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ACL procedures restore knee movement
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Dr. David Yakin examines a patient's knee. |
A torn ACL in the knee used to be a career-ending injury for an athlete. Not any more. Most athletes get the tear reconstructed, go through physical therapy and are back on the court or the field the next season, said Dr. David Yakin, a board-certified orthopedic surgeon at Sports Orthopedics and Spine.
A relatively new procedure, called a double bundle reconstruction, does even more, says Dr. Yakin, who teaches the outpatient procedure to other physicians. The double bundle actually recreates the regular anterior cruciate ligament because it replicates the two strands of the ligament.
The ACL – or anterior cruciate ligament – is one of four major knee ligaments that provide joint stability. The ligament consists of tough, fibrous tissue that spans the knee joint; it's attached to the tibia, the leg bone below the knee, and the femur (or thigh bone) above the knee. A normal ACL has two primary bundles of fibers, which is why Dr. Yakin calls the double bundle reconstruction a better alternative when it can be done.
"You can't just sew a torn ACL ligament," Dr. Yakin explains. "It requires reconstruction."
The more common ACL reconstruction — single bundle reconstruction — replaces one of the bundles, and this does a good job of preventing the tibia from moving forward on the femur, he says. "The second bundle's job is to give the patient rotational stability."
In a single bundle reconstruction, the surgeon uses a tendon graft from either the patient or a cadaver to replace the torn ACL. The graft is kept in place by a device or screw that attaches it to a tunnel or hole in the femur and another in the tibia.
With a double bundle reconstruction, the surgeon uses two tendon grafts to reconstruct both bundles in the ACL. He creates two tunnels in the tibia and two in the femur. Each grafted tendon goes through one of the tunnels in the tibia and into one in the femur and is then held in place.
Both ACL reconstructions can be done with an arthroscope, a flexible narrow tube with a light on the end that allows the physician to see the inside of a joint without major incisions. Instead of major incisions, the doctor uses tiny incisions to insert the arthroscope and do the reconstruction.
The arthroscopic procedures are done in a same-day, outpatient surgery center with the patient given a general anesthetic. The patient goes through physical therapy for several months to get his motion back and strengthen the muscles. The patient usually doesn't get back to sports or vigorous activity with an unprotected knee for eight months, Dr. Yakin said.
The typical patient coming to him with a torn ACL is an athlete playing a sport like basketball, soccer or football where he or she cuts, twists and pivots. Tom Brady with the New England Patriots and Jerry Rice with the San Francisco 49ers both had torn ACLs and returned successfully to the game. "Probably every football team has a player out with a torn ACL," Dr. Yakin says.
Female athletes, he says, are more prone to tearing their ACLs. "Physicians aren't sure of the reason; one theory is hormonal changes."
"For most of the rest of us, tearing your ACL is a matter of luck. If enough force is placed across your knee in the right direction, the ACL will tear."
Dr. Yakin firsts examines the patient's knee, checking for instability. When needed, he'll do an MRI at the clinic to get a definite diagnosis. What happens next depends on the age and activity of the patient. He recommends surgery if the patient is under 25 or if the patient is an active 25- to 45-year-old and wants to remain active. "The vast majority of people want to return to their activities," he says. A patient's knee also must have enough room for him to do the double bundle instead of a regular reconstruction.
When he can, Dr. Yakin prefers the double bundle reconstruction over the single bundle. "I started doing it about three years ago. I took courses and met with the doctor who developed it." Today, he teaches other physicians how to do the double bundle reconstruction through the Arthroscopic Association of North America.
"The double bundle," he says, "returns the knee to closer normalcy; it recreates a person's God-given anatomy."