from Motonews.com ACL injuries by drmark

[drmark]

Several of my brother and sister riders in Houston, turned me on to this site where they said folks were talking about me. I am not only a rider but an Orthopaedic surgeon who specializes in Sports injuries, particularly motocross I have read all the posts, and would like to attempt to educate my brother and sister off road motorcyclists about ACL injuries.

First and foremost, MX is the most physically demanding and ACL demanding sport around. Compared to MX football is for wusses. I don't even have to bother comparing it to soccer, field hockey, volleyball, lacrosse and other sports that normal people who want to live to 100 years old participate in.


After an ACL rupture, the injured rider must start immediate rehabilitation. These centers on exercises to regain range of motion, strength, and a normal gait. We recommend Advil 4 tabs, 4 times per day, and the stationary bike one hour per day every day. It may take a few days to work up to this, but generally within a week an injured rider can do it. We don't recommend immobilization or crutches after a day or so. ABSOLUTELY CONTRAINDICATED IS EARY EMERGENCY SURGERY. I put that in caps because, when an operation is done acutely (right away) the risks of persistent stiffness is high. BTW, all the posts that talked about people's second, third, and fourth operations, came about because of stiffness, called in the medical field, Arthrofibrosis. This is entirely preventable if you wait and take your time.

Another question has come up regarding choice of graft. People have rightly opined that an allograft (from a dead person, usually an injured motorcyclist who was not wearing a helmet) will enable them to have the fastest recovery from the surgery. Those that opined that is possible to get AIDS from this graft are correct, but the chances are too low to be a part of the decision making process. Allografts would be the answer if they were live tissues. Unfortunately, they are dead (of course, they are from a cadaver). The athlete's body needs to replace this dead tissue with live tissue. This will occur over a period of a year. During that year, the only activity that is allowed is bicycling. Now, I know someone will say that they went back to riding at two months and they are fine. They would be provided they never have a bad get off. If so the allograft is in the trash. Most of Houston's local MX pros and star amateurs have had an allograft for their FIRST ACL procedure. I don't recommend allografts for MXer. They are fine for middle school teachers, who belong to a health club.

Hamstring tendon and patella tendon from the injured knee work. However, then the knee has to suffer from the operation and the ravages of the graft harvest. Harvest of hamstring tendons don't cause a lot of trouble when they are harvested, but since that tendon does not have bone at the end of it, the tendon much heal to the bone. This is an uncertain process and takes about eight months to a year to mature, in spite of new fancy and expensive screws. Remember, screws can't cause stuff to heal, despite what the commercials say. It just can't happen. Therefore the injured MXer is relegated to the stationary bicycle for a year.

When the patella tendon is utilized, it has bone at both ends and bone to bone healing, which is highly reliable is complete in one month. Further the tendon is alive, and an injured MXer can be back in the bike as soon as his knee feels well. This usually takes six months. It takes six months because of the ACL surgery and the graft harvest. In fact the total temporary disability associated with the graft harvest and the surgery is greater than what you would expect from simply adding these two problems together.

So, to summarize, the patella tendon graft can get an injured MXer back by as little as one month post op, if the darn knee didn’t hurt so much. Six months seems to be the shortest period prior to return to riding.

We believe that we have developed a solution to this problem which can get guys back by as little as three months. As our Clinic, we harvest the patella tendon from the OPPOSITE knee. Our strategy is that we divide the problem amongst both knees. The ACL knee, get over the procedure rapidly, just like it would in an allograft case. However, this graft is alive, and is recognized by the body as itself. The bone blocks heal in a month, and the tendon stays strong in its new job as a ligament. By three months, the knee feels well enough to compete in MX, and its safe to do so because, the bone blocks would have healed and the living tendon stays strong in its new job.

Now, on the day of surgery, the opposite knee is started on a program to regain strength in the quadriceps. This continues for the same three months that the ACL knee needs before return to competition. By three months, both knees are good to go.

Now someone may ask if now a guy has two bad knees. In fact not. Injured riders at our Clinic are able to walk 300 feet the afternoon of their surgery without crutches, and never ever utilize crutches, braces, or casts in the early period. (The choice of a sports brace after rehabilitation is the subject of another post) The day of surgery everyone is able to move each knee from hyperextension to 120 degrees of flexion. Although I recommend that guys take it real easy the first week, and spend that first week in bed, the wake boarder I did last Friday, took his girlfriend to a wedding that next day.

Some may have heard that after a patella graft is taken people have anterior knee pain. That doesn't occur when the donor knee is not the ACL knee.
Others may have heard that you can't kneel after this procedure. Again, this doesn’t occur when the donor knee is the ACL knee. For good measure, we bone graft the defects in the patella and upper tibia to avoid excessive stresses on the bone remaining.


A few words about screws and such. At Sanders Clinic, we do not use screws to hold in the grafts. We tie heavy sutures over buttons which sit outside the bone. These buttons do not irritate the soft tissue and never need to come out. Furthermore, the tension in those sutures can be adjusted after I take the knee through 30-50 cycles of a full range of motion before I close the wound. With screws, once you put it in, you have to hope for the best, as if it’s too tight, the guy will never again fully straighten or bend his knee. The other advantage is that these buttons sitting on the outside of the bone will not cause a hole in the bone if they ever need to be removed for a revision of the ACL surgery and don't get in between the bone graft and the host bone, so healing can occur from all sides. (Remember, if the ACL is fixed perfect, and rehabbed perfectly, is not guaranteed against a really bad get off, and surgery may be necessary to rebuild it again. I don't mean to scare your guys, but as an MXer, I know what things can happen.) So, if revision surgery is necessary for a retear, it can be done in one stage rather than a first stage for removal of screws, and bone grafting, then another definitive operation 10 weeks later. Everything I mention is this paragraph is designed to avoid further operation that will not only cost us money, but take us away from our bikes.

I have way more to say on this issue, so below is the link to the Sanders Clinic Webpage on ACLs. Read it, the following pages, view the illustrations and the FAQs, and read the testimonials. Look also at the links for Salvage of Failed ACL procedures.
Here they are: [Only registered and activated users can see links. ]
[Only registered and activated users can see links. ]

If brother or sister riders have questions, they can post them on this, PM me, or call my cell phone listed below.

Good luck and Safe riding,
drmark
CRF 250 #57
Mark S. Sanders, MD
Houston, Texas
Cell: 713.907.6076

[Macho393]

Doc, I suppose if I ever get hurt bad................(since Howard swears by you) I might have to take a trip to Texas.
My mother works at Arkansas Childrens Hospital. This is the only place in her book. Anyway my question is, does your clinic share information on what you have learned with other units.

[yz250guy]

Very informative. Thanks for the information! Now let's hope I never need to refer back to it!

[drmark]

We are delighted to share information. The problem in orthopaedics is getting the information through so many thick heads. Especially those guys who think that because I ride, I am TOO crazy to be considered serious.

[Big Maico 393]

Originally Posted by drmark

Especially those guys who think that because I ride, I am to crazy to be considered serious.

So whats wrong with being crazy ? Everyone told the Wroght brother's that they were crazy & that man would never fly!

They also said that man would never set foot on another planet.


Crazy? maybe! more like forward thinking & I'm glad to have you here, to look after us!

[crfjedi393]

I totally agree with what Big M said! I have yet to meet a doc that really understands motocross. I get the impression that some of them are just "making money off of idiots like us". So, YES it's great to have a forward-thinking doctor in the house who rides and understands. I am very happy to have you posting here.

[SirFallsALot243]

Hey doc, very interesting read. I have a question for you. I recently broke my femur in a bad get off on an ATV. I rolled it, and it landed on me, breaking just above the knee. The break was VERY minor, I was only on crutches for 3 weeks. Now its the end of the 4th week, and i was told I can walk with a knee immobilizer on. I have been doing this for a week. The femur was broken just above the knee, and not all of the way through. It was a chunk that was broken off the actual bone. The main damage was a huge contusion on the bone, and an MRI showed the whole femur was bruised all of the way into the knee. I also slightly tore a tendon in my knee, but Im not sure which one. It goes from the back side of my calf (fibia or tibia) to my femur. When I take the brace off, I cant bent the knee much past 100-110 degrees. I cant kneel. Sometimes when walking, at hyperextension I feel a strange pain. But recently ive been walking without the brace (only occasionally), and my range of motion is returning. The knee is feeling much better, even though Im supposed to have the immobilizer on for another week- 2 weeks. My question is: Would it be beneficial to walk/ use the stationary bike without the brace? I think that if I discontinued use of the brace, it would heal much more quickly. When I wear the brace, it becomes very stiff, and i cant bend it past 90 degrees. What would your recommendation to me be? I dont really trust my current doctor, as he sees over 100 people a day. I didnt get surgery or anything. They put me in an immobilizer and put me on crutches. Generally speaking, I feel pretty good walking on it 99% of the time.

[drmark]

I would ditch the brace, the knee immobilizer and ride that bike one hour per day, every day.

[Woody_393]

Great information. I've got an appointment with a local Ortho for a knee popping I heard when I had a very minor get off about a month or more ago. I had hoped it would go away since it didn't really hurt very much, but it still hurts a tad today, so I'm going to go get it checked out. My thoughts are Meniscus (sp?), but we'll see.

I'll post more information after my appointment. My normal doc couldn't tell any difference in the two knee's, so hopefully it's nothing major other then maybe some cleanup.