Knee

What is an ACL Tear?

The anterior cruciate ligament, or ACL, is likely the most well known musculoskeletal structure in the sporting world. In basic terms, this ligament is responsible for preventing the tibia bone from moving anterior in the knee in relation to the femur bone. This is a function that is needed for running, cutting and jumping. Due to its function in the sporting arena, it is commonly a structure that is injured. Patients will feel a non-contact “pop” in their knee, followed by significant pain, difficulty bearing weight, and an effusion, or painful blood accumulation in the knee joint. Occasionally, initial evaluation on the ball field will allow for diagnosis of an ACL tear. Commonly, however, the initial pain prevents an appropriate exam and further evaluation is needed. At your first office visit, Dr. Davis will perform a knee exam gently, with the goal of assessing stability of the structures around the knee. Tests assessing the anterior translation of the tibia bone will give him insight into what is injured. At this time, he will gather x rays to assess for bony injury. This will be followed by an MRI to assess the soft tissue structures of the knee and determine what is, in fact, injured. Additionally, it is fairly common that multiple structures are injured about the knee alongside an ACL tear. These injuries will also be discussed at length during your office visit with Dr. Davis.

Treatment

Treatment for ACL tears is fairly clearly indicated. Due to poor outcomes historically, non-operative management is typically not well tolerated. It may be indicated in those who are fairly low functioning or have high risks associated with undergoing an operation. The negative result of treating a complete ACL tear non-operatively is the rapid development of debilitating degenerative arthritis of the knee joint. This doesn’t, however, mean that an ACL tear has to be reconstructed immediately. In fact, “pre-hab”, or pre-surgical rehabilitation, is typically required to allow for your range of motion to return prior to undergoing an operation directed at preventing stiffness and poor outcome. During your initial visit, this timeline will be discussed at length with Dr. Davis, along with the plan for getting you back to sport/activity as soon as possible. 

Surgical Intervention

Over the years, treatment for ACL tears has been divided into two categories, repair versus reconstruction. Although there has been some newfound discussion on ACL repairs, the gold standard remains ACL reconstruction at this time. This involves performing a knee arthroscopic surgery that allows for removal of the remnant ACL ligament, as well as the footprint on the tibia and femur bones. An ACL graft will then be prepared, introduced through drill tunnels on the femur and the tibia, and held in place on each side. This functions to restore the checkrein provided by your native ACL. Different ACL graft times have been discussed and studied over the years, including hamstring tendon, quadriceps tendon, patellar tendon, and cadaver graft. Each has different strengths and weaknesses. Dr. Davis predominately prefers to use your quadriceps tendon to harvest graft due to well studied and proven graft strength and size. A full discussion will be had during your post operative visit regarding the different graft types, benefits/downsides, and which option is best for you. As with any surgery, there are risks associated. These risks include stiffness, infection, residual instability, and others. Although he risks are low, Dr. Davis will acknowledge and discuss them with you preoperatively to allow you to make an informed decision about your treatment. Additionally, he will discuss the actionable steps taken to attempt to prevent these risks from occurring.

Post Op

Following surgery, a sterile dressing and hinged brace will be applied for several days, followed by removal of the dressing and clearance to shower. Weightbearing will be allowed in the brace and range of motion stretching/exercises will be initiated immediately. This will be guided by physical therapy from the start. At the first post-operative visit, Dr. Davis will assess your motion, assess your incisions and monitor your receipt of therapy and progress. Over the subsequent weeks, focus on range of motion and strength will occur, with the goal of full ROM by 6-8 weeks post operatively. As motion progresses, initiation of closed chain exercises and proprioceptive (sense of self in space) training will occur. As your strength and range of motion improve, progression of functional ability, while still focusing on decreasing swelling/pain will occur. The goal of running in a straight line is 3 months while progression to lateral movement/pivoting in the 6-9 month range. Release for full participation in sport will occur around the 9 month mark. Several studies have shown that this protocol can be progressed depending on patient ability. However, this is a good standard protocol to follow. All of these details will be discussed during your visit and your postoperative care will be discussed continually throughout your relationship with Dr. Davis.

What is a meniscus tear?

The knee joint has two menisci or “shock absorbers” that are in place to prevent damage to the cartilage. They resist stresses in the knee joint and aid in preservation of the knee joints ability to provide painless motion and weight bearing. Occasionally, however, an injury may cause damage to these structures. Usually from a non-contact insult, but occasionally from a fracture, the menisci may be torn. Particularly, the lateral meniscus is commonly torn in the setting of an ACL tear. This causes pain, swelling and discomfort with walking and movement of the knee. You will occasionally feel a pop or catch that makes motion almost impossible. If severe, the knee may not move very much at all. Upon your initial evaluation, Dr. Davis will utilize some special exam tests to determine if the meniscus is injured. If so, xrays and an MRI scan will be needed to further determine the degree of damage. 

Treatment

Treatment typically depends on multiple factors including additional injuries, age of the patient, chronicity of the tear, and more. If the injury is acute in a young patient, attempts will be made to perform an arthroscopic meniscus repair, utilizing suture and suture anchors to restore the meniscus’s ability to protect the knee joint. Occasionally, an acute tear may be so severe that repair is not possible. In these cases, meniscus removal, or a meniscectomy may be performed. Dr. Davis will do his best to avoid this result because accelerated joint degeneration will result. In young patients with non-reconstructible menisci, meniscus transplant may be an option. This however will have to be discussed at length to determine if you are a candidate. In the setting of chronic/degenerative tears in the older patient, repair is likely not indicated. Symptoms may include pain along with catching and popping. If the tear is associated with a high prevalence of pain, arthroscopic meniscal “clean up” will likely not be successful and the decision to move towards joint replacement may be discussed. All of this will be discussed at length in your visit with Dr. Davis. 

Surgical Intervention

In most cases, meniscus injury can be addressed utilizing an arthroscope, with minimally invasive techniques. This involves identifying the character of the tear and utilizing suture anchors to restore its stability and function. Portions of the tear that are non-reconstructible will be removed utilizing a shaver and other instruments.

Post Op

Post-operatively, small dressings will be applied that may be removed postoperative day 3. Range of motion exercises may begin immediately and will be led by a physical therapist. Weight bearing will be limited to protect any tears that are repaired. However, weight bearing may resume immediately if the torn meniscus tissue is removed. For repairs, weight bearing will be gradually progressed at around the 4-6 week mark, with the goal of full weight bearing by 12 weeks post operatively. This timeline will be discussed during your postoperative course with direct oversight by Dr. Davis. Strengthening and range of motion therapy will be continued with a goal of returning to sport by the 4-6 month mark, depending on the patient. This will be discussed at length during the postoperative course.