Shorts

So a frequent patient question is whether we use lasers, robots, or stem cells. And stem cells we already talked about. Lasers, there isn't really any application in orthopedic sports medicine, but we do use robots.

So the first common robot in orthopedic surgery was the Mako, and we've had it at HSS since 2007. I think both of us have been doing partial knee replacements for a long time.

And what it allows us to do is feed a CT scan into the robot and then capture data in real time about how that patient's particular knee moves and how tight it is or how loose it is.

Right. So it takes the guessing out of the operation a little bit, and you can very precisely take away just enough bone so that the implant actually fits perfectly.

And so the surgery takes us about, I would say on average, about 45 minutes, but it takes a little while to set up the robot and then close up the knee. Partial knee replacements are great for patients who have isolated arthritis in either the inside part of their knee, the outside part of their knee.

Because oftentimes the answer is, "Oh, you have arthritis, you need a complete knee replacement." And I still think it's a shame to throw away good stuff. So if really only one part of your knee's bone-on-bone, and we would get an MRI to confirm, but if the rest looks kind of good, then why throw that away?

Overall, I think patients are happier and they're much more likely to forget that they ever had a joint replacement if they can get away with a partial.

Right. Motion is better, so they can be more active.

The next topic we're going to discuss is the MISHA, and we get lots of questions because it's new technology and it's an implantable shock absorber that goes on the inside part of the knee.

And who is this mainly for? So, it's a bridging option for patients who have enough pain that something needs to be done, but the classic, let's say, do a knee replacement, they're not indicated for because they're maybe too young or too active.

So the surgery involves a scar on the inside part of the knee. It takes about 40, 45 minutes. Sometimes it's combined with other surgeries, like we've done it with meniscal repair or cartilage surgery. And most patients are back putting full weight on their leg within about two weeks.

But rehab is really important. Like, it's always teamwork, like you really need to work on your motion early on, because scarring is always a problem with any operation we can get.

So we certainly encourage patients to be bending their knee to 90 degrees as soon as possible after the surgery because there have been some patients who got stiff just by being worried about bending it.

And speaking of worrying about bending it, the nice thing is you don't really damage it. So it's fixed to the bone above and below the knee joint, and that means it bypasses the forces across the knee joint. And, and do you want to talk a little bit about options that you have after? Because that's one great thing.

Because it's not in the knee, you can, in actual knee joint, you can still have injections, you can still have PRP, you can still have gel, and at some point, if other parts of your knee wear out, you can always take it out and go on to the next surgery. It really doesn't burn any bridges.

So, patellar instability is one of our favorite topics, and there are different ways to stabilize a kneecap that's unstable, and one of them is...

an MPFL reconstruction. So at least when I was training, I never saw one, we didn't do them, it wasn't a thing. And over the years, it's now become sort of part of every, almost every patellar stabilization surgery. When you dislocate the patella, you stretch and often tear the attachment of the MPFL, and the MPFL isn't a very strong ligament to begin with, so that when we do surgery, we actually reconstruct it, we make a stronger ligament.

Yeah, and I mean, initially people even dismissed that the MPFL was a real structure because, as you mentioned, it's just this wimpy little thickening in the capsule, essentially.

So typically we take a donor tendon. You can take a patient's own hamstring, but the downside to that is significant hamstring weakness for at least the first 9 to 12 months, so at least for us.

Yeah, and also the age group I think that needs the surgery is the same age group that, if they have bad luck, also tears their ACL, and then a hamstring is at least one of the graft sources for ACL, which we'll talk about in a different, different cast.

So with an MPFL, most patients can get back to full sports somewhere between 4 to 6 months after surgery, and it is a very good operation for stability, especially with patients who have good alignment.

Yeah, and it's outpatient, small incisions.

And we're on the patellofemoral trip today. So let's talk about another option to stabilize the kneecap: a tibial tubercle osteotomy or TTO.

So when you do a TTO, you're actually moving the bone to line the knee up better. It's essentially to bring the patella into the groove. And it's a good operation for stability, but it's a good operation also for patients who have anterior knee pain because it can unload the kneecap and take the stress off of it.

So we're all built differently, and sometimes the kneecap sits too high or sometimes the tracking is really off, and this TTO can improve both. And it's an incredibly effective procedure. A lot of surgeons don't do a lot, so they're sometimes reluctant to even propose the surgery to a patient, but it is one of the strongest techniques to stabilize a knee.

So when we do a TTO, we make a small incision on the outside part of the front of the shinbone. The surgery takes about a half an hour, and we fix the bone when we move it with two screws. And since there's not a lot of fat or muscle overlying this area, a lot of people can feel those screws, so in many cases, we take the screws out, sometimes 6 months, 9 months after surgery. And that's not a very big deal operation.

That's usually no brace, no crutches, and people after a few days feel just fine. And in terms of small incisions, it's about the length of a finger. So sometimes you see these big incisions online, but that's not what we do.

Patellar instability, one of our favorite topics.

So, at least when when we were training, it was just physical therapy and more physical therapy and the braces really didn't work.

No. And people have been told sometimes for 10 10 years that they just, every time they dislocate, need need just PT. They were never offered any surgical solutions to that.

So, these days, you know, after one dislocation, we recommend getting an MRI because on the MRI, you can look at all the different anatomic variants and you can predict what the likelihood of redislocation is and then you can make an informed decision if you actually need surgery.

'Cause some people, just based on the information that we get from that MRI scan, some people's risk of redislocating may be 10%, and then I think maybe the answer of doing PT is the right answer. Other people may have a risk of 80%, and then waiting for the next one to happen is probably not a good idea because...

Every time the patella slips out, first of all, it's a really bad day or a really bad week, but it can cause permanent damage to the cartilage underneath the kneecap. And so, it is something that needs to be tailored as far as surgical decision making to a patient specifically based on all the different parameters we measure on MRI.

Yeah. So, just dismissing it as sort of a nuisance and tell the patients to just do more PT these days shouldn't really be done anymore.

Anyone who has even the faintest interest in winter sports by now has heard about Lindsey Vonn's ACL injury. And the remarkable thing is that she said she will try and compete with a torn ACL. So I get a lot of feedback from friends and patients who are shocked, because the assumption is always that if you tear your ACL, you have to have it reconstructed.

And I mean she's a very special case, so let's talk more general and for more normal people. But it's not necessarily true that you must have your ACL reconstructed. The reason why we consider getting an ACL reconstructed is to give you a stable knee. And why is that an important thing? So in the moment, a stable knee is a good thing. Most people don't really love not knowing what their knee is going to do if they do pivoting or twisting sports, whether that's soccer or pickleball, or live in New York, sidewalks are busy, somebody's jumping in front of you and you have to kind of corner quickly, and if your knee may buckle, that doesn't feel so good. So that's more in the moment, quality of life, you feel more confident with your knee and you can go back to sports that maybe that's maybe your social environment, you love to play tennis and pickleball.

But it's also joint-preserving, because if you have an unstable knee and it buckles, then every time that happens, it's almost like you jump the curb every time that happens, you run the risk of blowing your tire. With the knee, every time your knee buckles, you run the risk of damaging your meniscus or damaging it more. And that really sets the tone more long-term in terms of the development of arthritis. So if you have a good meniscus, it's worthwhile preserving it, and you're more likely to preserve your meniscus with a stable knee.

Now, if you don't really do any at-risk sports, you want to go on your spin bike, maybe a little older—I mean, I'm mid-50s, I wouldn't say that's terribly old, but it's older—that's a consideration. You may try and treat this non-operatively, especially if it's a partial tear. But if you're young, you want to go back to cutting sports, and your meniscus at the time of the initial ACL are still intact, then my recommendation generally is to try and get as stable a knee as you can, for now and for the future.

Take care.

Another ski injury-related talk.

So as most people by now know, Lindsey Vonn tore her ACL.

But I don't even want to talk about that very much, but it reminded me that she's a great example to discuss joint preservation versus joint replacement because she had a partial knee replacement a few years ago, and it clearly worked incredibly well. I mean, she made it to the Olympics with a replacement.

That, that's a first.

So why don't we always replace knees? Why do we bother with cartilage transplants, meniscus transplants, osteotomies?

They do have a significantly harder recovery than just replacing it. The reason why we bother is that a mechanical thing like a replacement limits your options. If you had a replacement, I can tell you what your next surgery will be. It'll be another replacement and generally a bigger one. So you go from a partial to a complete, from a complete to another complete, but now it's a revision situation, so the outcomes are not as good as the first full knee replacement, and so on.

If you are in your 50s or 60s when you start this process, then you're probably okay because, let's say, you started with a partial, then you keep that maybe till you're in mid 60s, you have one revision to a total, hopefully you're good.

But if you start that process earlier, let's say in your 20s, then you may end up needing three, four revisions in your lifetime, and that's definitely not good. They become more complicated and the outcomes become less good.

And that's where joint preservation comes in. Joint preservation is a bridging option. I wish I could promise that if we do an osteotomy in your 20s, you'll never need another surgery, but I can't. In fact, you most likely will have another surgery. And in fact, you probably will have a knee replacement, but you will have that knee replacement later in life. So you start that ticking clock later in life.

And with a joint-preserving surgery, I can't tell you what your next surgery is. It could be anything because you're not really burning any bridges or limiting options. The next thing may be an injection if we have some cool new thing that regrows cartilage, or a pill, or even if it is a knee replacement, and you delayed it for 15 years, it'll be a whole new generation of better knee replacements.

So that's the value in joint preservation. It's just you kick the can down the road, we treat your symptoms, you can be active, and you benefit from ever whatever we discover in the years to come.

Thanks very much.

So this video just is an introduction. So my name is Sabrina Strickland and I'm an orthopedic surgeon. I did my training, I started at Cornell for undergrad and then I went to Rush for med school, Hospital for Special Surgery for residency, and then I stayed there for a sports medicine fellowship where I've been in practice in New York City since 2002. And my specialty is sports medicine, but more specifically, I take care of a lot of complex knee and simple knee injuries. And we actually met at the International Patellofemoral Study Group.

And I was born in Munich and did all my medical school training in Munich, and then came to Boston in 1998 for what was supposed to be a three-month rotation, kind of fell in love with the medical system over here, ended up doing two years of research in orthopedics, and then my residency at Mass General and the Brigham as part of the Harvard Combined Residency, fellowship in sports medicine at Rush, and then back to Boston and joined the staff there at the Brigham and Harvard. And then after we met, I moved to New York and we've been in practice together since 2018.

So we kind of like to call our practice joint preservation. And when you first started calling it that, I made fun of him because I'm like, but ultimately, while we do replace parts of knees or actually total knees, we'd much rather preserve the knee. And so we do a lot of research, we do FDA trials, and we do a lot of surgery.

And a lot of people, even young people, come to us and they say, "Well, I've had this knee pain and I saw someone, and I was told, 'Well, you have cartilage damage, and there's nothing to do except waiting until you're old enough for knee replacement.'" And that's sort of what joint preservation surgery is all about, is offering solutions for people who maybe at some point they need a knee replacement, but right now is not the time, but they have pain and there's something that needs to be done.

So, joint preservation.

So, basically joint preservation is a phrase that talks about trying to preserve the knee. And usually what we're talking about is trying to prevent further arthritis or reverse it if we can.

Yeah, in a way young people with old knees, not really candidate for knee replacement, but enough pain that something needs to be done.

And sometimes it's just a little defect, so there's just sometimes a little piece of cartilage that's peeling away and you can do something quite minor like a gel injection or you can do what's called a chondroplasty where you arthroscopically go in and you just clean up the little flap, and it can make the knee feel much better, often it stops the swelling. That's not enough for everybody.

No, because sometimes the defects are bigger, and then you need to kind of fill them like you fill a pothole on a road. Hopefully just better.

So you can fill them with something that's called cell-based treatment.

So cell-based treatment is we go in, we do an arthroscopy, we take a little piece of cartilage, size of a fingernail clipping, and we send that to a lab and they can grow more cartilage from that.

And that's called MACI. Or we can do something called DeNovo where there's juvenile cells. So a younger organ donor, and we take their cells and we transplant it into the knee. And in both those cases, we're asking those cartilage cells to grow, which can take a long time, and it works pretty well, but it doesn't give you the cartilage that you started with.

No, but it comes fairly close. Nothing is perfect, and that's a little bit more like seeding grass, so truly something grows inside your knee. But then there are other options called osteochondral options, either taking a piece of cartilage and bone from you or from a donor.

When you take it from a donor, we try to size match them, so we're not taking, we want to match the anatomy as much as possible. And the nice thing about that is the cartilage is fully formed, and cartilage can live in another, in somebody else's body. It doesn't, it doesn't have rejection per se. It's not like a heart transplant where you have to take drugs to prevent rejection, but you do still have to have growth or bone ingrowth into that cartilage plug.

And to stick with the landscaping analogies, that's a little bit more like sodding. So, yeah, it still needs to kind of heal, the roots, quote unquote, the bone needs to heal, but at least it's fully grown cartilage.

And then lastly, we have some new techniques, which we have CartiHeal, which is coral, which we put into cartilage defects, and the body is pretty good at growing cartilage over it.

[dog barks] The dog bomb.

Yeah, it tries to help your body heal itself.

Sweet.

So, we're just going to talk for about a minute and a half about meniscal tears and the different kinds of meniscal tears we see. So, we see a lot of patients coming in with pain that just comes out of nowhere. They just take one more step and they have pain on either the inside or the outside of their knee.

Yeah, it doesn't have to be some big accident. Sometimes people just kneel on their bed or, like you said, just maybe running, don't step in a pothole. Just all of a sudden starts hurting mostly on the on the medial side. Yeah.

And I always say to patients, like once you hit 40, you can just sneeze and tear your meniscus. It doesn't take much. It's almost like getting a hangnail, it can just happen.

Yeah. So, it's unfortunate truth, and we are in our mid 50s, so we're not being ageist.

So, what do you do about it? So, the first step is is usually to try to get the inflammation down, and sometimes that's just taking Advil or a prescription anti-inflammatory, but sometimes it's getting a cortisone injection into the knee. And sometimes the knee can just quiet down and you forget it ever happened.

Yeah, and and if it goes away, it doesn't have to be treated, by and large, at least that's true for the vast majority of meniscus tears.

But sometimes we have to do surgery. And how do we decide? It depends how it's feeling, if it's responding to other treatments, and it depends what it looks like on MRI, because you can't see a meniscus on an X-ray.

Right. And the most important thing is is how much it hurts. So, if you have one, but it doesn't hurt, you ignore it, but if it hurts, then we talk about treatment.

A whole another topic and a topic for another video is what to do about repairable meniscal tears, and that tends to be in younger patients and it's usually a more traumatic cause, but we'll get to that in another video.

And now we'll talk about repairable meniscus tears.

So the most common ones I see are ones when a patient tears their ACL and then they also tear their meniscus, and a lot of times these are repairable. We can actually sew them back.

But that changes the recovery. So when people at a cocktail party talk about, "Oh, I have a meniscus tear," vast majority, I would say what, 90, 95% are the non-repairable, the hangnail ones.

But there are a subset of patients, for example, who tear the meniscus at the root, and that's a whole another ball of wax, because that's actually tearing the attachment of the meniscus. And it tends to happen in patients in their 40s and 50s, and they tend to feel a pop and acute pain in the back of their knee. Usually, they're not doing anything special, just walking.

Yeah, or stepping off a curb or so and then all of a sudden, yeah, it hurts in the back of their knee and then the pain may migrate towards the medial side. And again, you don't see it on X-rays, you get an MRI scan. And I would say those two meniscus tears, the root tears and the bucket-handle tears, they are not the ones where you can wait, because the outcomes are much, much worse or they just may not be repairable anymore if you wait months and months. So that's something, if you suspect you have one of them, then you need an MRI.

Ultimately, if we can get the meniscus to heal, that's the best option, because that's the only cushion you get and it's the cushion in between the bones of your knee, so it's really, really important.