Patient Story: Peter Gori

For patient Peter Gori, and others whose livelihood include physical activity, the occasional body aches and soreness are part of the job. Peter owns a landscaping business and therefore relies on his body to get the jobs done. But when that pain worsens, making movement difficult, it is time to seek professional help.

“I was never a ‘sit-down’ boss. My line of work causes me to rely on my body,” explained Peter, who was recently injured on the job. “I knew right away that I did something to my left shoulder, when I lifted a wheelbarrow filled with heavy debris.”

Peter is no stranger to shoulder or knee pain or Dr. Vitolo, who performed surgery on both Peter’s right shoulder and right knee in the past.

“When I tore the ACL in my right knee I met with Dr. Vitolo for a second opinion. After talking to him, I trusted him right away,” said Peter.

“Now after these surgeries, I wouldn’t trust anyone else. He is a phenomenal orthopedic surgeon who goes in and gets the job done.” 

 After an MRI showed significant injuries to his left shoulder, surgery was performed on May 10^th. However, the damage was worse than expected. He had three tendons that were damaged: two rotator cuff tendons and the biceps tendon. Peter continues to recover and is hoping for the best.

Q & A with Dr. Vitolo

Prognosis

“Due to the amount of damage his prognosis was guarded. But Pete could not do his job or resume his active lifestyle with the current injury he sustained.” 

 What pain can be expected following surgery?

“Initially it can be significant, but after the first few days it typically becomes manageable. 

 What after care is expected?

“Usually physical therapy for 8-12 weeks. However, because of the size of Pete’s tear, his physical therapy will be longer.”  

 Who is prone to a torn rotator cuff?

“Individuals who perform repetitive lifting like landscapers and laborers, or those who perform overhead jobs such as electricians and carpenters.  People active in weight lifting and other overhead sports such as, tennis and throwing may also experience such injuries.” 

 How common are rotator cuff tears?

“There is a one in twenty chance of rotator cuff tears in the general population. The incidences of rotator cuff tears is increasing in women.” 

 Can rotator cuff tears be prevented?

“There is no known preventive measures other than not doing the activity.  However, Pete’s surgery went well in part because he was in good physical condition to start and he has a positive attitude toward his recovery.”

 Importance of a positive attitude

“Pete was determined to get better. He owns his own business, which depends on his mobility so he was highly motivated. In addition, his desire to remain active and involved in sports and coaching also contributed to his determination to get better.  

 This is Peter Gori’s third operation performed by Dr. Vitolo. According to the doctor, with each surgery Peter has exceeded expectations from his surgery, namely a faster recovery as well as better –than- expected function after such a severe injury.

“Over 90% of the time the surgery is successful in restoring function and decreasing pain,” added Dr. Vitolo.

Peter’s right knee and right shoulder are now pain free. He hopes for the same outcome for his left shoulder. He expresses his gratitude for the surgeries Dr. Vitolo performed and believes the doctor’s skill is the reason for his successful surgery and recovery.

“I feel ahead of the game because of the work Dr. Vitolo does. He is a true professional, said Peter. “He put me back together and allowed me to resume my life. It has been life changing and I am very grateful.”

Skiing ACL Injuries and Recovery

 

The anterior cruciate ligament, frequently known as the ACL, is the most commonly injured ligament in the knee. Approximately 1 in 3,000 people injure their ACL every year. Several of these injuries occur while skiing in the winter months. Skiers are more susceptible to ACL injuries because they are constantly flying over bumps, landing a jump on the tails of their skis, recovering from a skid, or finding themselves temporarily off-balance. Most skiing injuries occur when a skier “catches an edge” as a result of these actions and their ski is pushed sideways and to the outside, resulting in a twisting motion of the knee. Advancements in surgical techniques and rehabilitation over the years have allowed patients with ACL injuries to participate in early pre and postoperative rehabilitation to return the patient to a preinjury performance level.

Before surgery, patients should focus on reducing knee swelling and establishing a normal walking pattern and active range of motion between 0° and 90°. Elevating the leg with a cold compress or using compression sleeves are two techniques that can be used to reduce knee swelling after the initial injury. If a patient is stable with a normal walking pattern, they may keep the brace unlocked and bear weight while performing daily activities. Otherwise, the brace should remain locked to provide support to the unstable knee. Patients should establish a good range of motion after the initial injury because preoperative range of motion is an important predictor of postoperative range of motion.  

To re-establish range of motion, please try some of these techniques:

1.    Prone hangs: Lie on stomach and slide down to the end of the table so that the thigh is supported and the lower leg hangs off. Hold this position for 30 to 60 seconds and repeat 5 to 10 times.

https://www.youtube.com/watch?v=nBjoOQ3D0cs

2.    Heel slides: Lying on your back, slide your heel towards your butt

https://www.youtube.com/watch?v=_jvUnWbBPXc

3.    Prone flexion: Lying on your stomach, flex your knee and bring your foot towards your butt

https://www.youtube.com/watch?v=lFz0wn_ssxs

               During the early postoperative phase (0-4 weeks after surgery), patients must strive to minimize pain and swelling, form a normal walking pattern with a goal to discontinue crutch use, achieve 90° flexion and full extension, and establish quadriceps function and control. Always ensure that the incisions are clean and dry and the knee is iced and elevated until the acute inflammation is controlled. After this inflammation is controlled, ice and elevate the leg 3 times a day for 15 minutes. Weight bearing with a brace and both crutches should also begin the day of surgery. Crutch use should be discontinued when the patient establishes a normal walk pattern without a limp and can walk up and down stairs without pain or instability. This phase is also important to establish range of motion and quadriceps function. We recommend attending physical therapy 2 to 3 times a week to extend range of motion to 120° and demonstrate straight leg raises without lag by week 4.

               During the strengthening phase (4 weeks-6 months after surgery), the brace should be shortened and unlocked. There should not be an increase in swelling or pain and the patient should focus on proper technique and achieving full range of motion as soon as possible. The following exercises should be performed during this phase of recovery: mini-squats, mini-lunges, leg press, hamstring curls, step-downs, wall sits, one-legged dead lifts, and 4-way hip exercises. Weights should gradually increase as strength improves. The patient can also start walking for exercise and use balance cushions to improve endurance and balance.

               The return to activity phase begins 3 months after surgery and ends when the patient returns to his or her sport. The patient must continue improving muscle strength with activities such as squats, lunges, plyometrics, and agility drills. At the beginning of this phase, the patient should perform low-impact activities on softer surfaces, eventually introducing walk/jog intervals and agility ladder drills, and finally cutting and pivoting with advanced plyometrics and team participation without contact. Each patient is unique and his or her return to sport should be individualized instead of follow a strict time line. Once the patient can jump without pain or instability, has full range of motion, regained muscle strength and balance, and can perform sport specific activities without pain, swelling, or instability, the patient is ready to return to the sport. 

_________________________________________________________________________________

If you suspect you have an injured ACL, it is important to see an orthopedic surgeon. To schedule an appointment with board certified orthopedic surgeon, John Vitolo, MD, call 973-300-1553.

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.

---

[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.

Why are women more susceptible to ACL tears?

In recent years, there has been discussion on why women and young girls are more susceptible to ACL tears. There are many theories on the reasons why, but today we will examine a main anatomic difference between men and women that is a contributing factor: the Q-Angle and wider pelvis.

The Q-angle is the angle at which the femur (upper leg bone) meets the tibia (lower leg bone). The Q-angle is determined by three areas of the human anatomy – the Anterior Superior Iliac Spine (ASIS), the center of the kneecap (patella) and the tibia tubercle.  The Q-angle is basically a line drawn from the ASIS down to the center of the kneecap to the tibia tubercle (see picture below).

The Q-angle in women is greater because women are anatomically built with a wider pelvis than men.  A normal Q-angle in men is 14 degrees, while women have a normal angle of 17 degrees. The greater the angle, the more at risk the person is for knee injuries, including ACL tears.

The fact that the q-angle is more pronounced in women than men leads to more stress on the knee joint and makes it less stable when put under stress. For this reason, when a woman participates in sports involving jumping, running or pivoting, she is naturally more likely to suffer an ACL tear. 

What can we do to prevent ACL tears in women?

Recently, emphasis is being placed on neuromuscular training programs.  Neuromuscular training teaches the body better biomechanic movements to improve the control of the dynamic knee stabilizers (the ACL and major ligaments that surround the knee).  Exercises that are included in a neuromuscular training program include stretching, plyometrics and strength training.  The goal of these programs is to teach athletes how to land, pivot and control the knee without placing as much force on the ACL.  One program was developed by the Santa Monica Sports Medicine Research Foundation and is known as the PEP Program: Prevent Injury and Enhance Performance. To learn more about this program, please visit http://smsmf.org/files/PEP_Program_04122011.pdf.  

If you suspect that you have an ACL tear or other orthopedic injury, it is important to see an Orthopedic Surgeon.  Skyview Orthopedic, the office of John Vitolo, MD is available to treat all your orthopedic injuries and concerns.  Our office is focused on treating each patient individually and offering the highest quality orthopedic care.  John Vitolo, MD holds dual board certification in Orthopedic Surgery and Sports Medicine. For more information call the office, 973-300-1553 or visit us online at www.skyvieworthopedic.com.

Advances in ACL Surgery: Anatomic Reconstruction

This summer, John Vitolo, M.D. attended a conference on a new ACL reconstruction technique at the University of Pittsburgh Medical Center, home to one of the largest and most respected orthopedic clinical and research departments in the United States.  Dr. Vitolo is now one of a few specialized orthopedic surgeons trained in this new surgical technique, called the “Anatomic ACL Reconstruction Method”.  

Since adopting this new procedure, Dr. Vitolo has noticed that his patients experience less post-operative pain, improved range of motion and better overall results.  Dr. Vitolo stated, “Anatomic method takes each patient’s individual anatomy into consideration and attempts to restore that natural anatomy.  By using a medial portal approach, you are able to put the new graft where the original ligament existed.  The results have been phenomenal.  Post-operative pain has decreased and my patients are recovering more quickly and returning to activities faster.”

The anatomy of every patient is different.  The “Anatomic Technique for ACL Reconstruction” looks at each patient individually and anchors the ACL to its original anatomical position by using the medial portal approach; therefore keeping the natural anatomy of the knee.  By doing this, the patient is less likely to suffer a repeat tear and is able to return to activities in less time.  It is also believed that using this new method can decrease  the risk of developing arthritis later in life. 

When the ACL is injured it cannot be repaired by fixing the original ligament.  A “new” ACL must be constructed by grafting tissue from the patient’s body (autograph) or by using tissue from a cadaver (allograft).  It has been shown that anatomic graft placement is critical to the success and clinical outcome of ACL reconstruction.

The main benefit to the new procedure is that it helps prevent a re-tear of the ACL because the graft is placed lower and mimics the body’s natural anatomy.  Non-anatomic bone tunnel placement is the most common cause of a failed ACL reconstruction.  

For more information or to schedule an appointment, please visit our website:  www.skyvieworthopedic.com or call 973.300.1553.