Episode 241 | Inside the OR: Important Lessons I Took From Watching ACL Surgery Firsthand – Part 1

What is up team? And welcome back to another episode on the ACL Athlete Podcast. I am super pumped to jump into this series because I had the opportunity to observe and shadow orthopedic surgery. I got to watch some ACLs and spend the day in the OR, recently, and hang out with a local orthopedic surgeon that I really respect and who does really good work. It was very refreshing to connect on. I’m trying to think of how many times I’ve been in the OR at this point, maybe five times, to watch ACL surgeries. But it’s been a while since I’ve seen ACL surgeries as of recent. It was fun to get back into the operating room and see updates on what’s new, different techniques, and the surgery itself.

Today, I want to share my takeaways and my experience from watching these surgeries, interacting with the surgeon, and interacting with the team. And what I saw, and connecting some of the dots, if you will, with what we see on the rehab side with different procedures and just the way that we go about this process as a whole, because I feel like it was just very eye-opening just to go back in there and watch this procedure. Then also work with these patients day in and day out for myself, for us as a team, as we’re mentoring other physical therapists. And most importantly, talking and educating our ACLers. 

I got to see bone patellar tendon bone autografts, which are basically the patellar tendon graft taken from themselves; meniscectomies where they cut away some of the meniscus; meniscus repairs where they repaired it instead of cutting it away; an LET which is a lateral extraarticular tenodesis, which we will talk about here soon; clean-outs and a whole host of things as they went through the process. I want to dive straight into this and talk through this series about my takeaways and the experience, so let’s get into it.

Number one, ACL surgery is a lot of work. It’s a lot of work. I was standing there, and I was getting tired. These surgeons and their whole team are working super hard. It is very systematic. It is very clean, if you will. If you bump into anything, they’re like, don’t touch that. When we look at the ACL surgeries themselves, it is a lot of work, and they’re on their feet all day. They’re doing these surgeries, they’re communicating, making sure they can be as precise as they can be, not to miss any details. And while the equipment and the team are there to help you, for the surgeons especially, it’s a lot of physical work, maneuvering the knee, and a lot of fine motor skills, as you can think about as a surgeon, depending on the area they’re working on. We think about a heart surgeon or a neurosurgeon versus maybe an orthopedic surgeon. There’s a whole spectrum of what they are operating on and what they need to do for this specific surgery. It really is an art and a science. The way I see it is a little bit of, they are doing carpentry work, they’re doing hardcore carpentry work—using the drill, using the hammer, moving the knee around. 

If you guys want a good example of this, go watch someone who does a total knee replacement or a hip replacement, especially total knees, and you’ll be like, wow. They’re basically in the garage with their home tools and they are rebuilding this knee. And those are a little bit more intense than the ACLs, but here, there are carryovers in the sense of yeah, they’re doing carpentry work and hard work in the knee. But I also like to think of that as also meeting interior design where they’re trying to make sure it looks good in there, that meniscus is well-formed if they repair it. They want to make sure that everything is symmetrical. There’s perfect alignment of the incisions; trying to make it as minimal as possible.

That was one thing that was really cool is that, they didn’t try to just open it right up, they were very intentional about the incisions because they know that one, we want to minimize the incision pieces. No one wants big incisions on them. And being able to also just make sure to respect that process and only do it as much as needed. They basically are needing both the art and the science that carpentry work and the interior design to do the job well. 

I think this is where it’s important to have a good surgeon who knows ACLs. And the thing that I started thinking about was like, who are you going to trust? The builder who has built two homes in the past year. Are you going to trust the builder who has built two hundred homes in the past year? Yeah, you’re going to go with the one who has done more volume. They have had trial and error. They have it down to a ‘T’ in a system. And some people might say that might mean that they just aren’t as precise on things, but it’s like they’ve seen so much volume that it ends up being better.

There is this random thing that just came to my mind. Basically, there was this professor that gave this project to their students and one group was assigned, find one perfect photo that they can take and they have to submit that particular photo. And then the other group was given the task of take as many photos as you can of this and submit your best. With the ones that did more quantity, they actually improved because the other group could only take one perfect photo versus the other group, they did so many reps of it that, of course, they had trial and error. And then eventually, they were able to find the one that was the best. It just makes me think along this lines of when we get the volume of it, you’re inevitably going to get better with it unless you’re just blindly not caring about it, which I see that too. But that’s just something that I wanted to add in here of the details, is that getting a good surgeon who knows ACLs, who does the volume of ACLs matters so much. Same thing with the physical therapists, like they need to make sure that they are seeing ACLs and doing quality work. I just wanted to give a shout out to surgeons who are doing this work and who are super intentional about this because it is hard. It was a long day in the OR and I wasn’t even doing anything. I know that they are super tired along with their staff with what they’re doing. Credit to them in their training and in the work that they do. I know it has taken a very long time to get to this point. That was one thing that I just wanted to share that ACL surgery is a lot of work and there’s a lot that goes into it. Picking the right surgeon is super important, along with being able to have the right rehab team in your corner.

Number two, there’s a lot of trauma to the knee, depending on the injury, the repairs, etc. There’s incisions, there’s grafts, there’s the harvest site of the grafts, bone tunnel drilling, potential repairs to the meniscus, an additional procedure like the LET where they take part of your IT band, screws put in, sutures. They’re putting things back together. There’s so much that is happening in this knee. It’s a lot of change and it’s a lot of trauma to the knee which leads me to my next point: symptoms compound. 

I want you to think about if someone only tore their ACL and got it repaired using an allograft, which is a cadaver graft. Now, think about if there was a meniscus and it needs to be repaired, which means they put stitches in there versus just cutting some of it away. When you cut some of the meniscus away, that’s a menisectomy and that is something that people don’t feel any pain with. It’s just cut away really. And when you have a repair, there’s probably going to be a little bit more sensitivity, but there’s also restriction in weight-bearing, typically inflection as well to 90 degrees, depending on the type of repair. But that adds a layer of complexity because there’s more trauma to the joint because, they put a stitch in there and they’ve anchored it down and they’ve maybe had to adjust a few things. That makes it a little bit more complicated. 

And then think about if it’s an autograft instead of an allograft. Autograft is an ACL or a tendon taken from your own body to use as the new ACL. Now think about adding in another procedure like the LET, which is part of the IT band anchoring to the outside of your femur; therefore, that’s another procedure. And this is without considering the initial injury and how bad it was, the prehab, the time between the injury and the surgery, and many other factors that go into this.

Many people compare their surgeries to each other thinking they all should progress along. Especially if someone’s oh, you had ACL surgery. So did I. And the thing is that there are so many layers to it. Even seeing the surgeries, the layers of details for each of these people were so different based on the sport, their age. One had another injury, another had another injury, and there are just so many layers to this besides it just being, hey, there’s an ACL. And even if it is an ACL with a patellar tendon, there’s so many other additional details that are left out that are really going to influence this person’s recovery. And overall trajectory in the first eight weeks, the first three months, six months, and beyond that, because that’s all going to compound on top of each other.

This is something that is really important in this because I know many ACLers are always comparing themselves to others in this process. Or maybe you’re in the clinic comparing yourself to another ACLer—same age, same graft, maybe even the same procedures. If we lined up 10 quad tendons and they were all taken from themselves and they had, let’s say, medial meniscus repairs, and let’s get specific, they had a bucket handle repair. Those are the things that happen and they had an MCL sprain that healed. You all 10 would progress very differently, and that’s the thing that is so important, but I know so challenging in this process. What I want you to think about is when I layer these different procedures on top of each other and comparing their surgeries to each other, they should all be assumed that they’re going to progress along.

But then think about the allograft by itself versus the ones where the patellar tendon graft was taken, the meniscus was repaired, and LET in one surgery, do you think that this person and their knee is going to be more symptomatic and painful than the allograft or even the patellar tendon autograft by itself or with a meniscus? I find that both the PT side and the patient side doesn’t consider this enough in the first eight weeks. What we need to do is make sure we respect the healing process post-op. This doesn’t mean we just chill out and don’t do anything, but we need to also stop trying to rush it, thinking if we go hard out of the gate we’ll get back faster. It’s just likely to set you back. I’ve seen this time and time again. We have ACLers right now they want to get after it. But then the thing is we have to pull them back a little bit and create some boundaries around this. Otherwise, they go for walks and they’re like, I just need to be active. We try to communicate about this. And then their knee is a little swollen and it sticks around. We have to make sure we respect this process, especially early on. It makes me lean into just continuing to keep it simple and respect this process. Because after you watch this and you think about this person who had the patellar tendon, meniscus repair and having an LET, that’s a doozy of a surgery to recover from. This person’s going to feel a lot more. Know that symptoms compound as you talk about these different factors of time since injury, what was done in the injury that hurt the other tissues, MCL, bone bruising, maybe there’s a micro fracture in there. There’s so many different details that could be placed into the injury itself that plays into even the surgery, and then the layers of surgery that happens as well. Think about this based on, especially if you’re comparing yourself to other people who have gone through this process. 

Next, I want to share about the LETs. I got to see a couple LETs and I actually haven’t seen these live in person. This was actually really cool to see. I watch surgical techniques on these and whatnot, but just being in the OR and watching this, as it’s unfolding and happening is super cool and getting to talk to the surgeon about it. But LETs are lateral extraarticular tenodesis. And they take the end of your IT band where it inserts to the lateral compartment of your knee, and they’re going to reinforce it to the lateral aspect of your femur to reduce rotational instability. This is very commonly done on second ACLs or revisions. We’re seeing this more and more, like a lot of LETs being done, especially for reasons like this. Or maybe someone’s super young and they have a long potential athletic career ahead, then the surgeon wants to get ahead of it from a re-injury standpoint. They might anchor this thing down to just give them their best shot.

The way that I think about the LET is essentially think about it as like a second seatbelt to the knee. And what we need to understand that this is a secondary insult also to the knee when the surgery is done, which means more pain, more stiffness, more swelling, especially because they’re anchoring this thing into the bone, into the femur. There is another point where the bone is drilled and you are going to have this thing anchored into your bone via the stitches and the screws and the button. Therefore, the bone is super sensitive as well.

We need to be mindful of this for our rehab and especially for regaining knee extension and flexion. This athletes will be stiff and there’s a chance that the lateral aspect can sometimes feel pinchy because of this reinforcement. We need to make sure that the knees mobility returns. That’s going to be super important. But we have noticed even working with LETs, depending on the technique/procedure as well, there’s so many out there. Modified Lemaire’s the most common, but this is something that is important because that’s going to influence some of the mobility of the knee and the symptoms that the athlete’s going to feel with this.

One thing that I do want to share that I was just thinking about here was the screw home mechanism of the knee, which is where the knee has a little bit of rotation with extension and flexion. There’s an internal rotation when the knee flexes and there’s an external rotation of the tibia whenever it comes into extension for the screw home mechanism to get into that full knee extension. There’s a slight bit of rotation, and I know that we put this in there for rotational instability. If there’s excessive rotation, because then that could put a little bit more strain on the ACL, which can cause it to tear in that position. This is to help prevent it from getting overstressed by being able to reinforce it so it doesn’t get there. I get that and I like that. The thing is that I wonder how much this influences that screw home mechanism for some people to get full extension because of that LET being there, and then potentially also end range flexion where people are being limited to, which is things that we see as end ranges of flexion and extension. People can have some trouble with. That’s something from the natural biomechanics of the knee. I’m just thinking out loud here, and for any of my ACLers or physical therapists who are listening, just food for thought in terms of thinking about this from a true anatomy and biomechanical standpoint. 

But one thing that was also interesting with this to see was the fascia in the outer layer of that IT band. Think about basically Saran wrap if you see your IT band on the outside of that knee coming in. When you cut through the skin, there’s another layer called your fascial layer. It’s basically Saran wrap and you cut through that as well. And then you’re slowly exposing that IT band of that actual like tissue. The thing that the surgeon did was close that up, making sure that the vastus lateralis or part of that quad is not peeking out. And that’s something that he said could be noticed. And depending on the technique and who’s learned it, sometimes they don’t go back in and repair that. With that, there is an interesting point of, okay, if you don’t repair that, then you’re going to have some quad muscle poking out those sides because that Saran wrap to keep it bundled in is not there, and you’ve also cut through that IT band. Anyways, he cut it. Then he made sure to sew it and repair it back together, which was also going to allow it to heal better and also make sure that lateral part of the quad at the very end of it doesn’t poke through the little gaps there. So that was a cool thing to just notice in the surgery.

Next up is menisectomy versus meniscus repair. And this was legit how it was listed on these patients on the surgical game plan when you saw them on the board: it’s a menisectomy versus meniscus repair. Surgeons majority of the time don’t know what they’re going to do until they get inside, depending on if there’s a meniscus injury or not. Whenever someone shares like, yeah, my MRI, it shows a meniscus injury. Most of the time, it’s going to be something that surgeon is not going to decide until they’re in that knee, whether they’re going to repair it or they’re going to cut some of that away with a menisectomy. And this is something that I see very common, is that sometimes people assume, oh, I’m going to get it repaired, or I’m going to get it cut away. They wake up from the anesthesia and they’re like, it got repaired. They were assuming it was a menisectomy. It was going to get cut away, and they ended up repairing it. So guess what? You have some weight-bearing restrictions for the first two to four weeks, if not six weeks, and you may not be able to also bend your knee beyond 90 degrees. That limits things a lot more than people would think. And so that’s something that was interesting just to see on the menu for the surgeon. And what they were doing is that, basically, if you have a meniscus-related issue, then just wait and see until you get inside. I always tell my ACLers, go in just expecting there’s going to be a repair. The highlight is that if it’s not, that’s awesome, then therefore maybe that meniscus healed or maybe they couldn’t save the part that was damaged. Therefore you could put weight on it, you can start moving a little bit faster versus a repair. We have to respect that to make sure we don’t undo the stitching to allow for that to heal well.

The other thing too is that the timing influences the repair as well, because if those edges are not approximated within a certain period of time. Then those edges can slowly start to just age, if you will, or retract that can also influence the repair with a meniscus injury. Something I was talking with a surgeon about which I thought was a very cool point that he had mentioned, in terms of the meniscus repair and the timing between the injury and when they end up actually having surgery. One thing that was interesting was that one athlete, his MRI, showed a small radial tear. He was planning to do a menisectomy and then once he got in there, there was another really gnarly tear that wasn’t picked up on the MRI. This goes to show for this athlete, of course, he didn’t wake up with a meniscus repair, but he ended up having to have more of his meniscus cut away because there was another tear that wasn’t picked up on the MRI and it just looked a lot worse than what was presented on the MRI. Just know that if you’re listening, that the MRI is one thing, even functional testing is one thing, especially for meniscus. It’s not super sensitive for us, to know like, all right, specifically this and where it is. It is just a matter of we got to go into the knee once you’re doing the ACL reconstruction to see what is going on. And that is going to influence the direction the surgeon is going to go with it. 

The next point I do want to bring up is the meniscus repair precautions. We need to respect the repair. And I even might be someone who might be like, oh, it’s fine. Let’s push this a little bit. But after being in there, I was just like, this is something that I do truly need to make sure I check myself on. Respecting the repair, making sure we respect, especially the weightbearing precautions and potentially the flexion limitations that a surgeon will prescribe. Now, if it’s just blatantly given across the board, I question that. But if there is meaning to this being like, you know what, I repaired X meniscus. This was the type of meniscus repair we did, and this is what we’re going to do from a weight-bearing and a range of motion limitation then I respect that. I think that’s something super important for us to be able to be aware of. When I was talking with this surgeon, I think a factor that goes into the decision is the athlete and the person themselves. I hadn’t thought about too much. You almost think of it objectively, is it a repairable meniscus or not? And while yes, if it is a very repairable meniscus, they will do it for sure.

But let’s say there’s a situation where it could be 50/50. A complex meniscus injury that is 50/50. They’re like, we could do a menisectomy and cut this away a little bit, and it’d be fine. We could also potentially repair it. In an ideal world, we want to repair it. That saves the meniscus, that gives us the tissue that we need, especially for long term for osteoarthritis. We just want to save as much tissue as we can for that. When it’s a 50/50, and if we’re thinking about the person or the athlete That they’re doing this too, they may cut it away if they think the athlete won’t listen to the restrictions. 

Now, hear me out here, and I was thinking about this a little bit. This doesn’t mean that they’re just going to, negligently (is that a word?) cut it away because of an athlete that won’t listen at all. I’m saying if it’s on the line, and even just being in the room and hearing the conversations and the decisions that were made on certain situations, I was just like, oh, this makes sense. And they have to make these judgment calls because this is one of the things that we were thinking through. If the athlete won’t listen to the restrictions, for someone who gets a meniscus repair, they typically have to be non-weightbearing for four weeks. That’s a long time to not put weight down. And what I find even personally is that a lot of people just don’t listen. They might be all right for the first two weeks and then they might start to be like, ah, it’s fine. Especially in their house, they might be like, all right, I could just put my toe down here. I could just like, walk from here to the fridge real quick. It’s not going to hurt anything. It’s like these micro, small, little, like breaking the rules and I know everyone does it. I even did it with my ACL sometimes. I get it this internal being as a human where you’re just like, it won’t hurt anything. It’s just a little thing. But everyone hates the non-weightbearing, and especially being restricted in a brace potentially to 90 degrees.

What I want you to think about is your cool high school, bro, that’s a 15-year-old male athlete, and they think they know better. The surgeon meets them, they try to get a gauge on them. They meet them pre-op just to see, so they’re gauging just all the different pieces and making a decision. And while, yes, they want to save the meniscus and we’ll try and I even saw that attempted. If it’s a 50/50 and the athlete seems like they won’t likely listen to the restrictions, that puts the surgeon, PT and everyone including the athlete in a tough spot. Because let’s say that they were told not to put weight on it for four weeks, but then they start to put weight on it at week one or week two thinking it’s fine and they undo the repair. They break one of the stitches that they put together to help sew that meniscus back. It allows for it to heal and go back to the way it was. But because they put weight on it, they tore one of the stitches and that separation came back. Then there needs to be another surgery and it complicates this entire process. But who’s getting the blame here? Yeah, exactly. This is something that is very challenging. This is one thing that I wanted to share that I thought was an interesting conversation and interesting point that was made, but just got me thinking about… where do surgeons go in terms of decision-making? This was some helpful insight for myself to think about, okay, there are different situations where they may make a choice based on the person themselves, which I think is honestly a very smart choice. But of course, they take it case by case and making sure that it’s not just such an obvious yes, repair or obvious no. It’s somewhere in the middle, in that gray area, which a lot of ACL rehab tends to live.

I hope that this was helpful. This is the first part of this series and I’m excited to share more. Please tune into the next episode because we are diving even deeper into some graft type stuff, into some nerve pain, tunnel drilling, talking about the new graft itself, internal bracing. Stick with me here. If you love this episode, then please leave a review, whether you are on Spotify, whether you are on Apple Podcasts. It means a lot to us, helps us reach more ACLers, more clinicians and coaches. I appreciate you for tuning in. And yeah, let me know if you have any questions on this series. Otherwise, tune in for next week’s episode as we continue. This is your host, Ravi Patel, signing off.