The Torn ACL: How Should It Be Fixed?

When a knee injury occurs to an athlete, the greatest concern is the stability of the knee.  Although most injuries are minor, the one that worries us the most is a torn anterior cruciate ligament (ACL).  The ACL provides the knee with rotational stability during pivoting or ballistic type sports activities. It is the major structure that protects the knee from damage. If the ACL is torn, the knee loses stability which causes additional damage to the surrounding structures, particularly the medial (inner) side of the knee. If recurrent episodes of instability occur and the knee suffers additional damage to the medial meniscus or articular cartilage, premature degeneration of the joint can occur.  Arthritis can subsequently can result from an ACL tear.

torn-acl

To combat this premature degeneration, the last 25 years of orthopedic sports medicine has seen an explosion in techniques to reconstruct (replace) the ACL. Scientific evidence suggests, if you can protect the knee from additional episodes of instability, premature degeneration and arthritis can be delayed or prevented.

Since the torn ACL is in the center of the knee joint and experiences high forces of stress, it can not be simply repaired in a traditional sense. We cannot “sew it back together” like most other torn structures in the human body.  In order to restore its proper function, the ACL has to be “replaced” (otherwise known as reconstruction).

In order to replace the ACL with a new ligament, we have to find a suitable substitute.  Tendons have been found to be the easiest source for the new “grafted” ligament.  We either use a tendon from the patient (autograft) or from another person (allograft or cadaveric tissue).

The most common sources of autograft are the patellar tendon and the hamstring tendon.  Each graft has pro’s and con’s. In general, that patellar tendon autograft is felt to be the most reliable because it has the longest track record and results in predictable outcomes. It has the downside of increased postoperative pain and prolonged recovery. These two problems have led to the development of the hamstring autograft as an option.  The hamstring graft (semitendinosis and gracilis tendons) has less pain, is more appealing cosmetically and clinically has equal outcomes in many studies. Some surgeons feel the autograft patellar tendon is the gold standard despite the studies that claim hamstrings and patellar tendons are equal.

My beliefs lie in the middle.  I feel a hamstring graft is an excellent option and generally prefer it.  For elite athletes who have access to therapy on a daily basis, I believe the patellar tendon is a better option. For the non-athlete who suffered an unusual injury resulting in an ACL tear, I utilize the allograft tendons (tibialis,patellar, peroneals).  Allograft tissue has proven to be safe from accredited tissue banks.  It results in a quicker return to activities of daily living and less post operative pain.

The latest development in ACL surgery is the use of two grafts in a double bundle configuration.  Although this method is enticing because it reproduces “normal” anatomy, it is still in the developmental phases. I consider it another option in the armamentarium above.  The surgery for two bundles is more complicated and more costly for a procedure that is already highly successful. The use of the double bundle ACL reconstruction will eventually either become mainstream or used for selected cases. Only time will tell.

If you have an ACL tear, and would like to discuss your options please contact me, or call my office at 313-277-6700.

Marc Milia MD 

MIOrtho.com

Sports Medicine On The Road: Out And About In Sault Ste. Marie Part Deux

While the remaining portion of our adventure around the Soo took place right in the hotel, there were some very interesting details along the way. Here are just a few shots of various parts in the Kewadin Hotel.

There are seven original clans, or dodems. The clans dictate one’s role in society. The bear is representative of police or a healer. Does anyone else see Winnie The Pooh?

Sculpture in the lobby of the Kewadin Hotel - Sault Ste. Marie

Capturing photos in brilliant sunlight is challenging and this day was no different, both indoors and outdoors.

At this time of day, the sunlight blitzed through the many panes of glass at the entrance.

The entire hotel decor is significant to the geographic region it resides in, as you can see in the solid beam work in the hotel entrance.

Along the walkway there is an abundance of artwork on display in cases, on the floor and walls. Each display case is adorned with a table lamp like the one shown here.

Clean lines and natural color make this simple table lamp attractive.

Many of the pieces of artwork are for sale by local artists. Does this remind anyone else of Tom Sawyer?

Boy fishing.

The following artwork likely has a detailed, specific interpretation in the Chippewa tribe. Without a tour guide to provide such an interpretation, the true meaning is lost. It’s best to appreciate the depiction of life through art.

The actual size of this wall hanging is over fifteen by thirty....feet! In this close up, the detail quilting is more apparent.

Mask crafted from wood.

This painting is one of twelve that when displayed, created a very large wall mural.

Flying spirit painting.

Sports Medicine On The Road: Out And About In Sault Ste. Marie

 With a break in the hockey action, it was time to head out. There are plenty of outdoor attractions to visit in and around the Soo.

The locks closed a few weeks back so there was not much going on this visit.

The Cloverland Electric Hydro plant was built in 1902, made of red sandstone and steel.

The Cloverland plant produces enough electricity to power one-fifth of the eastern U.P.'s needs.

Just a few minutes from downtown, you can find deep, thick forests of birch & white pines.

The walking bridge at Kewadin Hotel & Casino.

A tanker sits in the ice and water on the Ontario side, seemingly done for the winter.

The end of another day in the Soo.

Sports Medicine On The Road: 35th Annual Lions Cup Invitational

Lions meet the needs of local communities and the world. The 1.35 million members of our volunteer organization in 206 countries and geographic areas are different in many ways, but share a core belief – community is what we make it.

L-R: RJ Morris, Bob Rosbury (Notre Dame Prep); Tom Brown (Lions Club); John Ferroni (Sault Ste. Marie); Brian Dallas (Divine Child); Corey Markham, Micah Stipech (Houghton).

 

All four teams attended the breakfast held on campus at LSSU.

Sports Medicine On The Road: Lower Leg Contusions In Hockey

Soft tissue injuries in athletics are common and occur with greater frequency as the level of competition increases (youth>>high school). Sprains, strains and contusions are the most common injuries seen across all sports, regardless of level of participation.

A sprain denotes an injury to a ligament; a strain refers to a muscle injury and a contusion is better defined due to the way it happens (mechanism of injury), which is by direct contact with another player, the ground, equipment or other object and can affect muscles, bones and ligaments.

Contusions are the second most common injury in athletics, behind strains. Nearly all athletes will sustain a contusion (bruise) while involved in athletics. Contact and collision sports will produce several contusions in every practice or event, every day. For this piece, we are talking only about contusions to the area below the knee and above the ankle, typically from being hit by a puck or another skater.

Contusions occur when there is direct impact to the body, crushing muscle fibers and blood vessels below the skin’s surface. Contusions cause swelling and pain in the affected area and can also result in loss of range of motion in the surrounding area. When the connective tissue or blood vessels are impacted, they can tear and leak blood and fluid – this is the primary source of the swelling. Depending on the extent of tissue damage, there may be a blueish discoloration at the site of impact.

Most contusions are minor and heal quickly. It is important to have a proper evaluation by an athletic trainer or physician before returning to play as more severe contusions may require further evaluation and treatment.

courtesy of www.webmd.com

 

Treatment:

The goal should be to control pain, inflammation and bleeding by following the (P). R.I.C.E. principal:

P – protect the injured site from further impact by using a high density foam or gel padding. If necessary, remove the athlete from practice or game.

I – apply an ice pack for no more than 20 minutes. Repeat application every 2 hours.

C – using a compression wrap or bandage, wrap the affected area.

E – always elevate the injured area to a level higher than the heart. This will aid in fluid reabsorbtion and promote healing.

Continue to follow the PRICE principals for the first 48-72 hours following injury. Once it is safe to return to play, continued protection of the injured site may be necessary.

In hockey, following a lower leg contusion, the worst scenario when returning to the ice is to be struck in the injured area again…and again. If the shin pads do not adequately provide protection, then the use of a high density foam or gel padding is necessary. If the shin pads adequately cover the affected area but the pressure from wearing the pads is uncomfortable, apply a doughnut type pad to the area underneath the pads.

 

Sports Medicine On The Road: The Pullar

The local Lions service organization sponsors an annual high school hockey tournament featuring two teams from the U.P. and two teams from downstate. This weekend Divine Child, Notre Dame Prep, Houghton and Sault Ste. Marie HS will face off.

"The Pullar" was built in the 1930's and has been home to Sault Ste, Marie high school teams, juniors and Lake Superior State University Lakers.

The Pullar is an old barn with the charm only a few are able to appreciate!

 

 

Goalie equipment

 

At nearly a buck and a quarter apiece, that's a lot of "lumber" sitting in reserve!

 

Water soldiers standing guard.

Sports Medicine On The Road: Welcome To Da’ U.P.!

Oakwood Sports Medicine is on the road this weekend.

No, not somewhere warm and sunny this time. Check it out!

Mackinac Bridge January 20, 2012

 The Mackinac Bridge connects Michigan’s lower peninsula with the upper peninsula, fondly know as “da U.P.”!

The total length of this modern marvel is 26,372 feet, or 5 miles. The main towers are 552 feet above the water of Lakes Michigan and Huron below and vehicle traffic traverses the Mighty Mac 199 feet above those waters at the midspan. Over 3,000 workers spent 3 1/2 years constructing the bridge.

Welcome to Sault Ste Marie!

Settled in 1668 by French explorers, Sault Ste. Marie was named in honor of the Virgin Mary. The oldest city in Michigan and one of the oldest in the U.S., the Soo offers year-round fun and activities. With an average snowfall of 120″, the Soo more than contributes to the “Winter Wonderland” tag.

Video Era Begins – Steve Irwin

This video was taken at the Australia Zoo while on a sports trip to Australia. Steve Irwin, infamous for his lively personality and outlandish adventures, can be seen here feeding a live crocodile.

The very next day, Irwin took his one-month old son, Bob, into the arena with him while feeding the crocs. Irwin was blasted by critics for child endangerment in the news for days following.

Croc Hunter Video

Croc Hunter Video

This movie requires Adobe Flash for playback.

Rotator Cuff is to Blame for Majority of Shoulder Pain

by Marc J. Milia, MD

Orthopedics/Sports Medicine

Whether you swing a hammer or a tennis racket, the shoulder can become a source of pain by the end of the day. The majority of complaints involving the shoulder are actually related to the rotator cuff.

Anatomically, the shoulder is a ball and socket that is held together by ligaments and tendons. The rotator cuff tendons are a group of four muscles that come from the wing blade to form a cuff of tendinous tissue that inserts into the humeral bone (the ball). The rotator cuff resides below the acromion bone (from the wing blade).

Overhead athletes and manual laborers can develop irritation below the acromion bone from repetitive use or acute trauma. Consequently, rotator cuff problems can frequently arise.

In most cases, physical therapy or corticosteroid injections can solve the problem. However, on occasion, surgery might be necessary.

A program has been developed where the physician can utilize minimally invasive techniques to arthroscopically repair the rotator cuff in an efficient manner. The recovery phase’s discomforts can be alleviated by local nerve blocks that allow the patient to tolerate pain two to three days into the early postoperative phase.

With the benefit of new technology, the experienced orthopedic surgical team at Oakwood Southshore Surgery Center and physical therapy at Oakwood Southshore Medical Center, we have been fortunate to return many athletes and laborers back to their previous levels of activity.

Contact Dr. Marc Milia at 1-313-277-6700 or click here.