Anterior Cruciate Ligament – ACL Reconstructive Surgery

An ACL tear is most often a sports-related injury, but can also occur during rough play, mover vehicle collisions, falls, and work-related injuries. Most often ACL tears occur when pivoting or landing from a jump. In fact, about 80% of sports-related ACL tears are “non-contact” injuries, without the contact of another athlete.

Normal ACL

The diagnosis of an ACL tear is made on history and examination with 95% accuracy.  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 accurate.  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 concomitant injuries like a meniscus tear or typical bone bruises.

Surgery for ACL injuries involves reconstructing ligaments. Repairs do not work except in the very young as the ACL tissue deforms before it tears.  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, quadriceps tendon or hamstring tendons) or allografts (from a donor).  There are many advantages and disadvantages to both types of grafts, and Dr. Noy will discuss these with you to help you choose the best graft choice for you.

Dr. Noy does ACL surgery exclusively through arthroscopic techniques, utilizing very small incisions and specialized cameras and equipment.   The surgery is done as same day surgery, using a regional block which helps decrease anesthetic risks, decrease pain, and allows quicker initiation of exercises.  Because of special surgical and post-surgical techniques, most patients do not need to use narcotics after surgery, achieve at least 90 degrees of flexion the same day and can get back to a desk job within one week without crutches.  A brace is used to protect the leg for 2-6 weeks, and a custom playing brace is obtained for some athletes to use during the first year.  A good physical therapist is very important in optimizing your full recovery and Dr. Noy will help you obtain one if necessary.  Therapy is usually started after the first post-surgical visit, but exercises are started immediately at home.  Once you obtain full range of motion and strength after surgery (which is checked on a computerized test), you often will be allowed to get back to sports with a brace.  This has been as early as 2 months, but most patients are in the 3-4 months category.

Torn ACL

Reconstructed ACL

Arthroscopic ACL Surgery

Arthroscopic surgery Many orthopedic surgeons use arthroscopic surgery rather than open surgery for ACL injuries because: It is easy to see all the knee structures and work on them. It uses smaller incisions than open surgery. It has a much quicker recovery It may have fewer risks than open 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 purpose of the menisci is to help distribute 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 meniscectomy and meniscus 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 sewn 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.

Arthroscopic Meniscus Surgery

Meniscus tear

Recovery
Patients are typically able to leave the hospital after an hour in the recovery room, with the aid of a cane or crutches.  Dr. Noy uses special techniques that allow most patients to have a relatively painless recovery and most patients do not use the narcotics prescribed to them.  Most patients are allowed full weight bearing after surgery.  A knee brace is only used if a repair was done to limit full motion for a few weeks, but menisectomies do not require this.  A special cold therapy machine is used after surgery to help reduce swelling and pain.  Keeping the leg and knee elevated for the first few days to a week helps speed the healing process and decreases the full recovery time back to sports dramatically.  Physical therapy is usually started after the post op visit although some patients use their trainer or do a program on their own.  Full recovery is as early as 2-3 weeks for professional athletes, but usually takes 4-8 weeks for most patients.  Regular daily activities though are usually accomplished by 1 week.

Even after a successful reconstruction, it is possible to reinjure the ACL.  Most primary ACL reconstruction surgeries have an 80-90% success rate; however revision may be needed if poor reconstruction, poor rehabilitation, or reinjury occurs.  Typical symptoms of a poor reconstruction include: knee instability, pain, and an inability to return to desired activities.  If failure of the primary reconstruction occurs within six months, it is usually due to failure of the graft, negligent surgery technique, or a rehabilitation that was overly aggressive.  Failure occurring after one year will most likely be caused by reinjury to the ligament itself.

Preoperative planning is absolutely vital for a successful revision.  This allows Dr. Noy to identify exactly how the revision must be performed in order to correctly address every factor contributing to the primary surgery’s failure.  Once the patient’s individual needs have been ascertained, Dr. Noy will discuss every surgery and grafting option available to the patient in order to achieve maximum rehabilitation.

Depending on the extent of failure in the original reconstruction, multiple surgeries may be necessary.  If this is the case, preparatory surgeries are first performed to remove the old hardware, administer bone grafts to heal and fill drill holes so that new hardware can properly fit, and to realign the knee so that successful revision may be achieved.   If a preparatory surgery is needed, it will be three to six months before the secondary revision may be performed.  Depending on the specifics of the case, it is in this second surgery that new hardware is placed, new ligament tunnels are drilled, and the new graft is performed.

Recovery times vary with each individual case, and modifications to rehabilitation may be required.  These modifications, dependent on the patient’s weight-bearing status and range-of-motion limitations, require a lengthier, less aggressive rehabilitation than with the initial ACL Reconstruction.  The results of revision surgery are never as good as the primary reconstruction, making it important for the patient’s expectations to be properly placed.  The goal of revision is to return to normal daily activities, but not competitive athletics.  Fortunately, with thorough evaluation, treatment, and rehabilitation, most cases of Revision ACL Surgery are successful in correcting the damaged knee.

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.

Treatment of Torn Rotator Cuff

Most rotator cuff tears can be treated without surgery.  In fact, it is the minority of patients who end up undergoing surgical treatment for a rotator cuff tear.  Dr. Noy has a special program he has dubbed the No Pain Principle Program for shoulder rehabilitation that is often successful and avoids surgery. Non-operative rotator cuff treatments may include a home exercise program, physical therapy, anti-inflammatory pain medications, and cortisone injections. The goal of treatment is to reduce inflammation and pain, and strengthen the muscles around the shoulder to compensate for the torn muscles.

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 shoulder 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.

Surgery to repair a torn rotator cuff tendon usually involves:

• Removing loose fragments of tendon, bursa, and other debris from the space in the shoulder where the rotator cuff moves.
• Making more room for the rotator cuff tendon so it is not pinched or irritated. If necessary, this includes shaving bone or removing bone spurs from the point of the shoulder blade.
• Sewing the torn edges of the supraspinatus tendon together and to the top of the upper arm bone.

Dr. Noy does all rotator cuff surgery arthroscopically, meaning using a small camera and specialized equipment through small incisions.  The first step is to look at the tear and determine the type of tear and plan the best repair strategy.  It is very rare that Dr. Noy cannot repair the tendon, even in massive tears.  Inflamed or damaged tissue is removed as are any bone spurs that are contributing to the pain and tearing.  The goal is to attach the tendon back to the bone with a wide footprint and solid fixation.   The body then heals the tendon to the bone over the next several weeks.  Dr. Noy uses special knotless devices that allow this to happen more reliably, and allow earlier passive range of motion with the therapist to avoid frozen shoulders.  As with all his arthroscopic surgeries, the actual pictures are attached to your discharge instructions when you leave the surgery center so you can instantly see your repair.

Recovery

While all surgeries continue to improve for up to a year, the recovery is broken down to a few sections.  Since Dr. Noy does what is called a tensionless repair, waist level activities such as typing on a computer and eating are allowed immediately allowing those with desk jobs to return to work after in 2 days.  Passive range of motion is started initially with a therapist followed by active range of motion exercises around 4-6 weeks after surgery.  Strengthening is then done and most patients are back to full daily activities and even golf by 3 months.  Throwing a baseball is delayed a while longer, as this has the highest stresses on the repair.  The sling is worn for sleeping and walking around for 4-6 weeks after surgery, but is not needed when sitting at a desk. Dr. Noy has a specialized post-operative program that manages pain so well that most patients do not use any narcotics.  It is important to have a top notch physical therapist to help you recover after surgery, and Dr. Noy will help you obtain one if necessary.

About the Labrum

The labrum is a type of cartilage found in the shoulder joint that is more fibrous or rigid than the cartilage on the ends of the ball and socket. The labrum is firmly attached around to the rim of the socket. The labrum has basically two functions: to deepen the socket to help the ball stay in place, and to act as an attachment for the ligaments that attach the ball to the socket. If the shoulder is injured, the labrum can tear off of the rim making the shoulder

A Labral Tear

The Labrum

The most common patterns of labral tears are:

Bankart Lesions: This injury is the result of a shoulder dislocation or subluxation (partial dislocation).  The labrum is torn off the socket as the ball comes out of joint.  Sometimes the ligaments themselves can tear, but usually it is the labrum that tears with the ligaments attached.  Usually when this happens the labrum does not heal back in the right location, making the ligaments loose and the shoulder more susceptible to future dislocations.  Occasionally the bone will actually break off with the labrum and ligaments.

Posterior Labral Tears: A less common injury, but sometimes seen in athletes, this condition develops when the rotator cuff and labrum are pinched together in the back of the shoulder, making it difficult to rotate the shoulder inwards.

SLAP Tears: This is most commonly seen in overhead and throwing athletes, such as baseball/softball, volleyball, swimmers and tennis players.  The SLAP tear (Superior Labrum from Anterior to Posterior) occurs when the bicep tendon, which is attached at the top of the labrum and socket, peels off the labrum causing a tear with certain motions.  Bankart and SLAP tears make it difficult to throw, serve or even lift heavy bags.

SLAP Tear

Diagnosing Labrum Tears
Labral tears are diagnosed on history and examination.   There are very specific findings that make one suspicious for these injuries.  Confirmation is usually with an MRI scan, which is a non-invasive non-radiation test, but occasionally requires an MRI arthrogram (an MRI scan with contrast dye injected into the joint before the MRI is done).  The most accurate way of diagnosis is with an arthroscopy, when a small camera is inserted into the joint to look at it.  This is usually done at the same time as the corrective procedure, though, as a shoulder or sports trained orthopedic surgeon can usually make the diagnosis without it.

Treatment for Labrum Tears
Treatment depends upon the kind of tear, age of the patient and goals of the patient. Sometimes these tears are managed successfully without surgery, but if surgery is necessary, it can be done arthroscopically.  This means an excellent repair can be done with a small camera and specialized equipment that are inserted through very small incisions leaving virtually no scars but a solid repair.  SLAP lesions may be trimmed or reattached depending on the configuration of tear while Bankart lesions need to be reattached to the socket to recreate the proper tension on the ligaments.  This will prevent the shoulder from coming out of the socket.  Dr. Noy uses outpatient arthroscopic techniques exclusively for these procedures, including knotless anchors which provide excellent strength of repair, and plastic surgery closures so that often the scars are barely visible.

Arthroscopic Labrum Surgery

Recovery from Labrum Surgery
For most repairs, typing on a computer and waist level activities are allowed immediately after arthroscopic repairs, allowing many patients to return to work within two days.  Laborers and athletes obviously will take longer to get back to work as it takes at least four to six weeks for the labrum to heal back to the socket.  It is during this time that the repair needs to be protected the most.  Once the labrum is healed, a physical therapist will help you get range of motion and strength back over the next few months.  Because of the variability in the injury and the type of repair done, it is difficult to predict how soon someone can to return to sports after the repair, but most patients are back to golf and regular activities fully at 3 months.  Throwing is usually not started until 4-6 months, but we often will determine this by a strength test. The vast majority of patients have full function of the shoulder after labrum repair, and most patients can return to their previous level of sports with no restrictions.

About the AC Joint
The acromioclavicular joint, or AC joint, is a joint at the top of the shoulder. It is the junction between the acromion (part of the scapula that forms the highest point of the shoulder) and the clavicle. The AC joint allows the ability to raise the arm above the head. This joint functions as a pivot point (although technically it is a gliding synovial joint), acting like a strut to help with movement of the scapula resulting in a greater degree of arm rotation.

The AC joint is stabilized by three ligaments:
The acromioclavicular ligament: attaches the clavicle to the acromion of the scapula.
The coracoacromial ligament: runs from the coracoid process to the acromion.
The coracoclavicular ligament: consists of two ligaments, the conoid and the trapezoid ligaments.

A common injury to the AC joint is dislocation, often called AC separation or shoulder separation. This is not the same as a “shoulder dislocation,” which refers to dislocation of the glenohumeral joint. A shoulder separation is almost always the result of a sudden, traumatic event that can be attributed to a specific incident or action. The two most common descriptions of a shoulder separation are either a direct blow to the shoulder (often seen in football, rugby, or hockey), or a fall on to an outstretched hand (commonly seen after falling off a bicycle or horse).
Although a shoulder separation is a common injury, there are a few different types:
Type 1: is an injury to the capsule that surrounds the AC joint. The bones are not out of position and the primary symptom is pain.
Type 2: involves an injury to the AC joint capsule as well as one of the important ligaments that stabilizes the clavicle. This ligament, the coracoclavicular ligament, is partially torn. Patients with a type II separated shoulder may have a small bump over the injury.
Type 3: involves the same type of injury as a type II separated shoulder, but the injury is more significant. These patients usually have a large bump over the injured AC joint.
Type 4: is an unusual injury where the clavicle is pushed behind the AC joint.
Type 5: is an exaggerated type III injury. In this type of separated shoulder, the muscle above the AC joint is punctured by the end of the clavicle causing a significant bump over the injury.
Type 6: also exceedingly rare. In this type of injury the clavicle is pushed downwards, and becomes lodged below the coracoid (part of the scapula)

Arthroscopic surgical technique:
The patient is placed in the lateral or beach chair position under a general anesthesia, supplemented with a scalene block. The arthroscope is introduced into the glenohumeral joint via a standard posterior portal. An anterior portal is created with an outside/in technique using a spinal needle to verify position. An 8.25 mm cannula is then introduced through the anterior portal. A full radius shaver blade is put in position through the anterior cannula and worked through the rotator interval. The dead or damaged tissue is removed until the base of the coracoid can be seen.
A hole is drilled in the clavicle typically 35 mm from the distal clavicle. Once the hole is drilled, a graft is attached with a coracoid button on either side. The clavicle is reduced while the blue fiberwire is tightened. The excess graft and wire is then cut and the portals are sutured.

Graft with Buttons Being Placed

Tightrope being Tightened

After Surgery