Tough ACL case

[Ephesus]

22 y/o competitive skier

- surgery from another surgeon 3/04 ACL and menisci. Improvement.
Three months post-op, pt tears ACL. Surgeon and pt do not get along, I assume care. Skis the following winter, back on the FIS circuit using knee brace and is getting back to old levels of his racing abilities.
- 12/06 take over case, reconstructs the ACL with cadaver graft since pt could not ski after a few months into one season - reports too much pain. Very, very disgruntled.
- 1/15/07 post-op infection; surgery to clean the site, overnight stay with IV antibiotics, 10 days po antibiotics
- Pt continues physical therapy, 2 months into PT, the PT manipulates the affected leg and hears a pop, pt screams, goes home and complains about pain and has swelling for a week. do an MRI. ACL retorn

Would you do surgery again? Pt is requesting it, however he is on Medicaid and the reimbursement is only about 250 for the 1.5h surgery. I inherited him when he was on good insurance. I believe pt could ski competitively again and advised him of that if surgery was successful. Pt begs for the surgery and has said he's already making plans to ski in Chile this summer.

Advised him of other options (viz. physical therapy), but he rightly says his quads and hamstrings are very strong. Very well-built and strong pt: 6'2, 190, 7.5% body fat. Adamant about skiing again and he hasn't been able to do it much since the ACL was retorn, and he was wearing a brace.

Wants to ski without a brace in 6 months following surgery. Advised if we do do surgery, he will have to ski this summer with a brace, but it is possible that he won't need one for the 08-09 FIS race season. pt adamant about surgery, I am hesitant since every time the ACL has torn, it has torn directly in the middle. Not sure if a 3rd revision will help his prognosis.

Photo attached from previous ACL revision.

http://i22.tinypic.com/k19uvr.jpg

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[SOUNDMAN]

Tough to see in the photos but how is the notchplasty? Looks a little tight, but difficult to ascertain from the photos. Obviously positioning of graft, etc Could be the problem if he keeps retearing...just throwing out suggestions.

Tough call for you, being in there a third time, adequate tunnels and bone, may be hard to find. Would you have to do a staged procedure with bone grafting?

Skiing on it after 6 months seems a little early, in the practice I worked for athletes we would progress faster, but usually 9 months is the point where we were getting them back into the training routine.

Tough decision, any colleagues of yours have any opinions?

 

[Ephesus]

Notchplasty could be an issue.

My biggest concern is when I go in there next, what is to be found. Last time, I drilled the titanium bolts into the bone so deep, I had to bring in X-ray, and a 1 hour surgery turned into 2.5 hours. The scar on his leg shows how much digging had to be done.

I booked a 1.5h surgery and pt will stay overnight to be tx with IV antibiotics. Surgery was going to be tomorrow but has impetigo and I don't want him hooked up to IV antibiotics for 6 weeks if an infection spreads into the bone.

My former colleagues (left over disagreements) were ambivalent. None wanted the case, but none really had my experience. I've done many ACL revisions for sports players (team surgeon, including a professional hockey team) and they've all been successful. My new practice, with the other surgeon has no opinion either. Guess they don't want to touch the case for liability issues.

6 months seems early? That's odd. 6m has always been standard throughout. Though he isn't planning on a trip until July to Chile to start in powder, then is going to Mt Hood's ski camp for 3 weeks (he says this is an easy introduction, heh) so 9 months is still about right.

Post-op (granted there is no infection): no open chain exercises for 3 months. 4 months of PT tid including aquatics.

I think his biggest problem is he is an enemy against himself by not listening to what the doctors have to say and always pushing the limits.

Anyways, review: surgery scheduled next friday. Booked 1.5h but I have a feeling I'll be in there longer. Classifying as "PT failed." for lovely Medicaid. Will keep overnight and on IV Kefflax.

 

[plixit22]

One question- how does someone on Medicaid afford flying to Chile and Mt. Hood to ski? Something not right there.

 

[blast7]

Skiing on it after 6 months seems a little early, in the practice I worked for athletes we would progress faster, but usually 9 months is the point where we were getting them back into the training routine.

Tough decision, any colleagues of yours have any opinions?

I agree. The sports med docs in my area do not allow return to sport until around 7-9 months on average with the affected limb at least 85% strength of the unaffected limb along with a passing sport-specific functional evaluation by the physical therapist.

 

[SOUNDMAN]

I agree. The sports med docs in my area do not allow return to sport until around 7-9 months on average with the affected limb at least 85% strength of the unaffected limb along with a passing sport-specific functional evaluation by the physical therapist.

If anything especially in this patient above, I think I would really try to slow his return to sports until the 9 month mark. In addition, I wouldn't be afraid to do a staged procedure in this patient to make sure you have adequate bone stock, obviously dependent on fixation, but this is your third time in there, a staged procedure is definitely on the list, and I'm sure you spoke to him that this may be an issue once you got in there.

As I'm sure you have been trained, just be prepared for all the contingencies, you obviously know what you are doing. Let us know how it goes, it will be interesting to see how the surgery turns out for you on Friday! Good luck!

 

[Ephesus]

I'll post relevant case notes and the followup pictures when available that don't violate HIPAA guidelines.

I've always gone with the 6m mark, but it isn't exactly relevant as he's not going to be skiing until July. I didn't post full case facts, but after first setback, he recovered quickly.

At least he has motivation.

To the question; it is my understanding he has a rich grandmother. This isn't a debate for health care, take it somewhere else.

 

[Debridement]

I'll post relevant case notes and the followup pictures when available that don't violate HIPAA guidelines.

I've always gone with the 6m mark, but it isn't exactly relevant as he's not going to be skiing until July. I didn't post full case facts, but after first setback, he recovered quickly.

At least he has motivation.

To the question; it is my understanding he has a rich grandmother. This isn't a debate for health care, take it somewhere else.

i dont believe for one second that you are an orthopaedic surgeon.

however, if this 'patient of yours' is looking at a 3rd revision, you need to know that the most common reason for acl failure is improper tunnel placement, so dont redrill the old tunnels if theyre too ant. the second is residual instability, possibly unrecognized PLC injury, so check for that.

Ski DB

 

[plixit22]

I'll

To the question; it is my understanding he has a rich grandmother. This isn't a debate for health care, take it somewhere else.

This is a huge abuse of the healthcare system. Gets me irate to hear stories like this.

 

[Herman Bloom]

Tell him you'll do it if he pays you the difference in cash. Don't see why that should be a problem if he's got the money to ski in Chile. Otherwise, he can hit the road and find some generalist to do it.

 

[volkl7]

i dont believe for one second that you are an orthopaedic surgeon.

however, if this 'patient of yours' is looking at a 3rd revision, you need to know that the most common reason for acl failure is improper tunnel placement, so dont redrill the old tunnels if theyre too ant. the second is residual instability, possibly unrecognized PLC injury, so check for that.

Ski DB

i must agree. the whole story and the language used just do not seem quite right. and this is not exactly the most appropriate site to post such a question. hmmmm.....