by Elizabeth Hofheinz, M.P.H., M.Ed., March 4, 2020
Christopher Dodson, M.D., an orthopedic surgeon at The Rothman Orthopaedic Institute, is Head Team Physician for the Philadelphia 76ers and Associate Head Orthopaedic Surgeon for the Philadelphia Eagles. Dr. Dodson, who performs approximately 140 anterior cruciate ligament reconstructions (ACLs) per year, talks about the ongoing debate regarding the optimal graft—and the debate over ACL repair.”
“Whether choosing between a patellar tendon from the front of the knee, a hamstring tendon from the back of the thigh, or a donor tissue (allograft), it must be noted that there are downsides to each of these approaches,” states Dr. Dodson. “There are two ardent ‘camps,’ i.e., those who advocate for the use of autograft and others who firmly believe in allograft. Autologous tissue is the most commonly used graft, with even the quadriceps tendon being used as a source (although the research is not as solid in this area). The major downside of using a patellar tendon graft is the pain the patient experiences, something that is not a problem when using the quadriceps tendon.”
“For professional or collegiate athletes, I use a patellar tendon autograft; for middle aged patients who are active, as well as skeletally immature patients, I do a hamstring autograft. If someone is older and who wants to continue to ski and engage in other strenuous sports, I stabilize the knee using a cadaver graft because it comes with less early pain and overall fewer side effects.
And what of ACL repairs? Think, “marketing” says Dr. Dodson.
Dr. Dodson, who does not do ACL repairs, says, “Theoretically, the advantage of an ACL repair is a quicker return to play. And while there is published work, most people do not put credence in those studies. Hospital for Special Surgery, where I trained, actually put out a bold statement about not doing ACL repairs. There are only a small percentage of patients who would even be eligible for these surgeries—typically a young, healthy person with either a partial tear or a tear off of the femur. I think that some surgeons might be advertising this procedure as a way to get back to sports quicker, i.e., to attract business. When you tell someone that they could undergo a repair with a 4-6 month recovery or have a reconstruction and take 9-12 months to recover, well that may sway them.”
Dr. Dodson is also cautious when it comes to biologics.
“The literature gives us no proof that these treatments actually work. The only indication that has been shown to make a difference is the use of PRP in patients with knee arthritis. PRP seems to provide good pain relief when given intraarticularly. There are several studies now published that demonstrate superior efficacy of PRP compared to HA and cortisone for knee arthritis.”
“Biologic treatments are typically not covered by insurance; one of my patients told me that his stem cell treatment cost $15,000. While I don’t offer PRP as a first line agent, at some point I tell patients that it is an option if they are ready for knee replacement. Then I give them a series of two PRP injections spaced over a couple of weeks, which helps to lessen the inflammatory state in the knee. I make sure patients understand that they are not growing cartilage.”
And of course, there is all of the pandemonium around stem cells. “Although I think patients are learning to be wary of these random places that offer stem cells, the problem still exists as the public doesn’t understand what they are really getting. This is in part because no one understands. You can put a needle in one part of the hip retrieve some cells, but it is unclear how many you are getting. And most patients are under the impression that stem cells are going to replace cartilage. One of Dr. Dodson’s partners, Brad Tucker, M.D. has conducted an FDA study where they did true stem cell injections and got MRIs as follow-ups. They found that while there is some pain relief, there is still no change as far as cartilage growth on the MRIs. So you are not changing the joint…you’re just changing the symptoms.”
“When it comes to ACL or rotator cuff repair, I have not used biologic augmentation because when you are doing these surgeries you are often creating an environment where the bodies natural biologic agents are active. Some cases of ectopic bone growth have been seen when biologics are used to augment some surgeries. Other studies have shown a negative effect. And as much as PRP is beneficial in knee arthritis, the research is all over the place when it comes to showing benefits in rotator cuff surgery.”
“Ideally, we could create different types of stem cells and develop different models of injury and healing and experiment with which stem cells work well in different models. For example, you could have a one model where you attempt to get tendon to heal to bone…and another only for soft tissue healing. We need better information regarding what factors are needed to enhance each situation.”