ACL (Anterior Cruciate Ligament) Repair

ACL tears are increasing in frequency secondary to increased levels of participation, frequency of games and practice.

ACL tears are a common injury and being seen with greater frequency and at younger ages. Tears lead to loss of time from sport and activities and can lead to further joint deterioration without prompt recognition and treatment. The standard treatment is a reconstruction with autograft (patients tissue) or allograft (donor, cadaveric tissue). The choice of graft depends on several factors including age of patient and sports activity level. Currently, the time to return to sport has been shown to effect re-injury rates. Historically, 6 months after surgical reconstruction was considered an appropriate time to return to sports without restrictions. This notion has been challenged by recent studies noting lower re-injury rates by waiting 9 months or more to return to sports.

ACL graft (hamstrings)

Newer surgical instruments and a retrospective look at studies from decades ago regarding primary repair have lead to resurgence in interest in primary repair instead of reconstruction. Failure rates have been high with this technique in previous studies that lead to the abandonment of this procedure. However, when evaluating the results or success of repair in specific tears, the results can approach that of a reconstruction. Specifically, proximal tears (from the femur) have better success when repaired. The advantage of a repair is that the ACL can be saved, less invasiveness and potentially faster return to sports. If the repair were to fail the standard options for reconstruction still exist. This is particularly attractive in pediatric patients where reconstruction techniques can injure growth plates.

Not every patient is a candidate but the option should be available for those patients inclined to have a repair over a reconstruction. I offer this to my patients who are appropriate candidates based on MRI appearance and surgical evaluation. Below is a short video demonstrating a repair I performed and the technique utilized.

Video of ACL Repair

The Meniscus: 1 Minute Clinic

The Basics

The meniscus is a well-known structure in the knee that can cause pain, swelling and mechanical symptoms of locking or catching if injured. The meniscus is a C-shaped fibrocartilaginous tissue made predominantly of type 1 collagen. There are 2 menisci in each knee joint, 1 medial and 1 lateral.

The meniscus functions to provide shock absorption to the knee, provide stability and enhances cartilage nutrition of the joint.

Click on the link below to watch a 1 minute video on the meniscus.

Anterior Cruciate Ligament (ACL): Graft Choices

Anterior cruciate ligament tears are one the most common serious sports knee injuries that lead to prolonged time out from sports participation. It is estimated that approximately 100-200,000 ACL tears occur per year. The incidence of ACL tears has risen over the years due to increasing sports participation, training and the number of games athlete’s are playing. A concerning statistic is that the rate of tears in pediatric age athletes has increased over the last 20 years.

The ACL is an important ligament that provide stability to the knee particularly with pivoting and cutting movements that are common in sports. It is the primary restraint to anterior translation of the tibia on the femur, but also provides significant rotational stability to the knee. Most injuries to the ACL are non contact and occur with rapid direction changes, deceleration and landing from a jump. It is common for the athlete to feel a pop, immediate pain and develop swelling over the first 24 hours.

ACL reconstruction is the usual recommendation to treat an active person with an ACL tear. This is generally performed through an arthroscopic assisted procedure. One of the major considerations is which type of graft to use. In general, graft options include autograft ( the patient’s own tissue) and allograft ( a cadaveric donor tissue). Common autograft options include the patellar tendon, hamstring tendons and quadriceps tendon. Allograft options include the same plus different soft tissue grafts from other areas. Choosing the best graft for each patient depends upon the age of the patient, activity level and a variety of anatomical factors. I utilize all types of graft options in my practice and base the choice of the graft on multiple factors and discussions with my patients.

Arthroscopic photo of quadrupled hamstring autograft reconstruction

Within the autograft choices, each has its pro and cons. The patellar tendon graft is considered the gold standard, but the other graft choices may be a better option in select patients. Patient size, type of sport, age (growth plates still open) and history of other knee complaints in the past are important considerations when choosing a graft.

Risk Factors and Predictors of Subsequent ACL Injury in Either Knee After ACL Reconstruction
Prospective Analysis of 2488 Primary ACL Reconstructions From the MOON Cohort

The American Journal of Sports Medicine, Vol. 43, No. 7

It is generally accepted that autografts have a lower re-tear rate than allograft in younger patients, highly active patients and patients participating in competitive sports. Allograft reconstructions have a similar success rate in patients that are older (generally 35 year-old and up) and do not participate in highly competitive sports on a frequent basis. The research continues to define which grafts have the best success in different patients and new information continues to guide our decision making.

Meniscus Tears

Tears of the meniscus are a common source of knee pain. Tears can be due to sports injuries, slips and falls, car accidents and from degeneration. When a tear occurs from injury, pain is usually acute and sometimes the injury is associated with a pop and the development of swelling. The swelling could be immediate or occur over the next 24-48 hours. Pain is usually located at the joint line on the inside or outside of the knee. Degenerative type meniscal tears often occur gradually and got progressively worse but could have acute onset of pain as well. Associated signs and symptoms of a meniscal tear include pain at the joint line, swelling and sometimes locking or catching. In acute injuries, the meniscus can sometimes displace and cause locking or lack of motion of the knee.

Diagnosis of meniscal tear starts with a thorough history, physical exam and x-rays. X-rays are helpful to determine if there are any fractures with an acute injury, underlying arthritic changes and loose bodies within the joint. Underlying arthritis is frequently associated with degenerative meniscal tears. If x-rays are negative and clinical suspicion indicates a meniscal tear, an MRI may be ordered. Meniscal tears also occur frequently with ligament injuries to the knee, such as ACL tear. Special consideration should be given to meniscal tears associated with arthritic changes of the joint. In this particular situation, it is common to have a meniscal tear and arthritis at the same time. Current research indicates that in the majority of cases, pain comes from the underlying arthritis more so than the meniscal tear. It is common for your orthopedic surgeon to recommend nonsurgical management of a meniscal tear when there are significant arthritic changes present. There are certain indications and situations where more aggressive management of a meniscal tear would be warranted when they are underlying degenerative changes of the knee, a discussion with your surgeon will help determine which treatment method is most appropriate.

There are different types of tear patterns. They include vertical/longitudinal tears, radial tears (meniscal root variant), horizontal cleavage tears, complex tears, oblique tears, degenerative tears, and bucket-handle tears.

Treatment of meniscal tears depends on the level of symptoms, presence or absence of recurrence swelling, mechanical symptoms of catching and locking and the affective these on participation in sports or exercise. Treatment could include physical therapy, activity modification, anti-inflammatory medication and bracing. Treatment could also include injections, especially when there underlying arthritic changes. Surgical management is usually indicated for symptoms that are not responding to conservative treatment. Displaced bucket-handle tears causing locking or lack of motion usually require more urgent surgical intervention. The goal of treatment is to reduce pain, swelling and improve functional abilities and participation in exercise or sports. Below is a short video of a meniscal surgery I performed.

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