Episode 242 | Inside the OR: Important Lessons I Took From Watching ACL Surgery Firsthand – Part 2

What is up team? And welcome back to another episode on the ACL Athlete Podcast. We are continuing this podcast series, where we discuss my observations from shadowing an orthopedic surgeon and witnessing some ACL surgeries, which were really awesome, with a surgeon I really like here in the Atlanta area. This is just me continuing from part one. If you haven’t caught that, please go catch that first, because it really does help to bridge into this next episode for us to talk through things. 

The other thing I was going to say is that my son is acting like a little gremlin, so if you hear him yelling in the background, that he is around and our walls are not soundproof. You may hear him, acting his one and a half year old self. The first thing that I want to talk about, as we talked before, the main points were how ACL surgery is a lot of work, a lot of the nuances to this process, the trauma to the knee, there’s a lot of layers to it, the symptoms of it can compound the LET procedure, which is been around, but it’s becoming more and more popular and being done more often. And then talking about the decisions of meniscus repairs versus meniscectomies and those decisions going into the surgery and in the surgery itself, and then the precautions and hearing the decisions that are made in terms of, in the surgery, based on certain cases, because of patient compliance sometimes. 

That leads me to the next point that we are talking through, number seven, which is graft type. This surgeon is a big patellar tendon fan. He takes the bone on both ends, and then he takes the middle third of the patellar tendon. I respect this because everywhere else here, especially in Atlanta, seems to be doing quad tendons all over the place. It is like wildfire, y’all. It is crazy just to see how much it has ramped up. I have in person seen all the different graft types and procedures. But with that said, by far, the quad tendon is the most. This is just something that, by the nature of the selection of the population. Most surgeons here are doing them. 

One of the surgeons here in Atlanta is known for being one of the initial pioneers, if you will, of the quad tendon. I think it has influenced a lot, and they’re a big system here. It was refreshing to hear about a BTB or patellar tendon, which is what it is usually referenced as to be used. I like the patellar tendon. It was really cool to just see this harvested, to be able to see the bony fixations, the way that this is taken, the way that the graft is prepped, which was just fun. I was so fascinated. I had so much fun watching this surgery. It was wild as y’all could believe. It was just really cool to see how this was taken and put into the knee for a new ACL. Of course, this patellar tendon is taken. And for those of you from an anatomy standpoint, this is below the kneecap, that tendon, the middle third. You are taking the bone on the patella side (the kneecap), just a small piece of that bone, and then you are taking a bone on the tibial side, which is where that bone inserts onto the shin bone. They’re taking a small piece of that. Basically, you have a tendon in the middle, then you have bone on both ends. 

The thing that made me think about this is that this allows that graft to incorporate so well so early. Bone heals faster. It allows that fixation points to really lock in versus what we call a pure soft tissue graft, which is typically the hamstring or the quad. Sometimes they’ll take the top part of the patella for a quad tendon, but we don’t see this very often here in Atlanta. I feel most surgeons are avoiding taking that bone just because the graft itself is already pretty thick; therefore, they just take only the tendon itself versus the bone. But it depends on technique and surgeon preferences. But with that said, that’s different. Soft tissue just being tendon versus this one being bone tendon bone. 

One other interesting thing was just his take on taking the patellar tendon. This surgeon, he sees a lot of revision cases, including bad ACL procedures. I’ve referred some bad ACL procedures his way. Therefore, he sees a lot, he sees clean outs, he sees cyclops especially with quad grafts that tends to go hand in hand a little bit more than the other graft types. This is just my own anecdote, that I think we will see some future papers about if it is reported appropriately. But with that said, he says he thinks that the patellar tendon itself, if it is rehabbed really well, then it can do really great. I would agree with this, and I think any person who sees a lot of ACLs and work with ACLs. I’ve seen a variety of these grafts would agree. And don’t get me wrong, every single graft is a choice its own adventure. There’s nothing positive and no negative about any graft. There’s a negative about every graft, and we could get into the details of that, whether it is donor site discomfort, quad-related issues, whether it is kneeling pain, whether it is sprinting weakness, whether it is more numbness, sensitivity, all these things. There’s so many layers to it. 

But with that said, I will say that the patellar tendon I like, I think it’s a great graft. It’s the reason why it’s still done a lot in the professional setting. But based on speaking with other surgeons, from this surgeon, he noticed that the quad graft is also “easier to harvest,” which he mentioned. He said if it’s easier—oftentimes, it’s not always the right path. And just you guys know, he’s not fully against quad tendons as he sometimes uses them on the right patient, but that is not his preferable route. But I will let you mull over that quote or point and interpret it for yourselves. But that being said, just talking through graft type and this patellar tendon, it’s a good graft y’all. And the research also shows it’s a good graft. I know that sometimes that the downsides of it is talked up, especially if another graft is a surgeon’s choice. It’s easy to be backed into a corner, if you will, of no, this is the best graft and this is why the other ones are not right. I think this is super important because it steers people in a certain direction. 

The next point I want to bring up is the graft harvest. This one for me, I would say was a big one, just to observe and just to visualize and think about how much that donor site, the place that that graft was taken related to the morbidity and the pain and the discomfort that occurs whenever an autograft is harvested and that’s to the patellar tendon or the quad graft, which I’ve seen, or the hamstring graft. When those donor sites are taken, what is left over based on that graft being harvested. For the patellar tendon, the BTB, they take it the middle third of that patellar tendon, including cutting off some bone on both ends and also approximating the two edges together with the sutures. That’s where that middle third is taken. And then they basically take sutures on that patellar tendon, and they’re going to try and approximate that together. Think about closing the gap that’s what they’re doing in this procedure.

When I was looking at it and I was just thinking about this ACL world and what our athletes are thinking through and feeling, and that thing is exposed to a decent amount of trauma, if you will, cutting out that middle third. And not to mention there is an ultra highly innervated and neurovascular fat pad behind that tendon that is something that we want to be mindful of. We want to make sure we respect this healing process, as I’ve shared, while also finding this sweet spot to load this tendon. We don’t want to go hot out the gate and create some sort of patella fracture with the BTB. But with that said, we do want to load it and make sure that we just don’t ignore it fully. That’s where there is a sweet spot with this. But just thinking through this harvesting, I think just made me really think through like how we rehab it. I feel like sometimes the harvest site is a secondary thought or whatever the rehab will tackle it. But it’s a major player y’all, and it’s probably one of the biggest things that I see missed a lot of times.

If you take for example, these quad tendons who are coming out and I have no shade on the quad tendons, y’all. I know that I could talk a certain way. But I think they are good for the right person. I just think that they might be overly prescribed in the space currently, and they’re not meeting patients where they are with it. But I digress. But with that said, you take the quad tendon and that donor site, and while there’s quad weakness, there’s a lot of donor site discomfort where that quad was taken right at the end of the thigh or above proximal to the patella that is taken. It’s just interesting to observe people dealing with this donor site related issues months and months out from their procedure. I think this is something where we just have to make sure we are keeping this intentional versus a secondary thought or just see thinking it’ll resolve on its own. But think about this: Even if you didn’t have an ACL surgery, but someone just took out a hamstring tendon on the inside of your knee or the middle part of your patella or your quad tendon and that’s it. Think about your knee was otherwise fine, but they took that out. How do you think your knee would feel and your rehab like? Probably pretty serious. You had a pretty major surgery to remove something, and so that tissue is now influenced and insulted in a negative way because we had to just take that out.

But it’s often an afterthought, and we’re hyperfocused on the ACL procedure itself to protect that, which is important. But we have to remember with autografts, we have to take care of that donor site and we have to take care of where that muscle was attached and what is going to be the aftermath of that, not just later on in the process when someone has interrange knee flexion issues because of a hamstring graft or donor site, tendinopathy and issues because they’re six months in or patellar tendon issues. This stuff needs to be managed from the start. We need to think about the donor site as a bucket for this rehab process and tackle that along with our other buckets of need. It’s what we teach our mentees, our team as a whole, and it’s how we tackle ACL rehab. We’re making sure it has its own lane that we are focused on along with the rest of this process. It makes this process complicated and messy, but this is where you have to work with someone who knows this stuff so well. Because otherwise, it is going to be overlooked and then all of a sudden you’re trying to move your knee over your toe and then you feel that donor site just lighting up and it’s what’s restricting you from being able to load your quad, get into good shin angles and be able to progress in your rehab. This is something that’s so important is the grafts harvest site, and it’s just something that just was amplified by watching this surgery and the exposure that this thing had and what they had to do to repair it, but also to be able to put it in as a new ACL. That was a lot about a graft harvest site, but I hope that was helpful. 

Some things a surgeon decide to do and some don’t. This is something that I was thinking about based on talking with the surgeon and just him sharing a little bit. But basically when you have these procedures, there are certain codes that are put in and you see these big values that they are charging insurance and what is on the bill itself. There are medical supplies, there’s all the things like that are part of this process that are bundled in. You might not get the very specifics of this suture was used or this little fluid was used. But there are certain things where it’s like a left ACL reconstruction, LET, the big bucket items they will put in there. When I was talking with the surgeon, it’s interesting, the thing about the things that you’re paid to do versus the things that you’re not paid to do. He was like, you know what, I’m going to do this to my full list. There are certain things that you don’t necessarily have to do that I think just benefits the patient that you should do, but you don’t have to do it right. He was like, we’re not necessarily paid to stitch this particular thing back up. I could just leave it exposed and it’s fine, but I think it helps the patient in the long run. I value this so much because this can honestly be applied to any profession, including PT itself. Yes, we are just as guilty of, there are certain things that we should do that we are too tired to do or don’t want to do because it’s just more work. Like billing or reaching out to other people associated with the team, whatever that might be. There’s a lot of layers to it. 

With that said, I’m really going based on the conversation with this surgeon of where he said that there are some surgeons that may just not do this because they can’t bill for it. Being able to close up a certain sheath in front of the patellar tendon, like the periosteum and being able to close up the fascia around it to allow for better healing. These are the things that are interesting to talk with him about, that it’s extra work. It’s honestly tedious work. They rationalize maybe that it might also be necessary, which is all subjective. I’m not saying that all surgeons are out to do this, but it was just something that I observed and it was an open candid conversation around this. It was just something where as much as I want to believe the good in everything, I think that this is where it again, comes down to pick a good surgeon who knows this stuff, who respects you, who other people say are awesome or are not just the pro team surgeon.Yes, that could be a cool accolade, but let’s get some true human results that people are saying they did amazing with me, and they have the testimonials and they have the results to back it up. I think that is so important, especially with your particular procedure, graft type you want and everything that’s so important.

If you want a hamstring graft and all they do is quads, you might have to go find someone else and that’s okay. But with that said, I think it’s really important to consider this because it could be a 50/50 and that could be something that is really important for your recovery. But to them, they’re just like, they don’t see any value in it. They can’t bill for it. Therefore, it’s not necessary for them to do. And it’s a hard procedure. It’s something that takes work. It’s very tedious with certain things that don’t always go perfectly. And so just some food for thought as I was thinking about this and wanting to share about this procedure and this process.

Next up is nerve pain and sensation. This is super interesting in terms of talking about the graft harvest and then leading into just people’s neural components and what they sense this pain and the sensation around their shin, especially in their knee. And there are a lot of people who share that they get numbness and the weird sensations on their shin and around the harvest site, especially for that patellar tendon. This is something that even for myself, even though I had hamstring grafts, I had some numbness and sensitivity and there’s still some spots around my knee where I still feel it. But I would say overall my sensation has returned. Sometimes it like refers to another side of my shin, which is interesting, especially on my right knee. If I touch one area, I feel it on the other side, as a weird referral. I think that the neural pathways and the sensory, if it does regrow because nerves can grow. They’re slow, but it just depends on how disruptive they are. If they have the opportunity to get back to regrowing.

But with that said, I think sometimes they can create a different sensory input than what was before because it’s been disrupted. But what I want to break down here, more importantly, is that the saphenous nerve, which is a nerve that runs down our leg, is coming from bigger branches of nerves up in our thigh. This saphenous nerve is down the inside of the knee. If you’re just coming to the inside of the knee and down the inside of the shin. The branch of the saphenous nerve, specifically the inferior branch, this runs towards the front and the inside part of the knee. If you take your knee, and let’s take our right knee, for example, if you just run your left hand to the inside of that knee and then if you just spread your fingers out and run as a fan towards that patellar tendon, you’ll feel that patellar tendon, you’ll feel that kneecap, and then you’ll feel that bumpy like tibial tuberosity. That’s essentially how these nerves will fan based on that inferior branch of the saphenous nerve. When this gets cut or parts of it, this leads to maybe like a palm size type numbness on the front, more on the inside part of the knee. It just really depends and is variable. Think of this as not just one nerve, but small little hair-like nerves fanning out, right as I just shared, as it hits the medial to the front side of the knee where the patellar tendon is.

I also think this is strongly contributes to some of that kneeling and anterior knee pain and sensitivity ACLers experience after a BTB plus the middle third of that tendon is taken. But just know that it does not happen to everyone. I think that is often the excuse, as I had shared earlier, for surgeons to make use of another graft they prefer, especially for the quad graft. The kneeling pain is probably the number one thing they say. Again, right patient, right goals, right timing. Not saying it’s bad. I just think that sometimes it’s almost like overly. Estimated how much people will feel kneeling, pain or anterior knee pain?

I think anterior knee pain with the right rehab, if it’s managed well, that you don’t really deal with it. The kneeling sensitivity can happen and that I think is contributed to that neural network that gets interrupted. But if you want to see a visual or hear more on this, I did an episode on this because I felt like it was something I needed to, and I had people asking about it, and I feel like it helps. connect the why. Sometimes people are like, will I get this back or not? And it’s hard to say to be honest, and I don’t know that the surgeons can really tell you. But to be honest, some people, they get it back, some people don’t. Some people get like 50% back. It just really depends and only time will tell from the surgery and just giving time for that neural network to regrow and maybe it just stays disruptive, if you will. If you want to listen more on that episodes 93 and 94 on why numbness happens. I also have an image I share that highlights the innervation really well. Go check that out if you are interested as that will be super helpful from the neural side of things. 

The other thing I do want to share is that this, of course, still happens with other procedures such as quad grafts, hamstring grafts, as I shared earlier. I still had some with my hamstring graft. But if you look at the research comparing the hamstring graft numbness that people feel compared to a patella tendon, it’s much higher in a patellar tendon. If I’m not mistaken, it’s 30% compared to a hamstring graft that was either six or 9%. I’m blanking on the specific percentages of the research trial, but it showed differences between the two, which makes sense. Hamstring graft, like that’s going to be on the inside of the knee, more so the backside where you might be able to avoid that neural network, depending on the incision. And the way that the graft is harvested, is it on the backside or the front. And then of course the patellar tendon, you’re cutting right through that thing, man. There’s definitely branches that are coming in, so that might interrupt and disrupt essentially what that sensation is, especially on the shin and the front of the knee. That can influence a lot of things here. But the other thing is that even with the portals that they do, that can also be influenced. 

Even allografts, for example, can experience this. It might be lesser degree, because of where the portals, especially on the inside of that knee or on the inside of the patella where they put a little portal in, to be able to get the tools in, can interrupt that. Or maybe there’s a bigger one that is done because of harvesting or the surgical training technique as well. For the patella graft harvest. This makes a lot more sense after seeing it live again. The same thing on the lateral aspect can also be considered when the LET is taken. It impacts those nerves on the lateral aspect where the IT band is innervated and also the fascia itself. Some important considerations for that specifically.

And then moving on to our last point for this particular episode is the tunnel drilling and the placement is crucial. There are different techniques taught to surgeons just like graft types, and there are some that just make me so sad after the fact. But there is this older one that is not as good. If you look at the research across and what most surgeons are being trained on. Differently today. and the old one is more of a transtibial. It’s still being done, but it might be surgeons who are not maybe current with things or maybe their training was, nope, let’s say this is the way that I do it. This is who I learned it from, where it’s a more vertically placed ACL in the knee. They actually changed the footprint of the ACL. The surgeon described it as basically like a stripper pole. I thought that was pretty funny. And he was also throwing some shade on it because he doesn’t do them. But he has also revised a lot of them. 

I would also say that from my own understanding and deep dives in this area, this is not the way to go. This is typically not as helpful for rotational instability for the ACL, which is a big part of the ACL mechanism of injury. What is more common in most surgeons, I would say, do, especially who are in ACL world, is more anatomic. It’s more ideal. It fits the natural footprint of where the ACL was, which is what was done. That’s what I got to watch and see how he kind of was able to figure out the positioning of this, based on the femoral notch and depending on the angle. It wasn’t just vertically up, it was at a specific angle, whether it was 2 o’clock or 10 o’clock on the femur, and depending on the knee side, of course, is it the left or the right side. Those were all factors that played into it. It just makes sense though. That’s where the ACL was. We want to restore its natural anatomical positioning. 

What’s interesting is that it is also just more work. You got to figure out where it is versus maybe with the transtibial. It is just a straight shot so you can drill straight through. It’s a little bit more straightforward, which is not an intentional pun, but kind of does work out in this way. But it is something that, to his point earlier. It doesn’t matter if it’s more work, you just want to make sure you do what’s right. I thought that this was an interesting thing as well. Just to let you guys know who are listening along, it wasn’t that there was shade being thrown aggressively on other surgeons or anything. It was just more so of talking through maybe what is done in the space and it’s no different than me also sharing about how testing is not done appropriately by a lot of PTs. It’s just the standards need to be raced. And I think this is the thing that’s so important is that we need to also point out what’s being done out there needs to change because of our re-injury rates and what’s happening to these people who go on to injure again. And a lot of this stuff is honestly preventable. I respect it a lot because I think it’s important to call this stuff out, but also make sure to walk the walk, which is, I think what was exactly he’s doing. This was showing exactly what that looks like, the examples of it, and having plenty of people going out and doing things that they want to do, because of the work that he’s doing and the other PTs and people that they’re working with. I get to work with. 

And there’s no direct relationship. It was just more of an opportunity to connect. I just wanted to learn without any bias or anything whatsoever. There’s no true relationship here or any financial incentive or anything. It’s just more so of I’m sharing the raw experience of shadowing a surgeon with you guys. This is where I want to leave it for today’s podcast series and episode. What we will do is we will have one final episode, part three coming out next week, which we are going to be diving into internal brace, new ACL graft, and talking through those, some nuances of the previous stump of the ACL specialization.n And then starting to talk about some of the range of motion pieces. Definitely, some rehab nuances that you guys want to catch. Please tune in next week for the final part of this series while shadowing an orthopedic surgeon. Until next time, team, this is your host, Ravi Patel, signing off.