ACL SURGICAL NEWS: ALLOGRAFT VS. AUTOGRAFT

When the ACL is torn, is can rarely be repaired. Surgery is often required to reconstruct the ACL. If reconstruction is not performed, the knee is at increased risk of cartilage damage, meniscal tear and osteoarthritis. Especially in younger patients, surgical repair is recommended following an ACL tear.

Surgery is performed arthroscopically and the ACL is either repaired or replaced. If the torn ligament cannot be repaired, the ACL is replaced with a tissue graft. The surgeon and patient have the option to use autograft tissue or allograft tissue.

Autograft tissue is a tendon from another location on the patient’s body. Most commonly a surgeon would use a hamstring tendon or patellar bone tendon bone. With the patellar bone tendon bone, the middle third of the tendon is removed and used as the new ACL.

Allograft tissue is a cadaver tendon that is taken from another person. In this case, the surgeon would use the achilles tendon, patellar bone tendon bone or a hamstring tendon.

Autograft is recommended for patients 30 years old or younger. The failure rate of allograft tendons is much higher in those under the age of 30 and the risk of infection is very low. The downside of using the patient’s tissue is that the operation is more involved and painful. The surgeon must surgically remove the autograft tendon and then also repair the ACL. The patient is undergoing two procedures as opposed to one. 

Allograft tendons are preferred in patients over the age of 30. The advantage of allograft is that it involves less surgical time and is less painful. The disadvantage of allograft is increased risk of infection and rejection. It is important to mention that the advances in allograft testing and sterilization have improved significantly in recent years. Risk of infection and disease is extremely low. Another advantage with allograft is that there are now numerous options to choose from, which allows the surgeon some flexibility in deciding which option is best for each individual patient.

In summary, if you are having surgery on your ACL, it is best to talk to your orthopedic surgeon about which option is best for you. Each case is unique and should be evaluated thoroughly before making a final decision.  

ACL Injury and Prevention

ACL injuries are common and on the rise. These injuries can cause young athletes to sit on the sidelines for months, lose out on valuable scholarship money and lead to long term osteoarthritis. It is estimated that over 50,000 high school and college age female athletes suffer from ACL injuries each year.[1] While some of these incidents cannot be prevented, there are steps that can be taken to reduce the number of injuries. 

One common misconception about ACL tears is that they are a result of player-to-player contact and little can be done to prevent occurrence. While ACLs are injured/torn in this manner, most occur as a result of the following: 

• Sudden change in direction
• Cutting maneuvers coupled with a sudden stop
• Awkward landing following a jump
• Pivoting with knee fully extended while foot is planted on the ground

Unfortunately, female athletes are more susceptible to ACL injury. Anatomical differences, such as a greater Q-angle, are primarily to blame. Other factors include weak muscle groups, bad habits, improper form and decreased range of motion. The good news is that while we cannot change the anatomy, we can identify risk factors and help reduce the chance of injury. 

A few suggestions for prevention would include: 

• Strength training – especially the smaller muscles around the knee and the hamstring 
•  Jump routine exercises emphasizing proper form and landing
• Pivoting exercises – also focusing on proper form

These tools are most successful when implemented in early adolescence. By utilizing prevention tools early in life, we can ensure that kids are learning proper form and technique from the beginning. This alleviates the need to undo risky habits in the future. 

Many organizations are implementing pre-season screening programs where professionals can assess athletes and determine if they are high risk for ACL injury. If you have access to one of these programs, take advantage of it and use the prevention tools provided. In future posts, we will also highlight exercises and routines that could be helpful.

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[1] Stopsportsinjuriesnow.org

What is the ACL?

There are four major ligaments in the knee. The ligaments attach three bones: the thighbone (femur), the shinbone (tibia) and the knee cap (patella). There are 2 groups of ligaments in the knee; the collateral ligaments and the cruciate ligaments. The anterior cruciate ligament or ACL is one of the cruciate ligaments.

The two collateral ligaments are known as the medial collateral ligament and the lateral collateral ligament. The medial collateral ligaments are on the side of the knee and control sideways motion of the knee. These bands of tissue are intended to protect the knee from extending too far to either side.

The two crutiate ligaments are known as the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL). These two bands cross each other to form an “X”. The ACL is in the front and runs diagonally across the middle of the knee. The ACL and PCL keep the knee from moving too far forward or backward.

The ACL is the most commonly injured of all the ligaments in the knee. The ACL is key to providing stability in the knee and minimizing stress within the knee joint. When injured, surgery is typically required to recover from the injury. 

In future articles, we will discuss ACL injuries and injury prevention in greater detail. If you feel you may have injured your ACL it is extremely important to consult an orthopedic surgeon.

Case Study: Hard Labor Leads to Rotator Cuff Tear

A 50 year old male laborer came to our office following an injury at work. The patient felt a sudden pain while pulling a heavy object on wheels when the injury occurred.  We suspected a rotator cuff tear based on the symptoms he described. The rotator cuff is comprised of 4 muscles and keeps the shoulder stable and in place.

The patient’s symptoms included:
-          Great difficulty raising his arm overhead.
-          Significant pain and weakness in the shoulder.
-          Intense pain at night that caused difficulty sleeping.
-          Inability to raise arm above shoulder level.

Before Surgery

Before Surgery

After a thorough examination, we sent the patient for an MRI to confirm and determine the severity of the injury.  An MRI of his shoulder revealed a very large full thickness tear involving 2 out of the 4 rotator cuff tendons. Based on these findings, we recommended the patient undergo arthroscopic surgical repair and the patient agreed.

The patient underwent a shoulder arthroscopy; which included removal of a bone spur above the tear and a rotator cuff repair. In our practice, we strive to restore the natural anatomy of the body in any surgical procedure. In this case, we used bio-absorbable anchors and sutures to re-attach the torn tendons to the anatomically correct location of the bone. Anatomic re-attachment helps promote healing and reduces the risk of subsequent injuries.

Following surgery, the patient was placed in a sling for 4 weeks and began physical therapy 3 weeks after surgery. We have seen great success in keeping the shoulder protected for 3-4 weeks following a rotator cuff repair. This allows the shoulder to heal and reduces the risk of repeat tears, shoulder weakness and decreased range of motion. In a recent study at the Center for Special Surgery, this was protocol confirmed as the preferred option to beginning physical therapy sooner. (Click to view full article from the Center for Special Surgery)

After Surgery

After Surgery

Approximately three months post-surgery, the patient was able to lift his arm above his head without difficulty or pain and was able to return to light work duty. Five months post-op, the patient returned to work full duty without restrictions; including heavy lifting and repetitive overhead activities. After completing 5 months of on-going physical therapy, the patient continued to perform strength training exercises on the rotator cuff at home and tells us he is completely healed. He has his full strength back and is very pleased with the outcome of the procedure.

It is important to note that upon the conclusion of formal physical therapy, continued strength training at home is necessary to ensure a full recovery. Most rotator cuff repairs require a full year of healing before full strength returns. By being diligent and continuing a home-based strength training routine, a patient can increase his/her chances for a full recovery without any lingering symptoms. (Click here for some simple strength training exercises for the rotator cuff)

Our office specializes in injuries of the shoulders and knee. We treat each patient as an individual and carefully evaluate the best treatment plan in each case. If you would like to make an appointment, please call 973-300-1553 or visit www.advocareorthosportsmed.com to learn more.

What is Swimmer’s Shoulder?

Swimming is one of the few, if not only, sports that utilizes the upper body and shoulders to move the entire body forward. Swimmers, both male and female, tend to be very flexible and have more range of motion in their shoulders than the average athlete. Swimming is also unique because the water gives resistance that the air does not. The reliance on the upper body, coupled with the resistance of the water and repetitive use of the shoulder can lead to a spectrum of overuse injures termed “swimmer’s shoulder”. 

Swimmer’s shoulder rarely results in permanent injury requiring surgical intervention. The most common swimmer’s injury found on MRIs of the shoulder is tendonitis. Tears of the rotator cuff or labrum are much less common. 

Anatomy

In order to better understand swimmer’s shoulder, we need to review the anatomy of the shoulder. The key muscle group of the shoulder is the rotator cuff, which consists of the subscapularis, supraspinatus, infraspinatus, and teres minor. The primary role of the rotator cuff is to function as the dynamic and functional stabilizer of the glenohumeral joint.

The muscles and the attached tendons of the rotator cuff can be overused and injured in shoulder dominant activities such as swimming. The most commonly injured portion of the cuff is the supraspinatus. On the other hand, the "power muscles" of the shoulders, including the latissimus dorsi, pectoralis, and deltoid, are responsible for moving the arm through space or water, but rarely sustain significant injury.

Treatment

Treatment protocol for swimmer’s shoulder is as follows:

• Oral anti-inflammatories to decrease inflammation of the shoulder
• Strength training of the shoulder and rotator cuff
• Maintaining range of motion in the shoulder

The above is normally achieved with physical therapy or a physician directed home exercise program. It is important to consult a physician before adopting a treatment plan. Without guidance, one can potentially make the injury worse. 

Prevention

Swimmer’s shoulder may be avoided with a regimented dry land program in the off-season. Training programs should focus on strength training and flexibility of the rotator cuff and other shoulder blade muscles.  

For more information on shoulder injuries and conditions, please visit our website, www.advocaredoctors.com/orthosportsmed