Advanced Techniques for Knee Injuries: Q&A With Dr. Bert Mandelbaum of the Institute for Sports Sciences

Bert Mandelbaum, MD, is an orthopedic surgeon and co-chair for medical affairs at Los Angeles-based Institute for Sports Sciences. He is director of research for Major League Baseball and a physician for the U.S. men's soccer team.BertMandelbaum0228

Here, Dr. Mandelbaum speaks from his experiences to shed some light on advancements in minimally invasive surgical techniques for the repair of ACL and MCL injuries in professional athletes.

Question: What are the particular medical challenges in repairing ACL and MCL tears in such high-level athletes?

Dr. Mandelbaum: When you deal with professional athletes, it's a whole other subspecialty of issues: there are the orthopedic aspects, then there's an understanding of state-of-the-art techniques and what you need to do surgically. For a professional athlete, there are a different set of objectives. It's not a question of if a ligament or bone can heal — not only do professional athletes have to get back to the sport, they have to have a job, join a team and sign a contract. You have to think on the performance of an athlete on the organ, tissue and molecular levels. It's more than just a repair — it's optimal regeneration. Hopefully we can make them even better than they were before.

Q: What's the typical outcome for an ACL or MCL injury you might see?

Dr. Mandelbaum: It depends on what kind of injury we're talking about. For example, an MCL injury represents an injury to the medial column, and there are four sections to consider. When we talk about a general MCL injury, it's not connoted where the injury is within a spectrum. Outcomes are truly scalable to types of injuries. A superficial MCL stretch does not need to be repaired and will heal over time, but a total MCL blowout requires anatomic repair and is treated very differently from other injuries. There are also other comorbidities for every athlete, which have to be factored into the equation of getting the athlete back in the game.

Q: What advances in surgical techniques have you been seeing in the field?

Dr. Mandelbaum: There are several ways to get athletes back to work when they have multiligament injuries. You can reconstruct [the injury] all at one time, or you can do it in stages. I repair the medial column and meniscus first as an immediate procedure, then as a reconstruction about six weeks afterward to help the athlete regain range of motion. The reason surgeons are doing this is to eliminate the potential of arthrofibrosis. In general, arthrofibrosis is a problem, but in an elite athlete any arthrofibrosis can compromise prognosis and be a tremendous, performance-limiting issue. The two-stage repair approach is a better way to proceed to minimize arthrofibrosis.

Within the approach, when we anatomically repair the medial column, we consider some concurrent factors. We want optimal regeneration, where tissue acts like normal tissue. So we consider the scaffold, growth factors and cells — like stem cells to deliver healing — in the context of returning the athlete to full performance. Repairing the elite athlete is something of a systematic algorithm that deconstructs into all sorts of elements — biological, kinematic — and we have to consider each in the big scheme of things, which is getting elite athletes back to performing at the highest levels.

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