[Plea for accelerated rehabilitation after ligament plasty of the knee by a bone-patellar tendon-bone graft]

Abstract

Knee rehabilitation after ACL repair with bone-tendon-bone graft is still controversial. While there was a tendency to protect the graft and the donor site in the eighties, actual tendency is to propose more aggressive, so called accelerated rehabilitation protocol. An extensive analysis of the literature shows that this accelerated rehabilitation is justified because of histologic, biomechanic, surgical and clinical arguments. This accelerated rehabilitation is based on seven reasons, at least: 1) the necrosis of the graft, initially observed in animals, does not seem to be as important in humans as demonstrated by histological studies after in vivo biopsies; 2) the use of solid bone-tendon-bone graft, whose resistance is maximum in the early post-operative period and is superior to the resistance of the ACL; 3) the more precise positioning (more "isometric") because of optic magnification allowed by arthroscopy; 4) the absence of graft impingement, routinely controlled, because of a more posterior tibial placement of the graft and the eventual notch-plasty; 5) the solid and confident fixation of the graft because of interference screws; 6) anterior knee pain are less important when early constraints are applied on the knee; 7) finally, undisciplined and demanding patients who refuse all protection for the graft and the donor site, have good and stable results regarding stability of the knees. Early constraints on the knee after bone-tendon-bone graft and interference fixation give better tolerance on the extension mechanism without compromising integrity of the graft and knee stability. Appropriate level of constraints on the ACL graft and the donor site guides the collagenic reorganisation process. Early restoration of normal hyperextension, decreased knee pain and maintenance of muscular trophicity, allowing patients to go back to sport at 4 months, are the most evident benefits of this accelerated rehabilitation. These considerations cannot be applied to the other grafts (fascia lata, semi-tendinous, allografts ...) and to other ways of fixation (sutures, staples, ...).