Anterior Cruciate Ligament Lectures at Pan Africa Orthopaedic Conference

Today I will be delivering two lectures in Johannesburg, at the Pan-Africa Orthopaedic Conference.  One lecture is entitled Anatomic ACL reconstruction, the second Double Bundle ACL reconstruction, Is it worth it.  Come on out if you have a chance.

Should We Repeal PPACA?

I may be wrong, but it seems to me that trying to pass modern reform to our healthcare took 9 administrations until something was able to be done. 

Instead of trying to throw out the whole baby with the bath water, wouldn't it be prudent for us to keep the legislation and amend the law with the parts that we as orthopaedists want, and change the parts that we do not like.

I am no democrat or republican, but I am certainly an American, and I did want to see something get through. Was the legislation all that I wanted to see......absolutely not, does it address what I thought was the major problems, NO, but at least it is a starting point.

Instead of expending so many resources and energy to repeal the entire law, why not sit down with the main players in the Congress, and the Administration, and at first listen to each other without any respective filters.  Actually listen for once.  Then write out the points that are thought essential to be eliminated, and parts that need to be included or changed, in a logical, unemotional, unbiased, uninfluenced way.  Is that too much to ask from our intelligent, objective, and logical leader individuals?

What Do I Do When I Tear My ACL or Anterior Cruciate Ligament??

Anterior Cruciate Ligament Injury - How Do I Decide What To Do?

With increasing levels of activities in youth, especially young women, and the undying desire to continue to compete and “play hard” as adults, we are seeing an increasing number of anterior cruciate ligament (ACL) injuries across the globe.  Along with the obvious ligament rupture, concomitant cartilage injury and meniscal tears occur, and we know that when these important structures are affected, the long-term function of the knee joint may be compromised and progression to early osteoarthritis can be seen.  We all have family members and friends who have unluckily fallen off-piste, twisted their knee in friendly football or a charity rugby match.  Now more than ever, we are faced with the question, “What should I do when I tear my ACL?” 

Although doctors, on-line information, and scientific journals provide resources to help guide individuals through this important question, there is no universal agreement.  The result of this translates into uncertainty on the part of the patient.  Immediate surgery, delayed surgery, no surgery…….it takes a doctor (literally) to navigate the confusing amount of knowledge on the subject.   To be honest, I do not know how patients make choices in the age of TMI, or too much information.   The goal of this article is to provide a framework to help patients evaluate if they are doing the “right” thing.

Contrary to what many patients are told……ACL injury is not a life or death problem.  This means the injury does not need to be fixed on the day it occurs, or for that matter, within the first three weeks after injury.  What does science say about it? There is convincing evidence supporting both early and delayed repair, and with modern techniques, there is high probability it will be done quite well.  Is there a time when the repair should be done urgently?   In the setting of a locked knee, either secondary to cartilage or meniscal injury mechanically blocking the movement of the knee, the repair should be taken care of urgently.  Would you continue to drive your car around on a flat tire?  The same common sense principles apply here.  If the meniscus is blocking movement of the knee, walking on it for a long-time is ill advised because if the meniscus tissue becomes tattered from continued weight-bearing and attempted knee bending, the chance of successful healing is less when it is finally repaired.

So, what does this mean?  Using a simplistic approach, the only reason to fix the injury urgently is if you are a elite athlete and must get back to the pitch because of lost income. If one is an everyday person, then fixing the ACL can wait in most instances unless there is something blocking movement of the knee.  It is that simple and let’s keep it so.

Graft choice in ACL Reconstruction

Another important area generating many questions is what is the best graft to use for ACL reconstruction.  The simple answer is the best graft is that which your preferred doctor chooses.  If one asks a doctor that has a practice involving a great percentage of ACL reconstruction, then we may have a different answer.   Most doctors who devote a large percentage of their practice to ACL reconstruction will be well versed with all the different graft types.   In elite athletes, or those who have a significant “bowlegged” knee alignment, I tend to use more patellar tendon grafts.  I prefer to use hamstring grafts in most other patients.  In re-dos for failed reconstruction, all graft types previously discussed, as well as quadriceps and allograft sources, can be used successfully.

Double Bundle versus Single Bundle ACL Reconstruction

This is a controversial area, however there are some very good studies showing that the double bundle reconstruction may indeed be better in the following ways:  re-creating more normal anatomy, better knee kinematics, and less likely to fail as compared to single bundle anatomic hamstring ACL reconstruction.   This question will be answered in the near future.

Rehabilitation

Another important area for debate, but most would agree that a balanced approach utilizing closed chain (foot position fixed throughout exercise) and protected open chain, as well as balance and coordination types of rehabilitation programs are important for good functional outcomes.

Bracing is an area that has very good literature.  Knee immobilization immediately following surgery for up to 3 weeks has been show to be beneficial, however, beyond this, bracing has not shown much benefit.

Outcomes and Outcomes Assessment  

It is difficult to know where one is going, if it is not known where someone is coming from. From this standpoint, both objective and patient completed subjective assessments are key to ensure the best possible outcomes.  Some of the objective measurements include KT-1000, isometric, isokinetic, and functional testing.  Some examples of subjective measurements include IKDC, KOOS, Modified Cincinnati , and Tegner-Lysholm scores.  Even with all these measures, we are discovering that we are not as good as we think, and that for the highest demand athletes, the return to play at very high levels of competition after ACL reconstruction can be somewhere around 50-70%.   To compound this, we are also seeing significant, albeit low levels, of patients who develop premature arthritis when they should not.  This is challenging our understanding of the very reasons why we are performing the surgery in the first place.

What do I Need to Know?

ACL is not a life or death situation, and unless you are a high performance athlete, there is no reason, except for having a locked knee, that one has to undergo surgery urgently.  Make sure to find a doctor you are comfortable with, because ACL surgery and rehabilitation is difficult.  Assure the lines of communications are open, and that everyone is on the same page as far as expectations and timings of milestones.   Be sure that some sort of pre-operative assessment is done, because this will help to define where you are in the postoperative period, and is a helpful stimulant if enough effort is not being exerted on the part of the patient and/or therapist.  Also it is helpful to know when it is safe to go back to sport - it should be when function of the operated limb is at least 90% of the function of the non-operated limb.   Bracing can be helpful for a short period of time, but do not become dependent on the brace.  Rehabilitation is probably more important than the actual surgery, so make sure that a well-trained and dynamic therapist is found because it can make a huge difference in outcome.   Remember, ACL surgery is one of the most successful procedures performed by orthopedic sports medicine specialists, with more than 90% of patients having a good or excellent result.