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Sports Injuries & ACL Injury FAQ

I'm a motocross rider with an ACL injury and my Buddy says that I should have an allograft. Can you tell me why an autograft from the opposite knee might be preferable?

Even proponents of allograft reconstruction don't say that those grafts are stronger. They are dead, then frozen, and then thawed. Can those things make a tissue stronger? I don't think so!

The reported advantage of the allograft is that the recipient knee does not have to suffer the trauma of a graft harvest - in addition to an ACL reconstruction. On that subject, I agree completely.

Unfortunately, since the dead graft must be revascularized and then repopulated with live cells, it takes approximately a year away from sports. And even after a year, it's never strong enough to resume the activity that initially prompted the injury. That's why there are articles in the American Journal of Sports Medicine that advocate its use in "non high risk athletes and sedentary people over the age of 40."

The quintessential opposite of that description from the journal is a motocross rider!

Now if a living isogenetic graft coming from a source other than the injured knee were used, the bone-to-bone healing would heal the bone plugs in one month. And the only thing remaining is recovery from the surgery.

That is what we do with the contralateral graft. It is live tissue. It is strong. It does not further compromise the already injured and vulnerable knee.

The downside is that while the athlete is working the ACL knee in rehabilitation, he must also do rehabilitative exercises on the graft leg - which never hurts but must overcome some weakness over the first three months. As a practical matter, this changes little in the gym for the average athlete, who generally works both legs anyway.

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My daughter is 14 years old. She plays lacrosse, softball and basketball. She tore her ACL last week. Currently she is on rehab. Her doctor says that her growth plates are still open and she is too young for the regular surgery. I hate to have her miss out on competitive and school sports for two years. What should we do?

What to do with a junior high aged athlete with open growth plates has often been debated. Previously, surgeons have been reluctant to drill through the open growth plates for fear of causing a growth disturbance.

We have found that with appropriate patient selection, the performance of an anterior cruciate ligament reconstruction using the patella tendon secured by buttons (our standard procedure) is both safe and effective - even with growth plates that have not fully closed.

This can be accomplished in athletes who are not significantly shorter than their like sexed parent or sibling, have growth plates that are no longer wide open, and have reached Tanner Stage 4 sexual development.

To determine the Tanner Stage for an adolescent male, go to:
http://www.fpnotebook.com/Endo/Exam/MlTnrStg.htm

To determine the Tanner Stage for an adolescent female, go to:
http://www.aafp.org/afp/990700ap/209.html

After reconstruction of the anterior cruciate ligament, these young athletes are no longer at excessive risk for further episodes of knee subluxation (giving way) and subsequent injury to the menisci. At 90 days post surgery, nearly all are able to return to their favored sport without a knee brace. We know that these are the most athletically active years in a young person's life and believe it is no longer necessary to cause these young people to give up the activities which they covet most.

Lastly, we must keep in mind that these youngsters are exactly the ones that continue to put their knees at risk when they return. Typically 10 to 15 percent of them will retear their reconstruction as a result of another equally serious accident. In order to prevent such recurrence, we have initiated a program to improve balance and neuromuscular coordination.

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My son is a junior. He's a running back at a five-A school. Colleges are already looking at him. He tore his ACL in the game last Friday night and they want to operate this week. Should we let them?

Absolutely not! My friend and teacher Dr. Don Shelbourne of Indianapolis, IN conclusively proved that the incidence of severe stiffness limiting ones ability to go back to sports is dramatically increased when operations on the ACL are done "acutely." In other words, when they are done while the knee does not yet have full motion and is still filled with blood. The accelerated ACL rehabilitation of the "well-prepared" knee more than compensates for the waiting time between when the injury occurred and when the surgery takes place. Furthermore, there's no need to miss a week of school.

This knee requires an immediate Reconditioning Program. And surgery can be performed over the Christmas holidays. Your son will then be ready for spring practice. There are no emergencies in knee ligament surgery. Emergency knee ligament surgery is only performed in order to prevent athletes from getting a second opinion from someone more knowledgeable about ACL surgery!

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How do you know when ACL Reconstruction surgery is necessary?

If your ACL is torn and you play basketball, soccer, rugby, lacrosse, football, hockey, or enjoy rock climbing and do not want to give up these activities, ACL Reconstruction may be the best choice for you. It should also be considered if you are a policeman or a fireman and cannot give up those activities. If you are not athletic but your knee continues to give way or feel that it is "coming apart," the surgery may be a consideration.

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Is any other surgery required following ACL Reconstruction, to remove screws or make other adjustments?

Occasionally surgery is necessary for stiffness. That is now very unlikely if you scrupulously follow the accelerated rehabilitation program. We use buttons for fixation rather than screws now. The buttons are smooth and rarely irritate the overlying tissues, so they almost never need to come out.

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How long does an ACL Reconstruction last? How long will I be under?

The reconstruction should last your whole life. In elite teenage athletes who return to sports, 15 percent will re-tear their reconstruction. In elite athletes over thirty, about five percent will experience a re-tear. When a re-tear occurs, a second reconstruction can be done. In sedentary people, re-tears are nearly nonexistent.

Surgery lasts about one hour. Total anesthesia time is about 90 minutes.

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I heard that there could be permanent numbness on the front of the knee following such surgery. Is this true?

For about one year there is numbness around any surgical scar, but this usually goes away.

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What complications are likely, following ACL Reconstruction? Are there any permanent limitations? And what can be done to avoid those that may exist?

Some of the complications of the surgery include infection, risk of Thromboembolic disease (blood clots) and a re-tear as described above. And permanent stiffness of the joint is the possible limitation. But, we take a proactive approach to avoiding complications and any potential for permanent limitations. Patients are given an anticoagulant immediately following surgery to reduce the very small risk of Thromboembolic disease associated with such a surgery. Infections are avoided by following a carefully outlined plan for wound care and medication in ACL Reconstruction postoperative care. A reconditioning program to strengthen the knee and reduce swelling before surgery, as well as strict adherence to our accelerated rehabilitation program following surgery, has proven to significantly reduce the risk of stiffness to about one percent. The program also gives athletes the greatest chance for a successful reconstruction and reduces risk of a re-tear.

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Which is the best graft choice when planning an ACL Reconstruction?

Glad you asked! The best tissue is an autograft bone-tendon-bone preparation. The bone in the preparation heals better to the host bone than the tendon of a hamstring graft. The best place to get this bone-tendon-bone graft is the patient's opposite leg. When you do this, most athletes can be back in half as much time as when we take the graft from the injured knee.

We do not use autografts from the hamstring tendons. Although these grafts can be strong, healing must occur between the host bone and the tendon. Bone to tendon healing is not as reliable as the bone to bone healing, which occurs with the patella tendon autograft. Not infrequently, we have seen these grafts stretch out. For that reason, most surgeons who use the hamstring graft employ a postoperative brace for four to six weeks which extends from the hip to the ankle. Such a brace will interfere with our accelerated ACL rehabilitation, and prevent return to sports by three to four months.

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Why don't you use screws in ACL reconstruction? Why buttons?

Three reasons. The first and most important is that bone screws placed in the bony tunnel between the bone plug and the host bone limits the amount of contact between the bone plug and the host bone. This in turn limits the ability of the bone plug to heal to the host bone. The button is set on the outside of the bone tunnel and does not interfere with bony healing.

The second reason is that with our button technique the tension on the graft is adjustable. This is impossible with bone screws. With screws, it is very possible to make the graft too tight, subsequently capturing the knee and permanently limiting Range of Motion.

The third reason buttons are used is that the bone screws can irritate the overlying skin. When this happens, it is sometimes necessary to do a second operation in order to remove them. The surface of the button is smooth and will almost never irritate the overlying skin.

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