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Prakash Chandran (Host): If you've ever had a torn ACL, then you've likely been offered reconstruction surgery, wherein the injured ligament is replaced using new tissue. But did you know ACL repair is another route that can get you back to activity much faster? We're going to talk about it today with Dr. Carlo Orlando. He's an Orthopedic Surgeon.

This is Healthy Conversations. I'm your host, Prakash Chandran. So, Dr. Orlando, thank you so much for joining us today. I really appreciate your time. Now, so many of us have heard of the ACL and ACL tears. I was hoping that you could start with an overview of what the ACL is and why it gets torn.

Carlo Orlando, MD, FAAOS: The anterior cruciate ligament, or ACL, is a very important ligament that stabilizes your knee, especially when you're doing any kind of pivoting or twisting activity. It's a nightmare when athletes hear that word that they tore their ACL, because that usually means they're out for an extended period of time, up to a year, before they can return to their sport. So that's the last, one of the last things they want to hear that they tore. It is a very important stabilizer in the knee as I described. For everyday walking, you don't need it, but for any kind of aggressive pivoting and twisting activity, your knee will buckle or give out or partially dislocate if your ACL is not functioning properly.

Host: Okay, that makes a lot of sense. Now, I am assuming that it gets torn usually in sports, right? Whether you're, like you said, you're pivoting, maybe that's basketball or maybe even skiing. Is that correct?

Carlo Orlando, MD, FAAOS: Yes you can happen just very rapidly, quickly getting out of a car too quickly, or sometimes getting up from a kneeling position suddenly and pivoting and twisting, but there's always some kind of pivoting and twisting activity. It doesn't have to be a sport. It's most common in the sport, but, twisting to get in out of a chair. And if you're going from an awkward position, it can happen.

Host: Okay, understood. So when the ACL gets torn and diagnosed that it's torn, can you talk about the different paths of repair that are traditionally used to fix the torn ACL?

Carlo Orlando, MD, FAAOS: Well, the gold standard for years and years was not to repair it, it was to reconstruct it. The ligament was torn and the ligament is a tissue that attaches two bones together. And it's a white tendinous looking tissue. Up until about 10 years ago, the only option were to live with a torn and use a brace and possibly not be able to participate in those activities that involved aggressive pivoting, twisting, or to have it reconstructed or rebuilt.

And that means we have to make a new ligament out of some tissue and the question is where do you get the tissue from? It can be from part of your own body, you can use a tendon, your hamstring tendons, you can use your patellar tendon, you can use your quadriceps tendon, or you can use your allograft which is a tendon from a cadaver that can be pre ordered by your surgeon and used instead. There's a big difference in the failure rate in patients using cadaver tissue. There's a higher failure rate in younger active patients. So we don't like using cadaver tissue in patients that are very active and competitive. Say they're 30 years or younger.

Patients older that aren't very active, or if you're younger and you're not very active, you can use a cadaver graft. But so the procedure is outpatient and it's been that way and it takes an hour or so, but the recovery takes 10 months to a year. So when I say 10 months to a year, 10 months to a year before you return to play at your sport. You're back to strength training,maybe doing some jogging, riding a bike in a couple months, but actually returning to playing football, soccer, basketball, whatever, at the same level, it's 10 months to a year.

Host: Wow, that is quite a long time, and I can understand why you mentioned earlier that so many athletes kind of dread hearing that there's an ACL tear, because it just ruins their entire season and their entire year. So, what you just talked about was reconstruction. Let's talk a little bit about repair, the more non-obvious approach, and talk to us about some of the differences and also the recovery time associated with it.

Carlo Orlando, MD, FAAOS: So, when I was in training over 30 years ago, you never talked about repairing the ACL. They always failed. And that's because there was not a good technique or good way of repairing this. The ligament is only, it's about an inch long in the center of your knee. So was very difficult to try to repair it.

So we would either live with it or reconstruct it. And then about 10 years ago, we started realizing, well, wait a minute, we repair other ligaments in the shoulder, the elbow, the ankle, other joints. What makes this different? We thought it didn't have the capacity of healing. So some of the instruments and tools that we use to repair ligaments, say in the shoulder, we started playing around with realizing, wait a minute, we can use these in the knee.

And we can use the same techniques that we do in the shoulder in the knee. So we started playing around with it and realizing, yes, that now instead of replacing the anterior cruciate ligament, why not just repair it? And the patient keeps their own ligament. The surgery is faster, the recovery is faster, the feet, the knee feels more natural because you're keeping your ACL.

And sometimes you can't repair it. Sometimes it's shredded. It's torn in the middle and there isn't enough tissue to reattach to the bone. But the analogy I like using is kind of like a boat tied up to a dock. If the rope that attaches the boat to the dock, the cleat, the cleat where the rope is attached to the dock.

If the cleat rips off of the dock, why replace the rope? You just, put the cleat back on and it functions. So if the middle of the rope tears, you need a new rope. And it's the same thing with a torn anterior cruciate ligament. If it's torn in the middle, repairing it is not very successful. But if it just rips off the bone and there's enough length, why not reattach it and keep it?

So we started playing around with it. We started doing it. And it works. So we can't fix it in everyone. We won't know until we're actually in there looking at it, playing with it during surgery, if it can be fixed. And if it's fixed, we fix it. If it can't, then a backup plan, we have whatever tissue we're going to use to rebuild it available, that would be plan B.

So, I schedule my patients and I tell them we try to fix it. If we can fix it, that means you're going to get back to your activities in half the time if we can repair it. So, but unfortunately we don't know until we're actually in surgery looking at it and actually grabbing the tissue and seeing if we could, there's enough tissue there to put sutures in that will hold and repair it back to the bone.

Host: Okay, so this is not something you can necessarily assess during an x-ray or some sort of MRI, rather.

Carlo Orlando, MD, FAAOS: Not always. No, correct. You can assess sometimes it's been torn for so long and there's no, you can see on the MRI that there's no tissue there. Then you know, okay, that's not fixable. There's nothing there, but the after time, a lot of times the anterior cruciate ligament reabsorbs, it dissolves.

And on an MRI, there'll be an empty space where it belongs. Okay. We can't do anything about that. But sometimes it's, if it's a fresh tear, you can see on the MRI that if it's ripped off the bone, which a good percentage of the time it is ripped off of the bone itself, you can repair it, but you still, you don't know the quality of the tissue until you get in there arthroscopically.

What that means is when you put the camera in the knee and you look at the tendon, you look what's the damage, what's left and see if there's enough tissue that you can sew back to the bone.

Host: Okay. Tell me about the recovery time. Now you mentioned half the recovery time. So is it true like it's four to six months instead of ten to twelve?

Carlo Orlando, MD, FAAOS: Yes. So again, yes, I don't know until the time of surgery. Sometimes it's completely torn off the bone and I have to repair it, and that would be somebody that would probably be about five or six months before we would let them return to play. Every patient is different also. Sometimes you go in there and only 25 or 30 percent torn.

The majority of it is still intact. Until this technique, we would look at that, and it wasn't torn enough where we would rip out what's there and put in a new one. We'd say, well, we'll see how this patient does down the road. It's not torn bad enough to replace it now. And it may be in the future, they'll tear it the rest of the way and we'll have to come back another day.

That wasn't very satisfying. So a lot of the repairs I do now are tears that are not completely torn. They're just partially torn or the ligament is a little loose. It's a little stretched out. I can tighten it up with these techniques. So those patients would probably get back to their activities in a couple of months.

So it just depends on how good the repair is and the quality of the tissue. So the better the tissue, the better the repair, the faster I let them go back. We don't actually. I'm starting to get an idea of how long we need to wait for the healing process. Initially I was waiting six, seven months and now we're realizing patients are ready to go and sometimes in three or four months, it just depends on the quality of the repair, and the quality of the tissue.

Host: Okay, and I'll, can you give us a sense of the percentage of ACL tears that you see that can be actually repaired versus reconstructed.

Carlo Orlando, MD, FAAOS: I should know the answer to that question. I'm very aggressive. I always will try to repair it, even if it looks hopeless initially. I will throw some sutures in and try it, and I abandon it if it doesn't work. But I would say for the ones that I see I would say probably about 40 to 50 percent could be repaired.

And I'm very aggressive about repairing even partial tears. Sometimes the ACL will look okay. But then when I examine the knee, it's a little bit loose. And then when I put the camera in there, it's not, it's just partially stretched or torn, but I will throw some sutures in it and repair it.

So I don't have to worry about it. But the ones that are completely torn that can be repaired. It's not, it's less than 50%.

Host: So let's say a student athlete is listening to this. They've just heard that they or they fear that they have, might have gotten an ACL tear. Talk a little bit about their journey in coming to you to make this assessment, and also talk about how they can speed in a repair through rehab and through physical therapy, because I imagine that also plays a role.

Carlo Orlando, MD, FAAOS: Yes, it does. So the student athletes, I'm the team physician for all the local high schools in our, in the North County of San Luis Obispo, where we are. So all the athletic trainers at the local schools, they have my cell phone number and I help them provide orthopedic coverage for all the local games.

So they text me if they have a kid that they think's injured or they're just referred to their primary care or for a family member to come in. Obviously we examine the patient and then if I think there's some internal derangement of the knee, meaning something is torn or something's not right, I'll order an MRI.

And then the patient will come back and review it. A lot of times patients come in, you know, they injured their knee over the weekend and we get an x-ray, nothing's broken or dislocated and they have a sore knee. They can't bend it. They can't walk on it. They're using crutches. They instantly want to get an MRI.

And I tell them, well, first of all, that's not necessary acutely right away. It's not going to change the plan. So initially, when they injure their knee, you want to make sure nothing is broken or dislocated. But an MRI is not going to change the plan initially, because even if there is something torn and the patient needs surgery, we don't do it until the knee calms down, until the patient gains their range of motion back.

So usually 10 days, two weeks later, I'll reassess them. The knee's calmed down. I can do a better exam. And then if an MRI is necessary, we'll order an MRI. So then we do that, they come in and review the MRI, and then I tell them, okay, your ACL is torn. My first goal is, again, need to get their range of motion back.

They need the knee, the swelling needs to go down. We don't do surgery on a stiff, swollen, hot knee because they come out of surgery with a stiff, swollen, hot knee, and the rehab is a lot slower. There's plenty of studies out there showing when athletes tear their ACL, you really need to wait about seven weeks before the knees calm down enough to do the surgery, so they don't have that increased risk of post operative stiffness and swelling.

So there's no rush. So you get the MRI, you get the range of motion back, and then they see how they do. If the knee is unstable with everyday activities, getting out of the car, going up and down stairs, and then we talk about surgery. If the knee is stable and they're not a aggressive athlete, we can rehab them, and brace them, and they can live with it, with the possibility that they could do further damage in the future.

You don't have to operate on everyone. So, if they're an athlete that, I see a lot of high school kids that want to go to a D1 school or something and obviously this is devastating, especially if it's in their senior year. But we try to get them on the schedule to get them repaired or reconstructed as soon as they get their range of motion and their knee calms down and then, they got to go through the whole rehab process.

The rate limiting step in a lot of these procedures is after a couple of weeks, a couple of months, they get their motion back. They get the strength back, the pain goes away, but the tissue isn't ready yet. It's not ready yet for aggressive pivoting and twisting. And that's why in the reconstructions, it takes a whole year because the day you put the tissue in the knee, it's really strong.

It's ready to go. It's a strong graft. Problem is after two, three months, the body converts that dead tissue into a live ligament and it's biomechanically weaker after the third or fourth month. The knee starts feeling better. They want to test it out, but that's when they could tear their graft, or that's when they could tear, re-tear.

So that's what takes a long time. All the studies have shown it takes about a year for biomechanically, the tissue to regain its strength. So that's the physiology or the biology of the healing that we have no control over. So that's why athletes don't return to play after ACL reconstruction for a whole season, and sometimes longer, because that's what we're waiting for.

Host: So, Dr. Orlando, is there anything else that you'd like to share about ACL repair before we close here today?

Carlo Orlando, MD, FAAOS: Well, ACL repair is now mainstream, but as of up until about five years ago, it wasn't. I was one of the only surgeons doing it around here. And even when I was in Los Angeles, I was one of the few that was doing it. But the bottom line is you're not really burning any bridges if you repair it, or if you try to repair it. If it doesn't heal, if they re-tear it, you can always do the reconstruction. The question is, which tears are likely to heal and which aren't. And that's, unfortunately, that decision you won't know until you try. If it's an absolute waste of time, if there's no way there's enough tissue, then I wouldn't put the patient through that.

I could throw sutures in it and make it work for a couple of months, but if I know it's going to fail, we won't do it. Then we just go to doing the reconstruction, but it never hurts to try. So I would say that seeing a surgeon that is comfortable both repairing it and reconstructing it would be important. And now in the last 10 years, it's become a more common mainstream procedure. It was not until about five or six years ago.

Host: Well, Dr. Orlando, thank you so much for your time. I really appreciate it. That was Dr. Carlo Orlando, Orthopedic Surgeon. If you found this podcast to be helpful, please share it on your social channels. And for more topics of interest to you, you can check out our full library. I'm Prakash Chandran, and this has been another episode of Health Healthy Conversations.

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