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Knee rehabilitation after ligament according to TLS technique.

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Knee rehabilitation after anterior crossed ligament using tendons of the bridle according to TLS technique

Dr. ROBERT H.
CH North Mayenne


The need for autograft type of ligament reconstruction has become the views of poor results in the medium term simple sutures, peripheral plasty or ligament prostheses. Among the intra-articular plasty, the choice is usually between a door with the patellar tendon graft or a graft with the hamstring tendons. Techniques 2 give results very close to medium term, but the grafts with hamstrings exposed to less postoperative pain and a faster recovery.

Whatever the type of sample, the principles of reconstruction remain the same:

- A tendon transplant tendon half alone, prepared in 4 strands,
- An anatomical anchor to the femur and to the tibia,
- Pre optimal tensioning,
- Mounting in tunnels by a screw pressing on a strip.
The tendon graft ligament will then undergo a transformation process for 1 to 2 years. This should be free of excessive stress during the early months.

The intervention will be carried out at least a few weeks after the accident to let the inflammatory phase.


1) SURGICAL TECHNIQUE

The operating time of the ligament are:

1- sampling tendon (semitendinosus) by an oblique way anteromedial (3 cm) to make a neo-ligament 4 strands, calibrated to 8 or 9 mm

... / ...



2- arthroscopy to practice:

Locating anatomical points of presence,
Drilling blind tunnels, tibial and femoral
The rise and transplant blockage in each tunnel with a screw,
A possible meniscal gesture.


2) SPECIFIC PROBLEMS OF THIS TYPE OF TRANSPLANT


1- The tendon removal leaves a muscular body "orphan" who will likely adhere to its sheath. During this phase, the muscular body is fragile and overburdened, it may be responsible for painful phenomena type "breakdown."

2 fastening systems must be highly resistant to mechanical afford to wait a biological anchorage tendon - bone tunnel entrances, which takes several weeks or months. We must therefore spare the anterior translation forces, including those induced by quadriceps and outlaw any intermittent static work or work in open chain quadriceps for at least 3 months.


3) REHABILITATION


It started before the procedure if there is atrophy of the thigh

It will be customized and we give the main principles

- The operative day:
The leg remains slightly flexed to ensure maximum comfort during this painful phase; the knee will be frozen. A morphine infusion will be in place for 24-48 hours. Active mobilization of the ankle and the knee is encouraged that evening because we avoid most often the use of anticoagulants, source of hematoma. The bed is kept slightly sloping to promote venous return in the lower limbs.







- 2nd and 3rd postoperative day:
The physiotherapist will pick you up 1-2 times a day, you will be removed the day after surgery. Rehabilitation includes several steps:

- Walk the full support, even if meniscal suturing. - Purely active mobilization, closed chain, from 0 ┬░ to 60 ┬░ without going recurvatum.
- Wearing a brace is not necessary.
- It must involve regular mobilization of the ankle and hip.
- Hamstrings can be processed into pure static without resistance,

- 3rd to 30th postoperative day: rehabilitation continued in city using the same protocol.
- Mobilization of 0 ┬░ to 60 ┬░ active closed chain, for 15 days and beyond up to 90 ┬░
- Working in a closed chain,
- Work in co-contraction quadriceps and hamstrings.
- Work walking,
- Canes can be discontinued after 8 to 15 days depending on the patient.
- Strengthening the quadriceps, with the end of weights or walk on the anterior tuberosity of the tibia, isometric and dynamic is prohibited.
- 2nd and 3rd postoperative month:
- Walking is free with only an elastic compression stocking. It must then fight against the possible flexion pure active and if necessary by axial traction 2 kg for 20 minutes if he resists,
- Bending is recovered gradually to 130 ┬░ -135 ┬░ in 4 to 6 weeks, without forcing,
- A work in dynamic closed string Stepper or Squatt can be started,
- The proprioceptive work is started, first bi-podal, then monopodal using Freeman trays or manual stimulation of the physiotherapist,
- The scar will be massaged,
- It is possible to combine electrical stimulation co-contraction of the quadriceps and hamstrings.
- Of cycling is possible.

Professional work is usually taken between 2 and 6 weeks after surgery depending on the activity.



- After 3 months:
- Work continued in closed chain, eg cycling, swimming (crawl), the pre-jogging.

- Work in open chain quadriceps with proximal load (2-4 kg) is possible from the beginning of the 4th month
Complete recovery of the extension is imperative at this time,


Jogging, cycling, swimming are highly recommended, work on trampoline becomes possible in dual and single stance.


- More than 8 months
The patient can resume specific training of sports played:
- In case of footballer slalom runs with a ball in the foot,
- In case of volleyball, working impulse, receptions, jumps,
- In case of tennis, work acceleration, pivots, turns.


The resumption of sports can pivot from 9 to 10 months, if the surgical opinion is favorable, in principle if indolence, good passive and dynamic stability and good mobility. Isokinetic study is desirable to evaluate a residual deficit of hamstrings or quadriceps and correct, but it is mostly the patient's confidence in his knee that will be decisive. You will be regularly monitored in consultation for 2 years. Whatever type of plastic surgery, there is a risk of relaxation and re-break of about 10%.


Rehabilitation of ACL plasty with the tendons of the crow's feet is much more cautious, gradual than that of Kenneth Jones type plasty, for within the same time a satisfactory result but with much less pain on removal of the extensor, tendinopathy, patellar pain and better mobility final.

Doctor Nicolas LEFEVRE. - 26 janvier 2011.

Conflicts of interest: the author or authors have no conflicts of interest concerning the data published in this article.

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