25 Getting Back in the Game

Since he was seven, Duncan Elias has hadbut one dream: to be a professional footballer.

Countless times, he envisioned himselfscoring spectacular goals in front of adoringfans. Over and over, he has imagined himselfclutching a trophy and riding high on theshoulders of his cheering teammates.

Not once, however, did he picture himselfcarried off the field in pain, his dreamshattered by a torn ligament.

In May 2005, while playing a football matchas a member of the armed forces team,Duncan was injured. The 20-year-old hadjust executed a kick in midair in the NationalFootball League match when he was tackledand fell awkwardly.

That moment, his world crashed. RecalledDuncan, “As soon as I fell, I heard a poplike the sound you hear when you open achampagne bottle. I screamed in pain.I didn’t know what was happening.”

Carried off the field with a swollen knee,Duncan was told to go home and ice hisknee. He didn’t think much of the incident.

“After the game, I even went out with myfriends for dinner, though I was walkingwith a limp.” But later, he woke up at twoin the morning to find he could not lift hisleft leg. Using his mobile phone, Duncancalled his father and said, “I think we bettergo to the hospital.”

Duncan was referred to Dr Chang HawChong, a consultant orthopaedic surgeonat Changi Sports Medicine Centre, a unitwithin Changi General Hospital dedicatedto treating sports injury. Here, a MagneticResonance Imaging (MRI) scan was done.

Getting Back in the Game

Dr Chang Haw Chong,a Consultant Orthopaedic Surgeonat Changi Sports Medicine Centre

The diagnosis: Duncan had torn his anteriorcruciate ligament as well as his medialcollateral ligament.

“I have seen football injuries on the gameson TV and in real life, but I never imaginedit could happen to me,” confessed Duncan.

The tearing of the anterior cruciate ligamentis one of the most common sports injuries.Young people aged 15 to 25 who playbasketball, soccer and other sports thatrequire pivoting are especially vulnerableto this injury.

Ligaments are tough, non-stretchable fibresthat hold bones together. The anteriorcruciate ligament is a stabilising ligamentlocated in the centre of the knee joint andconnects the thighbone to the shinbone. Itlimits the side-to-side rotation of the lowerleg and prevents the lower leg from movingtoo far forward in relation to the knee.It also keeps the knee stable.

Once torn, the anterior cruciate ligamentunravels like a braid rope and does not healon its own. Typically, the anterior cruciateligament can be stretched beyond its limitand torn when one slows down suddenlyor pivots with the foot firmly planted, andby twisting or overextending the knee.

Landing awkwardly from a jump is also acommon cause of this injury. If the anteriorcruciate ligament is partially torn, the injurycan be rehabilitated. This was not the casefor Duncan.

The medial collateral ligament is anotherligament that sportsmen frequently rip(medial means on the side closer to themidline of the body). It connects the medialside of the thighbone to the medial side ofthe shinbone. Most medial collateralligament tears have the potential to heal.

Unfortunately for Duncan, his medialcollateral ligament injury was severe anddid not heal well despite knee bracing.Instead, he was given two grim choices:give up football or have both his ligamentsreconstructed.

Successful anterior cruciate ligamentreconstruction surgery tightens the kneeand restores its stability. It prevents furtherinjury and allows the patient to get back toplaying sports.

After the surgery, however, the patientneeds physiotherapy to strengthen his thighand calf muscles in order to support thereconstructed knee as well as to graduallyreturn his knee to full f lexibility and stability.This means a spell of six to nine months’absence from sports.

“I have seenfootball injuries onthe games on TV

and in real life, but Inever imagined it

could happento me.”

Duncan getting the all clear from Dr Chang

27 Getting Back in the Game

Two months after the surgery, he was ableto play basketball. Seven months later,he was completely pain-free.

Commented Dr Chang, “Duncan’s resultswere very good. He now has a stable knee.Measured with a knee arthrometer, his leftknee is now as tight (or strong) as hisuninjured right knee. He was walking withcrutches within the first month after thesurgery. At the four-month mark, his kneewas functioning as normal.”

Said Duncan, “I am satisfied with the result;the knee is definitely stable. When I startplaying football again, I believe myperformance will be as good as before.

In fact, Dr Chang said the next time I geta knee injury, it would be my right kneerather than my left because my left is nowquite strong.”

He has since recommended the surgery toanother friend who suffered the same injury.

“I told him that this is the best place to betreated because the doctors and the nursesare very good and the facilities here aretop-notch.”

Duncan added, “On hindsight, the operationwas the only option for me.”

“When I heard that I would not be able toplay sports for six to nine months, I gotlight-headed,” recalled Duncan.

“I was at a crucial stage in the developmentof my career. I have been playing in a teamsince I was seven and I have been turningout for Tampines Rovers (a local leagueteam) since I was 12. This is what I’ve alwayswanted to do. I was worried whether Iwould be able to carry on with football if Iwere away from the game for so long. Butmy mom talked to me and said I had to gofor the surgery since football is somethingI want to do my entire life.”

Once he had decided on the surgery, Duncanhad one more decision to make: to have theligament reconstructed using his own tissue(called an autograft), or using tissue takenfrom a cadaver (called an allograft).

While there is no difference between theperformance of an allograft and autograftin the knee over time, each has its prosand cons.

In the end, Duncan decided to opt forallograft. “Both my mom and I wereagainst an autograft because we didn’twant to touch a perfectly good leg,”explained Duncan.

Post-surgery, Duncan was on crutches forthree weeks and had a brace covering hisentire leg for a month and a half. But heput his heart into rehabilitation, undergoingthree rehabilitation sessions a week in orderto get back into the game.

Duncan’s rehabilitation was guided by ateam comprising a sports orthopaedicsurgeon, a sports physiotherapist and asports trainer who remained with himthroughout the entire rehabilitation period.

Duncan in arehabilitationsession

time. Incisions are also smaller — abouttwo times smaller than that for autograft.Another plus is that the graft can be madeto measure, to match the size of thepatient’s ligament.

Recovery from surgery is also usually easier,faster and less painful because the patientdoesn’t have to recover from the removalof his tendon for the graft.

There are, however, some downsides tousing allograft. Not only is allograft moreexpensive, there can be a risk of viraltransmission, including HIV and Hepatitis C.There have also been several reporteddeaths linked to bacterial infection fromallograft tissue, due to improperprocurement and sterilisation techniques.

However, Dr Chang pointed out that therisk of contracting HIV through an allograftis 1 in 1.67 million. Nevertheless, he addedthat orthopaedic surgeons who intend touse allografts on their patients must knowthe ins and outs of the tissue bank fromwhich they obtain their allograft. “Thesurgeon’s knowledge of the tissue bank’spractices in donor gifting and screening,serology testing and processing is importantwhen making the decision to use theseallograft tissues.”

In an autograft, the damaged anteriorcruciate ligament is replaced with strong,healthy tissue taken from another area nearthe patient’s knee. After harvesting the graft,the surgeon threads the graft through theinside of the knee joint and secures theends to the thighbone and shinbone.

Autograft offers a good track record ofsuccess of 92 percent worldwide and costsless than allograft because the graft comesfrom the patient’s own body. However,there are some drawbacks.

Autograft requires a bigger incision, so asto harvest the graft from the patient’s ownbody — usually a strip of tendon eitherfrom under the kneecap (patellar tendon)or the hamstring. This entails more pain aswell as a slower recovery. There is also arisk of impairment to the part from whichthe graft was borrowed.

An allograft is a graft taken from anotherhuman being, in this case, a cadaver. Theadvantages of using allograft tissue includeless pain — because the graft is not takenfrom the patient — and quicker surgery

Autograft Versus Allograft