Case study provided by Dr David Sweetnam, FRCS (Ortho) Dip Sports Med, London, UK. The patient's name has been changed to maintain confidentiality.
Going skiing can be thrilling, but as the case below illustrates, it can also be hazardous to the knees.
On the second day of her skiing holiday, 27-year-old June twisted her right knee after her skis became caught on those of her neighbor as she tried to get off a chair lift.
At the time of the fall, although it occurred very slowly, June was aware of a “popping” sensation within the right knee. Subsequently when she tried to stand up her knee immediately felt unstable and actually gave way underneath her. It became quite clear to June that she was unable to stand, let alone ski down the slope. As such, assistance was called to the slope and June was taken down the mountainside by the ski resort’s medical team.
Once at the resort, June was advised to put ice on her knee, and was taken to see the ski resort doctor immediately. The ski resort doctor said that June had not broken any bones, and this was confirmed by X-ray examination. However, the ski resort’s doctor suspected that there was a tear in one of June’s knee ligaments, and recommended she wear a knee splint for the rest of her holiday. He also informed her that she would be unlikely to ski for the rest of her holiday, and she should see a doctor on her return to the UK.
As is usual practice in ski resorts, June was also given a supply of injections of blood thinning agents, which are designed to prevent the possibility of clots forming, particularly for people who are travelling back to their home country by air.
On her return to the UK, June saw a consultant orthopedic surgeon at her local hospital, now seven days following her injury. June was still having difficulty walking normally, although this was partly due to the fact that she was still wearing the splint provided in the ski resort.
On examination by the specialist it was clear that June was unable to fully straighten her leg and that it was still swollen. Further examination revealed some tenderness on pushing the knee inwards, thus suggesting that she had injured the medial collateral ligament (MCL), the inside ligament of the knee.
The consultant also suspected that June had torn her anterior cruciate ligament (ACL), one of the middle ligaments of the knee. However, due to the swelling it was difficult to assess this ligament fully, and he suggested that a magnetic resonance imaging (MRI) scan should be performed. A MRI scan allows the soft tissues, ligaments and cartilages in the knee to be clearly examined. The results took a week to come back to the specialist, during which time the consultant recommended that June see a physiotherapist to help her regain some of her movements.
On review, the MRI scan confirmed that June had not only sustained a moderate (grade 2) sprain to the MCL, but had also, as suspected, a complete rupture of her ACL. Fortunately, none of the cartilages in June’s knee were damaged. Therefore there was no urgent need for surgical intervention, and it was suggested she continue with physiotherapy for the short term.
MRI scan of the knee showing acute rupture of the ACL (red arrow)]
When June was reviewed by the consultant for a third time, some six weeks later, she reported that while the range of movement in the knee had improved substantially, she still felt that the knee was rather “unstable.” She had also experienced an episode of the knee “giving way” underneath her when she was getting out of her car.
While knee pain was not a major problem for June, the sense of instability was obviously causing her a great deal of worry. As June was a young and normally very active person, she decided following discussion with her consultant that it would be wise to undergo surgical reconstruction of the ACL.
Three weeks later June had an operation to reconstruct her ACL using keyhole or arthroscopic surgery.
Arthroscopic surgery in progress]
During the procedure, two of June’s hamstrings from the back of her knee were used to reconstruct the detached ACL. In order to “harvest” the hamstrings, the surgeon made a small, vertical, 2 cm cut in the front of her shin, and another two smaller holes in the front of the knee.
The operation was performed under a general anesthetic and lasted approximately one hour.
Naturally, following the operation June’s knee was very stiff and care was taken to prevent the knee from becoming very swollen with a great deal of icing. Immediately after the operation the physiotherapist worked with June to regain a full range of motion in the knee, and helped her perform exercises that would enable her to walk without crutches. .
Although many patients undergoing arthroscopy can leave hospital the same day, when more significant surgery, such as ACL reconstruction is undertaken, it’s more usual for the patient to stay in hospital for a couple of days to work with the physiotherapist as mentioned.
Two weeks after her operation, June saw the consultant again, who removed the stitches from her knee. Her knee was moving almost through a full range of motion, but the consultant recommended that she continue working with the physiotherapy for at least another few months.
The consultant told her that it was important to wait until the graft had “taken,” before beginning her usual exercise. During this time she was working with the physiotherapist on a series of exercises that didn’t stress the graft, whilst allowing the leg muscles to build up again.
June took this advice and continued to work with the physiotherapist before returning to her gymnasium several months later. She continued to progress well, getting back to running at about three months, and playing tennis five months following surgery. As she had hoped, June was able to go skiing the following season, approximately 10 months after her original injury.