anterior cruciate ligament Archives | Jeremy M. Burnham, MD

Bone & Joint Clinic of Baton Rouge | Sports Medicine


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All Posts Tagged: anterior cruciate ligament

New Research from AOSSM 2018 on Best ACL Graft Choice for Female Athletes

When young, active athletes tear their ACL (anterior cruciate ligament), it usually needs surgery. Although a very small percentage of ACL tears can be repaired, the vast majority need to be reconstructed completely with a new ligament. Surgeons have known for some time that allograft (graft from donors) has a higher failure rate than autograft (the patient’s own graft). Common areas to harvest this graft are the hamstrings, the patellar tendon, and the quadriceps tendon. Although the hamstrings tendon is the most commonly used, several studies have suggested that it might have a higher failure rate in high demand athletes. New research published at AOSSM demonstrated a significantly higher re-tear rate using hamstring tendons compared to the gold standard (patellar tendon). Read more here…

Although there are many factors that determine the best graft choice for an individual patient, it is becoming increasingly clear that hamstring grafts are probably not the best options for most young, active athletes – especially female athletes. Female athletes are at the highest risk for tearing their ACL, and having a re-tear or tear of the other side later on. We recommend using patellar tendon (bone-patellar tendon-bone, or BTB) or quadriceps tendon grafts in most young, high demand athletes. We published a research paper demonstrating that if hamstrings are used, they often need to be augmented with extra tendon from a cadaver. You can read more about female ACL injuries in a book chapter we wrote about that topic.

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Pediatric & Adolescent Tibial Eminence Fracture

Background

Fractures of the tibial eminence, or tibial spines, are a type of knee injury often treatment by a sports medicine knee doctor. Tibial eminence fractures are bony avulsions of the anterior cruciate ligament (ACL) from its attachment to the tibia. Tibial eminence fractures are fairly rare and account for about 2-5% of pediatric knee injuries. These fractures occur most commonly in children between ages 8-14, although they occasionally occur in adults. These fractures often occur from hyperextension or rapid deceleration of the knee, similar to many ACL injuries. It is the traction on the ACL that leads to the avulsion injury. This is often seen with soccer, rugby, football, skiing, and other sports.

tibial spine tibial eminence pediatric knee doctor anterior cruciate ligament adolescent acl tear acl

Sapre V, Dwidmuthe SC, Bagaria V, Yadav S. Functional outcome in tibial spine fracture treated with arthroscopic pull through suture technique. J Orthop Traumatol Rehabil 2015;8:6-10

Classification

Tibial spine fractures are classified by the degree of displacement. Type I fractures are non- or minimally-displaced. This means the fracture is in great alignment and has not pulled away from the bone. Type II fractures show some lifting of 1/3 to 1/2 of the tibial eminence. The posterior “hinge” remains in place. Type III fractures are completely displaced. Type IIIA fractures have no malrotation, while Type IIIB fractures are rotated so the cartilage surface now faces the bony fracture site. Type IV fractures are displaced and comminuted.

tibial spine tibial eminence pediatric knee doctor anterior cruciate ligament adolescent acl tear acl

Speed-Bridge arthroscopic reinsertion of tibial eminence fracture; Orthopaedics & Traumatology: Surgery & Research, Volume 103, Issue 1, Pages 129-132
A. Hardy, L. Casabianca, O. Grimaud, A. Meyer

Treatment

Treatment is usually dictated by the degree of displacement. Type I fractures can be treated without surgery. This involves casting or bracing with the knee in full extension, or near full extension, for 3-6 weeks. Occasionally the knee is aspirated to remove the hemarthrosis (bloody swelling in the knee), which can help with symptoms. Isometric quad exercises are started immediately. Repeat x-rays are obtained through the course of treatment to make sure the fracture does not displaced (especially noticeable on the lateral x-ray). After adequate time for healing (4-6 weeks), more aggressive physical therapy is started to restore range of motion and strength.

Treatment of Type II fractures is somewhat controversial, although most Type III fractures are treated with surgeries. Some Type II fractures can be treated successfully with out surgery. Occasionally a closed reduction of the knee and casting is successful. The risk of treating a Type II fracture non-operatively is that meniscus or cartilage may become entrapped in the fracture site and prevent healing. Multiple fixation techniques have been described when surgery is needed. Many times, fixation can be done arthroscopically (through small incisions with assistance of an arthroscope).

Postoperative & Rehabilitation

Postoperative protocols can vary. In general, the knee is immobilized in near extension for 2-3 weeks. At that point, range of motion exercises are initiated. The main challenge after surgery is to prevent arthrofibrosis (stiffness of the knee) while allowing the repair to heal. Physical therapy is usually initiated at 2-3 weeks after surgery, and focuses on restoring range of motion and improving muscle strength.

References

Gans I, Ganley TJ. Tibial Eminence Fractures: A Review and Algorithm for Treatment. University of Pennsylvania Orthopaedic Journal.

May J, Levy B, Guse D, Shah J, Stuart M, Dahm D. ACL Tibial Spine Avulsion: Mid-term Outcomes and Rehabilitation. ORTHOPEDICS. 1; 34: 89. doi: 10.3928/01477447-20101221-10

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After Hours Sports Injury Clinic on Friday and Saturday

The Bone & Joint Clinic and Lake After Hours have teamed up to hold an after hours sports clinic on Friday nights and Saturday morning during football season. There are two locations open until 11 p.m. on Friday nights with sports medicine doctors on call, and Dr. Mazoch and Dr. Burnham have training room at the Lake After Hours on Drusilla on Saturday mornings from 9-10:30 a.m. or until the last patient is seen.

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New Research Article on Female ACL Injuries

Dr. Burnham co-authored a research study with Dr. Vonda Wright on female ACL tears. Dr. Wright is an orthopaedic surgeon who is an expert in sports medicine and fitness. This article reviews the most recent research on ACL injuries in female athletes. The rate of anterior cruciate ligament injuries is on the rise in female athletes. It is important that ACL surgery is not done on a “one-size-fits-all” basis, but rather must be individualized for each patient. ACL rehabilitation programs should target the hip, core, and trunk neuromuscular control. A team approach including the surgeon, athletic trainer, physical therapist, coach, family, and patient is paramount to success.

The research study was performed at the University of Pittsburgh Center for Sports Medicine.

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New Research Article on the Anterolateral Complex of the Knee

Dr. Burnham co-authored a research study with Dr. Freddie Fu, Dr. Volker Musahl, Dr. Elmart Herbst, and Dr. Marcio Albers on a hot topic in sports medicine. The research article describes the complex anatomy and function of the anterolateral knee, including the anterolateral ligament (ALL) and the anterolateral complex, which have received much focus in recent media stories. These anatomical structures play an important role in knee stability, especially in the setting of ACL injury and ACL reconstruction in athletes.

The research study was performed at the University of Pittsburgh Center for Sports Medicine.

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Return to Play after ACL Surgery (New Research) – Single Leg Step-Down Test

Dr. Burnham and colleagues recently published a research study on a test that may be useful in determining when patients can return to sports after ACL (anterior cruciate ligament) reconstruction. The test is called the Single Leg Step-Down test (SLSD). It has been shown to identify patients with weak hip and core musculature, which are important muscle groups to rehabilitate after undergoing ACL surgery. Although the surgery to reconstruct or repair the ACL usually takes only 1-2 hours, the rehabilitation can take 6-10 months. Determining the optimal time to return to sports is difficult, and no one test or measurement can determine when you are ready to return after surgery. However, numerous studies have shown that the trunk, hip, and core muscles are important factors in the neuromuscular control of the lower extremity, and that adequately strengthening these muscles after ACL surgery can help prevent against re-injury. In this study, performance on the SLSD test was significantly correlated with hip and core strength, especially in females. Further research will be performed to help determine the role of the SLSD test in predicting injury in athletes.

The research study was performed at the Biodynamics Gait Lab at the University of Kentucky, under the guidance of Mary Lloyd Ireland, MD and Brian Noehren, PT PhD. 

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