Jewish World Review April 2, 2003 / 29 Adar II, 5763

Getting up to speed after surgery

By Marnell Jameson | Brian Anderson was just doing what he'd been doing several times a week for the last 10 years. He was careening around a roller rink at high speed practicing for his next roller hockey game.

As the 29-year-old software engineer from Lake Forest, Calif., approached the turn, he tilted sideways toward the floor for momentum. Though it was a move Anderson, who played club hockey in college, had done thousands of times, this was different. He felt the pop in his right knee. And he was down.

Anderson had torn his anterior cruciate ligament, or ACL. One of four ligaments in the knee that stabilize the joint, the ACL runs through the center of the knee and keeps the thigh bone (femur) from sliding forward over the calf bone (tibia). Dr. Kevin Armstrong, an orthopedic surgeon who eventually treated Anderson, said ACL injuries typically occur when the foot is pointed away from the midline of the body and the knee twists while bending. Sudden stops or landing from a jump are other non-contact causes. ACL injuries also can occur when the knee gets hit.

Each year, an estimated 350,000 Americans suffer ACL injuries. They have two choices: Live without the supporting ligament or have it reconstructed. Torn ACLs don't heal on their own, and surgeons reconstruct about 15 percent to 20 percent of the torn ligaments, or 50,000 to 70,000 a year, according to Armstrong, also an assistant professor of sports medicine and orthopedics at University of Califorian-Irvine Medical Center. Deciding who should or shouldn't have a torn ACL reconstructed involves several factors: the patient's age, lifestyle, functional ability after injury and recovery, and the amount of arthritis already in the joint.

Younger people who want to continue an active lifestyle that involves knee-torquing sports, such as tennis, skiing or basketball, are the best candidates for reconstruction. Those who don't experience joint instability during normal daily activities and are content with sports such as cycling, swimming or walking, can usually do well without reconstruction.

Non-surgical treatment of the ACL involves rehabilitating the knee to build strength and bracing the joint until it's stable. The upside of this approach is that patients avoid the risks of surgery, pain and a lengthy recovery, which can take up to a year. The downside of not replacing the ACL is that if the knee chronically buckles, the joint tends to degenerate prematurely, which can lead to early arthritis.

The most common reconstruction involves using a piece of the patient's patellar tendon and regrafting it to replace the torn ACL. A second option involves taking a portion of the patient's hamstring, often the treatment of choice in women because the scar is slightly smaller. Third, surgeons can use an ACL from a cadaver.

For Anderson, surgery was the only option. "I need to play hockey to be happy,'' he says. "Although I was concerned about the surgery and recovery, that worry was never enough to make me consider not doing it. I was committed to do whatever it took to make my knee like it was before.''

Armstrong and Anderson decided on using a portion of the patellar tendon to reconstruct Anderson's ACL. So in January 2002, three months after his injury, Anderson underwent the outpatient surgery.

Anderson's insurance company, like most, covered both the surgery and the months of physical therapy that followed. He was back to work in three weeks and graduated from walking with crutches to walking with a leg brace within eight weeks.

Though recovery was long, painful and at times rocky (two weeks after the surgery, while trying to navigate the stairs in his home on crutches, he fell and fractured his elbow), Anderson didn't look back. "I held on to the fact that eventually my knee would be OK, and I would play hockey again.'' He went to physical therapy twice a week and did the strengthening exercises at home for half an hour twice a day.

But being healthy, fit and committed to rehab is only part of any comeback. The rest of recovery simply takes time. "You can't cheat biology,'' says Armstrong. "It takes almost a year for a graft to revascularize and be solid no matter how healthy you are.''

Recovering from ACL reconstruction takes longer when the meniscus or cartilage is also damaged; the average recovery takes eight to 10 months. After that, most patients return to full activity, including their cutting sports, with a brace. Gradually, they can play without it.

By December, Anderson was working out again with his team. Today he plays both ice and roller hockey with an adult league. Although Armstrong told Anderson he could start playing without his brace, he still wears it, "partially to keep my wife happy.''

Although no knee is ever as strong after ACL reconstruction as it was before the injury, Anderson says his new knee feels like 95 percent of what it was, and for that "I'm ecstatic,'' he says. "I love skating. I love the speed of the game. And I love being back.''

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