ACLr - Quadricep tendon autograft

[emergRN]

I have been checking to see if you have posted!  How is it coming along?

W

[Hockey98]

Hello!  Things are coming along, albeit quite slowly.  Pain is essentially gone, save for the scar from my meniscus repair which is constantly rubbed by my brace, although this is more a nuisance than any real pain worth mentioning.  Range of motion is improving somewhat, but swelling is really limiting what I can achieve.  I measured out at 0 extension and 85 flexion today at therapy.  I was just cleared today to begin 50% weight bearing, which I hope will help move some of this stubborn swelling out.  Quad strength is the only thing I can see considerable improvement in, as it has been returning rapidly in the past week.  Thursday at my most recent post-op visit I was unable to achieve a single straight leg raise and have since been busting my ass on them - I pulled off 40 today in therapy with a 3 pound weight on my ankle.  I also got to get on the exercise bike today for the first time, but was barely able to make it the whole way around, and it was with a fair amount of discomfort.  Looking at the big picture I suppose I have come a long way at this point, but of course I'd like to be further ahead.  I was going to post a picture on here of how it's healing up but I can not figure out the image posting on this forum.  Thanks for inquiring about my progress and I'll be sure to update more frequently.

[emergRN]

That is most excellent.  You will be amazed at how quickly you progress on the bike.  I can't believe how good your quads are coming back.  This graft source knocked the crap out of my quads, which I had really built up pre op!  Can I ask how big your quad tendon graft was?  Mine was 1.1cm x 10.5 cm.  I am trying to figure out if graft size can be correlated with the loss of quad strength.  It should be on your OR report!

W

[Hockey98]

I will see if I can find the exact size for you at my next post-op visit, but I can tell you that my scar is pretty small.  Even my therapist commented on the size of it, saying it was the smallest she had ever seen for a quad graft.  Also, if you recall from an earlier post I was unable to get the double bundle procedure because my knee was too small, so there is a very good possibility that my graft was, in turn, small. 

[emergRN]

My Quad harvest site scar is only an inch!  They don't need to make a big incision to get the graft out.  When you get the report, I would love to know the size of your graft because I am having a much harder time getting my quads back than you are, and I am much further along post op!  I am trying to figure out if the amount of tendon harvested has a direct impact on rehab.  Just a thought! 

W

[Hockey98]

Pretty much the last week of "boring" therapy is done, just one more day tomorrow.  I call it boring because thus far my time there has been limited to quad sets, straight-leg raises, heel slides...stuff I can (and have been...religiously) doing at home.  Next week I am allowed full weight bearing and, while this should add some interesting new concepts to my therapy program, I feel like there is no way I am going to be able to walk on this knee.  I have been primarily locked in extension for the better part of 5 weeks and have only been putting even partial weight on it for the past week and a half.  Occasionally I have sort of tested the knee a bit, applying more weight and unlocking the brace for a more normal walking gait, but....it just feels so weak.  I have progressed to 105 degrees of flexion and you were certainly right about the bike.  The knee still feels very awkward and takes quite a while to get loose enough to feel even somewhat normal, but flexibility-wise the bike has gotten much better. 

I'll update after my (second) first steps next week. 

[Hockey98]

I began walking again yesterday at therapy, albeit very carefully.  Everything still feels very weak and while the knee itself isn't buckling my lack of quad (and hamstring) control allow my knee to bend in ways that I don't intend while I am walking.  I have to focus intensely on walking properly and making sure I am at full extension before my heel hits the ground, otherwise my knee will bend forward a bit and give that buckling sensation.  My numbers in terms of flexion have not improved greatly.  I am at 107 degrees now, compared to 105 at this point last week.  Different tasks are becoming much easier though, such as standing  up and lifting my leg into the shower.  Along with walking, now that I am at full weight-bearing I am allowed to do wall squats, which already seem to have strengthened my quad somewhat.  No change in size as it still looks like linguine, but the strength seems to have made a bit of a jump since I have been bearing weight.

[Hockey98]

Walking has gotten much better at this point.  Completely off the crutches for about a week now and the feeling of instability has also vanished.  Had another post-op two days ago and I unfortunately was unable to obtain my operative report, however I inquired about whether the size of the graft taken could have an impact on the speed with which strength returns and was told that it certainly can.  Prior to my next visit (one month from now) I will call down there and see if they can have the report prepared for me so I can get an exact size for you. 

Everything else on my end has been improving steadily.  Still some stiffness, range of motion is still improving slowly and most notably swelling has finally gone down.

[emergRN]

It all sounds like it is going very well!  That is great!  Keep up the good work!  I will be checking in on your progress!

W

[Hockey98]

Summer classes have really ramped up, so unfortunately I will be unable to go to formal therapy for the next two weeks.  That being said, I have access to tons of therapeutic exercise modalities here on campus, and have been swimming religiously for the past three weeks.  After spending two weeks in the pool my flexion jumped up from 107 to 125, so I was extremely happy about that.  Strength doesn't seem to be making any rapid improvement, nor does the size of my leg - at all.  Pretty disheartening, but I'm quite aware there is still a long way to go.

A question for any of you out there who dealt with the post-op paranoia:  I was walking my dog around at a local high school and walking down a short decline (about 35 or so degrees) I felt a little bit of movement in my knee.  Nothing painful, but certainly alarming.  Any chance such a simple thing could have stretched the graft any?  I've been worried about it since the weekend and don't see the doc for another couple weeks.

[emergRN]

I think what you are feeling going downhill is most likely due to weak muscles.  Yes..the paranoia is perfectly normal.  I think it is our brain's way of making us protect that graft!  Way to go on the swimming, and the improvement with your flexion!

W

[Hockey98]

Just got back from another post-op visit.  Dr. Fu seems to think that everything looks very good.  My kt-2000 score on my reconstructed leg produced a 6 today, compared to a 5 last time.  I was a little concerned with that, especially considering my "knee-moving" incident I mentioned in the previous post, but they assured me it is nothing to be concerned with.  I was able to obtain a copy of my operative report for you.  It definitely made for an interesting read.

Here is what I got from my operative report regarding my graft:
"The graft dimensions were 8cm of soft tissue length, 16mm of bone block length, 10mm depth, and 10mm in width"

[emergRN]

I didn't have a bone block, but the diameter of your bone block is just slightly smaller than my soft tissue graft.  I will have to look up the length of mine, but it was longer than 8 cm.  I just had an arthroscopy done 10 days ago, and I can now say that the trouble that I was having had nothing to do with my graft!  That actually looks really good!  I had a meniscus tear, and I had a lot of damage under my patella.  The cause is speculative.  Anyway, a lot of the quad inhibition I was having was due to patellar pain, and not my graft harvest site.

So...How are you progressing now?

W

[Hockey98]

That's great to hear your graft is in good shape!  I had been having some slight pain in my patella and my therapist opined it may be due to the lack of quad strength allowing my patella to fall slightly out of the groove.  Perhaps that could have been a culprit in your case?  I hope everything is uphill from here on out with you.

I am doing well, still a few instances where I feel a slight buckling sensation, but knowing that the graft is secure I guess I can mark that down to weakness.  My OR report stated that my ACL was completely ruptured off of its femoral insertion, so I've reasoned that I can't possibly be less stable now, from a ligamentous standpoint, than I was prior to surgery.  Strength is still returning slowly and I am actually able to see a tiiiiiny bit of quad definition now, so hopefully this atrophy becomes less evident in the coming months.  I have made it a goal in my head to return to the ice by November 20, which would be exactly 8 months from my surgery date.  I have been working literally every single day to achieve this goal; it will just be a matter of Dr. Fu granting me clearance to lace up the skates.  Getting anxious just talking about it!

[emergRN]

Good luck with your goal!  Patellar tracking was certainly part of the culprit, and probably being pushed to do some closed chained exercises that irritated my knee greatly.  My goal is to ski Whistler next winter.  If I am going to do that I am going to have to crack at it!

I am exactly 8 months post ACL revision today! 

The buckling is probably from your quads.  I like to call that Bambi syndrome!

Be careful with your rehab.  I will tell you that if you get a lot of patellar pain, then slack off on that exercise and find something else to work that muscle group.  I have done both the hamstring graft and now the quad!  This quad business is not for the faint of heart.  I thought the hamstrings were hard to rehab until I had this done.  The quad graft is much more difficult to get over, no matter what the literature says.

You are doing great, and I am very happy for you.  I will continue to check in.  There aren't many of us who have had this graft source on here.

W