If you’re a skier, orthopedic surgeons say the question isn’t if you’ll tear your anterior cruciate ligament — it’s when.
The anterior cruciate ligament, or ACL, is the primary knee-stabilizing ligament. It prevents anterior translation and rotation of the tibia relative to the femur, making it critical for cutting and pivoting sports. Overall, tearing it is the most common ligament injury in the United States, happening roughly 200,000 times a year and resulting in approximately 100,000 surgeries.
It doesn’t take a backcountry ski accident to tear your ACL. You can hear the dreaded “pop” cruising a groomer, playing soccer, slipping on ice — or even something a little more absurd.
“I wish I would’ve written them down,” said Dr. David Khoury of Teton Orthopaedics. “Falling over in the lift line, stepping off a curb, Wii bowling, chasing a chicken ... I’ve seen over a thousand ACL tears — I’m sure I’m forgetting some.”
Whether you tear your ACL depends on your activity, your strength and your anatomy.
Gender and hormones are also potential factors. Women are three times more likely to tear their ACL. In cutting and pivoting college sports like soccer, basketball and rugby women are almost four times as likely. But skiing tends to equalize the playing field, and surgeons here see just about as many men as women in their offices.
They say April showers bring May flowers, but in Jackson, it’s more like February snow brings March surgeries. It’s the busiest month for surgeons like Khoury, who does 30 to 50 surgeries during ski season, sometimes up to seven a week, and between 50 and 100 a year.
In March alone, he said, he’d probably see 400 patients total. For comparison, most surgeons perform fewer than 10 ACL procedures a year.
“If the mountain’s busy,” Khoury said, “then we’re always busy.”
Under the knife
Surgeons say they like having the ability to put people back together.
“Being an active person, the idea of restoring people to their health and curing traumatic injuries was very appealing to me,” said Dr. Bill Neal of Orthopedic Associates. “I enjoy doing things with my hands.”
How quickly the procedure is scheduled post-injury depends on individual surgeons, their availability and how long they like to wait for inflammation to go down.
Start to finish, an uncomplicated ACL surgery takes about an hour. “You don’t want to rush through something, but you also don’t want to waste time when someone’s under anesthesia,” Khoury said.
Former orthopedic surgeon Dr. Peter Rork called the surgery a “very straightforward thing.”
“The anatomy of the ACL hasn’t changed in 75 million years,” he said. “You have to know where it originates and where it inserts. And once you master that, you’ve got it.”
During that time the torn ACL is taken out and a tendon is turned into the new ligament, attached to bone for better healing and fixation.
After a patient is under anesthesia the surgeon and his or her team examine the anterior cruciate ligament and surrounding structures. Roughly half of ACL patients also have damage to their meniscus, a pad of cartilage in the knee that acts as a shock absorber. A meniscal repair affects initial recovery, generally in that a patient is unable to put weight on the knee for longer, depending on the tear pattern.
After going through a “timeout” routine, in which members of the team ensure, among other things, that they’re operating on the correct knee, the surgeon threads an endoscope into the body to look around the joint.
If nothing new is discovered during that diagnostic arthroscopy, a graft is harvested. The surgical team prepares the graft while the surgeon removes the torn ligament and determines where it was once attached between the femur and tibia. That’s the place they’ll drill into your bones to position and then attach the graft.
“That’s where you make your sockets,” Khoury said. “You try and make it anatomic so it re-creates normal anatomy.”
The graft is fixed to both sides using a screw to the tibia and a titanium “endobutton” to the femur. Harvest sites are closed with sutures, stitches are put in and, voila, new ACL.
Surgeons say everything — from arthroscopic technology to fixation techniques — has changed for the better over the years. Surgeries now have a more anatomic, or similar to the original structure as possible, end result. Plus, nerve blocks and better anesthetic techniques mean less time in the hospital. But when the block wears off, you’ll still need strong medication.
“It can be a real eye-opener,” Rork said. “There’s no pain like bone pain.”
Research continues into the possibility that stem cells might help with ACLs, but surgeons say it’s too early to tell amid the hype.
“I believe stem cells will be the future,” Khoury said. “If you could at some point grow your own new ligament and not have to harvest and have comparable results … I don’t know how far away that is. But you should always be a little wary about accepting new treatments. You really want to see that it works and it’s durable.”
“It will be wonderful if and when that happens,” Neal said.
Here’s a big question
When it comes to ACL surgery, where to harvest a graft is the million dollar question.
Quad, hamstring, patellar tendon? The choice varies from surgeon to surgeon and has evolved over time.
“It’s seen the coming and going of different fashions and fads as they came along,” Neal said.
Each professional has a preference about what to use to replace the ACL, and the studies to back that choice. But all say they’re roughly equal in terms of stability and functional outcomes.
“They will all work if they’re done by a good surgeon who does the surgery well,” Khoury said.
Rork started using the hamstring graft in the late ’80s.
“Boy, I caught a lot of heat for that,” he said. “But I knew it was the right thing to do. And now everybody does hamstring grafts.”
Like Rork, Khoury likes the hamstring best. Neal feels strongly about the quad. In the late ’90s he heard about efforts to use the distal quadriceps tendon and started closely following the literature about it.
“By about 2010 I was pretty enthusiastic about trying to find a way to harvest that tendon to get the advantages of the quadriceps tendon without sacrificing the hamstring tendons and without taking a third of the patellar tendon,” Neal said.
He designed instruments, made locally, in 2012 that allow him to harvest the tendon and leave only a small scar.
Jackson surgeons have largely moved away from the patellar tendon. It’s not as big or strong, they say, creating a size mismatch. Patients may also experience additional pain and potential for arthritis that isn’t as likely with other choices.
Despite differences in graft preference, there are a lot of overlaps with the orthopedists here in Jackson. Rork and Neal both did their fellowships under renowned knee specialist Dr. Richard Steadman in South Lake Tahoe, California. Rork and Khoury trained at the same residency program at the University of New Mexico.
One thing they can agree on? Cadaver grafts are less than ideal. Allografts were popular because they saved surgeons time and resulted in fewer patient incisions, but they don’t tend to work as well, especially in young people, and have high failure rates, they said.
Even when left with your own two legs as the choices, something’s got to give.
“We don’t have spare parts,” Khoury said, “you’re taking something. There is some consideration because you are sacrificing something to rebuild your ACL.”
Your recovery varies
The months (and months, and months) of physical therapy after ACL surgery focus on rebuilding balance, regaining a full range of motion with extension and flexion, and bolstering quad, hip, hamstring and glute muscle strength. In other words, be prepared to do so many squats and lunges that you might be able to crank out sets in your sleep. And be prepared for exercises that used to be easy, like box jumps or standing up with one leg, to be incredibly difficult and a little terrifying the first time you try them.
In a hard-charging place like Jackson, recovery can feel like forever. And you won’t get sympathy from the bow-tie-wearing, often joke-cracking Rork, who also admitted he had an abrasive bedside manner.
“People would tell me, ‘Well, I can’t have this done because I have to ski,’” he said. “I said, ‘What are you, an infant? You don’t have to ski. You want to ski. And I understand that, but the ‘have to’ thing, you need to get over that.’
“I’m not a mollycoddling, hand-holding kind of guy.”
You can’t rush the process. A return to sports might take place around the nine-month mark, but patients and doctors agree it can take a year for your joint to feel totally normal again.
There are two components to healing, Khoury said. First, “the aspects you have control over,” such as regaining motion, strength and function. The second: biology.
“You can’t change the biology,” he said. “No no matter how far ahead you are with the aspects that you can control, you can’t change tendon to bone healing or tendon ligamentization.”
But if you want to rush the process and disregard your doctor’s orders, Rork said he’d love to know how it goes.
“This is your first ACL tear, not my first rodeo,” Rork said. “If you do everything I tell you to do, you’ll get a good outcome and I’m not going to learn a damn thing about it. But if you want to go out on your own, I mean, I’m not allowed to experiment on people. So go out and see what happens, that’s fine. I’m curious, too.”
If surgery is successful and the graft heals, with full strength you’ll be back to your baseline risk, meaning it’s just as likely to tear either ACL. Even if you do everything right, scientific literature indicates 10% to 15% of surgical reconstructions will fail.
“There are two kinds of surgeons who don’t have failures and complications,” Rork said. “The non-operating guys like me, and the liars.”
If you tear your ACL in the winter, chances are you’ll join a pack of fellow Jacksonites who are one, two, three weeks ahead of or behind you in the process. Rork said it results in a “herd mentality” that can be helpful when navigating the ups and downs of recovery. See that person walking without crutches? See that person doing jump squats with nary a grimace? That’ll soon be you.
Your doctor and physical therapist are likely almost as excited as you are for the eventual return to outdoor adventures in the Tetons.
“People go into medicine for a lot of reasons, but most people want to help,” Khoury said. “It’s really nice to help people and see them go back to the activities they enjoy.”