ACL repair - which graft?

Triathlon Forum
1

It’s been ages since I last posted, so it’s a little awkward to post again. But there’s nothing like an injury to get me to open up in a hurry.

Just a little update: I moved from Florida to Westlake Village CA in January to take up a new job. What a difference! The GF and I feel like we have been on a 6 month vacation. She can’t stop saying “it’s amazing!” (she said it 69 times on Highway 1 from Big Sur to SLO), and I get to run 2.5 mi to work… on trails and through a golf course! We do pay through the nose for it, of course, but it’s well worth it as long as the job holds up. Spot is still alive at 17 years old. Her two back legs are really weak now, and she’s a lot more high maintenance, but she’s still hanging in there. We still take her on hilly walks, and she looks like she’s having fun.

Now to the knee injury: I have a completely torn ACL and a bucket handle tear of the medial meniscus. I can’t extend my knee, so I’m on crutches now. The ACL was torn back in April in a jump from a window ledge. And the meniscus was damaged playing ultimate frisbee, tennis, and the Kinect (of all things!!) in the interveaning three months. I wish I had taken care of the ACL in April - it would have been much simpler. Oh well, live and learn…

My dilema is this. I can see a surgeon close by in Thousand Oaks, or I can choose a more prestigious surgeon (does a lot of athletes, including high profile ones) in Santa Barbara an hour away. There’s nothing wrong with either surgeon that I can see - no red flags. It’s a tradeoff between convenience and reputation.

Second, the research I’ve done (on ST mostly :wink: says to go with the hamstring graft in favor of the patellar tendon graft. The cadaver graft is not even in the running due to possible complications… until I talked with the “prestigious” surgeon who says the allograft is a better choice for me due to my advanced age (I’m 42, haha). This is throwing me for a loop. Anybody here know where this doctor is coming from?

He’s leaving the graft option up to me but counsels me to go with the allograft. A complicating factor is I can get the surgery done within a week if I go with the hamstring graft, but may have to wait ~4 weeks for the correct match for the allograft. Do I wait?

As far as the surgeon closer by in TO, I met with him last week and liked him just fine. He’s an excellent communicator, and he seems like a nice guy. Problem is, it’s harder to look up his record since he’s less well known. And I wasn’t educated enough to ask him good questions the first time around. I am meeting with him again on Wednesday to discuss the details and get a better read on him.

Meantime, anybody care to share with me how to choose a surgeon? How do I gauge the quality of the surgeon? How important is it that I choose a top-notch surgeon versus justa a solid surgeon? If the top-notch one makes me wait a long time, is it worth it?

2

I did patella tendon graft on both my knees (different times thankfully). One in 1993 and one in 1999. Both still intact with no issues and I have done multiple sports since (to include tri’s). Now of course I did just tear my meniscus but that’s totally unrelated.

As far as choosing a doc …I don’t think you need the premier doc- just ask all of the right questions (how many he’s done, success rate, etc., etc…) Good luck ----what a pain in the arse to have to go through.

3

I second the patella. Patella grafts held up beautifully for about 10 yrs now.

4

I did hamstring and had problems off the bat with my hamstring healing and then again with my meniscus.

5

I did patella as well. The longest part of rehab seemed to be the patella itself for me, but it has been great once it healed up.

6

I know some physical therapists. Don’t want to sound rude but with your age, go with the cadaver graft. You will have less post-op pain and be able to jump back into training faster.

7

As an orthopaedic surgeon whose specialty is ACL reconstruction, both HS and PT are good grafts but work better in certain circumstances and with different types of athletes. I do both, doing 60 % HS and 40 % PT. I wouldn’t do an allograft as failure rates are higher and infectious complications more common.
If you want to PM me the surgeons names, I’ll let you know if I know either of them.

8

I would definitely go the allograft route. Find a great surgeon. Everyone, including myself, have had more success with allograft than autograft. I did my hamstring the first time. I really really really advise you to NOT do hamstring graft.

9

My wife ruptured her ACL skiing last winter. Went to see a prestigious doc who works on professional athletes. He recommended the hamstring graft based primarily on the fact that at age 37, my wife had a high probability of getting a tendon from a donor who was much older than her. He said he would do either - and left the decision up to her - but the “if it were me” recommendation from him drove the decision.

9 weeks post-surgery she was cleared to run. 2 weeks after that she almost PRd a half marathon. 6 months out she’s very much back to her pre-surgery self.

YMMV.

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I know that despite your advanced age (haha!!), you will do an amazing job of healing and you will be back out there in due time!!! I am so proud of how well you are handling this setback.

Love you,

wormibu

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As an orthopaedic surgeon whose specialty is ACL reconstruction, both HS and PT are good grafts but work better in certain circumstances and with different types of athletes. I do both, doing 60 % HS and 40 % PT. I wouldn’t do an allograft as failure rates are higher and infectious complications more common.
If you want to PM me the surgeons names, I’ll let you know if I know either of them.

Clearly your answer lies herein ( and for god’s sake, don’t even look at quaketri’s response).

My 14 yr old son tore his ACL in April and i got similar advice from two prominent docotrs in NY. Given his age (and as indicated above in bold) we chose the hamstring. He’s still in rehab but recovery is going well. I’d pm the good doc above.
Good luck and please stop jumpimg out of windows :wink:

12

Had ACL and meniscus reconstruction surgery in 1998 after waterskiing accident, and have had no problems with the my knee. I went to see two different Ortho - knee specialists, and came away convinced that Kerlan Jobe in LA was where I wanted to have my knee done using a PT graft. They had there own medical / surgical facility (no hospitals = +), rehab on site, and Dr. ElAttrache is a stud with more accolades than one can imagine (i.e. LA Dodgers head physician, consultant to many other sports teams, involved in tons of research, etc.)

The Dr. struck me as a very passionate and confident. He stressed to me in a pre-op consultation that the key to a full recovery was going to be an aggressive and consistent rehab program. He even went so far as to call the PT and arrange to have me work with another PT when he felt that my progress was falling behind his expectations.

After 10+ years, I am still able to put together the speed work necessary to run a fast 5k.

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I’m a PT owning a clinic in a ski resort and see over 100 ACLs a season and have had my own ACL reconstruction (used hamstring and had a great result). I would advise strongly to go for the hamstring tendon. The patella tendon often gives ongoing knee pain and you miss the substance in the patella tendon more than you do in the hamstring. Call me a cynic but most ‘prestigious’ surgeons favor the cadaver graft as harvesting the graft is the most time-consuming part of the operation (slippery little suckers…) and using a cadaver graft that is on a dish ready to go means they can do say 4-5 more ops in a day. Assuming they have a waiting list of pts (as most surgeons who luck into looking after a high profile team do)…and that they operate two days a week, and say $15,000 as their own fee per operation 2x5x15,000x45 weeks a year = recommending cadaver grafts and scaring people about complications with hamstring grafts. As long as you take it very easy on the h/s in the initial period of your rehab and don’t tear it, all you need is 6-8 sessions of smashing your h/s in the gym say 4-6 months post op and the hamstring will be back to normal. Best of luck. (Go with your local guy I’d say)… oh and I’d ditch those crutches too…probably making your leg weaker every day at the moment no doubt and try to get that extension back as much as the menisuc will allow pre-op. Start seeing a PT now for prehab - a weak knee going in is a weak knee coming out. Best of luck.

14

Thanks everyone for your contributions. Reminds me of the clincher vs tubular detate, except now there are three choices :-).

I certainly get your point, avagoyamug, and I have been PM’ing Deak. I also had a nice phone conversation with E-man, who’s a physician assistant working on ACL reconstruction. That’s why I love this forum - the archive is great, and I can to talk to people as well.

It’s amazing that everyone I talk to says to get the best surgeon I can - that’s advice hard to ignore. So I am going with the doc in Santa Barbara and hope that he brings his skills to bear, especially on the meniscus repair, which requires good judgement and experience. The surgery is in 8 days, then I’m back in familiar territory as I can control my fate from then on.

As far as the ACL, doc is ordering an allograft now. But I will have one more conversation with him on hamstring vs allograft. I’m not in love with the allograft idea as I can’t choose the quality of the cadaver (I want a 23 year old healthy dead male with a great tendon!), but I can make peace with it. I’m hoping that the team is good enough and that I’m lucky enough to escape the complications. As for the possiblity of re-tear, I’ll just be careful with the agility sports. I’m mostly a runner and yogi anyway, so I don’t necessarily need the strongest ACL to get my kicks.

15

My ACL graft was a hamstring graft. The Dr that did it said that this is the one he had done on his ACl and wouldnt even consider the other one. 12yrs later and no issues (knocking on wood as I type)

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I am not an expert but have had a patellar reconstruction with great success. Surgery was at age 27 and still running strong at 32. My 2 cents is the graft is one thing but the end results are primarily dependent on the rehab work. The PT before and after surgery is what is going to make or break your long term recovery. Stick to single plane sports and avoid indoor soccer and you’ll be good to go.

17

I had my ACL done in '08 by a good surgeon at The Hospital for Special Surgery in NYC.
She does guys in the NFL.

I did some research and thought the cadaver graft would be the best choice.
She totally disagreed and said the hamstring would be best b/c its a stronger graft. I have a very physical job.
The patellar tendon graft is strong as well but she said everytime you bend down to crawl you may feel it in your knee.

I’m a fireman and we do a lot of crawling.

This lady did almost every guy I know on my job and that is what she told me. She used my hamstring and my knee is doing well.
The recovery is a little longer for the hamstring but she felt it was worth it.

I was never in a lot pain. Its just a long recovery.

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Here goes. I am a football (soccer) playing skier that does triathlons. I play ‘soccer’ ~4 days a week competitively (both small-sided and 11-a-side) and ski to a very high level (no fall stuff) during the winter. I started tris about 2 years a go as a group of us footballers decided to do NYC, and been doing it since. OK, so I basically came up short on a cliff jump (~40ft drop to 6 inches of ‘powder’ on ~20 deg slope, another metre further and it was waist deep, 45 degrees)…stupid thing to do considering it was a white out but there was a reason (still not a good one)…I didn’t fall though!!!. Anyway, I ended up with a compression/deep bone bruise of the tibia and a ruptured ACL…waited 6 weeks for the bone to heal then got my ACL surgery (March 15th). I went with the Achilles allograft. Reasoning: ACL injury is really common in football and I know a lot that have had repairs. The ‘newer’ dudes doing them are going for the allografts (especially Achilles as it is a beast of a tendon) and they have had no problems coming back at 6 months into full contact FIFA rules football. Same is also the case for the hamstring and patella autografts. However, the hamstring and patella guys have either had problems with the site of graft donation and/or had serious pain post-op and slower recovery times (makes sense when 2 things have to be repaired). My doc preferred a bone-pat-bone but was cool with my choice and did nothing to change my mind (he is a very good surgeon…ISK institute in NYC, very prestigious from what I can tell. US Dream team, Knicks, all that stuff, plus voted top surgeons in US weekly, ‘superdoctors’ and all that stuff (they take the pages out and frame them). Multiple friends went to Hospital for Special Surgery in NYC (#1 in the world for number of ACL repairs performed or something), but my insurance wasn’t as good there…cost me $40 for my surgery!!). Either way, make sure you choose a doc that specialises in ACL repair and doesn’t just do it along with everything else under the sun…a guy that does hundreds a year is gonna be better than one that does 10.

Anyway, at 2.5 month I did my first duathlon thing (Fly By Night…run-bike-run-bike-run) and placed in AG. Did my first tri 2 weeks later (LI Gold Coast) and will be doing NYC tri (@4.5 months post-op), Nations Tri and Mighty Montauk and I am in excellent shape now (leg still looks a little skinny, but I am faster on my bike, run and swim than before). I was running by 8 weeks or so and swimming & cycling by 3 weeks after surgery. I required the use of no painkillers and just iced a lot for the first few days. Use one of those CPM machines as well to speed recovery. Also, make sure that you start PT ASAP, I started the very next day after surgery and went 3 times a week for the first 8 weeks or so (25 total). I am 33, so by no means a young dude.

Here is a link to a really good forum on MensHealth that helped me loads as well on what to expect and getting opinions from people I didn’t know about grafts, etc. You can also see a very precise recovery timeline posted by me (same username as here)…pain level, exercises, swelling intensity, etc, etc. Plus another poster going by ‘JWR’ has a lot of good advice (which by no means agrees with me and had different experiences).

http://forums.menshealth.com/...0347/m/921102171/p/5

I go for my 6 month evaluation in September after having a KT1000/2000 test done and, fingers crossed, will get the go ahead to resume football, skiing, etc. (I did play a little bit the last 2 weekends but nothing competitive…feels normal though (but a lot of that can be muscle compensation)).

19

I did the hamstring route - I would have perfered the cadaver route but it was a one year wait ‘for the parts’.

I could hardly tell they did anything to my hamstring aside from some mild tenderness and very small incisions. For a week. It recovered good as new.

You have plenty of hamstring to go around so if they borrow some for somewhere else, it shouldn’t make a difference. I was hard pressed to find many people that had complications due to the hamstring.

Who cares who the surgeon is - make sure you get this fixed ASAP. Whichever one can see you first. As long as you have a few good references and he’s not straight outta school then so be it. Oh and make sure HE is the one doing the surgery and not some student with him looking over their shoulder. Just a thought.

I left mine like you did for too long. I couldn’t do any exercise and PT was a joke. My muscles atrophied and made recovery time billions of times longer than it should have been. Keep working out that leg BEFORE surgery (dont hurt it any more though!) and it will expedite your recovery afterwards. Thats my experience.

20

I have an allograft and I didn’t have to wait for a match. I’ve never heard of that before. There’s no blood supply to the ACL.

The allograft was a great option for me. Recovery time was real fast and I don’t have any other issues related to harvesting from the other 2 grafts.