Curbside Consult

A Renowned Surgeon Discusses New Approaches to ACL Repair

Bert R. Mandelbaum, MD, DHL (Hon)

Disclosures

January 06, 2016

Conducting the Physical Exam

With the information from the MRI, I move on to the physical exam to see how the picture I have formed of the interior of the knee is affecting the patient's range of motion and pain.

The physical examination includes the Lachman test, anterior drawer test, and pivot shift for the ACL, and then an assessment of medial or lateral laxity to check for damage to the collateral ligaments.[5]

After I've assessed the knee, I review my findings with the patient and the patient's support team. In the case of a youth athlete, that typically includes a parent, a coach, and sometimes a trainer. In the case of a professional athlete, an agent may also be involved.

In the case of a college athlete, I discuss such issues as whether we can "redshirt" the athlete. I discuss the status of athletic scholarships. A high school athlete may be a candidate for a scholarship, or hopeful of signing with a top college team.

Risks With ACL Reconstruction

Of course, there are risks with ACL reconstruction, as with any surgery, and not everyone with a torn ACL should have it reconstructed. A patient who is a cyclist or who practices yoga and has mild to moderate deficiency from the injury won't need reconstruction. A patient who has high instability that interferes with daily living is a candidate for reconstruction. There are some patients who can't walk to the bathroom after their ACL is torn.

An athlete who does pivoting and landing—as in football, basketball, or soccer—must have the stability to the knee to perform those activities. For these athletes, a torn ACL is like having loose bindings for a skier.

Then I get into issues of timing. Do I operate right away, or wait 3 weeks? I find that delaying is not as critical for most young athletes. But for the older athlete, it's important to let the swelling go down and let them get range of motion back.

The patient's age and athletic plans factor into the choice of graft materials, whether to use platelet-rich protein, and the approach to rehabilitation, all of which I'll discuss in my next column.

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