering service and ask for Dr. Klootwyk
Dr. Klootwyk’s assistants:
John Darmelio (Athletic Trainer, Clinical Asst.): 317-817-1294
Jeff Gray (Surgical Nurse, Clinical Asst.) 317-817-1295
Cindy Gramman (Secretary) 317-580-3516
Scheduling 317-817-1201 option 2
Physical Therapy: 317-817-1200
Methodist Hospital or Beltway Surgery Center:
Patient Accounts (Hospital charges)
800-552-6871
317-817-1125
St. Vincent Carmel Hospital:
Patient Accounts (Hospital charges)
800-582-8258
317-338-8035
34
Important Telephone Numbers & Office Hours
Section 19
Return to Work/School and Sports
Follow-up visits
You will have an appointment to see Dr. Klootwyk 6-8 days after
surgery. During this visit your dressing will be removed and your knee
will be examined by Dr. Klootwyk. Following the exam you will see the
therapist to review your exercise program and to add other exercises if
appropriate. Most patients are taught a home exercise program which
they can do on their own. You will then return for subsequent visits at 2
wks, 1 month, 2 months, 3-4 months, 6 months and 1 year after surgery.
At each visit your knee will be re-examined and if necessary you will see
the therapist to update your home exercise program.
Work
You may return to work/school within one to two weeks if you have
a sedentary job. If you have a job that requires manual work ( factory,
construction, etc ) then you may return to light duty within 2 weeks.
Return to full duty manual work will be based on your specific job and
your progress in rehabilitation. The range is 2-4 months.
Sports
Your doctor and therapist will give you specific guidelines to return
to sports. You can typically return to upper body weight training in 2
weeks. Lower body weight training will typically begin at 4-6 weeks.
Return to all weight lifting and contact sports usually occurs
approximately 3-4 months after surgery. Remember each patient moves
through rehabilitation at his or her own pace. An individual may
progress faster or slower than the average times listed above.
Follow-up Visits/ Return to Work/Sports
35