ACL...Poll

Well since Sean had his ACL replaced and i'm next up to bat. I have been debating on wether to go with Hamstring, Patella or Cadaver reconstruction. My Dr. and i are leaning towards cadaver since it will be a real ACL and i just want opinions on what everyone else has done.

I thought and was told that patella graft was the best as it has its own blood supply anyway. I heard that the cadaver has a faster recovery time, but had more failure rates...ask your doctor to provide percentages as to failure rates covering all the different procedures.

Which doc did you end up with Randy?

I think I already put this in the other thread, but I went with my own hamstring, for the following reasons:

1. I have a history of patella problems with my other knee ---> patella not an option
2. I have a good hamstring tendon available.
3. No risk of tissue rejection.
4. Since I'm in my 20's, my tendon would likely be "younger" than a cadaver tendon.

Other than a little bit of tightness the first couple weeks, I really didn't notice any pain specific to the hamstring. If I had to do it again (knock on wood I will never have to do it again), I would still choose the hamstring.

FYI, I think with the cadaver they use the achilles tendon, not the ACL (but I could be mistaken).

Went with the cadaver achillies tendon graph last October. I'm in my early 30's and wanted a less invasive surgery with a relatively quick recovery.
My OS at Stanford recommended thermal shrinking first, but after going in on surgery day they noticed that there wasn't much good ACL left. So they cut it out and drilled in a cadaver's achillies tendon. The recovery has been awesome. Was on cruches for 2 weeks doing TTWB.
I wear a CTI2 knee brace wakeboarding. I was back at w2w at 5 months with it.
My OS actually does not do hamstrings anymore, for the reason of strength. The way they radiate and keep the cadaver parts sterile now pretty much guarentees an acceptance.
My knee hasn't turned green, purple, or red, so I imagine the graph took.
At my 6 month post op appt, my OS was happy with my progress. Gave me the leg stretch test, passed.
Gave me the go ahead to lead my normal lifestyle again.
So my personal recommendation would be to do the cadaver graph. 5 month recovery, basically .0001% chance of tissue rejection, less invasive surgery, only 3 small pencil eraser holes and 1 2" below the knee VS long recovery for the patellar graph, your kneecap will take a long time to fuse back together leading you to a good chance of cracking it again, long scar in front of the knee.
Just my 2 cents.....

I had a patella autograft done in oct '99. My knee is very stable. After surgery, I did have a hard time getting my leg to completely straighten, even after months of rehab. I ended up getting it scoped in oct of 2000, to open up the "notch" and to clear out some more scar tissue and debris.

It is important to consider what your surgeon has the most experience with. If you already have a PT, ask them for their opinions too. They often see the real story. For example, because of my PT, I actually used a different surgeon for the post acl surgery; he was much better. My first surgeon is actually more well known, he is/was team surgeon for lots of pro sports teams; the other surgeon was younger, but according to the PT has a much better track record with his patients. I am very glad I switched.

If faster recovery is important, go with cadaver.
Otherwise go with patella autograft, it has the most success. If you have issues with patellar tendonitis, talk to the surgeon. I think I heard that removing part of the patella actually helps tendonitis, but I may be wrong there.

actually, check out

http://www.knee1.com/care/procedure20.cfm/1 and more the snip below from http://www.knee1.com/hero/hero.cfm/17/1

....
Although the patellar bone tendon autograft has often been referred to as the "gold standard" for ACL reconstruction, there are no studies showing it to be superior to four-stranded hamstring tendon grafts, the central quadriceps tendon, or allografts. One must not forget the importance of the surgeon's experience, skill and ability to safely harvest and use different types of graft tissue.

I just had a hanstring graft done 4 weeks ago. Originally, I was suppose to have the patella procedure but when my doctor went in, he found that my patella was too short and opted for the hamstring.
Recovery is coming along but not speedy. It's important not to rush the recovery time so the graft has ample time to set correctly. My roommate has assisted in over 800 ACL surgeries and he said that if you get the patella or hamstring graft, be careful from week 6-10 because that's when the graft is at it's weakest because the tendon cells are dying and regrowing as ligament cells.
Also, the patella procedure is suppose to be the stronger of the 3 options but supposedly, the recovery time is longer because you now have to let the area in which the patella was removed to heal. Plus, I heard there is more pain but I feel that's probably individual and on what pain meds your on.

I've heard that the cadaver method has a higher failure rate and I didn't feel comfortable with it because of possibility of rejection and infection.

Ask your doctor lots of questions, no matter how trivial they may seem. It's important you pick a doctor to with a strong record. Maybe inquire with former patients to see if they were satisfied. Also, consider the right physical therapist as well.

Good luck!

I just had mine done yesterday and I've been told by three different Orthopedic surgeons that being this young a cadaver should be your LAST choice as there is a higher risk of infection, disease and tends to be more problem matic in the future. I had my hamstring done and I was told thats the best possible route because you don't really use your hamstring all that much plus if you go with your patella you again have increased risk of future damage because if I remember correctly the patella becomes slightly weaker and if you do happen to blow your knee out again the patella will give out and you'll have more complications. My recomendation is to go with your Hamstring, its from your own body, they are live cells and studies have proven it has the highest success rate not to mention after the surgery your ACL will be stronger than before your injury. The only thing you use your hamstring for is to cross your legs and when you play hacky sack, you will still be able to do those things thats just and example of how little you use your hamstring. Whatever you do, do NOT use a cadaver! (IMO) I can't emphasize that enough, also as Ryan said make sure your doc has a lot of experience and knows what he's doing. Go to another specialist and see what they say. Your knee is a crutial part of your body and you don't want to mess this up. Good luck and remember, research, research, research and I STRONGLY recommend you getting a second opinion. Good luck. But remember again as others have said it is your body and ultimately the decision is yours and you want to be comfortable and confident in your decision as well as in your doctor. Good luck. Oh, minor side note, regarless of which you path you choose, after the surgery keep up with your pain killers, TRUST ME.

(Message edited by xtremebordgurl on May 26, 2004)

Interesting. I wonder why the Ortho's at Stanford Medical Center no longer recommend Hamstring Grafts as an option.

I guess to each his own.

Jason, I think age has a pretty big factor also in what choice to make, cause my doc said that if I were older (30+) he would have recommended the cadaver option but with my being so young he said the hamstring was defenitly my best bet. But you're right, different things work for different people so... to each his own.

i had the patella graph in 1996 when i was seventeen. the surgery was at the end of feb and i was playing football in august. i wore a brace through my senior year sports, but haven't worn it since. i don't ever even think about my knee anymore. i'm sure everyone thinks the way that they went was probably best. i am just adding that with the patella i haven't had any complications. the key is probably post-op rehab. do what the PT tells you religiously.

I'm with Jason and recommend the Allograft (cadaver) all the way! My results: I did the allograft 1.5 yrs ago...totally satisfied...1st w2w in 5.5 months, smooth water cruising at 4.

The top Docs out here are all saying that. I mainly consulted those that work with the professional sports teams - i.e. SF Giants, SJ Sharks, US Olympic. And they are all working with young people...as well as old guys like me.

Over the last 5 years the sterilization techniques (with radiation) have all but eliminated disease and rejection. That, and everyone I talked to who had autografts (grafts from their own body) said they were unhappy with the post-op pain levels and recovery (time & effort) I really only needed pain pills for the first couple of days...and was off the crutches on the 4th day.

No matter what though, I wouldn't ask any OS to do a surgery that he/she was not comfortable doing. I should probably say that twice!

Dr. Dillingham did a Cadaver graft for me at Stanford 12/02. No problems whatsoever. Recovery was fast and have full range of motion. It was an achellis tendon graft. Like Greg above, I was wakeskateing at 4 1/2 months and w2w and grabs by 5-6 months.

Do yourself a HUGE favor and do the cadaver graft. I had the hamstring graft done on my right knee, then blew my left knee out 2 years later and had the cadaver graft done. The difference is unbelievable. MUCH faster recovery, less painful rehab, and my left knee feels much more stable than my right.

I have no experience with the patella graft, but I would not recommend the hamstring graft to anyone if the cadaver graft is an option.

You guys have made some awesome points, maybe I was a little too quick to assume that the hamstring was the best route. Randy, ultimately its up to you and just some info for you, I am still in a TON of pain and I had the hamstring done (granted I just had it done 3 days ago)... maybe not the best choice but its done and over with so there's not much left that I can do except PT and all that fun stuff. Just go with whatever you feel most confident with and have confidence that your doc can do it. Good luck,and best wishes. Sidenote: When are you having it done?

Well i guess i'll have to give my two cents as well then. I blew out my ACL, LCL, and tore the MCL last july, got in and had surgery on August 11th, and was snowboarding and a little wakeboarding middle/late december. I personally cannot reccomend any otehr docter than Paul Murphy at Oasis medical right across the freeway from Wakesports Unlimited. He is a goof friend from knowing his children in Highschool and he used to be the head Charger Doc until the Moto X got to busy for him and he gave up the Charger Postion. Also, i am the fourth and last person to have reconstructive knee surgery in my family, my older brother, mom and dad have all had it all of us with a different way, bro used cadaver, mom had hamstring, and dad jsut trimmed it up, and I used the petellar. Out of all of these i had the best post surgery clinics, healing, and was the best takin care of, Dr. Murphy really did a great job. Now as far as which surgery to have, it depends on your age and what you want to do with it. The petellar is a slower healing process but in the end it gives you a stronger knee and will put you back into your sports with more confidence and control. The hamstring and cadaver will heal quiker, and not by much jsut like a month or so, but it will still be a good knee just not as strong as it was before. So after that knowledge it is up to you to decide which surgery. Also, no matter what, do all and above and beyond the rehab, i slaked and came out great and i can only wander how much better my knee would be if i had done it perfectly. If you have any other ? just let me know.

It seems to me that everyone has an opinion on this topic, but can anyone claim that their choice is a better choice than someone elses? No! Geoff, who told you that a cadaver graft will leave your knee less strong than before? Because the ortho's at Stanford will argue against that. It seems to me that Ortho's are going with what they feel most comfortable with and/or what they have more success at. I would think it boils down to preference and what feels right to you. It's good to solicit opinions, gather references, etc... but when it is all said and done, it is a matter of what you are most comfortable with and what your Ortho is most comfortable with. If one reconstruction was far superior than the other then I'm guessing everyone would follow...

Okay, go ahead. Flame me!

No flaming from me Stef, you made an excellent point. Let me just add tho, I don't think Stanford is the be all end all to knee surgery. Thats just one school of thought.. people have contracted aids and many other viruses from cadavers even tho the % is VERY low, it still happens, and not all cadavers will take. That doesn't mean its a bad option. I'm just saying that just cause the ortho's at Stanford say thats the way to go it doesn't make it the best. Thats kinda like if you were gonna buy a board, some people will swear by one company, but thats doesn't make that company/model the best, regardless of how knowledgeable the rider is (like a pro for example) that is making that claim.

Bess, exactly my point.


I am using Stanford as an example because I happen to have direct experience with them. Some argue that one reconstruction surgery is better than the other because this is what your ortho told you... I'm here to point out that there are other credible ortho's out there who will tell you differently.

ahhh I see, read ya loud and clear cheif! (even tho I know I was one of those people... )

Bess- I don't know who told you that you don't use you hamstrings is COMPLETELY OFF BASE.
Especially when it's the hamstrings that helps keep the femur from gliding off the tibia anteriorly when there is an ACL deficiency.

Having been taught by numerous PhD's & MD's the one thing I know for sure that there is a difference in philosophy when it come to East Coast vs West Coast training/education.

Bottom line when it comes down to repairs is what your lifestyle will allow....ie time off from work/school/medical issues.

I'm thinking that since I got a hamstring graft 2 days ago, I've got good mobility in my knee, not a whole lot of pain, it was what the surgeon recommended based on his specialty, it was the only surgeon I could go to with my med plan, blah blah blah, that I went with the best option for me. As long as you are confident with what the doctor is doing Randy, that should be all that matters (and pt!)

First off let me say, no where did i say the petellar was the best option for anyone, i thought i wrote enough about my experience to show that all i was talking about was mine and my family's own experience. In the 4 surgeries i have seen my family go through, my family and i thought mine worked out pretty well, but as everyone is saying on here and as i said too, it is all of personal reference, everyone is jsut trying to help people understand the ends and out of every option they have, there is no right or wrong choice for anyone.

Blah, blah, blah (that's just filler).

Patellar 6 weeks ago, doing pretty good. It was my physician's preference. I'm 36 years old.

The End

i've got a question. not that you should base your decision on this, and most is probably all covered by insurance, but is there a major price difference in the surgeries? it seems like a cadaver graft would cost more because of the "parts" involved. if so, and i'm not accusing anyone or have any basis for this, could the OS be making more money by recommending a certain procedure over another? let me say again, no basis for the above question, just a thought to discuss.

I think everybody heals completely differently and nobody can say what will be the best type of reconstruction for somebody else. What one person swears by, another might have had a bad experience with.
The absolute MOST IMPORTANT thing to remember about recovery is that the more aggressive you are with rehab, the quicker you will recover (most likely).
I have had surgery on both knees - just arthroscopic on my left knee to remove torn cartilage, and ACL reconstruction on my right knee. I had a patellar tendon graft with my ACL and I healed up a whole lot faster than with the arthroscopic surgery on my left knee - I think it was because I was horrible with PT the first time around. I was way more aggressive with PT for the ACL reconstruction because I didn't want to be out forever. I had my ACL done in September of 2002 and was snowboarding by January 2003.
Bottom line, I'd go with whatever graft YOUR doctor recommends because it's probably the one he does the most. There are so many different opinions on what is best, but I feel like the majority of recovery time depends soley on YOU and your rehab.

Phantom, I never said that you dont use your hamstring, I'm just saying that for most people it isn't a major tendon and most people can live fine without it. And its not completely gone when they use it, they only take a small portion of it. The surgeon said I'd feel a difference and know that they are probably gone but I wont be resticted at all when it comes to ROM, in that sense I wont even notice its gone...

Sean have you been working on getting your ROM back? I go to see the dock in like a week and I wasn't sure if I should be moving it arround yet or not. I'm thinking a lot of my pain is just stiffness, if you have started moving it arround what are you doing when you move it? I got my surgery done on the same day as you the 25th at 8am.}

(Message edited by xtremebordgurl on May 28, 2004)

You have to get good ROM back in the first few weeks. It is the most important thing. If you feel sore, push through it slowly with repetition. My hardest thing, because I didn't have full extension before the surgery is getting full extension. I'm working on that and bettering my flexion, other than that, just waiting. I'm sorry if I sounded perturbed early, but it is hard to have everyone rave about this choice and that choice when your doctor says go with one. I try to stay positive and work on the healing without worrying about where the weaknesses in my particular operation are. I know this is just asking pros and cons for the operations, but Randy, you should really ask your doctor's opinions about the 3 because that is why he is doing one or the other.

Dead parts? EEEEUUUUUUOOOOOWWWWWWW!

Another vote for hamstring - 16+ yrs without a problem!!!! But, I don't know why you are asking for medical advise on a wakeboarding forum....

Good Luck and REHAB HARD!!!!!

I haven't heard the rejection issues with the cadaver option but have two friends that went hamstring. I think they recovered to full quicker than I did (patellar) although I had to deal with some tendonitis during rehab. Anyway, I'm back to 100% and don't use a brace.. not needed. I actually feel more aches/pains in my "good" knee than the fixed one. Even with my rehab issues I was easily on the water in 5 months. I think it was more like 4. Good luck!!

One more data point (from Idaho). Blew out my left acl playing volleyball in 1994 (at age 34). My doc acknowledged that the pattelar tendon was then the "gold standard", as it had been done more times than any other method, and is proven successful. He also pointed out it is the easiest for a doc and perhaps why it is used so often. Nonetheless, he recommended the hamstring as a stronger repair and that worked for me. Surgery in May, snowboarding in December. Today, the limitations I have are from residual cartilege damage, so while I snowboard 30+ days per year and wakeboard all summer, basketball and soccer are basically not in the cards anymore. I'm not sure any different choice of ACL repair would have changed that.

Had the patellar autograft done on 16/04/03...
was on the water riding wakeskate without jumping the wake 3 months later in july... snowboarded with knee brace from december to april without hitting a kicker just to be sure...
my father being a chiropractor, he helped reactivate blood circulation in my knee right after the surgery... it helped speed up the recovery and had regained full mobility after a month...
the OS told me that the patellar was the strongest reconstruction and warned me about allograft having risk of rejection... he also informed me that the hamstring had a key role in supporting the knee when the acl is weak during the firsts month after the surgery... so we agreed to go with patellar tendon autograft...

Wow i step away from the computer for a few days to go out to Canyon Lake and see what happens. I appreciate everyones opininons. First off the only reason i asked this question on a wakeboarding forum is that many people have gone(going) throught the exact same problem as me and i want to have all the opinions(information) as possible. I have my appt. Teusday morning and i want to be able to ask the right questions. The Dr. has given me either the option of suregery or ? I have been in PT for a month for pre surgery at his request. I am really amazed at how good it feels as i have busted my butt and have nearly all ROM back and most of the strength and have not had any problems with it popping out or much discomfort at all. I have read alot of information not just from this board that supports a cadaver ACL and it was also what my Dr. recommended so i am leaning in that direction but still have some questions to ask many of which i got from this discussion so thank you all!