Episode 4: Dr. Alan Cheung

In this episode we speak with Orthopaedic surgeon, MMA fighter, ringside doctor and all-round nice guy, Dr. Alan Cheung. 

He has a special interest in martial arts and is a member of the Association of Ringside Physicians and is a certified Ringside Physician and provides coverage for several international combat sports events

In this episode we delve into the latest developments in ACL research and practice, discuss  his involvement in combat sports and why he puts his valuable hands at risk by continuing to compete in martial arts himself! We discuss the different types of ACL grafts and the pros and cons of each, and the difference in ACL grafts between countries, when is a good time to operate and what factors should be considered when deciding whether to operate or not. We finish up by discussing knee replacements.

Transcript

Dr Alan Cheung, Orthopedic surgeon

SUMMARY KEYWORDS

ACL, knee, injury, ACL reconstruction, people, Singapore, joint, surgeon, patients, orthopedic surgeon, physio, sports, athletes, surgery, knee replacements, cartilage, reconstruction, technique

SPEAKERS

Alan Cheung, Bevan Colless

Bevan Colless  

Alan is a surgeon in Singapore, how did you end up becoming an orthopedic surgeon - what's the pathway?  the general population probably don't really understand how you go from being a doctor to finally becoming an orthopedic surgeon

Alan Cheung  

Well sometimes your specialty chooses you I suppose in some ways. So, people who tend to like sports, have some understanding and experience of injuries and most sports will pick up some degree of injury and then just enjoy working with the human body in terms of general anatomy and biomechanics. And then finally enjoying the type of surgery that is involved in sports injuries, reconstruction, ligaments, replacing joints, and generally having a positive training experience and after some time end up as a consultant orthopedic surgeon.

I grew up in Cambridge, England, so I'm actually British, although my parents are from Hong Kong, and I used to play rugby for the local side, and I was quite short sighted back then. So when I was 16, I missed a tackle, and I just landed on my shoulder and it just dislocated then popped back in. I and I thought ‘Oh my God, that's really weird what happened’. But I was able to keep playing and I didn't get much done to it, but for some reason, my shoulders are predisposed to dislocation. My other shoulder dislocated. So, every game, I’d probably have one dislocation, but being 16, I decided, , I should actually stop some medical advice and seeing a physio, but I had to wait three to six months to see an orthopedic surgeon back in those days.  that was my first start on to path of injury and anatomy and, and how to recover from those positive experiences for my future career. So that's, that's how I ended up being an orthopedic surgeon.

Bevan Colless  

So, did you have an operation on either shoulder?

Alan Cheung  

I have to say that, no, I stopped playing rugby for other reasons. So, because I moved to London. And then I took about sports. And in retrospect, I wish I had because now I've got a very limited movement and some limitations in in my range of shoulder movement, although I don't have any type of subluxation. But it also shows that the human body is also very creative, healing, very adaptive, and there are many things you can do even if you are injured.

Bevan Colless  

You’re being very modest there it's obviously very difficult to become an orthopedic surgeon, it’s difficult enough to get into medicine, but what's the pathway, once you've once you've gotten into medicine to become an orthopedic surgeon?

Alan Cheung  

So, in England, you, you tend not to have a residency program like in The States where you just jump straight into it. And you do have a feeling out process mainly because it's usually that you can go straight into medicine with no premed.

So, from high school you go to medical school, and then you do several years as a junior doctor, usually as a junior in surgical rotation. And then you decide what you want to do. And then you compete to get on the orthopedic surgical training program, which is quite stressful. So, you have to jump through all sorts of hoops and, get certain amount of experience and write some research papers and take some exams. And so that sets you up onto your proper training pathway by which time you're usually married with young kids. And then, take some difficult exams at the end of that, go abroad to do a fellowship to get more experience. And then ‘hey presto’ you’re an orthopedic surgeon. But it does take a long time in the UK, it takes at least 10-12 years. It’s probably quicker in some countries, but they tend to have a  postgrad entry. So, all in all, like anything in life, it does take time sometimes to get to where you want to go. And it's more about the journey than the destination sometimes. But I enjoyed my training,  it was very broad. And certainly, there's a high volume of patients, because it's 60 million people, a lot of hospitals, and it gave me a pretty good grounding. And other career paths are probably equally as stressful if mine is stressful. But the thing about medicine is yours is like tunnel vision, you're fairly blinkered and you merge at the end of conveyor belts are thinking, Oh, maybe I wish I'd learned something about , how to invest or how x works or, , all these  things are useful when you're  in your mid to late 30s. So,  other careers are just as challenging, I'm sure it's very tough to set up your successful chain of physiotherapy clinics in Japan and also in Singapore. , a lot of people don't have business savvy to do that. So, it's, every career path has its challenges. I'm sure.

Bevan Colless  

You’re very kind. Thanks. And so how did you end up in Singapore? There's a bit of an anomaly. There's not a lot of UK surgeons, orthopedic surgeons in in Singapore.

Alan Cheung  

My parents moved back to In Hong Kong, and my wife, Sally is from Singapore. So, we had a lot of relatives in the East. And not many where we were in London. And we just thought it's probably at the end of my training, a job offer came up. At that time, about seven, eight years ago, Singapore was going through a big expansion program about two or three new public hospitals being built, desperately looking for people to come in, and fill the house, and I thought it'd be a good chance to go back to Asia, be closer to my family, just try something different. I really, like the UK as well. But it's a very predictable life story. You live in a town with one fish and chip shop, one pub, one curry house and, it's a great life you get, but it's not as exciting as living in Asia, being able to travel and just experience different cultures. And it's just a bit more interesting. Culturally there's a lot of differences in this very small area. So, I'm very glad I moved, I love living Singapore, it's always sunny all the time. And it's safe, it's clean. It's close to other countries. And ,  it's definitely been a good move for me and my family.

Bevan Colless  

It is a great place to live. And you're quite well known in the community for your love of Mixed Martial Arts, you’re a ringside doctor. How did you get involved in that sport?

Alan Cheung  

Well, I I've always liked martial arts I because I used to watch a lot of kung-fu movies as a kid and, and even did some for a bit at university. But through my training, I didn't have a chance to do that. So when I came to Singapore, I eventually enrolled in a martial art school called ‘Evolve’, which has a lot of branches around Singapore. And it's one of the biggest schools here. And then I started covering local amateur martial arts events, which in retrospect, I don't think I knew I was taking on at the time, because sometimes you go to these events, you're quite unsupported. And then I was scouted by Dr. Warren Wang, a friend of mine, who's the head of medical services at the One Championship. He said, ‘Well, why don't you and your team, try covering the events’. So, we started out, providing backstage medical cover, being a ringside doctor is not just at the event, although that's the most glamorous part of running and someone's been knocked unconscious, and we have to transfer them out of the ring to the hospital. But it involves screening the athletes pre and post flights. So, making sure they don't have any hidden injuries. And they’re cognitively functioning well. And then there's, with one win championship, they've got a very high safety standard. So they, they have a hydration test protocol where they ensure that the fighters are fighting in a hydrated state by meeting. So basically, they have a measure the concentration of urine throughout the pre-fight week. Because, as we know, if you rapidly dehydrated, which, which is the easiest way to cut weight, it can sometimes be very dangerous, even fatal. So making sure that the athletes are hydrated means that it's safer for them. And they're able to fight it their natural weight without impairing their performance. And then there's the finite itself. 

So looking after their athletes who get injured, which they invariably do, they have a predictable pattern of injuries, usually, then seeing them after the fight and all that  thing, treating their injuries. So it's  involved process and, again, there is a certification pathway run by the American College of Sports physicians, as they can assess your insights. I talked to certification, which is quite a fun, interesting thing to do leads on to other things. So , as an as an orthopedic surgeon, it's certainly another feather in my cat. I've met a lot of very interesting people and athletes in the martial arts world, but  without being part of the one championship, I've never met people like Hanzo Gracie have aggressive family to tell her death squads Mike Tyson Floyd Mayweather, lots and lots of other boxers martial artists. So it's, it's been pretty a pretty amazing experience. But , orthopedics is my number one. And  that that is  something I do for fun. But I'm primarily an orthopedic sports surgeon joint robotic, joining the construction section.

Bevan Colless  

And so you talked about the familiar pattern of injuries that you see amongst mixed martial arts athletes, what injuries are you seeing? There's a lot of concussions and facial injuries.

Alan Cheung  

So, there's essentially several ways to win a fight: to knock out your opponent. Usually, with a blow to the head, or less often the body blow and create and give them more physical damage, more blows landed. So obviously, head and facial injuries. And impact injuries are going to be the number one for someone who's to be knocked out and, but less commonly, these guys are in tip top condition. So, they are pretty strong and take a lot of damage. The other way is to through the submission, which can be through a choke, so strangulation or by putting joint in the position where it’s a submit or dislocate. If you force it any further and the opponent has to submit or tap out. So those ones tend to be potentially less damaging. Because the athletes are professional, they're not malicious, they know that their opponent has to submit and will have a career and continue fighting. So, they're not necessarily going to deliberately break an arm or two, dislocated joints apply enough pressure of enough skill to make their opponent quit. And same with the chokehold, they usually only apply for a few seconds and the referees have a high level of skill. And the care of the athletes is number one. So, they're good at spotting unconscious athletes and stopping the fight or stopping the fight earlier, if they think the athletes taking too much damage and is unable to defend themselves. So in general, though there are injuries, they're generally fairly minor So I’d say that martial arts, under the circumstances, is safer than a lot of sports, like rugby, or horse riding, for example, where, anything can happen really.

Bevan Colless  

That's an interesting statement. When there's some submissions,  it's similar to a joint capsule stretch, I assume where you wrenching the joint obviously, in a specific direction so that the joint is unable to go any further and do they actually get injured from those or not because the person doesn't put enough pressure on, even with that amount of pressure, where they're wrenching the joint capsule, will the joint usually bounce back from that without injury?

Alan Cheung  

Well, from personal experience, I train in Brazilian jujitsu and I’m not very good at it, so I tend to be the one who gets submitted and has to tap out. And, and so I've personally experienced all these, chokeholds and so, they're trying to use the technique, which is a strange situation and could be potentially lethal, or you there they are, the usual player with enough skill will have you to tap out quick enough before you're injured. There are certain types of submission holds, which are slightly more dangerous than others. So, typically the ones that involve putting pressure on your elbow, such as the armbar, tend to injure the arm collateral ligaments, and so if that's applied with enough force, you can also get some repetitive scarring. If they’re done repeatedly on the arm like I have and are not stupid enough to escape, but even though I've got bad shoulders, I've never had a shoulder dislocation. And minor finger injuries are fairly common to stop your finger or two into the plate, when you get hyperextension, but the leg locks are potentially more damaging to the knees, and you can get a lot of torque on the ankle, and the wrist locks as well you can apply that you can apply it can be very painful. And there's a lot of pressure on the small joints. And then, there's this thing called reaping the leg where you if you trap the knee at the wrong angle, you can pull out a force, and that can injure the ACL as well. But in general people that are taught the leg locks are at a more advanced level. So hopefully they are more skillful when they apply these leg-locks, they’re going to be brown belts or above. So that, like any, any sport has an inherent risk of injury. And although, obviously in martial arts, there is a risk of injury under supervised conditions and the appropriate protection. you're trying to modify your risk, whereas, if you're in a rugby field, and people are running around at full force when you can, it can be high impact and sometimes injuries can be a bit more severe.

Bevan Colless  

ASo has anyone ever suggested to you, that as an orthopedic surgeon, competing in martial arts might not be the greatest idea? I suppose your hands are quite valuable and important to your trade?

Alan Cheung  

Well, I have heard those things, why did choose it? Just because I enjoy it. As long as you're aware of the risks are. I take care of my fingers when I train, I have special gloves I wear, which splint your fingers. And as long as you have your hands like this (fingers bent), so I tend to develop a special grip to keep my hands in a protected position, where I don't extend the fingers fully. You just learn how to not get compromised. It's unfortunate, but every sport has its pros and cons. But I really do enjoy it. So that's why just keep paying. 

Bevan Colless  

Got to do it you love.  So let's get into talking about knees, we are on The Knee Gurus podcast after all. So you do a lot of knee surgeries, obviously. And what are the main knee surgeries you do, I know you do shoulders and ankles as well. So, what are the main surgeries that you perform?

Alan Cheung  

So with knees, essentially, that's pretty much everything and anything. So, meniscal repair, ACL reconstruction, multi ligament reconstruction, cartilage injuries, and then even down to the spectrum of eventually replacing the joints if it's very worn out. For shoulders, rotator cuff repairs and slap tears. So that those are the commonest shoulder operations, then ankle cartilage injury, ligament reconstruction for instability. In Singapore, people tend to be more generalists surgeons than in other countries. So I often think that moving to Singapore, I was very glad I had some  broads  training in UK, because you're able to deal with a variety of scenarios and situations. But, I also like, using robotic systems, I use a system called the Maker Plus II system, so I do all my joint replacements robotically as well.

Bevan Colless  

Robotic surgery is definitely gaining a lot of popularity recently, isn't it? With ACLs, what is your favorite graft source that you tend to recommend to your patients? 

Alan Cheung  

So I like to treat my patients as adults. So, I give the different pros and cons of each graft. The hamstring graft is tried and tested, developed in Australian by a surgeon named Leo Pincewski so that involves harvesting two of your hamstring tendons from inside your knee. And threading them through the bone. The only problem is that in Asia because we have a slightly smaller stature here, particularly ladies who are prone to ACL injuries anyway, I like to have minimum of 8.5 millimeter graft that is what's required to replace the original structure. So if you take two hamstrings, often in the Asian ladies, it's around five millimeters. And if you imagine the coils of a rope, the thicker your rope, the stronger it is. And if it's not thick enough, then it's going to be weak. So that's why I say to the ladies, well, look, especially if you've got hyper-laxity, that's another risk factor, failure to graft. And I always screen for whether they have very stretchy joints. And we might say, well, we might need to have an alternative. Before hamstrings were used we had the bone patellar tendon bone, a bone from patella kneecap, patella tendon, a bit of bone from the tibia, shinbone as well, that was threaded through. So that was my favorite technique. But the con is some people have small kneecaps, as well, if you're taking the same size chunk as you would in a big, Caucasian male, then persistent anterior knee pain is something they might have to deal with. And if they tend to squat or kneel a lot, then that might be a problem in future. So and then, we have other options, including the quads tendon which is gaining popularity. And that's just done through a small incision just above the kneecap and doesn't involve any bone. And that gives you a very strong consistent graft. And people don't tend to notice that they have had a strip of their quadriceps removed. And I'm tending to favor that one recently. Some research shows that it tends to work just as well as hamstring grafts. The other alternative allograft which has had a bad press in the past, an allograft is donated tissue from other human beings. So usually from Achilles’ tendon or one of the peroneal tendons. And that also gives you a very strong, reliable graft. And the modern techniques to clean and preserve the graphs and preparing is very clean, and doesn't tend to weaken the graft which it may have done 20 or 30 years ago. So, it's also very reliable alternative. I do have a favorite graft, but I tend to discuss with the patients, the pros and cons of each, and then we come to a decision for what's best for them.  That’s the way I tend to do it.

Bevan Colless  

It’s great that you've got the skills to be able to do all of them, because most of the time, you're  a hamstring guy or a patellar tendon guy. 

Alan Cheung  

Nowadays, you just have to be able to do several things at once.  If someone's had surgery already and if you've got a revision case, you have to be able to do different things. Sometimes graft options have already been used. And it's just good to investigate and for sure to do different things in different ways, basically, which is also makes things more interesting, as well.

Bevan Colless  

And the other procedure that's gaining a bit of popularity is repairing the ACL. So in in instances where maybe it's a partial tear, and thiere is a reasonable amount of, of the ACL still intact. What do you think about ACL repairs?

Alan Cheung  

Well, I do think it's an up and coming technique, but the issue is that not everybody is suitable for the technique, you basically have to have, as you say, a partial tear or a fresh tear off the femoral insertion, not a  mid substance tear and, and it usually has been done fairly soon. So, it's okay for countries like Singapore where people have access to surgeons who can do the ACL fix within a month. Or maybe not so good for countries where you have to wait 18 months to see to actually go from seeing a family doctor and you're waiting another 18 months post injury in the public system. So it has developed in systems where you have rapid access to a doctor. And then unfortunately, the results are not always as good as for a standard ACL reconstruction. And I don't think and whether it's because it's a technique that's slightly new, still being developed, or just structurally, it's not as strong as having, a new graft. So for my patients when I counsel them for, would you like a repair or we can do reconstruction? And they say, well, which is the better one? And then you say, Well most tend to do reconstruction, they tend to choose that.

Bevan Colless  

Interesting. So  there's been a bit of a shift recently towards delaying the surgery a little bit from the time of injury so that the person can work on the rehab and see how their stability is going and increase their function a little bit, but you're saying gets a little bit more difficult. The longer you leave a post injury before you operate, then the more difficult it is to do a repair, is it or maybe reduces the chance of success of the tear of the repair? 

Alan Cheung  

The timing of surgery is always a controversial issue. So is, and particularly for ACL repairs, there's not as much data as there as there is to support reconstructions. So what is the difference between repair and reconstructions? Repairs, when you are able to say, pass a stitch through keyhole surgery through the ACL, which has been damaged, and then thread and drill a small hole to fix in place with a little  button, whereas a reconstruction involves taking away usually taking away the old ACL. And drilling new tunnels in the bone that are about eight to nine millimeters in size and in line and passing a new graft or replacement from, for the ACL from other parts of your body and fixing it at both sides in your shin bone and your femur. So, reconstruction is more involved and sometimes requires a bit more recovery period, but tends to have better long term outcomes, at least to the techniques and the data we have today. So for ACL surgery, in general, usually the papers written suggest that, at least occur at least several weeks after your injury, you should be working with a physiotherapist to decrease the swelling, get a full range of motion, if possible, and just get a bit of strength in your quads. 

For when to have the operation, the exact timing is controversial, but you don't have it's not a lifesaving operation, you don't need to go straight to the operating theatre straightaway, obviously, conversely, if you don't fix your ACL, and you continue playing sports, which involve a lot of cutting movements, that is  pivoting or shifting away, for example, this can lead to instability and the knee giving away. And that process of giving away can damage other structures in your knees, such as your meniscus, which are rubbery shock absorbers between the bones, or the lining of the joint itself. And some papers suggests that if you delay your ACL reconstruction by six months, your chances of having further injuries to meniscus or cartilage goes up significantly. So I suppose the answer is, I tell my patients look, you don't have to have your ACL fixed. But if you do a particular type of sport it is useful. And if you do want to get your ACL fixed, then these are the routes, we don't know the exact optimal time but maybe between not too early not too late is a good, a happy medium.

Bevan Colless  

And that said hard episodes of instability, where your knees collapsing and giving way where the meniscus often gets damaged. And you really want to avoid that yet, people can do that even after having an ACL reconstruction. So it’s just important to counsel our patients that there is still a risk of that happening. Even with the operation? One of the things that I've always liked about your approach to surgeries is that you do tend to counsel people to start with a physio and get the strength back in the knee because I have noticed in Singapore, it tends to be dsurgeons tend to be quite quick to operate on ACLs. If somebody goes to see a surgeon, then, the process seems to be, okay, you've had the MRI,  you've done your ACL, let's schedule surgery, it just seems to be just  a natural progression.

Alan Cheung  

Well, being brought up and trained in UK, and Australia. And I tend to have followed that way of thinking. But to be to be fair, in Singapore, so a lot of the patients also have expectations, and, and they come in, say, I want my ACL fixed right now. And because of the pressures of the system, not many surgeons have the, we have the guts to say, well, actually, let's just wait a bit, and let's get you a bit stronger, and your knees all puffed up like a balloon. Let's get that down if we have an operation. So, that's my approach anyway, is to try and try and you refer you to a good physiotherapist first, and then just gives everyone’s confident that we're doing the right thing.

Bevan Colless  

And so as far as your post op guidelines for your ACLs . What's your favorite? Different surgeons tend to have different recommendations, some like to brace some like people on crutches and non-weight bearing for a little bit longer. What's your preferred protocol after ACL reconstruction?  And that changes depending on what graft to use a little bit as well.

Alan Cheung  

Sure, looking at the looking at the research, there's, there's no real evidence suggests that bracing the knee after ACL reconstruction has any major benefit, but my patients do tend to like it. And they do come back saying, I like to use him a brace him made them feel more confident, more secure. And if you have a patient who's maybe not the most coordinated person, they tend to fall over a lot, then there's no harm in having a brace to prevent any injury, any cartilage or meniscus, if I do an ACL reconstruction, if I do any meniscal work, or cartilage, with reconstruction procedure, I'll always use a brace because it's good to limit the range of motion, according to the stage of recovery, and also, direct the weight bearing pressures of the knee when there's a lot price and control it in some ways. So, I tend to use a brace as a standard, but I know from the data that we're storing for ACL reconstruction don't always have to, there's just social and patient preference.

Bevan Colless  

I'm a bit agnostic on braces post ACL as well, on the downside, they can really reaffirm the mindset of the patient, if they've got a bad knee and physios we're trying to get them to trust the knee. . But as you say, some people actually feel more supported in it and trust in a little bit a little bit more. So…t6l5T
I don't have a strong either way.

Alan Cheung  

The main thing for the patient is, it's really important for there to be  good three way communication between the surgeon, the physiotherapist and the patients, because basically, you're the patient if the doctor doesn't speak to the physiotherapist and doesn't keep an eye on what's going on and make sure everything's progressing well then then it can be difficult and likewise, if the patient feels that, his or her surgeon is speaking the same language as the physiotherapist they're all on the same page and all is encouraging and everything is going smoothly and according to plan, they feel a lot more reassured and able to stick with the rehab program.

Bevan Colless  

Yes, for sure, what about return to sport? What timeframe do you normally choose? Like what is your minimum period?

Alan Cheung  

Good question.  I'm although there's not a universal rehab program, I tend to ask my physios colleagues to follow the Melbourne rehab protocol, which is an ACL rehab program developed by in Melbourne, Australia. And it's a really a criteria-based phase return to sports. So you have several different phases following surgery. But it's not really time based, it's more: are you able to fulfill these criteria? As you well know. Because sure, you're very familiar with it. And so, from that point of view, I say usually return to play in about nine to 12 months, it's all really down to the criteria of the protocol. So, theoretically, if they're advanced, they could do certain things straight away, or have a very intensive physio program, , here, abouts, some professional athletes, being able to go back to say, Ibrahimovic went over to the States, but he was scoring goals, six months after his ACL reconstruction, but he is obviously in a totally different league. And he was in fantastic shape to begin with an army of physio, sports scientists, and that mentality of ‘I want to still continue my high paying career’. But for most mortals, the data suggests that the rate of re-injury to any standard baseline at nine months, so that's why we encourage our patients, just not to go back to sports for nine to 12 months afterwards, and to fill fulfill the criteria of the rehab protocol that has that's the usual.

Bevan Colless  

There's definitely been a shift away from the time-based markers. Early my career a physio, it was six months return to sport. And as you said, it was a very time focused rehab, we had to be walking without a limp at four weeks and running at 12 weeks, and we had to get you back to sport at six months. So it's been a long overdue shift, really this function based rehabilitation rather than time. Well, the other thing I wanted to talk about, and we've been talking about recently, and has become a hot topic, is ACL healing. Early in my career, I was always taught that the ACL is an intracapsular joint. In other words, it's doesn't protrude beyond the knee joint capsule. And inside that capsule, there's no blood supply. Therefore, when one is torn, it's torn, and it doesn't heal. But it seems like there's still not a lot of good quality research out there. But it seems like there's more and more awareness of the ACL having the ability to heal, which has been quite an interesting discovery. And amazing that we weren't aware of it after all this time. 

Alan Cheung  

Well you're right, it can do, particularly in younger patients. So, the problem with anything damaged within knee joints, is that it's not a very conducive environment for healing, because a lot of the structures in the knee, don't have a great blood supply, like cartilage on the meniscus, or the ACL. But the ACL does have a blood supply, when you look at it, it does actually contain blood vessels. And when you tear it, it does bleed. And that's why often the knee just swells up, because there's a Hemartherosis or it fills with blood. But because the knee is filled with synovial fluids, which is a fluid that is produced by the lining of the knee joint contains nutrients for the cartilage. And there's also lubricant as it moves, then, a lot of the time it's difficult for damaged structures to form a clot, you've got this fluid washing around is going to wash away the clots. And also the knee is always moving. So we don't really like to maybe back 30 years ago, if you had an ACL injury, you might be put in a cast, and then who knows your ACL might be in the right position to get back together again. But nowadays, we recognize that we don't really want a stiff wasted limb. Six weeks in the cast is not really ideal for the patient. So, we try and get a range of movements. And it's very difficult, I always liken the ACL to a rope. And when it tears a lot of the time, it just explodes. And putting all those little rope pins back together, right places fairly impossible, as the knees is always moving. What can happen sometimes, , if you're young child, if you're a youngster, you're a child. And sometime you're still developing, there's probably some plasticity within the ACL,tear it as possibility or healing as much better than an adult who's older who is a smoker, for example. And sometimes, if you tell one end to the ACL that can heal, I don't want to back onto the PCL in a slightly different position, so it doesn't always heal back to where it's supposed to heal. So it's cause up basically, and then, if you're lucky, I suppose. And it could be functioning. But more often than not, there's some degree of laxity. So once you do tear your ACL, there's a reasonably high chance that it's going to be less functional or non-functional afterwards. And then if you're very lucky with it, you're in the right place.

Bevan Colless  

It’s definitely going to be interesting to see what happens in that ACL healing space and trying to work out what the optimal protocol is and as you said, the age to, to  maximize your chances of ACL healing, as you say, without developing a stiff knee by locking it in a restricted range of motion, because that that's got its problems as well. .So when you're having these discussions with your patients about whether to have an ACL operation or not what , what are the main factors that you think, come into play for people when they're when they're making that decision?

Alan Cheung  

Well, it’s a good question. And every everybody is different.  The main thing for most adults is, ‘Can I continue playing the sport I love?’ A.  And B is it going to affect my livelihood, my career? So if someone is very sedentary, and they had a freak accident, and tore their ACL, but there's no chance that they could do anything more strenuous than walk to the supermarket to buy a loaf of bread, and they're probably not probably going to be able to survive without having an ACL, because, the function of the ACL is to resist those rotational forces, when you're turning, suddenly, you're pivoting or sidestepping, or cutting, cutting and moving at speed. So if you're never going to put in the hands of that pressure, and you don't really don't really need an ACL. So again, data suggests for sports that just involve moving in a straight line, like baseball, the rate of ACL reconstruction is much lower. But if you're involved in sport, which see a sport or the sports game planning or like, football, basketball, or rugby, those are the sports where an ACL is pretty crucial and most people are involved in high level sports will want a functional ACL or will be less happy to continue in their sporting career. So people who have got a manual labor job so, if you work in a job that requires you to be fairly physically fit, and to be able to run and move about and carry heavy objects. So, people in the armed forces people sometimes who work in oil rigs, and they tend to favour interventional approach to surgical approach. But I do have to counsel people that for most surgeries, it's not going to be a quick fix. And you're going to have a period of recovery that requires you have nine months of intensive physiotherapy. And if you've got a job which involves walking around and inspecting a plant or having to, to be physically capable, may take you four to six weeks,  you may be six weeks on crutches, so people there's all sorts of things in people's lives, which will be factors for and against surgery, I suppose all these and the timing of surgery. So many factors and everybody's different. So it's a personal choice.

Bevan Colless  

It's a hard one. And there's definitely seems to be a shift towards shared decision making and trying to weigh up all those factors. Talk with your family, as well as your surgeon, your employer, your physiotherapist and the seasonal considerations in our neck of the woods anyway. 

Alan Cheung  

I’m very, very jealous. Are you living on a ski resort?

Bevan Colless  

 It's got its pros and cons. It's not the best at the moment, we've had rain all day today, actually, but not much snow yet. And the lack of international tourism doesn't seem to be about to end anytime soon. But we'll get through. What can you see changing in the future of ACL management? What do you think will be trends that will continue to grow? Can you see the way that we're managing ACLs changing at all?

Alan Cheung  

It’s a good question.  The simultaneous reconstruction of the anterolateral ligaments is going to become more popular and more important as data comes in, over the next 10-15 years. And the anterolateral ligament is is also actually a fairly new ligament, which is described by one of my by a friend of mine called Alex DoddS at Imperial College.

Bevan Colless  

That went viral when he revealed that.

Alan Cheung  

And that was only about 10 years ago. So, remember, there's only been this existences ligaments has only been thought of in the last 10 years. And so, people thought that, okay, this isn't damaged from ACL being torn. And it's also an additional restraint of retry and reconstructive, which is a fairly simple process of volunteering can involve just taking a strip of your ITB and iliotibial band are turning into a little bit of a rope and fixing as well, it usually tends to provide a bit of additional stability and reduces the failure rate. So as the data comes in over the next 10 years, people will definitely see it as standard for their ACL reconstructions is just additional checking. And that would be part of the landscape of,  when you do the ACL, and you're automatically fixing the anterolateral ligament as well.

Bevan Colless  

Using a graft for that, or is it a repair?

Alan Cheung  

There's all sorts of techniques, the one I use is just using a strip, the middle third of the iliotibial band. So I call the Lamere technique developed by a French surgeon. So you just take the strip of the ITB about nine centimeters, you turn it into a little bit of a rope, you pass it onto the ligaments, and you fix it to the foot to the thigh bone with a new leg extension. So just for adds some additional restraints against rotational movements. So  that that is definitely going to become the standard for ACL reconstruction.  The quads tendons can become more popular. And there's all sorts of these things come in waves. So probably in different techniques and different materials and approaches. People are always experimenting with different  things, probably by absorbable implants becoming more popular things that just absorbed by the body.  But ACL reconstruction has been around for a while now. So we have a fairly  standardized approach. Maybe there won't be a huge  revolution in techniques, it's hard to reinvent the wheel, something that's been around for 30-40 years.

Bevan Colless  

The ACL is the most studied and published ligament in the body so that’d probably true. I know you've been very kind with your time, Alan. So  I wanted to talk about knee replacements. There seems to be a bit of a breakthrough in technology in knee replacements up until relatively recently, it was thought you'd get 10 to 15 years out of a knee replacement. But have we gone through that stage now? What can people expect? How long can they expect to get out of it knee replacement?

Alan Cheung  

Well,  if you if on average if your knees worn out just through old age with osteoarthritis, and you have your knee replaced age 60. The vast majority of people can expect that knee to last the rest of their lives. But the younger that you have your knee replacement, the likelihood that you will need a revision or second surgery down the line increase. Because in the last 15-20 years around the world, we have these things called Joint Registries, where it's a requirement for surgeons to basically say, ‘Okay, I've done this operation, and you can see how it develops over time’, so we can see whether it has worked well, because of the implant used, or the technique used, or the age of the patient at the time of surgery so we have a lot more data now about outcomes. So, in general, most implants that we use around the world are fairly reliable, but they're not, 100% infallible, so you have maybe a revision rate of about 10- or 20 years, so that maybe one in 10 people have a new replacement, after 20 years may have another surgery. And that might be as simple as replacing the kneecap, which is pretty straightforward. And it really shouldn't really be classified as a revision or failure. But it is. And this is why I replaced the cap all the time, every new patient, I do total new placement, I always replace the kneecap. But there can be factors such as infection or loosening of the implants or even fracture are wearing away of the implants, the liner, the plastic line in between the metal parts. So, all sorts of reasons. But if you have a 90% chance of lasting perhaps the rest of your life, on average, it's not too bad. And it has a pretty high satisfaction rates as an operation. So it's pretty popular.

Bevan Colless  

.Most people who have knee replacements you speak to afterwards and they say ‘my biggest regret was not getting it done sooner’.

Alan Cheung  

With all things, it's not 100%, the satisfaction rate is probably up there, you're 90, 90 plus percent. But even the best operations like hip replacement, there's always going to be something new. Hip and knee replacements and cataract surgeries are thought of as the three most successful surgeries in the world today. So it's quite a big, quite a important operation worldwide. .

Bevan Colless  

All right. So with the knee replacements, what, what age are most people getting their knee replaced these days?

Alan Cheung  

Well everybody is different. But luckily, that there's not so many people floating around with terrible rheumatoid arthritis, since they're a child needing in your 20s or 30s. because aside from the development of all the drugs, amazing drugs to combat it, so maybe post traumatic, but what has also been a lot more popular in recent years is not replacement to the joint, but realignment of the joint if possible. So that procedure where you cut the bones are called an osteotomy. And you shift the axis of the bone so that the weight of the body moves from the damaged area, to the less to the normal area. And that doesn't always last forever, but can give you another 10-15 years before you actually need a joint replacement. If you meet certain criteria, for example,

Bevan Colless  

Like you have a very specific point of cartilage damage.

Alan Cheung  

Yes exactly. So if it’s very isolated piecesof joint damage, you want to shift the body weight away from an area, that can be a pretty successful operation, although recovery is quite long, compared to a joint replacement, because you've got to wait for the bone to heal.

Bevan Colless  

Okay, great. Well, there we have it.  we could probably talk about knees all day, Alan, but we probably should wind it up there. You've been very good with your time and I'm sure you've given some great information on knees and knee injury and the injury management to our listeners that I hope they find useful. And,  it's great to have you in Singapore, you've doing some terrific work for the community. And we’re lucky to have you as in town,

Alan Cheung  

Thank you very much is it is a privilege to be on the show and thank you very much to the invites and to all those people listening to the podcast out there and , don't, ignore your pain. Don't try and play through your pain. Again, see, an excellent physiotherapist like Bevan or come to your friendly orthopedic doctor if you have a problem. 

Bevan Colless  

And how do our listeners find you?

Alan Cheung  

I'm pretty much on the internet, a Google search for me and you’ll find me. I'm basically within a hospital in Singapore. Pretty accessible, pretty easy to find. So just drop me a line.

Bevan Colless  

Thanks for listening to today's episode of the knee gurus. send in any questions or suggestions to the knee gurus@gmail.com. You can tweet us your thoughts at the knee gurus. Follow us on the usual social media platforms. And check out our collection of videos on YouTube. I'm Bevan Colless, founder of Asia physio. See you next time.