LI doc: Knee stability is key to Terrell Thomas
Based on what we know about Terrell Thomas' knee injury so far, one local and prominent orthopedist has some good news . . . and some bad news.
The bad news, according to Dr. Craig Levitz, chair of Orthopedics at South Nassau Communities Hospital in Oceanside, is that a partial tear in a patient who has had an allograft reconstruction - as Thomas did in September - usually requires another reconstruction surgery.
"It has been my experience that when MRIs come back with a partial tear of an allograft, often it is unstable and requires reconstruction," said Levitz, who has not examined Thomas nor reviewed his case beyond what is publicly known. "I always worry when I see that diagnosis after an allograft as opposed to after a native patella tendon [was used in the graft]. It's always dicey with these allografts. That's why we don't love them."
An allograft is the use of a tendon harvested from one person for use in another person. Surgeons generally prefer to harvest the patella tendon from the patient's own knee for a primary reconstruction. Since September's surgery was Thomas' second, though, that tendon had already been harvested.
Thomas appeared to suffer this most recent ACL injury when he slipped in coverage during one-on-one drills in Sunday's practice. While he rose gingerly from the spill, he remained on the field for several more drills before coming off to ice it. Thomas told head coach Tom Coughlin he was fine after that practice and was only sent for the MRI on Monday because he woke up with swelling.
Levitz said it is common for patients whose knee has already been reconstructed to not recognize the severity of the injury when it happens. Remember Domenik Hixon last year, who injured his reconstructed knee in Week 2 of the season and wasn't concerned about it until the following morning's MRI revealed a partial tear that required another surgery.
"Allografts, they tear differently," Levitz said. "Your normal ACL, you hear it many times, these guys run and they hear a pop. The native ACL just blows up. When you replace it with an allograft, what happens a lot is you don't necessarily get that same pop . . . It kind of stretches and elongates and frays. If it's a partial tear in an allograft, the question is how stable is it? How much did it elongate? If it elongated to the point where it doesn't give him much stability, it doesn't matter that it's only a partial tear. If it's unstable, the treatment is exactly the same as a full tear. On the other hand if it's just an MRI finding but on examination it's stable, then it's just like he didn't injure his knee. He'll be fine. It depends on the examination of his knee."
A source said on Monday that Thomas' MRI did reveal a partial tear. The Giants said Thomas is considering arthroscopic surgery to determine the extent of the damage. Levitz said that while a scope can give doctors a visual look at the ligament, the greater benefit is a physical examination of the knee while the patient is under anesthesia.
"After someone gets hurt and they're awake, they're scared and they kind of tighten up their knee and [the tests for stability] are very hard things to determine just with your hands," Levitz said. "When you're asleep, you can get a perfect exam. In my experience, and the experience of Jim Andrews who I trained with, the examination under anesthesia is more important than what you see through scope because now the patient is relaxed and you can really test the ACL."
That good news that was mentioned? While there is no record of anyone returning to the NFL after a third ACL reconstruction, Levitz said there is no physiological reason someone could not. The rate of failure goes from less than 1 in 100 after the first ACL reconstruction to close to 1 in 10 after a second (what is called "revision ACL surgery). But that rate remains there for all subsequent surgeries.
"There's no difference between the failure rate for one revision surgery versus four revision surgeries, other than the mental ability to go through the rehab," Levitz said. "Once the ACL is fixed and you go through the revision surgery and it heals and there's no permanent damage to the knee, you're just as good as you were after the first revision. Theoretically if Terrell Thomas has this fixed, he should be just as good as he was a year ago. The problem is it's part mental; the rehab is intense and it's one thing to commit to that the first time around and another to commit to it the second time around."