The Knee from Every Angle:
Dr. Joseph Sklar
By Tom Keppeler, Knee1 Staff
Many factors play into a patient’s recovery from anterior cruciate ligament reconstruction. The type of graft that is used, the patient’s physique, and the course of physical therapy will all play a role. Some factors are overlooked, however, most notably the patients’ expectations about their recovery and the type of “fixation device” used to anchor the graft to the leg. Dr. Joseph Henry Sklar has taken a proactive approach with both of these factors. He has been the designer or co-designer of two fixation devices that anchor ACL-reconstructing grafts to the bones inside the leg. In addition, Dr. Sklar has secured a grant from the National Institutes of Health to study the effect of a patient’s outlook on their recovery from ACL surgery.
Dr. Sklar is a partner at New England Orthopedic Surgeons, where he specializes in sports medicine and knee arthroscopy. He graduated from the University of Pennsylvania, where he obtained his undergraduate degree in psychology before graduating from U of Penn’s School of Medicine. He is a member of the American Board of Orthopedic Surgery, the American Academy of Orthopedic Surgeons, the Arthroscopic Association of North America, the American College of Sports Medicine, and sits on the Board of Directors for the Massachusetts Orthopedic Association.
|Hear Dr. Sklar explain his research into the mind's ability to heal the Anterior Cruciate Ligament here:
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Knee1: You have done quite a bit of work on the mind’s ability to heal the body, especially with the ACL. In fact, you recently received a grant from the National Institutes of Health to continue your research in this area. Tell me a little about your research.
Dr. Sklar: I conducted a preliminary study two years ago, in conjunction with two professors of sports psychology at Springfield College, Britt Brewer, Ph.D., and Judy Van Raalte, Ph.D. They were interested in further studying this phenomenon where a lot of high-power athletes seem to heal better if they have positive attitudes. The question is whether the mind has an influence over the body in terms of healing of tissues. A pilot study was done approximately three years ago; people going through ACL reconstruction were given a battery of tests that were designed to assess how positive their attitude was, what sense of optimism they had, whether they tended toward depression or dismay. Then, they correlated those results from the pilot study with the results from the therapy. The other things that were assessed were the therapists’ thoughts about the patients’ degree of compliance with the therapy program, how well they performed their exercises. At the end of that study, there were a lot of surprising results, and that was that the variability between who was successful and who was not successful after ACL surgery—whether they got back their strength, whether they had stiffness, and how tightly the graft healed—was dependent, in part, upon their mental attitude. There was no other explanation other than mental attitude. The psychologists did a multi-variant analysis, a regression analysis, of all the factors, and found that about 30 or 40 percent of the results of the surgery could be explained by nothing else than the person’s psychological make-up and attitude.
Knee1: Do you think this will lead, down the road, to doctors prescribing a good attitude alongside anti-inflammatories?
Dr. Sklar: Absolutely. The NIH gave us a half-million dollar grant to study a larger number of patients and to do further testing. If it can be established in the larger study that there is a clear-cut difference, a surgeon or doctor might be able to intervene ahead of time and teach positive imaging or otherwise encourage the patient to get into a healthy way of looking at their injury and of their body healing.
Knee1: In addition, you have focused some of your research efforts on the Anterior Cruciate Ligament. What attracted you to working with that specific ligament?
Dr. Sklar: My group is sub-specialized, and I was attracted to sports medicine. If you’re in sports medicine, you end up taking care of knees a great deal. As soon as I got involved in more of the operations, I started to think about how we could improve what we do: how to improve the instruments, the methods, the fixation of the ligament. Even now, we have not “solved” the ACL problem. There is still a fair percentage of failures that we don’t understand, and, as a result, there is always work to be done.
Knee1: You have also done a lot of research into certain fixation devices, including Smith & Nephew’s EndoButton, a non-metal, non-invasive fixation device to hold ACL repair grafts in place. Could you describe your work with this?
Dr. Sklar: The EndoButton is an extremely strong device for fixing grafts to the femur. I was the sole inventor of the Intrafix, and I was one of the inventors of the EndoButton, another fixation device. I was also very involved with the testing of the EndoButton, with a colleague, Dr. Charles Brown, who is based at Brigham and Women’s Hospital in Boston. As far as the biomechanical testing we did, we used human knees. We will soon publish an article that discusses all the different combinations of fixation devices that were out there a year ago. We used the same testing methods to test the IntraFix, which just came out last fall.
Knee1: What have your findings been on the two devices?
Dr. Sklar: The EndoButton is an extremely strong device for anchoring soft tissue grafts, like hamstring tendons. It is also very strong for anchoring bone-patellar-tendon-bone grafts into the femur. I use it for both grafts, and it is very easy to use. The IntraFix, so far, has proven stronger than anything else we have ever had inside the tunnel (the gap between the two condyles, or bumps, on the top of the shinbone, or tibia). If you are talking about fitting grafts totally inside the tunnel, there is nothing that can surpass the IntraFix right now. The only way you can grab some tendons and hold them securely is with a combination of something inside the tunnel and some heavy hardware outside the tunnel that needs to be removed later on. The beauty of the Intrafix is that the surgeon can have a lot of confidence that the tendon is fastened well inside the tunnel during rehabilitation and healing, and not have to use some device that has to be removed 30 to 40 percent of the time because it sticks out under the skin. A lot of the screws and washers and staples that surgeons have used to attach the tendon to the bone outside the knee stick out, causes discomfort, and have to be removed in a second operation later on. People have been looking for something that can be used on the tibia that could all be inside the tunnel, and yet was strong. One of the principal reasons that people have not used hamstring tendons more is because of just that, that they didn’t have something strong inside the tunnel. The hamstring tendons are very strong, but they have tended to stretch out in patients more than the bone-tendon-bone graft fixed with screws. People used to blame it on the tendons themselves, but it is not the tendons, it is the fixation, and, in particular, the fixation on the tibia that was the weak spot.
Knee1: What compels a doctor to use one fixation device versus any other?
Dr. Sklar: Hopefully, for any particular graft, the choice of fixation device is based on the doctor’s research on what is the strongest and what is most comfortable to use. As a result of biomechanical testing where you compare different fixation devices out there, we are getting much more scientific about how to compare devices to one another. There were no good tests that were available until about ten years ago, or even more recently. Then, it was based on word of mouth. Now, however, all sorts of devices have been developed: ACL-repair devices, ACL-fixation devices, and tissue anchors, they are all tested rigorously in labs by the manufacturers, and those results are reported in the literature. As a result, people can compare them and find out that another product is stronger than the one they are using, and may switch to that.
Knee1: Frank Noyes, a prior Knee Care Hero, is one of the many doctors who have noticed that ACL injury rates are higher in women. As a result, he developed the Sportsmetrics program of strength training to prevent ACL injuries in women. You have adapted Sportsmetrics to your own practice, right?
Dr. Sklar: Yes. Two years ago, when I heard about the program, I got in contact with the various physical therapy offices here in Springfield, Mass., and I tried to persuade them to offer healthy people who are going into those high-risk sports a class of Sportsmetrics. We have gotten to the point where we have trainers in most of the high schools who teach the Sportsmetrics programs to women who are going to be playing soccer, basketball, and the other high-risk sports. We are very excited about it, especially since the data that Noyes obtained shows that the rate of injury of the girls could be lessened from five times that of the boys to the same as the boys. Their performance, their conditioning and strength, is better than it would have been without the program. They jump higher, and they are in better shape.
Knee1: Have you had similar results with the program?
Dr. Sklar: We have not actually tracked it. The studies have been done pretty carefully in Cincinnati, and we have basically adopted it on the basis of their research. We did not feel the need to repeat the study.
Knee1: Have you changed any of the methodology of it?
Dr. Sklar: No. We have a videotape of his program, and the video tape is used to teach the students, and we adhere to it strictly.
Knee1: You have a forthcoming article in the Journal of Bone and Joint Surgery about the management of pain during and after outpatient surgery. Could you give us a preview?
Dr. Sklar: Many knee procedures are done on an outpatient basis now, which means that people are not in the hospital and can not get big shots of morphine to control their pain. We have worked hard to come up with combinations of medicine that leave people in less pain after ACL reconstruction than they would have been otherwise. You have to start before the cut is made, by giving the patient an anti-inflammatory—one of the newer ones, the Cox-2 Inhibitors, since they do not cause bleeding. From there, you infiltrate the skin and the inside of the knee with Marcaine. In addition, we are starting to use Morphine before the operation, whereas these medications used to be administered only after the operation. In effect, you suppress the nerves and you suppress the inflammation before it starts at the time of surgery. After the procedure, the key is to give the patients long-acting pain medicine, such as time-release Oxycodone, and anti-inflammatory medications. Patients are very comfortable after that, whereas, in the past, they used to be in a lot of pain. Getting the medicine in ahead of time, and using the multi-modal approach: using the anti-inflammatories, narcotics, and acetaminophen, seems to work the best.
Knee1: How do you see the biomechanical technology improving over the next few years?
Dr. Sklar: The next big step is going to be the introduction of biological growth factors that will accelerate the healing process. Ultimately, with all these fixation devices, their only purpose is to anchor the tendon or the tissue into a bone until the body has healed into the tissue, and you achieve biological fixation. Fixation devices should be seen as temporary, at best. If you add some growth factors, which people have already experimented with in animals, to the tunnel where the tendons are trying to heal, then you could get more thorough, more accelerated healing, presumably, than what we get now.
Knee1: What impact have the new fixation devices and methods in the past, say, 10 years, had on the healing process?
Dr. Sklar: The first way in which things have changed is that you can rehabilitate the patient more quickly and put more force across the knee at an earlier stage, because you have stronger fixation to hold the tissue in place. The sooner you can move the patient’s knee and get them exercising, the less likely it will be that you will get stiffness and atrophy in the leg. It used to be that we did not have good fixation devices, and we did not have good grafts. We used to have to hold those patients in casts or splints for long periods of time before we could let them exercise. During that time, some patients developed permanent stiffness. Now that there are stronger fixation devices, we can move the patient earlier and not worry about it stretching out. The second aspect of the new fixation devices, like the IntraFix, is that a device like that locks the tendons inside the bone tunnel and pushes the tendons out against the bone tunnel wall, instead of letting them move around inside the tunnel. Something like that, or like a bio-screw, which is made by a lot of companies, that presses the tendons into the tunnel wall, seems in experiments to accelerate the rate of integration and healing of the tendon into the bone. I think that is a major advance.
Knee1: You have a good following on the Internet, especially among users of our site, who have posted many good things about you. What would you say the key to developing a good practice and a loyal following?
Dr. Sklar: Well, I think you have to love it, you have to love what you are doing, I think you have to care about your patients, and that is something you either have or you don’t. I think that if you love your patients and you love what you’re doing, and you constantly work on trying to improve your technique and learn new things, then that’s about all you can ask for.
Picture courtesy of New England Orthopedic Surgeons.
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