Lloyd Perris to miss the rest of the season

[ugg]

At the beginning of the last quarter of the ressies game he started on the bench which was weird because there were plenty of topups playing and they usually start on the bench

But he eventually came on and even kicked a goal in that quarter

[Ampersand]

Poor guy. Is he a candidate for LARS or is he too young? I wonder if AJ's experience might affect his thinking.

[Nico]

At the beginning of the last quarter of the ressies game he started on the bench which was weird because there were plenty of topups playing and they usually start on the bench

But he eventually came on and even kicked a goal in that quarter

IIRC Lenny Hayes went back on or even played the next week and did his ACL well and truly after a "twinge".

[Auntie.Gerald]

Stanley brothers in rugby league have had 7 knee recons between them not sure if ACL and or Medial etc

[Ludwig]

Hopefully the fact that he was able to come back on indicates that it's only a partial tear and will be easier to heal, and perhaps a good candidate for LARS.

[giant]

That's his second ACL. He did one (same knee or other knee?) in the year before his final U18 year.

Ouch, really? Poor bastard, it really leaves a sour taste in your mouth no matter who gets one.

[Meg]

Unfortunately some people do seem to be susceptible to repeated knee problems. Daniel Menzel is only 22 y.o. and he has had four knee reconstructions, one on the right and three on the left. He hasn't played since September 2011 and is now out till next season.

[goswannies]

Hopefully the fact that he was able to come back on indicates that it's only a partial tear and will be easier to heal, and perhaps a good candidate for LARS.

'Fraid not. It can indicate a number of things. If his hamstrings were very active when they did the anterior draw or pivot shift tests to assess the ACL, it can easily yield a false negative (ie the ACL appears bot to be torn when it is). In some instances, if there isn't a lot of swelling, it can mask a more sinister injury, with medicos unaware of the severity and they allow the player to continue. Elite athletes generally have good quad/hammy muscle control which provides considerable dynamic muscle control that can compensate for lack of stability usually provided by the ACL. The dynamic stability can be adequate for controlled agility quick tests that might b preformed on the sidelines to assess of a player can return, but without an intact ACL the muscles cannot provide adequate support for uncontrolled or high impact forces.
Any of those circumstances might have allowed him to return.

The LARS graft is commonly suitable for a primary ACL repair (as opposed to a reconstruction using autologous tissues like patella tendon or hamstring), it's ok for players at the twilight of their careers as the shortened rehab time allows a rapid return (less deconditioning), players who have a small window of opportunity (approaching finals, or, say Olympics where they only get a chance every 4 years), also often used in work people who won't exert high impact forces but need to get back to work quickly, or people who have run out of autologous tissue.
Younger athletes are often directed away from LARS grafts as their is a school of thought that autologous tissue (athlete's own tissue) provides a stronger fixation in the long term, less chance of natural degradation, lower infection/rejection risk - and as a younger athlete has more years ahead of them to recover and rehab before Father Time naturally ends their career, it will potentially result in a more favourable outcome.

As for the chance of re-injuring, a recent study found nearly 30% of athletes sustained a 2nd ACL injury within 2 years of returning to activity, with 20% sustaining an opposite leg injury and 9% incurring a graft re-tear injury on the same leg. Females had twice the incidence of injury to the opposite leg than males.

While athletes often return to sport by 1 year postop, there is evidence that there is continued remodeling (and consequent strengthening of the graft for at least a year beyond that - possibly contributing to the re-injury incidence during that initial two years postop).

Females also have a predisposition to ACL injuries as the female hormones tend to result in slightly greater laxity in soft tissues, rendering them statistically more prone to injury.

[Ludwig]

Thanks goswannies for the medical clarification. I hope you don't mind a few more questions.

When the term 'rupture' is used, does that mean a total severing of the ligament or can it encompass partial tears as well?

In hybrid grafts, like the one used for AJ, do they combine autologous tissue with synthetic material?

I though I heard that several teenage footy players got LARS grafts. Maybe I'm thinking of the Menzel brothers.

[goswannies]

Thanks goswannies for the medical clarification. I hope you don't mind a few more questions.

You're welcome & no worries

When the term 'rupture' is used, does that mean a total severing of the ligament or can it encompass partial tears as well?

Rupture usually means completely torn. Partial tear is when some fibers are torn. Some are intact. The ACL has a poor blood supply and consequently a poor capacity to heal. A partial tear that doesn't compromise the ligament vascularity may heal, although some of this will be scar tissue which is less elastic (and consequently less effective that natural ACL tissue

In hybrid grafts, like the one used for AJ, do they combine autologous tissue with synthetic material?

By hybrid do you mean synthetic? The old carbon fibre ones, no. In fact they tended to degrade, leaving carbon particles that caused inflammation. The developers of the LARS suggest it is biocompatible allowing natural tissue to infiltrate the graft scaffold, increasing the strength. Not every surgeon subscribed to this, however.

I though I heard that several teenage footy players got LARS grafts. Maybe I'm thinking of the Menzel brothers.

Yes, they did, but there was a short period where the rapid recovery was fashionable ... until guys like Malceski & David Rodan re-ruptured. This caused many medicos to re-consider. Doc Larkins also gave it some negative press. The advantage for a young player, pre-draft, of having a LARS is that an ACL injury might not keep them out for as long (3 months vs 9-12 months) which might make them a more appealing draft prospect.

[Meg]

In a recent AFL.com.au article on Daniel Menzel it said the second of his three left knee reconstructions was a LARS procedure but that the LARS graft snapped when he was attempting to make a comeback through the VFL. So he hasn't had much luck with either form of reconstruction.

[aguy]

You're welcome & no worries


Rupture usually means completely torn. Partial tear is when some fibers are torn. Some are intact. The ACL has a poor blood supply and consequently a poor capacity to heal. A partial tear that doesn't compromise the ligament vascularity may heal, although some of this will be scar tissue which is less elastic (and consequently less effective that natural ACL tissue



By hybrid do you mean synthetic? The old carbon fibre ones, no. In fact they tended to degrade, leaving carbon particles that caused inflammation. The developers of the LARS suggest it is biocompatible allowing natural tissue to infiltrate the graft scaffold, increasing the strength. Not every surgeon subscribed to this, however.


Yes, they did, but there was a short period where the rapid recovery was fashionable ... until guys like Malceski & David Rodan re-ruptured. This caused many medicos to re-consider. Doc Larkins also gave it some negative press. The advantage for a young player, pre-draft, of having a LARS is that an ACL injury might not keep them out for as long (3 months vs 9-12 months) which might make them a more appealing draft prospect.

Where is your orthopaedic practice ? That could only have been the answer of an orthopaedic surgeon. I know too many

[goswannies]

Where is your orthopaedic practice? That could only have been the answer of an orthopaedic surgeon. I know too many

Haha, I wish! Just a physio working in orthopedics, but I spent a bit of time doing some research & my theses & publications investigated ACL outcomes.

[Conor_Dillon]

Surely if he has experienced an ACL previously he'd know straight away when he's done it again, and therefore wouldn't return to the field? And the medicos present would have to have known his inury history and therefore erred on the side of caution? Could someone with medical insight tell us whether returning to the field could have turned a potential ACL tweak into a full rupturing of the ACL?

[goswannies]

Surely if he has experienced an ACL previously he'd know straight away when he's done it again, and therefore wouldn't return to the field?

Not necessarily. Muscles can compensate to a degree (perhaps more so when they have been specifically trained for this role from the first recon. So the quick agility tests done on the sidelines to see if he's ok to return might looked ok. Also the pivot shift test is quite an uncomfortable test. It requires the player to be as totally relaxed as possible to detect the laxity. If you've had this done before and you are anticipating the resultant "clunk" there is a natural tendency to tense & this can yield a false negative result (ie the test might indicate the ACL is ok, when the feeling of stability is actually given by hamstring contraction that prevents the anterior tibial translation rather than a seemingly intact ACL. My second ACL rupture (in the same knee as the initial ACL recon) was initially diagnosed as a sprain in an emergency department Dr. The knee felt ok at the time of injury and it wasn't until 2 weeks later that my physio did the test when I was more relaxed that I was found to have re-ruptured.

And the medicos present would have to have known his inury history and therefore erred on the side of caution?

Ideally yes. But that is a judgement call.

whether returning to the field could have turned a potential ACL tweak into a full rupturing of the ACL?

Definitely yes. An analogy would be taking a rope. Apply tension & it holds nicely. Cut several strands of the rope and it's still ok without tension but apply tension ... fair chance the weakened rope will fail.