Mann Orthopaedics

ACL Reconstruction

Anterior Cruciate Ligament – ACL Reconstructive Surgery

Diagnosis of an ACL tear is made on history and examination with 95% acuracy.  Patients who have an ACL tear often feel that the knee came apart and came back together.  They may have felt a “pop” in their knee during the initial injury, or that the knee gives-out from under them.   Swelling is usually but not always immediate, and it is often a “big deal” and the athlete cannot continue to play.  ACL tears cause instability and swelling, but often are not painful unless the swelling is severe. On examination, there are three tests that suggest a torn ligament, and in the right hands are very acurate.  Sometimes the patient “guards” and a knee with a torn ACL does not feel loose.  An mri scan is an excellent way to check these knees, confirm a torn ACL, and check for concomittant injuries like a meniscus tear or typical bone bruises.

Surgery for ACL injuries involves reconstructing ligaments.  Partial ACL tears are insufficient and usually need to be reconstructed as well.  ACL reconstruction surgery uses a graft to replace the ligament.  The most common grafts are autografts (using part of the patient’s own body, most commonly the patellar tendon, quadircpes tendon or hamstring tendons) or allografts (from a donor).  There are many advantages and disadvantages to both types of grafts. 

Arthroscopic ACL Surgery

About the Meniscus
The meniscus is one of two small, “c” shaped pieces of cartilage that act as a cushion in the knee joint. They sit between the thigh bone (femur) and the tibia (shin bone), one on the outside (lateral meniscus) and one on the inside of the knee (medial meniscus).  The main function of the menisci are to help distrubute the forces that the knee sees, and help stabilize the joint.

Meniscus

Meniscus tears usually occur during movements that forcefully rotate the knee while bearing weight, such as in sports or running for a bus, but can also occur during stretches and yoga as well.  The swelling is often not immediate, and can be mild.  Depending upon the extent and pattern of the tear, symptoms can range from mild to severe pain (particularly when the knee is straightened), buckling (similar to a pebble in your shoe feeling), locking (the knee actually gets stuck and difficult to put weight on the leg – this is usually a “bucket handle tear”) and swelling.   Severe pain is common when a fragment of the torn meniscus catches between the femur and tibia, and can lead to buckling of the knee.  An injury to the meniscus can also cause an audible click or pop. If the meniscus injury is small, these symptoms may resolve with physical therapy or even without treatment, but larger injuries usually require surgery.

Meniscus Tears

Treatment and Surgery
Surgery for meniscus tears includes partial meniscus removal (meniscectomy – only the torn part is removed, and this is the most common), meniscus repair (when possible, this is performed as the meniscus is there for a reason), or a meniscus transplant replacement (rare).  The success rate of menisectomy and mensicus repair are very high, and the return to full sports is the norm. Arthroscopic meniscus repair surgery is an elective procedure so it can be scheduled based upon the patient’s needs, but is best performed within two months after the injury as the chances of the torn tissue being repairable go down over time and then the only choice is to remove the torn tissue.  Arthroscopic surgery is done by inserting small instruments and a small camera into the knee joint through two very small incisions. The surgery is done under light general and local anesthesia and takes less than an hour.

During meniscus repair surgery the torn section of meniscus is either removed (a partial meniscectomy) or the torn edges are swen back together with special devices. The goal is to save as much of the original, normal meniscus cartilage as possible.  Since the meniscus blood supply is located near the outer rim, repairs near the outer rim are more likely to heal successfully. Attempted repairs near the center do not heal (except in the very young) due to the lack of a blood supply in this area, and therefore menisectomy is usually performed in this area.  However, the success rate with this procedure remains extremely high as well.

What is a Torn Rotator Cuff?

The rotator cuff is a group of muscles and tendons that form a cuff over the ball (humerus) of the shoulder joint. These muscles and tendons hold the arm in its “ball and socket” joint and help the shoulder to rotate. The tendons can be torn from overuse or injury. The most common symptom of a rotator cuff problem is pain, usually over the top of the shoulder, but the pain can radiate down the arm all the way to the elbow.  Patients often have pain if they roll onto the shoulder at night.  Another symptom of a rotator cuff tear is weakness of the shoulder, causing difficulty in lifting the arm up overhead, to the side or raising the wrist and forearm away from the body.  There is often difficulty with activities such as reaching, getting dressed, or carrying objects.  History and physical examination are usually enough to suspect a rotator cuff tear, and an mri scan is often done to confirm the size and location of the tear if surgery is necessary.

Surgery to repair a rotator cuff is done when:

• A full thickness tear is caused by a sudden injury. In these cases, it is best to do surgery soon after the injury, as delaying treatment can cause atrophy of the muscle, retraction of the tendon with subsequent difficulty getting it back to the bone, and even arthritis from the shoudler not being properly located in the socket.
• A complete rotator cuff tear causes severe shoulder weakness.
• The pain has failed to improve with 3 to 6 months of conservative nonsurgical treatments.
• Full shoulder strength and function is necessary for your job or activities.