Case Studies

Having polio as a tot supplied this 57-year-old male of Hispanic descent with trouble enough when it came to walking. But a leg injury from a January 2004 fall at home ultimately proved too much – lost thereafter was his ability to ambulate.

The wheelchair-bound patient was first seen by us four months after the mishap. We observed a significant soft-tissue valgus instability of one knee attributable to damaged anterior cruciate and medial collateral ligaments. This damage – the effects of which were exacerbated by the pre-existing valgus deformity left over from the childhood bout with polio – rendered the joint incapable of weightbearing. Moreover, the absence of soft-tissue support in the knee had produced an anatomic malalignment of the femur in relation to the tibia. This malalignment viewed from the front was measured at approximately 15 degrees of valgus, which is twice that of normal.

Based on our comprehensive workup, we determined this patient to be an ideal candidate for ligament reconstruction surgery. However, since soft-tissue reconstruction cannot be performed amid an anatomic malalignment of such magnitude as that present in this case, it was necessary first to perform a distal femoral varus osteotomy to correct the malalignment and bring the patient out of anatomic valgus. This preliminary intervention occurred two months after our initial encounter with the patient and was performed on an inpatient basis. The two-hour procedure itself entailed removal of a 12-degree wedge from the femur, then breaking over the femur to place the bone in proper apposition. The femur was affixed by means of a DHS Synthes stainless steel plate. In November 2004, four months postoperatively, the hardware from the osteotomy was removed in order to create approach access for the next surgery – the ACL-MCL soft-tissue reconstruction – which transpired in February 2005 and required four hours of operating room table time to complete. This procedure made extensive use of allograft material and was performed chiefly by arthroscopy.

After the initial surgery, the patient’s leg was no longer in valgus and he healed well. However, he continued to experience significant soft-tissue laxity, as expected.

 

The second surgery – appreciably more complex and demanding than the first – was completed according to plan and free of complications. The patient then entered a four-month program of physical therapy in which practitioners worked on restoring his knee range of motion and flexibility and strengthening the joint. During this time (and extending until January 2006), the patient was seen by us on a regular basis. When last examined, he was found to be in sound anatomic condition: His knee exhibited excellent range of motion and was stable to weightbearing stress. Accordingly, the patient was fully ambulatory without need of a walker or cane.

ACL-MCL reconstruction was this patient’s only hope of walking again. No therapy, no bracing, no intervention apart from this would have made him wheelchair-independent.

 

However, while ACL reconstruction is a routine procedure among orthopedic surgery groups, MCL reconstruction is much less so – unless the group has extensive experience in advanced, state-of-the-art sports medicine, as we do. For us, this case represented yet another opportunity to apply to a nonathletic patient the robust surgical techniques and excellent perioperative technologies that enable injured worldclass sportsmen and sportswomen to quickly return to the playing field. And, as with so many of the athletes we treat, this nonathlete patient enjoyed an outcome that fully delighted both him and his primary care doctors.