Surgery in 3 weeks

[Eagle5US]

OK then, some of you may know that I injured myself acting like a teenager about 2 weeks ago...I have seen the Ortho gods and the following is the result of my MRI:

1. Anterio / lateral tear of the medial miniscus with complete disruption.
2. Torn ACL
3. Crushed and blunted medial articular cartilige.

So, the following questions:
1. What is the "classic" mechanism of injury to rupture an ACL?
2. What type of presentation and physical exam test are you likely to see?
3. In a non-hospital environment, how would you initially address it?
4. Now to the hospital, what are the BASICS of the surgical options for repair and which do you feel is better with a why.

We can follow my surgery and progress as it goes forward as a learning thread. My wonderful bride bought me a home wireless network set-up for my laptop so I can yak with you clowns from my recliner.
Suffice it to say I am finally walking and wearing a cyborg looking thing on my knee until I go back to the Ortho workshop for a nap and some cold steel.
I am incredibly fortunate in that an Ortho guy from Coronado is visiting Tripler and as soon as he heard there was an Operator with an ACL he took the case right away as he does all the SEALs and feels a connection. Good for his ego, damn good for my knee

The Eagle

[Sacamuelas]

Eagle-
On this topic, I will have to cheat to be professional enough in my terminology for this forum. Wouldn't be the first time.

I look forward to following this thread.

[Surgicalcric]

A couple of things Sir:

First off I wish you the best of luck with your surgery. It sounds like you are in good hands.

I did not tear my ACL, thank God, but I had a quarter size medial miniscus tear and two nickel size avulsed tears of the condyle and epicondyle. There was alot of edema and due to this I had to wait 10 weeks to have surgery.

I am going to leave the physical presentation for someone else given my history but will add my .02 later. I was however wondering if you asked the question about ACL repair choices because you are weighing options or for teaching/learning purposes? I have some input on that subject depending on the reasoning for the question.

You gotta love the Lovejoy knee braces. Makes you feel like part machine.

Keep us updated adn best wishes.

[Eagle5US]

Originally posted by Surgicalcric
A couple of things Sir:

First off I wish you the best of luck with your surgery. It sounds like you are in good hands.

I was however wondering if you asked the question about ACL repair choices because you are weighing options or for teaching/learning purposes? I have some input on that subject depending on the reasoning for the question.

You gotta love the Lovejoy knee braces. Makes you feel like part machine.

Keep us updated adn best wishes.

Thanks!!!
Hmmm...yes, much swelling indeed is still present...HOWEVER>>>
The SEAL orthopod gave me the choices to see which I would pic, he told me I chose "the right one" for the active / operational kind of guy that I try and be so this is for the learning aspect moreso than my choice aspect, I can explain why once the 2 main options are made available.
Not wearing a Lovejoy, but something I am quite pleased with by "B Raceing" say it fast..."bracing" has graphite composit hinges left and right with 7mm neoprine wraps backed my velcro straps...2 top / 2 bottom.
This baby is designed for COMFORT with an oblique patch missing in the rear (poplateal space) and a full 30% overlap in the front for even compression.
Quite sweet!
I am going to ask SEALPOD for surg photos...try and post.

Sacamuelas, it isn't cheating if you include your own perspective and learn something...

The Eagle...

[IrishEKU]

RE: What causes ACL injury?


Eagle,

I am not a medical professional at all, just experianced with "Ouch, tore my ACL." I ride bikes in my off time and have seen many times when you get "thrown" or bottom on a rise an injury like this happens. And no I am not talking about a pedel bike. I have seen quite a few pretty bad scrapes and injuries come from riding WFO on the trails.

After your time under the knife if pusue a sport like mine I would seriously think about investing in a good set of braces. Asterisk makes the best on the planet for about $550usd, but they will save your behind, if you ride.

Irish

PS. Good luck with the surgury.

[Eagle5US]

Originally posted by IrishEKU
RE: What causes ACL injury?


Eagle,

After your time under the knife if pusue a sport like mine I would seriously think about investing in a good set of braces. Asterisk makes the best on the planet for about $550usd, but they will save your behind, if you ride.

Irish

PS. Good luck with the surgury.

Thanks Irish, my grandmother's maiden name was Imm...
Your idea hadn't yet struck me, but sounds like a great suggestion. I will indeed look them up. Though I do not ride in your arena, I do like to do other things...things that have great "owey" potential.

Thanks again

Eagle

[Surgicalcric]

Well since it does not appear anyone else is going to give it a shot.

1. Three main noncontact MOI's are: planting and cutting or twisting, straight-knee landing, and one-step stop landing with the knee hyperextended. Of the three listed planting and cutting is most common.

2a. Examine injured knee after uninjured side has been examined and use this as a guide. Acute swelling with position of comfort flexed. Limited active range of motion will be present in the majority of cases. This can be caused by effusion, miniscal tear, entrapment of torn ACL, and/or hamstring spasm. Intra-articular effusion is readily apparent and results in symmetrical swelling of the entire knee. Tenderness on palpation should be present over the medial and lateral joint lines (for meniscal injury) and the medial and lateral femoral epicondyles, adductor tubercle, and proximal medial tibia (for ligament attachments). Major tendons of the knee (patellar, quadriceps, popliteal, and hamstring) should also be palpated for tenderness and swelling.

2b. Lachman's test is the most reliable indicator of ACL integrity and the Anterior Drawer test to a lesser degree. It should be noted though Anterior Drawer is rarely used in the acute setting do to effusion and guarding by patient. It is considered positive if excursion is larger on the injured side, or if no end point is reached. False negatives can occur with spasms or a displaced bucket-handle tear of the meniscus.

Posterior subluxation of the tibia with the knee in 90° of flexion (a positive sag sign) indicates PCL tear.

The MCL and LCL are commonly evaluated by applying varus and valgus forces to each knee at 0° and 30° of flexion. Significant displacement or "opening up" of the joint under stress or loss of a distinct end point denotes a positive test. In full extension, a positive test indicates a severe capsular injury in association with collateral ligament disruption.

McMurray's and Apley's tests are performed to detect or exclude meniscal injury. Both tests are considered positive if a painful pop is felt during manipulation and palpation of the knee.

3. Splint leg in the position of comfort, ice, MS for pain.

4. I do not have an informed opinion as to which method is best but I will note the surgical intervention I am aware of.

Patellar Tendon Allograft
Achilles Tendon Allograft
Gortex Implant
Double Loop Hamstring Graft- I have heard this is the new thing for ACL reconstruction as it is 2x stronger than original ACL and 1.3x stronger than Patellar Grafts. I would suppose I would have to go with this one.

[IrishEKU]

Originally posted by Eagle5US
Thanks Irish, my grandmother's maiden name was Imm...
Your idea hadn't yet struck me, but sounds like a great suggestion. I will indeed look them up. Though I do not ride in your arena, I do like to do other things...things that have great "owey" potential.

Thanks again

Eagle

2nd generation off the boat on my moms side, Kelleher.

LOL on the "Owey" potential. I once had to patch a guy up that decided it would be fun to do a body slide at about 60mph or so through a field. My "topped" off medpack with additional goodies came in handy that day. Even though he was wearing his gear he still looked like road kill. I have some pictures somewhere, should have seen the look on his face when I put on the latex gloves.

Word of caution on the braces, they need to be fitted. They also wont destroy your gear while being worn if your pants are the right size.

Asterisk Cell Braces

[Eagle5US]

You did really well with your research!
Plant and twist injuries account for a vast majority of ruptured ACL's...greater than 70% with associated miniscal tears.
Immediate and dramatic swelling is due to the blood escaping into the capsule from the injury itself...if there is nothing immediate, then by the following moring the joint will effuse (fill with fluid) as a protective measure.
Lachman's and drawers are exactly correct...
My "good" knee extrused (pulled forward) 5mm at the little knotty thing below my kneecap on my shin bone (the tibial tuberosity). This is where the patellar tendon attaches the kneecap to your shin.
My "bad" knee extrused 13mm with (of course) the mushy endpoint.
Two main options for active and athletic...
1. Hamstring harvest and double knot graft as you mentioned...
2. My choice...Doc's concurrance
Bone Tendon Bone graft with indwelling screws.
Takes a little longer to heal, but the results are top notch. A small piece of kneecap is harvested along with the attached patellar tendon...this is used as the new ACL and literally screwed into the bone for attachment.
Try and do too much too soon...fractured patella (Jerry Rice not to long ago), but let it heal appropriately has a tremendous level of stability.
It may not ACTUALLY be the best...but it is the one he has had the most success with at Coronado and sounds pretty industrial grade for a repair...
For stabilization in the field...something as simple as figure 8's with cravats work well for compression and stability. Your two main goals are resorption of fluid and prevention of the femur sliding forward further damaging the knee capsule and its structures.
Well done!

Irish, thank for the link!!!

Eagle

[Sacamuelas]

Thanks James and Eagle.

I knew about the test you described but didn't know its medical name. God knows I have been put through that test during my old soccer/football days.

I was a slacker on this one, NDD had me researching to much Colombia info to get to the med thread. Thanks guys and looking forward to those pics Eagle.

[Eagle5US]

Probably the worst "in hospital" post-op care I have ever received...but I'm all fixed.
At +48 hours, I am bearing weight and my bride is pushing me through my physical therapy/ROM torture sessions like a pro.
An oddity though...my dressings AND bandages were thoroughly bloodied, and the standard line from the hospital was not to change them for the first week because they were "sterile when applied in the OR"
Now, since bacteria and whatnot travels 300+ times faster in a liquid medium than in a clean dry dressing, I thouhgt this didn't make much sense. Add to that, the medium here is organic (blood) which would lead me to wonder about smell and colonization.
So, for the time being, I have changed my bandages but left my dressing in place.
I have some pretty cool scope photos that I will try to scan and post after a bit.

I have said before, nothing adds to the provider perspective like being a patient.

I think that calls for the start of another thread...

Eagle

[Sacamuelas]

Good to hear you got positive results Eagle. GIve em hell!!!

[Surgicalcric]

Eagle5US:

Glad to hear your surgery went well and that you are up and about.

[DoctorDoom]

x

[Eagle5US]

Originally posted by DoctorDoom
Good to hear you are recovering well Eagle!

I recall that the classic mechanism of injury to the ACL was a football "clipping" injury, or a tackle from behind and laterally. Is that still taught?

Thanks for the well wishes!
While the clip is still taught, the plant and twist is king
The new smileys are KICKIN!!! istachios:

Eagle