Dr. Mark Miller, an orthopedic surgeon at the Virginia Ambulatory Surgery Center often hears this kind of complaint:
"Doc, I fell and twisted my knee. I heard a pop. It hurt for a little bit. When I stood up, the knee felt as if it were not underneath me and my knee gave way. It swelled up by the next day and ever since, it feels like it's going to pop out when I cross the street quickly."
That's because this complaint usually comes from someone who has torn the anterior cruciate ligament (ACL) of his knee joint, something Miller treats often at his office.
Traditionally, those who tear the ACL get it replaced with patellar tendons from the kneecap. But for the first time at the University, the VASC is offering a new alternative - the quadrupl_e hamstring graft.
Miller says that this alternative is useful because the patellar tendon procedure is not the best technique for everyone.
"For patients who have a history of pain behind the kneecap or who have skinny patellar tendons, the hamstring graft is preferred," Miller said.
The ACL is the strong ligament in the middle of the knee that keeps the tibia from sliding forward on the femur.
Tearing the ACL is a serious injury and usually requires surgical repair or reconstruction for athletes and common folk alike. But with current techniques, a person can have his ACL repaired or reconstructed and resume everyday activities that same year.
He said the newly introduced hamstring graft is more attractive mainly because of the smaller incision - only an inch long for the hamstring, compared to about three inches for the patellar graft.
"We like to tailor the graft to the patient," Miller said.
The patellar graft is still a good choice for many patients who don't have pain behind the kneecap or skinny tendons, but the hamstring graft is a good alternative for someone who does.
For the hamstring procedure, Miller makes an incision in the hamstring, so two long tendons (semitendinosus and gracilis) can be "stripped." Miller folds the tendon strips in half to create the quadruple hamstring graft After drilling a tunnel in the tibia and femur, doctors attach the graft to the knee with an Endobutton, a device which is used to affix grafts to the bone.
After the graft is threaded through the femur side of the tunnel, the Endobutton pops open to lock the folded end of the graft into place. On the tibia side, a screw and spiked washer combination are used to ensure that the graft will not slip off, and once installed, the graft will work for the rest of the patient's life.
Miller is also doing research on the relatively new procedure's effects on the hamstring. He said that within three months, the tendons appeared to be growing back to within a few centimeters of the incision - much like a lizard's tail growing back after being snapped off. If research confirms this, the hamstring graft would be even more attractive for surgical candidates than the patellar graft, since the patellar tendon does not exhibit this same regenerative property.
Miller theorizes that when the cause of the regrowth is found, these findings could actually conceivably be used to help amputees recover lost limbs.
The ACL can be torn when people make quick changes of direction require participants to plant their feet, as well as contact injuries that shear the ACL. Because most athletes routinely perform either or both of these movements on the field, almost any athlete is prone to tearing his ACL. Still, the procedure would still work regardless of the way the ACL was torn.
This new procedure would be especially helpful for female athletes, who are in general more likely to injure their knees and tear the ACL, according to Miller.
According to a study by Dr. James Moeller, associate director of primary care sports medicine and an assistant professor in the departments of family medicine and orthopedic surgery at the University of Pittsburgh Medical Center in Pittsburgh, and Dr. Mary Lamb, family practice resident at Saint Margaret Memorial Hospital in Pittsburgh, women probably have a higher rate of ACL injury probably because female body alignment makes them more prone to the injury. Hormones also may play a part, as well as an imbalance between the strength of the hamstring and quadriceps.
Both Moeller and Lamb added that prevention of this type of injury is quite difficult.
Because tearing the ACL can often bench an athlete for several months, research continues to figure out how best to treat athletes so that they can have productive athletic careers.
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