In this review, the athlete had received his first
ACL surgery using the Hamstring
Semitendinosus auto-graft (HMST). The rehabilitation process took twelve months and the athlete was then cleared to play. The athlete did not feel comfortable enough to play without a brace for two months following the surgery.
During the two months the athlete did complain of general knee pain with associated weakness compared to his other leg. There was no girth difference measured with girth measurements.
After the two months of participation, while wearing the brace, the athlete removed the brace during the third month of play. After one month of utilizing no brace the athlete reinjured the ACL.
The second surgery used Bone-Patellar Tendon-
Bone auto-graft (BPTB) technique. After a nine month rehabilitation plan, the athlete was in preseason training with the team. The pre-season training was two weeks long for the first week the athlete wore the knee brace that was custom made for his knee. The second week the athlete was nervous but willing to play without the brace.
As of today there has been no issues with the athlete. He has been full participation all season.
The purpose of this case review is to inform athletic trainers of current literature and rehabilitation practices to treat athletes following an ACL tear. Since this particular injury is one of the most common injuries with all athletes today, research needs to be brought to the attention of all athletes. This is essential in deciding the best option on repairing for repair of the ACL. The research will examine all aspects of the rehabilitation process, knee laxity, strength, range of motion, and over all knee pain.
20-year-old Male
Right left dominant
Injury happened to left leg
5 th year senior Midfield player
No history of any other injury
First ACL surgery HMST
Second ACL surgery BPTB
The auto-graft is harvested from a small incision over the pes anserine. The semitendinosus tendon is found and removed but it is prepared in two different fashions; triple or quadruple graft style. The femoral tunnel is drilled transtibially but the tibial tunnels are drilled in standard fashion. The same location the Bone Patellar Bone auto-graft (BPTB) was placed are the same sites for the HMST. Screws are used to hold the auto-graft in place on both the femoral and tibial sites. The main advocates of the HMST auto-graft are the facts that support smaller cases of anterior knee pain compared to the BPTB. Osteoarthritis is another major factor that has been brought into the light about the advantages for HMST auto-grafts. Since the
BPTB auto-graft has a high result of patients that present with osteoarthritis the HMST auto-grafts do not represent with this issue 10 years plus after surgery.
For the BPTB, an incision is made between the inferior aspect of the patella to the tibial tuberosity and the middle third of the patellar tendon is removed with proximal and distal bone plugs. Arthroscopy is then performed to position the graft in the correct area of the meniscus and femoral condyle and for proper screw fixation.
The bone tunnels are prepared in a standard transtibial fashion. Once the tunnels are drilled the bone segments are put into place with screws. The auto-graft surgery is extremely useful in the younger and active populations.
The hypothesis for improved results in this population relates to the faster incorporation and healing into bone tunnels. The bone will set into place within 6 weeks, whereas soft-tissue auto-grafts can take 8-12 weeks or longer to achieve healing. Knee laxity plays a major roll into the reconstruction process and the BPTB auto-graft has demonstrated to have the least amount of knee laxity compared to all options for
ACL reconstruction.
This rehabilitation program below was given to the athlete by the doctor that preformed the surgery. An adjustable hinged brace was locked in place at 10 degrees of knee flexion for the first week and walked with toe-touch weightbearing using crutches through two weeks. At the end of two weeks the athlete could be at 90 degrees of knee flexion and all exercises were allowed between 45 and 90 degrees with 5 pounds of weight as tolerated. At week three the athlete could walk with the brace and without the crutches. Preparatory plyometric exercises could be performed as tolerated. At five weeks brace was to be discontinued unless the athlete felt unsafe in certain situations. Extend the knee against resistance and was full range of motion. Swimming and biking without resistance is permitted along with isotonic motions of the hip, and knee. Eight weeks the athlete was able to extend and flex the knee against unlimited resistance this was permitted by doctor. The bicycle can be promoted to riding with resistance and submaximal plyometric exercises. Twelve weeks the athlete was able to do unrestricted isotonic quadriceps strengthening was allowed. At four months the athlete was running in a straight line and first isokinetic strength testing was performed. At six and eight months the athlete was performing sports specific exercises and began to return to play.
As noted throughout the ten studies reviewed, there was some conflicting evidence and some evidence that is valuable. The affected muscle for each auto-graft was different; the HMST graft affected the hamstrings and the
BPTB graft affected the quadriceps. To benefit most from these auto-grafts the patients would benefit from going through a specialized rehabilitation program that would target the affected muscles. All of the patients in each study went through the same rehabilitation and as seen in all of the case studies, different auto-grafts need to go through different strengthening exercises. The difference of the affected muscle groups affects the amount of time the patient is out of play. With the BPTB graft the patients seemed to return to full activity two to four months sooner than those that had the HMST graft completed. Unlike the HMST graft, anterior knee pain is found more often with the BPTB graft.
Knee laxity was discussed a great deal within each study, determining that with the BPTB graft the athletes have less laxity in two out of the six studies. Patients within some of the studies were asked opinionated questions using a sliding scale. This could affect the overall report because the conclusion is supported with bias reports. The evidence did report on many occasions that the data found has one autograft over the other but with no statistical significance.
The many tests done within each study still lead to an indecisive decision on what auto-graft should be used for
ACL reconstruction. Out of the ten studies reviewed only two admitted to using the BPTB graft. This reason seemed to be based off of the rehabilitation program that was implemented. The focus of many rehab programs for ACL reconstruction is the quadriceps. As seen in the doctors rehabilitation plan for this athlete the focus was the quadriceps. That program was used for both ACL injuries. As noted in the athletes injury the HMST graft never felt strong and the athlete had pain in the back of his knee. During the second auto-graft the athlete followed the same rehabilitation as he did for the HMST graft. The athlete reported to have a much better feeling about this graft during the rehabilitation process. There was no pain within the knee as well. The athlete is full participation with no complications and is still playing soccer to this day Overall, the athlete stated that he would recommend getting the BPTB graft done and it is imperative to design rehabilitation programs specific to a given surgery option.