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
  1. In your opinion, how severe is the injury to my knee?
  2. Do you believe surgery is required? If so, what is the optimal procedure, and what are the associated risks?
  3. If reconstruction is recommended, do you recommend autograft or allograft?
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.

Review of Systems Pain localized diffusely around the left knee.
Past Medical History GERD
Past Surgical History None
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 MRI Left Knee - 10/10/2013 - page 8: Impression: 1. No ACL tear. 2. No evidence for meniscal tear. There is a healed or healing meniscal capsular sprain. Adjacent to the posterior horn of the medial meniscus. 3. Nearly healed trabecular injury of the posterior lateral tibia.
Pathology reports n/a
Laboratory values n/a
Other studes n/a
Opinion
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For the Patient
  
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The patient would like you to answer the following questions. Please respond to each of them, providing robust answers that explain your thinking and rationale.

1. In your opinion, how severe is the injury to my knee?
2. Do you believe surgery is required? If so, what is the optimal procedure, and what are the associated risks?
3. If reconstruction is recommended, do you recommend autograft or allograft?

Please summarize your recommendations for the patient and clearly outline the next steps that s/he should pursue. Whenever possible, list next steps in order of decreasing importance (i.e. most important to least important).


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