The “wait and see” approach usually leads to poor recovery or worsened injury. (Courtesy photo)

The “wait and see” approach usually leads to poor recovery or worsened injury. (Courtesy photo)

The moment you tear it is the moment to repair it

Almost all orthopaedic injuries are best repaired immediately. The old “wait and see” for most joint injuries has been proven to lead to scar tissue, loss of motion and arthritis.

With today’s accurate imaging, using repair and reconstructing techniques to restore normal anatomy beats living with deformities.

Here is a lineup of several fixes for injuries that need immediate repair…

ACHILLES TENDONS

Torn Achilles tendons can be repaired effectively without open incisions. When freshly torn, the free tissue ends are bathed in fresh blood, which contains healing growth factors. The tissue tries to heal, and if the ends are pulled together, they can heal in the strongest fashion. A percutaneous stitching technique permits sutures to be weaved into the torn ends without an open incision — which would expose the tendon to air, lose the fresh blood and increase the risk of scarring and infection. If you “wait and see,” the ends scar down and become irreparable.

MENISCUS CARTILAGE

Most torn menisci can be repaired, but aren’t. When the meniscus is partially or fully removed, the risk of arthritis skyrockets due to the loss of the joint spacer. Unfortunately, there are 800,000 meniscus tears in the U.S. annually, but only 10 percent are repaired, 0.01 percent are reconstructed with collagen scaffolds, and 0.02 percent are replaced with allografts. Yet if treated when freshly torn, they can often be repaired. New techniques of augmenting the torn meniscus with stem cells, growth factors, and collagen scaffolds make it easier to repair severely damaged meniscus tissue. Saving the meniscus is the key to preventing arthritis.

LIGAMENTS

The anterior and posterior cruciate ligaments in the knee joint guide the motion of the femur on the tibia. When torn, the abnormal mechanics lead to cartilage damage in much the same way that bad alignment leads to tire wear. While some knees do well with torn ligaments, the vast majority do poorly over time. There is no benefit to the “wait and see” approach. Freshly torn ligaments can sometimes be primarily repaired. Using improved techniques — including selection of only the strongest tissues and the addition of anabolic factors to stimulate healing donor allograft tissues — we can usually avoid the second site injury of harvesting the patient’s own patellar tendons or hamstrings.

DISLOCATED SHOULDERS

“Once dislocated, always torn” is the rule for the ligament labrum complex in the shoulder, which keeps the shoulder joint in place. Instability is never good for a joint, and the shoulder is no different. The techniques for labral repair have become so effective that repeat dislocation (in the absence of bony injury) is now uncommon.

ROTATOR CUFF

The tendons of the rotator cuff atrophy after tearing and retract away from their bony insertion. When freshly torn, they can be anchored back in their normal anatomic location, using an outpatient arthroscopic procedure. If they retract, the success rate declines proportionate to the degree of retraction and the health of the tissue. Early repair leads to full recovery.

“Doc, I twisted my knee, heard a pop and the knee swelled.” This story has a 90 percent chance of indicating a repairable lesion in the knee (torn meniscus, torn ligament, damaged articular cartilage surface). It needs to be examined, imaged with X-ray and MRI, diagnosed and repaired promptly — followed by great physical therapy and fitness training. When done well, bliss is achieved. When ignored, the agony of defeat is around the corner.

Dr. Kevin R. Stone is an orthopedic surgeon at The Stone Clinic and chairman of the Stone Research Foundation in San Francisco.

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