'A giant leap' in knee repair technology

When Neal Henzler tore his ACL while skiing at Crested Butte a few months ago, he knew who to call.

Henzler and his wife, Robin, are both active valley residents. They've broken bones and torn ligaments a bunch of times, so they have Dr. Rick Cunningham, of Vail Summit Orthopaedics, practically on speed dial.

Valley locals and visitors alike know all about the ACL - the knee's anterior cruciate ligament. We push our knees to their limits, both in the winter and the summer, and when our knees finally give away, we look to the valley's orthopedic surgeons to fix them. Every surgeon in town, except for one, uses the single bundle ACL repair technique. It's a good technique and has worked just fine for years, Cunningham says, but he thinks he's found a better way.

Cunningham was the first doctor in Colorado to start using the double bundle ACL technique, he says. Instead of repairing just one part, or bundle, of the two-part ligament, Cunningham is repairing both. It takes more time, and it's a more technical surgery, but he stands by it because he says it rebuilds the ACL to what it once was, not just something that resembles what it once was.

"I feel like I've been doing ACL surgery wrong my whole career," Cunningham says. "Up until a year ago, I was doing everyone single bundle with hamstring (grafts). And I think it's a good ACL (repair), but this is better."

Medical advancement

In medicine, there are gradual advances made over time, but the double bundle technique is "a giant leap," Cunningham says.

Cunningham learned the technique from Dr. Freddie Fu, an orthopedic surgeon at the University of Pittsburgh Medical Center, who swears by the technique because of the science behind it. It's relatively new in the United States - Fu began performing the surgeries a few years ago - but surgeons in Japan have been using the technique for about eight years, according to the American Academy of Orthopedic Surgeons.

The ACL has two intertwined bundles, which look like two cords weaved together. The way surgeons typically repair the ligament - repairing just one of the two bundles - has been good at preventing the lower leg from extending too far forward, Cunningham says. What it hasn't been as good at is giving rotational stability to the knee. The single bundle technique outcome has been fine for most patients, but Fu and Cunningham believe the double bundle, in which surgeons repair both bundles, is going to have a better long-term outcome because it replicates the original ligament much more accurately.

"A study recently showed that most people who hurt their ACL develop some evidence of arthritis in their knee at some point in the future," Cunningham says. "We think the reason for that is because we're not controlling that rotational stability in the knee and it's hurting the cartilage in the knee."

Fu had been studying the technique for years and he really bases things on science, says Dr. Bryan Bomberg, an orthopedic surgeon in Steamboat who is also now using the double bundle technique. Fu is one of those people that you meet and you just know he's a leader, Bomberg says.

"I spent some time with him and became convinced he was on the right track," Bomberg says.

While Cunningham and Bomberg agree that single bundle surgeries typically produce great results, that doesn't mean surgeons should stop looking for a better way.

"In medicine, we try to share our experiences and share our knowledge and share what works best for patients," Cunningham says. "This is not something I want to keep all to myself. I think other (surgeons) should consider it."

Only time will tell

Cunningham believes surgeons who perform a lot of ACL repairs will end up making the switch to double bundle. For surgeons who do just a few ACL repairs per year, the technicality of the double bundle technique would be more difficult for them.

"We'll do at least 10 (ACL surgeries) in a month," Cunningham says. "If you're a surgeon who doesn't do a lot and you try to tackle this technique, will you run into some complications? That's definitely a concern."

As for the patients undergoing the double bundle surgery, nothing really changes from their perspective, Cunningham says. It's still an outpatient surgery with "aggressive rehabilitation."

One of Cunningham's recent patients, Max Joyce, is experiencing just how aggressive the physical therapy really is. He's been going to JointWorx in Edwards since his Jan. 14, surgery, and he almost has his full range of motion back. His physical therapist, Allison Gelvin, isn't really sure whether the double bundle technique is the reason he's doing so well.

"Everyone varies so much that it's tough to tell if it's the surgery or the patient," she says.

Cunningham says he has seen evidence of faster recoveries in patients who had double bundle surgery. He's says many of his patients have been getting their strength back faster and their knees feel like they did before they tore the ligament.

"I think as a result, people will be able to get back to activities at the same level (they were at before)," Cunningham says. "We're seeing people at four months looking like the single bundle does at six or seven months. ...I know if I tore my ACL I'd be flying to Pittsburgh to have Dr. Fu do mine. I'm such a firm believer."

It will be a while before the long term effects are obvious, but Cunningham and Bomberg think the future looks good for patients having this surgery.

"Some of the effects take 20 to 25 years to become apparent," Bomberg says. "I think making (the ACL repair) more anatomic can only help our long term outcome and make the knees more stable."

This story first appeared in the Vail Trail.

Vail Trail writer Lauren Glendenning can be reached at 970-748-2983 or lglendenning@vailtrail.com.