Case Study: Chronic Knee Dislocations Due to Work Injury

A 31 year old male patient came into the office complaining of continuous knee pain. He also complained that his kneecap would “give out”. During the examination, we determined the problems began back in 2008 following a work injury. The patient explained that during the incident, he had twisted his knee at work, which had caused his knee to dislocate.

At the time, the patient had been treated with physical therapy and a brace. He was able to return to work following the injury but continued to suffer with the symptoms described above for years. Upon examination, it was determined that he was suffering from chronic patella instability and multiple dislocations.

As part of the examination, we noted the following:

•           Knee swelling

•           Increased patella laxity

•           Positive patellar apprehension sign

•           Increased Q angle

Before determining the exact treatment protocol, the increased Q angle indicated the need to perform a CT scan to measure the distance between the tibial tubercle and the trochlear groove. This is referred to as the T-T distance. A T-T distance greater than 2.0 cm requires the anteromedial transfer of the tibial tubercle and will decrease the T-T distance. This will encourage improved stability of patella.

It was determined that the best treatment approach was to combine two surgical procedures at the same time. The first procedure is referred to as MPFL reconstruction. The medial patellofemoral ligament or MPFL is a thin band of tissue that attaches the kneecap to the inner part of the knee. When the kneecap dislocates, it often tears the MPLF on the inside of the knee, which is important for stability in the knee. During the procedure, the MPFL is reconstructed and re-attached in the most anatomically correct position. To do this, we used a hamstring allograft and replaced the torn MPFL.

The second procedure is referred to as anterio-medialization of the tibal tubercle. The operation focuses on recentering the patella and reduces patellofemoral contact pressure. This improves the Q angle and reduces lateral vector force on the reconstructed MPFL.

The surgery proved to be a success. Following surgery, the patient was in a hinged brace and utilized crutches for 4 weeks. He then completed 12 weeks of physical therapy that was focused on edema control, range of motion and strength training. He was able to return to his job as a laborer 3 months post-op. He is currently doing extremely well and no longer suffers from patellar instability. He currently works 50-60+ hours per week without difficulty. 

Lateral Patellar Instability and the Medial Patellofemoral Ligament (MPFL)

Lateral patellar instability occurs when the kneecap dislocates out of place. The kneecap or patella is a small bone in the front of the knee. It glides along the femoral groove (a groove in the femur bone) as the knee bends and straightens. If the patella comes out of the groove completely, it is referred to as patellar dislocation. If the patella comes out of the groove partially, it is referred to as patellar subluxation.

Symptoms of dislocations of the kneecap are as follows:

-          Pain at the knee joint
-          Swelling
-          Obvious displacement of the kneecap (kneecap can often briefly dislocate and return, but pain and swelling will still be present)

When the kneecap dislocates, it often tears the medial patellofemoral ligament on the inside of the knee. The MPFL is a thin band of tissue that attaches the kneecap to the inner part of the knee. The medial patellofemoral ligament or MPFL is important for stability in the knee.

There are surgical and non-surgical treatments for patellar instability. Rest, ice and bracing have been known to heal the injury and prevent recurrent dislocations. However, surgical intervention is sometimes needed to correct recurrent dislocations.

If the MPFL is torn, the patient can potentially benefit from a surgical procedure known as MPFL reconstruction. Reconstruction of the MPFL is a surgical procedure that restores patellofemoral stability. The most successful and widely accepted approach to this procedure is to use an approach that restores the MPFL to its anatomically correct position. This procedure, along with other options, such as tibial tubercle osteotomy, and/or a trochleoplasty can be used to correct the problem. The exact treatment protocol varies by individual.

 

Prominent Orthopedic Surgeon to Open Office in Chester, NJ

Advocare Orthopedic and Sports Medicine Center, the office of NJ Top Doc orthopedic surgeon, John Vitolo, MD announced the opening of a satellite office in Chester, NJ on January 27^th 2015. The office will be located at 530 East Main Street in Chester, Suite 4A, with Advocare Aygen Pediatrics and Adult Care. This office location is being established to better suit the needs of patients from Morris County.

The new office is Advocare Orthopedic and Sports Medicine Center’s second location. “Opening the office in Chester is an important step toward expanding our practice into Morris County,” said Vitolo, “When we were presented with the opportunity to open an office in Chester, we looked at the area and noticed a need for orthopedic care. We are very excited to have this opportunity to offer quality orthopedic care in the area.”

The new office will focus on the treatment of orthopedic injuries and conditions of the shoulder and knee. Dr. Vitolo has over 20 years of experience treating sports and workplace injuries. Dr. Vitolo is committed to providing the highest quality, individualized care to his patients.

John Vitolo, M.D. is board certified in Orthopedic Surgery and holds a Subspecialty Certification in Sports Medicine.  Dr. Vitolo specializes in arthroscopic surgery of the shoulder and knee and was a former team physician for the Boston Red Sox.  He received his undergraduate degree from Brown University, then attended Columbia University and the University of Medicine and Dentistry of New Jersey.  Dr. Vitolo’s main office is located at 540 Lafayette Rd in Sparta, NJ.  Dr. Vitolo is currently accepting new patients and is also available for IME’s and second opinions. Please call (973) 300-1553 or visit advocareorthosportsmed.com for more information. 

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.