Adam C. Young, MD
Alan C. League, MD
Albert Knuth, MD
Alejandra Rodriguez-Paez, MD
Alexander E. Michalow, MD
Alexander Gordon, MD
Alexander J. Tauchen, MD
Alexander M. Crespo, MD
Alfonso Bello, MD
Ami Kothari, MD
Amy Jo Ptaszek, MD
Anand Vora, MD
Andrea S. Kramer, MD
Andrew J. Riff, MD
Angela R. Crowley, MD
Angelo Savino, MD
Anthony Savino, MD
Anuj S. Puppala, MD
Ari Kaz, MD
Ashraf H. Darwish, MD
Ashraf Hasan, MD
Bradley Dworsky, MD
Brian Clay, MD
Brian J. Burgess, DPM
Brian R. McCall, MD
Brian Schwartz, MD
Brian Weatherford, MD
Brooke Vanderby, MD
Bruce E. Noxon, DPM, FACFAS, FAPWCA
Bruce Summerville, MD
Bryan Waxman, MD
Bryant S. Ho, MD
Carey E. Ellis, MD
Carla Gamez, DPM
Cary R. Templin, MD
Charles L. Lettvin, MD
Charles M. Lieder, DO
Chinyoung Park, MD
Christ Pavlatos, MD
Christian Skjong, MD
Christopher C. Mahr, MD
Christopher J. Bergin, MD
Craig Cummins, MD
Craig Phillips, MD
Craig S. Williams, MD
Craig Westin, MD
Daniel M. Dean, MD
David Beigler, MD
David Guelich, MD
David H. Garelick, MD
David Hamming, MD
David Hoffman, MD
David M. Anderson, MD
David Raab, MD
David Schneider, DO
Djuro Petkovic, MD
Douglas Diekevers, DPM
Douglas Solway, DPM
E. Quinn Regan, MD
Eddie Jones Jr., MD
Edward J. Logue, MD
Ellis K. Nam, MD
Eric Chehab, MD
Eric L. Lee, MD
Evan A. Dougherty, MD
Garo Emerzian, DPM
Gary Shapiro, MD
Giridhar Burra, MD
Gregory Brebach, MD
Gregory J. Fahrenbach, MD
Gregory Portland, MD
Harpreet S. Basran, MD
Holly L. Brockman, MD
Inbar Kirson, MD, FACOG, Diplomate ABOM
Jacob M. Babu, MD, MHA
Jalaal Shah, DO
James M. Hill, MD
James R. Bresch, MD
Jason G. Hurbanek, MD
Jason Ghodasra, MD
Jason J. Shrouder-Henry, MD
Jeffrey Ackerman, MD
Jeffrey Goldstein, MD
Jeffrey Staron, MD
Jeffrey Visotsky, MD
Jeremy Oryhon, MD
Jing Liang, MD
John H. Lyon, MD
Jonathan Erulkar, MD
Jordan L. Goldstein, MD
Josephine H. Mo, MD
Juan Santiago-Palma, MD
Justin Gent, MD
Justin M. LaReau, MD
Kellie Gates, MD
Kermit Muhammad, MD
Kevin Chen, MD
Kris Alden MD, PhD
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Leigh-Anne Tu, MD
Leon Benson, MD
Lori Siegel, MD
Lynn Gettleman Chehab, MD, MPH, Diplomate ABOM
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Marc Breslow, MD
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Mark Gross, MD
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Michael Chiu, MD
Michael J. Corcoran, MD
Michael O'Rourke, MD
Nathan G. Wetters, MD
Nikhil K. Chokshi, MD
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Peter Thadani, MD
Phillip Ludkowski, MD
Priyesh Patel, MD
Rajeev D. Puri, MD
Rhutav Parikh, MD
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Richard Sherman, MD
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Scott Jacobsen, DPM
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Shivani Batra, DO
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Steven J. Fineberg, MD
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Steven M. Mardjetko, MD
Steven S. Louis, MD
Steven W. Miller, DPM
Surbhi Panchal, MD
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Teresa Sosenko, MD
Theodore Fisher, MD
Thomas Gleason, MD
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Todd R. Rimington, MD
Todd Simmons, MD
Tom Antkowiak, MD, MS
Tomas Nemickas, MD
Van Stamos, MD
Vidya Ramanavarapu, MD
Wayne M. Goldstein, MD
Wesley E. Choy, MD
William P. Mosenthal, MD
William Vitello, MD
ACL

ACL Injuries and Surgery

Episode 5

The Anterior Cruciate Ligament, or ACL, provides the knee the ability to do activities that require high degrees of cutting, pivoting, and accelerating. Dr. David Guelich explains, once the ligament is torn, the knee is largely rendered unable to perform these types of activities. Learn more about ACL injuries, how they are diagnosed and treated, what to expect if you need surgery, and about the typical timeline for recovery from ACL surgery.

Hosted by Eric Chehab, MD

David Guelich, MD

Featuring
David Guelich, MD

Orthopedic Surgeon with Fellowship Training in Orthopedic Sports Medicine

Episode Transcript

Dr. Eric Chehab:
Welcome to Illinois Bone and Joint's OrthoInform where we talk all things orthopedics, to help you move better, live better. I'm your host, Dr. Eric Chehab. With OrthoInform, our goal is to provide you with an in-depth resource about common orthopedic procedures that we perform every day.

Today, it's my pleasure to welcome Dr. David Guelich, who will be speaking about anterior cruciate ligament or ACL surgery. As a brief introduction, Dr. Guelich grew up in Utah and graduated from the University of Utah with a degree in biology in 1995. He earned his medical degree from the Medical College of Wisconsin, Milwaukee, in 2000 and after medical school, he came to Chicago to begin his residency in orthopedic surgery at Northwestern University. Dr. Guelich completed his surgical residency at Northwestern in 2005, and then spent a year in Texas at Baylor University School of Medicine, where he completed his advanced surgical fellowship training in sports medicine. Dr. Guelich returned to Chicago in 2006, where he has practiced ever since at the Chicago Orthopedics and Sports Medicine Institute, now part of Illinois Bone and Joint.

Dr. Guelich is deeply involved in surgery, education and training. He has been on the faculty at the University of Illinois Chicago sports medicine fellowships since 2009, and the program director there since 2016. This means Dr. Guelich has been training the next generation of sports medicine surgeons.

He's a fellow of the American Academy of Orthopedic Surgeons, the American Orthopedic Society of Sports Medicine, and the International Society of Knee Surgery, Sports Trauma, and Arthroscopy.

Dr. David Guelich:
Good morning, Eric. It's nice to be here.

Dr. Eric Chehab:
We're talking about the anterior cruciate ligament. What is the anterior cruciate or the ACL? And why is it so important?

Dr. David Guelich:
Well, the anterior cruciate ligament is probably the most studied ligament in the human body. I think there's maybe even tens of thousands of articles looking at the ACL and probably several reasons that's the case, but most importantly it's sort of the foundation of stability.
It's what provides the knee the ability to do things functionally that most of the joints can't do and really is a focus of study because once the anterior cruciate ligament is torn or injured, the knees really rendered dysfunctional, particularly for the things that require high degrees of cutting pivoting, what we call level one activities.

And as a result, it's injured commonly and it's also throughout different stages of life. We see ACL injuries in kids as young as preteens, and then obviously all the way into later generations. And as, as older generations have stayed active longer, we're not even seeing ACL injuries and potential surgeries and patients even in their sixties.

So, for that reason affects every generation. And it's been a high interest of mine and certainly orthopedic community.

Dr. Eric Chehab:
So what's life like for someone who tears their ACL? Before, any type of surgical procedure, what's their life like?

Dr. David Guelich:
Once an anterior cruciate ligament is torn, there's several different things to consider and the most important part of that is it is a traumatic event. So in many cases, particularly for younger patients, it's their first access point to medicine in general. And it's the first thing that's ever been wrong. And so I think one of the things that I always consider when I see a patient, obviously seeing a lot of ACL injuries, I always take a step back and try to get a sense of, who's coming into the room and, and how, what the effect that's going to have on their lives.

So whether it's a 17 year old, who's a potential scholarship athlete. If it's a 25 year old, young professional in Chicago if it's a someone from a community that has poor access to healthcare, and this is their first access or difficulty and challenges getting access to healthcare.

How do we address the injury specific to the patient that's sitting in the room? That's the first thing, what they notice probably more than anything is pain. ACL injuries are often quite painful. They're very disruptive to the knee joint. So there tends to be a lot of swelling, loss of motion.

And so, obviously we, the way we adapt the environment to them to make sure they're comfortable and how we examine them and process it with them. We want to be gentle with these patients and make sure they, we all remember that there's an injury here. In some cases, they're not that painful.
And in some cases we're even surprised that patients have torn ACL particularly in the setting of a second injury or in a patient who's had a prior ACL tear, but these are all different things that we kind of think about when we have patients that we evaluated.

Dr. Eric Chehab:
And so someone who injures their ACL, what would their life be limited by?

Dr. David Guelich:
So, it gets back to your first question. What is the ACL? It provides stability for a knee and it provides the ability to do more complex activities.

It also protects really important structures in the knee joint, and we know this pretty well now that the ACL's job is to create a knee joint that functions normally. And so when patients have an ACL deficient, knee or knee that doesn't have an ACL that's working correctly or surgery that's working correctly, they will have complaints of instability and that can manifest truly as the knee's giving out.

And that's pretty obvious to patients. In other respects, it provides a sort of environment where other injuries can occur. So, we can present with a torn meniscus cause the ACL isn't functioning correctly, or the ACL's torn. We can present with cartilage problems or both. And so sometimes we'll even, this well, we'll get patients come in and they have a meniscus problem and lo and behold, they didn't, haven't had a functioning ACL.

And so they thought they came in with one problem. And now they're leaving with two problems. Yeah. Yeah.

Dr. Eric Chehab:
How do ACL injuries usually happen? What's the typical mechanism you see?

Dr. David Guelich:
So, the classic injuries, what we call an indirect injury. So it's not such that, it's helmet versus knee. Those are slightly different types of injuries, but particularly in women athletics and indirect or non-contact injuries, more common. So it tends to be a near full extension or with any nearly straight in a force that's directed across the knee and then a pivot or a turn tends to be the mechanism of injury.

We see most commonly very common in skiing injuries as well, but not dramatic, oftentimes subtle injuries even with skiing. We know classically have great studies out in Vermont and how that we've first started to learn about ACL injuries was sort of a rotational moment with a knee near extension.
Now, clearly you can have a direct injury, a contact injury to the knee, and that's where we start to see more complex injuries where we see multiple ligaments injured. So it can be done in isolation. It can also be done in association with other ligaments.

Dr. Eric Chehab:
So, and cut change your direction type mechanism with the knee in a certain position is the usual mechanism not getting sideswiped or hit. That's not an common mechanism, but can happen obviously. And the ligament tears, it gets overloaded and gives out. And what will patients feel at the time? We frequently have patients come in saying they felt a pop or they heard a pop.

Dr. David Guelich:
Classic. And that associated with swelling, we know over 90% of the time is often associated with a torn ACL. I mean that versus a kneecap subluxing I mean, those are really the two mechanisms you most commonly hear and certainly present in the office.

Dr. Eric Chehab:
You and I both have a feel of when a patient comes in with an ACL injury from their history, their knee is swollen. They felt the pop but what other studies should a patient obtain in order to further evaluate the need?

Dr. David Guelich:
So classically an x-ray is helpful and it tells us a lot. It tells us both making sure there is a fracture, which actually can sometimes be confused for torn ACL, particularly with something called a tibial plateau fracture.

So plain x-rays are useful. And then classically MRI is really helpful and we get to that pretty quickly. swollen knee in my office gets an MRI pretty fast with this history, just because it's so helpful in evaluating these types of injuries.

Dr. Eric Chehab:
Now, typically we don't take the patient right away to surgery. There are some places that do.

And what happens over the first few weeks after an ACL injury? What are you asking your patients to do during that time?

Dr. David Guelich:
It's a really important point. And, and I really emphasize this with patients that. We need to get the knee back into a better position. We need to get you into a good position for surgery, and this is not an emergency.

There are some rare cases where it's important for us to get in there soon, but that's a rare event. So once the MRI is completed and we identify what we're dealing with, it's really important for these patients to get their swelling down, to get their quadriceps muscle firing again, to get all of their extension back.

In fact, if you don't get your knee all the way straight before ACL surgery, it's at least three or four times harder to get it back after. And those patients that don't, and we can talk about some of the challenges after ACL surgery. We'll battle that for a year. You know how that goes, and sometimes they'll never get it back.

So taking some giant step back, letting the dust settle, getting these patients into therapy early, getting their motion back in their quad function is really critical to a good result. That also gives the patients, the families that whatever that dynamic is time to start to really process through this and kind of look forward to what, the next year project's going to be as well.

So I think that's really important time for surgeons to take a step back with their patients, get them into, with a therapist as well that they trust because that's another really important relationship. And then moving forward and scheduling surgery in a, in a more processed way.

Dr. Eric Chehab:
The majority of anterior cruciate ligament injuries will eventually come to surgery, but let's go down the road of a non-operative patient. What's your typical patient who you treat non-operatively. What's their profile? What options do you offer patients when they injure their ACL for treatment. So let's start on the non-operative side.

Dr. David Guelich:
I mean, a non-operative managed patient can be, can be any age typically. I mean, especially as we get into the higher decades in life but it is important to give all patients an option of non-surgical management.

This is not going to cost them their life. This is a an opportunity for them to make that decision. Clearly a younger athletic patient, in my opinion, needs to have their ACL fixed. It's a generational issue and we'll protect them and hopefully serve them well over the course of the rest of their life.

As patients get out of the, and I, and I'm getting out of the forties as well as we get into the fifties and sixties classically those were treated more conservatively. I think there's more contemporary techniques that allow for good results in that age group as well. So I think that's a discussion to be had in that and that generation.

And a lot of it depends on also what activities these patients want. I mean, I have a very active skiing patient population and for those patients to not be able to ski because functionally, it really is important to have an ACL, then that's a discussion to have. So we've got to really make it about what the patients are interested in doing what their activities are.

I've said this often, you don't need an ACL to be a triathlete, right? You don't need one to run. You don't need one to ride a bike, you don't need one to swim, but we do need them to do cutting sports. So I think in that scenario it's good to have that dialogue. The other issue is what else is going on.

Sometimes the patient's well on their way to arthritis, and has an ACL deficient knee. We're not going to help a patient who's suffering from arthritic condition by fixing their ACL. We need to kind of look at overall the health of the knee. It's a big surgery. There's a lot. We'll talk about that.

But we want to make sure that we're offering these patients reasonably good choices. And in patients who have significant arthritis, they're probably not candidates for ACL surgery.

Dr. Eric Chehab:
Sometimes I'll present it as we have an option here to change your knee or change your life. And if you're changing your knee, you're opting for the surgery, so you can continue to do the things you like to do. And if you decide to change your life, you're dialing back your activities so that your knees stay stable. So you don't tear it up as you move through life. let's go to the surgical patient because that is the most common treatment for anterior cruciate ligament injuries.

We went through a little bit of the preparation preoperatively, that preoperative rehabilitation being so important for the outcome and normalizing the knee. Essentially being able to get the knees straight, being able to have the muscle refiring again, people's gait pattern returning more to normal before they even go into the operating room.

But let's go to the operating room. What's it like the day of surgery. This is an outpatient surgery for the majority of patients, correct?

Dr. David Guelich:
Correct. Yeah. So just as any outpatient surgery is and again, I kind of harp on this, but we all, I always tend to teach my residents and fellows that, you're in the operating room every day.

You're in the pre-op holding area every day, but these patients aren't. So I think identifying them early, getting them comfortable, finding a way to impart some humor early in the morning for them can sometimes be nice too, because this is a really, it's a stressful day and preparing the patients for seeing things and what they're going to go through that first morning of surgery is really important.

So we talk about that a little in the office, and then obviously we remind them when we see them. And all elective orthopedic procedures, we mark their leg. It's always a source of comedy for our patients, but we take that very seriously. And then they meet the anesthesiologist and we discuss some of the pain management issues.

And I think once again, here's where he seal surgery has really come a long way in how we manage pain, both before surgery. Typically they have something called a nerve block, which helps reduce the pain after surgery. Very simple procedure that's done. And then the return in the operating room. Put to sleep. And then we at that point prepare for surgery. I proceed from there.

Dr. Eric Chehab:
And I may have gotten a little ahead of myself with the questions you're going into surgery with a technique in mind of how you're going to fix the ACL. And that's the grafts choice discussion that we all have with our patients.

So I might hit the rewind button here just a little bit when you're in with the patient and you're deciding on how to fix it. There are different grafts that we can use. So, can you discuss the pros and cons of each of the most commonly used graft choices? We talk about using our own tissue or autograft or using donated tissue from a cadaver allograft. So let's start with the autograft tissue choices.

Dr. David Guelich:
Sure. A point of much debate. And I think if you were to get a hundred ACL surgeons in a room, there would be a discussion about this that would go on for hours. And my teaching is always that you need to be able to do them all and you need to know how to do them for all patients. And different patients benefit from different types of grafts. So the first thing to know is there is no perfect graft. If there was, there'd be one choice. Right? And so from an autograft standpoint, there's really three choices that we have. One is what's called a patella tendon or BTB bone tendon bone graft, which is taken from the front of the knee with a portion of bone from the kneecap, central tendon of the patella and then from the tibia. So that's bone, tendon, bone.

So hamstring grafts are an option where we take two of the three hamstring tendons from the inside or the medial side of the knee. It's a pure soft tissue graft and I would say there's probably dozens of different fixation techniques with hamstrings. Classically, a little less painful than a patella tendon and bone tendon bone and potentially a slightly faster rehabilitation due to that.

Concerns about hamstring weakness chronically with patients that you consider certainly distance athletes and others who may rely more on hamstrings. There is some consideration there. There's also only a specific size that we can get. So hamstring dimensions are what they will be.
So when we graft them, it's a certain number that we have. And so in certain larger patients, if they need a larger volume ACL, it may not be as ideal. And in certain cases with hamstring harvesting, we don't quite get the size that we want. And so we have to supplement that with an allograft. And an allograft. We could probably go to talk about that next, which may or may not be as ideal as having something that's a pure autografts grafting, but again lots of good results out there with hamstringing ACLs.

Dr. Eric Chehab:
And I don't have personally any experience with the quad tendon. That's relatively new. I don't know what your experience is.

Dr. David Guelich:
I'm really only looking at it in the revision setting. So if someone's had an injury to the ACL and had ACL surgery, our choices in terms of grafts, start to become more narrowed and I have a very busy revision ACL population. And if there isn't a patella tendon to be had, a quad tendon may be good. It will have to see that we're only about two- to three-year data out. I'm curious to see what that looks like at five, 10 years.

Dr. Eric Chehab:
But I think the most important thing for our listeners to know is that there is no perfect ACL graft or else we'd all be doing the same one. That the perfect graft would have no side effects whatsoever and would work every single time.

And each of these grafts come with a set of side effects. There's a set of side effects with the patella tendon, and there's a set of side effects with the hamstring or the quadriceps, even with the allograft. The side effect of that is that it tends to fail more frequently in younger athletic patients, much more frequently than when we use their own tissue.

So I think most ACL surgeons prefer using the patient's own tissue for younger athletic individuals and may reserve the allograft tissue for older or for the revision situation. Would you agree with that in general?

Dr. David Guelich:
I would agree that in general, in fact, in the early 2000s, we were using lots of allografts and as we start to follow those patients along, the failure rates were particularly as you said, in a younger athletic population pretty high.

And so we certainly, I try to avoid using them in that choice, I think for revision ACL, the results of those are so marginal in terms of their success rates that I've really looked to using autograft in the revision setting even more just because I think it gives them the best chance to, to heal. But yeah, that's a different category of patient.

Dr. Eric Chehab:
Well, you can put two orthopedic surgeons in room instead of a hundred to talk about ACL's and we could talk about graft choice forever and some of the differences, but every surgeon has some preference. We'd like to be all, think of ourselves as capable doing each one of these.
And we all have our preferences of what we think is better. There's debate. I think the way I heard it framed best is for choosing between side effects.

Dr. David Guelich:
I like that. I think that's good. And I think what's more important and probably really needs to be discussed a lot to do with where you put it and how you put it.

And in ACL function, I say this often, any monkey can put a noodle in a knee and call it an ACL, but really a good surgeon has to put it in exactly the right place under the right tension. That's where ACL function comes from. So graft choice is important, but putting in the right position is much more important.

Dr. Eric Chehab:
Yeah. So let's go back to that then. We were talking about the surgery and the day of the surgery. So let's get into the operating room, we were in the pre-op holding area where we left off with this graft choice discussion. So now let's go back into the operating room. And so what happens during an ACL surgery?

Just describe to our listeners in general, what we're doing. Creating a new ACL for a patient.

Dr. David Guelich:
Sure. So, first we examine the patient under anesthesia because it's our best opportunity to evaluate the patient. And again, obviously confirming that the ACL is not functioning, but also making sure the other ligaments are. So that's step number one.

Once the procedure begins Do the graft harvest, which is the technique to take the graft of choice. And then once that's completed that graft is prepared usually by an assistant to place back in the knee joint and provide stability. So once the graft is taken, we then actually do the arthroscopic procedure.

This is where we place small instruments with minimally invasive techniques. And we start to create an environment to restore the ACL. So we remove any remnants of the ACL had been injured and we identify the really important landmarks that I hinted at before that tell us exactly where the ACL goes for this patient.

Clearly every patient is different and so identifying those important landmarks. And then we create tunnels across the knee joint that accepts the graft that we then pass across the knee and fix it using several different types of fixation. And clearly we don't want to get into details of that today.

Right. Other important issue is what we also highlighted earlier, which is, well, what else is abnormal? So we want to identify meniscus pathology and almost all cases with ACL, those are repairable and actually heal very well. So we want to identify and, and hopefully repair meniscus injury. We also want to identify and catalog and treat any cartilage problems that we have and in patients would have significant cartilage injuries that can be a major obstacle in terms of their recovery and function.

So we want to also start to consider cartilage treatments at that same time, again, different topic, but these are all the things that tend to come in concert with a torn ACL and ACL surgery. Then once that's completed, we close the patient up, put them in a dressing in a brace and wake them up and get them to get them to the recovery room.

Dr. Eric Chehab:
And what's their first week going to be like, what's their first month going to be like, what's their first six months going to be like, let's start with the first week.

Dr. David Guelich:
ACL surgery is an invasive procedure and the patients will be swollen and sore and bruised. We'll be managing that pain. I think one of the important aspects of ACL surgery is preparing the patients for that first week, so there are a few surprises as possible. So we try to have a lot of those good discussions before surgery about what to expect, but they will be on crutches. They'd have a brace to protect the knee.

I think they're always surprised by how much function they have and how quickly they get it back and how much we really encourage them to do both. And so they're within physical therapy within 72 hours after ACL surgery. My team is making sure that everything looks good, so we want to inspect the incision, make sure those are healing well. We're particularly concerned about blood clots or DVT. So we have them in the office. And often cases putting them on aspirin to try to mitigate that risk. And then the patients need to get moving. So as you, we're both two too young to remember the days where they would cast patients after ACL surgery, which just seems horrifying today.

But we want their motion moving as quickly as possible. We want to get their swelling down as quickly as possible. There are surgeons who use devices to try to minimize that using ice and cooling devices. All of that is really trying to get the knee to be functioning more normally again, so that that's the first week. By four weeks, hopefully my patients are off crutches. We've minimized the size of their brace into a stationary bike, hopefully around four to six weeks. That's ideal. We talked a lot about motion prior to surgery. We are also very focused on motion after surgery, particularly getting the knee completely straight again or what we call extension.

And that is something that everyone is hyper-focused on. And, and I want to know from the therapist, we're having challenges achieving that. And then hopefully once we get around six to eight weeks, we have full range of motion and quad and hip functional returning to normal. I usually let patients know they're probably limping til about three months and hopefully by then their gait has returned to normal. We are starting to focus on higher level activities. In my clinic, the single leg squat is something I use all the time. It's kind of a funny term, but it gives us a good idea of how hip and quad function is.

Once that is symmetric, then patients can start to do a return to run program. And that's usually around the three to four month mark and then around six months, we're really trying to focus now on return to level one activities. Particularly in some of the more younger athletic patients less of a concern, 40, 50, 60 year olds. It's more of a nine to 12 month project, but in patients who are younger, I think around six months to nine months is a reasonable timeline.

At least in terms of knee function, I think the issue that I always try to touch on with patients is how do we transition from injury back through recovery, back to level one sport. And there's a lot that's gone into this emotionally and financially and physically, and about seven out of 10 patients get back to that level.

There's 30% of patients who don't. And, and my theory is that this is as much to do with psychological issues as it is physical or physiologic. And so we try to pick up on that along the way as well. So that what is the last three months of the recovery look like for a lot of patients they're sort of left out there and it's kind of done. Their insurance is maybe not covering these last visits, it's an expensive process, but I think it's also one of the most important processes is how do we get your head back as well?

It's, it's an emotional process for patients. And I look at, you know, something, even for IBJI's Performance Institute, these are opportunities for us to get these patients not just recovered, but all the way back to their identity and their sport. And I think it's a way for us to try to move the dial on these last 30% of patients who have had good ACL surgery, but don't have completed livable function.

So that's part, that's kind of one of the newer things that I've been starting to think about a lot. As I've, I've, 16 years of ACL experiences, what are the patients that aren't able to get all the way back? And why is that? And I think that's one of the things that I think we don't talk about.

Dr. Eric Chehab:
That 30% is troubling. We would like to get a hundred percent of patients back just like we want the perfect graft that has no side effects and works every time. We'd want the surgery to work every time and get patients right back to where they were before they were ever injured. And I agree with you. I think a lot of it is that last bit is so critically important to get from recovered to back to that level one confidence of being able to do what you're able to do beforehand. And then in terms of risk of reinjury, the data is reasonably clear that the knee that was operated on anywhere between five and 10% risk of reinjury based a little bit on graft choice. The patella tendon tends to perform a little bit better in terms of injury, risk reinjury risk. But there's also a risk of the other knee.

Dr. David Guelich:
That's a great point. There's several theories behind why the other knee is at risk, is there some genetic predisposition that we're picking up on? Also, we have patients that are performing level one sports and they have injuries and injuries can occur in the other knee as well.
Just as the nature of the types of things that they do. But yeah, it is an interesting concept that the other knee is potentially a risk. I think it's a lot to do with probably a myriad of factors.

Dr. Eric Chehab:
Probably anatomic. I mean, it's probably, we think it's independent.

Dr. David Guelich:
It could be, there's even some hormonal questions about ACL injury. But yeah, I, we're not entirely sure why the other knee's at risk, but it's probably multiple factors.

Dr. Eric Chehab:
So you mentioned the average return to sport about six to nine months for the motivated high-level athlete, it'd be nine to 12 months for the more recreational athlete. Age may play a little bit of a role in terms of the timeline. The quality of the therapy obviously plays a role as well in terms of the timeline.

And then what are some other possible complications of ACL surgery besides the ones who aren't able to make it back to sport.

Dr. David Guelich:
One of the things that we identify when, when ACL is torn on MRI, particularly as we see that there's a significant bone bruise, especially in the acute setting or a first-time ACL injury, we always identify that cartilage is associated with that frequently.

So one of the challenges that we have is with an ACL injury is that we can fix ACL, but because of the significance of the injury itself, those cartilage issues may develop over time. So this isn't something that's even identified at the time of surgery, but lo and behold, a year, maybe three years, five years later, this area where that original bone injury occurred, we can start to see cartilage problems develop.

So that's something that we want to particularly be kin to when we're in there at surgery, but also follow along meniscus problems are also commonly associated with ACL injury. And those are things that we have to address and can also create issues down the road as well, if they're not

Dr. Eric Chehab:
I frequently get patients asking me whether or not the surgery itself will prevent arthritis that they want to have their ACL done so that they don't get arthritis when they're older. And my take on the literature may differ from other people's, but I think this is another area of a little bit of controversy about whether or not ACL surgery actually prevents arthritis or not. I'm in the camp that it actually doesn't prevent arthritis. It produces a stable knee, but there's still the injury that occurred that predisposes people to arthritis. I think that what's your take.

Dr. David Guelich:
That is a consideration. We don't want to harbor on it, but an ACL injury is a significant joint injury. And it's not akin to a fracture. Fractures heal, bone goes on, life goes on. You're right. When the ACL's injured, as good as I think we are, and I think we can get patients highly functioning, it's probably never a normal joint again. However, I do believe in this continuum theory that if an ACL is not fixed and then an ACL deficient knee injures meniscus, which is common, and now we have a meniscal injury, that meniscus protects cartilage.

And so there's a continuum of progression that can certainly push a patient into an arthritic trajectory, if you will. think, and we hope that ACL surgery helps prevent that continuum, but your point is a good one in that the injury itself may predispose to arthritis down the road, just because of the severity of the injury. And we see that in other joints too. I mean, that's not unique to the knee.

So, I do believe that an ACL, a well-done ACL is a better knee than a life with an ACL deficient knee. And that the likelihood of having more activity in a more normal existence is probably certainly there in an ACL that's that's repaired or reconstructed.

Dr. Eric Chehab:
And then where do you see advances in techniques?  Down the road, where do, where do you think we're going to make our improvements?

Dr. David Guelich:
Well, we kind of talked about that 30% and I think everybody's focused on that. When we talk about joint replacement, nine out of 10 patients, get excellent results in an ACL, we haven't quite gotten there. We're always looking at graft choices, graft fixation. And again, as we've talked about, there's so many different ways to do this. It means not one of these is the ideal way. Maybe that's out there. We've had lots of discussions about biologics and the use of stem cells, platelet rich plasma. Is there some opportunity to improve some of the healing around that?

I haven't seen anything definitive. It would be great if it was, but there's a lot of that out there on the horizon. I haven't seen any data suggest that going through the expense of all that is really improving functional results. I still think we need to look a little bit more at the psychological aspects of how we manage these patients. As orthopedic surgeons, we're really good at managing musculoskeletal problems.

We should be more focused on how we prepare patients and get them through the end stage. A lot of the problems we deal with in sports medicine, aren't your projects. ACL is a year project. And I'm wondering if we shouldn't even think about it as a two year project and put the resources and the time and on these patients at the backend, like we do in the front end.

And I think that would be as a community, as a group of surgeons really well-received and probably be helping patients more too.

Dr. Eric Chehab:
There was a time when, probably before we were both in medical school, where you were seeing people return from ACL surgery a couple of months after. Jerry Rice is sort of a famous example.

There, some were returning very early because there was an allograft shift in the early nineties where professional athletes were getting allografts and they failed miserably. They kept retearing. And then there were people really trying to get back as quickly as possible from their ACL injury. And Jerry Rice was one of them who returned four and a half months after his ACL injury.

But in his first game back, fractured his kneecap from where the graft was taken and we sort of shifted away from this thumping our chest as surgeons that, 'I can get my patients back in six months. 'Well, I can get mine back in five months.' 'I can get back mine in four months.' Through the years, having learned that this is a process and letting the biology do its thing over the course of six to 12 months, and then also letting the patients do their thing of recovering from the whole process of being injured.

Having gone through a surgery, that's relatively traumatic for the first week or two, and then getting their life back for the next six months, it's a project. And it's interesting to hear you talk about the timeline being extended from three to four months or Jerry Rice to two years, which I completely agree with.

Dr. David Guelich:
Well, there's also a great deal of disappointment in a patient, if you don't meet expectations. And I think aligning the expectations with the patient is really helpful in success. I mean, that's how that's really the case in any orthopedic sports medicine procedure, and it all gets back to identifying who's sitting in the room.

Once the lights are on and the patient's asleep, it's going to be more or less the same surgery. Right. We have nuances and interests that we have to consider when we're in there doing the surgery. It's everything that happens outside of that, that I think dictates outcomes. We all have done probably thousands of ACL surgeries.

They should be pretty straightforward and consistent, but yet the outcomes maybe aren't and I think there's ways of us to look at that. Is it biologics? I'm not so sure on that. I think it gets back to really identifying with the patient, helping them kind of get through those last obstacles. And I think that's where we can really make progress.

Dr. Eric Chehab:
My guest has been Dr. David Guelich. David, thank you so much for being here. I appreciate your time. And for shedding light on ACL injuries and ACL surgery and recovery.

Dr. David Guelich:
Thank you, Eric. Appreciate it.

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