(bright upbeat music)
- Welcome my friends to the Bob and Brad podcast,
produced by Bob and Brad,
the two most famous physical therapists on the internet.
I am Bob and I'm exactly one half
of the Bob and Brad team.
Today my guest is an orthopedic surgeon,
Dr. Brent Warner.
And Dr. Brent Warner does a lot of arthroscopic surgery.
He does the shoulder, and the knee,
and even the hip sometimes.
But today we're gonna talk about knee menisci
or meniscus and ACL surgery,
and also shoulder rotator cuff repairs.
So enjoy the program
and you'll definitely will learn something.
Welcome to the program, Dr. Warner.
- Hi, thanks for having me.
I really appreciate it.
- So let's switch gears here a little bit
and go to an ACL surgery,
in your recommendations.
- Yeah.
- So you know, this is the surgery I was afraid...
injury, I mean that I was always afraid
my son was gonna get.
So any inroads to prevention at this point.
- Yeah, absolutely, you know,
if you look really at any, you know,
especially kind of lay press stories on ACL injuries,
everything will tell you that
we're seeing increased incidents of these in young people.
Now, some of that's probably just because young people
are increasingly active, right?
There's all kinds of different sports
and activities they can get into.
And so it's just maybe a case of exposure, right?
More people doing more things
where they might possibly get hurt.
But you know, even apart from that, yeah,
it does seem like there has been some increase
in recognition and, you know,
incidents of these types of injuries.
So a lot of people are trying to figure out,
"What can we do to minimize that,
"to reverse that trend."
So there's a lot of good research that has been done
looking at ways to prevent these tears.
A lot of it boils down to
kind of the biomechanics, you know,
of the lower extremities
and really a lot of it kind of core strengthened things too.
So the way people say jump and land
and how their knees absorb that pressure and shock
how the knees might twist, you know,
inward or outward.
You know, strengthening all the muscles around the knee
and in the pelvis, and the glutes, and the core,
and all of that,
those have downstream effects on how the knee functions
and the biomechanics of it.
And some of these programs have been shown,
they really do look like they can help prevent
at least some part of ACL tears or some proportion of them.
Sadly, I don't think anything is ever gonna make
that risk zero.
But yes, these prevention programs I think can be great,
especially for particularly high-risk patients
or high-risk sports.
You know, one of the most high incidences we see
is in female soccer players, for example.
- Yep.
- There have been a couple of good studies out there
showing that if you, you know,
put your women's soccer team
through one of these prevention programs,
you are probably gonna see a decreased number
of these types of injuries.
- Sure, and now you're gonna get the question,
"Can it heal on its own?"
- With very few exceptions,
the answer to that one is no.
If we think about kind of where the ACL
sits in the knee,
it kind of makes sense too.
So there's, you know,
there's four major ligaments
that sort of hold the knee together.
On the sides of the knee,
you have the collateral ligaments, the MCL,
and the lateral collateral ligament LCL.
Those are actually sort of exterior
to the joint itself.
They are not inside like the capsular lining
of the joint.
So they're surrounded by, you know,
other tissues and a lot of blood vessels and things.
So injuries to those ligaments,
maybe have a bit better ability
to heal themselves.
The cruciate ligaments the ACL, anterior cruciate,
and the PCL, posterior cruciate ligaments,
they're actually right down in the center of the knee.
They kind of crisscross one another
and that's why they're called the cruciate ligaments.
They're like a little X in there.
They attach actually to the bone,
you know, one end attaches to the femur,
the other end attaches to the tibia,
and then it's basically suspended there.
And it just kind of floats in the fluid
inside of your knee.
And there's really no way for, you know,
blood vessels to bring nutrients to that tissue
to get it to heal.
So if you've torn your ACL,
the chance that it heals is very, very small.
- So basically the two ends can't find themselves,
I mean...
- Exactly, right, yeah.
The two ends can't find themselves,
there's some thinking that
tears that were maybe the ligament just kind of
pulls just directly off its bony attachment
because it's then, you know,
potentially close to the bone
and the bone has some blood fly.
Those are the ones that are felt like maybe those
can heal a bit better.
But yeah, if you have a tear kind of
right in the middle of the ACL,
which is honestly the most common pattern we see,
those ones really will not heal on their own.
- So just two surgeries, I guess,
reconstruction versus repair.
- Yeah.
- Can you explain the difference.
- Sure, the real mainstay of treatment is reconstruction.
So repair would be where you, you know,
take those two torn ends
and like stitch them back together to try to get that tissue
to heal primarily.
And that's something that was tried a long time ago
and most all the studies showed that,
that really failed in the vast majority of patients.
There's a small subset of those patients
where again, those tears that maybe that
the ligament pulls just off of the bone.
- Sure.
- So the majority of the ligament
is pretty normal.
It's just that, you know, one attachment point,
those ones did a bit better with the repair strategies
in those older studies.
And there has been something
of a return of that it's a little bit
in Vogue right now, where people, yeah.
Looking at more repair-type strategies.
Most of those are focused on those kind of specific tears,
but those are really, really in general, pretty infrequent.
And I think a lot of the jury
is still out on whether those repair strategies
are really truly working.
You know, are they as good
or are they better than reconstructions?
I'm not sure anybody has
kind of shown that conclusively yet.
And there's also a lot of really neat research going on,
where other people are trying to do repairs
and sort of add things.
To either, you know, kind of wrap around the ACL,
to kind of keep blood supply or other nutrients there
and sort of really augment that healing.
So, you know, eventually down the line,
is it possible that repair might become more viable
kind of everyday treatment for this?
I think that's possible, but as of today,
really, that's not the main treatment we see.
So again, you know, what we do much more commonly,
is we do a reconstruction.
So, what that means is that,
the damaged ACL tissue,
the torn tissue actually gets removed,
and it gets replaced or reconstructed
with a graft of some type.
We're taking new healthy tissue
and then basically implanting that inside of the knee,
where it becomes now the ACL for that patient in that knee.
- Is that as a surgeon, is that your biggest decision?
Like what kind of graft I'm gonna do, or?
- Yeah, it is certainly amongst the biggest decisions
when we're doing this.
There is a lot of number of different factors
that we think of, when we're kind of making that choice.
And typically that's a pretty big part
of the discussion I have with the patient,
you know, once we've kind of concluded that,
"Okay, surgery is the right answer", then yeah.
The next question that follows is,
"All right, what are we gonna use for that graft and why?"
- So what are the choices?
- Yeah, broadly broken down,
there's really kind of two categories.
So, you could either use tissue from that own patient.
And so that's called auto graft tissue,
or you could use tissue from a cadaver,
that's called allograft tissue.
- Sure, and what parts of the body
are the allografts?
- Yeah, yeah,
(Bob laughs loudly)
so, almost always, we're gonna take that tissue
from right around the same knee,
that we're already working on.
Sometimes in, you know, say revision settings,
where somebody might need
to be having an ACL surgery done over again.
We might end up taking tissue from somewhere else,
often, like the opposite knee or something like that.
But, mainstay of treatment,
is to have that tissue taken from right there,
at that same knee that we're already doing surgery on.
And then there are a couple of choices there,
that have their various kind of pros and cons.
The two that are, you know, probably still most common,
that most people might have heard of,
would be to use a part of the patella tendon.
So that's the tendon that attaches the knee cap
or patella to the tibia,
the shin bone, right in the front of the knee.
It's a nice broad, flat tendon.
And we can take a strip,
kind of right out of the middle of that tendon,
along with a little bit of bone from the tibia
and the kneecap.
And so that's kind of maybe the sort of,
oldest sort of gold standard tried and true graft.
That was one of the first ones
that people used for this surgery,
back when it was developed.
Another would be to use hamstring tendons.
So, that's another one that's very, very common.
So, your hamstrings are the muscles
that run down the back of your thigh.
And two of those muscles have pretty long slender tendons
that actually attach to the shin bone,
kind of right below the level of the knee joint.
And so we're able to harvest,
as the term we use, basically harvest, those tendons.
And then kind of fold them up on themselves
to become the right length of an ACL.
And that becomes the graft.
So, those are probably the two most common worldwide
and in the US.
The third option, which has become
a bit more popular here recently ,
and which I honestly am quite a fan of,
is to use a part of the quadriceps tendon.
So, the quadriceps muscles,
are the thigh muscles on the front side of the leg.
And the quadriceps tendon is a nice,
big, thick, wide tendon, where those muscles
come down and then attached to the top
of the kneecap or the patella.
And so somewhat similarly to the patella tendon graft,
we basically take a strip of that,
tendon kind of right out of the mid portion of it.
We're able to, you know, repair that back afterwards,
and that has become a really nice,
reliable graft for us that I like quite a bit.
- So you said, Lapia asked, is this a painful surgery?
- You know, it does tend to be a bit painful.
To implant that graft inside of the knee,
we're doing a combination of both
arthroscopy and kind of open surgery.
So, arthroscopy means, I've got a little tiny camera,
down inside of the knee
where I can see everything up close
and magnified on a screen,
that kind of sits, you know, just a few feet away.
And then we also do have to make a couple
of different incisions on the knee.
One of those is gonna be, to harvest that graft tissue,
another one or two of those incisions are gonna be,
to help us actually implant that graft into the knee.
And to do that, we drill tunnels,
we drill holes in the bone of both the femur and the tibia,
right where that ligament would normally attach.
And the graft essentially gets kind of pulled
into those little tunnels.
And secured there in some way,
there's a number of ways to do that.
So, with all that work, usually a couple of incisions,
drilling holes in the bone, you know,
borrowing tissue to become our graft,
that does all cause some pain.
Now we do as much as we can to combat that
for the patient, right?
You know, they're gonna be a sleep
during surgery under anesthesia.
So, they feel anything during the procedure itself.
Here at my group and I think most places were very high
on using what's called regional anesthesia as well.
So, that means that anesthesia our providers there,
would actually give an injection of some anesthetic
numbing medication to that patient into their leg.
Which is gonna basically numb the knee,
and the majority of the leg along with it.
So typically when patients wake up up from surgery,
they don't have all that much pain right away.
That block, typically is gonna wear off within a day or so.
And usually they will see their pain increase somewhat,
but then we help them control that,
they're gonna have a couple different types
of pain medication,
they're gonna be icing their knee,
they're gonna be in a brace to help protect it
and control, you know, how much motion it can go through
and that kind of thing,
all of which is gonna help.
And so, yes, the first couple of days,
once that block is worn off,
that can be a little tough for people.
But, also very manageable, right?
And typically within a week or two of surgery,
people are starting to feel more like themselves again.
- Well, thank you again, Dr. Warner,
very impressive, great information
and hope some people will check you out
because, you're again in that zone.
(both laughs loudly)
A lot of surgeries, but you're young, so
all right. - Yeah.
- Thank you so...
- Thank you so much for having me.
It's been fun, I really, really appreciate it.
- Yep, thanks for being on.
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