Dr. Bernard R. Bach, Jr., is the Director of the Sports Medicine program at Rush-Presbyterian-St. Luke's Medical Center in Chicago. He is focused on sports medicine research and education, and believes his research has had a great impact on the care of athletes and others suffering orthopedic injuries.
Knee1: On what area of research are you focusing now?
Dr. Bach: The knee. Most of my publications deal with these ligaments injuries, specifically the Anterior Cruciate Ligament (ACL), and we have published a number of clinical follow-up studies and outcomes studies related to ACL surgery. That's been my major area, but we've also done some basic science studies, mechanical pullout testing of grafts, and gait analysis studies. Rush had been in the forefront of looking at gait analysis as it pertains to ACL deficient knees and ACL reconstructed knees. Since 1986, I have published over 200 peer-reviewed manuscripts, book chapters, and abstracts, with the majority of these works focused on the knee.
Knee1: Do you get your research and education ideas from patients?
Dr. Bach: I think any of us who do clinical research are often motivated by how are patients are doing. A lot of clinical questions we have may evolve from seeing those individuals. Right now, we are in the second phase of a clinical study looking at revision ACL surgery. There is very little information on clinical follow-up of ACL revision surgeries. We did a preliminary study two years ago and that's prompted us to continue with that and we're pretty excited about that group of patients.
Knee1: Results of your study comparing hamstrings and patellar tendons in grafts will be published in the winter edition of Clinical Orthopedics. Why do you think these results will be important for Sports Medicine?
Dr. Bach: Both tissues are excellent options for ACL surgery. If you look at the differences based on the meta-analyses, the patellar tendon grafts appear to be more durable. They have a slightly increased association of patellar pain. The hamstrings have a higher re-operation rate for hardware removal. The patellar tendon has actually higher patient-subjective satisfaction level.
Knee1: Which graft, patellar tendon or hamstring, is used more in ACL reconstructions?
Dr. Bach: It really depends. I think overall across the country, patellar tendon is by far the most popular graft choice. There are geographic pockets—I think on the West Coast—there's a tendency more toward hamstrings. It may be somewhat dependent regionally on the local experts and how they may impact the private practice orthopedists in that area. Among, for example, the Herodicus Society (a group of about 80 national and international orthopedic surgeons who are leaders in Sports Medicine), patellar tendon is by far the most common graft choice. If you look at the NFL team physicians' society, by far patellar tendon is by far the graft choice.
Knee1: Do you hope to educate other physicians or patients with your research and publications?
Dr. Bach: Although we spend a lot of time educating our patients and we have a lot of nice educational materials for our patients, I am talking about educating other Orthopedic Surgeons, the Fellows that we train, as well as training our Orthopedic residents. I think I can, by far, impact the care of more athletes e by my being able to do important research, publish that research and educate my colleagues, so you almost get an umbrella affect. If you disseminate this information, it's going to impact the care of more athletes in that fashion.
When you ask about educating patients that ties in with some of the research we've done I know what my results are, so I can tell patients what my results are in my hands. But I think that's important information you can share with your patients. I think a lot of patients are lost to follow-ups in people's practices, so they really don't know if the patient is doing well.
I tell patients that they're always a patient in my practice. We tell them that they need to keep in touch with us, because I want them to be part of subsequent clinical follow-up studies. Now, we're getting to the point where clinical follow-up studies are minimum 5, and 10-year follow-up studies. But this is a tough group of patients to track because they are younger—the patients are very mobile. It's extremely expensive to conduct these studies, so they're labors of love.
Knee1: You are very involved with the American Orthopedic Society of Sports Medicine (AOSSM). Talk about your role in helping further sports medicine research?
Dr. Bach: I've served as the national fundraising chairman for AOSSM and the orthopedic research and education foundation. A few years ago I directed the Herklotz Challenge, and we raised over $700,000 for Sports Medicine research. That's one of my proudest accomplishments—to help raise money that can be used by young investigators for continued research and education endeavors.
Knee1: In the next five to ten years, where do you see the funding for Sports Medicine research going?
Dr. Bach: I think there will be a lot of monies directed toward clinical outcomes. There's a clear need for excellent prospective outcome studies (and) a clear need for continued, well-designed clinical follow-up studies. I think we'll focus in the arena of ACL, rotator cuff and shoulder instability. I think the area of articular cartilage is going to receive a lot of funding, whether it deals with meniscal transplantation, articular cartilage resurfacing (such as Carticel) microfracture (or) allograft treatments for some of these real complicated problems. I think the Posterior Cruciate (PCL) is an area that will continue to see interests in terms of a funding standpoint.
Knee1: It seems like ACL injuries are much more prevalent that PCL injuries.
Dr. Bach: If you practice in a Level 1 trauma center, you're going to see a lot more high-energy Posterior Cruciate injuries related to motor vehicle accidents, pedestrian motor vehicle accidents and falls. But if you look at the average Sports Medicine specialist, the ACLs are at least 20-times more common than PCLs. One of the problems we have with the PCLs is sorting out whom we are going to fix. The indications haven't been historically well-defined. The procedure is technically challenging. The results have not been nearly as predictable as ACL surgery. We're starting to get some of those answers, but our understating of the posterior cruciate and of the posterior lateral corner is clearly lagging way behind our understating, knowledge of surgical treatments and results for ACL problems.
Knee1: Where do you see your research going in the next 5 to 10 years?
Dr. Bach: What I would really like to be able to achieve are my 10-to-15-year follow-up studies for our patellar tendon grafts, both for endoscopic and two-incision. That type of contribution—a really long-term follow-up—would answer a lot of our questions. It would probably document our concerns with regards to the need for performing ACL surgery to try and protect the knee joint.
One thing we're seeing with ACLs being reconstructed, if you look at the time from injury to surgery, that interval is much less than it probably was historically. Most of the patients who come in who are reasonable candidates for ACL reconstruction know what's out there now in the literature. They know that the procedure is performed on an outpatient basis. They know that the results are more predictable. So they are making a conscious decision to have these reconstructed. In contrast to the past where many patients were coming in 5, 8, 10 years down the road from their ACL (injuries) and were told that nothing could be done. So, I think we're getting to a point now where we're being able to treat patients earlier on in their "disease evolution," and hopefully what we'll see long-term is that those knees are holding up and doing better long-term.
Finally, my philosophy in adding my faculty to our (Sports Medicine) program (at Rush) is to find people that are going to be as good if not better than myself. And I think I've been very successful at that. I'm very proud of the physicians I have recruited to join us in building an elite level Sports Medicine program. These associates, Charles Bush-Joseph, M.D., Brian J. Cole, M.D., Anthony A. Romeo, and Greg Nicholson, M.D. are extraordinary clinicians, educators and researchers. The future of our program is in the hands of these young talented sports surgeons!