Dr. Michael Kelly is the Co-Director of the Insall Scott Kelly Institute for Orthopaedics & Sports Medicine at Beth Israel Medical Center in New York City. His practice focuses on knee injuries, including total knee replacement surgery. Dr. Kelly, a graduate of the University of North Carolina and Georgetown University Medical School, combined his passion for sports medicine and basketball when he became the Team Physician for the NBA's New Jersey Nets in 1999.
Knee1: What areas of orthopedics do you focus on at the Insall Scott Kelly Institute?
Dr. Kelly: In 1991, I was at Columbia Presbyterian Hospital in New York involved with Special Surgery where we ran in the service. Dr. Norman Scott was at Lenox Hill, and we decided to get together and form this group. We moved to Beth Israel Medical Center and brought Dr. Peter McCann, who was working with me in shoulders up at Columbia. Dr. John Insall's biggest claim to fame was knee replacements. He taught me as a fellow and taught Dr. Scott as a resident, so the three of us just did knees when we got here. We also started a fellowship. Dr. Insall had a fellowship for a long time, and (it) was pretty well known. Here, with the increased volume, we set up for four fellows, and we've carried that on for the past 10 years.
This is our 10th year now at Beth Israel and we've grown to eight members. Dr. Insall passed away last year, and we've tried to maintain his tradition where six of us only do knee surgery. So it's pretty heavily weighted toward the knees.
Knee1: Does each surgeon specialize in one specific type of knee injury or do all the surgeons treat all types of knee injuries?
Dr. Kelly: When you look at knee surgeons, they kind of fall into categories where they're either implant guys who do hips and knees, or sports guys who do knees and shoulders. I do knees from all the way up from the adolescent with the torn meniscus, ACLs, all the way through to revisions and total knee (replacements). Obviously, we are not weighted in trauma. We get some referred in from time to time; standard fractures of the knee, we don't do a lot, of those. We do get referred in difficult fractures around knee replacements.
(In) my own practice, I do a large number of knee replacements, (a) large number of ACLs, (and) a large number of arthroscopic procedures. That's different than most.
Knee1: At the 2002 AAOS convention in Dallas, you presented a symposium on Patellofemoral complications.
Dr. Kelly: It was a symposium on the patellofemoral component of knee replacements.
Dr. Paul Lachiewicz chaired the symposium. Dr. Robert Bourne, who is in Canada, talked a little bit about whether you should resurface the patella or not. In this country (there) tends to be more routine patella resurfacing. Dr. Arlen Hanssen, who is a fine knee surgeon at the Mayo Clinic, talked about some unique things that he does in the revision part of patellas. Dr. Robert Booth, from Philadelphia, talked about doing salvage procedures such as allografts. My topic was to look at the various complications and how you treat them of the kneecaps in total knee replacement.
Knee1: What complications do you find?
Dr. Kelly: Back in the late 80's and early 90's, as we started being very successful with total knee replacements, loosening rates were very small and the knees were not wearing out. One of the areas that remained a problem in knee replacements was the patella. You had things like fractures. You had things like instability where you would dislocate the patella. You had soft tissue problems related to the patella. Most of these are preventable with good surgical technique and reasonable implant design. There were implants with metal-back patellas that were in vogue in the late 80's that turned out to be disasters. So today pretty much everybody cements all-polyethylene patellas in place, and the rate of complications has really gone way, way down with much better surgical techniques. The vast majority of patella problems are self-induced.
Knee1: What do you mean by self induced? Is it by the patient or by the surgeon?
Dr. Kelly: A lot of the ones in the '80s were designed related. The second issue is, once you have a patella complication, sometimes they're very difficult to treat. But if you go back and look at the surgical techniques, typically errors in rotational alignment have led to a lot of these. Instrumentation has improved, and Dr. Insall, among others, had advocated the various anatomic landmarks for rotation of both the femoral and tibial components of knee replacements. So, as we started doing the operation better and balancing the soft tissues better, then the complication rate for the patellas in total knees has dropped considerably.
Knee1: Is there one main technique for total knee replacements or does every surgeons have his or her own method?
Dr. Kelly: In the replacement there are two large camps. One set of surgeons – which we are involved – is where we substitute for the PCL with our design and surgical techniques. Then there's another large group that in their design utilize, preserve and try to maintain function of the PCL. Within those two camps they're very different. And then the individual differences often have to do with just with the variations that come with different (product) designs.
Knee1: Is arthritis one of the main reasons for total knee replacement?
Dr. Kelly: Yes. We now have better than 20 years of follow-up from (Dr. Insall's) original work. It will be interesting to see as this generation ages. Once have injured yourself and/or had surgery … you've lost your meniscus or something like that, that subset of people it is well-known that they are going to have early arthritis. What is happening is as a people have gotten older and the results of knee replacement have continued with each year to get better and better because we have more follow-up … they're very willing to accept knee replacement.
Knee1: If I have arthritis now and know I may be a candidate for total knee replacement in the future, what would you have me do to keep my knees healthy now?
Dr. Kelly: The first thing you do is get an x-ray … because we know that arthritis is multi-factorial, there are some genetic components to it. If you looked at an x-ray and you do not have arthritis, then what you can do is … try and maintain a reasonable body weight. We tend to see obesity correlating with the arthritis. I think the other thing that I think is going to be helpful is cross training.
I have bad arthritis in my feet so my days are running long distance have stopped, but I am doing triathlons now because what I have seen from taking care of my professional athletes. We use a variety of different ways to maintain them to stay in shape when they have been injured. Cross training allows you to really stay fit, keep your weight at a certain appropriate ideal, if you will, in that range, and at the same time not just overload your knees. A bike, swimming, the elliptical trainers, all those things are useful.
As far as any of these nutriceuticals, I don't know that anybody has demonstrated clearly that taking Glucosamine and chondrotin sulfate is going to prevent arthritis. There is some question whether these agents would be contra-protective, if you will, or protect what you still have.
Knee1: For the last three years, you have been Team Physician for the New Jersey Nets. What is that like?
Dr. Kelly: It is very exciting! A job as a professional team physician, it is a lot of time and there is a lot of liability involved. In addition to taking care of your team, you also have to have your own consultants. I find it exciting, having played basketball a lot and been through the whole Carolina experience. I have been following basketball for a long time so it is enjoyable, demanding but enjoyable.
My partner, Dr. Scott, has been taking care of the Knick forever, and I used to help him. This year it's a little more fun to be the Nets doctor. The first two years we have had a lot of difficult injuries. This past year we made some trades, and we're top of the Eastern Conference now.
Knee1: What is the toughest medical call you have had to make in terms of a player's career?
Dr. Kelly: We had a young man who had multiple knee surgeries who was probably at a crossroads of either having an OATS procedure for a defect on his lateral femoral condyle or almost retiring. I researched all the various gurus. Very few of these cartilage resurfacing techniques have been utilized in elite athletes who are going to go back out and use them. This gentleman did; he had an OATS procedure. It took him a full year to recover, but he is now starting and playing nightly and doing very well.
Knee1: What do you think is one of the best innovations in orthopedic surgery?
Dr. Kelly: I think, in my own practice, our ability to restore athletes with ACL injuries back to the court, not so much get then back but get them back so much more quickly with less pain and less stiffness. (We do that) two ways.
There has been some contribution early in the 90's in terms of the arthroscopic-assisted procedures in the ACL. (It) helps to preserve the soft tissues and the cartilage by continually bathing the joint rather than having it open to air. Two, we have better materials by which to fix the graft. By understanding the anatomy and placement of our tunnels, putting the graft back where it belongs, in an isometric position where it is well-kept to provide a range of motion and fixing the graft with excellent techniques that will hold it tight right from the beginning. And then to accelerate our rehab where the patients are not longer immobilized. They move their knee immediately. I had a young man today who is a star football player from our high school here who is going back to playing baseball four months after his ACL (reconstruction) with no brace, no anything.
I think it has been the combination of surgical techniques, instrumentation and clinical research that has facilitated the recovery. In the old days, we used to take a knee that was injured … and operate on it that night. We would give them a knee that was nice and tight, but it would be stiff and painful and it would take 9-12 months to recover. Now, we rehab you for a couple of weeks to get rid of your swelling, to get rid of your pain, to restore your full motion and then we operate on you. From my experience, that has led to a lot less trouble with motion and pain and surgery.
Knee1: What are you doing in your current research?
Dr. Kelly: We are focusing on several new concepts in knee replacement. One is we have designed what is called the high-flexion knee. This was spurred by areas of the world that have very significant flexion (requirements in their daily lives). If you go to Japan, patients kneel. Patients in theses countries are very reluctant to accept total knee replacements because they are nervous they wouldn't get the motion back. As we get younger, more active patients, we're trying to improve the wear of knee replacements. So we are involved in investigational studies to use what's called a mobile-bearing knee in an effort to do that with our high-flexion patients.