Preoperative Issues - Clinical Tree

Introduction

Anterior cruciate ligament (ACL) ruptures are a common and potentially devastating injury in the athletic and active population. The incidence of ACL tears is rising in the United States, with recent estimates of 43.5 to 68.6 per 100,000 person-years. ^, Peak incidences occur in males aged 19 to 25 years (241 per 100,000) and females aged 14 to 18 years (227 per 100,000). ^, These injuries can be psychologically and physically devastating to patients who wish to return to athletics or an active lifestyle. ACL reconstruction is highly successful in returning patients to activities, , , but return to preinjury activity level is more challenging. ^, ^, ^, Many factors, including age, body mass index, sex, and concomitant injury, cannot be modified following an ACL injury. The purpose of this chapter is to discuss knee optimization before undergoing ACL reconstruction to provide the best foundation for postoperative outcomes.

An ACL tear is a highly traumatic event that typically results in large inflammatory response and hemarthrosis with associated soft-tissue swelling and effusion. The inflammation then contributes to generalized irritability of the knee that may result in loss of range of motion (ROM), influence the time of surgery, and increase the risk of postoperative complications if normal knee motion and full weight bearing are not obtained before surgery.

Timing of Surgical Intervention

Inappropriate timing of surgical intervention may contribute to the development of arthrofibrosis. , , Although many studies have reported on the timing of surgical intervention and its relationship to arthrofibrosis, currently most surgeons believe that motion restoration, quadriceps recovery, and resolution of posttraumatic edema and effusion are the critical determinants that can preoperatively impact the likelihood of arthrofibrosis development. An initial study demonstrated that ACL reconstruction within one week of injury was significantly associated with postoperative arthrofibrosis compared with reconstruction more than 21 days after injury. Several additional studies have also confirmed that early reconstruction (<7 days from injury) places patients at increased risk for postoperative complications compared with delayed reconstruction. ^, ^,

Mayr and colleagues further showed that the degree of residual swelling, effusion, and local hyperemia was strongly and significantly associated with postoperative arthrofibrosis. The persistence of inflammation may be a more important measurement of the patient’s readiness for reconstruction: if the knee is found to be inflamed at the time of surgery at more than four weeks after injury, the patients have even greater risk for developing postoperative arthrofibrosis.

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