BEAR trials ACL repair

I continued doing research on BEAR trial, including articles from ResearchGate, BEAR Trial 2 at Boston Childrens

Apparently an ACL tear is one of the most common types of knee injury, accounts for around 40% of all Sports Injuries.

Treatment can be surgical or conservative (which is reserved for sedentary patients).  Physically active patients seek surgical treatment to restore functional strength to the ligament.  The current standard surgery uses a graft made by stripping perfectly fine tendon tissue or ligament from elsewhere (hamstring, patella, etc.).  In addition to removing good tendon and having to recover from this in addition to the knee injury, I’m concerned from the high risk of early onset osteoarthritis in the injured knee from the standard surgery.

Rehabilitation from this takes 9 months to a year to regain the loss of quadricep strength and knee flexibility caused by having a portion of tendon removed.

From what I understand BEAR uses stitches and a bridging scaffold (a sponge injected with the patient’s blood) to stimulate healing of the torn ACL.  This maintains a clot that facilitates ACL regrowth by providing barrier from synovial fluid effects. 

Another way of saying it:

a suture repair to bridge the gap between torn ligament tends & incorporates a bioactive scaffold to promote self-repair.  The sponge is inserted into the area where the torn ACL once was, soaked in the patient's own blood and then attached to both torn ends of the damaged ACL. Over time, the sponge acts as a "bridge" and allows the ACL to reattach itself, thus re-growing a fully intact ligament.

The bovine scaffold acts as a bridge that lasts in the joint long enough to allow the ACL ends to heal back together. 

Patients then wear a restrictive hip-to-ankle post operative brace for 6 weeks, at which point they switch to another sports brace.

Recipients so far demonstrated faster recovery time than graft recipients, & hamstring strength at 3 months was significantly better in BEAR patients.

MRI results wait time: 16 days

April 30, 2018

I received the following email:

“We have received your MRI results and Dr. _____ would like to see you back in the AKIC to go over those results on:

Wednesday, May 16th at 10:45am.  (16 day wait time)

We are happy to report that there are no urgent surgical findings in your #knee. Please continue with rehab exercises (ie. physiotherapy, athletic therapy, or home strengthening/flexibility program) and activities as tolerated.  Please remain in linear activity only (no pivoting or twisting) and no impact exercise (no running or jumping).

Please reply to this email confirming the above appointment”

To which I promptly replied:

“Are there any non-urgent surgical findings?

It really blows my mind I know 2 people who had MRI's scheduled, results provided and in 1 case surgery conducted in less than 2 weeks, and I have to wait over 2 weeks just to review them.  A phone call would be great to give me an idea of what's going on. 

Also wondering if I am better to have results sent to my previous sports medicine doctor in Toronto and fly their to speed receipt of diagnosis.  I understand from my healthcare background this is due to the medical care system setup, not individual people.  If you would like to reduce your turn around times, I would be happy to help.

As for your recommendation not to run or jump, I can barely walk.

Evening prior to MRI I stepped off a curb and bent my knee more than it wanted, and it has been quite challenging since then.
Confirming the appointment in half a month.”

The step off the curb 3 days prior brought the inflammation back to where it started. 

Received call from AKIC doctor at U Calgary next day, who provided some clarification.  Very grateful for this.

*even though the radiologist completed their report promptly, & the doctor received it, there’s still a 16 day wait time for results instead of scheduling them within 24 hours of actual availability.  Go back 4 & 7 posts to see examples how wait times are reduced with lean healthcare in the emergency room and MRI, which can be done

Total Wait Time so far for diagnosis: 40 days

Plus the additional 16 days now.

ACL regrowth BEAR trials (bridge assisted ACL Repair)

After first finding an ACL healed itself, the 2nd thing I found were the BEAR trials run Boston Childrens in these two articles from 2016:

http://www.stack.com/a/radical-new-surgery-allows-you-to-regrow-your-acl 2016 stackmedia

https://www.bostonglobe.com/sports/2016/03/23/new-surgery-could-revolutionize-knee-repairs/BJISuh60AYKYTKWPwaYFWP/story.html Boston Globe

A safety study had been done on 10 patients, all reported “doing well, with knees working as well as knees treated with ACL reconstruction.”  The 1st patient surgery was Feb. 2015 (> 3 yrs ago), for Corey Peak, who also tore it skiing.  He concluded that it was a better option to treat a torn ACL; within 3 months post-surgery, his MRI showed that his ACL had started to naturally knit together; he was jogging on a treadmill. Soon after, cycling to work. 

Bridge Enhanced ACL Repair - How it works:

When viewed under a microscope, ACLs still have active cells and blood vessels after injury.  The ligament itself works hard to heal, however the synovial fluid — the lubricating substance that exists inside of all joints —washes away the blood clot that serves as the initial connection between torn tissue ends in other parts of the body. 

Conventional treatment for an ACL tear involves removing the torn ends of the ligament that’s trying to heal itself, & fabricating another from a tendon graft, usually done by stripping away good tissue (hamstring or patella).  Patients who had 1 injury then have to recover from 2 separate injuries—the torn ligament + the uninjured area where the graft was taken out.

Whereas a traditional reconstructions involves removing good tissue for a graft from another part of the body to fabricate an ACL, BEAR allows patients to re-grow their own ACL. This resulted in both quicker #recovery and fewer long-term complications than the traditional ACL amputation & reconstruction.

An estimated 150,000 ACL tears still occur every year in the USA. “ACL re-tear rate can be as high as 20% for teens.  Up to 80% of patients develop arthritis 15-20 years after surgery.”

Given the eligibility criteria timeline, I need to figure this out fast, as I was at 38 days, and I didn’t want unnecessary ligament removal.

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

PRP - Platelet Rich Plasma

I started doing my own research on knee injuries to understand what was going on better, and due to the poor response times and lacking diagnosis Alberta Health Services, I had to start looking into other options for service.

For a previous problem my then running coach Glenroy Gilbert recommended at I travel from Ottawa to Toronto to sports medicine Dr Anthony Galea who was very helpful.
(who's clients have included golfer Tiger Woods, Olympic medalists Dara Torres, Mark McCoy medalist (hurdles), Donovan Bailey; NFL players Jamal Lewis, Javon Walker , Santana Moss; Chris Simms, and figure skater Patrick Chan).
Major League Baseball players Alex Rodriguez, Huston Street and John Patterson have also received treatment from Galea (correct me for any wrong handles).

Looked him up again and saw a few years after that, he introduced PRP (Platelet Rich Plasma) therapy as a way to treat his patient injuries.

What I like about Dr. Galea is he does not let limitations of conventional medicine establishment prevent him from the practice of advancing medicine (see his TED talk).

PRP therapy is the process of treating an injury with a patient's own blood, concentrating & reinjecting your natural growth factors with the intent of promoting soft tissue growth in ligaments & tendons.  It is legal and widely used now, often paired with stemcell injections.

For ACL repair PRP alone did not appear to be a solution; at best it may have be an accelerator in the right situation.

Stem cells have potential, yet do not ensure the physical tissue's position is achieved (may not resolve leg lock) and sometimes result in tumors and defects - stem cell technology for ACL is too early from what I see, and there was not strong research backing this for ACL repair either.

So I continue to do as much research as I can late evenings & weekends.

*in US this would be 4 weeks post op

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

HOW TO REDUCE MRI TIMES

Here's an example

HOW TO REDUCE MRI TIMES:  

https://pubs.rsna.org/doi/full/10.1148/rg.347140025

This was done at Department of Diagnostic Radiology, Henry Ford Hospital,

2799 W Grand Blvd, Detroit, MI.

It is more complex than most I would expect, and the team did not quit, they followed through their learning. 

I've been implementing Lean for 10 years, part of that in healthcare, if you have questions or a hospital CEO interested in leading your facility to obtain these results.

It works. 

The question is are you learning how to apply it Alberta Health Services?

1 year MRI wait times in Alberta

I receive a call saying MRI appointment is for March 2019

- 1 year away. 

Cannot straighten leg or bend it near 90 degrees.

*Would be 3 weeks post op in US and recovering; being told I have to wait a year now here. 

Consider that other people have families, children or their elders to take care of; or may not be in a financial situation that allows a 1 year pause due to pending injury diagnosis - 1 year is unacceptable for MRI wait times.

It can impact their quality of life, #recovery potential & ability to economically contribute or support dependents. 

This situation supports unnecessary ACL amputation & ACL reconstruction when diagnosis & #treatment is not achieved within the time frame for natural ACL regrowth  - more explanation to follow.

Is MRI magnet time at 100% ?

If so, are we executing Lean Healthcare reducing costs in other areas to free up the available funding to purchase new equipment like so many other hospitals? 

For example, Lean has been used to improve hospital utilization, improving patient outcomes while reducing the need to add entire proposed #hospital WINGS.

When properly applied the CEO frees up $$, space & resources which can be redeployed for additional healthcare services (or MRI suites).

One way to learn a solution Alberta Health Services

- in the same way emergency wait times are consistently reduced through 3-5 day Rapid Improvement events, MRI wait times are reduced the same way.

see how it's done in next post

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%

Reducing wait time despite an increase in patient volume using Lean strategy in the Emergency Department

last post was on ER, here's examples and explanation what's required for any emergency room learning Lean Healthcare including Alberta Health Services

Note the requirement for *commitment at the top senior level*

- & engaging front line employees.

HEALTH POLICY AND CLINICAL PRACTICE/ORIGINAL RESEARCH Use of Lean in the Emergency Department: A Case Series of 4 Hospitals https://createvalue.org/wp-content/uploads/2010/01/lean-ER-Annals.pdf

If you don't think it's your obligation to provide these healthcare services; consider one day you will be the patient relying on them. 

(or waiting without)

Start now.

MRI wait time reduction example to follow.

Can make a pdf copy available & answer questions on how this is done.

Emergency Room visit 2

Mon Apr 2, 2018

- 16 days after injury

Noticed ankle swollen when waking up, paid attention to it and see if it goes away with movement over day.

Head to emergency Alberta Health Services after work, another 2 hours wait time *which could be reduced through a Rapid Improvement Event. 

Plenty of examples where this has been done, can be done in Alberta too.  Ask me it's what I do

Guy beside me had eye injury not wearing safety glasses & nail puncturing eye.  No requirement for safety glasses at their construction site - really?  Look out for your people!

Liked the doctor who helped me, he seemed to understand what was going on and was a bit disappointed with the lack of direction I received so far.

Things checked out ok,

I requested he provide something for the GP (in pic) - not sure what all it says - or if sometimes healthcare mistakes are made from misunderstandings on what's written!

I think it says:

"Seen here.  Has O/P  MKS ultrasound done mid march for skiing injury to L knee then seen again for swelling L leg & O/P u/s superficial thromboph______ L leg. 

___________ RX _____ + has follow up u/s booked tomorrow am _____ advised if increased swelling L leg + ankle _______ ____________ ________  _______ ____ ____ _____ 99% RA R calf 38cm  L calf 39.5cm ........

........

_____ ibuprofen 400mg

.......

have u/s + if toe start oral anticoagulation rivaroxaban 15mg ___ 21 days then 20mg daily x 3-6 weeks.

......

follow up (f/u) family MD after u/s"

glad I don't have to decipher on a regular basis - feel free to fill in any blanks/correct me/help finish decode.

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.

....................................

Wait Time for Diagnosis

Thu Mar 22

Drop in to my Chiropractor. and they notice a few things seem out of the ordinary & request another ultrasound to check for thrombosis / DVT

Mon Mar 26

Acute Knee Injury Clinic at the University of Calgary responds 6 days after request regarding appointment, says to complete forms online & they are booked out for weeks, Apr.19 is next appt;

which means I won't receive a diagnosis for another 4 weeks.

How many injured people cannot wait 1 month & still achieve a positive outcome?

*Another example where lean healthcare can reduce wait times & improve patient outcomes.

another Chiropractor appt. today, worked on shoulder as it was sore from how I've had to adjust to get in & out of truck.

*also grateful to be somewhere that healthcare is at least available

 ...................................

Thu Mar 27 - day 10

have DVT ultrasound appt identifying 3.8cm thrombus in 2 superficial veins of the popliteal trifurcation.  not sure where that is, feel free to tell us what popliteal trifucation means in comments.

Met family doctor, suggests some aspirin to help the body naturally disolve the clots, and to obtain a 2nd opinion from an orthopedic surgeon who should be available at the emergency.

head to Alberta Health Services Emergency

..........................................

Precursors to Lean – Mediterranean Ship Building?

From 1899-1905,

The Wright Brothers invented Knowledge Based Development (Lean Product & Process Development), evolved from their goal to study and advance the knowledge of flight.

At the same time, some shipbuilding references exhibited elements of lean practice (if you do your research, you’ll notice some non-lean elements also):

From 1899-1902,

Novelty was introduced as simplicity. Saving in lead time was achieved by standardization.

On December 11, 1906, 3 weeks short of Fisher's accelerated schedule, H.M.S. Dreadnought was accepted into the Royal Navy.  10 months from launching to full commissioning in the navy had never been equaled in the history of capital ships."

In 1400,

at the 46 hectare Arsenale di Venezia (Venice) dockyard, a production capacity of 6 galleys/ month was reached by the 1500’s.  They standardized ships, developed a new galley using less timber, and a standard frame.  Production occurred onsite for rope & armoury.  Modular construction and elements of one piece flow were also used.   Multiple designs were produced including the Mediterranean Brigantine, Galiot, Fusta, and Galea Bastarda.  At its peak in the 1600s the dockyard was turning out 1 ship a day.

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

............................   

How ACL Tear Occurred

Why I post this information:

Upon realizing Canadian orthopedics was 8 years behind current practices and unnecessarily removing ACL ligaments from patients clearly eligible to regrow them, I decided to make the information available to patients.

Here’s the start of how I found out orthopedic practitioners has not been informing people of their options, and in many cases do not even know themselves what is happening in their field.

Here’s the injury

March 17, 2018

Went skiing on backside of Lake Louise, marked where one gets off the lift, skied down and traversed

Top left shows where these pics were from with route there from front side

a couple pics of route marked & my friend making it up a steep

wide angle with route marked & on right you can see where the actual Lake Louise is & Fairmont hotel in relation to ski hill.

black line on right side shows route to this from back side; next pic is looking north

after travers, looking north (I think) from spot in previous pic

Where the previous pic taken from. Chateau Lake Louise in background. Not sure it bowl behind me goes to road or hike out needed - would like to know from someone who’s done it. Travers & skiing direction marked in green. video that wouldn’t upload here on my insta @ryancartiers

Not sure which of the 2 spines it was, recall the same curve marked in background to ski to ridge & drop in

on the way down after skiing 1st pitch, still up high, looking east I think. Snow was alright.

Found this pic online and only see 1 spine. Not sure where other is - looks like the curve though with face showing on either side below. Black is traverse, green is skiing.

Dropped in over shelf, landed ok - thought I was off but kept it together. Snow a bit cruddy. Caught left inside edge pulling the front of my ski out & behind me, bailed. Scramble to stop slide before rocks below. Had to use pole to undo binding. Couldn’t put enough pressure down left leg to lock into binding, so after a few tries picked up ski and slide across the steep below rocks on right side to reach flatter slope.

From pics pieced together this is my best guess where it happened.

Red is roughly the route out to make it onto the ski out.

1st pic friend took while waiting for me, just after fall, which was to the right of the rocks near the top right side of photo (outside of pic). Tried again to lock in binding, wasn’t happening. at 50% running 1 Nordica ski, knee hurt and still enjoying Lake Louise mountain life!

closer pic friend took while waiting for me.

trying to figure out if I need a month for this to heal and still ski May long weekend at Sunshine Village

…and skiing down to get onto ski out…

took a few breaks for the right leg heading down the ski out (route in next pic) - must have taken this photo on one of them. Told my friend to get a few more runs in when hit Paradise chairlift.

She had videos will post if we can find

Arrived at bottom for last chair (to get over to the front side). Liftees didn’t fuss about me keeping one ski in hand on the lift - much appreciated!

video that wouldn’t upload here on my insta @ryancartiers

off chair at top and over to gondola.    Ski patrol asked me if everything ok & liftee helps w skis - thank you

1st time I can recall downloading on a gondola when skiing an option.  For those who've never been here, sharing the view at Louise

__________________________________

walking in ski boots doable, from gondola to front of Lake Louise lodge;  waiting for friend to get car and give me a lift to end of parking lot.  Great #view from here.

curious if getting boots off will be difficult, went ok.

 _____________________________

since this was my friend's 1st time in LakeLouise I said we should drop by Chateau LL

Was a slow walk to the front.

____________________________

stayed Deerlodge next to Chateau Lake Louise - took the evening pic while icing

_____________________________

End of day March 17, 2018

Started icing Deerlodge - they have an outdoor deck w hot tub on top so its easy to sit in the snow on the side and #ice.

Stairs are less easy; manageable though.

sleeping was a challenge, finding a position not too painful long enough to fall asleep; seems like only a few hours Morning experience stiff & more painful.

I think it's just a sprain and may be able to recover for slushcup; friend has had a few ACL injuries in the US & typically sees the doctor, has an MRI next day, and surgery (if needed) within a week or so, starting recovery weeks from injury - I expect Canadian Healthcare to be at least comparable to US delivery whatever the diagnosis is. 

Guess what happened...

Solid Day at Agent2021

2018 01 24

Will the Eagles learn to exploit inefficiencies in football?

It may not be as factual / data based as the Oakland Athletics baseball run in 2002 (see 'A Lean guy watches Moneyball) or how the San Francisco Golden State Warriors Revolutionized Basketball,

read this article today and am interested to see how the Eagles do - not this season - but the next 2-3 seasons if they adopt a fact / data based approach to identifying the inefficiencies in football and exploit them.

*side note - still wish LeSean McCoy was with the Eagles; would love to see Buffalo win at some point now that he's with them

Initiating Service Excellence practices in the Canadian Federal Goverment

After some initial emails starting June 2017, received an invitation to speak with Kent Hehr MP Calgary Center to suggest introducing service excellence practices to the Canadian Federal Government. 

Used examples Washington has achieved, published in their 2014 & 2018 Results Washington reports you can see here:

2014 December Lean/Performance Management: Quantifying Results and Exploring the Viability of Self-Funding (PDF) 

January 2018: Results Washington Annual Report (PDF)