Dr. Jeffrey Halbrecht: A Surgeon for All Seasons
By Lindsey Christie, Knee1 Staff
The knee is susceptible to numerous injuries and wear and tear. In addition to the day-to-day stresses placed on our knees, people participate in active and extreme sports, which contribute to even more knee-joint stress. Thankfully, orthopedic surgeons continue to develop new ways to treat knee injuries and help people get back to their activities. Dr. Jeffrey Halbrecht of San Francisco uses several new technological advancements to treat his patients. Dr. Halbrecht helped develop procedures such as “office arthroscopy,” and the “all-inside” patella realignment. In addition, Dr. Halbrecht was one of the first surgeons in the United States to treat patients with articular cartilage defects using a procedure known as Autologous Chondrocyte Implantation.
Dr. Halbrecht, a board certified orthopedic surgeon, specializes in arthroscopic surgery and sports medicine. He is a member of the American Academy of Orthopedic Surgeons and the Arthroscopy Association of North America. He is an active member of the learning-center committee, which teaches other orthopedic surgeons from around the world current techniques in arthroscopic surgery. Dr. Halbrecht is a member of AOSSM (American Orthopedic Society for Sports Medicine), the medical director for the Women's World Pro Ski Tour, a consultant for the Association of Volleyball Professionals, and US Soccer, and an Associate Professor at the University of California at San Francisco in the Graduate Department of Physical Therapy.
Dr. Halbrecht obtained his undergraduate degree from Columbia University, where he graduated with honors, and did his medical school training at New York University, where he was president of the AOA honor society. He did his orthopedic training at the prestigious Hospital for Joint Disease in New York and has completed two fellowships, one in orthopedic biomechanics and research, and the other in sports medicine at the world-renowned Southern California Center for Sports Medicine.
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Knee1: When studying at New York University, how did you decide to specialize in orthopedic surgery and sports medicine?
Dr. Halbrecht: My original interest in orthopedics was based on several orthopedic rotations I did as a medical student. One special rotation in particular was a month I spent in Gothenburg, Sweden, as an elective doing sports medicine with a famous orthopedic surgeon. He was the team physician for the national soccer team and was doing exciting research on cartilage transplantation at the time.
My interest before that probably came from growing up as an athlete. I suffered from a lot of sports-related injuries in high school and as a consequence, I developed a close relationship with my hometown orthopedist. I marveled at how he could put me back together time and again, and get me back to sports participation. I knew then that I wanted to be an orthopedic surgeon.
Knee1: People have become increasingly involved in active extracurricular activities. There are weekend warriors, three-year olds playing soccer, and many more women out on the playing fields. Are you seeing a trend in certain injuries or procedures due to this extreme or athletic attitude that people have developed?
Dr. Halbrecht: Since the increase in participation of women in athletics, all of us (orthopedic surgeons) have noticed a dramatic increase in female athlete injuries. It seems that women are more prone to certain injuries. For example, they have a higher incidence of anterior cruciate ligament tears and they are more prone to getting stress fractures.
As far as extreme sports, we live in an era of constantly evolving and ever-increasing variety of sports and, as a result, we are seeing a change in the types of injuries. I think that one of the best examples is snowboarding versus skiing. There is a higher incidence of injury with snowboarding compared to skiing, however, the types of injuries are different. We have seen a dramatic increase in wrist and shoulder injuries, for example, in snowboarders as compared to skiers, but there seems to be a dramatic decrease in knee injuries.
Knee1: In talking to your patients on their first visit, do you get a sense of when they are incurring these injuries? Are they happening at the end of day or when they are trying new things?
Dr. Halbrecht: Most studies, at least in the skiing population, show that the average time to injury is three hours of skiing, which suggests that there is a fatigue factor. It is not usually the first run of the day; it is during the last run of the day that people tend to get injured. When your muscles are fatigued, you can’t handle that bump or twist or sudden fall that you’d normally be able to control and get out of.
In other sports, I think it depends. A lot of injuries are overuse injuries; people training for marathons or endurance sports often get injured because of training errors. They try to increase their mileage too quickly or they jump into a new sport thinking that they are in shape and that they can just transition right into the new sport. But every sport uses muscles a little differently.
Knee1: As a “knee mechanic,” you have helped pioneer minimally invasive arthroscopic surgery. You have certainly seen some changes since the start of your career; could you tell me a little about some of the advancements you have witnessed in arthroscopy?
Dr. Halbrecht: I think some of the more exciting areas are new techniques for treating ligament and cartilage injuries. For example, we have new techniques for cartilage transplantation, some of which can be done arthroscopically. Now, rather than having to do a full reconstruction on ligaments that are stretched, there are techniques that we use to shrink them. As we have gotten better at fixing ligaments we have gotten more confident in rehabilitating them so that the patient’s recovery time is much reduced.
A plethora of new devices such as absorbable tacks and mini staples have been developed. These products sometimes allow us to fix cartilage tears without having to make an incision to stitch up the tear. Technology has really changed the practice of orthopedics dramatically.
Knee1: You have developed something called “office arthroscopy.” Could you tell me what this procedure is and the types of patients you would treat with it?
Dr. Halbrecht: We do arthroscopic procedures under local anesthesia in our office using a miniature arthroscope. This procedure is typically used to treat people with cartilage injuries. We remove torn pieces of cartilage or small, loose fragments of cartilage floating in the joint. We can do many of the smaller knee surgeries right in the office that are usually done in the hospital.
Knee1: After the procedure, can the patient walk out of your office without assistance?
Dr. Halbrecht: When we do “office arthroscopy” we put a couple of band-aids on the patient and let them go.
Knee1: You have also developed the “all-inside” patella realignment. What does this procedure entail?
Dr. Halbrecht: That is a technique that we have developed over the last ten years. It seems to work really well and that’s what we’re using. The “all-inside” allows us to tighten the ligaments that help the tracking of the patella arthroscopically.
Knee1: Did that used to be an open procedure?
Dr. Halbrecht: That has definitely always been an open procedure. There were some other techniques that people describe that were sort of arthroscopically assisted, but they still require an incision to tie all the sutures. This technique is the first that really allows it all to be done internally inside the knee.
Knee1: Have these new procedures and devices changed rehabilitation and recovery times for the active patient?
Dr. Halbrecht: In the old days, some of the famous athletes who had ACL surgeries (people like Joe Namath) required up to two years to get back to full sports function. Now, we let people go back by six months and participate in full, active, competitive sports.
Knee1: You’ve been very involved with the repair of damaged articular cartilage and were, in fact, one of the first surgeons in the United States to perform Autologous Chondrocyte Implantation (ACI)?
Dr. Halbrecht: I was. I was the first surgeon on the West Coast to perform ACI and one of the first in the country.
Knee1: ACI is an exciting procedure. How does it work?
Dr. Halbrecht: ACI is a way of cloning cartilage. A surgeon can scrape cartilage cells from someone’s knee arthroscopically, grow the cells in a laboratory, and then re-implant the cartilage back into the damaged area of the knee.
Knee1: Who would be eligible for this kind of treatment?
Dr. Halbrecht: The typical patient is relatively young (from the ages of 20 to 50 years old). We usually treat people with an isolated cartilage defect or missing chip of cartilage on the weight-bearing surface of the joint. Usually, the way you can diagnose whether somebody is a candidate for ACI is through an MRI scan or during an arthroscopic procedure.
Knee1: Do they have to have undergone any prior treatments to be eligible for ACI?
Dr. Halbrecht: No, if you can identify the defect in advance on an MRI scan, then you can plan the procedure. However, a lot of times the injury is only picked up at the time of some other procedure.
Knee1: What is the recovery like for someone who undergoes ACI?
Dr. Halbrecht: There is definitely a more prolonged treatment period after an ACI. There is some type of protected weight bearing for six weeks. The recovery tends to last from six months to one year before we would let people resume full activities.
Knee1: Have any of the patients you treated minded this recovery period?
Dr. Halbrecht: Many of these people have very limited activities to begin with and many of them will suffer from arthritis at a young age. They are thrilled if we can make them better, even if it takes a long time.
Knee1: Do patients typically need a follow-up procedure after an ACI or Carticel?
Dr. Halbrecht: We follow them by examinations in the office and extensive physical therapy for the duration of their treatment. Probably 10 percent of patients wind up having a follow-up arthroscopic procedure to clean out scar tissue or verify that the graft is in good position. Other than that, we judge the success of the procedure by how well the patient is doing clinically. If they have no pain, we consider the Carticel procedure a success. We do not automatically recommend a repeat arthroscopy just to look at the graft.
Knee1: You work as the medical director of the Women’s Pro Ski Tour, what are the most common injuries among these downhill racers?
Dr. Halbrecht: Unfortunately, one of the most common injuries with downhill racers is severe ligament injury (the "blown-out” knee). Anterior cruciate ligament (ACL) injuries are probably the most common of the ligaments injured, but very often racers have combined injuries involving multiple ligaments and frequently, they have cartilage defects as well.
Knee1: Let’s talk about the average skier, skiers who are in the office all week and hitting the slopes on the weekend. How can they prepare themselves for the start of the season and how can they prevent injuries?
Dr. Halbrecht: Other than having safe equipment and skiing sensibly, we actually think that pre-season conditioning is probably the most important thing that people can do to help prevent injury. We have actually made a video that you can find on our Web site with some of the racers from the Women’s Pro Ski Tour. The video explains how to strengthen and condition before the ski season.
Knee1: Do you have any advice for skiers heading out to the slopes?
Dr. Halbrecht: Skiers need to be strong and have endurance in order to protect their knees. There are specific exercises that definitely strengthen the important ski muscles, which would basically be the quadriceps, the “glutes,” and the torso. Typical exercises that are good for training for skiing are: Stairmaster, bicycling, rollerblading, and squats.
For more information on conditioning and strengthening for the ski season, visit the Institute for Arthroscopy and Sports Medicine Web site.
Knee1: You also work with the snowboard tour; do you have any suggestions for snowboarders?
Dr. Halbrecht: Unfortunately, snowboarders’ injuries are more related to trauma to their upper extremities from falls onto outstretched wrists. People who are just beginning to learn how to snowboard should wear wrist guards because they are going to fall a lot. If you are going into a tumbling fall, try to bring your arms in close to your body so you don’t dislocate your shoulder.
Ankle and foot injuries are very common in snowboarding as well. People who are predisposed to having foot or ankle problems might want to consider more rigid boots. The downside to the more rigid boots is that as you start getting stiffer boots, the stresses have to go somewhere and we may start seeing more knee problems again. I think as far as ankle problems go, people should use a little bit of their own personal history. If they have a history of ankle sprains or foot problems from running or basketball, or if they have hurt themselves while snowboarding the season before, they may want to consider a stiffer boot.
Knee1: To wrap things up, there is a lot of research being conducted at the Institute for Arthroscopy and Sports Medicine. What do you think is the most promising or exciting technique in development?
Dr. Halbrecht: I think that the two most interesting developments are the cartilage-transplantation technique and the use of thermal energy to treat stretched ligaments either in the knee or shoulder.
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