KneeHab: Cadavar tissue, KAATSU and questions to ask before ACL surgery | SummitDaily.com

KneeHab: Cadavar tissue, KAATSU and questions to ask before ACL surgery

Editor's note: This article is part of an eight-week series about ACL, MCL and other knee injuries, featuring professional and first-hand info on surgery, rehab, recovery and prevention. See the Summit Daily sports section every Friday or Saturday for the next installment, and head online to SummitDaily.com for past articles.

Take it from a freshly injured skier: shop around before you sign your name on the dotted line at a surgery center.

On June 24, 2016, longtime Breckenridge local Josh Barilar was skiing a steep northeasterly couloir on Fletcher Mountain — one of several craggy peaks surrounding Breck's hometown 14er, Quandary Peak — when the snow gave out beneath him. It wasn't quite a true avalanche, he remembers, but it was enough to pull him uncontrollably down the tight, rocky chute before slamming him into a craggy outcropping.

"The accident was pretty much a fluke, and that's what everyone agreed on," said Barilar, who was skiing that morning with two partners, including backcountry maven Aaron Rice. "If this had happened in an open snowfield, we'd be laughing. It was like having a carpet pulled out from under you."

When the snow settled, Barilar had no concussion and only a broken finger, but his knees had been brutalized. His left knee was bruised — it didn't return to normal color for nearly five months — and the cartilage in his left knee was horribly mangled. The rocks managed to miss his MCL, ACL and menisci, but the overall joint damage was just as severe. He was airlifted out of the couloir after five hours and taken immediately to the hospital, where he stayed for two days while doctors pondered the damage.

The first diagnosis was grim: Barilar might never walk again, and he surely wouldn't run again. That didn't sit well — "I know I'll run again," he says — and so he sought second opinions from Vail-Summit Orthopedics and The Steadman Clinic, both based in Vail.

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In August, the Vail-Summit surgeons told him 16 months of recovery with one immediate procedure. Steadman surgeons told him two procedures — one to see what's wrong, a second to repair the damage — and a more palatable 10 months of recovery. Both clinics were confident he would walk, ski and bike again — they just couldn't agree on a timeline.

"Just because one doctor says one thing, don't be afraid to get a second opinion," said Barilar, a 32-year-old who was on Vail Resorts insurance when he got injured. "I was torn and didn't know what to do, but I had a lot of good advice and good guidance because the therapists in this county are amazing. You really can't pick a better place to get injured."

Knees in need

Ask for an orthopedic surgeon in Vail or Breckenridge and you'll hear the same thing: they're the cream of the crop — surgeons who regularly repair world-class athletes with the U.S. Ski Team, NHL, NBA, England's Premier League and other top-notch teams from across the globe.

But knee pain isn't limited to the pros. Every year, roughly 5.5 million Americans see orthopedic clinics for a knee problem and about 1 million opt for outpatient surgery, like an ACL, MCL or meniscus repair, according to an article in the March 2015 edition of Scientific American. Another 700,000 have one or both knees totally replaced, the article continued, with many cases traced to quick-cutting sports: tennis, soccer, basketball, skiing.

Of all the potential knee injuries, skiers are most susceptible to MCL and ACL damage. It comes down to the sport's movement: legs are attached to long, extended anchors (aka skis), and when these anchors get torqued, they can wrench and tear the intricate tissues of your knee joint. Because these tissues don't have good blood flow — the key to quick healing — they take months to mend. Some ligaments, like the ACL, won't heal at all if fully torn.

"Ultimately, if the knee is unstable, painful and there are functional limitations, the knee needs to be stabilized via a ligament reconstruction or repair," said Eric Dube, a physical therapist with Howard Head Sports Medicine. Without surgery, he continues, "there is a real risk of injuring other structures in the knee, like your menisci, cartilage, or other ligaments."

But recent studies suggest knee surgery isn't viewed the same across the world. In Europe, doctors are more likely to prescribe rehab instead of surgery for ACL injuries, while the opposite is true in the U.S. The findings are unusual: European studies show little difference between rehab-only and surgical patients, while American studies show that rehab-only patients are more likely than their surgical peers to develop meniscus issues after three to five years, according to physical therapist Paula Ashbaugh with Avalanche Physical Therapy.

"It's really interesting: In the long term, not everyone needs to get the ACL repaired," Ashbaugh said. "It depends on your sports and activity. Anything where you pivot and jump — basketball, beach volleyball, tennis — you want to get it fixed."

The $43K knee

So you've opted for surgery. Now you've got to pay for it.

Local ortho surgeons might be the best in the world, but that also means they charge more than surgeons in Denver or other regions. When paired with statewide increases for health care premiums — jumps of 20-46 percent in 2017 alone, according to past Summit Daily reports — even patients with health insurance need to brace for steep upfront costs from services like MRIs, prescription medication and post-operative equipment. Without insurance, an ACL repair in Summit County is unaffordable at roughly $43,000 (see sidebar).

But is it worth it? Yes, doctors agree. Sure, their livelihood is on the line, but veteran knee surgeon Rick Cunningham with Vail-Summit Orthopedics makes a compelling case.

First, ortho surgeons are better than ever before at placing new ACLs. Cunningham's colleague at the clinic, William Sterett, takes four X-rays of a patient's knees, calves, pelvis and femurs before an ACL repair. Together, he says the collection of images helps him match the new ACL to the patient's anatomy and posture.

"It comes down to placing the ACL anatomically," Cunningham said. "Here, where we are, there are doctors who do enough of these surgeries that we know what to look for right away."

Second, surgeons are discovering new and better ways to work with tissue. ACLs are repaired with one of several tendons, including those taken from cadavers, but Vail-Summit doctors are finding that the quadriceps tendon is best for young, active skiers. It lowers the chances your body will reject foreign tissue, he says, and boosts chances of long-term strength.

"We would hope that a repair is lifelong," Cunningham said. "There are some factors that help us achieve that and number one in my mind is using patient tissue instead of donor tissue for younger patients."

The meniscus question

But the biggest reason to repair a blown knee? Simple: another few decades of skiing with little residual pain, weakness or irritation.

"We're so much better at fixing ACLs than we were 10 or 15 years ago," Cunningham said. "We have a better understanding of where to place the ACL based on where it used to live. We're getting better than ever before."

So is technology. Along with improved techniques, ortho docs are also toying with biotech solutions for knee repair. The two most common — platelet-enriched plasma and bone marrow aspirate concentrate (see sidebar) — are taken from the patient and injected into the knee during the procedure to boost recovery. Another, more radical solution replicates tissue like the C-shaped meniscus with a 3-D printer. This option isn't approved for human patients yet, but researchers at Columbia University Medical Center say it could be the key to "true joint regeneration," according to the Scientific American article.

For ACL patients, the meniscus is a true wild card. Doctors won't know how badly it's damaged until they cut into a knee, and popular solutions have included shaving off entire portions of the tissue — a harbinger of arthritis later in life. A 2013 study in The New England Journal of Medicine found that shaving the meniscus, known as a meniscectomy, was no more effective than a simulated operation for pain relief.

Now, to bridge the gap between meniscectomy and experimental implants, ortho surgeons are getting getter at stitching the menisci back together. This means no loss of natural tissue — only an extra six weeks on crutches while the stitches heal.

"You hear horror stories on the internet all the time, but you can't get alarmed when you read these opinions because there's a whole history behind these things," skier Barilar said. "You have to do your own research to find out what you need."

Long road to normal

Because the damage to Barilar's knee was so complex — and because he'd already been laid up for nearly three months — he opted for the Steadman approach: two procedures, 10 months of recovery. Between and after each operation, he did physical therapy with Howard Head in Vail and the clinic's newest addition: KAATSU.

Barilar describes the KAATSU treatment system as a blood-pressure cuff for your leg. At PT, he wraps the cuff around his right leg and does the typical exercises, like calf pumps, lunges, squats and more. The KAATSU system tricks his body into thinking it's working harder than it is by slowing blood flow, which naturally produces human growth hormone.

"The best analogy I could come up with was like a donut on a baseball bat: you take it off and you can swing the bat faster," Barilar said. "I took off the cuff and it honestly felt easier to walk."

Barilar's first operation was in August 2016 and the second was in November. By February of this year he started walking again — his first real steps after being on crutches for nearly seven months.

"It's pretty wild to think that my muscle is coming back very, very well," Barilar said. "I'm not even five months out and I'm already lifting 40 pounds in lunges. You listen to your body — that's your best doctor — and I've been able to do those exercises. It's crazy."

KneeHab 101 series

Knee injuries are a part of sporting life in the mountains. Over the next few weekends, the Summit Daily sports section will print weekly articles about ACL/MCL injury, surgery, rehab, recovery and prevention, featuring interviews with local doctors, physical therapists and pro athletes. They’re the only knees you’ve got — show them some love.

Have a suggestion for the series? Email sports editor Phil Lindeman at plindeman@summitdaily.com.

Week 1 — “A club I never wanted to join,” injury column

Week 2 — Anatomy of an ACL/MCL injury

Week 3 — Yoga for ACL/MCL recovery

Week 4 — ACL surgery 101

Week 4 — “Slice, dice, make it nice,” surgery thoughts and pain column

Week 5 — Myth-busting for knee injuries

Week 6 — Post-surgery recovery, rehab and physical therapy

Week 7 — Man on the street: Summit locals talk knee injuries, video

Week 8 — “Betting on the long, hard road,” recovery column

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Cost of an ACL repair

Let’s be clear: without insurance, I wouldn’t be getting my ACL surgically repaired. The total cost of the operation, surgery facilities and post-op rehab would be more than I could afford at more than $42,500.

Luckily, I had insurance through my employer when I was injured. But even that didn’t combat steep upfront costs, and I didn’t add outside costs by seeking a second opinion or surgeon. It’s the harsh reality of elective surgery in the U.S. right now: After talking with billing departments at local hospitals, I found that collecting 50 percent of all fees upfront has been standard since the introduction of the Patient Protection and Affordable Care Act. I paid nearly $2,450 before going under the knife.

Insurance vitals

Provider — Anthem BlueCross BlueShield

Plan type — PPO (single person, no dependents)

My monthly cost — $134, or $67 per paycheck

Deductible — $650

Max out-of-pocket — $5,650

My responsibility — 20 percent of total charges until max out-of-pocket is met

Vail-Summit Orthopedics (surgeon, MRI, other scans)

MRI — $845, paid half upfront ($422.50)

ACL and meniscus repair — $10,848.64

My responsibility — $2,169.70, paid half upfront ($1,084.85)

Remaining charges — $1,507.35, plus remaining MRI fees ($422.50)

Edwards Surgery Center (facility, anesthesia, etc)

Surgery fees — $29,109

Facility co-pay — $175

My responsibility — $2,500, dropped from full 20 percent ($5,821) due to meeting out-of-pocket, paid half upfront ($1,250)

Remaining charges — $1,250

Post-op therapy (Avalanche Physical Therapy)

PT sessions — $120 for assessment session, $70 for all follow-up sessions

My responsibility — $14-$20 per session (paid full $190 upfront while insurance processes)

Total — $960 and up, based on 3 sessions per week for 4 months (possibility of $0 after out-of-pocket is met through other fees)

Medical equipment (Medequip)

Full knee brace — roughly $600

Crutches — roughly $150

Movement machine — roughly $900, declined

Total — $750, pending insurance

Post-op prescription drugs

Oxycodone (5mg) — $10, down from $33.29 without insurance

Morphine extended release (15mg) — $23.49

Total — $33.49

Totals

All items — $42,546.13

My responsibility — roughly $7,258 (before out-of-pocket)

Paid upfront — $3,393.34, minus medical equipment ($750)

Balance remaining — $3,864.66

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Helping Mother Nature help herself

For decades now, orthopedic surgeons have tried to answer a pressing question: How can we speed up Mother Nature for joint repairs?

The question begins with the ligaments, tendons and cartilage that combine to make joints. Unlike muscles and skin, these tissues don’t have high blood flow — the key to quick tissue recovery — and so rehabilitation takes longer than for cuts, bruises and even broken bones.

At two ortho clinics in the Vail area, Vail-Summit Orthopedics and The Steadman Clinic, surgeons are on the cutting edge of joint repair thanks to a pair of acronyms: PRP and BMAC. Platelet-enriched plasma (PRP) and bone marrow aspirate concentrate (BMAC) are two relatively new biomedical solutions for the problem of tissue recovery. During ACL and other knee procedures, doctors at both clinics prefer using a combination of both solutions to give Mother Nature a helping hand long before sutures are healed.

Here’s how it works: PRP and BMAC solutions are taken from the patient before an ACL repair, and then re-injected during the procedure. BMAC harnesses the power of stem cells for healing by mimicking other tissue: less than a year after surgery, bone marrow cells taken from the pelvis will show up as ACL cells in the knee. All BMAC cells are harvested from the patient, which skirts the touchy ethical issues that surround research with donor stem cells.

Dr. William Sterett at Vail-Summit Orthopedics admits the jury is still out on the efficacy of both solutions, but with strong evidence for positive results (and little evidence for negative ones), he recommends the duo for all ACL repairs.

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