By Katy Gladysheva, Knee1/Body1 Staff
Dr. Simonian is the Chief of Sports Medicine Clinic, as well as the Director of Sports Medicine Research and an Associate Professor of Orthopedic Surgery at the University of Washington (U of W) School of Medicine. He also currently serves as the Team Physician for the U of W Husky Intercollegiate Athletics Department, and has performed a similar role with the New York Mets in the past. His research has resulted in numerous publications in most prestigious American and international journals. Dr. Simonian is also the recipient of multiple awards.
You can read a chapter on Knee Injuries in Dr. Simonian's upcoming book here.
Knee1: Please tell me briefly about your decision on a sub-specialty within orthopedic surgery. What in particular attracted you to sports medicine?
Dr. Simonian: The rationale for moving towards sports medicine was the same reason that attracted me to orthopedics in general. I was interested in a field of medicine where I would have some impact on returning people to a normal and active lifestyle, and it seemed like the field of sports medicine facilitated that better than most because of the non-invasive, or least invasive, surgical techniques involved; as well as the motivation of the patients. I deal with a highly motivated population. Also, I personally had a great interest in sports growing up and sports medicine seemed like a nice match; I found it very helpful to be able to relate to people from that perspective.
Knee1: Do professional athletes comprise the majority of your patient population?
Dr. Simonian: I would say that the percentage of patients who are high-level or elite athletes probably comprise about 5% of my practice; about 75% of my patients are recreational athletes - people who are involved in skiing and other popular recreational sports; and there is a group who are no longer involved in athletics and are having problems that are degenerative in nature or resulting from overuse rather than injuries, and are typically candidates for total knee replacements or joint replacements. Since I do run the sports medicine clinic, most of my patients have had some sort of involvement with sports activities either in the past or in the present time, but that is certainly not a requirement for coming into my clinic.
Knee1: What would you say are some of the most common types of injuries you encounter?
Dr. Simonian: I would say that the great majority of injuries that I see are knee injuries, followed by shoulder injuries, which are significantly less common, but are still an important part of my practice. The primary knee injuries that we see are ligament and cartilage injuries of the knee joint. Some ligament injuries will heal on their own, while others, provided that the patient wants to return to a high level of sports, require surgical reconstruction. I would say that a tear or sprain of the medial collateral ligament (MCL) is the most common type of ligament injury. The majority of the time the MCL tear or sprain heals on its own and the athletes then return to sports without any difficulty. The time to return can be anywhere from 4 to 12 weeks, depending on the severity of the tear, and often a knee brace is used during that rehabilitation period to protect the ligament from additional stress. The way the MCL is typically torn is when someone takes a blow from the outside portion of the knee and the knee is buckled inward, tearing this particular ligament, which resides on the inside on the knee.
Knee1: What about ACL injuries, which seem to affect a lot of patients as well?
Dr. Simonian: ACL (anterior cruciate ligament) injuries are a little less common, but considerably more severe than MCL tears. In contrast to the MCL, the ACL does not heal (grow together) on its own (due to a limited blood supply). There are also ACL braces available to provide stability in the ACL deficient knee, and they may be enough for some people, but they are never as good as reconstruction. ACL reconstruction is actually one of the most common types of surgeries that I perform. These are for people who want to return to a high level of function. However, not everyone needs their ACL. If somebody is just involved in sports like jogging or cycling and do not pursue any cutting or twisting activity with any regularity, they can get away with an ACL-deficient knee, possibly with a help of a special custom-made brace (which can be very expensive). Although new types of braces are being devised to maximize the stabilization of the femur and the tibia – the two main bones that come together at the knee joint – braces can never be expected to completely mimic the true motion of the knee, since the knee joint is more than just a simple hinge. Thus, people who want to return to any cutting or twisting often times require reconstruction, with an additional goal to protect the cartilage. Often when the ACL tears, the knee subluxates (partially dislocates) and that puts the meniscus cartilage and the articular cartilage at risk for damage. And we do know that a damaged cartilage can bring on the onset of arthritis at a much earlier age.
Knee1: Are there any new technologies that are being implemented in orthopedic surgery in general, and knee reconstruction in particular?
Dr. Simonian: I think a lot of things have been done in the past few years to make the surgery a much better surgery for both the patient and the operating team. Most ACL surgery is now done on the outpatient basis; 5-10 years ago it required hospitalization for up to five days. Part of this improvement is because we are using much less invasive techniques done arthroscopically and are able to violate much less of the patients tissue causing less additional trauma to the knee. Another thing that has greatly revolutionized ACL reconstruction is our post-operative rehabilitation. In the past patients were put into casts for a period of time; as the result of that we had many problems with stiffness and truly regaining function after the surgery, and it often took more than a year for someone to get their knee motion back. Now we have patients returning to normal activities nearly as fast as they can tolerate it and begin motion exercises within a week of surgery. Most patients have regained near-full range of motion by one to two months after surgery.
Knee1: In addition to less invasive surgeries, are there any other novel approaches that you are implementing in your practice?
Dr. Simonian: There has also been a lot of advancement in the ways of fixing the graft in position. When the ACL tears, you can’t repair the ends together. In the past, there have been attempts to do that, but they all failed, since the ACL ends just do not predictably heal back together. So, you have to bring in new tissue to reconstruct the ACL. And we are exploring new graft sources. The different sources that are available are the central portion of the patella tendon, a couple of the hamstring tendons, a portion of the quadriceps tendon, and there is also material from cadavers. There are, of course, pros and cons to all of these options that have to be considered in each particular case.
Knee1: Where do you see the potential for new advances in knee reconstruction?
Dr. Simonian: I think on the horizon, we are going to start looking at not only how the implants mechanically fix the graft, but also implants that have growth-factors and other materials that might accelerate the healing process. The next step beyond that is to actually grow these ligaments in the lab possibly using the patient’s own cells and then re-implant them in the knee; and I think that that’s not in the too far distant future. There would be great advantages to that, since it would be the patient’s own tissue that we would be using, and it would eliminate the need to take any normal tissue from anywhere else in the patient’s body.
Knee1: We have talked quite a bit about treatment, yet I know that you have also been involved in a community outreach program trying to promote awareness about knee injuries and focus on prevention. In conclusion, can you offer us a few quick tips that anyone leading an active lifestyle can use to try to prevent injuries to their knees?
Dr. Simonian: It is important to keep in mind knee injuries occur in athletes of all skill levels, so while it is important to pay close attention to prevention, nothing can completely eliminate the risk of an injury. The most important aspect is good training and maintaining yourself in excellent physical condition prior to engaging in high-risk sports, which involve a lot of twisting and turning, and are not necessarily contact sports, such as basketball and soccer. Good cardiovascular shape is another key, since we see many more injuries when people get tired. And, of course, proper stretching, sports-specific conditioning, as well as understanding and honoring your personal limitations all need to be taken into account.
You can read a chapter on Knee Injuries in Dr. Simonian's upcoming book here
To Contact Dr. Simonian, please e-mail: [email protected]