Michael Kane: Dr. Roux is an orthopedic surgeon who subspecializes in sports medicine, arthroscopic surgery, and treatment disorders of the knee and shoulder. His treatment goal is to restore maximum function through comprehensive treatment utilizing minimally invasive surgical techniques. Dr. Roux received his undergraduate Master’s Degree from Stanford University, his Medical Degree from the University of California at San Diego, and completed the combined Orthopedic Residency Program at Harvard University.
So, Dr. Roux, what Is like to do is talk to you a little bit today about why you decided to do what you do in terms of becoming a surgeon. What sparked your interest in orthopedic medicine?
We have really, really good basic science; we have really good clinical societies, so we do studies; we follow the things we use — objective measurements to make decisions. I really like that you combine the science with the clinic part of it.
And then the other thing I liked is you can see your results. In a lot of medicine, your results are not always super obvious to you, whereas our results in orthopedics are pretty obvious. You know if you stabilize a knee, you can recognize that. If you fix a fracture and it heals, you can recognize that. If you have a locked knee with a meniscus, you repair it and then the person can bend through a full range of motion. Your improvement is easily measured and recognized.
Michael Kane: Excellent. You mentioned a love of working with your hands. Did you work with your hands like your dad or your grandpa, in terms of working on cars or carpentry, or is it more you knew you had good hands through your sports?
Dr. Roux: Through sports. My father was a chemist and then later a business executive, but he was very, very artistic and did a lot of woodwork and wood carving and he was good at that. I emulated some of that from his influence. In that sense yes, but more on an artistic basis. I was very interested in art in college, and I graduated with a biology major, both as an undergraduate and a graduate, but I actually started out as a fine arts major in college, so I have always had an interest in that.
Michael Kane: So how about once you are in the field, what got you interested in shoulders and knees?
Dr. Roux: Well, we do sports medicine the way training goes in the United States now and you do a Sports Medicine Fellowship. The surgical part of it really emphasizes knees and shoulders, and I really like arthroscopic surgery and I really enjoy performing those procedures. And, frankly, we’re further along with arthroscopic surgery and knees and shoulders than we are in any other joints.
To tell you the truth, I am somewhat of a perfectionist so I like it to be perfect, and I think that I have gone that way because I think I’m good at it and I think it’s what we are best at in arthroscopic surgery right now so I like that, and it is continually evolving. I really believe in specialty medicine. I think it’s not easy to keep up being a specialist or even a sub-specialist or as trying to be a generalist, I think it’s really difficult to keep up in everything, so I try very hard to keep up in my area.
Michael Kane: It is similar to the commercial building industry. There no master builders anymore. The fields are too complex.
Dr. Roux: Right, it’s very difficult.
Looking at ACL Injuries
Michael Kane: Since this is the season for fall sports, let’s go along the route of the ACL injury, since that is such a common one in sports. I have some questions about that. Number 1: Does it seem like there is a lot more non-contact versus contact ACL injuries? Now it could be that it was always that way and it’s just we research it a lot better, but I was wondering if you could comment on that?
Dr. Roux: Why I think we are understanding ACL injuries more and more, and I think there are more ACL injuries now then there were, for instance when, I played sports in high school, I know that there are. And there are a lot of reasons for that.
Back when I was in high school, we tended to be a little bit more well-rounded athletes. We did football during football season; we did basketball during basketball season; we did baseball or track during the spring. We didn’t have such continuous exposure to certain risks, and I think that is one of reasons why there are more ACL injuries today.
If you are a high school soccer player, a woman or a man, you’re pretty much playing soccer all year round. Well that’s a pretty risky activity. The same thing can be said of basketball, and so those are in there.
The majority of injuries in those sports, or at least ACL injuries, are no-contact. They occur with cutting and planting. In football we still see, or rugby, we still see a high number of contact injuries but they tend not to be isolated injuries, they are MCL/ACL’s, ACL/LCL’s, and ACL posterolateral corner. The contact injuries are a little bit more complex. I think we are seeing more ACL injuries in general, and I think you have more people playing, a relatively higher percentage of the athletic population, playing cutting sports like soccer and basketball relative to football than we had in early generations.
Michael Kane: You talked about statistics. There is a striking difference in the number of ACLU injuries in female athletes in relation to their male counterparts. The research shows up to a 4:1 female to male ratio. I know that there are a lot of reasons but I wonder if you would comment on what you think some of those reasons are?
Dr. Roux: I think one of the main reasons that women have such a higher incidence of ACL injuries is alignment. There is a different hip structure in a female pelvis than a male pelvis that causes different lower extremity alignment and you see more valgus or relatively knock-kneed alignment in a female population than a male population and that predisposes you to ACL risk.
The other thing that you see is notch size. Women are smaller; they tend to have a smaller notch, but even if you look comparing them to a similar sized male, they tend to have a tighter notch. If you look at male athletes that are small like me, you know I’m not the biggest guy in the world, I probably have a pretty tight notch, so I bet I’m at greater risk for an ACL injury than you are because you are a bigger, taller guy and probably have a bigger notch.
Those anatomic features, alignment, notch size are big. There are definitely some hormonal contributors to that that we haven’t completely worked out yet, so it is hard to make too many comments on that. And then, you know the women, if you look at the sports they predominate they are cutting sports, they are soccer and basketball, field hockey. Those are really high-risk sports whether you’re a man or a woman.
They participate in high-risk activities. They have a greater incidence of alignment problems. They have a greater incidence of a tight notch. They may have a hormonal predisposition to tear, and then they train differently. They may not be as apt to work on their proximal musculature and so that may also put them at greater risk.
Michael Kane: When you see an athlete that has a tear and you make an assessment, sometimes it’s clear that they have fully torn the ACL and sometimes they have a partial tear. How do you decide in a surgical versus a non-surgical approach?
Dr. Roux: One of it depends on their age and certainly their activity. Now we are a pretty good idea if they’re complete or incomplete injuries. We are good at exam. We have excellent imaging studies now. It’s not very common that we not know if it’s a complete or incomplete injury.
If it’s a complete injury in a young person that wants to participate in cutting activities, then it’s an easy decision to fix them. If it’s an older person that’s not participating in cutting activities, it might be a pretty easy decision not to fix them. The gray area is you get the in between people. I’m 58 years old but I’m pretty active and I do a lot of cutting activities to try to stay in shape everything like that. I’m 58 and if I had an ACL tear just knowing what I like to do I would probably fix it. Now would I fix it in every 58 year old? No. But there are people that I would. And so it’s their activity level, their age, and then other things that really contribute to me are the other injuries associated with the ACL tear. If they have meniscus pathology, particularly if they have a reparable meniscus, then if I’m going to repair that meniscus, I have to stabilize the knee to protect the meniscus repair. People will often ask me what’s more important to you when these young people get injured and they have meniscus pathology and the ACL pathology. I say they are both kind of equally important to me for different reasons.
Michael Kane: That is an interesting insight. I was just reading some research on a large database showing that in the long term, you’re going to save a lot of medical cost if you do repair that ACL. Even if you have a young athlete or let’s say had a young person that tore an ACL but they weren’t very active. If you don’t repair it; if they have instability, it looks like over their life span there is going to be a lot of money spent on treating problems that develop over time as a result of that instability. Things like meniscal tears, degenerative arthritis, and giving way or locking of the knee.
Dr. Roux: I’m aggressive about fixing ACL injuries in young people, and if they don’t have concomitant meniscus pathology, then I want to protect those menisci, so that’s an argument toward fixing it.
If they’re really loose and I think they are going to have other episodes of giving way, then I’m more motivated to fix it, again to protect the menisci and to stabilize that knee. If you look at the spectrum, I am relatively aggressive about fixing ACL injuries in young people.
Michael Kane: How have the surgical techniques changed in the last 20 years?
Dr. Roux: We’ve become more and more minimally invasive. If you look at our incisions, they’re smaller. If you look at what we’re doing inside the joint, it’s smaller. If you look at our bone tunnels, they’re smaller. We tend to use sockets now rather than through-and-through tunnels. With minimally invasive surgery, you do less associated damage through your surgical procedure. We are more and more anatomic with our position of graft placement, which I think is really important. I think that’s the most important new trend. We have better techniques for fixing the graft in place.
If you look at me over the last 25 years, 24-25 years, I’ve been in Yakima for just over 24 years, 20 years ago I did mostly patellar tendon grafts and that’s a great graft. Some people still call it the “gold standard.” The reason it’s a good graft to use is it has bone plugs at each end; it’s really easy to fix it into place, and it’s pretty easy to get it to heal into place. One thing that’s happened over the last 20 years — we now have just as good techniques of holding soft tissue grafts in place, a hamstring tendon, a quadriceps tendon, and they have some advantages in terms of the morbidity of harvesting them. Over the last 20 years I’ve done more soft tissue hamstring grafts than I have patellar tendon grafts.
But I think it’s important to be facile in both because for one reason or another you might have somebody that you shouldn’t use their hamstring or you shouldn’t use your quadriceps or your patellar tendon and you have to be able to have other options.
Michael Kane: What are the quick things that come to mind that would help you make that decision, go with patellar tendon versus hamstring. In other words, what would make you go “we shouldn’t use this hamstring?”
Dr. Roux: A lot of times I can palpate their hamstrings down there and if they’ve had a bad medial hamstring injury before and I can’t palpate their tendons then I might want to image them first to see if they have good enough tendons to harvest.
If you have a lot of scar down there from previous and distal medial hamstring tear than it can be difficult to harvest the tendons. And it goes the other way around. If somebody has had a patellar tendon injury, then you might want to stay away from that graft.
Michael Kane: In terms of the stability of the graft is there any difference?
Dr. Roux: I think there is more variation individual to individual than there is. I think the important principals in ACL surgery are to use an adequate graft and I think the hamstring, patellar tendon, and quadriceps tendon can all work exactly the same. When you need to have an adequate graft and an adequate amount of it and you’re tunnel placement has to be meticulous, it has to be perfect. I like all of those grafts in different situations.
On ACL Recovery
Michael Kane: We see some amazing results in terms of the ability of the athlete to return to play. In the past, you were going to be out for a year, meaning 12 months before you’re going to get back to full activity. Athletes like Adrian Peterson of the Minnesota Vikings made it back in half that time.months. He is the best player on the field and literally he had a career year following his surgery. Is that common? Is that more common? Is it because of what you mentioned in terms of techniques or is that because he is a freak athleticism?
Dr. Roux: A little bit of both. There is a minimum and it used to be not too long ago that I would get athletes not uncommonly back at 4 months. That’s probably risky if you look at all the data that we have now. Now, most of those were patellar tendon grafts that are healing a little bit more completely a little bit earlier; but I think all the data now show that you want to have at least 6 months and then you have to meet other criteria as well. They should have full range of motion; they should not have a knee joint effusion, and they should demonstrate normal strength and balance/proprioception.
If people come back before 6 months then they are probably lucky that they haven’t re-injured it and you gotta understand Adrian Peterson is at the upper realm of capabilities, a tremendously strong person with great tissue. I wouldn’t be rushing people back and if you look 20 years ago for almost all my sports injuries I’m getting people back faster, oftentimes in less than half the time than we did previously. But in ACL surgeries I’m going slower; I’m going 6 months or more and trying to demonstrate normal strength and normal function before we put them back out there.
Michael Kane: Excellent. Could you just briefly describe the difference between an autograft and an allograft?
Dr. Roux: Auto means self, so an autograft is from the person who’s injured. It’s a piece of tissue that comes from the individual that is having surgery. Allo means others and an allograft is a graft from a cadaver, from another person. Auto is from self and allo is from a donor, cadaveric donor.
Michael Kane: When would you choose to use an allograft?
Dr. Roux: The situation where I use allograft is multiple ligament injuries. I get a lot of those in my practice and if you have more than two ligament injuries, then it’s hard to take it all as autograft. You’re forced into a situation where you’re taking some from the same knee and some from another knee. In that situation, I frequently use allograft. But in terms of ligament reconstruction, if it’s a single ligament injury, I prefer autograft.
Michael Kane: What do you think are the key factors in return to play?
Dr. Roux: You gotta have a good graft in good position. You have had to have an adequate healing time.
Michael Kane: So the good graft in good position you would know that on the table?
Dr. Roux: Yes.
Michael Kane: You’re testing?
Dr. Roux: Yes. You’ve had to have an adequate healing time, which I think is 6 months or more. And then you want to demonstrate full range of motion. You don’t want to have any really active inflammation going on so you don’t want to have a knee joint effusion, and then you need to have normal strength about the joints, in your knee, normal quad and hamstring strength, normal strength about your leg and foot and ankle. Those are kind of my criteria. Adequate healing time, healed graft, normal physical exam, good stability on physical exam which comes from having a good graft in the right position. And then full range of motion and normal strength.
Michael Kane: Okay, so that means now they’re going to go back. You’ve Okayed them to return. Do we brace them or not brace them?
Dr. Roux: Well, I gotta admit, I have a tendency to brace them. Now not everybody listens to my recommendation and I have athletes that return to play without bracing, and the reason that I do that is I take care of a lot of competitive athletes that are going back at 6 months, which is still early, not as early as before but it’s still early and that graft is not completely matured. In animal models, it takes 12 to 18 months for the graft to fully mature. I have a tendency to send them back around 6 months as long as they’ve done an adequate rehabilitation and then I do protect them in a brace for that first year. After they get beyond that 18-month mark, I don’t really care. I think it’s about 30% or 40% like the brace and 60% or 70% don’t like the brace. However, is there really strong, compelling science that the brace is helpful? There’s not. However, in my experience, we’ve had a relatively low re-injury rate and so I continue to go with my practice.
Michael Kane: How about bracing as a preventative device? You see a lot of college athletes, particularly on the offensive line wearing braces.
Dr. Roux: Well, the braces at the college level have been shown to be effective for collateral ligament injuries, which are more common than ACL injuries in linemen. It’s not that ACL injuries are uncommon; it’s just that the other is more common. I think there’s a strong argument for preventative bracing for ACL/MCL injuries in linemen. I don’t think that there’s any data out there that shows that it decreases cruciate ligament injuries.
Michael Kane: Is there anything else you thought was important that we could talk about?
Dr. Roux: I mentioned earlier that I think one of the reasons that women athletes have a higher incidence of ACL injuries is they do tend to train differently than men; but I think both in a female and a male population that there is a definite indication for some of these programs that decrease ACL injuries, particularly in high-risk sports. And the things that those programs tend to emphasize are core strengthening, strengthening about the hips and proximal musculature, and balance training. There are different programs to do that. I really don’t have a favorite right now but I think those types of programs can be very, very helpful in decreasing the incidence of these type of injuries.
Michael Kane: Thank you for your time Dr. Roux.