Wiemi Douoguih, MD, Orthopedic Surgeon at MedStar Orthopaedic Institute at MedStar Washington Hospital Center, talks about repairing torn ACLs.
Interview conducted by Ivanhoe Broadcast News in October 2019.
When talking about ACL tears, what’s happening?
DOUOGUIH: The ACL stands for the anterior cruciate ligament – cruciate because it crosses with the posterior cruciate ligament. They literally make the shape of a cross in the knee. The anterior cruciate ligament, I like to tell my athletic patients is, like the quarterback of the athletic knee. So, when you tear the ACL, you sort of lose your way. You don’t have any leadership. You don’t have a guidance. So people that have torn their ACL really have a difficult time, if not, impossible time playing, cutting and pivoting sports. Sometimes if they run in line or if they swim, they can get away with not doing anything. But people that do basketball, ski, hockey, football, soccer, it’s almost impossible.
Why would it be impossible? Because of the back and forth movement?
DOUOGUIH: Because the knee unpredictably gives way. You’ll be running along and just when you need to make a move, suddenly it shifts. The knee collapses, person falls to the ground or injures something else. It’s just a very disconcerting feeling. And people don’t have the confidence to play sports after they’ve torn ACL in most cases.
What have been the traditional ways of repairing ACL tears?
DOUOGUIH: The traditional way or conventional way of fixing an ACL is by replacing it. You take a tendon from somewhere else in the body and that tendon acts like a rope and hopefully will keep the knee stable. In most cases, it does a very good job. In fact, when I finished my fellowship training back in 2003, I thought we were essentially perfect at it. You know, you’re almost brainwashed into thinking it’s perfect. But now we’re in the era of big data. So, we see that some of the earlier studies had biases. We’re sort of sifting out some of the bad data and finding that maybe we’re not quite as good as we thought we were at fixing the ACL. We used to think it was just a musculoskeletal injury when in fact it also has a strong neurophysiologic component. When you take out the ACL and replace it with a dead tendon from somewhere else, you’re losing nerve fibers that act like a neural connection, like a circuit. So, you’ve broken the circuit. What happens in the human brain is that it’s like a GPS system. You take a wrong turn, the map disappears. You must pull over to the side of the road and wait for it to recalibrate. Once it recalibrates, it gives you a totally new map. This is analogous to the scenario in which the patient has undergone a conventional ACL reconstructionand it may take 18 to 24 months to re-establish that map in your brain. So, the athlete is really at a deficit for a long time after that surgery and they may never get quite back to where they were before even though you have a mechanically stable knee.
Are you in some cases taking tendons from that athlete and removing them? Is there also a secondary wound or a secondary area that needs to heal?
DOUOGUIH: Absolutely. And that’s the gold standard treatment for ACL reconstruction. It involves taking a strip of tendon from somewhere else, whether it’s the patellar tendon, the quadriceps, or the hamstring. It’s sort of robbing Peter to pay Paul in a sense that you’re taking something from somewhere else and now you have a little deficiency there. It can affect the rehabilitation because it’s painful. And in the case of hamstrings, for example, you’re losing an element that helps the knee do its job dynamically and potentially exposing your new reconstruction to an increased chance of failure.
Tell me a little bit about the new procedure that you’re using.
DOUOGUIH: The new procedure involves repairing the ligament and then augmenting it with a Kevlar-like laced suture that goes through the middle of it and acts like a seatbelt or checkrein while you’re healing. Studies in pigs have shown that if you just repair the ligament, it’s not enough. You must add some sort of scaffold so that while it’s healing, you’re protecting it, otherwise it’ll fail. When they added a scaffold and compared the results of reconstruction with an augmented repair, they found that they were very similar and maybe even superior in the case of the repairs. This preclinical work has led some to think of re-examining a surgery we discarded years ago. Back in the ’70s, ACL repair was discarded because the results were “abysmal” on paper. I say abysmal in quotations because that’s what the authors concluded irrespective of the actual findings. But, as I’ve thought about biological preservation of the ACL and some new ideas have come forward, I go back and look at that the old papers with a new lens. Maybe there was a subset of those patients that we threw out that were going to do OK. One of the problems with the old methods of ACL repair was the way we treated them after surgery. We’d lock them up in a cast for six weeks with the knee bent 20 degrees. The other problem was maybe people were repairing ligaments that were too damaged and lumping them in with ligaments that were probably appropriate to get fixed. So, we said, it’s only 40% of patients that are doing well, so we’re just going to throw that away. That’s an F on a test so that’s no good when instead maybe we should have been more nuanced and said hey, listen, maybe there’s a subset for whom repair is actually appropriate. My interest in ACL repair is a little bit of a convoluted route, but it started by taking care of a professional baseball team. We had a catcher that went down with an injury to his knee, and he tore his ACL. I recommended we do a patellar tendon replacement. We’d take a piece of the patella tendon and replace the ACL. And he said, you know, I trust you. But my agent, he usually has me go see a guy in Colorado by the name of Dick Steadman, famous orthopedic sports medicine surgeon at the time – he recently retired. He had a technique where he apparently just pokes some holes in the bone to stimulate a healing response and lays the ligament back down. Then he repaired it. I was thinking, this is not going to work, there’s no way. I called another renowned orthopedic surgeon who I would often consult with who’s a friend and a mentor to get some advice. I was convinced there’s no way this is going to work. He came back, six months out, spring training. I thought for sure he was going to be sloppy and lose and I was going to tell him he’s going to need a reconstruction. I went to evaluate his knee, and it was stable. Now four years later, he was still playing in the league. Got his starting position back. Then four years later, he re-tore his ACL. So, everyone was saying he should have just had it fixed the way you recommended. People were sort of patting me on the back saying, you got it right the first time. And then I thought about it. He had four more years as a starting catcher in major league baseball. It’s possible that if he had it reconstructed that maybe he wouldn’t have done it. In the meantime, some other things that happened sort of opened my eyes to a new way of looking at dealing with ACL. I was giving a lecture in Florida about a shoulder procedure that I developed. After I was done, a gentleman comes up on stage with a kilt and horn-rimmed glasses and a polka dot tie and says, I’m fixing the ACL. And everybody looked at each other like, you know, crazy. I was still of the mind that we don’t repair ACLs. We reconstruct them. We take a tendon from somewhere else. It doesn’t work. Very dogmatic in my mind. I was convinced. I listened to the guy speak and I thought it was interesting. He had about 20 patients. When he came back the next year, he’s got 50 patients. Next year he comes back, he’s got 150 patients. He’s got two failures, and there’s a Premier League soccer player that he’s operated on. I called him up and said you need to come to the United States. I have a lab here at MedStar Washington Hospital Center. He came and gave us a lecture. He showed me some compelling video of people doing things two and three weeks out after their surgery that I wouldn’t even think of having my conventional ACL reconstruction patients doing. He said between the internal brace and the repair of the native ligament I’m getting my folks back faster. And, if it fails, you could always go back and do the ACL reconstruction. It’s as if you’re doing it on a virgin knee because the surgery could create such minimal damage to the knee. So, I did my first ACL repair back in August 2014 on a yoga instructor. I saw him at his six-month follow up and his knee felt stable. I told him I think you can go back to instructing yoga again. He says well, I went back to yoga instructing in two weeks. It dawned on me that he just went back after two weeks, and now six months later his kneeis stable. He’s now five years out. So, it was really eye opening for me.
You’ve mentioned the Kevlar and the internal brace. What is it that you’re doing when you’re in there?
DOUOGUIH: The internal brace is a high-tensile strength braided suture that because of its strength and the way we anchor it, it prevents the stresses that the knee sees from being imparted to the ligament as its healing. It’s been shown in the lab now that over time that stretches out, which is good because eventually you want the ligament to see stress. But it stretches out in such a way at a time when the ligament is no longer vulnerable. We’ve looked at this in the lab by cycling the knee and sort of estimating what the stresses would be after surgery to find out what happens. Now in the old days, we were worried about these augmentation devices stress shielding the ligament. So, it never saw the proper stress. Then when it did see the stress, it was too weak and didn’t heal. It had atrophied. That was part of the reason why we thought maybe it failed. But with newer generation augmentation devices, specifically internal brace, it seems like it perfectly stretches out at a time when the ligaments healed enough that it can withstand the stresses.
Can you describe for me how you go about actually performing the procedure? Is it minimally invasive?
DOUOGUIH: Absolutely. It’s minimally invasive. As you described, there are little tiny holes. We don’t have to make a big gash in the knee to harvest the graft. In fact, when I first started doing these, I had a therapist send a patient back and said go tell your doctor he’s full of nonsense. There’s no way he did an ACL surgery on you. We laughed when the patient came back because they just weren’t used to seeing it look like a knee scope. It looks like a simple knee arthroscopy. So, the less trauma that you see, the quicker your rehab’s going to be. I’ve seen patients have less atrophy, which I think is partially attributable to the lower trauma that you experienced. But it’s also due to the fact that you’re preserving the circuit. You keep the native ligament, so you keep the nerve fibers that send the message to the brain, so that it can send information to the quadricep muscles and the pelvic muscles that help deliver the motion components of the knee.
When I hear Kevlar, I think of heavy-duty police vests. Is that the strength of the material?
DOUOGUIH: I say Kevlar because people associate it with a bullet-proof vest. It’s like Kevlar in terms of its tensile strength. But I say Kevlar almost colloquially because it’ll help people envision what you’re putting in the knee. People ask if it is going to be harmful to the knee, or can it be toxic? It’s been used in over a million applications now in the human body, in multiple different ways. It’s something that we used before it was an internal brace to help stabilize or pass a ligament or repair a rotator cuff into the knee. So, it’s something that’s biologically inert and safe. It’s been FDA approved. It’s something that’s not experimental but going to be safe.
What kind of rehab is involved?
DOUOGUIH: The rehab really doesn’t change. The only thing that changes is I lose sleep at night worrying that they’re going to go too fast because they feel too good. It begins with weight, their early weight bearing, early range of motion, beginning to get the muscles strengthened and then resume functional activity when they’re pain free and the swelling is gone. Usually by two weeks, their gait pattern is virtually normalized, where I find some of the folks that we do ACL reconstruction on it can take six to eight weeks, sometimes three months before their gait normalizes. Brian was a great patient, a model patient. He played hockey and skis and really wanted to get back to these activities. He had the procedure and had a fantastic recovery. He was able to return to downhill skiing at 10 months, post-operatively. He was able to get back to competitive hockey, recreationally and really hasn’t looked back. From an early stage, he was able to get back to walking and just general function quicker than I would have expected with a conventional ACL reconstruction and really didn’t have many complaints.
What is the rate of recovery like with ACL reconstruction?
DOUOGUIH: Reconstruction at 10 years, there’s about a 40% risk of osteoarthritis. At 20 years, it’s up to 60%. In young athletic patients, there’s up to 30% incidence of new ACL injury after a conventional reconstruction. So, we know that the gold standard is not perfect. I don’t even know if you want to call it gold. It’s what we have available. It’s pretty good. But it’s not perfect. I explain that to the patients. I say we’re going to do something that preserves your normal anatomy for the most part. If it doesn’t work, we could always go back and do the other. And as it turns out, it’s been successful. We just presented at a national meeting our first 28 patients with minimum two-year follow up. We had a 14% failure rate in that first 28 patients. But the remaining patients were able to get back to their previous level of activity without restriction.
Is it still considered experimental or is it FDA approved?
DOUOGUIH: It was never considered experimental when we started it in the sense that ACL repair has been performed since 1920. It was discarded by most surgeons in the 1970’s because there was overwhelming data at the time that ACL reconstruction was superior to repair. Again, if you look at the literature from that era, some of it was flawed or I would say that some of the conclusions were flawed and weren’t nuanced enough to be able to make these big blanket claims. But we do know that reconstruction is good enough bit to get rid of repair altogether may not have been the right answer. Now, we’re seeing that with increased athletic participation from a young age, earlier cases of ACL injury, people getting younger and younger at the time of ACL injury now becomes more important. If you injure your knee at 30, you develop arthritis by the time you’re 50. And, a lot of people get arthritis in their knee by the time they’re 50. But if you’re 13 or 14 and you injure it, by the time you’re 30, you may have a knee that functions like a 65-yearold knee or a 70-year-old knee. There are all kinds of data now showing that there’s health problems associated with arthritis.
How long does the procedure take?
DOUOGUIH: It’s shorter than doing a conventional ACL reconstruction. Usually it takes about 35 to 40 minutes to do an ACL reconstruction and about 25 to 30 minutes to do the repair. So, it shaves down about 10 to 15 minutes. Brian had described it to us as almost a rope tying everything together.
Could you expand on that a little bit?
DOUOGUIH: You put stitches into the native ligament and then you pass the rope through the center of the ligament, or around the ligament. So, you’re doing two things – you’re repairing the native ligament and then you’re augmenting it with this rope that we call the internal brace.
Is there anything I didn’t ask that you would want to make sure people know about what you’re doing?
DOUOGUIH: This surgery is not for everybody. It’s important to understand that the vast majority of my patients still get a conventional reconstruction. If the ligament is shredded and the location of the tear is more in the mid-substance, those don’t seem to do as well. The ones that are torn right off the bone and the ligament is otherwise preserved and appears healthy seem to be the best candidates or a high-grade partial tear of the ligament that confers functional instability to the knee. Those seem to be the ones that do the best.
It’s amazing what you can do to repair the body that you couldn’t do five years ago, 10 years ago…
DOUOGUIH: Yeah. Well, the thing is, what’s funny about this is you could do this 30 years ago when people threw it out and they didn’t realize maybe you’re throwing out the baby with the bathwater. Maybe it is applicable in certain patients. I don’t do this in all my patients. I think that’s the only thing I would add is that most patients in my practice I’m still doing a conventional reconstruction.
Does insurance cover it?
DOUOGUIH: Insurance covers it because it repairs something that has been done for a long time. With augmentation of the repair, it’s basically a reconstruction. So, insurance companies look at that the same way.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
So Young Pak, MedStar Washington Hospital Center PR
202-877-2748
Sign up for a free weekly e-mail on Medical Breakthroughs called First to Know by clicking here
