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With the right care, most sports related knee and shoulder injuries can be fixed with excellent results. Here are my answers to some of the common questions I get from athletes and patients.
My indications for ACL reconstruction:
a. Regardless of age – If you want to continue to play sports requiring cutting, pivoting, jumping, or twisting (like football, baseball, soccer, lacrosse, basketball etc.) you must have an ACL.
b. If you are a teenager or young adult, I recommend ACL reconstruction. The natural history of an ACL deficient knee, whether you are playing sports or not, is early onset arthritis due to recurrent instability and the increased stress (shear stress) across the knee.
c. Lastly, regardless of age and desire to play sports, if you are having instability with your knee during regular day-to-day activities, I recommend ACL reconstruction.
ACL reconstruction surgery is an outpatient surgical procedure done under general anesthesia in combination with a regional anesthesia that numbs the leg for 12-18 hours. The torn ACL cannot be repaired. It has to be replaced with tissue that either comes from elsewhere in your body (called an “auto-graft”) or from a cadaver (called “allograft”). In your first visits, we will have a discussion about graft options. We then choose together which graft option is best for you. The graft will be routed through bone tunnels drilled in the shin bone (tibia) and thigh bone (femur) and held in place with a combination of cross pins or screws that absorb over time. Positioning of these bone tunnels is crucial to getting proper anatomic positioning of the graft and long term excellent functional result.
Patellar tendon auto-graft has long been considered the gold standard in ACL reconstruction. This is the most common graft in professional sports and the graft I use most frequently. Among the advantages is bone –to- bone healing of the graft bone plugs in the bone tunnels. Patellar tendon auto-graft provides reliable long term results with highly reproducible graft testing in the office during the final follow-up visit. A disadvantage is a small chance (about 4%) of lasting knee pain in the front of your knee (anterior) from where the graft tissue was taken. This happens rarely but is a consideration especially for a basketball player or jumping athlete who may be prone to developing overuse anterior knee pain conditions. Patients will also have frequent short term numbness over the front and sides of their knee which typically goes away over time.
Hamstring auto-graft is my graft choice for young patients who have skeletons that are still developing. It is an excellent graft choice and does not differ from patellar tendon auto-graft in long-term results. Since growth plates could prematurely close, we can't pull bone plugs across them. Hamstrings or all soft tissue grafts are the “go to” graft for many of my colleagues; it allows for an easier recovery since it requires no additional bone cutting/harvesting. It has a theoretical disadvantage of hamstring weakness postoperatively.
Allograft tissue comes from a cadaver. The primary advantage of allograft is that you don’t have to “rob Peter to pay Paul.” I use allograft probably 25-30% of the time. I think that patients have a much easier time with allograft than auto-graft in the first 6 weeks after surgery. I recommend this graft for an older, less active patient who still plays sports or has instability with activities of daily living. There is a higher failure rate when using allograft in younger patients. There is also a small risk of disease transmission with use of allograft tissue. However, I have been using the same tissue bank for over 10 years and have seen no problems with disease transmission as compared to my auto-grafts. Overall, I have been very happy with allograft reconstructions while making sure that it’s the right choice for the right patient.
Each graft option yields excellent results. The most important factor is patient specific requirements and the surgeon’s experience with the graft choice.
The first two weeks after surgery are usually the toughest. Patients are in a brace but are allowed to put weight down on the knee right away. Most patients are off crutches within a few days and walking with their leg in a straight, extended position. The goal of therapy in the first 6 weeks is all about regaining motion. At the two week visit, we take out the stitches. Patients should be able to do multiple straight leg raises, flex their knee to at least 90 degrees, and be off pain medicine. At 6 weeks, patients should have full range of motion, no swelling, no pain, and no limp. You should be able to walk down my hallway so that I can’t tell the difference between your two knees.
At the six week mark, we begin the strengthening phase of therapy. We need to build up the quadriceps and hamstrings as knee function continues to improve. At 3 months, patients can start jogging in a straight line. By 4 ½ months, we start some gentle agility exercise and hop work. This continues up to the 6 month milestone. If all goals of therapy are met, you will undergo a functional hop test to compare the knees. If the knee we operated on performs 85% or better compared to the knee we didn’t operate on, patients are released back to sports.
Meniscal tears typically cause pain at the joint line or either side of the knee. You might feel a “mechanical sensation” or a locking or catching in your knee. You may feel ok moving in a straight line but have difficulty with rotating or twisting. You may also have difficulty doing a deep knee squat or crouching down like a baseball catcher. In addition to pain and mechanical sensations, meniscal tears often have associated swelling in the knee.
Isolated lesions of the articular cartilage in younger patients typically occur after a traumatic event or series of events. Unlike arthritis, these lesions are rarely acquired or degenerative. Like meniscal tears, articular cartilage lesions can cause joint tenderness, swelling and mechanical feeling sensations in your knee. After a careful physical examination, I will obtain a standing x-ray to make sure there is no evidence of arthritis. If we need one, an MRI may be necessary to differentiate between a meniscal tear, isolated chondral lesion, or bone bruise.
It must first be put back into socket (reduced). This may occur spontaneously but often has to be done manually in the emergency room. Afterwards, x-rays are required to confirm the joint is properly reduced and determine if there are fractures or bony defects that may cause instability again in the future. I will typically keep patients in a sling for about a week so that you’re more comfortable. I like to start range of motion exercises early and will recommend physical therapy to better help your shoulder’s return of motion, strength and function.
It mostly depends on your age. Younger patients have a higher likelihood of their shoulder dislocating again. A traumatic dislocation often causes a Bankhart tear. A Bankhart tear is a detachment of the soft tissue bumper (the labrum). This detachment destabilizes the joint. Although surgery is sometimes needed, I will not typically recommend surgery for the first time dislocation. If you’re a younger patient, I will have a long discussion with you explaining that recurrent shoulder instability episodes are common and if a second dislocation occurs, I will be recommending surgery to repair the labral detachment and tighten the ligament/capsule.
In patients over the age of 40, recurrent instability is less likely and we are often successful at non-operative treatment. Shoulder dislocations in this age group have a high incidence of rotator cuff tears. I closely monitor patients to make sure they regain their strength. If weakness persists, an MRI may be necessary to find out if there is an associated rotator cuff tear.
The rotator cuff muscles originate off the shoulder blade and form tendons that insert out laterally onto the ball portion at the top of your arm bone (the proximal humerus). The rotator cuff provides both lifting and rotation strength to the shoulder and helps to stabilize the joint by pulling the ball into the shoulder socket.
Low-grade rotator cuff tears: partial tears (or bony detachment of the tendon) involve less than 50 percent of the rotator cuff insertion.
High-grade rotator cuff tears: partial tears that involve more than 50 percent of the rotator cuff insertion.
Full thickness rotator cuff tears: These are tears where you have a complete detachment of the rotator cuff tendon.
Rotator cuff tears can cause pain and weakness when you elevate and rotate your shoulder. Most partial tears are initially treated without surgery by modifying activity, physical therapy, and cortisone injections. If conservative treatment fails, I will typically order an MRI so we can determine if the tear is low grade partial, high grade partial, or full. Surgery may be necessary for failed attempts at non-operative treatment.
I recommend surgical repair for younger patients with full thickness rotator cuff tears. Untreated full thickness rotator cuff tears increase in tear size, can retract from its bony insertion site, and atrophy the attached muscle. If misdiagnosed or left untreated, a repairable tear can become irreparable over time.
The treatment of full thickness rotator cuff tears in older patients has to be considered on an individual basis. I will typically recommend surgery for more active patients or those having pain and limitations during day-to-day living activities. If diagnosed timely with minimal tendon retraction and no muscle atrophy, patients can expect to return to most activity without discomfort and excellent restoration of strength and function.