Grand Rounds

Opinion completed 5/12/15

Michael Miller
35 years old, Male
Left knee grade 3 anterior cruciate ligament (ACL) sprain

Initial diagnosis	Left knee grade 3 anterior cruciate ligament (ACL) sprain.
Proposed treatment	Left ACL reconstruction with autograft vs. allograft.
Goal of consultation	The patient seeks a second opinion to define the optimal course of treatment.
Chief complaint	I am a active individual. About a third of the time I play, my knee will buckle, causing severe pain. Within minutes, the pain lapses and I am then able to continue playing. I can run, walk, and cycle with no pain at all. I even trail run for about 20 miles a week in the mountains. I would prefer to avoid surgery, but am worried about causing permanent damage to my knee.
Questions from the patient	In your opinion, how severe is the injury to my knee? Do you believe surgery is required? If so, what is the optimal procedure, and what are the associated risks? If reconstruction is recommended, do you recommend autograft or allograft? Do you recommend any alternatives to surgery? If yes, what are the risks and benefits of these treatments? Will avoiding surgical treatment result in permanent damage to the knee? Would there be any activity restrictions with and without surgery? Would you recommend physical therapy before or after surgery? If so, what is the recommended intensity and duration of physical therapy? What can I do to prevent recurrence of this or similar injuries?
History of Present Illness	Mr. Miller is a 35 year-old male with a history of left knee pain and instability for the last 2 months secondary to left ACL tear diagnosed by MRI. The pain has been persistent since January. He describes moderate pain, looseness, and instability around the left knee. The pain increases with activity. On 9/24/13, the patient’s treating physician noted the presence of a grade 3 ACL sprain, mild left knee effusion, and pain at the end of flexion. MRI of the left knee revealed an ACL tear. He recommended range of motion and strengthening exercises, and surgical ACL reconstruction.
Background information	The ACL is tissue that connects the thighbone to the shinbone, at the knee. Most ACL injuries occur during certain sports such as basketball, soccer, football, skiing, and tennis. Symptoms include knee swelling, instability, and pain. Treatment may include surgery and physical therapy.
Review of Systems	Pain localized diffusely around the left knee. See page 5 of Medical Records.
Past Medical History	Lorem ipsum dolor sit amet, consectetur adipiscing elit. Aliquam congue semper libero, et accumsan nisi posuere vitae. Phasellus feugiat metus at diam dictum sagittis. Quisque efficitur ante ipsum, eu placerat ipsum faucibus eget. Praesent dictum, quam a faucibus rutrum, nibh neque vehicula felis,
Past Surgical History	Lorem ipsum dolor sit amet, consectetur adipiscing elit. Aliquam congue semper libero, et accumsan nisi posuere vitae. Phasellus feugiat metus at diam dictum sagittis.
Medications	None
Allergies	NKDA
Family history	No relevant history
Social history	Software developer. Enjoys running, tennis, travel, and time with family. Tobacco: none Alcohol: moderate use
Physical exam	6’1”, 190 lbs No pain on patellofemoral compression, no atrophy or crepitus. Mild effusion is present.
Imaging reports	Please see included.
Pathology reports	n/a
Laboratory values	n/a
Other studes	n/a

For the Patient

Summary to the patient
Briefly Summarize the patients chief complaint, history of present illness and relevant past medical/surgical history. Our staff physicians got you started, feel free to edit as you see fit.

Thank you for allowing me to review your case and provide my opinion. Before answering your questions and providing my recommendations, let me summarize your medical history and concerns based on what I have learned from your medical records and the questionnaire you completed.

You are a 35-year-old male, active and in good health, who injured the right knee while skiing on May 11, 2015.

You were diagnosed with a tear of the medial collateral ligament and anterior cruciate ligament in your right knee. This was confirmed by an MRI, which also showed a medial meniscal tear and damage to the lateral tibial plateau (part of your tibia, your shin bone) in your knee.There were also some minimal degenerative changes noted in your knee.At the time of your examination on December 19, 2013, your knee was stiff and swollen and examination was difficult to perform.In summary, you have a torn ACL and MCL of the right knee with medial meniscal tear and an impaction injury of the posterior lateral aspect of your tibial plateau.

Questions from the patient
Answer these questions from the patient.

1. Do I need surgery? If so what kind of surgery do you recommend? What is the expected recovery time?

In my opinion, you do NOT need surgery at the present time. Surgery in the presence of a sniff knee (such as yours) canonly lead to complications with stiffness and difficulty with rehabilitation. You would only need surgery if you developed significant laxity or looseness in your knee over time. As I mentioned above, many patients are able to completely avoid surgery by participating in 6-12 weeks of physical therapy. The recovery time fornon-operative treatment of this injury (via physical therapy alone) is approximatelythree months.Again, the need for an ACL reconstruction, which is a major surgery that takes9 to 12 monthsto recover from,willonlybe indicatedif your knee gives way with activities of daily living or the sports/activities you wish to perform.If the ACL reconstruction is performed before you have full range of motion in your knee you are at a high risk of developing significant stiffness in your knee, which is then very hard to treat and can make your knee worsethan it is with the small amount of looseness.An ACL reconstruction (which, again, I think is unlikely you will ever need) should not be considered until after you have completed a full physical therapy regimen, else you risk worsening the stiffness in your knee.I think you will be able to do hiking and skiingwithoutever needingan ACL reconstruction.The medial meniscal tear that is associated with your injury may be degenerative in nature (meaning caused by normal wear and tear that occurs with age) and therefore may have been partially present even before the skiing injury. If residual symptoms occur because of the medial meniscal tear after you have completed your physical therapy, mainly medial jointline tenderness (your doctor can check for this in a physical exam), this can be addressed with a simple arthroscopic surgery down the line.You should also know that you already have a small amount of arthritis in your knee, which will probably be madeworse by the injury, whether you have surgery or not.

2. What type of rehabilitation do you suggest for your patients with my condition?

What type of therapy, duration of treatment, etc.?In my opinion, you should have physical therapy three times a week for at least six weeks. The purpose of this physical therapy is mainly to decrease the stiffness in your 
knee. It is very important to obtain full extension of your knee so that you are able to walk normally in the future. Obtaining full extension of your knee will usually take anywhere from four to six weeks of physical therapy, and you may benefit from continuing therapy for up to 12 weeks.After six weeks of therapy, then you should be reevaluated to see if your knee has obtained the appropriate range of motion and to see if there is some residual laxity in your knee.

3. What restrictions you do advise for me? 

I am very active, but I do not want to hurt my knee in the future.For now, your activity would be limited to swimming and biking, when you obtain sufficient range of motion to be able to participate in these activities.In the future, once your knee has recovered from the non-operative program (the physical therapy listed above), you would be able to do activities that do not require twisting/pivoting (sports such as tennis, soccer, baseball, and football all require pivoting, so they would not be recommended.) In reviewing your history, I see that you enjoy skiing. You will still be able to ski with a knee brace. You should not need a knee brace for other activities besides skiing.

Summary of next steps
Indicate 2-3 actionable next steps for the patient based on this opinion.

1) I recommend 4-6 weeks of physical therapy to decrease the stiffness of your knee. Some patients benefit from up to 12 weeks of physical therapy. For many patients with your injury, physical therapy is sufficient and they are able to avoid ever needing any surgery.

2) I do NOT recommend that you undergo ACL reconstruction at the current time, and I think it is unlikely you will ever need reconstruction of your ACL. Undergoing an ACL reconstruction early (now) before the stiffness in your knee has had a chance to improve with physical therapy can lead to stiffness of your knee and long-term problems that may be evenworsethan your original injury. Performing an ACL reconstruction too early can lead to overall worsening of your knee in the long term. ACL reconstruction is a major surgery with 9-12 months of recovery time, so it should be avoided unless necessary. For your case, with physical therapy, you will likely be able to avoid this major operation.

Links for the patient
When appropriate provide any links links that you would reference for your own patients. We got you started. Feel free to edit as necessary.

www.sportsmed.org
http://orthoinfo.aaos.org/topic.cfm?topic=A00549
www.scoi.com/patient-education.php
www.wheelessonline.com

For the Treating Physician

Patients share these opinions with their treating physician. This section is for you to provide some guidance to the treating physician.

Links for the Treating Physician
If you have something that may be helpful, here is a space to include citations for published articles, information about new clinical studies or web links that would benefit for the treating physician.

1. Non-operative management of ACL injuries in the general population, Journal of Bone and Joint Surgery. May 1996, Volume 78, Casteleyn et al.
2. Non-operative treatment of acute ACL injury in a selected group of patients, AJSM. March 1995, Volume 23, Buss et al.
3. Operative and non-operative treatment of MCL ruptures with early ACL reconstruction, AJSM. July 2006, Volume 34, Halinen et al.
4. Activity level and subjective knee function 15 years after ACL injury at perspective longitudinal study of non-reconstructive patients, AJSM. July 2007, Volume 35. Kostogiannis et al.
5. Motion loss after ligament injuries in the knee part 1 causes AJSM. September 2001, Volume 29, Millett et al.

Before your opinion is sent to the patient, it is reviewed/read by a Grand Rounds Staff Physician. The Staff Physician may (a) reorganize what you’ve written to make it easier for patients to understand; (b) contribute background information about the patient’s disease or condition in order to contextualize your recommendations; (c) “translate” medical jargon into patient-friendly language; and/or (4) make stylistic changes in your writing. The Staff Physician’s goal is not to alter the substance of your opinion but rather to make your insights and recommendations as accessible to the patient as possible.

Note from the Patient

Thank you Dr. Spinelli for all of your help! Lorem ipsum dolor sit amet, consectetur adipiscing elit. Maecenas laoreet erat sit amet ligula lobortis, ac euismod quam convallis. Sed cursus quam nec ex accumsan maximus. Praesent et ullamcorper orci. Ut malesuada ligula vel nisi varius tincidunt. Etiam commodo tellus quis lectus fringilla mollis. Maecenas egestas sodales gravida. Quisque laoreet et velit eget convallis. Vestibulum ante ipsum primis in faucibus orci luctus et ultrices posuere cubilia Curae; Praesent et consequat ante. Curabitur non ante nibh. Nulla egestas neque ac convallis tempor. In quis urna sed ipsum placerat consectetur. Donec facilisis, turpis id cursus ornare, tellus nulla sodales sapien, ut commodo mi ex vitae erat.

Note from the Staff Physician

Thank you for completing this case in such a timely fashion. We look forward to working with you again in the future.

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