September 19, 2023 • 57 mins
Are your hamstrings the unsung heroes of knee stability? Discover how this overlooked muscle group plays a crucial role in maintaining the health of your ACL with our guest, Dr. Jeffrey Pope, a renowned orthopaedic surgeon from Kayal Orthopaedic Center. His expert insights on the anatomy of the ACL and its interplay with the hamstrings are revelations that you won't want to miss.
Injuries can throw life off balance, especially those as common and challenging as an ACL tear. This episode is your guide to understanding the epidemiology, signs, and symptoms of ACL tears, as well as the assessment methods used to diagnose them. But the knowledge-sharing doesn't stop there. Dr. Pope also weighs the pros and cons of nonoperative care and reveals the circumstances when an ACL reconstruction or repair becomes necessary. If you've ever wondered about the importance of physical therapy or the criteria to be met before surgery, this episode is for you.
Buckle up for a deep dive into the exciting world of ACL surgery advancements. From autograft and allograft therapies to arthroscopic techniques, we explore it all. Listen in as Dr. Pope deciphers these complex medical terms and procedures, discussing the indications, benefits, and potential risks involved. With a focus on the post-operative biological process, he emphasizes the necessity of a minimum nine-month wait before returning to sports activities. Wrapping up, Dr. Pope shares invaluable advice on managing ACL tears and offers a message of hope for recovery, reminding us that patience, perseverance, and the right care can conquer even the toughest challenges.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Robert A. Kayal, MD, FAAO (00:00):
Hello and welcome to another edition
of the Kale Ortho podcast.
Today is September 19th 2023,and today's special guest is our
very own Dr Jeffrey Pope.
Dr Pope is a fellowship trainedboard certified orthopedic
surgeon at the Kale OrthopedicCenter and we're so privileged
and pleased to have him with ustoday.
Welcome to the podcast.
(00:20):
I greatly appreciate, dr Kale.
Before we get started, dr Pope,why don't you just take a
couple minutes and tell ourviewing and listening audiencea
little bit about yourself?
Jeffrey Pope, MD, FAAOS (00:29):
Well, my name is Jeff Pope.
I am from Wycoff originally.
I graduated from Rampo HighSchool.
My mother taught in theelementary schools and middle
school in Wycoff.
I've been through the area andafter leaving Wycoff I wanted to
make sure that this is theplace that I came back to.
(00:49):
I love Bergen County and it'sbeen a part of my upbringing and
a part of what changed me to bewho I am today.
After finishing in at Rampo HighSchool, I went to Penn State
for my undergraduate and at PennState I double majored.
One was in pre-medicine.
However, I really liked thepart of nutrition and nutrition
(01:09):
science, mainly biochemistry,and elected to double major and
finished my college career atPenn State.
After finishing at Penn State,I graduated with an excellent
background in nutrition scienceas well as pre-medicine, as
accepted to medical school atUniversity of Medicine and
Dentistry of New Jersey, what wenow call Rutgers Medical School
(01:31):
.
I graduated with high honorsfrom Rutgers Medical School and
then a platform orthopedicresidency and got into my first
choice, which is NYU School ofMedicine, as well as NYU
Hospital for Joint Diseases FromNYU, which gave me an excellent
background in orthopedics.
From my intern year through mychief year, I decided I wanted
(01:54):
to specialize in sports medicine.
I applied to University ofChicago and was accepted, and I
spent a year there treating thelocal athletes at the University
of Chicago as well as the folksin that area for their sports
related injuries.
Robert A. Kayal, MD, FAAOS (02:10):
Wow, those are some very impressive
credentials.
Dr Polpin, I'm so excited tohave you as part of this
practice for the past 15 years,delivering your excellence in
sports medicine and arthroscopyto our community of patients.
Thank you, dr Go.
Awesome, we have so much incommon.
We both grew up in BergenCounty, specifically in Wycoff,
new Jersey.
We both came back home topractice medicine and both
(02:34):
married amazing women, right?
So tell us a little bit aboutyour beautiful wife, piper, and
your beautiful two boys that youjust had a few years back.
Jeffrey Pope, MD, FAAOS (02:42):
My wife Piper and I were married in
2012.
We met in Chicago during myfellowship as at the University
of Chicago and my wife wasworked in the operating room for
a surgical device company.
We met there and I was luckyenough to give it to her to come
back to New Jersey from Chicagoand she grew up in Southern
California.
So that was a tough pull backto this post, but we made a work
(03:08):
and shortly thereafter we wereblessed with two boys who will
be turning five in the nextmonth, harlan and Lachlan.
Twin boys, and they're just thethe most incredible part of my
life.
Robert A. Kayal, MD, FA (03:18):
Awesome .
It's so nice to hear Jeff, andwe're just so happy to have both
you and Piper and your two boysback in Bergen County as well.
You've been such a blessing tothis practice and to so many
patients over the last 15 yearsthat Dr Pope's been with us at
the K L Orthopedic Center.
Dr Pope serves as the chief ofsports medicine and orthroscopy
at the K L Orthopedic Center,and today's topic that he's
(03:40):
going to help present to ustoday is a very common problem
called the anterior cruciateligament tear or the ACL tear.
So let's just jump right in and, for the benefit of our viewing
and listening audience, dr Pope, let's just first explain a
little bit about the anatomy ofthe ACL.
What is the anterior cruciateligament?
Jeffrey Pope, MD, FAAOS (04:00):
Well, the anterior cruciate ligament,
and maybe take a step back.
What is a ligament in general?
A ligament is a structure thatconnects one bone to another.
There's no muscle involved,it's static, it doesn't contract
, it doesn't expand and it'ssomething that keeps the knee
stable, particular the ACL, andit keeps the bottom part of the
knee, what we call the, thetibia, from shifting or
(04:22):
subloxing in a position that itshould not, mainly to the front.
Robert A. Kayal, MD, FAAO (04:26):
Right , so the the ligament, like you
said, is a static stabilizer.
So a joint is held togetheressentially by a combination of
both static and dynamicstabilizers, right?
So static stabilizers would bethe construct of the bone itself
, maybe the ligament tostructures that connect the
bones to the other bones.
But there's also dynamicstabilizers that help stabilize
(04:49):
the joint as well, and those aretypically the muscles that
surround the joint.
So, for instance, we can dophysical therapy to help
stabilize a joint, but ligamentto structures are static and we
have no control over thosestructures.
So if they fail or tear, thoseoften have to be surgically
managed.
Jeffrey Pope, MD, FAAOS (05:07):
So, as far as for the ACL, one of the
best friends of the ACL, theirhamstrings.
The hamstrings are the musclesin the back of the thigh and
what they serve to do is tobring your hip backwards and
flex your knee, and in doing so,it helps to keep the lower part
of the knee stable and helps toback up your ACL from keeping
the the bottom part of the kneefrom slipping forward.
Robert A. Kayal, MD, FA (05:30):
Exactly , we like to say that the
hamstrings back up the ACL right.
So if you're doing, if you'reconcerned about a compromised
anterior cruciate ligament, alot of times what we'll do is
we'll focus on strengthening thehamstrings in order, in effort,
to back up the weakenedanterior cruciate ligament.
The hamstrings originate offthe the pelvis, in the back of
(05:50):
the pelvis, and insert on thefront of the shin.
So if those muscles are strong,they serve to back up the
anterior cruciate ligament,preventing that shin bone from
what we call subluxinganteriorly over the thigh bone,
the femur right Absolutely.
So maybe we'll demonstrate thatfor the benefit of our viewing
audience at least, with theusage of a model.
(06:11):
Okay, sounds great.
Jeffrey Pope, MD, FAAOS (06:12):
This is a model depicting the patient's
right knee.
This is the top part, the thighbone where it ends into the
knee.
This is the shin bone where itstarts in the knee then goes
down towards the ankle.
Today's talk is about our ACL,which is this ligament in the
front here which goes from theshin bone up to the thigh bone
and connects and gives that arigid connection, keeping it
(06:33):
from shifting and translating ina way that it should not.
This model is really focusingjust on the ACL, doesn't show
our other soft tissue, such asmuscles, tendons, ligaments on
the side as well.
So just a disclaimer about that.
But today's talk is again aboutour ACL.
There's two different portionsof the ACL, two different what
we call bundles.
(06:53):
There's an intermedial bundle,which is the main one that we
focus with keeping the bottompart of the knee from shifting
or subluxing towards the front.
That's the intermedial bundle.
That's what you see mainlydepicted in an ACL.
It goes from the inside part ofthe notch on the outside
towards the shin bone andinserts in the front.
That is the main part of whatwe typically treat and
(07:17):
reconstruct.
The posterior lateral bundle,which is behind the intermedial
bundle, is a really importantportion of the ACL in regards to
rotational stability.
With pivoting and twisting onthe knee, it provides rotational
stability so that way itdoesn't sublux or shift in a way
that is going to cause damageto the knee itself.
One important part of the ACL,even though it is not a
(07:39):
stability portion, is a sensoryorgan.
Our ligaments inside our kneeshave multiple portions of it
that provide feedback to us andtell us where our joint is in
space, so that way we can closeour eyes and know where our
finger is or how to jump withoutlooking at where our feet are
going to land on the ground.
In medicine, we call thatproprioception, and it's
(08:00):
something that is a vital partof being an athlete and knowing
where your feet are, where yourhands are in space, without
having to actually see them.
Robert A. Kayal, MD, (08:09):
Absolutely .
Thank you so much forelaborating on that, dr Pope.
How often do you see patientswith ACL tears in your office on
a regular basis?
Jeffrey Pope, MD, FAAOS (08:18):
ACL injuries are an exceedingly
common complaint and diagnosisthat we see in the office.
Acl is the most commonlyinjured ligament in the knee and
something that is a part ofeveryday office work.
Acl injuries typically occur inpatients that are younger,
sports related and occur withactivities that require starting
(08:40):
, stopping, pivoting, shiftingand sudden acceleration or
deceleration events.
So typically these occur inathletes.
However, can occur in patientsthat are skiing, which is a
little bit of a lower energytype energy.
There's a very high rate ofinjury in female athletes,
specifically volleyball andbasketball players, for a number
(09:02):
of different reasons.
It can be due to a differencein the and the notch, which is
the area where the ACL has toreside, as far as for the room
for it, the size of the ACL.
Also different ways thatpatients land on their knees,
with how they contract theirmuscles, whether it's mostly
with the thigh muscles, in thefront, the quad muscles, or
whether they co-contract theirhamstrings as well.
Robert A. Kayal, MD, FAAOS (09:25):
Yeah , I mean.
Given the fact that the ACLligament is so important and
vital to the stability of theknee, you can imagine that
anytime that knee is put in sometype of provocative position,
it can potentially rupture.
So we know that the ACL tearsare commonly associated with
planting pivoting, rotationalmaneuvers to the knee, awkward
(09:47):
movements of the knee, awkwardlanding techniques.
But a lot of it has to do withpatients anatomical, mechanical
alignment as well, correct?
Jeffrey Pope, MD, FA (09:56):
Absolutely different bone shapes and the
shin bone will predisposepatients to having a more
likelihood that they tear theACL when they twist or pivot on
it.
As well as different genders,that's something that is much
more common in women than men.
It happens four and a halftimes more commonly in women
than men, and also in differentperiods of different portions of
(10:21):
a woman's period.
It's more likely to not happenwith ligaments of slacksity.
Robert A. Kayal, MD, FAAOS (10:27):
And we also realized that patients
that have weakness in their notonly their lower extremity
muscles but their core as wellcontributes.
I know that patients that haveweakness in their, for instance,
their hip abductors and theirhamstrings and mechanical
alignment problems arepredisposed.
(10:47):
We know that patients that landimproperly are significantly at
increased risk of developingthese ACL tears.
So those are some of the thingsthat we focus on in
preventative care, which we'llget to in a little bit making
sure that we focus our attentionon strengthening the patient's
(11:09):
core and their hip abductors andlanding techniques, which we'll
discuss in a little bit, toprevent the likelihood of these
patients developing an ACL tear.
So, dr Pope, now that we'vediscussed the anatomy and the
prevalence and epidemiologyassociated with this injury, the
ACL tear, what is the patient'stypical chief complaint when
(11:32):
they present to the office aftersuffering an injury to the
anti-acreusial ligament?
Jeffrey Pope, MD, FAAOS (11:36):
Most, commonly, patients will complain
of swelling and decreasedability to put weight on that
leg, stiffness, the inability tobend the knee fully, difficult
weight bearing, sometimes evenmechanical symptoms like locking
or catching inside their kneeor the wanting to give way or
buckle on them Some of the mostcommon complaints when patients
(11:57):
come to the office.
Robert A. Kayal, MD, FAAOS (11:58):
So then, what is the classic
history of the present illness?
What is the classicpresentation of someone that had
just suffered an ACL?
Jeffrey Pope, MD, FAAOS (12:06):
tear Without it at.
The most common complaint ofpatients that they feel is a pop
inside their knee where theywill shift or buckle, and then
almost immediately after they'reunable to place weight on it,
they may have to get helped offthe field.
Afterwards it may feel better.
They'll usually have a lot ofswelling and difficulty bending
immediately after.
Robert A. Kayal, MD, FA (12:26):
Exactly A textbook presentation.
They hear a pop, they suffer aninjury.
They hear a pop, they collapseto the ground, their knee swells
up like a balloon and theycan't wait that right.
That's a classic textbookpresentation of an ACL tear and
often the history is telling aswell, because usually they'll
complain that they were struck.
It was contact sports struck onthe side of a knee.
(12:49):
The whole knee blew out.
Or it would be a rapiddeceleration maneuver or a
planting pivoting rotationalmaneuver.
All of this is commonlyassociated with that classic pop
that Dr Pope described and theknee swells immediately, blows
up like a balloon.
Patients can't walk on it andthat is the classic presentation
.
But I must be honest.
I know that's textbookpresentation but I must be
(13:10):
honest.
Over the years of treatingthese injuries, haven't you seen
some of these, especiallyyounger girls, where they come
in with not that classicpresentation, where they come in
with not even too much swellingand you examine them and their
ACL is blown?
Jeffrey Pope, MD, FAAOS (13:26):
That's absolutely correct, rob Never
surprised to see how strong someof our patients can be and not
necessarily feel that discomfortor pop that most patients will
complain of.
And when you look at their exam, you expect to see swelling.
You expect to see discomfortand ability to fully bend the
(13:48):
knee or even some lag in tryingto strain it out.
And they have really goodmotion.
The knee is not significantlyswollen.
However, their objectivetesting, which is when I look at
their knee and I test theligaments to see if they're
stable or not, it's very clearthat they have suffered an ACL
tear.
First we look at swellingwithin the knee.
I'll take a look and feel thepatient's joint.
(14:09):
If there's fluid in the joint,that's the first clue that
there's likely a disruption ofthe ACL.
If there's increased fluid inthe knee, then the next thing
that I look at is to see whatthe knee motion is, make sure
that there's no significanthyperextension of the knee, see
what their ability to flex theknee is and also check the
ligaments on the side of theknee to make sure that there's
(14:30):
no other injury.
When we look at the ACLspecifically, there are three
separate tests thattraditionally I look at.
The first is the anteriordrawer where I pin the knee up
about halfway, shift the kneeforward and see how much play
there is in the knee.
I always check the normal sidefirst and then I'll check the
injured side to see what isnormal for that patient.
(14:51):
We all have different abilitiesto bend our knee and to have
ligaments as laxity or tightness.
After looking at an anteriordrawer, I'll straighten out the
knee a little bit more and lookat a Lachman test.
A Lachman test is the singlemost sensitive test that we have
to tell us whether, on physicalexam, there is a tear at the
ACL.
This looks at the bottom partof the knee compared to the top
(15:13):
part and we see how far it canshift, pulling it forward and
testing the ACL.
Lastly, check it for anendpoint as well, absolutely See
whether it's firmer, seewhether it is soft and if it's
soft, another clue that there'spotentially a tear at the ACL.
Some patients are able to do apivot shift test relatively
early on.
Others can't.
(15:34):
That's another way to take alook at that second part of the
bundle, the postural out ofbundle, and tell us whether
there's rotational instabilityat the knee or not.
Robert A. Kayal, MD, FAAOS (15:43):
With respect to that swelling in
that knee.
Is there anything else you cando to assess that swelling, to
maybe lead you to believe thatmaybe there is in fact an
anterior cruciate ligament tear?
Jeffrey Pope, MD, FA (15:54):
Absolutely , rob.
When I look at the knee and ifI do see that there is swelling
with the knee, very commonlyI'll discuss with the patient
taking the fluid out of the kneeand that will help me determine
whether there is just regularjoint fluid in the knee or
whether it's blood.
And I know.
If there is blood inside theknee that we're taking out, it's
a 90% chance it's either an ACLtear or a knee-cap dislocation.
Robert A. Kayal, MD, FAAO (16:16):
Right , yeah, the ACL is very
vascularized, so that's one ofthe classic presentations where
they get that pop and then thatacute swelling.
Well, that acute swelling istypically what we call in
medicine a hemarthrosis, wherethe knee will fill with blood,
completely fill with blood veryquickly and cause pain and
stiffness and swelling obviously.
(16:37):
Now, typically a hemarthrosisor blood in the knee is often
caused from an ACL tear or anoccult fracture in the knee or
possibly a what's called aperipheral meniscus tear.
But typically when we get bloodin the knee, that increases our
index of suspicion for ananterior cruciate ligament tear.
So now that you've done yourphysical exam, you're pretty
(17:01):
sure that there is an ACL tear.
You've taken blood out of theknee, potentially.
What's next?
Jeffrey Pope, MD, FAAOS (17:07):
The next step, after taking a look
and removing the fluid from thepatient's knee or assessing
further, would be to get anX-ray.
Plain films in the office arehelpful to take a look at the
patient's overall alignment andto make sure there's no other
bony injuries.
Actually, to show us the bone,it doesn't show us the soft
tissue.
Robert A. Kayal, MD, FAAO (17:24):
Right and we're also looking because
there's blood in the knee thatwe want to make sure there's no
fracture.
You had mentioned the MPFL tearor the patella dislocation can
also cause blood in the knee.
So the X-rays help with theoverall evaluation of the bony
alignment of all the structuresof the knee joint itself.
So the X-ray is now a negative.
Nothing's abnormal on the X-ray.
(17:45):
What are you going to do toconfirm your diagnosis?
Jeffrey Pope, MD, FAAOS (17:49):
To confirm the diagnosis, we look
at the soft tissue using an MRI.
An MRI helps to tell us notjust about the bone, but also
the ligaments, the meniscus, thecartilage, the soft tissue
inside the knee fluid as well,and make sure that, whatever is
torn, we understand what and towhat degree, and also know what
is not torn and what is healthyRight.
Robert A. Kayal, MD, FAAOS (18:11):
When these injuries occur, they're
usually significant enough forceto disrupt the anterior
cruciate ligament, so theseinjuries are often associated
with other concomitant injuries,such as meniscus tears, other
ligamentous injuries, thingslike that In the acute ACL tear.
What is the most common injurythat's associated with that in
the knee?
Jeffrey Pope, MD, FAAOS (18:31):
So right when it happens when the
knee shifts and sublux, the mostcommon thing that's torn
besides the ACL is the lateralmeniscus.
The outside part of the kneehas a meniscus which helps to
transmit weight from the top tothe bottom part of the knee.
When the knee shifts in a waythat it shouldn't, it's very
likely that when the bones pinchand hit each other, they
(18:52):
disrupt the meniscus in the backof the knee as well.
Robert A. Kayal, MD, (18:54):
Absolutely so.
That's just another reason whywe like to get the ACL.
We're usually pretty sure,based on the history and the
physical exam alone, that theACL is torn.
The MRI just confirms thatdiagnosis.
But it also assesses for otherconcomitant injuries, such as
this lateral meniscus tear.
But often there's other fairlyclassic pathodontic findings on
(19:16):
an MRI that we appreciate.
What are such findings?
Jeffrey Pope, MD, FAAOS (19:19):
Dr Pope Sure.
Most commonly we'll see bonebruising and bone bruising on
the outside part of the knee,which is also where that lateral
meniscus frequently gets torn.
The reason that there's bonebruises is because of the knee
shifts in a way that itshouldn't and one bone hits the
other in a way that it normallydoesn't.
The bottom part of the outsideof your thigh bone will hit the
back part of that shin bone andbetween the two, once the bones
(19:41):
hit, they'll also pinch themeniscus during that injury.
That's right.
Robert A. Kayal, MD, FAAOS (19:46):
Very often these injuries are
associated with lateral sidedknee problems.
We mentioned the lateralmeniscus tear.
We mentioned the lateral bonebruising.
This is because it's arotational problem.
When this ACL is torn, therotational component of the
anterior cruciate ligament ispredominantly the posterior
lateral bundle that Dr Pope soeloquently alluded to earlier in
(20:08):
his presentation.
Dr Pope, now that you've gottenthe MRI and you've reviewed the
results with the patient, we'veconfirmed that the diagnosis is
consistent with an anteriorcruciate ligament tear.
What's next?
Jeffrey Pope, MD, FAAOS (20:20):
Next part is deciding on what is the
next appropriate course for thepatient.
Not every patient that has atorn ACL needs ACL either repair
or reconstruction.
There's different types ofpatients, obviously, and those
are the ones that we really haveto tease out.
Who's indicated for repair orreconstruction and who are our
copers that may do quite wellwith nonoperative treatment.
(20:44):
In general, at the beginning westart with nonoperative
treatment for everyone Before weget our MRI results.
We start with physical therapy.
We start with bracing.
We want to mobilize the knee.
The reason we want to mobilizethe knee is, with all the blood
that's in the knee and theswelling and the soft tissue
injury, there's going to be alot of scar tissue.
That scar tissue is somethingthat's going to inhibit the
(21:05):
patient's ability to move theknee.
Sometimes, just with an ACLtear, it can become what we call
a cyclops lesion.
It can fold down on itself andbecome a mechanical block to
motion.
Other times we'll haveligamentous end meniscus
injuries that will inhibitmotion, such as a bucket handle
tear of the meniscus, where itgets trapped in the joint, and
that's something that cannot bemobilized appropriately.
(21:27):
There will be different timepoints at which we look to
schedule a surgery if it issomething that is a surgical
candidate, versus treating thepatient with conservative
modalities physical therapy,icing, anti-inflammatories to
try to reduce the swelling atthe beginning.
Looking at these two differentgroups young patients that want
(21:47):
to be active and be involvedwith a lifestyle that involves
sports and rotational, cutting,pivoting types of activities
there's absolutely no role fornon-operative treatment for
those patients unless they'resomething a medical condition
they can't have surgery for.
For the older patients that haveosteoarthritis in their knee,
(22:09):
that's more likely the patientthat's going to be the co-oper,
the patient that will brace,will do the conservative
modalities anti-inflammatories,physical therapy, bracing try to
improve their motion, improvetheir strength, improve those
dynamic stabilizers that wetalked about earlier the
hamstrings and try to ensurethat their knee is as stable as
possible and they may not need areconstruction or repair to get
(22:33):
stability within their knee.
Because we age and patients aregetting more and more active at
an older age, we're seeing thependulum swing to a point where
we're treating patients notnecessarily based off of a
chronological age.
You're 55 and at that point youeither can or cannot have any
ACL reconstruction.
(22:53):
We're looking to see how oldwould you look on a tennis court
?
How old, did you look on abasketball court?
So we're not looking at yourdriver's license.
We're looking to see how activeyou are and what kind of
lifestyle you want to enjoy, andour indications have expanded
to treating patients that areolder, as long as we're not
seeing significant degenerativearthritis.
Robert A. Kayal, MD, FAAOS (23:15):
Yes.
So to summarize, Dr Pope, ifyou have an individual or
patient that's active,participating in a lot of
planting, pivoting, rotationalmaneuvers soccer, football,
volleyball, tennis, pickleball,racquetball those patients are
going to get surgery, providedthey don't have any significant
arthritis in their knee.
As they get older and developarthritis and live a more
(23:37):
sedentary lifestyle, one thatdoes not entail a lot of
planting, pivoting androtational maneuvers, often
those patients can be treatednonoperatively as what we call
copers.
So if you are participating inactivities that we call inline
exercises, where there's not alot of rotational movement
around the knee, then sometimeswe can strengthen those patients
(24:01):
in physical therapy and they'llhave enough stability, because
the ACL is not really utilizedthat much in those inline
exercises.
It's only really the planting,pivoting, rotational maneuvers
and sports and activities thatrequire a pivot or a rapid
deceleration or a suddensignificant change in movement
(24:26):
or trajectory of that knee joint.
That really relies heavily onthe anterior cruciate ligament.
But, like Dr Pope said,patients are living longer.
They're living longer healthy,active lifestyles.
More and more of them areparticipating in sports and
activities that really relyheavily on an intact anterior
cruciate ligament and because ofthat, most of us orthopedic
(24:50):
surgeons are really treatingthose patients more aggressively
to restore their quality oflife to the lifestyle that they
deserve.
Jeffrey Pope, MD, FAAOS (24:57):
We don't treat patients just based
off of what their intake formsays.
We treat patients a la carte,which is we listen to them.
We have a discussion of whattheir wants, their desires as
far as for the participatingsports, or maybe a desire to be
more sedentary, and that's adifferent discussion as well.
Robert A. Kayal, MD, (25:14):
Absolutely , and there are other reasons to
do an ACL reconstruction aswell or a repair.
And what happens to the load onthe posterior horn of the
medial meniscus, for instance,if the ACL is ruptured?
Are there other soft tissueinjuries that can occur down the
road, more in a chronicenvironment, if an ACL is left
(25:36):
untreated?
Absolutely.
Jeffrey Pope, MD, FAAOS (25:38):
Dr Kale .
The two things that are most ofconcern to me in an ACL
deficient knee areosteoarthritis, which is loss of
cartilage in the knee, and theother part is a tear of the
meniscus on the opposite side ofthe knee.
The inside part of the knee,the back part of the knee on the
inside, is another restraint totranslation or shifting of the
(25:58):
lower part of your leg.
If you involve cutting orpivoting your knee, if your ACL
and your hamstrings aren'tworking as well as what they can
to help prevent shifting ofyour knee, then the next thing
that happens is the knee willpinch the meniscus on the inside
of the knee, causing a medialmeniscus to tear, particularly
in the back of it, and that'smore of a secondary chronic
(26:20):
injury to happen in an ACLdivision knee.
Robert A. Kayal, MD, FAAO (26:23):
Right and I think that that's
important to mention.
And patients understand thatthe meniscus, like the ligament,
is a static stabilizer.
So if someone is going toproceed with nonoperative care
and decide to try to strengthenthe need to provide stability,
the stability would then becoming from the muscles that are
(26:44):
strengthened, specifically thehamstrings in particular.
But if, for whatever reason,that stability is not intact
enough to provide that knee withthe stability when stressed,
then there's going to be asignificantly increased load on
the backup to the ACL and thatwould be the posterior horn of
the meniscus.
So in the chronic situation,patients that end up proceeding
(27:09):
with nonoperative care for anACL tear very often develop
posterior horn medial meniscustears.
Dr Pope already mentioned thefact that in the acute scenario
patients, when suffering an ACLtear, often suffer a concomitant
lateral meniscus tear.
But in the chronic scenario, ifleft untreated, they often will
endure a posterior horn medialmeniscus tear.
(27:31):
So in effort to avoidsubsequent injury to other
structures, some of us wouldencourage the patient to undergo
an ACL reconstruction or repair.
Jeffrey Pope, MD, FA (27:42):
Absolutely , rob, and when we talk about
injuries, we talk about ingeneral, as surgeons, risks and
benefits of surgery.
But with looking at an ACL, youalso have to speak about the
risk and the benefits ofnonoperative care.
And again, one of those risksis an increased risk of
potentially getting arthritis inyour knee and secondary
meniscus tear, on the insidepart of your knee Exactly.
Robert A. Kayal, MD, FAAOS (28:04):
So, now that we've decided to place
these patients in physicaltherapy to rehab these knees,
whether or not they're going tohave surgery or not, what are we
focused on in physical?
Jeffrey Pope, MD, FAAOS (28:14):
therapy Early on.
We want to regain motion.
Motion is exceedingly importantto get the scar tissue out of
your knee and, as well, we wantto work on stabilizing or
strengthening, excuse me.
We want to work onstrengthening our dynamic
stabilizers, which are ourhamstring tendons and also our
quad tendon.
Our quad tendon is somethingthat well.
It doesn't necessarily help outour ACL.
(28:35):
It's something that we'll getinhibited by having that fluid
in the knee and the injuries.
We really want to make sureboth the front and the back of
the knee are as strong as theycan be.
Robert A. Kayal, MD, (28:44):
Absolutely , and if we're going to do
surgery it's incumbent upon usto wait until that knee sort of
looks like a normal knee right.
We have to restore range ofmotion fully.
We have to have good patellamobilization.
There should be little to noresidual swelling.
Really the patient should havelittle to no complaints in that
knee other than the instabilityfrom the deficient ACL correct.
Jeffrey Pope, MD, FA (29:06):
Absolutely , rob.
There are a few indications foracute ACL repair or
reconstruction.
One of those is if you have abucket handle meniscus tear that
is locked in the knee and itcannot be mobilized, and in
others, if there are otherconcomitant or other additional
ligamentous injuries thatprovide the knee with minimal
stability, there's a furtherrisk.
Robert A. Kayal, MD, (29:27):
Absolutely .
But I've seen in my own patientpopulation that sometimes
patients are frustrated.
Right, they have the ACL tear.
They want to get fixedimmediately and they don't
really understand sometimes whywe're waiting so long to do
their elective procedure.
We don't want to operate inthat milieu when there's
tremendous swelling because,like Dr Pope mentioned, there's
a tremendous amount of scartissue that can develop from
(29:50):
that hemarthrosis or blood inthe knee.
So it is really very, veryimportant that the patients
undergo typically about four tosix weeks of physical therapy
preoperatively to restore thatrange of motion, to get rid of
all the swelling, to make surethat the knee looks and acts
like a normal knee, except forthe instability.
Jeffrey Pope, MD, FA (30:09):
Absolutely .
It's important for the knee tobecome an area where it's going
to be conducive to surgery.
It's going to be appropriatefor surgery but also gives you
the time to develop thatdoctor-patial relationship and
make sure that you'recomfortable with the person
who's taking care of you.
Robert A. Kayal, MD, FAAO (30:24):
Right , that's a great point.
Okay, dr Pope.
So our patient just completedhis or her course of physical
therapy and is now coming backto see you in the office.
Let's assume that this patienthas opted to proceed with some
type of surgical repair orreconstruction of their torn
antiochrocea ligament.
(30:45):
What options are available?
Jeffrey Pope, MD, FAAOS (30:47):
for this patient.
Traditionally, when torn istorn, the ACL in general is not
amenable to repair.
It's something that you can'tstitch because of the fluid
inside the knee inhibiting theends of the ligament to heal
back to each other.
The fluid will break down thefibrin clot, which is
exceedingly important for thebiology and healing of one end
(31:08):
of the ligament back to theother.
So if the ligament itselfdoesn't have the ability to heal
for the most part,traditionally our teaching was
to reconstruct a ligament, andreconstruction means to remove
the ligament as you were bornwith and then to place another
ligament in its place.
There's a lot of differentoptions for how to do that.
(31:29):
It could be done with autograph, which means you take it from
yourself.
You can look at taking part ofthe hamstring tendons either one
or two tendons to remove themfrom the leg and then to there.
Therefore use them toreconstruct and to put in place
of the ACL.
That's something that is onevery valid way of reconstructing
(31:52):
the ACL.
Another way is to take the bonepatellar tendon bone, which is
part of the kneecap, theligament that goes from the
kneecap down to the point ofyour shin bone, and a piece of
bone at the end of that, thebone patellar tendon bone.
It's something that can be usedto reconstruct and has been for
many years the gold standard ofACL reconstruction.
(32:14):
It gives you very firmendpoints and allows for bone to
bone healing, which is thoughtto be advantageous, especially
in athletes.
One option to look outside oftaking the bone patellar tendon
bone more recently is takingyour quad tendon.
The quad tendon can be takenwith a piece of bone.
(32:34):
However, with more advancedarthroscopic techniques, you can
use just the soft tissueportion only of it.
This is a technique that ismore new.
With this advance inarthroscopic techniques, you can
instill the quad tendon withinthe knee anatomically in the
area where the ACL was, andsuspend it and allow it to heal
(32:58):
without having to take any ofthe bone from the kneecap and
therefore potentially decreasingkneecap pain and discomfort
throughout the recovery.
Robert A. Kayal, MD, FAAOS (33:08):
It sounds like in all these
examples that you just nicelylaid out for us, you're sort of
stealing from Peter to pay Paul.
You're taking certain bodyparts from the patient and
transferring them into otherareas to recreate this ACL.
Some of that is, and must be,associated with a significant
(33:30):
amount of morbidity to thepatient right.
Jeffrey Pope, MD, FAAOS (33:32):
You're taking more morbidity when you
take the patient's own softtissue.
For some patients, they wouldjust prefer not to have anyone
else's tissues on their body andthat's completely
understandable.
However, there is definitelymore morbidity, which means more
pain and discomfort with theprocedure, potentially a little
bit delay in them coming alongand decreasing their pain and
(33:55):
mobilizing afterwards aftersurgery.
Robert A. Kayal, MD, FAAOS (33:58):
Yeah , I think you know traditionally
the advantage of thisautographed therapy where we
steal from Peter to pay Paul,whether it be the bone patella
bone autographed or thehamstring autographed or now the
quadriceps tendon autographed.
The advantage would be that there-rupture rate traditionally
has been lower than withallograft therapy.
(34:20):
Allograft therapy is where wedon't steal from Peter to pay
Paul but rather use cadavergraft material to reconstruct
the anti-recruciate ligament inour patients.
It's certainly a less invasiveprocedure because we don't have
to harvest from a donor site andbring that tissue to a
(34:40):
recipient site.
So it's definitely lessinvasive with probably a less
painful post-opera of course andfaster recovery.
But the downside potentially isthat there is potential very
small risks of allograft donormorbidity but also potentially
an increased re-rupture rate.
So typically in very youngpatients, very athletic young
(35:05):
individuals, will often proceedwith autographed therapy as
opposed to allograft therapy orpossibly repair what Dr Rapov is
about to talk to us about.
But I think it's important tonote that patients understand
that they have choices whenundergoing ACL reconstruction.
There are different graft sitesand both of us are very
(35:28):
familiar and very comfortableproceeding with any type of
these surgical options.
But we often like to haveconversations with our patients
to discuss the risks andbenefits of each type of
procedure and make our decisionstogether with our patients,
don't you agree?
Jeffrey Pope, MD, FA (35:44):
Absolutely , rob.
The patient has to be involved,and without that you're not
going to get the outcome thatyou want.
So you want to make surethey're comfortable and you're
comfortable.
Robert A. Kayal, MD, (35:52):
Absolutely so.
We spoke about autographedtherapy.
Cadaver Allograph therapy isadvantageous in a certain group
of patients as well.
Has there been anything recentthat has come to the area of
sports medicine and arthroscopy,as it pertains to ACL surgery,
that you would consider maybe agame?
Jeffrey Pope, MD, FAAOS (36:13):
changer Absolutely.
Within the past five to sixyears, we've seen increasing
arthroscopic techniques wherewe're able to, for certain types
of ACL tears, instead of havingto reconstruct it, which means
to remove it, we're able tostitch it and fix it back to the
bone that it tore from.
So these advanced arthroscopictechniques are a repair as
(36:35):
opposed to a reconstruction.
Robert A. Kayal, MD, FAAOS (36:36):
Yeah , and you and I have done a
bunch of these, and they're justreally a fantastic new
advancement in the area of ACLsurgery in that we're
essentially restoring thepatient's anatomy.
We're not disrupting any of theintact fibers, but rather
repairing the fibers back to thebone.
By doing this, it's certainlymuch less invasive.
(36:59):
We're not stealing from Peterto pay Paul, we're not
harvesting from a donor site,but rather we're keeping the
intact torn anti-increaseligament and anatomically
repairing it back to the bonewhere it tore off of.
What are some of the advantagesof doing that, as opposed to
the ACL reconstruction that wediscussed?
Jeffrey Pope, MD, FAAOS (37:19):
One main advantage is to have the
patient have a more normalfeeling knee.
That means that they can knowwhere their knee is in space.
It feels like when it moves, itis theirs, it's not someone
else's.
With that there's also a mucheasier revision of repair as
opposed to having to revisesomething that was previously
(37:40):
reconstructed.
By revision I mean there'salways a chance in the future
that someone could rupture theirknee, their ligament, again If
they had a repair.
God forbid.
They had a devastating injury, afall, a contact sport, and we
see even more MMA and rotationaltwisting pivoting of these now
(38:01):
that we used to.
One does have another tear ofthat same ACL.
It makes the revision of it,meaning redoing the surgery,
much easier and transitioning toa reconstruction from repairing
it the first time.
As opposed to redoing areconstruction where you worry
about the bone tunnels, whereyou have to drill through
expanding and having to graftthem Potentially, you have to do
(38:23):
it in a stage procedure whereyou have to take out what's torn
, fill in the bone tunnels andallow them to heal.
That and then do a secondarynon-surgery thereafter.
That's a great point.
Robert A. Kayal, MD, FAA (38:33):
That's a great point.
Essentially, after the repairyou're dealing essentially with
virgin anatomy.
The bone stock is completelythere.
The real estate is there,whereas in the patient that had
a prior ACL reconstruction thatbony anatomy is already
compromised.
There's tunnels there.
We have voids in the bone To doa revision and drill other
tunnels.
Potentially it can be a problemthat, like Dr Pope mentioned,
(38:55):
might have to be addressed in astage manner where those bone
tunnels are first filled in withbone graft, let that bone
reconstitute and consolidate andthen take the patient back
three or four months later anddo an ACL reconstruction after
that bone stock has beenrestored.
That's tremendouslyadvantageous.
Jeffrey Pope, MD, FAAOS (39:12):
One other potential benefit of doing
an ACL repair versusreconstruction is it does have
in quite a few patients a littlebit of a quicker recovery
Because you're not making biggertunnels in the bone.
They're much smaller.
There's less bleed in the kneeafterwards.
The control over the thighmuscle is much quicker to
recover from.
Most patients get moving fasterquicker with doing a repair
(39:36):
than a reconstruction.
Robert A. Kayal, MD, FAAO (39:39):
Right .
What are the indications for anACL repair?
Can everyone have one?
Jeffrey Pope, MD, (39:44):
Traditionally , most indications were for an
ACL that was torn off one partof the bone or the other, either
the thigh bone or the shin bone, Mostly in adults.
If that was a case of a bone ifthat was a case, it'd be off of
the thigh bone.
However, there are somechildhood injuries where you can
actually pull a piece of thebone off of the shin bone and
(40:04):
then that can be repaired aswell.
But to talk about the mostcommon portion with adults, only
tears traditionally that wereright off the bone, where you
have the whole length of theligament, can be stitched up
using advanced arthroscopictechniques and then secured back
to the bone using differenttypes of anchors or stitches to
(40:28):
repair it.
Robert A. Kayal, MD, FAAOS (40:29):
And sometimes we can't even tell
right until we get in there.
Jeffrey Pope, MD, FAAOS (40:32):
It's a discussion you always have to
have with the patient.
You can't say for sure when yougo in that you'll definitely be
able to repair it.
It's something that isevaluated at the time and you
always have to have thediscussion that, if it cannot be
repaired, the next step wouldbe to reconstruct it at that
point?
Robert A. Kayal, MD, FAAOS (40:47):
Yeah , so both of us will tend to go
into surgery talking to thepatients that we're going to
work in earnest to try to repairthe patient's native ACL back
to the bone.
But, for whatever reason, if wecan't do that, based on
evaluation of the torn ligament,we would be prepared to do the
ACL reconstruction at the sametime.
Correct, absolutely, yeah.
And what about partial tears?
(41:09):
Are partial tears of the ACLmaybe a good indication to
repair the one bundle that hasevolved off the bone?
Jeffrey Pope, MD, FAAOS (41:16):
Without a doubt, when there are partial
tears and if a patient that isinvolved in cutting or pivoting
or sudden stopping and jumping,that's absolutely a hard
indication in discussion withthe patient.
To repair a single bundle, it'ssomething that could be done
very easily, whether it's theintramedial bundle, the main one
that we look at with shiftingof the knee from front to back,
(41:39):
or the posterior lateral, whichis involved with the twisted and
pivoting.
Robert A. Kayal, MD, FAAOS (41:42):
Yeah , I'd like to just emphasize
that point because, like Dr Popementioned, each bundle has a
particular function.
So if you leave a patient witha compromised ACL, either the
anterior medial bundle is tornor the posterior lateral bundle
is torn.
Some form of stability will becompromised and we want this
patient to have a normal feelingknee, and so to do a repair of
(42:04):
a partial ACL is one of the mostbeautiful operations because
the other bundle is completelyintact.
So the likelihood that thatpartial tear is going to heal is
probably so much better becauseit's not really feeling the
stress or the load of a completeACL tear.
Correct, without a doubt?
Yeah, absolutely so, dr Pope.
(42:25):
In this era of orthobiologicaltherapies, or what we call
orthopedic regenerative medicine, has there been any
technological advancementsrecently that have maybe allowed
us to indicate more and morepatients for an ACL repair as
opposed to a reconstruction?
Jeffrey Pope, MD, FA (42:45):
Absolutely , rob.
Previously, as we werediscussing, repairs can only
happen when the ACL is torn offof one end of the bone or the
other.
Now, with more mid-substancetears tears within the ligament,
where it's not just off thebone we've expanded our
indications for repair using acertain type of orthopedic
(43:05):
biologic implant called a bareimplant, and what that allows us
to do is to stitch the ligamentand also to bridge that gap,
where the ligament is notsurrounded in joint fluid, where
it can't heal, and we stitch itto the, to the native ligament,
we allow it to be in a betterenvironment for healing and it's
something that can bridge thegap, which we weren't able to do
(43:28):
previously.
Robert A. Kayal, MD, FAAOS (43:29):
Yeah , specifically that's what the
bare implant stands for, right,the BEAR bridge-enhanced ACL
restoration.
So we're bridging that gapbetween the stump of the
anterior crucial ligament andthe bone to which it naturally
inserts right.
So we're bridging that gap andputting essentially a
(43:50):
orthobiological, regenerativemedicine, collagen-based implant
in that interface to preventthe synovial fluid and the
degradative enzymes from everapproaching that fibrin clot,
which typically would precludebiological healing.
So now you have this barrier,this bridged, enhanced allograft
(44:12):
that is allowing the fibrinclot to form and for that ACL to
heal back to the bone much moreefficiently and readily has
really revolutionized the waywe're indicating these patients
for ACL repair and it's reallyshifting that pendulum for many
of us to really try to restorepatients' normal anatomy.
(44:33):
That's where we're at in 2023.
We're really pushing theenvelope and trying to repair
things as opposed to replace orreconstruct things using
patients' own anatomy andbiology.
Jeffrey Pope, MD, FAAOS (44:45):
One thing that we know, rob, is that
the ACL wants to heal.
We see that there's cellmigration.
That happens after you tear inyour ACL.
We know that there are growthfactors in that area.
We just need to get the jointfluid out of the way and, by
using the bare implant, itallows us to take the ligament,
put it right into this collagenmatrix and then to allow it to
heal to the bone, and it'ssomething that happens over
(45:07):
eight weeks.
After eight weeks, the implantwill slowly resolve and at that
point you have this healing mesh, this healing matrix of cells
that are able to ultimately giveyou a native ACL back.
Robert A. Kayal, MD, FAAOS (45:21):
Yeah , it's beautifully put.
I think the vendors havetremendously assisted us in this
by offering these technologiesNot only the vendors providing
the bare implant, but othervendors that are providing us
with better instruments andsuture anchors, for instance, to
fixate this graft back to thebone.
Technology has improvedsignificantly in that regard
(45:43):
Without a doubt.
Jeffrey Pope, MD, FAAOS (45:44):
It's taken a bigger procedure in
making a more streamlined,making a more efficient, but
also something that is lessprominent to the patient and
less painful.
Robert A. Kayal, MD, FAAO (45:53):
Right .
What is this internal bracethat we use in the operating
room as well?
Jeffrey Pope, MD, FAAO (45:57):
Internal brace to me is a big part of
ACL repairs as well as the bareinternal bracing is able to give
you a very strong suture thatgoes from one part of the anchor
, the fixation that crosses thejoint, and then goes to the
other part, and is fixed as wellin the other end of the bone.
What it does is it allows theACL to heal without having the
(46:22):
stress on it that it wouldotherwise see and less
likelihood that it's going tore-tare.
Robert A. Kayal, MD, FAAOS (46:27):
It essentially parallels the ACL
repair right, it parallels theACL and it serves as literally
an internal brace.
It protects the repair byessentially serving the function
of the anterior cruciateligament, providing that
stability along the course ofthe anterior cruciate ligament
so that the repair can takeplace without excessive stress
(46:51):
on the repair.
It's really an internal braceor an internal splint to protect
the repair until we don'treally need it anymore.
Over time that internal braceor that internal splint will
weaken over time, but it reallyserves its function early on
while that ACL repair is takingplace and then we really don't
(47:13):
need it anymore.
It's almost like to extrapolateto fracture management surgery.
When we put a plate or screwson a broken bone, that plate or
splint is only used until thebones heal.
Once the bones heal we don'treally need the hardware anymore
.
We don't typically go in toremove the hardware, but we
don't really need the hardwareanymore To extrapolate from that
(47:36):
concept to the area of sportsmedicine and arthroscopy and
specifically ACL repair.
That's exactly what thisinternal splint is doing and
that also has revolutionized theway we're able to do these
repairs, because it's protectingthe repair, alleviating stress
on the repair and allowing thatbiological process, that fibrin
clot to form and for it toultimately heal back to bone.
(47:59):
It's not just us deciding okay,in 2023 we're going to do ACL
repairs again.
We've tried that in the pastand it hasn't really done so
well.
It's fraught with complications.
But now the pendulum isswinging back because of these
significant advancements thatwe're outlining today the
technologies from the vendors,the orthobiological therapies,
(48:22):
the collagen barrier implantthat's essentially a barrier to
that enzymatic degradation ofthat clot, and the implants that
are utilized now in theoperating room to secure
fixation and to augment fixationAll of this has led us to our
approach to the aggressivesurgical management of ACLs via
(48:46):
ACL repair.
I think Dr Polk and I feel verystrongly that if we had our
choice, we would do ACL repairon every patient that had an ACL
tear.
We often go into surgery withthat mindset that we want to
repair that ACL instead ofreconstruct that ACL, and less
prove an otherwise intraoperably.
Without a doubt, Now that wetalk about ACL repair and
(49:10):
postoper, of course, what'sactually happening when
something is being repaired?
Or if we use, for instance, agraph whether it's an allograph
or an autograph what's happeningto that new ACL or that
repaired ACL over the next year.
Jeffrey Pope, MD, FAAOS (49:29):
As soon as the camera comes out of the
knee, we have a healing responsethat starts.
There are cells that migratefrom around the knee, from
within the ligament, from thebone that's there to work on
healing.
There are growth factors thatare laid out and you see a
revascularization of this area.
If it's a repair, you see theligament start to heal back to
(49:51):
the wall, to the bone.
If it is a bare implant, yousee this implant of collagen
start to become vascularized and, as well as it starts to shrink
and then the environment thatit's in is a biologic mesh of
healing you see it start torevascularize and then, after
(50:12):
revascularizes, it can getstronger.
When you have other soft tissuecells that come in and hold
down and put in a more thickenedtype of construct there.
In regards to a reconstruction,when you're talking about the
graft themselves or for the mostpart, either a cellular or, if
it's autographed, you don't havemuch blood vessels there, you
(50:36):
do see a vascularization.
You see blood vessels thatstart to permeate the soft
tissue and to give that softtissue life.
Robert A. Kayal, MD, FAAO (50:45):
Right , and that's a biological
process.
That doesn't happen overnight,right?
So a lot of times, you know,patients are like why is it
taking so long?
Well, we have nothing to dowith that.
That's a biological process andfor most orthopedic surgeons,
most orthopedic surgeons wouldnot allow their patients to get
back to any sports activitiesfor a minimum of nine months and
(51:08):
in my hands, I typicallyrecommend 12 months to protect
that repair or thatreconstruction so that it is
revascularized and the collagenfibers have been formed in that
graft or that repair is robustand strong and able to endure
the stress associated withsporting activities.
Jeffrey Pope, MD, FA (51:28):
Absolutely , rob.
On top of that, you also needto strengthen your dynamic
stabilizers.
While you're having yoursurgery and preoperatively,
hopefully, you're strengtheningyour hamstrings.
You need to make sure aftersurgery that you're
strengthening them as well.
You're gaining mobility in yourknee and, again, you're gaining
the trust in your knee.
If you go out and you just wantto play because it's been three
months, you're not going tohave that trust in the knee and
(51:50):
you're going to suffer, likelyanother injury.
Robert A. Kayal, MD, (51:52):
Definitely physical therapies.
Most of these patients are inphysical therapy for six months
to a year after this, andthere's a lot of studies and
literature that support thatthis biological process extends
well beyond one year, two, threeyears after surgery, and so
it's very, very important togive that ligament or that
repair ample time to heal,because you don't want to go
(52:12):
through this operation again andyou definitely want to rehab it
all along, like Dr Popementioned, and strengthen those
backup secondary stabilizers andthe dynamic stabilizers,
especially the hamstrings, tosupport that graft for the rest
of your life.
On the note of physical therapy,I know earlier on we mentioned
(52:33):
what we can do from aneuromuscular training
perspective to try to minimizethe risk of recurrent tear or
tear to the other knee, becausea lot of these cases are
actually bilateral.
If you tear one ACL, there's asignificant likelihood that
you're going to potentially tearthe other ACL, and so during
(52:54):
physical therapy and in sportspreventative medicine,
neuromuscular programs, we liketo focus specifically on body
mechanics, landing techniquesand making sure that the core
stabilizes, the abductors of thehip are stabilized and certain
mechanics are focused on andaddressed in physical therapy.
(53:17):
What are some of the things welike to do, dr?
Jeffrey Pope, MD, FAAOS (53:19):
Pope, most importantly, as we said
earlier, hamstring strengthening.
However, working with yourathletic trainer and your
physical therapist are going tobe critical to your healing and
your recovery.
Making sure that you can have ahamstring curl that is at least
75% to 90% of your other side,your normal side.
That's one goal that we look at.
(53:40):
Another is to be able to singlestance, hop on the surgical leg
for 20 times to make sure thatit's not going to buckle or give
way.
So there are a lot ofparameters that we look at.
As far as for thighcircumference, we'll take a tape
measure, put it around thatthigh and then compare with the
other side, with the normal side, and make sure that we're
within a centimeter of the otherside.
Robert A. Kayal, MD, FAAOS (54:02):
Yeah , and we also want to focus
aggressively on agility, rightBalance, coordination,
proprioception like Dr Popementioned in the past, knowing
where the limb is in space, alot of plyometrics in physical
therapy, box jumping and thingslike that.
We really want to focus on allof those things and specifically
when it pertains to jumping, wewant to make sure that when
(54:25):
patients jump and land they landproperly.
They land with their hipsflexed and their knees flexed
and their ankles flexed and wewant to make sure that the
shoulders and the hips and theknees and the ankles sort of all
line up.
I think that the mainpredisposing mechanical
malalignment is occurringprimarily at the knee.
I think when patients land witha knock knee deformity or a
(54:48):
valgus deformity, thatsignificantly stresses the ACL
and leads it to rupture.
So we want to make sure thatpatients do not land with a
knock knee deformity.
We want to make sure that theirhips are abducted, separated a
little bit, as opposed to kneesin.
We don't want to internallyrotate the legs.
We want to make sure that whenwe land that the knees are over
(55:13):
the ankles and the toes.
We don't want to land with theknee extended in any way.
So essentially, hips out, kneesout, feet out.
You don't want to have anyinternal rotation or a valgus
malalignment upon landing, andthat is critical to avoiding
these.
And these are things that we,as orthopedic surgeons, can
quarterback and prescribe tohelp any sports program prevent
(55:38):
ACL tears and, for the patientthat was unfortunate enough to
suffer one, maybe prevent it onthe other side.
Are these some of the thingsthat you employ in your practice
, dr Pope?
Jeffrey Pope, MD, FAAOS (55:47):
Even some things as small as
orthotics.
If you have someone that has aflat foot deformity, you have a
valgus knee, a knock kneedeformity something like
orthotics can help keep theirankle appropriately aligned.
And if their ankles are wellaligned, then hope their knee
will be, and so on and so forthgoes up the chain.
You want to make sure that yourknees are facing forward, as Dr
Kaila said, not inwards.
You want forward or out, sothat way you land in the
(56:10):
appropriate way, with lessstress on your ACL.
Robert A. Kayal, MD, FA (56:13):
Awesome , so this has been a
tremendously enlighteningexperience.
Dr Pope, I'm so glad we finallygot together to talk about this
injury ACL tears such a commoninjury and I'm just so happy
that you took the time toexplain to our patients how we
manage these.
It was a very thoroughconversation and hopefully very
informative and enlightening toour patients.
(56:34):
We hope that you found ithelpful.
Jeffrey Pope, MD, FAAOS (56:37):
It's a pleasure and honor to have you
here today, Dr Pope.
Thank you so much, Dr Pope.
Robert A. Kayal, MD, FAAOS (56:41):
It's been an amazing 15 years and
we're just so blessed to haveyou.
So thank you for your timetoday.
I'm so thankful to be here.
Hello and welcome to another edition
of the Kale Ortho podcast.
Today is September 19th 2023,and today's special guest is our
very own Dr Jeffrey Pope.
Dr Pope is a fellowship trainedboard certified orthopedic
surgeon at the Kale OrthopedicCenter and we're so privileged
and pleased to have him with ustoday.
Welcome to the podcast.
(00:20):
I greatly appreciate, dr Kale.
Before we get started, dr Pope,why don't you just take a
couple minutes and tell ourviewing and listening audiencea
little bit about yourself?
Jeffrey Pope, MD, FAAOS (00:29):
Well, my name is Jeff Pope.
I am from Wycoff originally.
I graduated from Rampo HighSchool.
My mother taught in theelementary schools and middle
school in Wycoff.
I've been through the area andafter leaving Wycoff I wanted to
make sure that this is theplace that I came back to.
(00:49):
I love Bergen County and it'sbeen a part of my upbringing and
a part of what changed me to bewho I am today.
After finishing in at Rampo HighSchool, I went to Penn State
for my undergraduate and at PennState I double majored.
One was in pre-medicine.
However, I really liked thepart of nutrition and nutrition
(01:09):
science, mainly biochemistry,and elected to double major and
finished my college career atPenn State.
After finishing at Penn State,I graduated with an excellent
background in nutrition scienceas well as pre-medicine, as
accepted to medical school atUniversity of Medicine and
Dentistry of New Jersey, what wenow call Rutgers Medical School
(01:31):
.
I graduated with high honorsfrom Rutgers Medical School and
then a platform orthopedicresidency and got into my first
choice, which is NYU School ofMedicine, as well as NYU
Hospital for Joint Diseases FromNYU, which gave me an excellent
background in orthopedics.
From my intern year through mychief year, I decided I wanted
(01:54):
to specialize in sports medicine.
I applied to University ofChicago and was accepted, and I
spent a year there treating thelocal athletes at the University
of Chicago as well as the folksin that area for their sports
related injuries.
Robert A. Kayal, MD, FAAOS (02:10):
Wow, those are some very impressive
credentials.
Dr Polpin, I'm so excited tohave you as part of this
practice for the past 15 years,delivering your excellence in
sports medicine and arthroscopyto our community of patients.
Thank you, dr Go.
Awesome, we have so much incommon.
We both grew up in BergenCounty, specifically in Wycoff,
new Jersey.
We both came back home topractice medicine and both
(02:34):
married amazing women, right?
So tell us a little bit aboutyour beautiful wife, piper, and
your beautiful two boys that youjust had a few years back.
Jeffrey Pope, MD, FAAOS (02:42):
My wife Piper and I were married in
2012.
We met in Chicago during myfellowship as at the University
of Chicago and my wife wasworked in the operating room for
a surgical device company.
We met there and I was luckyenough to give it to her to come
back to New Jersey from Chicagoand she grew up in Southern
California.
So that was a tough pull backto this post, but we made a work
(03:08):
and shortly thereafter we wereblessed with two boys who will
be turning five in the nextmonth, harlan and Lachlan.
Twin boys, and they're just thethe most incredible part of my
life.
Robert A. Kayal, MD, FA (03:18):
Awesome .
It's so nice to hear Jeff, andwe're just so happy to have both
you and Piper and your two boysback in Bergen County as well.
You've been such a blessing tothis practice and to so many
patients over the last 15 yearsthat Dr Pope's been with us at
the K L Orthopedic Center.
Dr Pope serves as the chief ofsports medicine and orthroscopy
at the K L Orthopedic Center,and today's topic that he's
(03:40):
going to help present to ustoday is a very common problem
called the anterior cruciateligament tear or the ACL tear.
So let's just jump right in and, for the benefit of our viewing
and listening audience, dr Pope, let's just first explain a
little bit about the anatomy ofthe ACL.
What is the anterior cruciateligament?
Jeffrey Pope, MD, FAAOS (04:00):
Well, the anterior cruciate ligament,
and maybe take a step back.
What is a ligament in general?
A ligament is a structure thatconnects one bone to another.
There's no muscle involved,it's static, it doesn't contract
, it doesn't expand and it'ssomething that keeps the knee
stable, particular the ACL, andit keeps the bottom part of the
knee, what we call the, thetibia, from shifting or
(04:22):
subloxing in a position that itshould not, mainly to the front.
Robert A. Kayal, MD, FAAO (04:26):
Right , so the the ligament, like you
said, is a static stabilizer.
So a joint is held togetheressentially by a combination of
both static and dynamicstabilizers, right?
So static stabilizers would bethe construct of the bone itself
, maybe the ligament tostructures that connect the
bones to the other bones.
But there's also dynamicstabilizers that help stabilize
(04:49):
the joint as well, and those aretypically the muscles that
surround the joint.
So, for instance, we can dophysical therapy to help
stabilize a joint, but ligamentto structures are static and we
have no control over thosestructures.
So if they fail or tear, thoseoften have to be surgically
managed.
Jeffrey Pope, MD, FAAOS (05:07):
So, as far as for the ACL, one of the
best friends of the ACL, theirhamstrings.
The hamstrings are the musclesin the back of the thigh and
what they serve to do is tobring your hip backwards and
flex your knee, and in doing so,it helps to keep the lower part
of the knee stable and helps toback up your ACL from keeping
the the bottom part of the kneefrom slipping forward.
Robert A. Kayal, MD, FA (05:30):
Exactly , we like to say that the
hamstrings back up the ACL right.
So if you're doing, if you'reconcerned about a compromised
anterior cruciate ligament, alot of times what we'll do is
we'll focus on strengthening thehamstrings in order, in effort,
to back up the weakenedanterior cruciate ligament.
The hamstrings originate offthe the pelvis, in the back of
(05:50):
the pelvis, and insert on thefront of the shin.
So if those muscles are strong,they serve to back up the
anterior cruciate ligament,preventing that shin bone from
what we call subluxinganteriorly over the thigh bone,
the femur right Absolutely.
So maybe we'll demonstrate thatfor the benefit of our viewing
audience at least, with theusage of a model.
(06:11):
Okay, sounds great.
Jeffrey Pope, MD, FAAOS (06:12):
This is a model depicting the patient's
right knee.
This is the top part, the thighbone where it ends into the
knee.
This is the shin bone where itstarts in the knee then goes
down towards the ankle.
Today's talk is about our ACL,which is this ligament in the
front here which goes from theshin bone up to the thigh bone
and connects and gives that arigid connection, keeping it
(06:33):
from shifting and translating ina way that it should not.
This model is really focusingjust on the ACL, doesn't show
our other soft tissue, such asmuscles, tendons, ligaments on
the side as well.
So just a disclaimer about that.
But today's talk is again aboutour ACL.
There's two different portionsof the ACL, two different what
we call bundles.
(06:53):
There's an intermedial bundle,which is the main one that we
focus with keeping the bottompart of the knee from shifting
or subluxing towards the front.
That's the intermedial bundle.
That's what you see mainlydepicted in an ACL.
It goes from the inside part ofthe notch on the outside
towards the shin bone andinserts in the front.
That is the main part of whatwe typically treat and
(07:17):
reconstruct.
The posterior lateral bundle,which is behind the intermedial
bundle, is a really importantportion of the ACL in regards to
rotational stability.
With pivoting and twisting onthe knee, it provides rotational
stability so that way itdoesn't sublux or shift in a way
that is going to cause damageto the knee itself.
One important part of the ACL,even though it is not a
(07:39):
stability portion, is a sensoryorgan.
Our ligaments inside our kneeshave multiple portions of it
that provide feedback to us andtell us where our joint is in
space, so that way we can closeour eyes and know where our
finger is or how to jump withoutlooking at where our feet are
going to land on the ground.
In medicine, we call thatproprioception, and it's
(08:00):
something that is a vital partof being an athlete and knowing
where your feet are, where yourhands are in space, without
having to actually see them.
Robert A. Kayal, MD, (08:09):
Absolutely .
Thank you so much forelaborating on that, dr Pope.
How often do you see patientswith ACL tears in your office on
a regular basis?
Jeffrey Pope, MD, FAAOS (08:18):
ACL injuries are an exceedingly
common complaint and diagnosisthat we see in the office.
Acl is the most commonlyinjured ligament in the knee and
something that is a part ofeveryday office work.
Acl injuries typically occur inpatients that are younger,
sports related and occur withactivities that require starting
(08:40):
, stopping, pivoting, shiftingand sudden acceleration or
deceleration events.
So typically these occur inathletes.
However, can occur in patientsthat are skiing, which is a
little bit of a lower energytype energy.
There's a very high rate ofinjury in female athletes,
specifically volleyball andbasketball players, for a number
(09:02):
of different reasons.
It can be due to a differencein the and the notch, which is
the area where the ACL has toreside, as far as for the room
for it, the size of the ACL.
Also different ways thatpatients land on their knees,
with how they contract theirmuscles, whether it's mostly
with the thigh muscles, in thefront, the quad muscles, or
whether they co-contract theirhamstrings as well.
Robert A. Kayal, MD, FAAOS (09:25):
Yeah , I mean.
Given the fact that the ACLligament is so important and
vital to the stability of theknee, you can imagine that
anytime that knee is put in sometype of provocative position,
it can potentially rupture.
So we know that the ACL tearsare commonly associated with
planting pivoting, rotationalmaneuvers to the knee, awkward
(09:47):
movements of the knee, awkwardlanding techniques.
But a lot of it has to do withpatients anatomical, mechanical
alignment as well, correct?
Jeffrey Pope, MD, FA (09:56):
Absolutely different bone shapes and the
shin bone will predisposepatients to having a more
likelihood that they tear theACL when they twist or pivot on
it.
As well as different genders,that's something that is much
more common in women than men.
It happens four and a halftimes more commonly in women
than men, and also in differentperiods of different portions of
(10:21):
a woman's period.
It's more likely to not happenwith ligaments of slacksity.
Robert A. Kayal, MD, FAAOS (10:27):
And we also realized that patients
that have weakness in their notonly their lower extremity
muscles but their core as wellcontributes.
I know that patients that haveweakness in their, for instance,
their hip abductors and theirhamstrings and mechanical
alignment problems arepredisposed.
(10:47):
We know that patients that landimproperly are significantly at
increased risk of developingthese ACL tears.
So those are some of the thingsthat we focus on in
preventative care, which we'llget to in a little bit making
sure that we focus our attentionon strengthening the patient's
(11:09):
core and their hip abductors andlanding techniques, which we'll
discuss in a little bit, toprevent the likelihood of these
patients developing an ACL tear.
So, dr Pope, now that we'vediscussed the anatomy and the
prevalence and epidemiologyassociated with this injury, the
ACL tear, what is the patient'stypical chief complaint when
(11:32):
they present to the office aftersuffering an injury to the
anti-acreusial ligament?
Jeffrey Pope, MD, FAAOS (11:36):
Most, commonly, patients will complain
of swelling and decreasedability to put weight on that
leg, stiffness, the inability tobend the knee fully, difficult
weight bearing, sometimes evenmechanical symptoms like locking
or catching inside their kneeor the wanting to give way or
buckle on them Some of the mostcommon complaints when patients
(11:57):
come to the office.
Robert A. Kayal, MD, FAAOS (11:58):
So then, what is the classic
history of the present illness?
What is the classicpresentation of someone that had
just suffered an ACL?
Jeffrey Pope, MD, FAAOS (12:06):
tear Without it at.
The most common complaint ofpatients that they feel is a pop
inside their knee where theywill shift or buckle, and then
almost immediately after they'reunable to place weight on it,
they may have to get helped offthe field.
Afterwards it may feel better.
They'll usually have a lot ofswelling and difficulty bending
immediately after.
Robert A. Kayal, MD, FA (12:26):
Exactly A textbook presentation.
They hear a pop, they suffer aninjury.
They hear a pop, they collapseto the ground, their knee swells
up like a balloon and theycan't wait that right.
That's a classic textbookpresentation of an ACL tear and
often the history is telling aswell, because usually they'll
complain that they were struck.
It was contact sports struck onthe side of a knee.
(12:49):
The whole knee blew out.
Or it would be a rapiddeceleration maneuver or a
planting pivoting rotationalmaneuver.
All of this is commonlyassociated with that classic pop
that Dr Pope described and theknee swells immediately, blows
up like a balloon.
Patients can't walk on it andthat is the classic presentation
.
But I must be honest.
I know that's textbookpresentation but I must be
(13:10):
honest.
Over the years of treatingthese injuries, haven't you seen
some of these, especiallyyounger girls, where they come
in with not that classicpresentation, where they come in
with not even too much swellingand you examine them and their
ACL is blown?
Jeffrey Pope, MD, FAAOS (13:26):
That's absolutely correct, rob Never
surprised to see how strong someof our patients can be and not
necessarily feel that discomfortor pop that most patients will
complain of.
And when you look at their exam, you expect to see swelling.
You expect to see discomfortand ability to fully bend the
(13:48):
knee or even some lag in tryingto strain it out.
And they have really goodmotion.
The knee is not significantlyswollen.
However, their objectivetesting, which is when I look at
their knee and I test theligaments to see if they're
stable or not, it's very clearthat they have suffered an ACL
tear.
First we look at swellingwithin the knee.
I'll take a look and feel thepatient's joint.
(14:09):
If there's fluid in the joint,that's the first clue that
there's likely a disruption ofthe ACL.
If there's increased fluid inthe knee, then the next thing
that I look at is to see whatthe knee motion is, make sure
that there's no significanthyperextension of the knee, see
what their ability to flex theknee is and also check the
ligaments on the side of theknee to make sure that there's
(14:30):
no other injury.
When we look at the ACLspecifically, there are three
separate tests thattraditionally I look at.
The first is the anteriordrawer where I pin the knee up
about halfway, shift the kneeforward and see how much play
there is in the knee.
I always check the normal sidefirst and then I'll check the
injured side to see what isnormal for that patient.
(14:51):
We all have different abilitiesto bend our knee and to have
ligaments as laxity or tightness.
After looking at an anteriordrawer, I'll straighten out the
knee a little bit more and lookat a Lachman test.
A Lachman test is the singlemost sensitive test that we have
to tell us whether, on physicalexam, there is a tear at the
ACL.
This looks at the bottom partof the knee compared to the top
(15:13):
part and we see how far it canshift, pulling it forward and
testing the ACL.
Lastly, check it for anendpoint as well, absolutely See
whether it's firmer, seewhether it is soft and if it's
soft, another clue that there'spotentially a tear at the ACL.
Some patients are able to do apivot shift test relatively
early on.
Others can't.
(15:34):
That's another way to take alook at that second part of the
bundle, the postural out ofbundle, and tell us whether
there's rotational instabilityat the knee or not.
Robert A. Kayal, MD, FAAOS (15:43):
With respect to that swelling in
that knee.
Is there anything else you cando to assess that swelling, to
maybe lead you to believe thatmaybe there is in fact an
anterior cruciate ligament tear?
Jeffrey Pope, MD, FA (15:54):
Absolutely , rob.
When I look at the knee and ifI do see that there is swelling
with the knee, very commonlyI'll discuss with the patient
taking the fluid out of the kneeand that will help me determine
whether there is just regularjoint fluid in the knee or
whether it's blood.
And I know.
If there is blood inside theknee that we're taking out, it's
a 90% chance it's either an ACLtear or a knee-cap dislocation.
Robert A. Kayal, MD, FAAO (16:16):
Right , yeah, the ACL is very
vascularized, so that's one ofthe classic presentations where
they get that pop and then thatacute swelling.
Well, that acute swelling istypically what we call in
medicine a hemarthrosis, wherethe knee will fill with blood,
completely fill with blood veryquickly and cause pain and
stiffness and swelling obviously.
(16:37):
Now, typically a hemarthrosisor blood in the knee is often
caused from an ACL tear or anoccult fracture in the knee or
possibly a what's called aperipheral meniscus tear.
But typically when we get bloodin the knee, that increases our
index of suspicion for ananterior cruciate ligament tear.
So now that you've done yourphysical exam, you're pretty
(17:01):
sure that there is an ACL tear.
You've taken blood out of theknee, potentially.
What's next?
Jeffrey Pope, MD, FAAOS (17:07):
The next step, after taking a look
and removing the fluid from thepatient's knee or assessing
further, would be to get anX-ray.
Plain films in the office arehelpful to take a look at the
patient's overall alignment andto make sure there's no other
bony injuries.
Actually, to show us the bone,it doesn't show us the soft
tissue.
Robert A. Kayal, MD, FAAO (17:24):
Right and we're also looking because
there's blood in the knee thatwe want to make sure there's no
fracture.
You had mentioned the MPFL tearor the patella dislocation can
also cause blood in the knee.
So the X-rays help with theoverall evaluation of the bony
alignment of all the structuresof the knee joint itself.
So the X-ray is now a negative.
Nothing's abnormal on the X-ray.
(17:45):
What are you going to do toconfirm your diagnosis?
Jeffrey Pope, MD, FAAOS (17:49):
To confirm the diagnosis, we look
at the soft tissue using an MRI.
An MRI helps to tell us notjust about the bone, but also
the ligaments, the meniscus, thecartilage, the soft tissue
inside the knee fluid as well,and make sure that, whatever is
torn, we understand what and towhat degree, and also know what
is not torn and what is healthyRight.
Robert A. Kayal, MD, FAAOS (18:11):
When these injuries occur, they're
usually significant enough forceto disrupt the anterior
cruciate ligament, so theseinjuries are often associated
with other concomitant injuries,such as meniscus tears, other
ligamentous injuries, thingslike that In the acute ACL tear.
What is the most common injurythat's associated with that in
the knee?
Jeffrey Pope, MD, FAAOS (18:31):
So right when it happens when the
knee shifts and sublux, the mostcommon thing that's torn
besides the ACL is the lateralmeniscus.
The outside part of the kneehas a meniscus which helps to
transmit weight from the top tothe bottom part of the knee.
When the knee shifts in a waythat it shouldn't, it's very
likely that when the bones pinchand hit each other, they
(18:52):
disrupt the meniscus in the backof the knee as well.
Robert A. Kayal, MD, (18:54):
Absolutely so.
That's just another reason whywe like to get the ACL.
We're usually pretty sure,based on the history and the
physical exam alone, that theACL is torn.
The MRI just confirms thatdiagnosis.
But it also assesses for otherconcomitant injuries, such as
this lateral meniscus tear.
But often there's other fairlyclassic pathodontic findings on
(19:16):
an MRI that we appreciate.
What are such findings?
Jeffrey Pope, MD, FAAOS (19:19):
Dr Pope Sure.
Most commonly we'll see bonebruising and bone bruising on
the outside part of the knee,which is also where that lateral
meniscus frequently gets torn.
The reason that there's bonebruises is because of the knee
shifts in a way that itshouldn't and one bone hits the
other in a way that it normallydoesn't.
The bottom part of the outsideof your thigh bone will hit the
back part of that shin bone andbetween the two, once the bones
(19:41):
hit, they'll also pinch themeniscus during that injury.
That's right.
Robert A. Kayal, MD, FAAOS (19:46):
Very often these injuries are
associated with lateral sidedknee problems.
We mentioned the lateralmeniscus tear.
We mentioned the lateral bonebruising.
This is because it's arotational problem.
When this ACL is torn, therotational component of the
anterior cruciate ligament ispredominantly the posterior
lateral bundle that Dr Pope soeloquently alluded to earlier in
(20:08):
his presentation.
Dr Pope, now that you've gottenthe MRI and you've reviewed the
results with the patient, we'veconfirmed that the diagnosis is
consistent with an anteriorcruciate ligament tear.
What's next?
Jeffrey Pope, MD, FAAOS (20:20):
Next part is deciding on what is the
next appropriate course for thepatient.
Not every patient that has atorn ACL needs ACL either repair
or reconstruction.
There's different types ofpatients, obviously, and those
are the ones that we really haveto tease out.
Who's indicated for repair orreconstruction and who are our
copers that may do quite wellwith nonoperative treatment.
(20:44):
In general, at the beginning westart with nonoperative
treatment for everyone Before weget our MRI results.
We start with physical therapy.
We start with bracing.
We want to mobilize the knee.
The reason we want to mobilizethe knee is, with all the blood
that's in the knee and theswelling and the soft tissue
injury, there's going to be alot of scar tissue.
That scar tissue is somethingthat's going to inhibit the
(21:05):
patient's ability to move theknee.
Sometimes, just with an ACLtear, it can become what we call
a cyclops lesion.
It can fold down on itself andbecome a mechanical block to
motion.
Other times we'll haveligamentous end meniscus
injuries that will inhibitmotion, such as a bucket handle
tear of the meniscus, where itgets trapped in the joint, and
that's something that cannot bemobilized appropriately.
(21:27):
There will be different timepoints at which we look to
schedule a surgery if it issomething that is a surgical
candidate, versus treating thepatient with conservative
modalities physical therapy,icing, anti-inflammatories to
try to reduce the swelling atthe beginning.
Looking at these two differentgroups young patients that want
(21:47):
to be active and be involvedwith a lifestyle that involves
sports and rotational, cutting,pivoting types of activities
there's absolutely no role fornon-operative treatment for
those patients unless they'resomething a medical condition
they can't have surgery for.
For the older patients that haveosteoarthritis in their knee,
(22:09):
that's more likely the patientthat's going to be the co-oper,
the patient that will brace,will do the conservative
modalities anti-inflammatories,physical therapy, bracing try to
improve their motion, improvetheir strength, improve those
dynamic stabilizers that wetalked about earlier the
hamstrings and try to ensurethat their knee is as stable as
possible and they may not need areconstruction or repair to get
(22:33):
stability within their knee.
Because we age and patients aregetting more and more active at
an older age, we're seeing thependulum swing to a point where
we're treating patients notnecessarily based off of a
chronological age.
You're 55 and at that point youeither can or cannot have any
ACL reconstruction.
(22:53):
We're looking to see how oldwould you look on a tennis court
?
How old, did you look on abasketball court?
So we're not looking at yourdriver's license.
We're looking to see how activeyou are and what kind of
lifestyle you want to enjoy, andour indications have expanded
to treating patients that areolder, as long as we're not
seeing significant degenerativearthritis.
Robert A. Kayal, MD, FAAOS (23:15):
Yes.
So to summarize, Dr Pope, ifyou have an individual or
patient that's active,participating in a lot of
planting, pivoting, rotationalmaneuvers soccer, football,
volleyball, tennis, pickleball,racquetball those patients are
going to get surgery, providedthey don't have any significant
arthritis in their knee.
As they get older and developarthritis and live a more
(23:37):
sedentary lifestyle, one thatdoes not entail a lot of
planting, pivoting androtational maneuvers, often
those patients can be treatednonoperatively as what we call
copers.
So if you are participating inactivities that we call inline
exercises, where there's not alot of rotational movement
around the knee, then sometimeswe can strengthen those patients
(24:01):
in physical therapy and they'llhave enough stability, because
the ACL is not really utilizedthat much in those inline
exercises.
It's only really the planting,pivoting, rotational maneuvers
and sports and activities thatrequire a pivot or a rapid
deceleration or a suddensignificant change in movement
(24:26):
or trajectory of that knee joint.
That really relies heavily onthe anterior cruciate ligament.
But, like Dr Pope said,patients are living longer.
They're living longer healthy,active lifestyles.
More and more of them areparticipating in sports and
activities that really relyheavily on an intact anterior
cruciate ligament and because ofthat, most of us orthopedic
(24:50):
surgeons are really treatingthose patients more aggressively
to restore their quality oflife to the lifestyle that they
deserve.
Jeffrey Pope, MD, FAAOS (24:57):
We don't treat patients just based
off of what their intake formsays.
We treat patients a la carte,which is we listen to them.
We have a discussion of whattheir wants, their desires as
far as for the participatingsports, or maybe a desire to be
more sedentary, and that's adifferent discussion as well.
Robert A. Kayal, MD, (25:14):
Absolutely , and there are other reasons to
do an ACL reconstruction aswell or a repair.
And what happens to the load onthe posterior horn of the
medial meniscus, for instance,if the ACL is ruptured?
Are there other soft tissueinjuries that can occur down the
road, more in a chronicenvironment, if an ACL is left
(25:36):
untreated?
Absolutely.
Jeffrey Pope, MD, FAAOS (25:38):
Dr Kale .
The two things that are most ofconcern to me in an ACL
deficient knee areosteoarthritis, which is loss of
cartilage in the knee, and theother part is a tear of the
meniscus on the opposite side ofthe knee.
The inside part of the knee,the back part of the knee on the
inside, is another restraint totranslation or shifting of the
(25:58):
lower part of your leg.
If you involve cutting orpivoting your knee, if your ACL
and your hamstrings aren'tworking as well as what they can
to help prevent shifting ofyour knee, then the next thing
that happens is the knee willpinch the meniscus on the inside
of the knee, causing a medialmeniscus to tear, particularly
in the back of it, and that'smore of a secondary chronic
(26:20):
injury to happen in an ACLdivision knee.
Robert A. Kayal, MD, FAAO (26:23):
Right and I think that that's
important to mention.
And patients understand thatthe meniscus, like the ligament,
is a static stabilizer.
So if someone is going toproceed with nonoperative care
and decide to try to strengthenthe need to provide stability,
the stability would then becoming from the muscles that are
(26:44):
strengthened, specifically thehamstrings in particular.
But if, for whatever reason,that stability is not intact
enough to provide that knee withthe stability when stressed,
then there's going to be asignificantly increased load on
the backup to the ACL and thatwould be the posterior horn of
the meniscus.
So in the chronic situation,patients that end up proceeding
(27:09):
with nonoperative care for anACL tear very often develop
posterior horn medial meniscustears.
Dr Pope already mentioned thefact that in the acute scenario
patients, when suffering an ACLtear, often suffer a concomitant
lateral meniscus tear.
But in the chronic scenario, ifleft untreated, they often will
endure a posterior horn medialmeniscus tear.
(27:31):
So in effort to avoidsubsequent injury to other
structures, some of us wouldencourage the patient to undergo
an ACL reconstruction or repair.
Jeffrey Pope, MD, FA (27:42):
Absolutely , rob, and when we talk about
injuries, we talk about ingeneral, as surgeons, risks and
benefits of surgery.
But with looking at an ACL, youalso have to speak about the
risk and the benefits ofnonoperative care.
And again, one of those risksis an increased risk of
potentially getting arthritis inyour knee and secondary
meniscus tear, on the insidepart of your knee Exactly.
Robert A. Kayal, MD, FAAOS (28:04):
So, now that we've decided to place
these patients in physicaltherapy to rehab these knees,
whether or not they're going tohave surgery or not, what are we
focused on in physical?
Jeffrey Pope, MD, FAAOS (28:14):
therapy Early on.
We want to regain motion.
Motion is exceedingly importantto get the scar tissue out of
your knee and, as well, we wantto work on stabilizing or
strengthening, excuse me.
We want to work onstrengthening our dynamic
stabilizers, which are ourhamstring tendons and also our
quad tendon.
Our quad tendon is somethingthat well.
It doesn't necessarily help outour ACL.
(28:35):
It's something that we'll getinhibited by having that fluid
in the knee and the injuries.
We really want to make sureboth the front and the back of
the knee are as strong as theycan be.
Robert A. Kayal, MD, (28:44):
Absolutely , and if we're going to do
surgery it's incumbent upon usto wait until that knee sort of
looks like a normal knee right.
We have to restore range ofmotion fully.
We have to have good patellamobilization.
There should be little to noresidual swelling.
Really the patient should havelittle to no complaints in that
knee other than the instabilityfrom the deficient ACL correct.
Jeffrey Pope, MD, FA (29:06):
Absolutely , rob.
There are a few indications foracute ACL repair or
reconstruction.
One of those is if you have abucket handle meniscus tear that
is locked in the knee and itcannot be mobilized, and in
others, if there are otherconcomitant or other additional
ligamentous injuries thatprovide the knee with minimal
stability, there's a furtherrisk.
Robert A. Kayal, MD, (29:27):
Absolutely .
But I've seen in my own patientpopulation that sometimes
patients are frustrated.
Right, they have the ACL tear.
They want to get fixedimmediately and they don't
really understand sometimes whywe're waiting so long to do
their elective procedure.
We don't want to operate inthat milieu when there's
tremendous swelling because,like Dr Pope mentioned, there's
a tremendous amount of scartissue that can develop from
(29:50):
that hemarthrosis or blood inthe knee.
So it is really very, veryimportant that the patients
undergo typically about four tosix weeks of physical therapy
preoperatively to restore thatrange of motion, to get rid of
all the swelling, to make surethat the knee looks and acts
like a normal knee, except forthe instability.
Jeffrey Pope, MD, FA (30:09):
Absolutely .
It's important for the knee tobecome an area where it's going
to be conducive to surgery.
It's going to be appropriatefor surgery but also gives you
the time to develop thatdoctor-patial relationship and
make sure that you'recomfortable with the person
who's taking care of you.
Robert A. Kayal, MD, FAAO (30:24):
Right , that's a great point.
Okay, dr Pope.
So our patient just completedhis or her course of physical
therapy and is now coming backto see you in the office.
Let's assume that this patienthas opted to proceed with some
type of surgical repair orreconstruction of their torn
antiochrocea ligament.
(30:45):
What options are available?
Jeffrey Pope, MD, FAAOS (30:47):
for this patient.
Traditionally, when torn istorn, the ACL in general is not
amenable to repair.
It's something that you can'tstitch because of the fluid
inside the knee inhibiting theends of the ligament to heal
back to each other.
The fluid will break down thefibrin clot, which is
exceedingly important for thebiology and healing of one end
(31:08):
of the ligament back to theother.
So if the ligament itselfdoesn't have the ability to heal
for the most part,traditionally our teaching was
to reconstruct a ligament, andreconstruction means to remove
the ligament as you were bornwith and then to place another
ligament in its place.
There's a lot of differentoptions for how to do that.
(31:29):
It could be done with autograph, which means you take it from
yourself.
You can look at taking part ofthe hamstring tendons either one
or two tendons to remove themfrom the leg and then to there.
Therefore use them toreconstruct and to put in place
of the ACL.
That's something that is onevery valid way of reconstructing
(31:52):
the ACL.
Another way is to take the bonepatellar tendon bone, which is
part of the kneecap, theligament that goes from the
kneecap down to the point ofyour shin bone, and a piece of
bone at the end of that, thebone patellar tendon bone.
It's something that can be usedto reconstruct and has been for
many years the gold standard ofACL reconstruction.
(32:14):
It gives you very firmendpoints and allows for bone to
bone healing, which is thoughtto be advantageous, especially
in athletes.
One option to look outside oftaking the bone patellar tendon
bone more recently is takingyour quad tendon.
The quad tendon can be takenwith a piece of bone.
(32:34):
However, with more advancedarthroscopic techniques, you can
use just the soft tissueportion only of it.
This is a technique that ismore new.
With this advance inarthroscopic techniques, you can
instill the quad tendon withinthe knee anatomically in the
area where the ACL was, andsuspend it and allow it to heal
(32:58):
without having to take any ofthe bone from the kneecap and
therefore potentially decreasingkneecap pain and discomfort
throughout the recovery.
Robert A. Kayal, MD, FAAOS (33:08):
It sounds like in all these
examples that you just nicelylaid out for us, you're sort of
stealing from Peter to pay Paul.
You're taking certain bodyparts from the patient and
transferring them into otherareas to recreate this ACL.
Some of that is, and must be,associated with a significant
(33:30):
amount of morbidity to thepatient right.
Jeffrey Pope, MD, FAAOS (33:32):
You're taking more morbidity when you
take the patient's own softtissue.
For some patients, they wouldjust prefer not to have anyone
else's tissues on their body andthat's completely
understandable.
However, there is definitelymore morbidity, which means more
pain and discomfort with theprocedure, potentially a little
bit delay in them coming alongand decreasing their pain and
(33:55):
mobilizing afterwards aftersurgery.
Robert A. Kayal, MD, FAAOS (33:58):
Yeah , I think you know traditionally
the advantage of thisautographed therapy where we
steal from Peter to pay Paul,whether it be the bone patella
bone autographed or thehamstring autographed or now the
quadriceps tendon autographed.
The advantage would be that there-rupture rate traditionally
has been lower than withallograft therapy.
(34:20):
Allograft therapy is where wedon't steal from Peter to pay
Paul but rather use cadavergraft material to reconstruct
the anti-recruciate ligament inour patients.
It's certainly a less invasiveprocedure because we don't have
to harvest from a donor site andbring that tissue to a
(34:40):
recipient site.
So it's definitely lessinvasive with probably a less
painful post-opera of course andfaster recovery.
But the downside potentially isthat there is potential very
small risks of allograft donormorbidity but also potentially
an increased re-rupture rate.
So typically in very youngpatients, very athletic young
(35:05):
individuals, will often proceedwith autographed therapy as
opposed to allograft therapy orpossibly repair what Dr Rapov is
about to talk to us about.
But I think it's important tonote that patients understand
that they have choices whenundergoing ACL reconstruction.
There are different graft sitesand both of us are very
(35:28):
familiar and very comfortableproceeding with any type of
these surgical options.
But we often like to haveconversations with our patients
to discuss the risks andbenefits of each type of
procedure and make our decisionstogether with our patients,
don't you agree?
Jeffrey Pope, MD, FA (35:44):
Absolutely , rob.
The patient has to be involved,and without that you're not
going to get the outcome thatyou want.
So you want to make surethey're comfortable and you're
comfortable.
Robert A. Kayal, MD, (35:52):
Absolutely so.
We spoke about autographedtherapy.
Cadaver Allograph therapy isadvantageous in a certain group
of patients as well.
Has there been anything recentthat has come to the area of
sports medicine and arthroscopy,as it pertains to ACL surgery,
that you would consider maybe agame?
Jeffrey Pope, MD, FAAOS (36:13):
changer Absolutely.
Within the past five to sixyears, we've seen increasing
arthroscopic techniques wherewe're able to, for certain types
of ACL tears, instead of havingto reconstruct it, which means
to remove it, we're able tostitch it and fix it back to the
bone that it tore from.
So these advanced arthroscopictechniques are a repair as
(36:35):
opposed to a reconstruction.
Robert A. Kayal, MD, FAAOS (36:36):
Yeah , and you and I have done a
bunch of these, and they're justreally a fantastic new
advancement in the area of ACLsurgery in that we're
essentially restoring thepatient's anatomy.
We're not disrupting any of theintact fibers, but rather
repairing the fibers back to thebone.
By doing this, it's certainlymuch less invasive.
(36:59):
We're not stealing from Peterto pay Paul, we're not
harvesting from a donor site,but rather we're keeping the
intact torn anti-increaseligament and anatomically
repairing it back to the bonewhere it tore off of.
What are some of the advantagesof doing that, as opposed to
the ACL reconstruction that wediscussed?
Jeffrey Pope, MD, FAAOS (37:19):
One main advantage is to have the
patient have a more normalfeeling knee.
That means that they can knowwhere their knee is in space.
It feels like when it moves, itis theirs, it's not someone
else's.
With that there's also a mucheasier revision of repair as
opposed to having to revisesomething that was previously
(37:40):
reconstructed.
By revision I mean there'salways a chance in the future
that someone could rupture theirknee, their ligament, again If
they had a repair.
God forbid.
They had a devastating injury, afall, a contact sport, and we
see even more MMA and rotationaltwisting pivoting of these now
(38:01):
that we used to.
One does have another tear ofthat same ACL.
It makes the revision of it,meaning redoing the surgery,
much easier and transitioning toa reconstruction from repairing
it the first time.
As opposed to redoing areconstruction where you worry
about the bone tunnels, whereyou have to drill through
expanding and having to graftthem Potentially, you have to do
(38:23):
it in a stage procedure whereyou have to take out what's torn
, fill in the bone tunnels andallow them to heal.
That and then do a secondarynon-surgery thereafter.
That's a great point.
Robert A. Kayal, MD, FAA (38:33):
That's a great point.
Essentially, after the repairyou're dealing essentially with
virgin anatomy.
The bone stock is completelythere.
The real estate is there,whereas in the patient that had
a prior ACL reconstruction thatbony anatomy is already
compromised.
There's tunnels there.
We have voids in the bone To doa revision and drill other
tunnels.
Potentially it can be a problemthat, like Dr Pope mentioned,
(38:55):
might have to be addressed in astage manner where those bone
tunnels are first filled in withbone graft, let that bone
reconstitute and consolidate andthen take the patient back
three or four months later anddo an ACL reconstruction after
that bone stock has beenrestored.
That's tremendouslyadvantageous.
Jeffrey Pope, MD, FAAOS (39:12):
One other potential benefit of doing
an ACL repair versusreconstruction is it does have
in quite a few patients a littlebit of a quicker recovery
Because you're not making biggertunnels in the bone.
They're much smaller.
There's less bleed in the kneeafterwards.
The control over the thighmuscle is much quicker to
recover from.
Most patients get moving fasterquicker with doing a repair
(39:36):
than a reconstruction.
Robert A. Kayal, MD, FAAO (39:39):
Right .
What are the indications for anACL repair?
Can everyone have one?
Jeffrey Pope, MD, (39:44):
Traditionally , most indications were for an
ACL that was torn off one partof the bone or the other, either
the thigh bone or the shin bone, Mostly in adults.
If that was a case of a bone ifthat was a case, it'd be off of
the thigh bone.
However, there are somechildhood injuries where you can
actually pull a piece of thebone off of the shin bone and
(40:04):
then that can be repaired aswell.
But to talk about the mostcommon portion with adults, only
tears traditionally that wereright off the bone, where you
have the whole length of theligament, can be stitched up
using advanced arthroscopictechniques and then secured back
to the bone using differenttypes of anchors or stitches to
(40:28):
repair it.
Robert A. Kayal, MD, FAAOS (40:29):
And sometimes we can't even tell
right until we get in there.
Jeffrey Pope, MD, FAAOS (40:32):
It's a discussion you always have to
have with the patient.
You can't say for sure when yougo in that you'll definitely be
able to repair it.
It's something that isevaluated at the time and you
always have to have thediscussion that, if it cannot be
repaired, the next step wouldbe to reconstruct it at that
point?
Robert A. Kayal, MD, FAAOS (40:47):
Yeah , so both of us will tend to go
into surgery talking to thepatients that we're going to
work in earnest to try to repairthe patient's native ACL back
to the bone.
But, for whatever reason, if wecan't do that, based on
evaluation of the torn ligament,we would be prepared to do the
ACL reconstruction at the sametime.
Correct, absolutely, yeah.
And what about partial tears?
(41:09):
Are partial tears of the ACLmaybe a good indication to
repair the one bundle that hasevolved off the bone?
Jeffrey Pope, MD, FAAOS (41:16):
Without a doubt, when there are partial
tears and if a patient that isinvolved in cutting or pivoting
or sudden stopping and jumping,that's absolutely a hard
indication in discussion withthe patient.
To repair a single bundle, it'ssomething that could be done
very easily, whether it's theintramedial bundle, the main one
that we look at with shiftingof the knee from front to back,
(41:39):
or the posterior lateral, whichis involved with the twisted and
pivoting.
Robert A. Kayal, MD, FAAOS (41:42):
Yeah , I'd like to just emphasize
that point because, like Dr Popementioned, each bundle has a
particular function.
So if you leave a patient witha compromised ACL, either the
anterior medial bundle is tornor the posterior lateral bundle
is torn.
Some form of stability will becompromised and we want this
patient to have a normal feelingknee, and so to do a repair of
(42:04):
a partial ACL is one of the mostbeautiful operations because
the other bundle is completelyintact.
So the likelihood that thatpartial tear is going to heal is
probably so much better becauseit's not really feeling the
stress or the load of a completeACL tear.
Correct, without a doubt?
Yeah, absolutely so, dr Pope.
(42:25):
In this era of orthobiologicaltherapies, or what we call
orthopedic regenerative medicine, has there been any
technological advancementsrecently that have maybe allowed
us to indicate more and morepatients for an ACL repair as
opposed to a reconstruction?
Jeffrey Pope, MD, FA (42:45):
Absolutely , rob.
Previously, as we werediscussing, repairs can only
happen when the ACL is torn offof one end of the bone or the
other.
Now, with more mid-substancetears tears within the ligament,
where it's not just off thebone we've expanded our
indications for repair using acertain type of orthopedic
(43:05):
biologic implant called a bareimplant, and what that allows us
to do is to stitch the ligamentand also to bridge that gap,
where the ligament is notsurrounded in joint fluid, where
it can't heal, and we stitch itto the, to the native ligament,
we allow it to be in a betterenvironment for healing and it's
something that can bridge thegap, which we weren't able to do
(43:28):
previously.
Robert A. Kayal, MD, FAAOS (43:29):
Yeah , specifically that's what the
bare implant stands for, right,the BEAR bridge-enhanced ACL
restoration.
So we're bridging that gapbetween the stump of the
anterior crucial ligament andthe bone to which it naturally
inserts right.
So we're bridging that gap andputting essentially a
(43:50):
orthobiological, regenerativemedicine, collagen-based implant
in that interface to preventthe synovial fluid and the
degradative enzymes from everapproaching that fibrin clot,
which typically would precludebiological healing.
So now you have this barrier,this bridged, enhanced allograft
(44:12):
that is allowing the fibrinclot to form and for that ACL to
heal back to the bone much moreefficiently and readily has
really revolutionized the waywe're indicating these patients
for ACL repair and it's reallyshifting that pendulum for many
of us to really try to restorepatients' normal anatomy.
(44:33):
That's where we're at in 2023.
We're really pushing theenvelope and trying to repair
things as opposed to replace orreconstruct things using
patients' own anatomy andbiology.
Jeffrey Pope, MD, FAAOS (44:45):
One thing that we know, rob, is that
the ACL wants to heal.
We see that there's cellmigration.
That happens after you tear inyour ACL.
We know that there are growthfactors in that area.
We just need to get the jointfluid out of the way and, by
using the bare implant, itallows us to take the ligament,
put it right into this collagenmatrix and then to allow it to
heal to the bone, and it'ssomething that happens over
(45:07):
eight weeks.
After eight weeks, the implantwill slowly resolve and at that
point you have this healing mesh, this healing matrix of cells
that are able to ultimately giveyou a native ACL back.
Robert A. Kayal, MD, FAAOS (45:21):
Yeah , it's beautifully put.
I think the vendors havetremendously assisted us in this
by offering these technologiesNot only the vendors providing
the bare implant, but othervendors that are providing us
with better instruments andsuture anchors, for instance, to
fixate this graft back to thebone.
Technology has improvedsignificantly in that regard
(45:43):
Without a doubt.
Jeffrey Pope, MD, FAAOS (45:44):
It's taken a bigger procedure in
making a more streamlined,making a more efficient, but
also something that is lessprominent to the patient and
less painful.
Robert A. Kayal, MD, FAAO (45:53):
Right .
What is this internal bracethat we use in the operating
room as well?
Jeffrey Pope, MD, FAAO (45:57):
Internal brace to me is a big part of
ACL repairs as well as the bareinternal bracing is able to give
you a very strong suture thatgoes from one part of the anchor
, the fixation that crosses thejoint, and then goes to the
other part, and is fixed as wellin the other end of the bone.
What it does is it allows theACL to heal without having the
(46:22):
stress on it that it wouldotherwise see and less
likelihood that it's going tore-tare.
Robert A. Kayal, MD, FAAOS (46:27):
It essentially parallels the ACL
repair right, it parallels theACL and it serves as literally
an internal brace.
It protects the repair byessentially serving the function
of the anterior cruciateligament, providing that
stability along the course ofthe anterior cruciate ligament
so that the repair can takeplace without excessive stress
(46:51):
on the repair.
It's really an internal braceor an internal splint to protect
the repair until we don'treally need it anymore.
Over time that internal braceor that internal splint will
weaken over time, but it reallyserves its function early on
while that ACL repair is takingplace and then we really don't
(47:13):
need it anymore.
It's almost like to extrapolateto fracture management surgery.
When we put a plate or screwson a broken bone, that plate or
splint is only used until thebones heal.
Once the bones heal we don'treally need the hardware anymore
.
We don't typically go in toremove the hardware, but we
don't really need the hardwareanymore To extrapolate from that
(47:36):
concept to the area of sportsmedicine and arthroscopy and
specifically ACL repair.
That's exactly what thisinternal splint is doing and
that also has revolutionized theway we're able to do these
repairs, because it's protectingthe repair, alleviating stress
on the repair and allowing thatbiological process, that fibrin
clot to form and for it toultimately heal back to bone.
(47:59):
It's not just us deciding okay,in 2023 we're going to do ACL
repairs again.
We've tried that in the pastand it hasn't really done so
well.
It's fraught with complications.
But now the pendulum isswinging back because of these
significant advancements thatwe're outlining today the
technologies from the vendors,the orthobiological therapies,
(48:22):
the collagen barrier implantthat's essentially a barrier to
that enzymatic degradation ofthat clot, and the implants that
are utilized now in theoperating room to secure
fixation and to augment fixationAll of this has led us to our
approach to the aggressivesurgical management of ACLs via
(48:46):
ACL repair.
I think Dr Polk and I feel verystrongly that if we had our
choice, we would do ACL repairon every patient that had an ACL
tear.
We often go into surgery withthat mindset that we want to
repair that ACL instead ofreconstruct that ACL, and less
prove an otherwise intraoperably.
Without a doubt, Now that wetalk about ACL repair and
(49:10):
postoper, of course, what'sactually happening when
something is being repaired?
Or if we use, for instance, agraph whether it's an allograph
or an autograph what's happeningto that new ACL or that
repaired ACL over the next year.
Jeffrey Pope, MD, FAAOS (49:29):
As soon as the camera comes out of the
knee, we have a healing responsethat starts.
There are cells that migratefrom around the knee, from
within the ligament, from thebone that's there to work on
healing.
There are growth factors thatare laid out and you see a
revascularization of this area.
If it's a repair, you see theligament start to heal back to
(49:51):
the wall, to the bone.
If it is a bare implant, yousee this implant of collagen
start to become vascularized and, as well as it starts to shrink
and then the environment thatit's in is a biologic mesh of
healing you see it start torevascularize and then, after
(50:12):
revascularizes, it can getstronger.
When you have other soft tissuecells that come in and hold
down and put in a more thickenedtype of construct there.
In regards to a reconstruction,when you're talking about the
graft themselves or for the mostpart, either a cellular or, if
it's autographed, you don't havemuch blood vessels there, you
(50:36):
do see a vascularization.
You see blood vessels thatstart to permeate the soft
tissue and to give that softtissue life.
Robert A. Kayal, MD, FAAO (50:45):
Right , and that's a biological
process.
That doesn't happen overnight,right?
So a lot of times, you know,patients are like why is it
taking so long?
Well, we have nothing to dowith that.
That's a biological process andfor most orthopedic surgeons,
most orthopedic surgeons wouldnot allow their patients to get
back to any sports activitiesfor a minimum of nine months and
(51:08):
in my hands, I typicallyrecommend 12 months to protect
that repair or thatreconstruction so that it is
revascularized and the collagenfibers have been formed in that
graft or that repair is robustand strong and able to endure
the stress associated withsporting activities.
Jeffrey Pope, MD, FA (51:28):
Absolutely , rob.
On top of that, you also needto strengthen your dynamic
stabilizers.
While you're having yoursurgery and preoperatively,
hopefully, you're strengtheningyour hamstrings.
You need to make sure aftersurgery that you're
strengthening them as well.
You're gaining mobility in yourknee and, again, you're gaining
the trust in your knee.
If you go out and you just wantto play because it's been three
months, you're not going tohave that trust in the knee and
(51:50):
you're going to suffer, likelyanother injury.
Robert A. Kayal, MD, (51:52):
Definitely physical therapies.
Most of these patients are inphysical therapy for six months
to a year after this, andthere's a lot of studies and
literature that support thatthis biological process extends
well beyond one year, two, threeyears after surgery, and so
it's very, very important togive that ligament or that
repair ample time to heal,because you don't want to go
(52:12):
through this operation again andyou definitely want to rehab it
all along, like Dr Popementioned, and strengthen those
backup secondary stabilizers andthe dynamic stabilizers,
especially the hamstrings, tosupport that graft for the rest
of your life.
On the note of physical therapy,I know earlier on we mentioned
(52:33):
what we can do from aneuromuscular training
perspective to try to minimizethe risk of recurrent tear or
tear to the other knee, becausea lot of these cases are
actually bilateral.
If you tear one ACL, there's asignificant likelihood that
you're going to potentially tearthe other ACL, and so during
(52:54):
physical therapy and in sportspreventative medicine,
neuromuscular programs, we liketo focus specifically on body
mechanics, landing techniquesand making sure that the core
stabilizes, the abductors of thehip are stabilized and certain
mechanics are focused on andaddressed in physical therapy.
(53:17):
What are some of the things welike to do, dr?
Jeffrey Pope, MD, FAAOS (53:19):
Pope, most importantly, as we said
earlier, hamstring strengthening.
However, working with yourathletic trainer and your
physical therapist are going tobe critical to your healing and
your recovery.
Making sure that you can have ahamstring curl that is at least
75% to 90% of your other side,your normal side.
That's one goal that we look at.
(53:40):
Another is to be able to singlestance, hop on the surgical leg
for 20 times to make sure thatit's not going to buckle or give
way.
So there are a lot ofparameters that we look at.
As far as for thighcircumference, we'll take a tape
measure, put it around thatthigh and then compare with the
other side, with the normal side, and make sure that we're
within a centimeter of the otherside.
Robert A. Kayal, MD, FAAOS (54:02):
Yeah , and we also want to focus
aggressively on agility, rightBalance, coordination,
proprioception like Dr Popementioned in the past, knowing
where the limb is in space, alot of plyometrics in physical
therapy, box jumping and thingslike that.
We really want to focus on allof those things and specifically
when it pertains to jumping, wewant to make sure that when
(54:25):
patients jump and land they landproperly.
They land with their hipsflexed and their knees flexed
and their ankles flexed and wewant to make sure that the
shoulders and the hips and theknees and the ankles sort of all
line up.
I think that the mainpredisposing mechanical
malalignment is occurringprimarily at the knee.
I think when patients land witha knock knee deformity or a
(54:48):
valgus deformity, thatsignificantly stresses the ACL
and leads it to rupture.
So we want to make sure thatpatients do not land with a
knock knee deformity.
We want to make sure that theirhips are abducted, separated a
little bit, as opposed to kneesin.
We don't want to internallyrotate the legs.
We want to make sure that whenwe land that the knees are over
(55:13):
the ankles and the toes.
We don't want to land with theknee extended in any way.
So essentially, hips out, kneesout, feet out.
You don't want to have anyinternal rotation or a valgus
malalignment upon landing, andthat is critical to avoiding
these.
And these are things that we,as orthopedic surgeons, can
quarterback and prescribe tohelp any sports program prevent
(55:38):
ACL tears and, for the patientthat was unfortunate enough to
suffer one, maybe prevent it onthe other side.
Are these some of the thingsthat you employ in your practice
, dr Pope?
Jeffrey Pope, MD, FAAOS (55:47):
Even some things as small as
orthotics.
If you have someone that has aflat foot deformity, you have a
valgus knee, a knock kneedeformity something like
orthotics can help keep theirankle appropriately aligned.
And if their ankles are wellaligned, then hope their knee
will be, and so on and so forthgoes up the chain.
You want to make sure that yourknees are facing forward, as Dr
Kaila said, not inwards.
You want forward or out, sothat way you land in the
(56:10):
appropriate way, with lessstress on your ACL.
Robert A. Kayal, MD, FA (56:13):
Awesome , so this has been a
tremendously enlighteningexperience.
Dr Pope, I'm so glad we finallygot together to talk about this
injury ACL tears such a commoninjury and I'm just so happy
that you took the time toexplain to our patients how we
manage these.
It was a very thoroughconversation and hopefully very
informative and enlightening toour patients.
(56:34):
We hope that you found ithelpful.
Jeffrey Pope, MD, FAAOS (56:37):
It's a pleasure and honor to have you
here today, Dr Pope.
Thank you so much, Dr Pope.
Robert A. Kayal, MD, FAAOS (56:41):
It's been an amazing 15 years and
we're just so blessed to haveyou.
So thank you for your timetoday.
I'm so thankful to be here.
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