Dr. Anthony A. Schepsis

Coastal Orthopedics
Beverly, MA
Professor of Orthopedic Surgery
Boston University School of Medicine

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ACL surgery

AFTER YOUR ACL SURGERY


Anthony A. Schepsis, M.D.

 Coastal Orthopedics

Beverly- Lahey Health

978-927-3040978-927-3040

You have just undergone reconstruction of your anterior cruciate ligament (ACL).  The post-operative instructions should answer most of your questions about caring for your knee from the time of discharge to your first follow-up appointment with Dr. Schepsis (10-14 days after surgery).

 

  1. Prescribed Medication:
    1. For pain:

1.  Oxycodone (5mg) one to two tablets as needed every 4- 6 hours pain

2.  Toradol (ketorolac) 10 mg one tablet every 6 hours for 5 days (no refills)

Take the following only after the Percocet and Toradol are gone (or for mild pain)

3.  Tylenol (2 extra strength tablets every 3-4 hours) or

  1. Advil (Ibuprofen) two every 4 hours with food
  2. Antibiotics:

1.  Keflex 500mg every 6 hours until completed (prevents infections)

  1. Enteric coated Aspirin (325 mg) starting the day after surgery (tomorrow) unless there is an allergy or medical contraindication (e.g. GI ulcer disease).  We recommend for you to take aspirin for 4 weeks.  Aspirin is to reduce the risk of blood clots following ACL surgery.  This is particularly important in high risk patients: over the age 40 or females taking oral contraceptives.
  2. Other medications: ­­­­­­­­­­­­­­­­­­­_______________________________________________________
  3. Brace:
    1. The brace is initially locked in extension (your leg straight).  It is to be worn this way for walking and sleeping until Dr. Schepsis tells you otherwise.  It is taken off for your exercises as well as for the CPM (continuous passive motion) machine.  It can be unlocked for sitting.  The length of time it is to be worn locked with walking depends on your individual case.  If you had a meniscal repair, it may be locked for walking up to 4 to 6 weeks.  Further instructions will be given at your first follow-up appointment. 
    2. In most cases, a cryocuff device which supplies compression as well as ice to your knee has been applied under your brace.  You will be instructed in its use before discharge.  It should be used regularly for the first 3 days after surgery.  Before walking, it should be drained and the brace straps tightened.  After three days, you should still use the cryocuff for icing the knee; though, you do not have to wear it all the time.
    3. The snug white stocking on your leg is called a TED stocking and keeps the swelling down in your lower leg and foot as well as your knee.  It also helps prevent blood clots.  It is to be worn for the first 2 weeks after surgery.  After this, an ace bandage just around the knee under the brace is sufficient.
    4. Swelling in your lower leg below the knee and/or the foot can occur from being on your feet for longer periods of time in the immediate post-operative period or from the brace straps and/or cryocuff being too tight and constricting.  You can lie down on your back, elevate you leg on pillows above the level of your heart and remove/reposition the brace and cryocuff.  If you continue to have swelling, while lying on your back, remove the brace and bandages and do ankle pumps.

3.       Dressing Instructions:

  1. Expect some bloody staining through your dressing, especially in the first couple of days.  If mild, just leave the dressing intact for the first 5 days after surgery. If moderate, the dressing can be changed sooner.  If excessive, contact the office immediately at 617-638-5633617-638-5633.
  2. In routine cases, the dressing can be changed 5 days after surgery.  Pull the stocking down and remove the wrap and bandage around you knee.  The incision site will be covered with white steri-strips and/or sutures.  Do not remove the steri-strips.  This will be done at your follow-up visit.  There will be approximately 3 tiny “nick” portal site incisions with 1 to 2 stitches.  You can clean these sites with alcohol or peroxide and apply a Band-Aid. Apply sterile gauze pads to the incision site and wrap the knee loosely with kerlex or kling bandage.  Only change the bandage as necessary after this until your follow-up appointment. 
  3. You must cover the incision with a bag to shower or bathe.  Keep the incision dry.
  4. Report any pus or unusual drainage immediately, especially if it is associated with increased pain, redness, warmth, and a temperature > 101°F.  However, it is normal to have a low grade temperature for the first few days following surgery.
  5. CPM (Continuous passive motion):
  6. The CPM machine is to be used at home starting the day after surgery.  The brace should be removed while using it.  The initial setting should be from 0° (knee straight) to 40°.  The machine should be used in two hour sessions, three times a day.  Set the machine at a slow speed.  Try to increase 10 degrees per day, although this is not always possible.  The machine has been prescribed for 2 weeks, at which time the CPM representative should be called to pick it up.  If you pause the machine for a period of time, stop it at 0 degrees (with the knee straight) so your knee does not get stiff in a bent position.
  7. If you had a meniscal repair you will be restricted to maximum of 90° flexion on the CPM machine.  Otherwise, you may flex pass 90º, up to 120º once comfortable.
  8. Company used for CPM machine:  ____________________
  9. Physical Therapy
  10. Formal physical therapy should start within 2 to 3 days after surgery, with sessions initially 3 times per week.
  11. You will be given home exercises by the physical therapist and you should do these along with the following exercise flow sheets provided for you to get started.  These are very important in addition to the CPM.  In particular, the exercises to straighten you knee completely (towel extension) is critical during the first couple of weeks. 
  12. A written physical therapy protocol has been supplied to you and your therapist.  This is a “rough guideline” and there will be a lot of individual variations. 
  13. Crutches and weight bearing:
  14. In standard cases, you can weight bear as tolerated with 2 crutches, meaning you can apply as much weight as you feel comfortable as time progresses.  You will use 2 crutches for at least the first 3 weeks and given further instructions at your follow-up visit. 
  15. Meniscal Repair Precautions:  If you had a meniscal repair you will have more restrictions in terms of weight bearing and how long you will be on crutches. Usually the brace will be worn in a locked position for a longer period of time as well. Meniscal REPAIR precautions are:
    1. Do not bear weight on the surgical leg for 4-6 weeks.
    2. No flexion (bending) past 90 degrees for 4-6 weeks.
    3. Driving Instructions:
    4. Right knee- no driving for the first couple of weeks (approx 1-2). You will be able to get back to automatic driving sooner than standard.
    5. Left knee- automatic driving is acceptable once you are comfortable. 
    6. We advise no driving while taking narcotic medication.
    7. Follow-up appointment:

a.    Call 978-927-3040978-927-3040 to schedule your follow-up appointment, preferably 10-14 days after surgery.

 

  1. Other Instructions  ­­­­­­­­­­­­­­­­­­­­________________________________________________________________.






Patient:

DOS:           

                                                                        Anthony A. Schepsis M.D.

                                                      Coastal Orthopedics

                                                      Beverly- Lahey Health

                                                      978-927-3040978-927-3040

ACL REHABILITATION PROTOCOL

I.               Immediate Post-Op

  1. Bledsoe brace locked at 0 °
  2. Cryocuff incorporated in brace with TED stocking
  3. Patient instructed in performance of ROM exercises: 2-3 times daily
    1. “Towel” extension:  obtain passive extension at least 30 minutes by propping heel up on pillows.
    2. Passive flexion – off side of bed.
    3. Good leg assist for passive ROM out of brace.
    4. Prone extension stretch
  4. Isometric hamstrings
  5. Isometric quads at > 45°.  Quad sets, SLR at 0°
  6. SLR for quad control
  7. Cocontractions
  8. Ankle pumps
  9. Weight bearing as tolerated with crutches (except meniscal repair)
  10. Meniscal Repair Precautions:
    1. Nonweight bearing for 4-6 weeks
    2. Limit flexion to 90° for first 4 weeks

II.             Days 3-4 to 2-3 weeks

  1. CPM  for home use (2 hour sessions, 3 x per day- slow speed for 2 weeks)  Start at the degrees of flexion obtained in hospital.  Progressive increase in increments of flexion.  Increase 10° increments per day up to 90°, then increase in 5° increments as tolerated.
    1. Goal:  0-100 of flexion (emphasis on full extension)
  2. Outpatient P.T.:  3 times per week
  3. Use TED stocking until follow up appointment ( 10-14 days)
  4. Continue Cyrocuff as needed
  5. Home exercises: 3 times per day
    1. Towel extensions
    2. Prone passive stretching (if necessary for extension)
    3. Wall & heel slides for flexion (or comparable flexion exercises)
    4. Active assisted knee flexion only
    5. Good leg assist passive extension
    6. Isotonic hamstrings
    7. Open chain quads 90°- 45° (if tolerated)
  6. WB as tolerated with crutches (unless meniscal repair)
  7. Brace at 0° for ambulating and sleeping
  8. Cryocuff after exercises or if swelling occurs
  9. EMS Protocol:  High Voltage, Cocontractions

III.           Weeks 3-6

  1. Fit with Protective Derotation Brace (0-100° minimum):  week 2-4: depending on individual case.  Exception:  Meniscal repair stays in Bledsoe for 6 weeks.
  2. Wean down on one crutch or cane
  3. EMS  Protocol
  4. Continue ROM exercises as before with home program
  5. Water Conditioning (can start earlier if there is complete wound healing)
  6. Swimming-  well leg kick only
  7. Stationary Biking, Stairmaster, ¼ Squats     
  8. Start Easy Closed Chain Quad Exercies
  9. Isotonic Hamstring
  10. Quads 90-30’ (if no patellar irritation)
  11. Stress Full Extension.  Should have 120° of flexion by 6 weeks

IV.           Weeks 6-12

A.   Most strengthening exercises for quadriceps are to be closed kinetic chain exercises

  1. Bilateral knee bends; progress to unilateral knee bends
  2. Calf raises (double to single leg)
  3. Leg press machine (90- 10’)
  4. One leg balancing

B.   Brace for high risk situations only

  1. Wean off crutch or cane
  2. Stationary Biking (for ROM first, then gradually add resistance)
  3. Continue heel slides for flexion at home
  4. Passive flexion stretch
  5. Water conditioning
  6. Swimming (flutter kick only)
  7. Increase hamstrings
  8. Strengthening
  9. If quad strength > 70% - rope jumping ( with brace ), leg press, hip slide, squat rack (90- 10’), stairmaster
  10. Discontinue Derotation brace for ADL’s

V.             3-5 Months

  1. Cycling and swimming (progress to road bike)
  2. Isokinetic’s at 5-6 Months with extension stop of 20’ (no low angular velocities)
  3. Jogging at 3-4 months (if quad strength > 70 %)
  4. Proprioceptive exercises (balance board)
  5. Leg Press
  6. Strength Test, KT – 1000.  If > 70% strength, lateral shuffles, cariocas, jumping rope, isotonics with 20’ extension stop
  7. Closed Chain Quad Strengthening with increasing resistance

VI.           5- 12 Months

  1. Progressive Strengthening without restrictions on extension
  2. Proprioceptive exercise
  3. Sports specific activities
  4. Biking and swimming
  5. Return to all sports (per physicians instructions)
  6. Jumping sports last
  7. Serial isokinetic testing as indicated
  8. Running program with emphasis on agility and power
  9. Functional activities
    1. side- cutting
    2. back pedaling
    3. cutting
    4. pliometrics

F.   Protective brace for pivoting and jumping activities until 24 months

G.  Running sports to cutting sports

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