FAQ Category: Knee

Preventive or prophylactic bracing is becoming more popular now that there is some evidence that it can reduce the risk of knee injuries. This is especially true for protecting the medial structures of the knee. Medial refers to the side of the knee closest to the other leg.

It’s the medical collateral ligament (MCL) with all its supportive structures that keeps the knee from rotating too much or sliding forward and back. The MCL aids and assists other ligaments inside the joint (e.g., the anterior cruciate ligament or ACL) with this function. This is especially important when force, load, or pressure is applied along the lateral (outside) of the knee toward the medial side.

Understanding the anatomy helps us see how a direct blow to the lateral side of the thigh or leg can disrupt the medial collateral ligament (MCL). Football and rugby players are at risk for this type of injury.

A second mechanism of injury occurs in skiers, basketball players, and soccer players. They plant the foot on the ground and rotate the leg above the foot when pivoting, cutting, or changing directions quickly. The force of that movement pattern can overpower the strength of this ligament. A strong enough force takes out the medial collateral ligament (MCL) along with the meniscus, the anterior cruciate ligament, and other bits and pieces of the soft tissues.

Here again, a protective brace that allows full function and all knee motions but prevents injury could be very helpful when playing either soccer or rugby.

That’s a good question and one that we have more answers for now that advanced imaging technology has helped us understand the basic anatomy of ligaments and other soft tissues.

People with an isolated medial collateral ligament (MCL) injury have the best chance of recovery without surgery. But most MCL injuries are part of a more complex (combined) injury that includes other soft tissues. It’s those combination injuries that are more likely to leave the patient with an unstable joint that requires surgery.

Let’s back track a little and see how the anatomy and biomechanics of the medial collateral ligament affect treatment choices and recovery. The name medial tells us the ligament is on the side of the knee closest to the other knee.

This ligament has both parallel and diagonal fibers that run between the tibia (lower leg bone) and the femur (upper leg bone). The dual directional fibers are necessary to provide stability and restraint to the knee joint.

The anatomy is fairly complex as the fibers are interwoven in superficial and deep layers with the fascia (connective tissue). In the same way, the MCL interconnects with other nearby soft tissue structures along the medial side of the knee. In addition, the hamstring muscle, which wraps around the knee from the back of the thigh adds dynamic support to the medical collateral ligament (MCL).

One key feature of the medial collateral ligament (MCL) that directs treatment is the fact that it is one of the few ligaments that can heal itself. It is located outside of the joint so with the right kind of management, many MCL injuries can be remodeled and restored enough to support load placed on the knee.

A second important factor is the relationship of the MCL to its supporting structures. Dynamic reinforcing fibers from the hamstring muscle makes it possible for the knee to cope with higher stress and load across the knee. By strengthening this muscle group and maintaining a good balance of muscle support, the joint is supported without the MCL ligament.

If, after a good three-to-six months’ of rehab, the knee is still unstable, then surgery is a second option. But the rehab program (really a “prehab” program in such cases) isn’t wasted time. Many surgeons recommend this type of training before surgery to help ensure the best possible outcomes after surgery.

Knee arthritis affecting only one side of the joint is a common problem. It occurs as a result of uneven load and weight-bearing on the joint. This type of unicompartmental arthritis is the result of malalignment somewhere in the leg.

Treatment choices depend on the age of the patient, activity level, intensity of the painful symptoms, and severity of the joint damage. One possibility is a procedure called an osteotomy.

The surgeon cuts through the proximal tibia (upper part of the lower leg bone) and makes a wedge- or pie-shaped opening. Bone graft material is used to hold the wedge open until the patient’s own bone fills in the gap. A metal plate holds the two edges of the bone in place until complete fusion takes place.

An osteotomy of this type realigns the angle made between the bones of the leg. It can shift your body weight so that the healthy side of the knee joint takes more of the stress. This procedure evens out the weight from one side of the joint to the other side and takes some of the load and pressure off the damaged side.

But how well does it work for unicompartmental osteoarthritis? The idea of reducing load on the injured side in order to preserve the tissue still left or to regenerate new cartilage isn’t new.

Previous studies have been able to show that the body does form fibrous cartilage on the damaged joint surface. But it’s not exactly the same as the original tissue, so the next question is: how well does it hold up under load and pressure? In other words, how functional is this treatment approach?

A recent study from Australia suggests changes in the cartilage do occur. The results showed that patients were able to generate some articular cartilage but not back to a normal amount. The lateral side of the knee still had more normal (and thicker) articular cartilage than the medial side.

Changes were visible at the six month check-up. Improvements continued to be seen at the 12 month and 24 month follow-up appointments. Knee function was also significantly improved. Further study will be done to see if the joint cartilage reaches a level close to normal.

The knee joint has several different layers of cartilage and bone. You are probably familiar with the meniscus. That’s a C- or horse-shoe shaped piece of thick cartilage between the femur (upper leg bone) and tibia (lower leg bone).

Then there’s the articular cartilage. Articular cartilage lines the joint and is located between the meniscus and the first layer of bone (called the subcondral bone). Damage to the articular cartilage (before it reaches all the way down into the subcondral bone) can potentially regenerate itself.

One way to encourage restoration of damaged articular cartilage is to remove load and pressure on the joint where the damage is located. An osteotomy accomplishes this by shifting the load from one side of the joint more toward the other side (or at least a more even distribution).

Collagen tissue that makes up articular cartilage has a special type of cell woven into and through it. This extracellular matrix includes molecules called glycosaminoglycans (GAGs) provide compressive strength to the cartilage.

In theory, taking load off the joint surface allows the joint to make more GAG. A higher concentration of GAG creates a more normal articular cartilage (not just a dense fibrous cartilage).

Researchers are studying the effects of osteotomy and load on GAG concentration. They are able to use special MRIs with dye that seeps into the cartilage and subchondral bone to show the effects of this procedure.

In one small study recently published, results showed that patients were able to generate some articular cartilage but not back to a normal amount. Changes were visible at the six month check-up.

Improvements continued to be seen at the 12 month and 24 month follow-up appointments. Knee function was also significantly improved. It’s possible that continued changes occurred after the 24 month mark. Further study will be done to see if the joint cartilage reaches a level close to normal.

Surgeons treating patients with anterior cruciate ligament (ACL) tears are always advised to look for damage to other knee structures during the arthroscopic exam. One of those potential soft tissue injuries is a ramp lesion.

What’s a ramp lesion? It involves the medial meniscus, a C-shaped piece of thick cartilage inside the knee. There are two of these protective liners: medial (side closest to the other knee) and lateral (side away from the other knee).

Tears of the medical meniscus are common with ACL injuries. A ramp lesion is a special type of medial meniscus tear that hasn’t been studied as much as other types of meniscal tears.

A ramp lesion occurs when one particular edge of the medial meniscus (near the posterior or back portion of the cartilage) comes loose. The tear is located where the meniscus meets the synovium (lining of the knee joint). It is usually a lengthwise or longitudinal tear.

Normally, the posterior horn of the medial meniscus is a difficult structure to see even with an arthroscope. Tight joints with little laxity keep this portion of the meniscus out of sight. But with ligamentous laxity (such as occurs when the anterior cruciate ligament is torn) makes it possible not only to see this portion of the medial meniscus, but also to check it for tears or ramp lesions.

It occurs most likely as a result of increased torsional (twisting) and shear forces of the tibia (lower leg bone) as it moves against the femur (thigh bone). Anytime the ACL is torn or stretched too much, the tibia can slip and slide more than it should underneath the femur. That’s when the back edge of the meniscus is most likely to crack, tear, and/or pull away from the bone.

Studies have shown that removing damaged or torn menisci (plural for meniscus) isn’t a good idea. Patients with missing menisci end up with joint arthritis. Repairing the damage provides much better long-term outcomes. Small ramp lesions may not need surgical repair, whereas, larger lesions may need to be sewn back down to allow for complete healing. Further studies are needed to confirm these finding before firm recommendations can be made.

A ramp lesion involves the medial meniscus, a C-shaped piece of thick cartilage inside the knee. There are two of these protective liners: medial (side closest to the other knee) and lateral (side away from the other knee).

A ramp lesion occurs when one particular edge of the medial meniscus (near the posterior or back portion of the cartilage) comes loose. The tear is located where the meniscus meets the synovium (lining of the knee joint). It is usually a lengthwise or longitudinal tear.

It occurs most likely as a result of increased torsional (twisting) and shear forces of the tibia (lower leg bone) as it moves against the femur (thigh bone). Anytime the ACL is torn or stretched too much, the tibia can slip and slide more than it should underneath the femur. That’s when the back edge of the meniscus is most likely to crack, tear, and/or pull away from the bone.

You may not be so unusual or alone with your ramp lesion. Here’s why we say that. In a recent study of 868 patients with ACL injuries, there were 16.6 per cent who had a ramp lesion of the medial meniscus. This was determined through arthroscopic examination.

And from the data collected in that study, it looks like the longer the ACL injury goes untended, the more likely it is that a ramp lesion will develop. At least that was true up to 24 months after the injury. Beyond two years, the number of ramp tears that developed later leveled off.

Two additional risk factors for ramp lesions were identified: age (younger than 30) and sex (male). Three-fourths of the group only had one ramp lesion (no other tears in the meniscus). But the remaining one-fourth had a ramp tear plus one other meniscal tear — either of the same meniscus or of the lateral meniscus.

Patellofemoral pain syndrome (PFPS) is characterized by pain along the front of the knee. The pain is brought on or made worse by activities like squatting, running, sitting for long periods of time, and going up and down stairs is common.

PFPS affects one of every four young athletes. The condition is so common in runners that it is often called runner’s knee.

Physical therapists and sports physicians are actively seeking ways to help treat this problem. The goals of treatment are to reduce pain, decrease swelling, and restore function by improving strength and joint motion.

These goals are accomplished in one of two ways: conservative (nonoperative) care and surgery. Of course, the conservative approach is recommended first. The physical therapist uses a variety of techniques to assist the patient with patellofemoral pain syndrome (PFPS).

Tools (also referred to as modalities) are used such as cold or heat therapy, electrical therapy, and biofeedback. Each of these modalities provides several options to choose from. The use of elastic (resistive) bands that you mention is one way strengthening is done for the hip and knee to help this condition.

The bands come in different colors. Each color signifies the strength of the resistance starting with yellow (mild resistance) and going up from yellow to red to blue, green, and black (greatest resistance).

Recently, a physical therapist from the Department of Kinesiology at Louisiana State University took the time to review studies using elastic resistance to treat patellofemoral pain syndrome (PFPS). The goal was to look for and report on any evidence that this method of treating PFPS is effective.

Results did show that using elastic resistance bands improves muscle strength. But the significance of this finding for patellofemoral pain syndrome (PFPS) was lost by the fact that the studies were poorly designed.

The author concluded that “elastic resistance exercise may reduce pain and improve function and strength in patients with PFPS.”

That’s not the same as saying there is strong evidence supporting elastic resistance exercises in the treatment of PFPS. Further study is needed to identify just what does improve strength and result in good (the best!) outcomes for this condition.

In the meantime, there’s nothing wrong with showing your granddaughter what you used and have her ask her physician or physical therapist if something like that might help her. It won’t hurt. It may not help as much as something else but until we know what that is — elast

Many gyms or athletic clubs keep a supply of tubing or elastic bands for their patrons to use. Most of the time the colors do indicate the strength from weak to strong. Yellow is usually for mild resistance then red, blue, green, and black (greatest resistance).

If your facility does not offer this service, you can often find a supplier in the yellow pages. Look for businesses that sell medical supplies like wheelchairs, walkers, back supports, and so on. They usually keep a supply on hand for local physical therapists who do not stock their own or for patients who just need a single band, not the whole box.

Ask for a 36 inch piece — that will be long enough for most uses. The cost should be minimal for a single band (no more than a couple dollars). If you do not have a specific exercise program, see a physical therapist and get an exercise prescription that is best for you.

The therapist will guide you through a progression of intensity, number, and frequency of exercises. You don’t want to launch into a self-made program and over do it, aggravate and already existing problem, or bring on a new problem.

Despite how often this type of injury occurs in young athletes, there isn’t a great deal of evidence to direct treatment. Surgeons use an algorithm (step-by-step approach) to the management of first-time patellar (knee cap) dislocations. This algorithm has been published in sports and orthopedic journals. It is based on current evidence and has been revised as new data is available.

The algorithm directs the physician to conduct a thorough history and physical examination. The history includes questions about how, when, and why the injury happened. It’s important to find out if the patient ever had a similar injury in the past (for either knee). A previous history of knee dislocation is a red flag for recurrent (repeated) patellar dislocations.

Clinical tests performed by the physician must confirm that a patellar dislocation occurred. Just as important, the examiner checks for any injuries or damage to other areas of the knee (e.g., ligaments, cartilage, connective tissue, bone). X-rays and MRIs help identify areas of damage to the joint surface. MRIs are especially helpful in looking for any fragments of bone or cartilage in the joint.

Conservative care is the main approach for this problem. Surgery is only considered when there is a large fragment displaced. And that piece of bone or cartilage must be big enough to have at least one or two pins put through it to reattach it to the main bone.

Otherwise, all evidence points to the conservative approach recommended by your surgeon. Reducing the time of immobilization to less than the six weeks needed for full healing and recovery is risky.

Those patients who stop wearing a brace after only three weeks are at a much higher risk of a repeat dislocation. Recurrent damage makes it harder for the knee to heal and regain stability. The evidence suggests that every effort should be made to convince your daughter to follow the surgeon’s advice at the front end.

It’s disappointing to be out of the game right out of the gate. But in the big picture, this conservative approach may help ensure many more years of injury-free sports participation.

It sounds like you may be wondering about the natural history of recurrent patellar dislocations. Natural history refers to what happens after an injury in the long-term. For example, will it heal on its own? If not, what should be done to help the healing process?

Based on the evidence from research to date, we can offer the following information:

It’s always best to check with the prescribing physician when changing something in the way a home or exercise program is carried out. In the case of ice therapy, there are different reasons why this might be used.

In some cases, the cold constricts (closes) blood vessels in the area in order to keep swelling down. For other patients, it’s meant as an analgesic (pain reliever) as it freezes the skin and temporarily halts pain messages to the brain.

Patellofemoral pain syndrome is often marked by pain across the front of the knee whenever the patella (knee cap) moves up and down over the front of the leg. Symptoms are especially pronounced when this motion is combined with compression through the knee (e.g., squatting, going up and down stairs, jumping, running long distances).

Studies comparing the use of ice alone against other modalities such as heat, biofeedback, or electrical stimulation have not shown a difference with any of these modalities. That was true whether the heat, cold, or electrical modality was used alone or in combination with others.

In the end, there simply isn’t enough scientific evidence to support the solo or combination use of modalities mentioned.There’s no doubt that sorting out which modalities might be useful and in combination with what other treatment options (in terms of modality use) is a challenge.

But if there is no added benefit of using such modalities, then they should be discontinued. With so many variables yet to study, it’s clear that future research in this area is needed.

In the meantime, check with your physician and find out if you should still use the ice and perhaps what the intended benefit may be for you. This may help you understand why you should continue using ice. Or perhaps you will find your physician agrees with you and recommends dropping it or using something else.

Low level laser therapy (sometimes referred to as therapeutic light) can have a positive effect on tissue repair and pain control. You know how good it feels on a sunny day after weeks of rain and gray skies.

Laser as a form of light energy has the same effects on the body at a cellular level. Light energy is absorbed by the cells and is then transformed into energy. That energy can be used to repair or regenerate various parts of the cells.

With patellofemoral pain syndrome (PFPS) knee pain develops as a result of compressive loading forces across the patellofemoral joint. The patellofemoral joint is where the patella or knee cap glides up and down over the lower end of the femur (thigh bone).

Altered alignment of the knee and muscle weakness of the hip and knee contribute to this very common problem among athletes. Overuse through endurance activities such as running, squats, going up and down stairs, and even sitting for long periods of time are risk factors as well.

The resulting symptoms of pain, tenderness, and swelling can lead to reduced knee motion and function. Laser may help with the symptoms of patellofemoral pain syndrome but there is no evidence that it works any better than a placebo or “sham” (pretend) treatment.

There are dozens of considerations when studying laser: wavelength used, power density, length of time laser is used (duration of treatment), how long between injury and treatment, and so on. Much more study is needed before laser will be recommended for the treatment of patellofemoral pain syndrome.

Radiofrequency (heat treatment) is used to kill the small branches of the sensory nerves to the knee (genicular nerves). The procedure is called a radiofrequency neurotomy.

Nerve blocks are used to confirm that nerve irritation is the problem and source of pain. But a nerve block only provides temporary effects. Once the pain comes back, then radiofrequency ablation is a good choice to end painful symptoms permanently.

The neurotomy is minimally invasive. The surgeon creates a tiny tunnel through the skin and soft tissues down to the bone. Fluoroscopy (real-time X-rays) and sensory stimulation are used to make sure the surgeon is close enough to the nerve to make accurate contact.

After the nerve is located then a radiofrequency probe is passed through the tunnel to the nerve. The tip of the electrode is heated up to 70 degrees Celsius (about 160 degree Fahrenheit) for 90 seconds. This ensures that the nerve is destroyed and no further pain transmission can get through.

Complications and problems along the way can occur but these are uncommon. Sometimes patients report “unbearable” pain during the procedure. This response is likely from sensitive nerve endings on the bone where the radiofrequency probe touches.

You should consider the treatment a success if the patient got at least 50 per cent improvement in pain for more than a 24-hour period. Anything less than those criteria are considered a failed treatment.

There are times when the RF treatment is not successful. This is most likely because the target nerves vary in their anatomic location. And sometimes there are extra branches that still supply the joint with nerve impulses.

Pain is relieved only if and when all branches of the sensory nerves to the knee are found and destroyed. If the first procedure doesn’t completely eliminate the pain, neurotomy can be repeated a second and even third time.

Well, we aren’t sure what’s been tried so far. The usual course of action is a pharmalogical approach with antiinflammatories and analgesics (pain relievers). Finding the right drug (or combination of drugs) can take some time but is usually effective.

Other conservative measures may include steroid injections, bone stimulation therapy, and exercise. Yes, believe it or not, many studies have shown that exercise actually helps patients with severe knee pain from osteoarthritis.

For patients who do not want surgery, there are other alternative treatments such as hypnosis, acupuncture, and osteopathic or manual therapy. Other hands-on methods that have not been studied or proven effective but are still available include Reiki, BodyTalk, Therapeutic Touch, Healing Hands, and so on.

If nothing in that list appeals to you, there are some surgical options. The first is a neurotomy, which means to cut or destroy the sensory nerve that send pain messages from the skin, joint, and soft tissues to the brain.

Sometimes surgeons use high frequency radio waves to heat branches of the sensory nerves (hot enough to kill the cells). The procedure is called radiofrequency ablation or radiofrequency neurotomy. Usually a diagnostic nerve block is done to make sure that will work.

And a knee replacement is often an option. But perhaps you are too young for that just yet. For sure, you should get back with your surgeon and explore any and all options available.

Pain severe enough to wish someone would cut your leg off can usually be reduced if not eliminated. It may take some time and a trial-and-error approach but some combination of the suggestions made here should work.

The timeline currently used for athletes after anterior cruciate ligament (ACL) surgery goes something like this. Rehab and recovery after surgery takes a good four to six months for everyone. Sports specific training is designed to return athletes to their sport by the end of a year’s time.

The real question isn’t can they get back into action within 12 months of the surgery, but rather, can they participate at their preinjury level? A recent study conducted at the Musculoskeletal Research Centre at the La Trobe University in Australia actually took a look at this question. They asked, are most athletes really back on the field, court, or track by the end of 12 months?

They collected data on over 500 athletes who were treated by a single surgeon for an ACL rupture. They all had the same surgical procedure so at least from a surgical point-of-view, the playing field was “level” so-to-speak.

They also analyzed the results to see if there were any specific factors that could predict who would do well and how soon athletes did, indeed, return to their sports participation.

Some of the items reviewed included 1) whether the athlete was engaged in seasonal versus year-round sports, 2) how soon the surgery was done after the injury, and 3) whether sex (male versus female) made a difference. In other words, were men or women more likely to return-to-sports before the end of the first year?

Patients were contacted after the end of a full 12-months following surgery. They were asked if they had returned-to-sport (or attempted to return) and their current playing status. If they had not yet returned-to-sport, they were asked why not and if they intended to return (and how soon).

As it turns out, two thirds of the 503 athletes had not attempted participating fully in competitive sports at the time of follow-up. About half of those 335 athletes had attempted training and/or modified competition. Most of these folks were male. The other half (some men but mostly women) had made no attempt at sports activity.

Some patients had given up because of the knee problems. An equal number gave up sports for other reasons. A large number (159 patients — an equal number of men and women) still planned to return to competitive sports but 84 had no intention of doing so.

The results of this study showed the expectation of return-to-sports within 12 months of ACL surgery may not be realistic. The authors note that using the preinjury level of participation as the key measure may be somewhat restrictive but it is a more accurate reflection of real life for athletes.

More study is needed to clear up some of these differences before we will know for sure. For now, it looks like many athletes may need more than the traditional six to 12-month break from sports after ACL reconstruction.

First of all, don’t think you are alone. According to a recent study from Australia, many athletes have a disconnect between what the tests show and what they can actually do on the field or court.

The question immediately arises about the athlete. Is he or she holding back because of fear of reinjury? Lack of self-confidence? Is it just a psychologic problem or is there some intuitive knowledge the body is relaying to the mind that the knee just isn’t ready for that level of activity? We don’t know yet — maybe a little bit of both, maybe not.

Perhaps it has more to do with the test measures. It’s possible that the current testing used really doesn’t tell the whole story. Many patients seem to have good joint motion, strength, and apparent stability. Commonly used tests such as the Cincinnati Sports Activity Scale (SAS) and the International Knee Documentation Committee (IKDC) evaluation don’t seem to correlate well with the actual return-to-sport rate.

In other words, the athletes’ test scores show normal or nearly normal knee strength, motion, and strength. Yet the athletes’ ability to perform essential skills for their sport is poor or non-existent.

Some studies using a simple hop test as a measure of readiness for return-to-play indicate that this single test may be a better predictor than the main tests used. This is an area where more investigation and study are needed.

Probably both but you’ll want to double-check on that and ask the surgeon directly. The femoral-fibular reconstructive surgery is designed to restore the soft tissue structures of the posterolateral (back/side) corner of the knee joint.

When multiple ligaments in the knee are torn or damaged, the joint can become unstable. It slides too far into external rotation and gaps too much along the lateral (side) of the knee joint.

A piece of tendon from the Achilles (heel) is used to replace the damaged fibular collateral ligament (FCL) and the popliteus muscle-tendon-ligament (PMTL). The joint capsule that is torn along that back corner is incorporated into the graft in order to restore stability to the area.

But as much as the graft restores normal knee biomechanics, it is not a fully anatomic (natural) unit. In order to avoid overloading the graft (even after healing and recovery), patients are advised to avoid high-impact activities. Only low-impact activities such as biking or swimming are encouraged. This is to protect the knee joint.

By following your surgeon’s advice, you will be able to participate in daily activities (at work and at home) and low-impact recreational and sports without pain. There is a fairly high rate of joint degeneration and arthritis in patients who have had this procedure. These recommendations may help slow down the degenerative process but this has not been proven with studies yet.

Femoral-fibular posterolateral reconstruction is the most commonly used surgical technique to stabilize a knee with multiple ligaments that are damaged. Without this important soft tissue support, posterolateral (back and side) instability of the knee joint occurs.

To be more precise, the soft tissues being replaced are the fibular collateral ligament, the popliteus muscle tendon-ligament (PMTL), the popliteofibular ligament, and the posterolateral (joint) capsule.

When these structures are torn or damaged, the knee slides around and can partially dislocate (called subluxation) or fully dislocate. That’s what is meant by knee instability. Together, these soft tissues work to keep the knee joint from hyperextending (extending beyond a neutral position), externally rotating too far, or opening (gapping) too much along the side.

And that’s why it’s important to do more than just repair damage to this area. In this procedure, a piece of the Achilles tendon from the back of the heel is used to replace torn ligaments along the back (posterior) and side (lateral) aspect of the knee. The surgeon actually has to rebuild (reconstruct) this group of four ligaments and capsule that make up the back/side corner of the knee joint.

Basically, tunnels were drilled into the femur (thigh bone just above the knee) and into the fibula (small bone along the outside of the lower leg bone and located just below the knee joint). The Achilles tendon graft (taken from a tissue bank, not from the patient) is threaded through the tunnels with just the right amount of tension to mimic the natural ligamentous function.

The femoral-fibular reconstruction is a fairly simple procedure. The way the graft is put in and looped around actually makes a double graft. The extra strength of this configuration tied into the fibular collateral ligament (FCL) works well. The placement of the femoral-fibular graft forms a solid foundation for the complete reconstructive procedure.

This technique does restore joint stability. It allows lateral joint gapping needed for normal movement. But it prevents abnormal lateral joint opening when stress is applied to that side of the joint.

As a result, all three posterolateral structures are restored allowing for normal (or near normal) motion, function, and stability. This reconstructive procedure mimics the natural knee and that’s important for both daily activities and recreational sports.

Severe damage to the anterior cruciate ligament (ACL) of the knee often requires reconstructive surgery. The surgeon uses graft tissue taken from a donor bank (called an allograft) or harvested from the patient (an autograft).

As you have discovered, the reported failure rate for this surgery is as high as 20 per cent. That’s one out of every five patients — an unacceptable level for any surgeon. The reported range is from zero to 20 per cent, so clearly there must be some reasons for this wide range.

Some experts suggest the problem is with the terminology. What “failure” means to one surgeon may not be the same to the next. There isn’t a uniform, agreed upon definition that is used by everyone reporting their results in the literature.

Some surgeons use the results of clinical tests to determine failure based on instability. For example, the joint moves too much from front to back or side to side when pressure is applied. Or measurements from a special tool called the KT-1000 arthrometer show there’s a problem. Others stand by MRI documentation that shows a re-tear.

Taking a closer look at the studies published on this topic, there seems to be about a 12 per cent failure rate for allograft tissue. It’s possible that some specific factor about the allograft is responsible for a portion of these failures. But exactly what that might be remains unknown. It could be the age of the donor at the time of death. It could be the way the donor tissue is processed and stored.

More study is needed before we can pinpoint all the reasons why graft failure occurs. The real key may be to find a surgeon who has a low failure rate. Discussing your concerns with your surgeon may also help reduce your anxiety in this area. It is a real concern and not one that surgeon or patient should take lightly.

Severe damage to the anterior cruciate ligament (ACL) of the knee often requires reconstructive surgery. As you now know, the surgeon can use graft tissue taken from a donor bank (called an allograft) or harvested from you, the patient — that’s called an autograft).

If you have heard about the advantages and disadvantages of each choice, you probably know there are failures with either approach. Surgeons do everything they can to ensure graft success and patient satisfaction. A recently published article from surgeons at the University of Southern California point out a few things about allografts that might be important.

For example, donor tissue can come from patients of all ages. In the case of tendons or ligaments, there are age limits. The donor can not be more than 60 years old. Studies have not been done to show if matching the patient age to the age of the allograft is important.

But it makes sense that the stiffness and load donated tissue can withstand should match the level of activity of the recipient (i.e., you or the patient receiving the graft tissue). It’s possible that tensile strength of the tissue and biomechanical
load each tissue can withstand before failure differs with age. The potential for differences have not been investigated and compared.

Then there is the matter of how the graft tissue is prepared, processed, and stored for use. How the graft tissue was sterilized could make a difference. Did the graft come from an accredited tissue bank?

There is an organization called the American Association of Tissue Banks (AATB) that sets standards for tissue processing and donor eligibility. But there’s no law that requires tissue banks to follow their guidelines.

Surgeons are advised by the American Academy of Orthopaedic Surgeons (AAOS) to use donor tissue only from tissue banks that are inspected and approved by the American Association of Tissue Banks (AATB) or the Food and Drug Association (FDA). AATB authorized donor banks test carefully to make sure the donor tissue is free of diseases, viruses, and infections such as HIV or hepatitis. The tissues are inspected, cleaned, and sterilized before being stored.

Donor grafts have many advantages. Using donor tissue reduces surgical time, improves cosmetic result, and eliminates potential pain and other problems without a donor site on your body. It is also possible that your recovery and rehab will proceed more quickly with fewer glitches.

If you have not discussed these aspects of allografts with your surgeon, this may be a way to further educate yourself and come closer to making a decision.