Johns Hopkins Orthopaedic Surgery
May 18, 2015

Although some surgeons may prefer to master one proven approach to repairing ACL damage, Andrew Cosgarea has found that an individualized approach works best for his diverse patient population.

As the director of sports medicine and head team physician for The Johns Hopkins University’s athletics department, Cosgarea provides care not only for athletes, but for patients of various ages and activity levels. His patients may be seventh graders or septuagenarians, professional athletes or weekend warriors.

Once he knows how active a patient wants to be, Cosgarea tailors the operation and graft for that patient’s reconstruction. “Surgical treatment for an ACL tear used to be based on age,” says Cosgarea. “Today, it should be about activity level.”

For example, if patients want to be able to walk and perform activities of daily living only, surgery may not be necessary. Depending on how these patients tolerate the tear, nonsurgical approaches like a brace or physical therapy may be the best option.

“Not everyone needs a reconstruction,” he says. “Many people function well even with a torn ACL. The ones that need surgery are those who can’t function at their desired activity level.” 

For patients who want to play a sport like tennis, basketball or lacrosse — activities that include cutting and pivoting, changing direction quickly, and accelerating or decelerating — Cosgarea would likely choose an autograft using the hamstring tendons or patella tendon. Allografts are usually reserved for patients with the lowest activity demands, or patients whose previous surgery fails and they require a revision reconstruction.

Depending on the graft used and the quality of bone present, Cosgarea generally chooses screws for fixation of the patella tendon; he uses buttons and similar devices for fixation of the hamstring and allografts.

Cosgarea, who was a team physician for the Baltimore Orioles from 2000 to 2010, also takes patients’ occupation into account when deciding on the right approach to ACL reconstruction. “In the case of athletes, actors or laborers, they need to be able to perform their job, which requires a large amount of physical activity.”

After surgery, patients are usually off of crutches within a week and doing physical therapy for two to three months. Like surgery, patients’ physical rehabilitation is tailored to their specific activities and when they need to return to them. Cosgarea says the vast majority of his patients are back to their desired sport or occupation within seven to nine months.