Finding an Orthopedic Surgeon

May 18, 2018

Saturday 2:27am

Mackay Office reply:

“I have forwarded this message to Professor Mackay, and for his advice on theatre availability.”

I settle in to wait the weekend.  (won’t be skiing slushcup Sunshine village this year)

Monday is a Holiday in Canada however not in Scotland so I can follow up then.

My persistence may be paying off, thanks to David Hunt Tribe Medical , Peter from Gateway Surgical did contact me and suggested Jesse Shantz or Andrea Veljkovic are potential providers of current orthopedic practices in Canada; turns out they are also private – I contact them regardless, as the failure of the Canadian Healthcare system is not leaving an alternative.

The earliest option they have is an initial appointment for consultation Wed May 23 followed by surgery in Vancouver May 30.  For some reason private healthcare is not allowed in Alberta, so to provide care patients have to fly to BC for the procedure.  I would return right after, and they suggest I have food for a week or 2 & someone to help me while I’m healing & less mobile. 

Some of my questions were for the surgeon so I wait to hear back from Jesse… 

Anterior Cruciate Ligament Repair Revisited. Preliminary Results of Primary Repair with Internal Brace Ligament Augmentation: A Case Series

The next report I came across really put the it into perspective the need for alternatives given complications and lower than toted outcomes of ACL reconstruction, and how InternalBrace initially measured up within the first 3 months – back in 2015.

Anterior Cruciate Ligament Repair Revisited. Preliminary Results of Primary Repair with Internal Brace Ligament Augmentation: A Case Series

https://www.omicsonline.org/open-access/anterior-cruciate-ligament-repair-revisited-preliminary-results-of-primary-repair-with-internal-brace-ligament-augmentation-a-case-series-2161-0533-1000188.php?aid=52900

“estimates suggest that in the United States alone 400,000 ACL reconstructions are carried out each year. As the majority of ACL injuries occur in patients of working age, the economic burden to both patients and society is considerable”

“ACL reconstruction. The technique either involves removing or bypassing residual ACL tissue, without any attempt to repair the ligament”

“In the majority of cases, sufficient tissue remains for a repair to be considered, particularly if surgery is carried out within 6 weeks of injury”

*What really strikes me – perhaps from my continuous improvement background – is removal & reconstruction is a work around to the problem*

“A number of problems have been identified with ACL removal however, with autograft harvest associated with a degree of morbidity from tissue loss. Hamstring muscle weakness following harvesting averages 10% in most studies with anterior knee pain common with patellar tendon grafts”

“loss of proprioception a particular problem. Not surprisingly therefore the majority of studies of gait after ACL reconstruction show abnormal gait patterns and altered knee kinematics which may be linked to the higher rate of early Osteoarthritis”

Orthopedic & Muscular System: Current Research ISSN:2161-0533

“68 consecutive patients who underwent Anterior Cruciate Ligament repair with IBLA were followed for a minimum of 1 year following #surgery … between Sept 2011 and Sept 2014”

“Only patients who had completed one year of follow-up were included … max time from injury to surgery was increased to 3 months”

*I’m within this time frame, & receiving a diagnosis that will not facilitate a successful outcome*

“Beyond this time the ACL remnant begins to remodel and retract, and the tissue is no longer able to be placed back at its original attachment point”

“Loss of proprioception is important as it may lead to overloading of the ACL graft ... It is estimated that less than 50% of patients return to sport after reconstruction, and those that do often find that they cannot perform at the same level as pre-injury/pre-surgery”

“The majority of studies assessing gait and knee kinematics post-ACL reconstruction show an improvement in gait pattern compared to pre-surgery, but compensatory mechanisms of muscle use persist in the majority of patients indicating sub-optimal performance of the reconstructed graft. Graft donor site morbidity from tissue loss and scarring is well documented with hamstring weakness and anterior knee pain problematic after hamstring and patellar tendon harvesting respectively”

“modifications introduced to the ACL reconstruction technique to try to improve outcomes include: changes in graft tunnel position, double bundle rather than single bundle grafts, retention of the ACL remnant and variations in graft fixation techniques.

NONE of these modifications have been shown to make a significant difference to patient reported outcomes.”

*Earlier return to function could result in less hospitalisation and healthcare usage post-operatively, with an earlier return to work and sport. This could potentially have benefits not only to the patient but to the health service and society as a whole.

the time to surgery in patients undergoing acute ACL repair with IBLA is likely to be shorter than those undergoing ACL removals, the majority of whom will have failed a period of conservative care.

https://www.omicsonline.org/open-access/anterior-cruciate-ligament-repair-revisited-preliminary-results-of-primary-repair-with-internal-brace-ligament-augmentation-a-case-series-2161-0533-1000188.php?aid=52900

A Review of Ligament Augmentation with the InternalBrace

Despite the timeline passing for DIS eligibility, the fact a repair option regrowing ACL’s has existed for so long spurred me to keep looking.

I came across article A Review of Ligament Augmentation with the InternalBrace

https://www.researchgate.net/publication/288006378_A_review_of_ligament_augmentation_with_the_InternalBrace_The_surgical_principle_is_described_for_the_lateral_ankle_ligament_and_ACL_repair_in_particular_and_a_comprehensive_review_of_other_surgical_ap

Halfway through the 18 pages I find some application to the ACL, how it reduces harvest site morbidity & cost.

Based on the US stat 1 – 10 per 1000 people = 100k – 400k ACL reconstruction s occur annually; Canada would have 32,000+ reconstructions, which involves removing or bypassing the remaining ACL, despite in the majority of cases sufficient tissue remains for a repair to be considered, particularly within 3 months.

It explained grafts do not produce a normal feeling knee; there’s a loss of proprioception, which when present is important as this prevents overloading of the ACL graft; and estimates less than 50% of patients return to sport, and those that do often find they cannot perform at the same level.

“Graft harvest is associated with a degree of morbidity from tissue loss; muscle weakness with hamstring grafts & anterior knee pain are common with patellar tendon grafts.”

“there is a decrease in knee power and work performed postoperatively by the muscles around the injured knee”

“compensatory mechanisms of muscle use persist in the majority of patients, indicating sub optimal performance of the reconstructed graft”

There was also a study cited confirming “significant increase in osteoarthritic changes as early as a year post op” and stats on reconstruction failures.

“The clinical benefits of a well prepared and healed ACL are likely to be greater for patients than those offered by a traditional ACL reconstruction”

“Sufficient ACL tissue can remain for up to 3 months following ACL injury to allow a repair; procedure is time dependent as the ACL remnants are not suitable for direct repair after the tissue retracts and atrophies”

• Perhaps this is an option I am still within the timeline for.  I have just under 5 weeks left if it is.

The Internal Brace is a 2mm high molecular weight polyethylene that protects a repair by being a check rein if the ligament is stretched beyond its physiological range.  Should failure occur reconstruction remains possible without compromise to the knee joint.

Earliest patients are from Sept. 2011

If found suitable, the ability to repair a torn ACL can be confirmed at the time of #surgery.

“Early phase rehabilitation was consistently accelerated.  Limited pain and selling facilitated early range of movement, muscle control and restoration of function.”

“…avoidance of donor site morbidity & minimal surgical trauma.”

“better outcomes were achieved for ACL repair at the majority of time points”

“Pain…was less in patients”

“4 cases had arthroscopically confirmed ACL healing”

“…eliminate the shortcoming of current reconstruction techniques”

“…change in orthopaedic practice relegating ligament reconstruction appropriately as a salvage procedure; only if the tissues fail to heal adequately after augmentation & repair.”

The article is from back in 2015, so I start searching the authors of the published medical journal studies and references to find other research they’ve done.

Orthopedics - Intrinsic Healing of the Anterior Cruciate Ligament in an Adolescent

Apr 27-29

The majority of the weekend I spent searching anterior cruciate ligament repairs & learning what an ACL repair is, and the 1st article I found was how a 12 year old boy suffered a complete traumatic rupture of his ACL, which intrinsically healed. 

You can find the article

“Intrinsic Healing of the Anterior Cruciate Ligament in an Adolescent”

in The American Journal of Orthopedics, August 2015

https://mdedge-files-live.s3.us-east-2.amazonaws.com/files/s3fs-public/issues/articles/ajo04408e294.pdf

Alberta Health Services Emergency Department Wait Times

Thu Mar 27 - day 10

Happy to see hand washing % sign on wall in emergency Alberta Health Services; still need to start continuous improvement though.

Triage & admitting were reasonably quick; next wait room was 2 hours - at least they know the wait time - no sign of Lean Healthcare.

While waiting for knee diagnosis saw the sign (in pic) - assuming someone else has also - hoping I don't rely on it either if still in disrepair.

At least it's visual.

speak to orthopedic surgeon,

says we can do aspirin and check in about 10 days to see if things clear up, or weeks of Rivaroxaban.

Has a pager call (they still exist!) & says to look it up while he takes the call.

A quick review of its side effects and I don't see why one would take this unless absolutely necessary.  There's also no reversal (as there would be warfarin/rat poison).

We talk more and are in agreement checking back in 10 days is a reasonable course of action.

He says he'll get a 2nd opinion from the hemotologist, comes back and is pro Rivaroxaban prescription.

I call it and point out how flip flop this is, & I prefer not to take the prescribed anticoagulate.  We agree so I'll set up another ultrasound.

I look up natural blood thinning options and adjust my diet with daily pineapple for bromelain, tumeric, apple cider vinegar, cayene pepper, garlic, fish & sardines, lemon, green tea and natto.

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Torn ACL - wait time for diagnosis

noticed more painful to walk in running shoes than ski boots

Sunday March 18

- drove back to Calgary

Will be interesting navigating healthcare as a patient with my background implementing lean at 3 hospitals.  Alberta is behind all the western Canadian provinces in their adoption of Lean Healthcare to improve patient outcomes.

BC started a few years before they moved me there,  Saskatchewan is at the point they're using 3P, and Alberta sandwiched in between by my measure has not even started.

Going to pay particular attention to wait times.

Monday March 19

went to see my doctor who sent me for xray & ultrasound on knee - went same day - report in photo.  I still think everything is ok and may be able to hit May long Sunshine village. Didn't go for the meds or crutches.

so far

88% wait time (10.75 hours) for

12% value add/service (1.5 hours).

Tuesday March 20

morning - walking is tough, actually considering crutches MRI & Acute Knee Injury Clinic appointments requested.

Wed. Mar 21

24 hours later AKIC responds to request, no appt yet.

Nothing from MRI. 

*If I were in the US I would have had it yesterday and would be reviewing the results.

let's see how long it takes Alberta Health Services

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