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Dr. Marc Haro

Guest Post by:

Marc Haro, M.D.
Assistant Professor
Orthopaedics - Sports Medicine
MUSC Health
 

As the Super Bowl approaches, one of the major stories is the return of Rob Gronkowski.  Gronkowski, the tight end for the Patriots, sustained a major knee injury last year in a game against the Cleveland Browns when tore both his anterior cruciate ligament (ACL) and his medial collateral ligament (MCL).  Many worried that if he would ever be able to return to his elite level of play.  However after undergoing an ACL reconstruction, he not only returned this season, but also returned to his All-Pro form.  As did Tom Brady, who also sustained an ACL tear in 2008. Concussions have rightfully been prominent in the discussion of NFL injuries recently, however a poll by USA Today last year found that knee injuries were even more feared by NFL players than head injuries1. While players worried about concussions and their long-term consequences, most players feared a devastating knee injury that might be a career-ending event.  And until a few decades ago, it often was.

What exactly is the ACL?

The ACL is one of the 4 major knee ligaments and it helps keep the knee stable with twisting and cutting maneuvers. It runs from the femur to the tibia and is located in the center of the knee.  Unfortunately with an unexpected cut, twist, or an awkward landing, the ACL can tear. Typically people hear a “pop” and know something serious has happened to their knee.  Surprisingly, most people are able to walk off under their own power, but soon thereafter the knee starts to swell and get stiff. Unlike other ligaments in the knee, the ACL will not heal on its own.  The ACL is typically not needed for straight-ahead activities such as walking or even light jogging.  So if people have no intention of returning to cutting or twisting activities, non-operative treatment may be appropriate. However, if individuals desire to remain active and return to sports, an ACL reconstruction is often recommended.

Who tears their ACL?

While anyone can sustain an ACL injury, most tears occur as a non-contact injury in young, active individuals, especially those participating in competitive sports such as soccer, basketball or football.  However, participating in any sport that requires cutting, twisting, or landing, puts you at risk for an ACL tear, regardless of age.  Numerous studies have shown that women are 3 times more likely to sustain an ACL tear than men, though the reasons behind this is not well established2.   It may be structural differences in the ACL, or possibly as the result of neuromuscular or hormonal differences between genders.

What do I do if I tear my ACL?

Most people are able to walk and function reasonably well without an ACL, however returning to high level cutting or twisting sports can be challenging.  Without an ACL there is a concern about what happens to the cartilage in the knee if it remains unstable.  If you tear your ACL, you should discuss with your surgeon whether you need an ACL reconstruction, and if so how it should be done.  Of most importance is not to rush into surgery.  Studies have shown it is important to allow the knee to calm down and the range of motion to return to normal before having surgery; otherwise post-operative stiffness can be a significant problem3.

How is it reconstructed?

Over the past several decades there has been an evolution in how ACL tears are treated.  It wasn’t until the 1960’s and 70’s that orthopaedists realized that an ACL tear was actually a significant injury.  Once it was realized that tearing the ACL led to instability and eventually arthritis, ACL injuries have become the most researched topic in orthopaedics.  Early ACL surgeries were done as an open procedure where a graft was placed in a tunnel drilled into the femur and tibia. With the rise of arthroscopic surgery in the 1980’s, techniques became popular that allowed the surgery to be done through smaller incisions. This led to a boom in ACL reconstructions and now 50,000 reconstructions are performed per year4.  Unfortunately, doing so many ACL reconstructions has led to some bumps in the road. Researchers found that people were still getting arthritis and having instability, despite undergoing a reconstruction.  It was realized that with the current reconstruction techniques, surgeons were not consistently placing the ligament in its native location. Over the past decade, there has been a major emphasis on surgical techniques that restore the normal anatomy, and produce a more modern “anatomic ACL reconstruction”.

Another important aspect of ACL surgery is what graft is used to reconstruct the ligament.  A variety of grafts can be used, and each has their pro’s and con’s.  The two major categories of graft choices categories are allografts (cadaveric donor grafts) or autografts (your own tissue).  While studies have shown that all grafts typically have good outcomes, more and more studies are showing allografts are associated with higher failure rates, especially in younger, highly active individuals.  When Carson Palmer of the Arizona Cardinals retore his previously reconstructed ACL, many speculated that it was because cadaveric tissue was used in his initial surgery5.  But if you aren’t trying to return to professional or collegiate sports, the use of allograft tissue may be worth a discussion with your surgeon. Historically there have been two major autograft choices.  A patellar tendon graft is where a small piece of bone from your patella and tibia are taken along with a strip of tendon and this is to reconstruct the ACL.  The other option has been to use the hamstring tendons to reconstruct the ligament.  Both have been very successful for ACL reconstructions.  A new graft has recently emerged, the quadriceps tendon, and early data suggests may also be as good of graft choice as the other options.

How long will it take me to get back?

In the late 1980’s and early 1990’s surgeons began to realize that it was important to not only restore stability to the knee, but it was important for people to get normal strength and motion back if they wanted to return to sports or activities.  Surgeons began to allow patients to move their knee early after a reconstruction and while scary at first, surprisingly the grafts did not “stretch out”6.  Patients actually got better faster and were returning to sports at a higher level than ever.  Now it is well accepted that getting your motion back early after surgery is one of the most important factors to having a good outcome.  Once motion comes back, strength usually follows.  Typically most surgeons will tell patient that getting back to sports will require approximately 6 months after surgery, however depending on graft choice this can vary from 4 months to 1 year.

If I have surgery can I reinjure it?

Yes, it is possible to retear an ACL after it has been reconstructed.  Much as with sustaining a first ACL tear, if you return to risky sports at high levels, you are at higher risk of sustaining a retear.  In young active females the risk of sustaining a second ACL can be as high as 20%7.  Interestingly enough, women seem be twice as likely to tear their other ACL as they are to retear their reconstructed knee.  While this may be related to the size of the native ACL versus the larger, reconstructed ligament, this has not been completely proven as of yet.

While Rob Gronkowsky, Tom Brady and numerous other NFL athletes have made returning from ACL surgery look easy, it is actually a complicated process that requires teamwork to get back to such a high level of activity.   It takes a motivated patient, precise surgical technique and a skilled therapist to get back to such high levels of activity.  So if you, a friend or family member sustains an ACL tear, seek out an orthopaedic surgeon who is part of a sports medicine team to help get back in the action.

References:

  1. http://www.usatoday.com/story/sports/nfl/2014/01/27/nfl-players-injury-survey-knee-head-concussions/4918341/
  2. Prodromos CC, Han Y, Rogowski J, Joyce B, Shi K.  A Meta-analysis of the incidence of tears as a function of gender, sport, and a knee injury-reduction regimine.  Arthroscopy.  2007;23(12):1320-5.
  3. Shelbourne KD, Wickens JH, Mollabashy A, DeCarlo M.  Am J of Sports Med.  1991;19(4): 332-6
  4. Frank CB, Jackson DW.  The science of reconstruction of the anterior cruciate ligament. J Bone Joint Surg Am. 1997;79:1556-1576
  5. http://espn.go.com/nfl/story/_/page/hotread141119/arizona-cardinals-carson-palmer-keeps-connection-acl-donor-family
  6. Shelbourne KD, Nitz P.  Accelerated rehabilitation after anterior cruciate ligament reconstruction.  American Journal of Sports Medicine.  1990;18(3):292-9
  7. Shelbourne KD, Gray T, Haro M.  Incidence of subsequent injury to either knee within 5 years after anterior cruciate ligament reconstruction with patellar tendon autograft.  Am J Sports Med.  2009;37(2):246-51

Guest Post by:
Bobby Weisenberger, ATC, PES
Head Athletic Trainer Charleston Battery
MUSC Sports Medicine

 

During the NHL season it is very common for players to miss playing minutes while recovering from injury.  However, this season players were missing playing minutes for an entirely different reason, illness.  Several players were diagnosed and quarantined for having the Mumps Virus.

While we rarely see mumps in the United States, outbreaks are still a possibility.  These outbreaks occur in locations where people spend a lot of time in close contact with others.  Common areas for possible outbreak are classrooms, sports teams, and college dormitories.

Mumps is a viral infection that primarily affects the parotid salivary glands.  Signs and symptoms of Mumps are:

  • Parotitis or swollen salivary glands, which can affect one or both sides.  This is where Mumps actually gets it name from the swollen looking cheeks
  • Pain with chewing and or swallowing
  • Loss of appetite
  • Weakness and fatigue
  •  Headache
  • Fever

If the overwhelming majorities are vaccinated with the Measles, Mumps, Rubella (MMR) injection, how did this happen in the NHL?  While the vaccine is good, it has been shown to lose its effectiveness after 10 years.  Most children are now given a booster vaccine, which will take them into their early 20s.  This is significant timing because if immunity weakens after 10 years, this places individuals in their early 20s, which is the college age, and coming into the time where players are being drafted into the professional teams.

Mumps are spread through contact with the salvia of an infected person.  Examples are: 

  • Breathing in saliva droplets can infect a person after an infected person has coughed or sneezed
  • Touching items that have been coughed, sneezed, or spit on and then putting your hands into your mouth
  • Sharing eating utensils or cups with an infected person can also spread Mumps

This makes sports teams vulnerable because players typically pass and share water bottles.  This combined with the very close contact, hands/gloves to the face, heavier breathing, coughing, and spitting created the perfect storm for the outbreak in the NHL.

Below is a list of players and officials who either tested positive for Mumps Virus or showed symptoms of Mumps along with a timeline of the outbreak courtesy of ESPN.

http://espn.go.com/blog/nhl/post/_/id/33596/tracking-down-where-the-nhl-mumps-outbreak-started

Players, officials diagnosed with mumps or showing mumps-like symptoms

Anaheim Ducks: Corey Perry (Canadian), Francois Beauchemin (Canadian), Clayton Stoner (Canadian), Emerson Etem (American).

Minnesota Wild: Ryan Suter (American), Keith Ballard (American), Marco Scandella (Canadian), Jonas Brodin (Swedish), Christian Folin (Swedish).

New Jersey Devils: Travis Zajac (Canadian), Adam Larsson (Swedish), Patrik Elias (Czech), Scott Clemmensen (American), Michael Ryder (Canadian).

New York Rangers: Tanner Glass (Canadian), Derick Brassard (Canadian), Joey Crabb (with AHL Hartford; American), Lee Stempniak (American).

Pittsburgh Penguins: Sidney Crosby (Canadian), Beau Bennett (American), Olli Maatta (Finnish), Steve Downie (Canadian), Thomas Greiss (German)

St. Louis Blues: suspected but not confirmed

NHL officials

Referee Eric Furlatt, linesman Steve Miller

No confirmations of team support staff being diagnosed with the disease have been reported, although an intern with the Pittsburgh Penguins radio staff has been confirmed to have the virus.

Timeline of events related to the mumps outbreak in the NHL:

Sept. 12: Local health unit issues mumps alert in Orange County, California, where some Anaheim Ducks players live.

Oct. 2: Blues play Wild in preseason game.

Oct. 4: Blues play Wild in preseason game

Mid-October: St. Louis Blues players reportedly test positive for mumps -- Joakim Lindstrom and Jori Lehtera reportedly had mumps-like symptoms -- although the team has never confirmed this.

Oct. 16: Referee Eric Furlatt works Blues-Kings game.

Oct. 17: Keith Ballard of the Minnesota Wild misses game against Ducks with mumps-like symptoms; referee Eric Furlatt works game.

Oct. 19: Ducks play Blues.

Oct. 23: Linesman Steve Miller works Blues-Canucks game.

Oct. 27: Wild play Rangers.

Oct. 30: Ducks play Blues.

Early November: Furlatt misses games with mumps-like symptoms.

Nov. 3: Blues play Rangers.

Nov. 4: Wild play Penguins; Blues play Devils; linesman Steve Miller works Blues-Devils game.

Nov. 5: Corey Perry and Ryan Getzlaf of the Anaheim Ducks miss game vs. Islanders with flu-like symptoms.

Nov. 6: Blues play Devils.

Nov. 7: Ducks play Coyotes; Getzlaf returns, Perry sits out second consecutive game.

Nov. 8: Marco Scandella of the Minnesota Wild shows first signs of mumps-like symptoms, but plays 22:04 against Montreal Canadiens.

Nov. 9: Ducks play Canucks; Beauchemin misses game with the flu.

Nov. 11: Wild play Devils; linesman Steve Miller misses game, later reported to be because of mumps-like symptoms; Perry and Beauchemin diagnosed with mumps; Rangers play Penguins.

Nov. 13: Wild play Sabres; Jonas Brodin and Scandella of the Wild sit out with illnesses later suspected to be mumps.

Nov. 15: Rangers play Penguins.

Mid-November: Team physicians sent email by NHL-NHLPA joint health and safety committee with recommended changes to bench and dressing room behavior.

Nov. 23: Ducks play Coyotes; Clayton Stoner of the Ducks scratched with mumps-like symptoms.

Nov. 24-28: Penguins immunized and tested for mumps.

Nov. 28: Sidney Crosby of the Penguins treated for injury to right side of neck; Crosby is treated and tested for mumps; results are negative.

Nov. 28: Tanner Glass of the New York Rangers sent home from Philadelphia after showing flu-like symptoms.

Nov. 29: Wild play Blues; Glass diagnosed with mumps; Rangers get booster shots.

Dec. 2: Devils play Penguins.

Dec. 4: Ryan Suter of Minnesota Wild diagnosed with mumps.

Dec. 8: Rangers play Penguins; Crosby plays 18:56, his shortest time on ice in eight games.

Dec. 10: Travis Zajac and Adam Larsson of the New Jersey Devils diagnosed with mumps.

Dec. 10-11: Crosby tested again; no symptoms displayed and tests showed no indications of an infection.

Dec. 11: Penguins visit nearby children's hospital.

Dec. 12: Crosby, who had previously had a booster shot before the 2014 Olympics, held out as a precaution after face swells; spent time around teammates in dressing room; Crosby's DNA sent to CDC for further testing.

Dec. 14: Crosby and Derick Brassard of the New York Rangers diagnosed with mumps.

Dec. 15: Beau Bennett of the Pittsburgh Penguins tested for mumps; Detroit Red Wings offer mumps booster shots to players.

Dec. 16: Bennett diagnosed with mumps.

Dec. 17: Marc-Andre Fleury, Robert Bortuzzo and Olli Maatta of the Penguins tested for mumps as a precautionary measure.

Dec. 18: Fleury tests negative for the virus, backup goalie Thomas Greiss held out as a precaution; Rangers isolate Lee Stempniak while he is tested for the mumps; AHL Hartford Wolfpack forward Joey Crabb and head coach Ken Gernander tested for mumps; radio intern with the Pittsburgh Penguins confirmed to have case of the mumps

Dec. 19: Olli Maatta tests positive for mumps.

Dec. 22: Penguins Steve Downie, Brandon Sutter and Thomas Greiss sent home from Florida to be tested for mumps virus; Crabb and Stempniak test positive for the mumps

Dec. 26: Downie and Greiss diagnosed with mumps.

Dec. 27: Patrik Elias, Scott Clemmensen and Michael Ryder of the New Jersey Devils diagnosed with mumps.

What can we do to protect ourselves from future Mumps outbreaks?

  • Centers of Disease Control (CDC) and the Mayo Clinic agree that the most important thing we can do to prevent Mumps is get the MMR vaccine. 
  • It is also important to have a booster vaccine
  • Once vaccinated, prevention begins with simply measures such as washing your hands
  • Make sure your hands are properly cleaned before touching your face or putting your hands to your mouth
  • Do not share eating utensils or cups with others
  • Cover all coughs and sneezes
  • Use your own water bottle when possible
  • When sharing water bottles do not ever touch your mouth to the bottle
  • Quickly isolate and quarantine any individuals suspected to have Mumps and seek immediate medical attention

Guest Post by:

Tina Brown

I’m Tina Brown, the school nurse at Hemingway Elementary School.  I just discovered a way to solve this problem.  It’s called the South Carolina Telehealth Alliance, a collaboration of academic medical centers, community hospitals and local providers delivering care in the school setting.

By connecting the brightest minds from across the state and bringing together innovative resources and scientific breakthroughs, every child can receive access to care – when and where they need it most.  Instead of asking for a day off work and making the long trip to a physician’s office in a neighboring city, parents need only sign the consent forms for telehealth and their child will be seen during school hours. During a telehealth session, the child is at my side as I call in a provider from MUSC Children’s Hospital or the local community for a teleconsult. I can use special instruments - a digital stethoscope, a digital otoscope and an exam cam - to transmit high definition images and audio. The provider sees what I see and hears what I hear. The child’s parent is called and invited to participate in the visit over the phone, and the child’s primary care provider is apprised of the consult. Although rashes and infections are common reasons for teleconsults, the services can also support children with more serious conditions, ensuring that children with asthma, for example, are using their inhalers correctly. 

Watch the video below to see how we use Telehealth in Hemingway.

Learn more about how telehealth is improving health care access for children across South Carolina.  sctelehealth.org/muschealth

 

Guest Post by:

Paul J. Hletko, M.D., FAAP
Georgetown Pediatric Center

 

The Road.  It Can be Your Best Friend, or Your Worst Enemy.

That can depend on where you are and where you need to be.  Now, we’re bridging the distances with a new kind of road with real-time connections thanks to the South Carolina Telehealth Alliance and MUSC Health. This collaboration is connecting the brightest minds across the state to offer South Carolinians access to medical specialists without having to leave the comfort of their hometowns.

As a rural pediatrician in Georgetown, I have become one of the earliest outpatient adopters of the telehealth-based pediatric specialty services offered by MUSC Children’s Hospital.  My practice receives consultative services in sickle cell management, nutrition counseling, Parent-Child Interactive Therapy (PCIT), the Heart Health Program and telepsychiatry. With these electronic telehealth consults, I’m able to draw on a range of pediatric specialists any day of the week. Telehealth is sort of like my Linus blanket.  It’s so reassuring to have pediatric sub-specialty talent readily available in real time in a rural community.

For example, when a young child throws a tantrum or behaves disruptively, I like to rely on MUSC Children’s Hospital developmental pediatricians to observe the encounter and, through Bluetooth-enabled earpiece, provide the parent real-time, PCIT- informed guidance about how to handle the situation.  Faced with the pediatric obesity crisis, I like that my overweight or obese patients and their parents have access to MUSC Health nutritionists who work side-by-side with endocrinologists, pediatric pharmacists, and bariatric specialists. And I like it when I can call Dr. Julie Kanter, a pediatric hematologist at the MUSC Children’s Hospital, and have her on a teleconsult in real time to help me quickly treat a child in sickle cell crisis.   These are examples of a move forward that will sweep the nation, and it’s nice to see MUSC Health at the vanguard of this movement.

You can learn more about how telehealth is improving health care access by visiting sctelehealth.org/muschealth.  Also, hear more about how my practice, my patients and families are benefiting through telehealth services in this video.

 

Wear red on Friday, February 6 to kick off American Heart Month and raise awareness of heart disease—the number one killer of women. Cardiovascular diseases kill more women than men. But 80 percent of cardiac events in women could be prevented if women made the right choices for their hearts involving diet, exercise and abstinence from smoking.

Mark your February calendar for these heart healthy activities:

Go Red: Get a group together from your office, church or neighborhood to raise awareness and share information about heart disease. Download free materials from the American Heart Association to help you plan for National Wear Red and throughout February.

Visit your doctor: Schedule time with your doctor to discuss any risk factors you may have and steps you can take to lower your risk. Need to know what puts you at risk? Find out about the risk factors for women.

Listen to your heart: Symptoms of a heart attack in women can be different than those in men. Get the facts and share with your favorite lady.

Know how to treat a lady: At MUSC Health, we are committed to the education of women about the risks of heart disease, and to state-of-the-art prevention, early detection and treatment of heart disease in women. Learn more about our  heart specialists.

Share the love: Post your photos from American Heart Month and National Wear Red Day to the MUSC Health Facebook page at  https://www.facebook.com/MUSChealth!

 

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