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ACL Repairs Should Be As Unique As the Athlete Who Needs One

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A sudden stop. A twist. A blow to the knee. These are some of the common ways an injury can occur to the anterior cruciate ligament (ACL).

It can happen to someone playing in the adult tennis league, as well as professional athletes in the National Hockey League.

Samaritan orthopedic and sports medicine surgeon Christopher McCrum, MD, the new orthopedic consultant for sports injuries with Oregon State University athletics, has treated patients at all levels, including a fellowship with the team physician for the NHL’s Pittsburgh Penguins during their 2017 Stanley Cup Championship season.

With ACL injuries, the outcome Dr. McCrum is working toward remains the same, whether he’s helping someone to resume daily activity or working with an elite athlete. And the same evidence-based treatments used to care for injured athletes are available to help patients at Samaritan Athletic Medicine Center.

“My goal is getting people back to their highest functional level,” he said.

Diagnosis, Decisions

To diagnose an ACL tear, an X-ray is taken to rule out injury to the bones. Then an MRI scan can confirm a tear and look for other soft-tissue damage.

There are many good treatment options, including nonsurgical rehabilitation. Not everybody needs an ACL to live day-to-day life, Dr. McCrum said.

“Some people are able to run and jump,” he said. “For others, even getting out of the car or pivoting in the kitchen is enough not to be able to cope.”

In athletes who play sports like soccer, basketball, football or volleyball, the knee isn’t stable enough without the ACL intact.

“Particularly with young people, there’s a big advantage to repairing the ACL,” Dr. McCrum said. “If the ACL is deficient, you could end up injuring other parts of the knee.”

Reconstruction Options

A surgeon takes tissue from somewhere else in the body or uses cadaver tissue to reconstruct the ACL. For older patients and older athletes, cadaver tissue can be a good choice because this method allows for a quicker recovery period. In younger athletes at higher risk of reinjury, there are three different graft tissue choices for ACL reconstruction: the quadriceps tendon, the patellar tendon and the hamstring.

The quad tendon graft is one of Dr. McCrum’s preferred choices for younger athletes. He makes a small incision over the thigh to harvest a strip of the quad tendon. This method has a low failure and retear rate, and people tend not to experience pain kneeling after surgery.

“It’s the most common one I do because of the risk and benefits,” he said.

The other most common graft for athletes is the patellar tendon. During surgery, a piece of bone is removed from both the kneecap and the tibia, along with a strip from the patellar tendon.

“The patellar tendon graft is the most common used by professional athletes,” Dr. McCrum said. “It’s tried and true, and we have really good long-term outcomes.”

But with a patellar tendon graft it can hurt to kneel after surgery where the pieces of bone were removed. That’s why Dr. McCrum prefers the quad tendon graft.

Another soft tissue graft option is the hamstring. This can be a good choice for people who have quadriceps weakness. Because bone is not removed, there is no worry about kneeling pain.

Dr. McCrum discusses the options so that patients understand the pros and cons.

“People are generally in-tune with their own bodies and can make a good choice,” he said.

Surgery, Recovery & Rehabilitation

Surgeons prefer to wait for swelling in the knee to go down and range of motion to return before reconstructing the ACL. Reconstructive surgery is performed as an outpatient procedure, which means a person can go home from the hospital the same day.

The anesthesiologist can use a procedure called a nerve block to numb the nerves around the knee to make it more comfortable. Patients start rehabilitation right away.

“It’s not a be-cooped-up-in-bed-type of surgery,” he said. “It’s a get-back-on-your-feet-and-get-going surgery.”

Depending on if the surgery was ACL-only or more involved, expect to use crutches for two to six weeks. Most people are back to full participation in their activities within a year, sooner for some high-level athletes.

“In sports medicine, we perform lifestyle saving surgery,” he said. “I want you to get back to the activities you enjoy.”