Time Magazine Workout Enhancers

Many times the exercise recommendations you read are not applicable to the average person. Today's web article from Time magazine is actually relevant ideas most people can incorporate in their personal workout routine. Read the article HERE

Revision ACL Reconstruction

Revision (redo) ACL reconstruction which occurs when the original ACL reconstruction fails is not necessarily common, but is an important issue for those unfortunate patients and those of us that care for these patients. This began to be evident to us with the publication of one of the early ACL reconstruction studies that utilized patient reported outcome measures. These outcome scores ask patients how they are doing rather than surgeons declaring how well the patient was doing. While maybe intuitive that asking patients how they are functioning after an ACL reconstruction is the correct way to assess outcome it was an unusual approach at the time. These outcome measures are validated and can be as accurate as any outcome measure available. These patient reported outcome measures have formed the backbone of our approach in the Multi-center Orthopaedic Outcomes Network (MOON) group and the Multi-center ACL Revision Study (MARS).

The study Kurt Spindler and I wrote and published was a minimum 5 year outcome analysis of ACL

reconstruction. Read the study Here In that study we found that gaining weight(> 15 lbs) and failing to advance your educational status following ACL reconstruction resulted in worse patient reported outcomes (PROs) at 5 years. Interestingly, the strongest predictor for a worse outcome was if the reconstruction was a revision ACL reconstruction. The journal (Journal of Bone and Joint Surgery) did not want or allow us to include the revision reconstructions and so we published a paper of just first time (primary) reconstructions. This made us curious and we began to pay more attention to the outcomes of revision ACL reconstructions. We noted following the formation of the MOON Group similar findings with worse results with the revision ACL reconstructions. Revisions made up only ~10% of our reconstructions and that even with 17 surgeons in the group we could not accumulate enough patients quickly enough to do the sophisticated statistical analysis and modeling to answer the question of “Why do these patients do worse?”.

It was not intuitive why they necessarily would have worse function, more pain and lower activity levels compared to primary reconstructions. For this reason we knew we needed at least 50 surgeons contributing patients and thus formed the nationwide Multi-center ACL Revision Study (MARS). MARS is an 83 surgeon, 52 site study for which Washington University Sports Medicine Division is the coordinating center and I serve as principle investigator for the study. The American Orthopaedic Society for Sports Medicine supported the concept and offered participation to its members. We enrolled 1215 patients and obtained NIH funding to support 2 year follow up. The demographics of the study and our initial study can be found HERE. Future blogs will discuss our findings that are changing and shaping the care of the revision ACL reconstruction patient. We recently submitted a competitive renewal grant to the NIH to support 10 year follow up analysis of these 1215 patients. See the MARS Facebook page for additional information. MARS

Meniscus Tears

The meniscus is the soft rubbery bumper cushion that sits between the thigh bone and the leg bone. There are two menisci in the knee; a medial (inside) and a lateral (outside) meniscus. These structures act as shock absorbers that decrease the stress seen by the articular cartilage found on the end of the thigh bone and leg bone. Meniscus injuries are quite common and occur in patients of all ages. Arthroscopic surgical treatment of a meniscus injury is the most common orthopaedic surgical procedure done in this country. An injury can occur as a result of squatting, turning or twisting during almost any activity.

Once the meniscus is torn, symptoms like locking, clicking, and catching may occur. In addition, patients will frequently notice swelling in the knee. The pain will be localized along the joint line on the inside or the outside of the knee depending on the tear. The diagnosis is made based upon a history and physical exam and frequently special tests. X-rays are usually normal. If there is some question regarding the diagnosis, an MRI can be obtained to confirm a tear. Most tears remain symptomatic and will ultimately require treatment if they interfere with activities of daily living or sports and recreation activities.

90% of the time, the appropriate treatment is arthroscopy to remove the torn fragments rather than

repair. Often the meniscus cannot be repaired due to the lack of blood supply, which prevents healing factors from getting to the area of injury even when repaired by stitches. Arthroscopic meniscal debridement is one of the most common procedures performed in orthopedics. It is typically very successful in decreasing symptoms and allowing patients to return to their normal activities. The fact that the patient has torn the meniscus increases their risk of arthritis over the next 15 to 20 years. Removing the torn fragments does not increase this risk, but merely decreases the symptoms from the tear.

Recovery from an arthroscopy to remove the torn meniscus is relatively short. It is a minimally invasive outpatient surgery with typically 2 to 3 small puncture wounds to perform the surgery. The patient will typically be weight bearing as tolerated, but he/she may need to use crutches for a few days following the surgery. Swelling typically improves during the first week. Patients with sedentary jobs can return within one to two days. More physical laborers may take longer to recover. Patients typically return to sports or exercise by 4 to 6 weeks following a short period of physical therapy. Future blogs will describe meniscus repair and review the research we are currently involved with at Washington University Sports Medicine regarding meniscus repair.

NY Times: Doctors experiment with new ways to fix the ACL

Martha Murray an outstanding researcher is getting closer to repairing ACLs without having to graft them. Read the NY Times article for more details here: Doctors Experiment with New Ways to Fix the ACL. I think this has real potential as I told the reporter. Avoiding using a graft and maintaining the native ACL would be a major step forward for the care of the ACL injured patient. I look forward to her upcoming randomized trial.

St. Louis Blues Team Physicians

Our Group is dedicated to care for the injured athlete and provides care for a variety of sports teams in the region. Here is a story describing our work with the St. Louis Blues
St. Louis Blues Team Physicians

Rick Wright St. Louis Business Journal

Here is an article in the St. Louis Business Journal discussing our research and work to restore patients to activity. Also a nice mention of our family hobbies. St. Louis Business Journal

Shoulder Instability

The shoulder is the most frequently dislocated joint in the body. The ball and “flat” socket configuration of the joint allows the largest range of motion of any joint in the body but sacrifices stability. A shoulder dislocation occurs for 2 reasons: 1) from a traumatic injury that forces the ball out of its socket 2) from an inherent baseline laxity of the ligaments. On occasion, the shoulder slides back into place on its own. Most of the time the shoulder needs to be put back into place in the hospital with medication to help relax the muscles. Once the shoulder is back in place, patients are usually put into a sling for a couple of weeks to allow the shoulder to heal. At this point a physical therapy program can begin to restore range of motion and strength. Unfortunately, the torn tissue with the joint does not always heal enough to restore stability to the joint. Therefore, if someone dislocates their shoulder once, there is a good chance that it will happen again. This depends somewhat on age and activity. If a person less than 20 dislocates twice there is a >90% chance it will continue to dislocate. In these settings frequently surgery is chosen to restore stability.

Surgical treatment of a shoulder dislocation depends on what is injured in the shoulder. X-rays and an MRI are done to look for what is injured inside the joint. Surgery to fix the shoulder can be done arthroscopically through small incisions most of the time. Surgery is aimed at repairing the small bumper of tissue, called the labrum that tears off of the socket. The labrum is the structure that attaches the ligaments to the socket (glenoid). On occasion, an open surgery may need to be done to repair the labrum or to fix bone fragments that have broken off the socket to improve stability. If the bone on the socket wears away from repeated shoulder dislocations, bone from another part of the body may be needed to reconstruct the socket to make the shoulder stable again.

For patients with baseline loose ligaments due to stretchy collagen surgery may not be the first line of treatment. Due to their loose ligaments they are prone to stretch out surgical reconstructions so a long period of therapy is tried first before resorting to surgery.

After surgery, patients are placed in a sling to protect the shoulder for 4 weeks. Patients then begin a controlled physical therapy program and return to sports often takes 5-6 months. Arthroscopic surgery outcomes are usually successful 90% of the time with no further instability. Here at Washington University we are involved with a multi-center instability study as part of the MOON Shoulder Study Group to analyze predictors of successful shoulder stabilization surgery. Future blogs will look at additional issues regarding shoulder instability.

A recent article highlighting ACL reconstruction in an elite trampoline athlete can be found HERE. She has done great and is back competing.

ACL Injuries

The anterior cruciate ligament (ACL) is one of the four main ligaments of the knee. It is the primary restraint that provides rotational stability to the joint. It is often injured during cutting, twisting, jumping, change of direction or pivoting-type maneuvers. In addition, it is often associated with meniscal or articular cartilage injuries in greater than 50% of patients. Females are up to 3-6 times more likely to be injured than males, given the same athletic performance. Once the ACL tears, it is not able to heal itself. Repair of the torn ends does not work either. Anterior cruciate ligament reconstruction is one of the most common operations performed in orthopaedic sports medicine with more than 200,000 reconstructions performed in the U.S. annually.

Treatment options consist of either conservative (non-surgical) or surgical treatment. Conservative treatment involves modification of those activities that involve cutting, twisting, jumping, or pivoting. In-line activities can typically be resumed once pain and swelling subsides. A physician may prescribe anti-inflammatory medication and physical therapy to regain normal knee motion and strength. Bracing may also be prescribed for certain at-risk activities. Some patients may be willing to reduce or eliminate those activities that may cause instability episodes.

Surgical treatment consists of reconstruction of the ligament as its direct repair is not feasible due to the inability of the torn ligament to heal. This surgery involves the placement of a reconstructive graft taken from the patient’s knee’s patellar tendon (the tendon located beneath the knee cap) or from the hamstring tendons. Alternatively, your surgeon may choose to use a donor graft, known as an allograft, to reconstruct the ACL. The surgery itself takes approximately one hour and is performed on an out-patient basis with less than 1% percent risk of complications. Allograft reconstruction is not advised for younger, active patients.

Extensive physical therapy is required for a successful recovery from ACL reconstructive surgery. It is necessary following the surgery in order to regain full knee motion and strength, and to return to athletic activity. Most patients are able to return to play following ACL reconstruction approximately 6 months postoperatively. The overall success rate of ACL reconstruction using present-day surgical techniques is well over 90%.

Future posts will give additional detail regarding the treatment and outcome of these injuries.

Sports and ACL Injuries

This blog was created to provide patients with information regarding sports injuries, their treatment and outcomes. I hope to provide more detailed information than can be readily found on the internet. It will highlight research findings from my own work as well as my Sports Division at Washington University. Additionally I will feature research findings coming from our work as part of the Mult-center Orthopaedic Outcomes Network (MOON) and the Multi-center ACL Revision Study (MARS). There will be posts on all anatomical areas and conditions seen in sports injuries. I look forward to your comments and ideas to improve the blog.