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Health & Fitness

Doctor becomes Patient: Part 2

Part 2 of doctor becomes a patient, documenting injury, surgical decision making when faced with combined ACL and MCL tear.

After a severe combined ACL and MCL injury while playing basketball, I was faced with a decision: operate on one or both ligaments?  All too often, athletes are faced with this exact same question.  All it takes is a planted foot, and a valgus force to be applied to the outside of the knee. 

Often seen in football, when the player receives a blow from the outside directed at the knee.  Also seen in soccer, when planting for a kick, and someone slide tackles the player.  In some cases, the ACL can tear even without contact by another player.  The term often spoken of is the “unhappy triad”, which occurs with such a valgus force to the knee.  The triad consists of injury to the 1. ACL, 2. MCL, 3. Medial meniscus. 

So how does a person decide whether to fix the ACL and MCL vs. only the ACL?  For lower grade MCL tears, the answer is unanimous to let it heal without surgery.  But what about a grade 3 tear, which is more severe?    The literature shows evidence of slower recovery of strength as well as slower recovery for range of motion, if both ACL and MCL are repaired.  Thankfully, the good news is that long term outcomes from combined ACL and MCL repair is as good as nonsurgical management of MCL. 

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Bottom line for me is that I prefer the least invasive and the most conservative approach possible.  Technically, if I didn’t plan on playing sports again, it would be feasible to avoid surgery completely and leave the ACL tear and MCL tear.  The main problem is that even though I’d be able to run in a straight line, if I tried cutting or pivoting, my knee would likely buckle from lack of ACL.  So my decision was to repair the ACL and treat the MCL non-surgically.  As an aside, there is a large psychological hurdle to have surgery done one or two months after you tear an ACL because by this time the swelling has gone and the pain has also gone.  In fact, I felt probably 95% recovered in terms of pain and function for typical daily activities.  Knowing that the post-operative recovery would be slow and painful after having felt so good feels almost like going through getting injured all over again. 

To treat my MCL tear, I decided to perform a nonsurgical treatment called prolotherapy.  Prolotherapy is an injection treatment which consists primarily of dextrose, which is injected into the injured area to promote healing.  Since the MCL is a ligament that is quite close to the skin, it does not require a deep injection, and thus allowed easy visualization using an ultrasound for pinpoint accurate injection.  Also I should mention that initially after MCL injury for at least two weeks, it is very important to wear a knee brace with the ability to lock between full extension and 90 degrees of flexion. The idea is to prevent further injury to the ligament that is already damaged.  

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In addition to prolotherapy I also had physical therapy, and went to the gym several times a week to strengthen the leg and core preoperatively.   The reason “pre-habiliation” is important is because I had to consider that post surgery there would be limited range of motion as well as atrophy of muscles, and I wanted to ensure that I did not go into surgery with these problems and exacerbate the challenges I would face after surgery. 

Surgery was performed on 7/20/2011, nearly two months after the initial injury.  I was given the choice to have general anesthesia or spinal anesthesia.  Prior to this I had never had the experience of being unconscious, so I gave it some thought.  General anesthesia means that a person is made unconscious using medications, and typically the airway is secured with a breathing tube.  Spinal anesthesia involves a needle which enters the space in the spine where it is safe to place a catheter which then delivers numbing medication.  I chose the latter.  

As an aside: anesthesia is a very interesting thing.  It reminds me of the idea of falling asleep, where the more I think about it, the more fascinating it is.  I remember the anesthesiologist telling me that I would feel a pinch in my arm as he inserted the IV.  The next thing I know, I’m sitting up in my recovery bed, my right knee is bandaged with a brace around it, and what’s more, I’m all dressed in the clothes I came in with!  I have no recollection of getting dressed post-operatively. 

Intra-operatively, the knee was stressed to evaluate the integrity of the torn MCL, and was found to have intact stability of the MCL, in spite of non-surgical treatment.  Therefore the MCL was not operated upon. 

The ACL repair was finished and I went home to begin the long recovery process. My advice to anyone who has to undergo ACL reconstruction is to not underestimate the recovery process.  Know in advance that it will not be an easy road to take, but if you work hard, it will pay off in the end.   

Join me on my next blog when I discuss post operative recovery, pain medications and more.      

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