Jul 26, 2018
A new procedure can lead to quicker, more effective recovery after ACL repair. Orthopedic Surgeon Dr. Evan Argintar explains how internal bracing works and who can benefit from the procedure.
Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.
In today’s episode, we talk to Dr. Evan Argintar, assistant director of sports medicine at MedStar Orthopedic Institute at Washington Hospital Center about their exclusive use of internal bracing in ACL repair and reconstruction.
Host: Thanks for joining us today, we’re talking to Dr. Evan Argintar an orthopedic surgeon and assistant director of sports medicine at Medstar Orthopedic Institute at MedStar Washington Hospital Center. Welcome, Dr. Argintar.
Dr. Argintar: Thank you for having me.
Host: Today we’re talking about internal bracing, which can be used to stabilize a joint and accelerate healing time allowing a patient to resume activity faster. When you say ‘internal bracing’, what do you mean, and how does that work?
Dr. Argintar: So, traditionally with ligament reconstruction whether that be in the knee or the elbow, we’ve traditionally used a graft. A graft is another tendon. Sometimes that can be from the person. Sometimes that can be from a cadaver, the most common example in my practice is the ACL. You need to put a new ligament where the old ACL ligament was, and that whole process of maturation can take anywhere from eight to ten months and that requires the body to do this process called ‘sinovialization’ which is a fancy way of saying becoming part of the human body. The issue with that process is at about two or three months the ligament you put in there becomes weak, and what we’ve found is that’s the time when it’s most likely to fail. And so researchers have developed an internal brace which is nothing more than a really strong suture that’s made out of a polyethylene or a plastic that travels with the new ligament, and it gives it stability and allows it to maintain the structural integrity throughout this process of maturation but specifically at the two to three month period when patients are ramping up their rehab but when their ligament might be weakest. So, what we’re finding here at Medstar Washington Hospital Center in our research is that patients seem to be doing better, they’re having better clinical outcomes and they’re more predictable.
Host: When you say it travels with the ligament, what do you mean?
Dr. Argintar: For an ACL, you have to drill tunnels into bone, and so when you create a new ACL, you’re putting that new ACL in tunnels into bone where the old ACL ligament was. And so this new internal brace travels right next to the ligament, so it has the same trajectory, and it has the same biomechanical forces on it. if you think about it as sort of a temporary ACL, while the new ACL is maturing, to me in my mind that’s how I make sense of it.
Host: That makes sense to me too. You mentioned the ACL. What other parts of the body is this useful for?
Dr. Argintar: We’ve been using it in elbow reconstruction. Sometimes people can have lateral or even medial elbow instability, and we’re finding that whenever you’re doing a repair of a ligament, or a reconstruction of a ligament, meaning taking a tendon from somewhere else in the body or taking a cadaver and incorporating it to replace the old one, this gives additional stability, which allows me as an orthopedic surgeon to be potentially more aggressive earlier on with therapy. Which I think helps mobilization, and it allows patients to be more aggressive in their therapy, which I find anecdotally is helping with outcomes.
Host: When you don’t use the internal bracing, when you’re taking that tendon from somewhere else in the body or from a cadaver which is a donor body, where typically would you take it from? Would it be that same area? Would it be a different limb?
Dr. Argintar: It all depends on the surgery. The most common example would be with an anterior cruciate ligament or ACL reconstruction. Now certainly you can take it from a cadaver and that’s the least painful of all options for patients, but traditionally there are two main sources for patients—one is the bone patella bone which is taking a little piece of bone on the knee cap and a little piece of bone on the tibia or the leg bone and the connecting ligament in between. The other option is a hamstring tendon, which can be taken from the front or the back of the knee. Those would be the two most common examples in ACL surgery.
Host: How long has this been available for the ACL, and are people coming and asking you about it?
Dr. Argintar: We’ve been finding that as word gets out that we’re doing more of this internal bracing, people are seeking us out for second and third opinions for ACL reconstructive surgery, and elbow reconstructive surgery, absolutely. We have research pending but not yet published which is demonstrating that this is a safe procedure it’s also allowed us to do ligament repair in a setting where traditionally we were unable to repair ligaments—it’s that strong. (4:27)
Host: What is the preparation process and what should a patient expect before, during, and after the procedure?
Dr. Argintar: Preparation for ACL surgery is all about the pre-rehabilitation. Sometimes we’ll actually send people to physical therapy in order to get their range of motion. What we know for all surgeries is that if you go into a surgery with poor motion you get poor motion afterwards. Most times, I’m able to educate patients on how to get that motion beforehand, so if they’re successful with those exercise programs, they are in very good shape for surgery.
Host: Is this something that can be done under general anesthesia or is it local anesthesia?
Dr. Argintar: This is all done with general anesthesia. It’s done as an additional component to surgical procedures in the operating room. It doesn’t increase the length of the surgery, in fact in some cases it might even make it faster.
Host: You mentioned before that this allows patients to be a bit more aggressive in their therapy and it allows you to get them into that therapy a little bit quicker. Could you talk about that process? What is the traditional trajectory from ACL surgery into therapy as opposed to internal bracing?
Dr. Argintar: So typically with ACL reconstructive surgery, patients will have surgery—for the first ten to fourteen days they worry about nutrition and health hygiene and then about two weeks afterwards they initiate physical therapy. The problem is that therapy can be modified based on how strong you think your repair can be, so as we incorporate these extra elements that improve or increase the strength of a surgical procedure, that will give clinicians more confidence to be more aggressive earlier on. Although me personally I rehab now ACL repairs and ACL reconstructions exactly the same, I think as we collect research moving forward respectively what we’re actively doing. In fact, we’re one of only three centers to my awareness, in the United States that are collecting this research and doing this type of surgery. Traditionally, ACL reconstructive surgery, the whole rehabilitation, is somewhere between eight and 10 months and is very patient specific. We know that for ACL repair, which is for keeping the ligament and putting it back where it came from, that’s a surgery that absolutely requires this internal brace for additional stability. We have found anecdotally that the atrophy of the muscle after surgery is less, and patients get back to sport activities quicker. A perfect example is two firefighters that I recently took care of. I prepared them for the eight to 10 months of rehabilitation, which is a lot of sedentary work for people who very much want and need to be active, need to have rotational stability in their knee, need to put out fires, and everything they need to do that happens in their job every day. I can think of two recent patients who were happy to get back to their job at six months without restriction. And that two months of lack of them doing sedentary work was transforming both to their job and to their mental health, because patients certainly want to get back to normal living, whether it be work or sport.
Host: What sort of research data are you picking up? What does that look like and what is the patient’s role in your collection of that data for your research?
Dr. Argintar: So we’re looking at research on lots of different levels. One is “is this internal bracing safe?” and the answer is unequivocally ‘yes’. Personally, I’ve done several hundred of these procedures, and my partners have had similar experiences, so we have looked at that data, and it has been submitted and will be ideally published in the next year demonstrating the efficacy and safety of this procedure. Two, we’re looking at how this will allow us to repair ACL ligaments in the knee. Again, we have a lot of anecdotal evidence based on over a hundred patients with ACL repair which is a real new aspect of knee sports medicine. Once upon a time people attempted repairs and they were fraught with failure, and for a long time this was sort of ignore as not a possibility. As we learn better about the anatomy of the ACL and we’ve incorporated these new technologies we have revisited the idea of ACL repair and we have found the success rate has been excellent here.
Host: Why were surgeons having a difficult time repairing the ACL?
Dr. Argintar: It has a lot to do with understanding the anatomy, number one. When people attempted these repairs twenty years ago—what we know now, but what we didn’t know then is that the origin where the ACL starts was not as accurate as we understand it now. In fact, the whole way we do ACL reconstructive surgery has really changed over the last five years. It’s not uncommon now for me to see patients who had the old gold standard ACL and we unfortunately have to revise them because they don’t have the rotational stability. So it’s that information all the new research that’s come out over the last decade about simply understanding where the ACL starts and where it goes coupled with the evolution of all these minimally invasive ways to incorporate these new interesting technologies that allow for repair this has all culminated to the ability to repair ligaments in a way that we never had the ability to do.
Host: Part of your research is determining whether this is safe, and you’re saying that yes it is safe, anecdotally at least. What are some of the safety concerns that individuals have had about this procedure?
Dr. Argintar: So, there are no specific safety concerns. Whenever there are new technologies in place in a knee joint for example or outside of a joint, you want to make sure that the benefits of the device aren’t outweighed by the negative aspects of the device. So, as we launch our investigation and this was based on the success of other institutions, even internationally, we have found that this is completely safe. In fact, when I look at my ACLs with and without the internal brace, I need to look at my report to see who has received that brace, because from the outside there’s no easy way to determine—it’s that similar.
Host: That’s a very good sign. What does your patient base or your patient demographic look like for this procedure?
Dr. Argintar: Typically, people who are getting ACL surgery or elbow reconstructive tend to be younger, more active, age to me is not important. Level of activity is. I’ve certainly done ACL surgery in people who numerically, chronologically perhaps are a little bit older but I meet people who are chronologically old who are more youthful than some of my patients. I would say ACL surgery in general is something that is done for people in their young teens up through their forties but there are certainly outliers on both sides of that bell curve.
Host: Is there anybody who this procedure would not be safe or effective for, in your opinion?
Dr. Argintar: No. This would be safe for anyone who needs this type of surgery. So, we’ve had patients traveling across the country for this type of treatment, patients regionally from Philadelphia and new York, or west like Colorado, the good news is that the word is out on the street -- people who are wanting to maintain their anatomy, which makes logical sense, people who want to see if they’re candidates for ACL repair, are seeking out medical centers like MedStar Washington Hospital Center, where doctors are doing cutting-edge surgery that might obviate the knee for reconstructive, larger surgeries.
Host: Is there anything else that you would want to elaborate on or if somebody’s interested in receiving this type of procedure what would be the process for them to get to you?
Dr. Argintar: Certainly, see one of me or my colleagues who specializes in sports medicine here at MedStar Washington Hospital Center. Again, we’re one of few centers in the country this is using and researching these technologies to strengthen ACL reconstruction, as well as even do ACL repair, so we’re excited to be on the forefront of this new cutting edge sports medicine intervention.
Host: Thank you so much for joining us today, Dr. Argintar.
Dr. Argintar: Thank you for the opportunity.
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