ACL Injury Repair

Hi, I’m Blake Gillette. I’m an orthopedic surgeon at Canyon View Medical Group in Spanish Fork. ACL’s a big topic in sports, ranging from the young adolescent athlete,all the way up to the 60 year old who is actually functionally very active,but tears their ACL. So, it’s a huge topic and there’s a myriad in ways of fixing the ACL.

Start with the younger athlete, especially with as much sports as the kids are involved in these days. It’s a huge topic. So, kids that are still growing, so they actually have open growth plates. It’s more tricky to do the ACL because you don’t want to do anything that might cause disruption to the growth plate. So, depending on the maturity level and how much growth they have remaining, generally we avoid any type of ACL reconstruction where you actually are fixing the graft with screws and tunnels.

Because those screws can affect the growth plate. And so, generally we use a suspensory mechanism such as like, a button on the femur that holds the graft, but doesn’t have anything other then graft tissue going across the growth plates. In addition, we’ll usually use again their hamstring. Their own patient’s own hamstring and with the button. And same thing on the tibia, we do something that is fixed outside of the growth plates, so as not to affect growth. Now as you move up to more of the mature athlete, it depends on the type of sports you do.

So, if you’re a very high-level soccer player for instance, you’re gonna be doing a lot of pivoting, a lot of twisting or a high-level football player, you need to have the strongest graft possible. And usually, you’re trying to get back as fast as you possibly can. So in those cases, we’ll generally use what are called the Bone-Patellar Bone Autograft. So on the same side, the affected side, we’ll take a plug of bone from the knee cap, as well as the tibia and then the middle third of the whole patellar-tendon. And even though it sounds, you know, quite intrusive to take that much, we found that people have done very well even in terms of, you know,extending the leg out, without any deficits with that graft.

Now with those grafts, the reason why they’re so effective and what we would consider the gold standard or probably the best in this population is because you can get back to sports within about five months rather than the standard six months with another autograft or nine months with an allograft or a cadaver tissue because you have bone-to-bone integration of the bone block sin the tunnels.

And those again, generally use screws, so that’s why we don’t use that one in immature athletes but we use it in high-level or athletes basically in football, soccer, volleyball, basketball,where there’s a lot of pivoting, cutting, twisting type motion. Then as you get older, it becomes less clear. It depends on how much you’re doing. Whether it’s just recreation, weekend warrior stuff or high-level marathons or even active in sports at a professional level. And so, kind of getting away from the autografts or your own tissue, if you’re basically a weekend warrior, just do some jogging, not really doing any heavy pivoting or twisting, then we start getting into allografts which are cadaver tendons such as anterior tibialis, achilles and peroneus longus.

And those because there’s a nine month wait period to go back full to sports, we don’t do them in younger athletes. But, it’s less morbidity to the patient because we don’t have to take hamstring tendons. We don’t have to take your own patellar-bone or your patellar-tendon, so from that standpoint,it’s a little bit easier recovery.

Joint Replacement vs Repair

So people that are candidates for joint replacement are people that have been dealing with arthritis pain, usually from osteoarthritis, kind of the wear and tear arthritis. Some people do suffer from rheumatoid arthritis,which presents its own difficulties and challenges. But, anyone that’s been suffering for many years, months is a candidate. As long as they have at least attempted some conservative treatment generally, that includes injections, physical therapy,modification of your activities, just to try to improve.

Weight loss is a big one. But once you’ve exhausted those conservative options,generally it’s time to start to consider a joint replacement. So a joint replacement is generally,this is the standard, what’s called a total knee arthroplasty or a total knee replacement. It’s the most common type of replacement that’s performed. These components, after the bone is cut are generally cemented into place the most common form. And then once they’re cemented in place,this plastic liner is popped into the, in between the two metal surfaces. And so the people are now rubbing metal on plastic rather that bone on bone arthritis pain.

So the pain goes away with the arthritis and now they have metal and plastic. Now one other option in certain populations,and this is dependent on your x-rays and where you actually have arthritis. The way I like to look at it is, if they have arthritis in one compartment of the knee,which most commonly is the inside part or the medical side of the knee.

Then, why not only replace only that part? Especially when the other side,the lateral side is unaffected and the patella femoral joint is unaffected. People who have partial knees,as you can see here it’s still the samein metal implants on both sides of the bone with the plastic insert. But people generally say that the knee feels more normal when they have a partial knee replacement. That’s because we maintain all of the ligaments. The collateral ligaments on the sides and then the two cruciate ligaments on the inside.

Generally with standard total knee arthroplasty, at least one if not two of the cruciate ligaments are sacrificed to,just allow the implant be put in the correct position. So, one other option people can have,some people have isolated arthritisto only the patella femoral joint,or the joint behind the knee cap. So, it rides right here into the femur bone or the thigh bone. Even that joint by itself can be replaced again,isolated fashion because if you don’t have arthritis in these two compartments, why take away bone that’s basically normal cartilage.

So when we look at these joint replacements,if you have arthritis in two of the three, generally you’ll get a total knee replacement. But again, if it’s isolated to just this joint,the medial and even in more rare instances,the lateral side of the knee,you can replace those with just partial knee replacements.

So here at Mountain View Hospital,we do these surgeries all the time. We have a group of highly trained,skilled professionals helping both the surgical technicians,the surgical assistants, as well as the anesthesiologist. Who are up to date on the most recent type of anesthetic blocks, which are very important for all types of surgeries. So as not to have complications,’cause nothing’s worse than doing a great surgery, but yet there’s a complication from say a nerve problem because of the block. So, we have anesthesiologists that have been trained in these techniques using ultrasound guidance so that we don’t affect the nerves in a bad way long term.