Encouraging Evidence in Support of ACL Preservation

Celebrating about a decade of advanced orthopedic treatment resulting in ACL tear regrowth and results. About a year ago I participate in this study to help contribute results.  

It’s amazing public health is still not offering this, and much of the the orthopedic community is a decade behind current practices.

I’m border line starting a petition for to get Alberta Health to stop unnecessary body part removal and protect orthopedic surgeons from a class action lawsuit from the 1100 or so patients a year receiving the wrong procedure.

InternalBrace is my 1 window of opportunity to save the ACL

May 17, 2018

wait time: 58 days

time remaining to avoid removal: 4.4 weeks 

I set my alarm for 2am, still pursuing every possible avenue – InternalBrace is my 1 window of opportunity – hoping to find a way I can do this without travel.

2:13am

The Mackey Clinic emails me the details they need, followed by a 2:27am email

“As per last email if you could provide your details, I will check theatre slots for you.  So don’t worry about booking a consultation yourself.

In situations where a patient is traveling, as you are, the consultation, pre op assessment and surgery date – will be over 3 days usually.   Are you able to travel at short notice ?”

3:56am

I reply

“I have the (MRI) pictures and am unable to open without PACS; Please let me know if you use the PACS system for viewing. 

I am contacting Alberta Health tomorrow as they said this should not be a requirement.

Also, is it preferable to work on increasing range of motion in preparation for surgery ?

(currently it is stiff; MRI does not show retracted tissue; cannot straighten leg, have increased range to straighten >2.5cm.  cannot bend all the way back - concerned bending may cause synovial fluid to erode any clot present)

Reviewing the studies on the Arthrex site, curious if this is still in trial phase stage - I'm still on board for it, just curious as the 2yr study results mentioned more results are needed.

Thank you, looking forward to this”

• I’d been using a small stack of books below my #knee to push down to, and was removing them to gain range.  It seemed exciting to make progress until I measured 2.5cm - which isn’t much.

I also mentioned Dr Difelice and asked what other surgeons may provide current options.

6:38am

Mackay Office

“I would encourage early mobilisation as it will accelerate post op recovery.  Logistically Greg Difelice would be easier to access, although we use different variations on the same technique.  Although surgery is cheaper here, travel does add up. 

I would normally encourage patients to take a 2 week vacation here before returning home, with DVT precautions – although there is still some associated risk.”

9:06 am

I send the requested info and reply “Travel on short notice is expected for this, let me know what the openings will be so I can work backwards and plan flights.”

Adding to my evaluation is the timeliness of having the procedure done which reports better outcomes the sooner it’s completed.

10:16am

I receive a reply from Tribe Medical to my email to find a rep Arthrex who can identify where this is offered in Canada

I look up Calgary orthopedic surgeons and am curious who is the most forward thinking that would be using current methods.  Also figuring out how I can get the MRI report translated so I understand the technical / medical verbiage clearly.  Searching what non-delineated ligament means…

Also the attenuation rate to determine how long I have.

23:57pm

I reply:

“Curious what you meant by different variations of the same technique; if they have names let me know I'll look them up - if too complicated we can discuss in consult.  

I did a bit more digging and have identified a Jesse Shantz and Andrea (Andy) Veljkovic who can do this in Canada, however private health care is not allowed in Alberta so I have to fly regardless, in their case to Vancouver.  Curious if you know them.  I can ask what technique they use if this is important, or any other question you suggest.  Depending on when we theatre availability in Scotland … they said they can provide some follow up in Calgary after, and earliest they could do procedure is May 30.  

I'd like to have an idea of theatre dates and cost for procedure in #Scotland so I can calculate the exchange.  I have no problem staying for at least 2 weeks as you suggested.  Please let me know how time sensitive this is, and if May 30 is further off than desirable - if so it may be in my best interest to pursue a more expensive yet timely option to improve potential outcome.

I've figured out how to open the images, the program that does this is called Onis Viewer available free here:

http://www.onis-viewer.com/ProductInfo.aspx?id=19”

now I'm figuring out how to set up a 200Mb transfer to you.”

AKIC (Acute Knee Injury Clinic) U Calgary - ACL tear follow up - appt 2

May 16 cont...
10:45

2nd AKIC U Calgary appointment (Finally)
.
Wait Time has been 57 days so far,

19 days behind actual scan completion
.

follow up to go over April 27 MRI results

Again, I feel reluctance to work with me, in only 2nd appointment.  When I bring up ligamys doctor does not seem familiar with it and can't answer questions.  I ask if he read the emails I sent with the information and am told they were not read.
.
.
I inform him the surgeon responded I may be an ideal candidate for InternalBrace and am told “We don’t do that here.”  Concerned the help that could be offered on this will not be provided I said “I just need you to support which ever surgeon I end up working with by helping me get him the information he needs.” I do this to ensure consensus is established on how we’re going to proceed with expectations & responsibilities as I don’t know what may be required.
.
.
I told him I’d send the medical journal on Internal Brace to share & discuss with the surgeons so they know what I was referring to and how they can provide this option.
.
.
At this point I’m perplexed why they don’t know about this and am having some doubts about the Canadian Healthcare system.

1:46pm

I send the AKIC sportsmed doctor at U Calgary information on internal brace to share with the surgeons he had yet to tell me a name of, as I’ve lost faith they’re offering current practices however I don’t see why they wouldn’t be interested in learning practices with better patient outcomes.   https://www.arthrex.com/what-surgeons-are-talking-about/131FD01B-7B44-491D-B5F7-015A9474A65E

2016 article on AHS from the Calgary Herald on MRI wait times increase in Calgary – how many of these could be understood by the work from my Aug 12 post:

https://www.google.com/amp/s/calgaryherald.com/news/local-news/ahs-seeks-answers-to-the-reasons-behind-lengthy-calgary-mri-waiting-lists/amp?source=images

Still eating fresh pineapple for bromelain, found in every part of the pineapple, but most plentiful in the stem.  Seems the clot isn’t a concern anymore;  pineapple enzyme is supposed to help break up existing clots and prevent future ones from forming.  I usually blend it into a smoothie.

InternalBrace Ideal in this situation

May 16, 2018
wait time: 57 days
time remaining to avoid removal: 4.5 weeks
.
Working on how I can get the MRI photos to display.
. 
Just after midnight I follow up on the email I sent to Dr. Mackay, they reply after 4am.  At 9am I let them know I’ll get the MRI pictures.
. 

4:35am

Dr Mackay replies “It would appear that the InternalBrace could be ideal in this situation. It allows the ACL and MCL to repaired simultaneously if required. 
.
If the ACL cannot be fully reconstituted it can be augmented with a reduced sized graft and backed up with the internal brace, reducing the #surgical insult. This approach also supports accelerated rehabilitation.” 
.
I have a window.
.
I’m working in the morning so I try to get back to sleep each night as soon as I can. 

8:43am

Follow up Dr Difelice with an email.  I ended up calling at some point yesterday and they answered my questions.  USA healthcare costs are WAY higher, not sure what problem is driving this for them (more on this later). 

10am

I ask what else they need at the Mackay Clinic and what schedule provides the best possible outcome. 

---------------

If you were like me with no prior knee injury knowledge, and read the same published articles, we'd share the foundation that an ACL regrows itself supported by multiple cases in different medical journals and other media, and over 110 surgeries; and be looking forward to your doctor going into more detail on this.
.
.
You also might assume the specialist advising you on potential courses of action to choose from - because it’s their field of expertise - will be able to further educate you on it. 

This is the problem with assumptions and why one must validate them (beyond a Continuous Improvement event).
.
.
I didn’t receive the impression during the 1st appt my enthusiasm was shared when asking about alternatives to avoid unnecessarily removing a ligament that’s trying to heal or damaging good tissue to harvest a graft; nor did I receive replies to my specific questions in emails.

Grade 3 sprain explanation

I finally come across an article explaining what a grade 3 sprain is.  (May help someone else trying to decipher this)

"About ½ of all injuries to the anterior cruciate ligament occur along with damage to other structures in the knee, such as articular cartilage, meniscus, or other ligaments.

Injured #ligaments are considered “sprains” and are graded on a severity scale.

Grade 1 Sprains

The ligament is mildly damaged in a Grade 1 Sprain.  It has been slightly stretched, but is still able to help keep the knee joint stable.
 

Grade 2 Sprains

Stretches the ligament to the point where it becomes loose.  This is often referred to as a partial tear of the ligament.
 

Grade 3 Sprains

This type of sprain is most commonly referred to as a complete tear of the ligament.  The ligament has been split in 2 pieces, and the knee joint is unstable.

Partial tears of the ACL are rare;

More ACL injuries are complete or near complete #tears."
 

To better understand I pull out my #MRI again and reread (in Oct 6 & 7 posts).

May 15, 2018 Ligamys, Canadian Research Ethics Board, bear trial

2am

Reply from my DIS ligamys inquiry arrives, still 21 days, so not an option.  Also received 5 more published papers on its results.

8am

I receive a reply from Canadian Research Ethics Board from my efforts to get an application in for BEAR Trial.

10:42am

I send the DIS published research to my Sports Medicine doctor at AKIC University of Calgary in preparation for my appointment 10am tomorrow.  Is it strange to expect someone would be interested in their field of expertise?

11:09am

BEAR explains they are confused that I’m trying to both introduce their device to Canada, as well as be a patient. 

12:27pm

I email BEAR again, and tell them I’m trying to both introduce their device to Canada, as well as be a patient.

3:07pm

BEAR trial let’s me know they won’t help even if I move to meet their 3 hour criteria.  Still no criteria provided for me to pass on to my friend in the US.

I never ended up receiving a link from BEAR Trial to their 3rd trial criteria which I asked for several times to forward to a US friend. 

I learn in addition to hospital funding, grant funding from the NFL (NFLPA player study harvard)  was a significant factor in making BEAR trials possible.  Curious if they are offering this to NFL players when they get injured.

8:52pm

I send the ultrasound to The Mackay Clinic, and inquire about my shortening timeline to avoid ACL attenuation, or other potential options to avoid removal if unnecessary.  And maple syrup.

Found more info on internalbrace primary repair #surgical technique here:

https://www.arthrex.com/what-surgeons-are-talking-about/131FD01B-7B44-491D-B5F7-015A9474A65E

Despite the situation, I still had awesome #ski season, including the day this happened – even though this happened it was still a great day!

May 14, 2018 Ligamys

2:00am

Got up from 2am-4:30am Calgary time to reach Scotland at 9am UK time by phone, and then sent them info.  Laughing because having a hard time to believe the absurdity that I actually need to call another country on this when the assumption is Canada has advanced healthcare.

2:44am

Just to be sure, I send an email asking if DIS / Ligamys is still limited to 21 days or if advances have been made where it can be done further out.

11:35am

I send an email to Dr. Mackay outlining my situation up till now - mentioning I’ve achieved an additional 2.5cm of range to straightening over the last week – and my appointment in 3 days. 

Still grateful for my situation every time I see someone in worse shape than me.

info on ALL (Anterolateral Ligament)

May 13, 2018

53 days since injury.

I come across some info on ALL (Anterolateral Ligament) and find:

‘Despite technologic advances in the surgical technique for ACL reconstruction, some patients continue to have rotational instability post operatively, decreasing the return to sport rate. Failures can occur because of improper tunnel positioning, problems with patient rehabilitation, or non-optimal incorporation of the graft used for reconstruction’

and

‘recent biomechanical studies have shown it is an important stabilizer against anterolateral tibial rotation’

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5263705           

Then found in Dr DiFelice NY’s article

Ground Breaking ACL Repair Approach Could Help 80,000 in US Alone

“Skier Veronika Velez Zuzulova competed 20 weeks after suffering a torn right ACL: an injury that according to traditional thinking should have required ACL Reconstruction Surgery and an 8 - 12 month #recovery.

Foregoing the traditional, Zuzulova opted for ground breaking ACL repair surgery instead of ACL removal & graft reconstruction – that had her training just 6 weeks after surgery with enough time to enable her to be ready for the Pyeong Chang Olympic Games.”

“more than 150 Repairs and has published both two-year and five-year post-surgery data on his initial cohort to validate the procedure’s success”

“published more than 15 professional, peer-reviewed articles on the subject”

“unwarranted bias which limited ACL Repair as an option” 

“failing to recognize that ACL Repair success was much higher when treating specific types of tears, the data lead to the erroneous conclusion that ACL Repair was not a reliable course of action.”

Can “repair greater than 50% of the athletes who present to him with ACL tear”

“up to 80,000 of the 300,000 patients suffering ACL tears in the US alone may be helped”

French surgeon Dr. Bertrand Sonnery Cottet performed Zuzulova’s surgery, and again the article mentioned Scotland's Dr. Gordon MacKay at The Mackay Clinic.

Despite the mounting cases and supporting publications suggesting that, for the appropriate tear type, ACL Repair is the preferred treatment method, the shift away from unnecessary reconstructions —widely ascribed to by orthopaedic surgeons—has been slow. 

"To keep all options open, athletes, parents and healthcare professionals need to take a closer look at ACL Repair," says Dr. Gregory S. DiFelice. This is especially important for younger athletes who have been shown to have high rates of re-injury and can develop significant arthritic changes as early as 10 years post-reconstruction. 

"success rate with ACL Repair is approximately 95% in all comers from recreational up to professional athletes. In the few patients that have suffered re-injury, Reconstruction was performed without undue difficulties. It is interesting to note that Dr DiFelice uses the standard Reconstruction procedure only as the last resort whereas the majority of #surgeons use it as their only option."

https://www.gregorysdifelicemd.com/olympic-skier-miracle-comeback.html

Analysis of the older data reveals certain subgroups, especially proximal tears with good tissue quality, had better outcomes.   

Again, the acuteness of the tear was a significant factor in repair – it is quite clear the direction I was being in given in Canada was wrong, and reducing the likelihood of a positive outcome.

I email Dr Difelice to find out what I can ask at my appointment this week, and am prepared to go to the US again.

Also email DIS again.  Ensuring I exhaust all potential options.

MRI - Richmond Road Diagnostic - Alberta Health Services

I want to mention how grateful I am we actually have access to healthcare.

Just the fact that it is available at all in a world where many don't have the option.

A lot of people complain without offering a solution or appreciating the fact that despite the imperfections, we're lucky to be in this part of the world.

Last 2 weeks I'm starting to walk (limp?) a bit better despite limited range of motion; has it improved slightly?  for straightening I have gotten it a cm or two closer to the ground, not sure if that translates to a degree or more.

Still very slow, just to & from parking lot for work & necessities, which has been treacherous at times.

Lucky snow & ice is gone in the city; would not have been able to walk on ice.

Apr 26

- evening before MRI

stepped off curb; it must have been a bit lower than I expected, likely I was going a bit too fast as I feel things are improving - bending beyond the comfort zone and couldn't stay up, naturally caught myself with the other leg & hands on the road.  Push through the pain to straighten it again, stood up and assessed.  Sat on my bumper for a few minutes while it settled down.  Hopefully it didn't make anything worse; happy the MRI is tomorrow and we can finally get a diagnosis. 

Surprised no one stopped to ask if everything's alright; there's a fair bit of traffic in this area - it wouldn't have help me, but what if it was someone else that actually needed help?

After this I decide to start keeping detailed notes regarding #injury progress & how it feels.

Apr 27

- MRI scan

- 37 days after injury

- surprisingly long walk from front door to the MRI lab, a great exercise in patience for me.

wait time of 37.4 days for 15-30 minute scan Alberta Health Services

*side note

- within the week I waited, my friend requested & received and MRI at a private clinic in Calgary

- so the problem at Alberta Health is not a shortage of access to equipment or capacity.  Had my appointment not been moved up I would have done the same, as the doctor explained there is a window to treat these injuries for a positive outcome

Diagnosis still pending - wait time 29.4 days

Apr 18, 2018

another chiropractor appt, we work around the thrombosis. 

Hats off to Jacquelyn at 360brainbody who noticed I should get the additional ultrasound & has been helpful throughout.

Apr 19

Interested in finally getting diagnosis

32 days after injury. 

The Acute Knee Injury Clinic at U of C provides a great service and can often diagnose without the need for an MRI. 

They experience a spike in skiers as knee clinic patients in March / spring time.

Due to my limited range of motion, they couldn't assess and are concerned it might be leg lock; they want an MRI, bumped it up from next year to next week. 

see last post link for how MRI wait times could be reduced through introducing continuous improvement.

wait time (non-value add) 29.4 days

service (value add time) <60min

Ultrasound

Ultrasound on Apr 3rd, no change in clot;  not overly worried about it either.

Grateful this happened after snow left the city; wouldn't have been able to walk on ice.

Apr 6

- 21 days after injury

**This is the 1st window which I'll explain after.

- still no diagnosis - appt is on the 18th - & no MRI yet. 

*I would be 2 weeks post op at this point in the US. 

Starting to think I might not make skiing Sunshine village May long.

Now questioning what the impact is of delaying treatment?

Ultrasound (see pic) on the 12th said 'stable' which I was excited about thinking 'ok' when actually this means 'hasn't dissolved' a.k.a. my leg still has a friend that should leave.

value add time: 6 hours = 1.5%

wait time (non-value add): 396 hours = 16.5 days = 98.5%