kayalortho Podcast
I would like to take this opportunity to welcome you to another episode of the kayalortho Podcast. My name is Dr. Robert A. Kayal, and I am a board-certified Orthopaedic Surgeon and Founder, President & CEO of the Kayal Orthopaedic Center. We are a large multi-specialty and multi-disciplinary musculoskeletal medical center in Northern NJ and NY, specializing in orthopaedic surgery, interventional pain management, rheumatology, podiatry, chiropractics, physical therapy, massage therapy, acupuncture and high-resolution, cross-sectional medical imaging. For additional information or to schedule an appointment with one of our health care providers, you can contact us at 844-777-0910 or at kayalortho.com.
kayalortho Podcast
Exploring ACL Tears and Surgical Solutions: Wisdom from Dr. Jeffrey Pope
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.
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 trained board certified orthopedic surgeon at the Kale Orthopedic Center and we're so privileged and pleased to have him with us today. Welcome to the podcast. I greatly appreciate, dr Kale. Before we get started, dr Pope, why don't you just take a couple minutes and tell our viewing and listening audiencea little bit about yourself?
Jeffrey Pope, MD, FAAOS:Well, my name is Jeff Pope. I am from Wycoff originally. I graduated from Rampo High School. My mother taught in the elementary schools and middle school in Wycoff. I've been through the area and after leaving Wycoff I wanted to make sure that this is the place that I came back to. I love Bergen County and it's been a part of my upbringing and a part of what changed me to be who I am today.
Jeffrey Pope, MD, FAAOS:After finishing in at Rampo High School, I went to Penn State for my undergraduate and at Penn State I double majored. One was in pre-medicine. However, I really liked the part of nutrition and nutrition science, mainly biochemistry, and elected to double major and finished my college career at Penn State. After finishing at Penn State, I graduated with an excellent background in nutrition science as well as pre-medicine, as accepted to medical school at University of Medicine and Dentistry of New Jersey, what we now call Rutgers Medical School. I graduated with high honors from Rutgers Medical School and then a platform orthopedic residency and got into my first choice, which is NYU School of Medicine, as well as NYU Hospital for Joint Diseases From NYU, which gave me an excellent background in orthopedics. From my intern year through my chief year, I decided I wanted to specialize in sports medicine. I applied to University of Chicago and was accepted, and I spent a year there treating the local athletes at the University of Chicago as well as the folks in that area for their sports related injuries.
Robert A. Kayal, MD, FAAOS:Wow, those are some very impressive credentials. Dr Polpin, I'm so excited to have you as part of this practice for the past 15 years, delivering your excellence in sports medicine and arthroscopy to our community of patients. Thank you, dr Go. Awesome, we have so much in common. We both grew up in Bergen County, specifically in Wycoff, new Jersey. We both came back home to practice medicine and both married amazing women, right? So tell us a little bit about your beautiful wife, piper, and your beautiful two boys that you just had a few years back.
Jeffrey Pope, MD, FAAOS:My wife Piper and I were married in 2012. We met in Chicago during my fellowship as at the University of Chicago and my wife was worked in the operating room for a surgical device company. We met there and I was lucky enough to give it to her to come back to New Jersey from Chicago and she grew up in Southern California. So that was a tough pull back to this post, but we made a work and shortly thereafter we were blessed with two boys who will be turning five in the next month, harlan and Lachlan. Twin boys, and they're just the the most incredible part of my life.
Robert A. Kayal, MD, FAAOS:Awesome. It's so nice to hear Jeff, and we're just so happy to have both you and Piper and your two boys back in Bergen County as well. You've been such a blessing to this practice and to so many patients over the last 15 years that Dr Pope's been with us at the K L Orthopedic Center. Dr Pope serves as the chief of sports medicine and orthroscopy at the K L Orthopedic Center, and today's topic that he's going to help present to us today is a very common problem called the anterior cruciate ligament 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 of the ACL. What is the anterior cruciate ligament?
Jeffrey Pope, MD, FAAOS:Well, the anterior cruciate ligament, and maybe take a step back. What is a ligament in general? A ligament is a structure that connects one bone to another. There's no muscle involved, it's static, it doesn't contract, it doesn't expand and it's something that keeps the knee stable, particular the ACL, and it keeps the bottom part of the knee, what we call the, the tibia, from shifting or subloxing in a position that it should not, mainly to the front.
Robert A. Kayal, MD, FAAOS:Right, so the the ligament, like you said, is a static stabilizer. So a joint is held together essentially by a combination of both static and dynamic stabilizers, right? So static stabilizers would be the construct of the bone itself, maybe the ligament to structures that connect the bones to the other bones. But there's also dynamic stabilizers that help stabilize the joint as well, and those are typically the muscles that surround the joint. So, for instance, we can do physical therapy to help stabilize a joint, but ligament to structures are static and we have no control over those structures. So if they fail or tear, those often have to be surgically managed.
Jeffrey Pope, MD, FAAOS:So, as far as for the ACL, one of the best friends of the ACL, their hamstrings. The hamstrings are the muscles in the back of the thigh and what they serve to do is to bring your hip backwards and flex your knee, and in doing so, it helps to keep the lower part of the knee stable and helps to back up your ACL from keeping the the bottom part of the knee from slipping forward.
Robert A. Kayal, MD, FAAOS:Exactly, we like to say that the hamstrings back up the ACL right. So if you're doing, if you're concerned about a compromised anterior cruciate ligament, a lot of times what we'll do is we'll focus on strengthening the hamstrings in order, in effort, to back up the weakened anterior cruciate ligament. The hamstrings originate off the the pelvis, in the back of the pelvis, and insert on the front 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 subluxing anteriorly over the thigh bone, the femur right Absolutely. So maybe we'll demonstrate that for the benefit of our viewing audience at least, with the usage of a model. Okay, sounds great.
Jeffrey Pope, MD, FAAOS:This is a model depicting the patient's right knee. This is the top part, the thigh bone where it ends into the knee. This is the shin bone where it starts 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 the shin bone up to the thigh bone and connects and gives that a rigid connection, keeping it from shifting and translating in a way that it should not. This model is really focusing just on the ACL, doesn't show our other soft tissue, such as muscles, tendons, ligaments on the side as well. So just a disclaimer about that. But today's talk is again about our ACL.
Jeffrey Pope, MD, FAAOS:There's two different portions of the ACL, two different what we call bundles. There's an intermedial bundle, which is the main one that we focus with keeping the bottom part of the knee from shifting or subluxing towards the front. That's the intermedial bundle. That's what you see mainly depicted in an ACL. It goes from the inside part of the notch on the outside towards the shin bone and inserts in the front. That is the main part of what we typically treat and reconstruct.
Jeffrey Pope, MD, FAAOS:The posterior lateral bundle, which is behind the intermedial bundle, is a really important portion of the ACL in regards to rotational stability. With pivoting and twisting on the knee, it provides rotational stability so that way it doesn't sublux or shift in a way that is going to cause damage to the knee itself. One important part of the ACL, even though it is not a stability portion, is a sensory organ. Our ligaments inside our knees have multiple portions of it that provide feedback to us and tell us where our joint is in space, so that way we can close our eyes and know where our finger is or how to jump without looking at where our feet are going to land on the ground. In medicine, we call that proprioception, and it's something that is a vital part of being an athlete and knowing where your feet are, where your hands are in space, without having to actually see them.
Robert A. Kayal, MD, FAAOS:Absolutely. Thank you so much for elaborating on that, dr Pope. How often do you see patients with ACL tears in your office on a regular basis?
Jeffrey Pope, MD, FAAOS:ACL injuries are an exceedingly common complaint and diagnosis that we see in the office. Acl is the most commonly injured ligament in the knee and something that is a part of everyday office work. Acl injuries typically occur in patients that are younger, sports related and occur with activities that require starting, stopping, pivoting, shifting and sudden acceleration or deceleration events. So typically these occur in athletes. However, can occur in patients that are skiing, which is a little bit of a lower energy type energy. There's a very high rate of injury in female athletes, specifically volleyball and basketball players, for a number of different reasons. It can be due to a difference in the and the notch, which is the area where the ACL has to reside, as far as for the room for it, the size of the ACL. Also different ways that patients land on their knees, with how they contract their muscles, whether it's mostly with the thigh muscles, in the front, the quad muscles, or whether they co-contract their hamstrings as well.
Robert A. Kayal, MD, FAAOS:Yeah, I mean. Given the fact that the ACL ligament is so important and vital to the stability of the knee, you can imagine that anytime that knee is put in some type of provocative position, it can potentially rupture. So we know that the ACL tears are commonly associated with planting pivoting, rotational maneuvers to the knee, awkward movements of the knee, awkward landing techniques. But a lot of it has to do with patients anatomical, mechanical alignment as well, correct?
Jeffrey Pope, MD, FAAOS:Absolutely different bone shapes and the shin bone will predispose patients to having a more likelihood that they tear the ACL 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 half times more commonly in women than men, and also in different periods of different portions of a woman's period. It's more likely to not happen with ligaments of slacksity.
Robert A. Kayal, MD, FAAOS:And we also realized that patients that have weakness in their not only their lower extremity muscles but their core as well contributes. I know that patients that have weakness in their, for instance, their hip abductors and their hamstrings and mechanical alignment problems are predisposed. We know that patients that land improperly are significantly at increased risk of developing these ACL tears. So those are some of the things that we focus on in preventative care, which we'll get to in a little bit making sure that we focus our attention on strengthening the patient's core and their hip abductors and landing techniques, which we'll discuss in a little bit, to prevent the likelihood of these patients developing an ACL tear. So, dr Pope, now that we've discussed the anatomy and the prevalence and epidemiology associated with this injury, the ACL tear, what is the patient's typical chief complaint when they present to the office after suffering an injury to the anti-acreusial ligament?
Jeffrey Pope, MD, FAAOS:Most, commonly, patients will complain of swelling and decreased ability to put weight on that leg, stiffness, the inability to bend the knee fully, difficult weight bearing, sometimes even mechanical symptoms like locking or catching inside their knee or the wanting to give way or buckle on them Some of the most common complaints when patients come to the office.
Robert A. Kayal, MD, FAAOS:So then, what is the classic history of the present illness? What is the classic presentation of someone that had just suffered an ACL?
Jeffrey Pope, MD, FAAOS:tear Without it at. The most common complaint of patients that they feel is a pop inside their knee where they will shift or buckle, and then almost immediately after they're unable to place weight on it, they may have to get helped off the field. Afterwards it may feel better. They'll usually have a lot of swelling and difficulty bending immediately after.
Robert A. Kayal, MD, FAAOS:Exactly A textbook presentation. They hear a pop, they suffer an injury. They hear a pop, they collapse to the ground, their knee swells up like a balloon and they can't wait that right. That's a classic textbook presentation of an ACL tear and often the history is telling as well, because usually they'll complain that they were struck. It was contact sports struck on the side of a knee. The whole knee blew out. Or it would be a rapid deceleration maneuver or a planting pivoting rotational maneuver. All of this is commonly associated with that classic pop that Dr Pope described and the knee swells immediately, blows up like a balloon. Patients can't walk on it and that is the classic presentation. But I must be honest. I know that's textbook presentation but I must be honest. Over the years of treating these injuries, haven't you seen some of these, especially younger girls, where they come in with not that classic presentation, where they come in with not even too much swelling and you examine them and their ACL is blown?
Jeffrey Pope, MD, FAAOS:That's absolutely correct, rob Never surprised to see how strong some of our patients can be and not necessarily feel that discomfort or pop that most patients will complain of. And when you look at their exam, you expect to see swelling. You expect to see discomfort and ability to fully bend the knee or even some lag in trying to strain it out. And they have really good motion. The knee is not significantly swollen. However, their objective testing, which is when I look at their knee and I test the ligaments to see if they're stable or not, it's very clear that they have suffered an ACL tear. First we look at swelling within the knee. I'll take a look and feel the patient's joint. If there's fluid in the joint, that's the first clue that there's likely a disruption of the ACL. If there's increased fluid in the knee, then the next thing that I look at is to see what the knee motion is, make sure that there's no significant hyperextension of the knee, see what their ability to flex the knee is and also check the ligaments on the side of the knee to make sure that there's no other injury.
Jeffrey Pope, MD, FAAOS:When we look at the ACL specifically, there are three separate tests that traditionally I look at. The first is the anterior drawer where I pin the knee up about halfway, shift the knee forward and see how much play there is in the knee. I always check the normal side first and then I'll check the injured side to see what is normal for that patient. We all have different abilities to bend our knee and to have ligaments as laxity or tightness. After looking at an anterior drawer, I'll straighten out the knee a little bit more and look at a Lachman test.
Jeffrey Pope, MD, FAAOS:A Lachman test is the single most sensitive test that we have to tell us whether, on physical exam, there is a tear at the ACL. This looks at the bottom part of the knee compared to the top part and we see how far it can shift, pulling it forward and testing the ACL. Lastly, check it for an endpoint as well, absolutely See whether it's firmer, see whether it is soft and if it's soft, another clue that there's potentially a tear at the ACL. Some patients are able to do a pivot shift test relatively early on. Others can't. That's another way to take a look at that second part of the bundle, the postural out of bundle, and tell us whether there's rotational instability at the knee or not.
Robert A. Kayal, MD, FAAOS:With respect to that swelling in that knee. Is there anything else you can do to assess that swelling, to maybe lead you to believe that maybe there is in fact an anterior cruciate ligament tear?
Jeffrey Pope, MD, FAAOS:Absolutely, rob. When I look at the knee and if I do see that there is swelling with the knee, very commonly I'll discuss with the patient taking the fluid out of the knee and that will help me determine whether there is just regular joint fluid in the knee or whether it's blood. And I know. If there is blood inside the knee that we're taking out, it's a 90% chance it's either an ACL tear or a knee-cap dislocation.
Robert A. Kayal, MD, FAAOS:Right, yeah, the ACL is very vascularized, so that's one of the classic presentations where they get that pop and then that acute swelling. Well, that acute swelling is typically what we call in medicine a hemarthrosis, where the knee will fill with blood, completely fill with blood very quickly and cause pain and stiffness and swelling obviously. Now, typically a hemarthrosis or blood in the knee is often caused from an ACL tear or an occult fracture in the knee or possibly a what's called a peripheral meniscus tear. But typically when we get blood in the knee, that increases our index of suspicion for an anterior cruciate ligament tear. So now that you've done your physical exam, you're pretty sure that there is an ACL tear. You've taken blood out of the knee, potentially. What's next?
Jeffrey Pope, MD, FAAOS:The next step, after taking a look and removing the fluid from the patient's knee or assessing further, would be to get an X-ray. Plain films in the office are helpful to take a look at the patient's overall alignment and to 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, FAAOS:Right and we're also looking because there's blood in the knee that we want to make sure there's no fracture. You had mentioned the MPFL tear or the patella dislocation can also cause blood in the knee. So the X-rays help with the overall evaluation of the bony alignment of all the structures of the knee joint itself. So the X-ray is now a negative. Nothing's abnormal on the X-ray. What are you going to do to confirm your diagnosis?
Jeffrey Pope, MD, FAAOS:To confirm the diagnosis, we look at the soft tissue using an MRI. An MRI helps to tell us not just about the bone, but also the ligaments, the meniscus, the cartilage, the soft tissue inside the knee fluid as well, and make sure that, whatever is torn, we understand what and to what degree, and also know what is not torn and what is healthy Right.
Robert A. Kayal, MD, FAAOS:When these injuries occur, they're usually significant enough force to disrupt the anterior cruciate ligament, so these injuries are often associated with other concomitant injuries, such as meniscus tears, other ligamentous injuries, things like that In the acute ACL tear. What is the most common injury that's associated with that in the knee?
Jeffrey Pope, MD, FAAOS:So right when it happens when the knee shifts and sublux, the most common thing that's torn besides the ACL is the lateral meniscus. The outside part of the knee has a meniscus which helps to transmit weight from the top to the bottom part of the knee. When the knee shifts in a way that it shouldn't, it's very likely that when the bones pinch and hit each other, they disrupt the meniscus in the back of the knee as well.
Robert A. Kayal, MD, FAAOS:Absolutely so. That's just another reason why we like to get the ACL. We're usually pretty sure, based on the history and the physical exam alone, that the ACL is torn. The MRI just confirms that diagnosis. But it also assesses for other concomitant injuries, such as this lateral meniscus tear. But often there's other fairly classic pathodontic findings on an MRI that we appreciate. What are such findings?
Jeffrey Pope, MD, FAAOS:Dr Pope Sure. Most commonly we'll see bone bruising 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 bone bruises is because of the knee shifts in a way that it shouldn't and one bone hits the other in a way that it normally doesn't. The bottom part of the outside of your thigh bone will hit the back part of that shin bone and between the two, once the bones hit, they'll also pinch the meniscus during that injury. That's right.
Robert A. Kayal, MD, FAAOS:Very often these injuries are associated with lateral sided knee problems. We mentioned the lateral meniscus tear. We mentioned the lateral bone bruising. This is because it's a rotational problem. When this ACL is torn, the rotational component of the anterior cruciate ligament is predominantly the posterior lateral bundle that Dr Pope so eloquently alluded to earlier in his presentation. Dr Pope, now that you've gotten the MRI and you've reviewed the results with the patient, we've confirmed that the diagnosis is consistent with an anterior cruciate ligament tear. What's next?
Jeffrey Pope, MD, FAAOS:Next part is deciding on what is the next appropriate course for the patient. Not every patient that has a torn ACL needs ACL either repair or reconstruction. There's different types of patients, obviously, and those are the ones that we really have to tease out. Who's indicated for repair or reconstruction and who are our copers that may do quite well with nonoperative treatment. In general, at the beginning we start with nonoperative treatment for everyone Before we get our MRI results. We start with physical therapy. We start with bracing. We want to mobilize the knee.
Jeffrey Pope, MD, FAAOS:The reason we want to mobilize the knee is, with all the blood that's in the knee and the swelling and the soft tissue injury, there's going to be a lot of scar tissue. That scar tissue is something that's going to inhibit the patient's ability to move the knee. Sometimes, just with an ACL tear, it can become what we call a cyclops lesion. It can fold down on itself and become a mechanical block to motion. Other times we'll have ligamentous end meniscus injuries that will inhibit motion, such as a bucket handle tear of the meniscus, where it gets trapped in the joint, and that's something that cannot be mobilized appropriately. There will be different time points at which we look to schedule a surgery if it is something that is a surgical candidate, versus treating the patient with conservative modalities physical therapy, icing, anti-inflammatories to try to reduce the swelling at the beginning.
Jeffrey Pope, MD, FAAOS:Looking at these two different groups young patients that want to be active and be involved with a lifestyle that involves sports and rotational, cutting, pivoting types of activities there's absolutely no role for non-operative treatment for those patients unless they're something a medical condition they can't have surgery for.
Jeffrey Pope, MD, FAAOS:For the older patients that have osteoarthritis in their knee, that's more likely the patient that'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, improve their strength, improve those dynamic stabilizers that we talked about earlier the hamstrings and try to ensure that their knee is as stable as possible and they may not need a reconstruction or repair to get stability within their knee. Because we age and patients are getting more and more active at an older age, we're seeing the pendulum swing to a point where we're treating patients not necessarily based off of a chronological age. You're 55 and at that point you either can or cannot have any ACL reconstruction. We're looking to see how old would you look on a tennis court? How old, did you look on a basketball court? So we're not looking at your driver's license. We're looking to see how active you are and what kind of lifestyle you want to enjoy, and our indications have expanded to treating patients that are older, as long as we're not seeing significant degenerative arthritis.
Robert A. Kayal, MD, FAAOS:Yes. So to summarize, Dr Pope, if you have an individual or patient that's active, participating in a lot of planting, pivoting, rotational maneuvers soccer, football, volleyball, tennis, pickleball, racquetball those patients are going to get surgery, provided they don't have any significant arthritis in their knee. As they get older and develop arthritis and live a more sedentary lifestyle, one that does not entail a lot of planting, pivoting and rotational maneuvers, often those patients can be treated nonoperatively as what we call copers. So if you are participating in activities that we call inline exercises, where there's not a lot of rotational movement around the knee, then sometimes we can strengthen those patients in physical therapy and they'll have enough stability, because the ACL is not really utilized that much in those inline exercises.
Robert A. Kayal, MD, FAAOS:It's only really the planting, pivoting, rotational maneuvers and sports and activities that require a pivot or a rapid deceleration or a sudden significant change in movement or trajectory of that knee joint. That really relies heavily on the anterior cruciate ligament. But, like Dr Pope said, patients are living longer. They're living longer healthy, active lifestyles. More and more of them are participating in sports and activities that really rely heavily on an intact anterior cruciate ligament and because of that, most of us orthopedic surgeons are really treating those patients more aggressively to restore their quality of life to the lifestyle that they deserve.
Jeffrey Pope, MD, FAAOS:We don't treat patients just based off of what their intake form says. We treat patients a la carte, which is we listen to them. We have a discussion of what their wants, their desires as far as for the participating sports, or maybe a desire to be more sedentary, and that's a different discussion as well.
Robert A. Kayal, MD, FAAOS:Absolutely, and there are other reasons to do an ACL reconstruction as well or a repair. And what happens to the load on the posterior horn of the medial meniscus, for instance, if the ACL is ruptured? Are there other soft tissue injuries that can occur down the road, more in a chronic environment, if an ACL is left untreated? Absolutely.
Jeffrey Pope, MD, FAAOS:Dr Kale. The two things that are most of concern to me in an ACL deficient knee are osteoarthritis, which is loss of cartilage in the knee, and the other part is a tear of the meniscus on the opposite side of the knee. The inside part of the knee, the back part of the knee on the inside, is another restraint to translation or shifting of the lower part of your leg. If you involve cutting or pivoting your knee, if your ACL and your hamstrings aren't working as well as what they can to help prevent shifting of your knee, then the next thing that happens is the knee will pinch the meniscus on the inside of the knee, causing a medial meniscus to tear, particularly in the back of it, and that's more of a secondary chronic injury to happen in an ACL division knee.
Robert A. Kayal, MD, FAAOS:Right and I think that that's important to mention. And patients understand that the meniscus, like the ligament, is a static stabilizer. So if someone is going to proceed with nonoperative care and decide to try to strengthen the need to provide stability, the stability would then be coming from the muscles that are strengthened, specifically the hamstrings in particular. But if, for whatever reason, that stability is not intact enough to provide that knee with the stability when stressed, then there's going to be a significantly increased load on the backup to the ACL and that would be the posterior horn of the meniscus. So in the chronic situation, patients that end up proceeding with nonoperative care for an ACL tear very often develop posterior horn medial meniscus tears. Dr Pope already mentioned the fact that in the acute scenario patients, when suffering an ACL tear, often suffer a concomitant lateral meniscus tear. But in the chronic scenario, if left untreated, they often will endure a posterior horn medial meniscus tear. So in effort to avoid subsequent injury to other structures, some of us would encourage the patient to undergo an ACL reconstruction or repair.
Jeffrey Pope, MD, FAAOS:Absolutely, rob, and when we talk about injuries, we talk about in general, as surgeons, risks and benefits of surgery. But with looking at an ACL, you also have to speak about the risk and the benefits of nonoperative care. And again, one of those risks is an increased risk of potentially getting arthritis in your knee and secondary meniscus tear, on the inside part of your knee Exactly.
Robert A. Kayal, MD, FAAOS:So, now that we've decided to place these patients in physical therapy to rehab these knees, whether or not they're going to have surgery or not, what are we focused on in physical?
Jeffrey Pope, MD, FAAOS:therapy Early on. We want to regain motion. Motion is exceedingly important to get the scar tissue out of your knee and, as well, we want to work on stabilizing or strengthening, excuse me. We want to work on strengthening our dynamic stabilizers, which are our hamstring tendons and also our quad tendon. Our quad tendon is something that well. It doesn't necessarily help out our ACL. It's something that we'll get inhibited by having that fluid in the knee and the injuries. We really want to make sure both the front and the back of the knee are as strong as they can be.
Robert A. Kayal, MD, FAAOS:Absolutely, and if we're going to do surgery it's incumbent upon us to wait until that knee sort of looks like a normal knee right. We have to restore range of motion fully. We have to have good patella mobilization. There should be little to no residual swelling. Really the patient should have little to no complaints in that knee other than the instability from the deficient ACL correct.
Jeffrey Pope, MD, FAAOS:Absolutely, rob. There are a few indications for acute ACL repair or reconstruction. One of those is if you have a bucket handle meniscus tear that is locked in the knee and it cannot be mobilized, and in others, if there are other concomitant or other additional ligamentous injuries that provide the knee with minimal stability, there's a further risk.
Robert A. Kayal, MD, FAAOS:Absolutely. But I've seen in my own patient population that sometimes patients are frustrated. Right, they have the ACL tear. They want to get fixed immediately and they don't really understand sometimes why we're waiting so long to do their elective procedure. We don't want to operate in that milieu when there's tremendous swelling because, like Dr Pope mentioned, there's a tremendous amount of scar tissue that can develop from that hemarthrosis or blood in the knee. So it is really very, very important that the patients undergo typically about four to six weeks of physical therapy preoperatively to restore that range of motion, to get rid of all the swelling, to make sure that the knee looks and acts like a normal knee, except for the instability.
Jeffrey Pope, MD, FAAOS:Absolutely. It's important for the knee to become an area where it's going to be conducive to surgery. It's going to be appropriate for surgery but also gives you the time to develop that doctor-patial relationship and make sure that you're comfortable with the person who's taking care of you.
Robert A. Kayal, MD, FAAOS:Right, that's a great point. Okay, dr Pope. So our patient just completed his or her course of physical therapy and is now coming back to see you in the office. Let's assume that this patient has opted to proceed with some type of surgical repair or reconstruction of their torn antiochrocea ligament. What options are available?
Jeffrey Pope, MD, FAAOS:for this patient. Traditionally, when torn is torn, the ACL in general is not amenable to repair. It's something that you can't stitch because of the fluid inside the knee inhibiting the ends of the ligament to heal back to each other. The fluid will break down the fibrin clot, which is exceedingly important for the biology and healing of one end of the ligament back to the other. So if the ligament itself doesn't have the ability to heal for the most part, traditionally our teaching was to reconstruct a ligament, and reconstruction means to remove the ligament as you were born with and then to place another ligament in its place. There's a lot of different options for how to do that. It could be done with autograph, which means you take it from yourself. You can look at taking part of the hamstring tendons either one or two tendons to remove them from the leg and then to there. Therefore use them to reconstruct and to put in place of the ACL. That's something that is one very valid way of reconstructing the ACL.
Jeffrey Pope, MD, FAAOS:Another way is to take the bone patellar tendon bone, which is part of the kneecap, the ligament that goes from the kneecap down to the point of your shin bone, and a piece of bone at the end of that, the bone patellar tendon bone. It's something that can be used to reconstruct and has been for many years the gold standard of ACL reconstruction. It gives you very firm endpoints and allows for bone to bone healing, which is thought to be advantageous, especially in athletes. One option to look outside of taking the bone patellar tendon bone more recently is taking your quad tendon. The quad tendon can be taken with a piece of bone. However, with more advanced arthroscopic techniques, you can use just the soft tissue portion only of it. This is a technique that is more new. With this advance in arthroscopic techniques, you can instill the quad tendon within the knee anatomically in the area where the ACL was, and suspend it and allow it to heal without having to take any of the bone from the kneecap and therefore potentially decreasing kneecap pain and discomfort throughout the recovery.
Robert A. Kayal, MD, FAAOS:It sounds like in all these examples that you just nicely laid out for us, you're sort of stealing from Peter to pay Paul. You're taking certain body parts from the patient and transferring them into other areas to recreate this ACL. Some of that is, and must be, associated with a significant amount of morbidity to the patient right.
Jeffrey Pope, MD, FAAOS:You're taking more morbidity when you take the patient's own soft tissue. For some patients, they would just prefer not to have anyone else's tissues on their body and that's completely understandable. However, there is definitely more morbidity, which means more pain and discomfort with the procedure, potentially a little bit delay in them coming along and decreasing their pain and mobilizing afterwards after surgery.
Robert A. Kayal, MD, FAAOS:Yeah, I think you know traditionally the advantage of this autographed therapy where we steal from Peter to pay Paul, whether it be the bone patella bone autographed or the hamstring autographed or now the quadriceps tendon autographed. The advantage would be that the re-rupture rate traditionally has been lower than with allograft therapy. Allograft therapy is where we don't steal from Peter to pay Paul but rather use cadaver graft material to reconstruct the anti-recruciate ligament in our patients. It's certainly a less invasive procedure because we don't have to harvest from a donor site and bring that tissue to a recipient site. So it's definitely less invasive with probably a less painful post-opera of course and faster recovery. But the downside potentially is that there is potential very small risks of allograft donor morbidity but also potentially an increased re-rupture rate.
Robert A. Kayal, MD, FAAOS:So typically in very young patients, very athletic young individuals, will often proceed with autographed therapy as opposed to allograft therapy or possibly repair what Dr Rapov is about to talk to us about. But I think it's important to note that patients understand that they have choices when undergoing ACL reconstruction. There are different graft sites and both of us are very familiar and very comfortable proceeding with any type of these surgical options. But we often like to have conversations with our patients to discuss the risks and benefits of each type of procedure and make our decisions together with our patients, don't you agree?
Jeffrey Pope, MD, FAAOS:Absolutely, rob. The patient has to be involved, and without that you're not going to get the outcome that you want. So you want to make sure they're comfortable and you're comfortable.
Robert A. Kayal, MD, FAAOS:Absolutely so. We spoke about autographed therapy. Cadaver Allograph therapy is advantageous in a certain group of patients as well. Has there been anything recent that has come to the area of sports medicine and arthroscopy, as it pertains to ACL surgery, that you would consider maybe a game?
Jeffrey Pope, MD, FAAOS:changer Absolutely. Within the past five to six years, we've seen increasing arthroscopic techniques where we're able to, for certain types of ACL tears, instead of having to reconstruct it, which means to remove it, we're able to stitch it and fix it back to the bone that it tore from. So these advanced arthroscopic techniques are a repair as opposed to a reconstruction.
Robert A. Kayal, MD, FAAOS:Yeah, and you and I have done a bunch of these, and they're just really a fantastic new advancement in the area of ACL surgery in that we're essentially restoring the patient's anatomy. We're not disrupting any of the intact fibers, but rather repairing the fibers back to the bone. By doing this, it's certainly much less invasive. We're not stealing from Peter to pay Paul, we're not harvesting from a donor site, but rather we're keeping the intact torn anti-increase ligament and anatomically repairing it back to the bone where it tore off of. What are some of the advantages of doing that, as opposed to the ACL reconstruction that we discussed?
Jeffrey Pope, MD, FAAOS:One main advantage is to have the patient have a more normal feeling knee. That means that they can know where their knee is in space. It feels like when it moves, it is theirs, it's not someone else's. With that there's also a much easier revision of repair as opposed to having to revise something that was previously reconstructed. By revision I mean there's always a chance in the future that someone could rupture their knee, their ligament, again If they had a repair. God forbid.
Jeffrey Pope, MD, FAAOS:They had a devastating injury, a fall, a contact sport, and we see even more MMA and rotational twisting pivoting of these now that we used to. One does have another tear of that same ACL. It makes the revision of it, meaning redoing the surgery, much easier and transitioning to a reconstruction from repairing it the first time. As opposed to redoing a reconstruction where you worry about the bone tunnels, where you have to drill through expanding and having to graft them Potentially, you have to do it in a stage procedure where you have to take out what's torn, fill in the bone tunnels and allow them to heal. That and then do a secondary non-surgery thereafter. That's a great point.
Robert A. Kayal, MD, FAAOS:That's a great point. Essentially, after the repair you're dealing essentially with virgin anatomy. The bone stock is completely there. The real estate is there, whereas in the patient that had a prior ACL reconstruction that bony anatomy is already compromised. There's tunnels there. We have voids in the bone To do a revision and drill other tunnels. Potentially it can be a problem that, like Dr Pope mentioned, might have to be addressed in a stage manner where those bone tunnels are first filled in with bone graft, let that bone reconstitute and consolidate and then take the patient back three or four months later and do an ACL reconstruction after that bone stock has been restored. That's tremendously advantageous.
Jeffrey Pope, MD, FAAOS:One other potential benefit of doing an ACL repair versus reconstruction is it does have in quite a few patients a little bit of a quicker recovery Because you're not making bigger tunnels in the bone. They're much smaller. There's less bleed in the knee afterwards. The control over the thigh muscle is much quicker to recover from. Most patients get moving faster quicker with doing a repair than a reconstruction.
Robert A. Kayal, MD, FAAOS:Right. What are the indications for an ACL repair? Can everyone have one?
Jeffrey Pope, MD, FAAOS:Traditionally, most indications were for an ACL that was torn off one part of the bone or the other, either the thigh bone or the shin bone, Mostly in adults. If that was a case of a bone if that was a case, it'd be off of the thigh bone. However, there are some childhood injuries where you can actually pull a piece of the bone off of the shin bone and then that can be repaired as well. But to talk about the most common portion with adults, only tears traditionally that were right off the bone, where you have the whole length of the ligament, can be stitched up using advanced arthroscopic techniques and then secured back to the bone using different types of anchors or stitches to repair it.
Robert A. Kayal, MD, FAAOS:And sometimes we can't even tell right until we get in there.
Jeffrey Pope, MD, FAAOS:It's a discussion you always have to have with the patient. You can't say for sure when you go in that you'll definitely be able to repair it. It's something that is evaluated at the time and you always have to have the discussion that, if it cannot be repaired, the next step would be to reconstruct it at that point?
Robert A. Kayal, MD, FAAOS:Yeah, so both of us will tend to go into surgery talking to the patients that we're going to work in earnest to try to repair the patient's native ACL back to the bone. But, for whatever reason, if we can't do that, based on evaluation of the torn ligament, we would be prepared to do the ACL reconstruction at the same time. Correct, absolutely, yeah. And what about partial tears? Are partial tears of the ACL maybe a good indication to repair the one bundle that has evolved off the bone?
Jeffrey Pope, MD, FAAOS:Without a doubt, when there are partial tears and if a patient that is involved in cutting or pivoting or sudden stopping and jumping, that's absolutely a hard indication in discussion with the patient. To repair a single bundle, it's something that could be done very easily, whether it's the intramedial bundle, the main one that we look at with shifting of the knee from front to back, or the posterior lateral, which is involved with the twisted and pivoting.
Robert A. Kayal, MD, FAAOS:Yeah, I'd like to just emphasize that point because, like Dr Pope mentioned, each bundle has a particular function. So if you leave a patient with a compromised ACL, either the anterior medial bundle is torn or the posterior lateral bundle is torn. Some form of stability will be compromised and we want this patient to have a normal feeling knee, and so to do a repair of a partial ACL is one of the most beautiful operations because the other bundle is completely intact. So the likelihood that that partial tear is going to heal is probably so much better because it's not really feeling the stress or the load of a complete ACL tear. Correct, without a doubt? Yeah, absolutely so, dr Pope. In this era of orthobiological therapies, or what we call orthopedic regenerative medicine, has there been any technological advancements recently that have maybe allowed us to indicate more and more patients for an ACL repair as opposed to a reconstruction?
Jeffrey Pope, MD, FAAOS:Absolutely, rob. Previously, as we were discussing, repairs can only happen when the ACL is torn off of one end of the bone or the other. Now, with more mid-substance tears tears within the ligament, where it's not just off the bone we've expanded our indications for repair using a certain type of orthopedic biologic implant called a bare implant, and what that allows us to do is to stitch the ligament and also to bridge that gap, where the ligament is not surrounded in joint fluid, where it can't heal, and we stitch it to the, to the native ligament, we allow it to be in a better environment for healing and it's something that can bridge the gap, which we weren't able to do previously.
Robert A. Kayal, MD, FAAOS:Yeah, specifically that's what the bare implant stands for, right, the BEAR bridge-enhanced ACL restoration. So we're bridging that gap between the stump of the anterior crucial ligament and the bone to which it naturally inserts right. So we're bridging that gap and putting essentially a orthobiological, regenerative medicine, collagen-based implant in that interface to prevent the synovial fluid and the degradative enzymes from ever approaching that fibrin clot, which typically would preclude biological healing. So now you have this barrier, this bridged, enhanced allograft that is allowing the fibrin clot to form and for that ACL to heal back to the bone much more efficiently and readily has really revolutionized the way we're indicating these patients for ACL repair and it's really shifting that pendulum for many of us to really try to restore patients' normal anatomy. That's where we're at in 2023. We're really pushing the envelope and trying to repair things as opposed to replace or reconstruct things using patients' own anatomy and biology.
Jeffrey Pope, MD, FAAOS:One thing that we know, rob, is that the ACL wants to heal. We see that there's cell migration. That happens after you tear in your ACL. We know that there are growth factors in that area. We just need to get the joint fluid out of the way and, by using the bare implant, it allows us to take the ligament, put it right into this collagen matrix and then to allow it to heal to the bone, and it's something that happens over eight weeks. After eight weeks, the implant will slowly resolve and at that point you have this healing mesh, this healing matrix of cells that are able to ultimately give you a native ACL back.
Robert A. Kayal, MD, FAAOS:Yeah, it's beautifully put. I think the vendors have tremendously assisted us in this by offering these technologies Not only the vendors providing the bare implant, but other vendors that are providing us with better instruments and suture anchors, for instance, to fixate this graft back to the bone. Technology has improved significantly in that regard Without a doubt.
Jeffrey Pope, MD, FAAOS:It's taken a bigger procedure in making a more streamlined, making a more efficient, but also something that is less prominent to the patient and less painful.
Robert A. Kayal, MD, FAAOS:Right. What is this internal brace that we use in the operating room as well?
Jeffrey Pope, MD, FAAOS:Internal brace to me is a big part of ACL repairs as well as the bare internal bracing is able to give you a very strong suture that goes from one part of the anchor, the fixation that crosses the joint, and then goes to the other part, and is fixed as well in the other end of the bone. What it does is it allows the ACL to heal without having the stress on it that it would otherwise see and less likelihood that it's going to re-tare.
Robert A. Kayal, MD, FAAOS:It essentially parallels the ACL repair right, it parallels the ACL and it serves as literally an internal brace. It protects the repair by essentially serving the function of the anterior cruciate ligament, providing that stability along the course of the anterior cruciate ligament so that the repair can take place without excessive stress on the repair. It's really an internal brace or an internal splint to protect the repair until we don't really need it anymore. Over time that internal brace or that internal splint will weaken over time, but it really serves its function early on while that ACL repair is taking place and then we really don't need it anymore. It's almost like to extrapolate to fracture management surgery. When we put a plate or screws on a broken bone, that plate or splint is only used until the bones heal. Once the bones heal we don't really need the hardware anymore. We don't typically go in to remove the hardware, but we don't really need the hardware anymore To extrapolate from that concept to the area of sports medicine and arthroscopy and specifically ACL repair.
Robert A. Kayal, MD, FAAOS:That's exactly what this internal splint is doing and that also has revolutionized the way we're able to do these repairs, because it's protecting the repair, alleviating stress on the repair and allowing that biological process, that fibrin clot to form and for it to ultimately heal back to bone. It's not just us deciding okay, in 2023 we're going to do ACL repairs again. We've tried that in the past and it hasn't really done so well. It's fraught with complications. But now the pendulum is swinging back because of these significant advancements that we're outlining today the technologies from the vendors, the orthobiological therapies, the collagen barrier implant that's essentially a barrier to that enzymatic degradation of that clot, and the implants that are utilized now in the operating room to secure fixation and to augment fixation All of this has led us to our approach to the aggressive surgical management of ACLs via ACL repair.
Robert A. Kayal, MD, FAAOS:I think Dr Polk and I feel very strongly that if we had our choice, we would do ACL repair on every patient that had an ACL tear. We often go into surgery with that mindset that we want to repair that ACL instead of reconstruct that ACL, and less prove an otherwise intraoperably. Without a doubt, Now that we talk about ACL repair and postoper, of course, what's actually happening when something is being repaired? Or if we use, for instance, a graph whether it's an allograph or an autograph what's happening to that new ACL or that repaired ACL over the next year.
Jeffrey Pope, MD, FAAOS:As soon as the camera comes out of the knee, we have a healing response that starts.
Jeffrey Pope, MD, FAAOS:There are cells that migrate from around the knee, from within the ligament, from the bone that's there to work on healing. There are growth factors that are laid out and you see a revascularization of this area. If it's a repair, you see the ligament start to heal back to the wall, to the bone. If it is a bare implant, you see this implant of collagen start to become vascularized and, as well as it starts to shrink and then the environment that it's in is a biologic mesh of healing you see it start to revascularize and then, after revascularizes, it can get stronger. When you have other soft tissue cells that come in and hold down and put in a more thickened type of construct there. In regards to a reconstruction, when you're talking about the graft themselves or for the most part, either a cellular or, if it's autographed, you don't have much blood vessels there, you do see a vascularization. You see blood vessels that start to permeate the soft tissue and to give that soft tissue life.
Robert A. Kayal, MD, FAAOS: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 do with that. That's a biological process and for most orthopedic surgeons, most orthopedic surgeons would not allow their patients to get back to any sports activities for a minimum of nine months and in my hands, I typically recommend 12 months to protect that repair or that reconstruction so that it is revascularized and the collagen fibers have been formed in that graft or that repair is robust and strong and able to endure the stress associated with sporting activities.
Jeffrey Pope, MD, FAAOS:Absolutely, rob. On top of that, you also need to strengthen your dynamic stabilizers. While you're having your surgery and preoperatively, hopefully, you're strengthening your hamstrings. You need to make sure after surgery that you're strengthening them as well. You're gaining mobility in your knee and, again, you're gaining the trust in your knee. If you go out and you just want to play because it's been three months, you're not going to have that trust in the knee and you're going to suffer, likely another injury.
Robert A. Kayal, MD, FAAOS:Definitely physical therapies.
Robert A. Kayal, MD, FAAOS:Most of these patients are in physical therapy for six months to a year after this, and there's a lot of studies and literature that support that this biological process extends well beyond one year, two, three years after surgery, and so it's very, very important to give that ligament or that repair ample time to heal, because you don't want to go through this operation again and you definitely want to rehab it all along, like Dr Pope mentioned, and strengthen those backup secondary stabilizers and the dynamic stabilizers, especially the hamstrings, to support that graft for the rest of your life.
Robert A. Kayal, MD, FAAOS:On the note of physical therapy, I know earlier on we mentioned what we can do from a neuromuscular training perspective to try to minimize the risk of recurrent tear or tear to the other knee, because a lot of these cases are actually bilateral. If you tear one ACL, there's a significant likelihood that you're going to potentially tear the other ACL, and so during physical therapy and in sports preventative medicine, neuromuscular programs, we like to focus specifically on body mechanics, landing techniques and making sure that the core stabilizes, the abductors of the hip are stabilized and certain mechanics are focused on and addressed in physical therapy. What are some of the things we like to do, dr?
Jeffrey Pope, MD, FAAOS:Pope, most importantly, as we said earlier, hamstring strengthening. However, working with your athletic trainer and your physical therapist are going to be critical to your healing and your recovery. Making sure that you can have a hamstring curl that is at least 75% to 90% of your other side, your normal side. That's one goal that we look at. Another is to be able to single stance, hop on the surgical leg for 20 times to make sure that it's not going to buckle or give way. So there are a lot of parameters that we look at. As far as for thigh circumference, we'll take a tape measure, put it around that thigh and then compare with the other side, with the normal side, and make sure that we're within a centimeter of the other side.
Robert A. Kayal, MD, FAAOS:Yeah, and we also want to focus aggressively on agility, right Balance, coordination, proprioception like Dr Pope mentioned in the past, knowing where the limb is in space, a lot of plyometrics in physical therapy, box jumping and things like that. We really want to focus on all of those things and specifically when it pertains to jumping, we want to make sure that when patients jump and land they land properly. They land with their hips flexed and their knees flexed and their ankles flexed and we want to make sure that the shoulders and the hips and the knees and the ankles sort of all line up. I think that the main predisposing mechanical malalignment is occurring primarily at the knee.
Robert A. Kayal, MD, FAAOS:I think when patients land with a knock knee deformity or a valgus deformity, that significantly stresses the ACL and leads it to rupture. So we want to make sure that patients do not land with a knock knee deformity. We want to make sure that their hips are abducted, separated a little bit, as opposed to knees in. We don't want to internally rotate the legs. We want to make sure that when we land that the knees are over the ankles and the toes. We don't want to land with the knee extended in any way. So essentially, hips out, knees out, feet out. You don't want to have any internal rotation or a valgus malalignment upon landing, and that is critical to avoiding these. And these are things that we, as orthopedic surgeons, can quarterback and prescribe to help any sports program prevent ACL tears and, for the patient that was unfortunate enough to suffer one, maybe prevent it on the other side. Are these some of the things that you employ in your practice, dr Pope?
Jeffrey Pope, MD, FAAOS:Even some things as small as orthotics. If you have someone that has a flat foot deformity, you have a valgus knee, a knock knee deformity something like orthotics can help keep their ankle appropriately aligned. And if their ankles are well aligned, then hope their knee will be, and so on and so forth goes up the chain. You want to make sure that your knees are facing forward, as Dr Kaila said, not inwards. You want forward or out, so that way you land in the appropriate way, with less stress on your ACL.
Robert A. Kayal, MD, FAAOS:Awesome, so this has been a tremendously enlightening experience. Dr Pope, I'm so glad we finally got together to talk about this injury ACL tears such a common injury and I'm just so happy that you took the time to explain to our patients how we manage these. It was a very thorough conversation and hopefully very informative and enlightening to our patients. We hope that you found it helpful.
Jeffrey Pope, MD, FAAOS:It's a pleasure and honor to have you here today, Dr Pope. Thank you so much, Dr Pope.
Robert A. Kayal, MD, FAAOS:It's been an amazing 15 years and we're just so blessed to have you. So thank you for your time today. I'm so thankful to be here.
