ACL Tears-That Terrible Pop You Felt in Your Knee

We hear it all the time, "I felt this pop in my knee."  It may occur skiing, playing basketball, soccer, or even while at work.  Rest assured that when you feel it, you will know something happened in your knee.  The "pop" sensation is often followed by swelling, instability, and a trip to see me!

So what is the ACL (Anterior Cruciate Ligament)?  The ACL is one of two ligaments that sit the in center of our knee in a crossing pattern. (The name "cruciate" comes from the Latin cruci or crux meaning cross.)  The ACL is responsible for what is called anterior/posterior stability or you knee shifting forwards and backwards, as well as some rotational movements.  Often individuals tear the ligament with a non-contact injury like twisting their knee, pivoting, or shifting with their leg planted.  All of these movements cause the femur bone and tibia bone, where the ACL attaches, to shift and put stress on the ligament.  If the stress becomes too great the ligament will give resulting in an ACL tear.

Usually after the tear, one will experience a period of reduced range of motion, swelling, and instability.  This is often when the patient is seen for their first in office appointment. X-ray studies are almost always negative in ACL tears. Physical exam findings will show swelling and positive testing for laxity or looseness in the knee. Often, patients are sent for MRI scans which will confirm the diagnosis of an ACL tear, and rule out an other injury to the meniscus or other ligaments.

Most patients will begin a short course of physical therapy to regain range of motion. It is always recommended that patients have a return of their range of motion and a reduction of their swelling before under going ACL reconstructive surgery.  Motion before surgery always dictates motion after surgery, so it is much easier to rehab a knee if the motion was full before surgery.   At this point a lot of individuals are feeling significantly better, their swelling is down and motion is back; they are thinking--"Why am I having surgery?"  Which is not  a terrible question.  So let me answer it.

The ACL stabilizes the knee from shifting whether that be big noticeable shifts or small more micro-shifting. Each time the knee shifts there is potential for injury or tearing to the meniscus, and damage to the articular cartilage on the ends of the bones.  The more times the knee shifts the more damage or at least risk for damage a patient accumulates.

Ok, now you have decided to have surgery right?  Well the first decision you have to make is what type of tissue to use to reconstruct the ACL.  This is a bit of a hot topic but I will break it down for you with the speech I usually give patients.  Autograft (your own tissue) vs Allograft (cadaver) has been debated and honestly if you ever have a chance to use your own tissue you probably should.  There are always disease transmission risks with any cadaver tissue--they are very small! However if you are that 1 in Million person you will not care what the odds were.  Also there are multiple studies that show there is an increased risk of graft failure in allografts compared with autografts.  Here are a few example studies:  1.  Autograft vs Allograft ACL Reconstructions: A Prospective, Randomized Clinical Study with Minimum 10 Year Follow-up         2.  Prospective Comparative Study of ACL Reconstruction Between Using Hamstring Autograft and Soft Tissue Allograft

There are 3 types of autografts most surgeons choose from: patella tendon, hamstring, and quadriceps.  All have pros and cons and in a good surgeon's hands would be fine choices for your graft.  I will just give you a run down of each.  Patella tendon, also know as a BTB graft has been around the longest and is considered the gold standard we compare everything else too.  It takes a small portion of the patella tendon from the front of the knee and usually also a piece of bone from both the patella and the tibia "(shin bone) to form the graft.  This is a strong graft similar to a native ACL however some patients especially those older than teens tend to get some knee cap pain from this graft.  Hamstring tendon grafts have also been around a long time and  take a small piece of the hamstring from the back of the thigh from it's attachment on the shin bone.  This does not involve removing any bone, but does not act as much like a native ACL and some think it can stretch a bit.  A quadriceps tendon graft removes a small portion of the central quadriceps tendon with or without a small piece of the patella bone.  The quad graft is a newer graft and fewer surgeons are using it on a regular basis, it does have similar properties to a native ACL.

Courtesy of Arthrex Inc

Surgery involves removing the old torn ACL and drilling bone tunnels in the tibia and femur.  These
tunnels will allow for the graft to be pulled into the knee and secured with metal buttons or screws that come in a variety or materials.  Rehab protocols will vary by surgeon, some will place patients in post operative braces and on crutches, some will begin physical therapy with in days or weeks.  The most important thing to remember when it comes to rehabilitation is that it will take 9-12 months for the graft to mature and heal.  That means a slow return to activities!  I cannot stress that enough.  I could do a whole separate blog on ACL rehab. If you take nothing else from this remember that everyone will heal at a different rate and it is important to listen to your body and doctor.  Often a return to full athletic sport may take up to one year depending on the sport and athlete.  

    

Stem Cell Answers

Lately I have had patients asking me about stem cell injections for arthritis, newly popular treatment for a variety of aliments. Stem cells are immature cells that have not yet "differentiated" or formed into their final cell type.  This makes them very useful in regenerative medicine and also controversial.

Stem cells can be found in many tissues through out the body including bone marrow, fat, muscle, and brain tissue. 1  Stem cells can also be harvested from human embryos. This particular topic is very controversial and not on our agenda for today.  So lets just stick to what we call "adult" stem cells, or those harvested from grown humans.  The beauty of an undifferentiated stem cell is in its future.  Much like a young college co-ed, it doesn't know what exactly it will be when it grows up, but the world is often its oyster.

Kelly Hotchkiss, student, VCU Department of Biomedical Engineering, School of Engineering Hotchkiss’ image shows human mesenchymal stem cells that present a spread pattern of attachment after being prepared on a glass surface." 2

Depending on what tissue the stem cell is harvested from will determine what cell lines it could potentially form.  For example, in orthopedics we love to use the bone marrow because it contains a stem cell known as the mesenchymal cell (MSC).1  This cell line has the potential to turn into bone and cartilage.1  Other cell lines in bone marrow have potential to turn into other blood cells, etc.  This is useful in certain cancer treatments when patients are in need of more healthy cells/blood.  Also, once implanted it is thought that the cell is actually influenced by the cells around it to differentiate into the same type of tissue.1  A kind of scientific peer pressure if you will!

Mesenchymal cells can be harvested from different areas of the body.  The characteristics of the cells may vary slightly depending on the harvest site, but the important factor is if the MSC can turn into a "chondrocyte" or cartilage cell.  For this reason many surgeons like to use bone marrow, intuitively one would think that MSC from bone would have a high potential to turn into bone and cartilage tissues.  Also these cell lines are the most studied forms, with experiments dating back to the 1960s.  More recently fat has been used as a donation site for stem cells.  Adipose (fat) tissue also contains mesenchymal cells and as one article put it, "adipose is an abundant and easily accessible source." 3  So essentially we have A LOT more fat to choose from as a society, why not use it!

Bone marrow is usually harvested from the hip in the operating room under anesthesia.  Adipose tissue can be taken from several areas including the stomach, love handles, and buttocks.  Once harvested it is treated to remove excess cells and spun down using a machine called a centrifuge to get MSCs.  The cells are then re-implanted into the knee (for example) in the area of the cartilage defect.  Post operative protocols are varied depending on surgeon but may include non-weight baring for a period of time, braces, and physical therapy.

Centrifuge

These procedures are still new and considered experimental by insurance companies.  This makes them cost more money out of pocket unfortunately.  Where there is exciting research being done on the topic the results vary from paper to paper and I would consider the jury still out on some of the overall conclusions.  Before undergoing these injections make sure you have a conversation with your provider and understand exactly what to expect.

   

         
Sources:

1.  http://stemcells.nih.gov/info/basics/Pages/Default.aspx

2. https://news.vcu.edu/article/Small_wonders_The_microscopic_images_currently_on_display_at

3. Koh, Y. G., MD, Kwon, O. R., MD, & Kim, Y. S., MD. (2014). Second look arthroscopic evaluation of cartilage lesions after mesenchymal stem cell implantation in osteoarthritic knees. The American Journal of Sports Medicine, 42(7), 1628-1637. Retrieved April 12, 2016, from www.sagepub.com/journalsPermissions.nav.

So You've Decided to Have a Total Knee...

This will be a follow up piece on my segment from October 2015 "Total Knee Arthroplasty--Why So Spooky?"  If you have not looked at it I recommend taking a peek to get some general background on knee arthritis and surgery selection.

Ok so you have decided to take the plunge and sign up for a total knee arthroplasty (TKA).  What happens next?  First, I recommend making a list of questions about the procedure and follow up care and scheduling an appointment with your surgeon.  During this appointment you can become more comfortable with the surgery schedule as well as short and long term expectations.

Day of surgery questions to consider:  Where will the operation take place?  We perform TKA surgery in both an outpatient setting at the surgery center, and inpatient at the hospital.  A person's health, age, insurance, type of surgery, and preference all go into making the decision of outpatient vs inpatient surgery.  Is there an information class?  Many hospitals and total joint centers offer classes preoperatively to educate patients on how to prepare for surgery and what to expect the day of surgery. (For more information on Missouri Baptist's class click Here.)  Do I need surgical clearance?  Most total knee patients will need some form of clearance from at least their primary care physician.  Often depending on health conditions patients may need to visit cardiologists, pulmonologists, other doctors, and even have tests run before being cleared for surgery.

Example of Post Operative Total Knee Arthroplasty Components

Short term expectations to consider: How long will you stay in the hospital/surgery center?  This depends on your choice of having one knee replaced or having both done at the same time.  Also your health will depend on how long you stay in the hospital.  Often stays average 1-3 days.  Will you have home health?  Many of our patients have the assistance of home health and home physical therapy for a few weeks.   This will vary depending on surgeon preference and patient ability.  Will you be on a blood thinner?  Studies show that there is an increased risk of blood clots the first few weeks after a replacement type surgery.  Your surgeon will likely place you on a type of medication to thin your blood and prevent clots for 2-4 weeks.  Also he/she may include leg stockings or leg pumping devices to increase blood flow for a period of time.  Where will you go to physical therapy?  This is important.  You want to make sure that the therapist you work with has experience with joint replacements.

Long term expectations to consider:  Should my therapist be doing that?  I hear a lot about how mean physical therapists are!  When it comes to total knee replacements 99% of the time they are doing exactly what they should.  Therapists are really trying to get range of motion back in the joint.  When I visit our patients in the hospital I always tell them that they have a 6 week window where range of motion is really essential.  Their knee is trying to scar around their new components and the more we can move the knee the more mobile the scar will become.  We all scar--that is inevitable, the more mobile the better.  The more motion the better.  This is why the PT is so hard on people the first 6-12 weeks after a knee replacement.  Often patients thank them later.  When will I get better?  In medicine we try to give estimates and averages based on our experience with past patients.  So on this question it is difficult with TKAs.  I will tell you that at 12 weeks post op most people have their motion back and are doing their day to day activities well but still need strength.  Patients will continue to see benefits and improvements from a TKA for the whole first year.

Before any surgery I encourage you to ask questions until you are comfortable with the procedure.  As providers we want our patients to be our partners in healthcare and understand why tests, exams, and procedures occur.  TKAs are a big undertaking but can have great success and provide much needed pain relief to those suffering from arthritis.  Feel free to ask questions! 


  

Osgood Schlatter Disease-It Hurts When I Jump!

Osgood-Schlatter disease occurs in adolescent athletes during growth spurts.  As my young cousin Kendyll can attest it hurts! Often found in running athletes like soccer and basketball players OSD can be frustrating to children throughout their childhood until they reach skeletal maturity.

The bones of the body grow in areas called "growth plates."  Growth plates are cartilage collections located at the ends of bones. These centers for growth are the last portion of the bone in children to harden--which occurs at skeletal maturity.  Because the cartilage is softer then the surrounding bone, injury is more likely to happen in these areas. OSD is inflammation of the growth plate just below the knee cap.

Figure #1

The tibia is the shin bone in the lower leg.  It helps form the knee joint and contains a growth plate just below the knee.  The growth plate is at a site called the "tibial tubercle"  a tubercle in the body means a bump in the bone that has a tendon attached to it. Note in figure #1 that the patellar tendon attaches to the tibial tuberosity. As a young soccer player repeatedly runs or jumps the patellar tendon pulls on the growth plate on the tibial tuberosity and can cause pain and swelling. (Figure #2)     

Figure #2

Treatment can include nonoperative management with rest, stretching, strengthening, physical therapy, anti-inflammatory medications, ice, and bracing with a Cho-Pat strap.  The Cho-Pat (figure #3) strap places pressure on the patellar tendon during activities and can provide some relief.       

Figure #3

Unfortunately, even with treatment symptoms may continue to come and go until the child reaches full bone growth.  This maybe be anywhere from around age 14-16 depending on sex.  Even with the resolution of symptoms individuals may have a prominence of the tibial tubercle for their entire life.  This is caused by the trauma to the growth plate which may never totally fuse to the bone underneath.  This is called a "fibrous union" meaning that the growth plate is held on by tough tissue rather then bone. Adult patients usually have no symptoms related to the non-fused growth plate.   

Very often we xray patients in the office and see old evidence that they had OSD as a child.  It no longer effects them but they may have some bulging of the tibia in that area.  Their xray looks like figure #4. Note that the tibial tubercle is slightly separated from the rest of the tibia.  A minority of adults may have some pain with kneeling in this area, and rarely have the small bone growth removed surgically if symptoms are severe.   

Figure #4

Osgood-Schlatter disease can be a struggle for children until they reach the end of their growth.  However with some activity modifications and treatment they are able to have a full active childhood.  Once they achieve full bone maturity they rarely have continued symptoms and can continue with an active adult life.  

Next Topic: How nutrition can help in the healing process. It really is what you eat!

Sources:
http://kidshealth.org/parent/general/aches/osgood.html#   


http://www.mayoclinic.org/diseases-conditions/osgood-schlatter-disease/basics/definition/con-20021911

Total Knee Replacements--Why so Spooky?

This topic is brought to you by popular demand!  I've had great deal of requests for a topic on total knee replacements or as we call them in the ortho world TKAs (Total Knee Arthroplasty).  TKAs can seem overwhelming and downright SPOOKY if you are faced with the possibility of surgery.  Let's see if we can dust some cobwebs off the common myths about TKAs and reveal the truth hidden underneath!

I have a conversation about the compartments of the knee with patients on a weekly basis, so this may sound familiar to some of you.  The knee is separated into three compartments, the inside of the knee (Medial compartment) outside of the joint (Lateral compartment) and the knee cap joint (Patellofemoral compartment).   The knee may wear in one, two, or all three of those compartments and the amount of wear determines what surgery is recommended.

There are two types of cartilage within the knee. The Meniscus the large shock absorber between the bones and Articular cartilage which covers the ends of the bones.  Articular cartilage acts in a similar way to enamel on our teeth, it in itself does not feel pain, but when it is worn away the bone beneath feels pain.  This is considered arthritis (just like a cavity in your tooth) and can be very painful.

When you have this break down in cartilage in one of the compartments in the knee that one area of the knee can be replaced.  This is called a Unicompartmental Arthroplasty or "Half Knee."   I personally think we should call them "1/3 knee replacements" but my opinion doesn't seem to count for much!  The problem is when individuals begin to develop damage in two sometimes all three compartments of the knee.  This is global or total knee arthritis, and is when surgeons recommend a TKA to replace the entire knee.

By the time a patient needs a total knee replacement it is usually easy to see on xray studies.  As you can see on my background images for the blog the patients' knees are pretty healthy with good space between the thigh bone (femur) and shin bone (tibia).  He did not need a TKA he was actually a young healthy teenager.  In contrast, this knee shown below, has no joint space at all in the medial compartment, or "bone on bone" arthritis.  The patient also has bone spurs that have formed at the ends of the femur and tibia at the joint line.  The body will try to put down bone in areas where cartilage has been worn away.  It is a protective mechanism in the body but unfortunately backfires and causes us to lose range of motion.     

Total knee arthroplasties as we know them were developed in the early 1970s.  The surgery continues to be tweaked and modified on a regular basis but many of the concepts are the same.  We still replace the end of the femur and the tibia with metal components and a plastic spacer replaces the meniscus.  There are many companies on the market today and most will tell you their knee components are the best around.  I compare this to care manufactures.  Many are built on similar constructs with different bells and whistles, but all will drive you from one place to another.  I  think the most important concept is that your surgeon is comfortable working with the implant.  Most joint surgeons have a preferred brand or two that they feel works best for their patients and has had the best outcomes in their hands.


There are two major distinctions when it comes to total knee replacement implants--cemented vs press fit components.  The type of component a surgeon uses often is related to where he/she was trained.   A "press-fit" component get its name because it is actually impacted or pressed onto the ends of the bones.  The idea is that the patient's own bone will actually adhere or grow into the metal components forming a stable construct.  This is good for younger patients who may need a second replacement procedure early in their lifetime because revising these implants is a little easier.  A cemented implant requires gluing or cementing the metal onto the bone.  This also forms a stable construct, and maybe good for older patients or patients with poor quality bone.  The cement allows for a secondary fixation when poor quality bone may not be quite enough.

TKAs are a fascinating topic and relevant to so many people.  I hope this provides a background on the procedure and need for a replacement.  As I began writing this article it became clear that it would be too large for one post.  We have so much more to discuss!! Hospital stays, rehabilitation, risks vs benefits of surgery.   I will have to post a TKA Part Two in the near future.  Feel free to ask questions if you would like them included in that article.

Next post in two weeks is a surprise...     

   

For more info on TKAs check out the AAOS webpage here





Sources
Ranawat, C. (2002). History of Total Knee Replacement. J South Orthopedics Assoc, 11(4), 218-26. Retrieved September 22, 2015, from http://www.ncbi.nlm.nih.gov/pubmed/12597066