Knee Injuries: ACL Tears and Recovery After a Car Accident

Knee fracture and anterior cruciate ligament tear due to a car accident, Dr. Si?

Hello Dr.
Shih, I was in a car accident last December, and I still cannot walk independently and need a walker.
I have some concerns regarding the entire medical process conducted by the surgeon who performed my operation, and I hope you can help clarify them.
The diagnosis certificate states that I have a right tibial plateau fracture and a right anterior cruciate ligament (ACL) tear.
After the surgery, the doctor placed my right leg in a cast-like fixation and initially advised me to move my toes, lift my foot, and practice walking with a walker.
However, after three months post-surgery, my condition remained the same.
During each follow-up, the doctor only reviewed the X-rays and said that my recovery was going well.
By the fourth month, I felt that this approach was not effective, so I removed the fixation and sought rehabilitation therapy at a clinic.
I found online that most people start rehabilitation about one to two weeks post-surgery and can walk better by three months.

Currently, my knee flexion is around 110 to 120 degrees, but sometimes my knee feels weak and unstable.
Following the rehabilitation therapist's advice, I have been wearing a knee brace.
A few days ago, I visited another orthopedic hospital to check my recovery status.
After reviewing the X-rays, the doctor stated that the initial surgery was not performed correctly, that the ACL was not properly secured, cartilage had been removed, and that the metal screws could not be taken out, indicating a serious issue that would prevent normal function.
He suggested an MRI and further surgery.

How could the findings of these two doctors differ so significantly? I discussed these concerns with my rehabilitation therapist, who mentioned that my bones have healed, that I need to continue rehabilitation to stretch the ACL, and that regarding the cartilage, there are two possibilities: one, it may be compressed due to tight ligaments as shown in the X-ray; two, if cartilage was indeed removed, there are ways to address it, so I shouldn't worry too much and should continue rehabilitation.

This is my current situation, and I hope you can help me assess it.
I am concerned that delaying further action may worsen my injury.
Thank you for your assistance.

Xiao Yang, 20~29 year old female. Ask Date: 2016/05/05

Dr. Shi Guozheng reply Orthopedics

A cruciate ligament tear with an associated fracture that is non-displaced does not require surgical fixation.
If there is displacement, surgery can be performed to stabilize the fracture.
The issue with the ligament is not solely about treating instability, but rather addressing pain or functional impairment.
Based on your description alone, a comprehensive assessment cannot be made, so it is essential for you to consult a physician for a detailed evaluation.

Reply Date: 2016/05/05

More Info

After a car accident, knee injuries can be complex and multifaceted, particularly when they involve structures such as the anterior cruciate ligament (ACL) and the surrounding bones and soft tissues. Your situation, involving a right tibial plateau fracture and an ACL tear, is indeed serious and requires careful management to ensure proper recovery.

Firstly, it's important to understand the anatomy and function of the ACL. The ACL is one of the key ligaments that help stabilize the knee joint. When it is torn, it can lead to instability, pain, and swelling in the knee. The tibial plateau fracture you mentioned can further complicate the situation, as it may affect the alignment and stability of the knee joint.

From your description, it seems that you underwent surgery to address these injuries, which is often necessary in cases of significant ligament tears and fractures. Post-surgery, the standard protocol typically involves immobilization of the knee to allow for healing. However, the duration of immobilization can vary based on the severity of the injury and the surgeon's protocol. It is common for patients to begin gentle range-of-motion exercises shortly after surgery, but the timeline can differ significantly from one case to another.

You mentioned that after three months of following your surgeon's advice, you felt stagnant in your recovery and sought rehabilitation independently. This decision is understandable, especially if you felt that your progress was insufficient. Rehabilitation is crucial after knee surgery, particularly for ACL injuries, as it helps restore strength, flexibility, and function to the knee. The fact that you have achieved a range of motion of 110-120 degrees is a positive sign, indicating that your knee is beginning to regain some functionality.

However, the concerns raised by the second orthopedic surgeon regarding the quality of your initial surgery are alarming. Discrepancies between medical opinions can occur, especially in complex cases like yours. The second surgeon's comments about the ACL not being properly fixed and potential issues with the cartilage suggest that further evaluation is necessary. An MRI is often recommended in such cases to assess the integrity of the ligaments, cartilage, and any other soft tissue structures that may have been affected during the accident or surgery.

Regarding your knee feeling unstable and weak, this could be attributed to several factors, including inadequate healing of the ACL, muscle weakness due to disuse, or even issues related to the tibial plateau fracture. It is essential to address these concerns with your rehabilitation team. They can tailor a program that focuses on strengthening the muscles around the knee, improving proprioception (the body’s ability to sense movement and position), and gradually increasing the load on the knee joint.

In terms of next steps, I recommend the following:
1. Follow Up with Imaging: If you haven't already, proceed with the MRI as suggested by the second orthopedic surgeon. This will provide a clearer picture of the current state of your knee.

2. Consult with a Sports Medicine Specialist: If possible, seek a second opinion from a sports medicine physician who specializes in knee injuries. They can provide insights into the best course of action based on the MRI results.

3. Continue Rehabilitation: Work closely with your physical therapist to develop a comprehensive rehabilitation plan. Focus on strengthening exercises, balance training, and functional movements to prepare for a return to normal activities.

4. Monitor Symptoms: Keep track of any changes in pain, swelling, or instability in your knee. Communicate these changes to your healthcare providers, as they may influence your treatment plan.

5. Consider Surgical Options: If the MRI reveals significant issues with the ACL or cartilage, you may need to discuss potential surgical interventions to correct these problems.

Recovery from knee injuries, especially after significant trauma like a car accident, can be a lengthy and challenging process. It is crucial to remain proactive in your treatment and advocate for your health. With the right approach and support, you can work towards regaining full function of your knee and returning to your daily activities.

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