Skin closure is either subcuticular or vertical mattress prolene ( non absorbable monofilament ) suture.

Suture removal occurs 10-14 days post op.

Wound dressings are primapore (non waterproof ) on the skin and steristrips across the incision.

Dressings are to remain clean and dry , apart from some blood staining that may appear immediately postoperative.

Showering requires cover with clingwrap / plastic bags.

Dressings should be changed only if wet, loose or for wound inspection if required clinically.

Venous thrombosis occurs through stasis ( slow blood flow ) , hypercoagulability (increased “stickiness” of blood) and damage to veins.

Clot prevention is both chemoprophylaxis ( medication ) and mechanoprophylaxis ( movement ).

Unless predisposing factors are present the mainstay of prophylaxis is mechanical with early mobilisation , weightbearing as directed and active range of motion exercises.

Preoperatively known risk factors should be disclosed.

Postoperatively any concerns regarding the potential of deep venous thrombosis would require contact and review, with referral for a venous Doppler scan.

Surgery is controlled trauma.

The response to trauma is an inflammatory reaction which is a reparative process. Rehabilitation should not race repair but respect the rate of recovery as dictated by nature.

For most orthopaedic procedures the bone or soft tissues take the first six weeks to “heal”, the second six weeks to “consolidate”, the third six weeks to “adapt” biomechanically, and the fourth six weeks to “normalise”.

Wound management (clean / dry dressings until sutures removed), tissue management (regular icing) and active range of motion exercises (as dictated by symptoms, low resistance stationary cycling), coupled with manual (hands on) rather than machine techniques, guided by the physiotherapist, are the key rehabilitation recommendations.

Essentially, apart from ACL reconstruction, the first six weeks of rehabilitation is the physiotherapy phase, the second six weeks is the gym phase and at twelve weeks, the introduction of sport specific skills with a considered return to sport based on achieving strength, stability, mobility and proprioception thereafter.

Clearance to return is multifactorial and multidisciplinary requiring assessment and agreement by all treating medical professionals.

May remove velband / crepe bandage on first postoperative day to apply regular ice to reduce swelling.

Dressings may be blood stained, but must be kept clean and dry.

Physiotherapy appointment on the first postoperative day.

Static quadriceps exercises, inner range quadriceps exercises and straight leg exercises may commence on the first postoperative day. Terminal active extension must be achievable if performed as free active exercise otherwise assisted active exercise should be implemented.

Weight bearing as tolerated except following osteoochondroplasty, where specific instructions will guide weightbearing status. If active terminal extension is not achievable, crutches will be required.

Progress range of motion through active more so than passive techniques. Contract / relax techniques may be commenced as pain dictates.

Stationary cycling with low resistance and seated may be introduced as range dictates, monitoring patellofemoral symptoms.

Hydrotherapy / swimming may commence once sutures removed.

Generally, the first six weeks post operative are viewed as physiotherapy / rehabilitation, with the second six weeks gym / sport specific skills, with a return expected six to twelve weeks post operatively.

The first six weeks post operatively as per knee arthroscopy.
Monitor patello-femoral and graft donor site symptoms ( hamstring or patella tendon ) accordingly. A brace is required for patella tendon graft and limits range for up to 4 weeks.

Monitor knee extension but avoid passive mobilisation / manipulation as lag may be present six to twelve weeks postoperative.

From six weeks graduated non loaded/weight-bearing resistance may commence, principally through stationary cycling, leg press and inner range leg extension from 0-45 degrees flexion.

Swimming (pool or open still water) may commence after six weeks, but do not use flippers and take care with ingress / egress from the water and its surrounds.

After range / strength adequate beyond 12 weeks, balance, proprioceptive and co-contraction drills can be progressed from double to single leg stance.

No jump, land or pivot activity should be introduced until after 24 week review.

Running should be preferably pool / mini trampoline, rather than land based up to 24 weeks.

Subsequent to six month review and satisfactory progress, sport/work specific skills may be introduced, while maintaining a gym strengthening programme.

A return to full activities should be anticipated by 9 – 12 months post operative in accordance with appropriate review and attaining satisfactory parameters with regards to strength, stability, mobility and proprioception of the knee joint.

Brace is usually not required but repaired tissue integrity may dictate the application for six weeks.

May remove velband and crepe bandage to apply ice on the first postoperative day.

Static quadriceps exercises encouraged but significant pain inhibition can de-function the quadriceps for up to six weeks.

Assisted active straight leg raise and inner range quadriceps exercises commence when static contraction achieved.
Active range of motion rather than passive mobilisation or manipulation.

Resistance exercises after six weeks commence with closed chain techniques and if terminal extension is restored , inner range leg extension from 0-45 degrees may be progressed.

Avoid lunge , squat, kneeling, stairs and step up/down exercises except for eccentric quadriceps control.

Anticipate sport specific skills after twelve weeks and a return before twenty four weeks.

Open or arthroscopic surgery follows a similar rehabilitation.

A brace is not required and velband and crepe bandages may be removed on the first postoperative day.

Static quadriceps and inner range quadriceps exercises commence with emphasis on activating terminal extension which may require assisted active techniques for up to six weeks.

Active knee flexion only to avoid passive stretching of the repairing tendon.

Resistance exercises after six weeks commence with closed chain techniques and if terminal extension is restored, inner range leg extension from 0-45 degrees may be progressed.

Avoid lunge, squat, kneeling, stairs and step up/down exercises except for eccentric quadriceps control.

Anticipate sport specific skills after twelve weeks and a return before twenty four weeks.

Velband and crepe bandages may be removed on the first postoperative day.

Rehabilation may be progressed as tolerated once wound is healed and stitches removed.

Physiotherapy to commence on the first postoperative day.

Weightbearing as tolerated with usual progression from frame to crutches to walking stick over the first two weeks post operatively.

Hydrotherapy may commence only after sutures are removed. Driving may be achievable by six weeks postoperatively.

Supervised physiotherapy may be required for six to twelve weeks postoperatively, however the emphasis in recovery is increasing functional use, as pain and range allow, usually by re-instituting preferred activities as soon as practical.

May remove velband and crepe dressing to apply ice on first post operative day.

Remain on crutches until sutures removed.

Perform active ankle range of motion exercises as symptoms allow.

Physiotherapy may / may not be required until first review.

Weightbear as tolerated and progress under physiotherapy guidance, except for osteochondroplasty, from first to six week review.

Anticipate return to activity from six weeks postoperative.

Postoperatively a cast or brace is required for six weeks.

Non – weightbearing on crutches is recommended for six weeks.

Following removal of cast or brace physiotherapy commences for range,strength, and progressive weightbearing at six weeks for ligament stabilisation and at eight weeks following syndesmosis stabilisation whether screw or tightrope utilised.

Swimming and stationary cycling may commence at six weeks.

Running is not considered until beyond 3 months and requires restoration of strong, sustainable, repeatable, single leg heel raise.

A plantarflexion anterior plaster slab is applied postoperatively and when stitches are removed a plantarflexion brace non or partial weighbearing is applied for five weeks. Crutches are required for six weeks.

After six weeks , weightbearing can commence, with progression up to twelve weeks postoperatively to a foot flat, non push off ( plantargrade ) gait. Physiotherapy supervision may / may not be required .

Physiotherapy may commence twelve weeks postoperatively to restore range and strength. A return to full activity is anticipated beyond six months postoperatively.

Velband and crepe bandage may be removed on the first postoperative day.

Remain weight bearing as tolerated on crutches until sutures removed.

Rehabilitation may progress as tolerated once sutures removed.