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00:00Carol, a fixture at my high school and college was torn ACLs. Volleyball, lacrosse, soccer,
00:04field hockey, a torn ACL, surgery to reconstruct it, then weeks on crutches, months of recovery,
00:10and oftentimes it was girls, not boys, who tore their ACL. Which I find interesting. I guess I
00:15would have thought it was the other way around. Girls and women tear their ACLs at a higher rate
00:19than men and boys. This is Dr. Martha Murray's world. She's orthopedic surgeon-in-chief for
00:24Boston Children's Hospital. She joins us here in Boston, where we are at Boston Children's
00:28Hospital. Dr. Murray, welcome. How are you? I'm good. Thank you so much for having me.
00:31Nice to have you. So you've got this background in material science and engineering. It's not
00:36typical for a surgeon. We're going to talk about your innovation in ACL surgery in just a minute,
00:40but on the boys versus girls, men versus women, why do ACL tears affect women more than men?
00:47Well, it's a really interesting question, and it's been one of much debate for the last few decades,
00:51and there have been things like, well, it must be a hormone cycle, or it's the shape of women's hips
00:56and their valgus angles to their knees, but a really interesting study came out very recently
01:01from the Harvard School of Public Health, as well as Harvard University with Dr. Danielson and Dr.
01:05Richardson, where they actually showed that the studies that say that women tear their ACL more
01:09frequently than men were often based when the women's teams were smaller than the men's teams,
01:15and the way they calculated exposures was the number of practices or games you played in,
01:19not necessarily your playing time. So if you're a man who's on a hockey team versus a woman who's on a
01:25hockey team, the women's teams were smaller, so those women were playing more, so they were planting,
01:30and hockey is a bad example. Soccer would be better, but if the team is smaller, the women are going to
01:35be planting and pivoting and playing much more time per game or practice. So more stress, more use.
01:41More stress, more use, more tears.
01:42So maybe women and all things equal, maybe women and men don't have a different rate of torn ACL.
01:48Correct. When they corrected for unit of exposure, so kind of game time playing rather than just a game,
01:54the injury rates look very similar.
01:56Wow. That's totally different than what?
01:59Yeah.
02:00I mean, is this the standard now? I mean, do you think this is it?
02:04It's relatively new work that's coming out, but it resonates with most of us who take care of women
02:09and men on their athletic teams.
02:11Yeah.
02:11I want to ask about your background, material science and engineering.
02:14I know Tim said it's not typical for a surgeon, but I think it's a really smart combination.
02:20Well, I have a doctor, a foot doctor, same thing, engineering, and he doesn't just deal with my foot.
02:26He thinks about, okay, what are you doing? What else is going on in your body?
02:29Tell me about that mix and why it's kind of unique and smart and ties things together.
02:34Well, for me, it was actually of necessity, right?
02:37So I was an engineering graduate student, and a friend of mine came into a party one night on crutches,
02:43as Tim was saying, and had torn his ACL.
02:45And I said, oh, are they going to go sew it back together?
02:47And he was a med student.
02:48He was like, you stupid engineer.
02:49We can't sew it back together.
02:51You have to take it out and replace it with a graft of tenet that they're going to take from the back of my leg,
02:55and then it's all this rehab.
02:56And I thought, that seems kind of excessive, right?
02:59Like, that's a lot to have to go through.
03:01And so I spent the next six months or so in the medical school library just reading everything I could
03:05about why didn't the ACL heal.
03:06And I realized nobody really had figured out why it didn't heal.
03:09They tried it sewing back together.
03:11It didn't work.
03:11So then went to grafts.
03:12And we've been doing grafts for 50 years, and nobody really asked why doesn't it heal.
03:17And so for me then, there was no biomedical engineering at that time.
03:20And so my choices were to continue on with my project,
03:22which was developing airplane wings that were invisible to radar.
03:27And I thought, well, that's a really cool project, but I really want to figure out this ACL thing.
03:31And my advisor was like, well, I guess you could go to medical school.
03:33So this is a Netflix series in the making.
03:37Okay.
03:37Well, the advisor obviously had an impact, and your friend obviously had an impact.
03:40But fast forward, you know, 30 years plus, and you have actually invented a new way to treat ACL tears,
03:47the bear method.
03:48You did figure out that there's a reason why ACLs don't heal like an MCL would actually heal.
03:54Why is that?
03:56Well, it's really interesting.
03:57So both the medial collateral ligament and the anterior cruciate ligament are ligaments.
04:00When you look at them under the microscope, they look very similar.
04:03But interestingly, when the MCL tears, you can go in a brace, and at about six weeks,
04:07that ligament will heal fine in your back playing soccer.
04:10In contrast, the ACL, when it tears, even if we try to sew it back together, it doesn't heal.
04:15And so we wondered why.
04:17And so we did a series of studies where we looked, and we compared the two tissues and their response to injury.
04:21And what we found was that actually the response to injury is very similar in the two ligaments.
04:25So the tissue and the cells in the tissue were doing exactly what they were supposed to do in both tissues.
04:29But the difference was in the MCL, when it tears, the ends bleed,
04:33and that blood clots and forms what we call a hematoma between the two torn ends of the ligament.
04:38And then in contrast, in the ACL, because it lives in this fluid environment of the joint,
04:42the ends bleed, but instead of making a clot or hematoma between the torn ends of the ligament,
04:47the blood disperses through the fluid of the joint.
04:50And so the two ends never have that scaffolding, that biologic scaffolding, to hold them back together.
04:54So once we discovered that, then it was a fairly logical step to say,
04:58is there some way we could immobilize the blood in between those two torn ligament ends
05:02and get that biologic signal where it needs to be to encourage healing of the ACL?
05:06And that's really what bridge-enhanced ACL repair, or BEAR, is.
05:10So the magic is kind of the sponge that we've developed that can absorb the patient's blood.
05:15You can place that blood-laden sponge in between the torn ends of the ACL,
05:19sew the ACL back together.
05:20But now you have the biology plus the sutures and the repair, and the ligament will heal.
05:25So what is done in terms of numbers or percentage with the method that you pioneered,
05:31what you invented, versus actual reconstruction and using other ligaments?
05:37That's a great question.
05:38So this is still fairly new.
05:39So we got FDA approval for this product in 2020, and so it's only been in practice for a few years now.
05:46There are studies coming out of Children's here, which is where we did the first studies, of course.
05:50But now other centers are coming along and doing follow-on studies, and those results are starting to come out.
05:54And it's very exciting to watch it grow.
05:57I'm also curious.
05:58You mentioned, like, FDA approval.
05:59Like, the approval process, is it a smart one?
06:03Is it the right one in terms of making sure that what's being done and studied, the R&D,
06:08that it's safe for when it's finally done on patients?
06:10Or is it preventing things from maybe put into use sooner?
06:16Like, I'm just curious where you guys weigh in.
06:18You're in it.
06:18You're in it every day.
06:20Yeah, I think it's a delicate balance.
06:22But I would say in our personal experience, the FDA was an amazing partner.
06:25Okay.
06:26So we were able to get into an early adoption program where they actually met with us
06:30and helped us and put together a panel of experts that would help us figure out how to make this
06:34the safest possible product and the most effective product before we went to patients.
06:38And we found their advice incredibly valuable.
06:40There was a lot of conversation and back and forth.
06:42And just having them, it felt like it was a team effort because we were in alignment.
06:47I mean, as a physician, I was going to be shaking the hands of these patients and my partners were.
06:51And we wanted to make sure things were as safe as possible.
06:53So they helped us with that.
06:54Do we have data yet on long-term impact or long-term outcomes yet when it comes to the
07:01Bayer procedure?
07:02Yeah.
07:02Our longest data that we have is at about six years.
07:05And it's only in the small number of patients in those first studies that we did.
07:08But the reason that we want to study it longer term is because, as you may know, many of these
07:13patients will develop arthritis early in life.
07:15And as a pediatric orthopedic surgeon, I want to make sure we have a procedure that's going
07:19to last my patients for 60 or 70 years, not have the knee break down in 10 or 20 years.
07:25And so we're very interested in this arthritis question with Bayer.
07:28And in our preclinical studies, we were able to see that arthritis was actually much less
07:33in the subjects that we treated with an ACL repair with the sponge versus a reconstruction.
07:39So we're interested in seeing if that same thing plays out in patients.
07:42And the early data suggests that it is true.
07:45But again, that's very early data on small numbers of patients.
07:48So we're excited to see how that pans out.
07:49We're talking with Dr. Martha Murray.
07:51She's orthopedic surgeon-in-chief for Boston Children's Hospital.
07:55That's where we are, Tim and me, on this Friday.
07:58Preventive care.
07:59So much of what we talk about often when we're doing interviews is preventive care.
08:04And I feel like the whole health community has been thinking about this for a long time.
08:08So what's the preventive care so that as much as we don't want you unemployed, how do we
08:12think about taking better care if we're living longer?
08:15How do we think about this?
08:17So there's a couple questions on that.
08:18So one is, how do we help our teenagers reduce their risk of injury?
08:22And I think the main thing for that for our athletes when they're in it...
08:25Because we push kids when they're younger.
08:26I think a lot of parents really push kids.
08:29So some things we can do to help them is help them work on strengthening in addition
08:32to just play time.
08:34And another thing is cross-training.
08:35So not playing the same sport all year round or playing the same sport every day.
08:39Giving their body a chance to rest and heal between exposures to sport.
08:42It's as simple as that.
08:43I think so.
08:44Wow.
08:44Does ACL tear happen more in kids than adults?
08:48And if yes, is it because kids are the ones who are playing sports and we're just sitting
08:52at computers?
08:53I think that's probably part of it.
08:54Again, it gets to this exposure question.
08:56How many times do you plant and change direction?
08:58And so the peak of ACL Andrews is really the high school athlete because everybody's
09:03playing a sport.
09:04And so we see a lot of them there.
09:06I want to ask you about social media and all of us sitting on phones or sitting in front
09:09of screens.
09:10I keep thinking that we're going to one day, I don't know whether it's 50 years from now,
09:14we're going to have a neck that basically goes over there.
09:16Or maybe not because we're going to have glasses on.
09:18How do you think about this digital world?
09:21You're laughing.
09:21Can you surgically remove my phone from my hand?
09:24That's what Carol wants to know.
09:25But I do think about what it's doing to us.
09:28Well, look at it.
09:29Not just on mine.
09:30I've got the ACL fixed for you.
09:31I don't know if I can fix this social media problem.
09:33But physically, I'm just thinking how kids are in their phones constantly and stuff and
09:38the shape.
09:39Do we need to be thinking about what this is doing to our spine and different things?
09:44I think so.
09:45But I also think things come in cycles, right?
09:47And we see now, if you walk down the street, you see everybody's on their phone.
09:50I think five years from now, we're going to look back at that and say, why are we doing
09:54that?
09:54Maybe we'll start looking up at the sky more.
09:56I hope so.
09:57Yeah.
09:57That's what I hope, too.
10:00Yeah.
10:00I mean, gosh, that's like you're opening up.
10:02You know, I know.
10:03I look around on the subway and just everybody, and I'm just thinking the curvature and I
10:07don't know, whatever.
10:08What's the next thing you're working on or that you're excited about?
10:10I'm really excited about a product that we're working on for rotator cuff injuries.
10:14And it's a product that's injectable so that potentially-
10:17That's great.
10:18Yeah.
10:18You can have ultrasound of your shoulder, see where the tear is, and then inject the
10:21product into the tear, maybe in an office visit.
10:23So that's what we're working on.
10:24But very early days on that.
10:26Again, a challenge with pediatric patients as well?
10:28No, this is more adults, but we thought if we could make this work for a ligament, maybe
10:32we could try it for the rotator cuff tendon.
10:34And the nice thing about the rotator cuff is it is accessible by ultrasound and injection,
10:38and it's a pretty easy model for us to study.
10:40If we can make that injectable work there, then there's lots of other places we could
10:44apply it, meniscus, other things.
10:46Did you ever figure out the invisible airplane wings?
10:48No.
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