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Bob's ACL WWWBoard
Re: ACL graft, retorn meniscus, ACL again? -- Some chronic issues from karate...
Posted By: Michael Frind
Date: Wednesday, 10 March 2010, at 2:10 p.m.
In Response To: 3rd surgery - ACL graft, meniscus repair, bucket tear meniscus, ACL again? (Trudee)
Dear Trudee,
Your knee situation is a complex one, and it is well worthwhile to look at the historical aspects because they provide insight into the more recent events.
You noted that you enjoy participating in karate, and that this places a lot of twisting-type demands on your knee. You also noted that you had a hamstring ACL graft about seven years ago, after tearing in the ACL in karate. And, you noted that this was followed by a difficulty in regaining full range of motion, and that a meniscus tear was dealt with via partial menisectomy.
You then noted that, in December 2009, the knee made crunching noises during karate, but you were able to finish the class. You also noted that the knee felt unstable after this incident. (How violent were the pivoting movements? When you pivot, do you plant your entire foot on the ground, or do you pivot on only the front portion of your foot?)
I note that crunching noises are commonly associated with meniscal problems. You noted that an MRI scan found a bucket-handle meniscal tear with rearwards displacement (more on this later), as well as articular-cartilage damage. It was unclear whether the articular-cartilage damage was in the form of bone-bruising (smashing-type articular-cartilage damage, as typically accompanies ACL tearing) or whether it was the chronic type (i.e. from long-term problems, or perhaps from abnormal knee biomechanics potentially arising from a slightly incorrectly placed original ACL graft).
Given that the MRI scan also found ample scar tissue, and also given that you had problems regaining full range of motion after the initial surgery 7 years ago, it may be the case that you are more prone to intra-articular scar-tissue formation than the average person. This is something to mention to any physiotherapist you consult in the future. (Note: The difficulty in regaining full range of motion after the surgery 7 years ago could also have been due to a slightly incorrectly placed graft. Also, note that an error in graft placement could make the ACL more prone to stretching out or failing...which in turn could explain the December 2009 incident. How easily did this knee incident occur? If the knee suddenly felt unstable after a relatively minor pivoting incident, then a gradual yet very pernicious stretching-out of the grafted ACL might have been occurring over the past 7 years.)
Of course, the scar-tissue issue is not the most serious concern on its own. It is a secondary problem, given the recent feeling of instability, which implies tearing of the 7-year-old grafted ACL, and also given the serious meniscal damage, which may not be repairable. (As a general note: When a knee suddenly starts making crunching noises, and especially if these noises are accompanied by locking or clicking, it is a good idea to stop all activities and have the knee checked out immediately. Continuing to pursue activities with a knee that makes such noises could result in a simple meniscal tear being transformed into shredding-type damage. A simple bucket-handle tear is often quite amenable to repair, given that such tears typically occur quite close to the outermost edge of a meniscus, and given that the outermost third of a meniscus is vascularized. But the more damage that is done, the harder it becomes to suture the torn pieces back together. And, more damage increases the likelihood that the tearing extends into the innermost [and avascular] third of the meniscus, where repairs are not feasible. Concerns of meniscal-tissue loss are especially acute in a knee which has already undergone partial meniscus removal, as your knee did in 2003.)
You also noted that you were scheduled to undergo knee surgery in mid-February (so, roughly two weeks ago), and that at this time, the surgery would examine the ACL. Given the unstable feeling that you reported (from the December 2009 incident), it seems safe to say that your knee requires revision ACL reconstruction if it is to become stable again. What did the surgeon decide to do? And, also, what was done about the displaced bucket-handle meniscal tear?
Yours truly,
Michael Frind.
Knee Library http://factotem.org/library
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