The Anterior Cruciate Ligament (ACL) is a cord of tissue connecting the femur (thigh bone) to the tibia (leg bone) at the knee. The knee is connected by 4 major ligaments: the Medial Collateral Ligament (MCL), Lateral Collateral Ligament (LCL), Posterior Cruciate Ligament (PCL) and the ACL. The ACL prevents excessive anterior translation of the tibia and also controls rotation of the knee. When the ACL is torn, the knee can move abnormally leading to instability and meniscus tears.
ACL tears are common in athletes and often require surgery to provide a stable knee which allows a return to sports and decreases the risk of a meniscus tear in the future.
PRIOR TO SURGERY
Prior to surgery, many patients require a period of 1-3 weeks of physical therapy to decrease swelling and inflammation and restore normal range of motion. If surgery is performed on an acutely inflamed knee there is a higher risk of arthrofibrosis post-operatively. This means that the knee fills with scar tissue and becomes very stiff, delaying recovery and sometimes requiring additional surgery.
ACL reconstruction involves removing the torn ACL and replacing it with a graft of new tissue. Much of the surgery is done arthroscopically. This means that small, 4-5 mm incisions are made and a camera and instruments are used inside the knee to perform the surgery without an open incision. During surgery, the surgeon uses drills to make tunnels in the bone at the site of the old ACL. Meniscus tears, when present, are repaired or trimmed. The ACL graft is then pulled into the joint and fixed with any one of a number of devices. Most ACL surgery is done on an outpatient basis. There are many choices for anesthesia but many patients have a regional block. This means that the leg is numbed up with an injection and the patient gets medication during surgery to make them relaxed or even fall asleep completely. General anesthesia is an option as well.
There are several graft alternatives, the most common are patella tendon grafts, hamstring grafts or cadaver grafts (allografts). Patella tendon grafts are also called bone-tendon-bone (BTB) grafts. The surgeon makes a 5-7 cm incision on the front of the knee from the patella (kneecap) to the tibia and removes the central 1/3 of the tendon with a block of bone from the patella and tibia. This graft is then secured to the bone with metal screws. The screws stay in forever unless the ACL fails and needs to be re-done. In the past, advantages of the BTB graft included a lower rate of failure and more rapid healing of the graft into the bone. With current techniques, hamstring grafts have a similar success rate. Disadvantages of the patella tendon graft include pain when kneeling for up to a year or longer, more postoperative pain, and a larger scar. There may be a slightly higher incidence of arthritis under the kneecap in future years but data is inconclusive. Many surgeons reserve BTB grafts for male athletes in collision sports (football, hockey).
Hamstring grafts are harvested through a 2-3 cm incision just to the medial side of the knee. The hamstring tendons are stripped off the muscle. The hamstring muscle is left in place and most people form a new hamstring which takes up to a year. Most studies show that there is minimal (10%) loss of hamstring strength and most patients don’t sense that the muscle is weak. The graft is then pulled into the knee and fixed with any of a number of screws or devices. Advantages of hamstring grafts include less anterior knee pain, less postoperative pain, a small scar, less trouble getting back range of motion (although it can still be a problem). In the past, hamstring grafts had a higher rate of loosening and failure than patella tendon grafts. With newer, stronger implants to secure the graft, this no longer seems to be the case.
Cadaver grafts (allografts) are ligaments (commonly hamstring, Achilles tendon or patella tendon) harvested from a dead person which are screened for disease and then sterilized and used as a graft. Advantages of allografts are decreased surgical time, smaller scars, and there are lack of donor-site problems such as pain and weakness. In most studies allografts have a high rate of success but a slightly higher failure rate than the patient’s own tissue. In addition, allografts take longer to incorporate into the surgical knee than the patient’s own tissue which can lead to a higher rate of re-tear. While rare, some patients can have an immune reaction to the graft which leads to rapid failure.
Recovery from ACL surgery takes many months. The worst pain is within the first 48 hours and patients are given pain medication on discharge. Crutches are needed for anywhere from a few days to several weeks depending on the patient. A brace is usually worn for several weeks when you are up ambulating. There are often stitches which can’t get wet for 1-2 weeks. I usually have my patients come in 2-3 days following surgery to check the surgical site, perform an X-ray and review instructions. Many patients have significant swelling which can be painful. An aspiration can be performed to remove the fluid from the knee with a needle, which lessens the pain. Physical therapy starts 3-5 days after surgery. The goal is to restore range of motion and regain strength while not putting too much stress on the graft as it heals. Most people attend physical therapy 2-3 times per week for 3-6 months. I allow patients to start on an exercise bike 1-3 weeks after surgery. Jogging is 3 months on average, and a return to full sports is usually allowed at 6-9 months. After surgery on a right leg, most people can’t drive for 8-10 weeks.
Initial treatment of an ankle sprain follows the RICE philosophy (Rest, Ice, Compression, and Elevation). Patients are given crutches to use for at least a couple of days. If the ankle is very swollen and painful, immobilization in a brace, or even a cast, can be helpful to make the swelling come down.
In athletes, they often start physical therapy with a therapist fairly early (in the first 1-2 weeks) to allow them to return to sports safely and quickly. In the non-athlete, physical therapy may not be needed; the patient can often do exercises at home. The most common cause of recurrent injuries to the ankle are an inadequate amount of strengthening and rehabilitation. The athlete is sometimes recommended to wear a brace on return to sports for 3 months to try to decrease the risk of a re-injury.
Approximately 15% of patients fail to respond to this standard treatment and may require repeat X-rays, MRI, further physical therapy or even surgery.
ARTICULAR CARTILAGE RESURFACING
As noted earlier, the articular cartilage is the slippery surface at the end of bones that allows smooth gliding to occur within the joint. There are several options available to treat patients with articular cartilage defects. These treatments apply to acute articular defects, not the more diffuse articular cartilage damage present in arthritis.
The most common method to treat articular cartilage defects is an arthroscopic procedure termed microfracture. The purpose of the operation is to insight a healing response within the defect by performing multiple perforations of the underlying bone. This is performed with an awl and promotes bleeding, which in turn forms a fibrocartilage repair tissue, which helps to resurface the bone. This repair tissue is not as sturdy as the native hyaline cartilage, but is certainly a smoother surface than the underlying bone and leads to decreased pain and resolution of symptoms in many patients. Following surgery, the patient typically needs to keep weight off of the affected joint for 6 weeks or longer and full recovery may take 6-12 months.
Another option available to surgeons is a procedure called OATS (osteo articular transfer system). This operation involves harvesting bone plugs with intact articular cartilage present from other areas of the knee and then exchanging them for dowels taken from the area of articular cartilage deficiency. This is frequently performed with an incision (open procedure) and has a goal of restoring hyaline cartilage to the defect. As with all of these resurfacing procedures, a period of protected weightbearing is indicated following the procedure.
For larger defects, an option exists to take a large dowel of bone to exchange and thus fill the defect. This requires use of allograft bone (cadaver bone).
Autologous chondrocyte implantation (ACI) is the final option available for articular cartilage defect treatment. This is a two-stage operation where first chondrocyte cells are harvested in an arthroscopic procedure. These small samples of tissue are then grown to form a specimen that has large numbers of chondrocytes or cartilage forming cells present. These are then, in a separate open procedure, implanted into the defect beneath a thin layer of tissue. This procedure as well has the theoretical advantage of restoring hyaline-like cartilage to the area of defect.
There are pros and cons of all of these described procedures. Many of these complex issues require thoughtful preparation, both on the part of the surgeon and on the part of the patient.
CHONDROMALACIA PATELLA / PATELLAR PAIN
Pain in the anterior aspect of the knee is very commonly encountered and has many different etiologies. The most common cause for pain, especially in older patients, involves wear and tear on the backside of the patella, a condition known as chondromalacia patella. The cartilage on the back of the patella is the thickest in the body, as it is subjected to the greatest joint forces anywhere in the body. It has been noted that from rising from a seated position, the patella experiences forces equal to 3-5 times the body weight. Nonoperative management for patellofemoral arthritis is usually indicated with hamstring stretching, quadriceps strengthening and weight loss frequently advised.
Patellofemoral pain can also be caused by soft tissue issues. Synovial bands, termed plica (meaning shelf), can be a common cause of anterior knee pain, especially in younger patient's under 20 years of age. These bands of tissue get caught beneath the patella and cause snapping frequently just to the inner side of the patella. Hamstring tightness is frequently observed in these patients and vigorous quadriceps strengthening and hamstring-stretching programs are indicated. At times activity modification and sport change may be indicated. For patients with longstanding issues, at times arthroscopic removal of these bands may be indicated.
Instability of the patella may also cause symptoms in the anterior aspect of the knee. If the patella is moving abnormally with flexion and extension of the knee, excessive joint pressure forces can occur and this may be the cause of symptoms. As is the case with most conditions, nonoperative measures are first attempted, especially strengthening of the medial quadriceps muscle. At times surgical realignment procedures may be indicated for patients with prolonged symptoms.
For those patients with severe degenerative changes involving the patellofemoral joint, joint replacement either in the form of total joint replacement or in selected patients, a selective resurfacing of the patellofemoral joint may be indicated.
HIP ANTHROSCOPY PROCEDURES
Hip arthroscopy has been used for many years but has been limited due to the technical demands of this procedure. Over the last few years an improvement in the diagnosis of hip conditions and significant improvement in surgical technique and instruments have greatly increased the ability of the surgeon to treat hip disorders arthroscopically. It is not used to treat arthritis and therefore is usually performed on patients less than fifty years old with non-arthritic hip conditions.
Arthroscopy of the hip requires a special operating table to distract the hip to allow space to place instruments and fluid into the joint. This is a highly specialized procedure that requires extensive experience.
What conditions can be treated?
- Labral Tears
- Femoral Acetabular Impingement
- Loose Bodies
- Recalcitrant Trochanteric Bursitis
- Gluteus Medius / Minimus Tears
A minimally invasive procedure, Arthroscopy allows your doctor to examine tissues and joints inside the knee in great detail. During an arthroscopic procedure, a thin fiber optic light, magnifying lens and tiny television camera are inserted into the knee and is performed often to confirm a diagnosis made after a physical examination and other imaging tests. In some instances, it is then possible to treat the problem through the small incisions around the joint. Because it is minimally invasive, knee arthroscopy offers many benefits to the patient over traditional surgery such as no cutting of muscles and tendons, smaller incisions, less bleeding and scarring. Knee injuries that are frequently treated using arthroscopic techniques include but not limited to: meniscus tears, mild arthritis, ACL and PCL tears, and patellar (knee cap) misalignment.
Depending on the tear pattern it can be treated with debridement (trimming/removal) or with repair utilizing sutures (stitches) to reattach the labrum to the rim of the socket.
Treatment for patients diagnosed with a labral tear in the shoulder is based on location of the tear, activity level, and degree of functional impairment. Many tears of the superior labrum (SLAP tear) will cause pain with overhead activity or repetitive activity above shoulder height. Stretching of the posterior capsule and specific exercises to strengthen the muscles of the shoulder blade and rotator cuff often provide relief. Surgical repair is often necessary for overhead athletes or those with ongoing pain despite attempted therapy. Anterior labral tears result from shoulder instability. This occurs as a result of dislocation or repetitive abnormal shifting called subluxation. Active patients, athletes, and those at high risk for repeat dislocation (laborers) usually require surgery to stabilize the shoulder. Less active patients or those with shoulder instability without a labral tear (multidirectional instability) are usually treated with physical therapy exercises, with surgery only necessary for those with severe functional impairment or multiple dislocations. Most labral repairs are performed arthroscopically with excellent recovery of function and return to sports.
A first time episode of patella dislocation is usually treated with rest, bracing, and anti-inflammatory medication. Physical therapy is often recommended after the swelling and pain have resolved. Most people will recover fully and return to all activities after full quadriceps strength is obtained. A functional brace to stabilize the patella is usually necessary for return to activities and sports. If x-rays or MRI show evidence of fractured cartilage, an arthroscopy is necessary to surgically remove or repair the loose pieces. Repair or reconstruction of the stabilizing ligament of the kneecap is often performed at the same time to reduce the chances of repeat dislocation. For those patients without cartilage damage, surgery is necessary only for repeat episodes of instability or debilitating pain.
Patients with chronic instability of the patella without dislocation are treated with bracing, stretching and strengthening exercises, and anti-inflammatory medications. Chronic instability often comes from poor alignment of the kneecap joint, which can often be helped with therapy to optimize the entire leg from hip to foot, and foot orthotics may be prescribed as well. Most people will see significant improvement with non-operative treatment. For those who fail to improve with these treatments, realignment surgery is considered. These procedures may include realignment of the bone (osteotomy), reconstruction of the stabilizing ligament of the patella, or a combination of the two.
ROTATOR CUFF REPAIR