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

ELMSLIE TRILLAT SURGERY

Table of CONTENTS

How does your knee work?.............................................................................................. 1 Section 1

What’s wrong with your knee? ......................................................................................... 3 Section 2

How does surgery correct my knee problem...................................................................... 4 Section 3

Potential risks of surgery ........................................................................... 6

Peri-operative risks ............................................................................................ 6

Post-operatvie risks ........................................................................................... 7

Section 4

Pre-operative planning.................................................................................................... 8

Special tests ..................................................................................................... 8

Pre-operative Physical Therapy ............................................................................ 8

General medical check-up .................................................................................. 8

Section 5

The day of surgery ......................................................................................................... 11

Check-in ......................................................................................................... 11

Anesthesia...................................................................................................... 11

Surgery ........................................................................................................... 12

Post-operative recovery unit.............................................................................. 12

Section 7

Your hospital stay ......................................................................................................... 14

Nursing duties ................................................................................................. 14

Pain management ........................................................................................... 14

Control of Swelling .......................................................................................... 15

Physical therapy .............................................................................................. 15

Discharge from the hospital .............................................................................. 15

Section 8

Limitations after surgery ............................................................................................... 13 Section 9

Phase I: Pre-operative ................................................................................................... 9

Pre-operative Goals ........................................................................................... 9

Exercise ........................................................................................................... 9

Strengthening ................................................................................................. 10

Section 6

Table of CONTENTS

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

Section 10

Phase II: 1 to 6 Days .............................................................................. 22

Hospital Discharge Goals ................................................................................. 22

Exercises ........................................................................................................ 22

Section 11

Phase II: 7 to 14 Days ............................................................................ 24

Goals ............................................................................................................. 24

Exercises ........................................................................................................ 24

Section 12

Phase III: 1 to 3 Weeks ........................................................................... 26

Goals ............................................................................................................. 26

Exercises ........................................................................................................ 26

Section 13

Phase IV: 3 to 6 Weeks ............................................................................28

Goals ..............................................................................................................28

Exercises .........................................................................................................28

Section 14

Table of CONTENTS

Return to work (school) and sports ............................................................ 35

Follow-up visits ............................................................................................... 35

Work .............................................................................................................. 35

Sports ............................................................................................................ 35

Section 19

When to call the doctor ........................................................................... 33 Section 17

Important telephone numbers/office hours ............................................... 34 Section 18

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 16

Phase II: 1 to 6 Days .............................................................................. 29

Early Phase Goals ............................................................................................ 29

Exercises ........................................................................................................ 29

Agility ............................................................................................................. 30

Final Goals...................................................................................................... 30

Final Exercise Progression ................................................................................ 30

Section 15

How does your knee work? 1

Section 1

How Does Your Knee Work?

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

Figure 1: Bones of the knee joint

Trochlea

Fibula

Femur

Tibia

Figure 2: The extensor mechanism as viewed from the side

Quadriceps

Patella

Patellar Tendon Gastrocnemi-

Hamstrings

2 How does your knee work?

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).

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)?

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)).

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

What’s Wrong With Your Knee? 3

Section 2 What’s wrong with your knee?

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

Normal Abnormal

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

2

A

A

B

B

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 instru-

ments 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.

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 in-

volves making an incision under the skin. The tissue along the out-

side of your patella is cut or released to allow more freedom of move-

ment as your patella glides up and down with normal knee motion.

(Figure 7) This will help decrease the irritation, pain, and friction un-

der the patella as well as help decrease the chances of the patella

sliding out (dislocating).

4

Figure 5: The arthroscope, which is used to

examine the inside of your knee

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.

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 en-

velope 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 tu-

berosity. 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 attach-

ment 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.

What Kind of Surgery is Performed? 5

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.

A B

6 Potential Risks of Your Surgery

Peri-operative risks

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:

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 anti-

nausea 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!

Potential Risks of Your Surgery 7

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.

1. 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.

2. 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.

3. Failure of graft healing - in rare cases the graft tissue fails to heal

properly leading to recurrent instability.

4. Hardware failure - in rare cases the hardware may fail due to screw

migration of material failure.

Post-operative risks

Special Tests

Section 5 Planning Before Your Surgery

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.

8 Planning before your surgery

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.

Phase I: Pre-operative 9

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 exercis-

es prepare your knee for surgery or normal daily life by reducing swell-

ing, increasing range of motion, and restoring a normal walk. You will

be educated about the surgery procedure and what you can expect fol-

lowing 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 in-

structed by a Physical Therapist or Certified Athletic Trainer. This pack-

et should be used only as a guide. Each therapist will individualize your

rehabilitation and you should follow his/her instructions.

1. Regain full range of motion (ROM).

2. Regain adequate strength.

3. Control swelling.

4. Surgical procedure education.

Pre-operative goals:

Exercises:

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. Fig. 9: Heel props.

10 Phase I: Pre-operative

2. Prone hangs (Fig. 10): This is also to regain extension. It can be per-

formed on the edge of a bed, table, or stairs with your knee caps hang-

ing 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.

1. Leg press

2. Quarter squats Pre-operative goals: (Fig. 12): This picture demon-

strates 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.

Strengthening:

Fig. 13a: Fig. 13b: Fig. 13c Fig. 13d

Lateral step-downs Lateral step-downs Front step-downs Front step-downs

Starting point. Heel taps the floor. Starting point. Heel taps the floor.

Fig. 14: Stairmaster.

Fig. 10: Prone hangs.

Fig. 11a: Towel slides.

Fig. 11b: Heel slides.

Fig. 12: Quarter squats.

The day of surgery 11

Check-in

Section 7

The Day of 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.

Figure 15: Room in the surgical holding

area where you will wait for your 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.

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

The day of surgery 13

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 un-

derstand 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.

14 Your Hospital Stay

Nursing Duties

Section 8 Your Hospital Stay

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 discontin-

ued. 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 even-

ing (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.

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.

Control of Swelling

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.

Physical Therapy

Figure 16: CryoCuff

Your Hospital Stay 15

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

16 Limitations after surgery

Activity

Section 9

Limitations after Surgery

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.

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.

Driving

What to expect at home 17

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 re-

turn to activity. The program allows for full weight-bearing with nor-

mal 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 differ-

ent rate, so the phases may actually overlap. The program is per-

sonalized for each individual.

18 What to expect at home

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.

Medications and Pain Management

Figure 17: Heel prop exercise

What to expect at home 19

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 sur-

gery. 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.

Assistive Device

Fig. 17: Partial weight

bearing with crutches.

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.

Cryotherapy

Figure 16 CryoCuff

20 What to expect at home

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 steri-

strips 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 re-

moved. 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 recom-

mended 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.

Wound Care

This scar was from a patient

who was 2 months postop.

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

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.

Activity

Figure 18. CPM Machine

22 Phase II: 1 to 6 Days

Fig. 9: Heel prop.

Fig. 19: Leg raise.

Fig. 17: Partial weight

bearing with crutches.

Section 11

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).

Phase II: 1 to 6 Days

Hospital Discharge Goals:

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.

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 re-

main on your knee at all times except when performing your exer-

cises or walking. The water should be changed hourly during the

day and can be left alone through the night unless you wake up.

Exercises:

Phase II: 1 to 6 Days 23

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 exer-

cise 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 possi-

ble 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.

24 Phase II: 7-14 Days

Phase II: 7-14 Days

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).

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 per-

formed on the floor or bed next to a wall. Place your unin-

jured 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.

Fig. 21a: Heel strike. Fig. 21b: Toe off.

Fig. 22: Towel extensions.

Fig. 23: Wall slides.

Section 12

Phase II: 7-14 Days 25

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. 24a: Single leg

extension in the mid-range.

Fig. 24b: Single leg extension at

the end range.

Fig. 25a: Double leg

heel raises.

Fig. 25b: Single leg

heel raises.

26 Phase III: 1 to 3 Weeks

Section 13

Phase III: 1 to 3 Weeks

Goals:

1. Strong quad set (Figure 26) and ability to lift leg.

2. Minimal swelling.

3. Full weight bearing with immobilizer and without crutches.

4. Increased knee flexion.

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) are the best way to gain full knee flexion.

3. You should begin full weight bearing without crutches. As this be-

comes tolerable, discontinue use of crutches. It is very important to

use crutches until you can walk without a limp.

Fig. 21a: Heel strike. Fig. 21b: Toe off.

Fig. 26 Quad Set.

Fig. 22: Towel extensions.

Phase III: 1 to 3 Weeks 27

Fig. 24a: Single leg extension in

the mid-range.

Fig. 25a: Double leg heel raises. Fig. 25b: Single leg heel raises.

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 repeti-

tions of double leg heel raises.

28 Phase IV: 3 to 6 Weeks

Section 14

Phase IV: 3 to 6 Weeks

End of Phase Goals:

1. Normal gait.

2. Increase to full flexion .

3. Maintain full extension.

4. 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.

Fig. 27: Single leg knee bend.

Agility:

1. If you have full ROM and other necessary goals have been met, then sport

specific activities and agility drills can be initiated.

Phase V: 6 Weeks on 29

Phase V: 6 Weeks on

Early Phase Goals:

1. Full ROM.

2. Consistent strength workouts.

3. Begin return to sport/ activity.

4. Strength .to 75-80% of non-involved leg with Cybex testing.

Exercises:

1. Greater than or equal to a 90º squat (Fig. 28) as tolerated.

2. Unilateral leg press

3. Single leg step-downs (Fig. 13a-d)

4. Stairmaster (Fig. 14)

5. Bicycle

6. Once the incisions (Figure 29) have healed (4 weeks), swim-

ming and pool workouts are great for endurance and strength

training without added stress to your knee joint.

Section 15

Fig. 28: 90º squat.

Fig. 29: Surgical incision

Need picture here

30 Phase V: 6 Weeks on

1. Your ability to return to controlled agility training and sport specific ac-

tivity 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 spe-

cific drills.

Agility:

1. Return to prior activity level.

2. Achieve full strength.

Final Goals:

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.

Final Exercise Progression:

Pain

Section 16

Common Problems

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 medica-

tions 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.

Common Problems 31

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.

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 in-

crease your pain and slow down your recovery. You can minimize swell-

ing by staying down, using the T.E.D. hose and the Cryo/Cuff Vas-

cutherm , and staying in the CPM machine.

32 Common Problems

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.

Numbness and tingling

Lateral (outside of knee) numbness in your knee should be ex-

pected following ACL reconstruction. This is a result of the front surgi-

cal 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 ser-

vice to page the office.

If you experience any of the following problems, call our office:

Section 17

When to Call the Doctor

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

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.

Section 18

Important Telephone Numbers and Office

Hours

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

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.

Follow-up Visits/ Return to Work/Sports 35

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.

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