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I had mine done at 49 and have zero regrets. He has also done both of my shoulders with perfection
Never had the rod taken out either but that's a different topic all together.
Best of luck to your friend.
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The patella tendon is the way to go for the best result. Cadavers are not for athletes. It takes a full year for your body to completely accept the graft. Until then it can fail very easily like an old rubber band!
Dr. marks technique is when he harvests the graft he leaves bone on booths ends of it. Then when he makes a new ACL out of it it's bone on bone healing and not a ligament trying to attach to a bone. Basically after the bones heal in 3 weeks you are rock solid and good to go. You just have to wait 3 months for the knee cap to heal fully where the graft was taken or it could break in a crash.
I've owned a public track for over 12 years and have seen many many ACL surgery results and most don't end good. If you want to talk to Dr Mark he is very accessible, PM me and I'll give you his cell number. He answers or calls back. The guy loves what he does and loves being the best at it..
2. For some patients, Cadaver grafts are definitely THE way to go. My personal opinion is that few active / MX / Offroad athletes are in this group...but that is just my opinion.
3. Anyone posting their own personal experience, and using that as evidence of what you should do are not competent to offer advice. One person's experience is NOT statistically significant. Look at statistically significant studies.
4. Go to a surgeon who does a LOT of ACL procedures. This is the single most important thing you can do! True experts have done over 5,000 cases. I think I heard that Don Shelbourne (Indianapolis..former Colts team doc and ACL surgery pioneer) has now done over 10,000 cases. When Travis Pastrana bangs himself up...he goes to Don Shelbourne...you can verify this. Mark Sanders (6000+ cases) in Houston did his fellowship with Don, and uses the same techniques as Don. As an aside, Don and Mark do contra-lateral Patella grafts almost exclusively...read Shelbourne's papers.
Again..ASK YOU DOC HOW MANY HE DOES A YEAR...and HOW MANY HE HAS DONE IN TOTAL. If he says "300!" like that is a lot..RUN. There is NO substitute for experience.
5. Do your research, decide on the procedure you want...THEN find the best Doc at that procedure. Do not go to a doc that does hamstring grafts 95% of the time, and have him to a PTG.
6. Saying you do not need to have your ACL fixed because "athlete X" did not have his fixed, is foolhardy. Everyone's anatomy is different. MX puts loads on the knee that are unpredictable and can be orders of magnitude larger than for running sports. If you have a non-functional ACL, loads will shift elsewhere...and you have a significant chance of damaging other knee parts that can not be corrected as easily. ACL surgery = 95% success rate... Meniscus repair is a crap shoot. Go ahead..tell yourself that you can overcome not having an ACL by working out your knee more...but dont go crying when you tear your meniscus, etc...and 10 years from now your knee is junk and you need a replacement.
7. Cadaver grafts do not reach full strength for a very long time. The dead tissue takes years to transition to living through ligementization. Docs who regularly treat MX athletes report a statistically significantly higher rate of failure in cadaver grafts vs Patella. Any one case does not tell you anything.
8. Hamstring grafts can create weakness and hamstring pain, but the actual repair tissue is the strongest. The anchoring of the tissues is not as strong at a patella graft (bone plug to bone plug), however. Even though cavaver tissue tests show the hamstring repair is stronger, the Patella Tendon graft has lower rates of failure amongst athletes.
9. Rehab on the Patella is toughest, and not suitable for many patients (but should not be an issue for any sort of MX / Offroad athlete).
10. Your mileage may vary.
1. They insist on Pre-hab. They will not generally do the surgery right after injury, but want you to a lot of pre-hab prior to cutting.
2. They drill with the knee at a more acute angle
3. They harvest the donor material from the opposite knee when possible. Read Don Shelbournes papers to understand how he came to the conclusion that this worked better.
4. They have very aggressive re-hab routines.
Other than that...they perform a pretty standard patella tendon graft...and they do it with a very high level of expertise.
https://www.youtube.com/watch?v=EZ36BPIoRF0
1.Cadaver - good if you are young and plan on being very active for many more years. Also that you have more time to heal and that god forbid it doesn't take and you have to do it again.
2.Patella - was for many years the way to go and still is a good choice but the chances of pain in the crouched position, standing on the kneecap, etc is much more likely.
3.Hamstring - has come a long way in recent years as they have made the process stronger by "twisting" them together and they have gotten better about the processes for securing/attaching it. Apparently we have way more hamstring than most of us need.
One of my wife's best friends husband also happens to be an orthopedic surgeon specializing in knees so I asked him. He said he had not done anything but hamstring in about 3 years, in 10, and that he considered it the new "gold standard" because of the advances they had made. I went this route and have had no problems at all and I still ski hard to include bumps and no problems ever doing MX. I do avoid air on skis a bit more though just because.... I also have many friends that had a patella and they tend to complain about pain more than I do.
I have always wondered when some say they are walking in a day or a week after surgery. My Dr was the exact opposite - take your time, rehab, don't push it, etc. I think it was like 4 weeks for me. To me that makes sense because it just seems logical that the tendon needs to adhere to the bone for a while. My advice is do exactly what your are told as far as rehab.
So from my experience it depends on your age and what your intentions are going forward. Good luck no matter what.
One patella graft
two Hamstring (taken from myself)
one Hamstring (human donor)
Patella was painful and badly performed. First lesson find the best knee surgeon you can not the local guy.
Two hamstring grafts left me with tight hamstrings that also cause pain n the knees and weak hamstring muscles.. Much stretching required after exercise.
Last Op (Human donor) was fast recovery/no pain and ofcourse no adverse affect to any other parts of my body.
Being one of the top knee guys in the nation, Dr Shelbourne was called upon to do a lot of revision surgeries...re-repairing an ACL that failed after a previous surgery. That meant he was forced to take the donor graft from the opposite leg because it had already been harvested from the same side. Over the long run, he found that revision cases healed faster and better than ACL repairs where it was the first injury. This make no sense. He eventually (over more than a decade of research) narrowed it down to the opposite side donor site as being the positive correlation. Then he started doing that on primary surgeries. Sanders did his fellowship with Shellbourne.
Surgery is trauma. When the donor tissue comes from the same leg as the repair with a patella tendon graft, you have two areas of trauma...the donor site, and the holes in your knee and the ACL repair. The rehab for each of those trauma sites is different. For the ACL, it is mainly range of motion. For the patella harvesting site...it is re-building strength to compensate for the loss of tissue. Having the trauma on the same leg makes it harder to re-hab each area. This leads to less aggressive work by the patient, and poorer recovery. I can not imagine having had both the harvest site and the repair on the same leg. Re-hab would have been so much harder.
Go read the papers....you can find ones of interest here...
http://www.fixknee.com/research-and-publications/research-studies
I had mind done in 2011 after a rupture (as in the whole thing exploded) with a cadaver because I don't huck fat triples to flat on the reg. It's pretty good now, also feels stronger and more solid than my other knee.
Read the papers for you self...
GRAFT SELECTION IN ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION
Nathan A. Mall, MD, Geoffrey S. Van Thiel, MD, MBA, Asheesh Bedi, MD, Brian J. Cole, MD, MBA
Rush University Medical Center, Department of Orthopaedics, Division of Sports Medicine
University of Michigan, Department of Orthopaedics, MedSport
Rockford Orthopedic Associates, Rockford, IL
"Bone patellar tendon bone autograft and hamstring autograft are two of the most popular graft sources for ACL reconstruction. Figure 1. These grafts have reported donor site morbidity; however, most surgeons would agree that the risk of catastrophic failure with allograft may outweigh the risks of donor site morbidity in the young, active patient."
In laymens terms...for young or active people, cadaver grafts are too weak, and too prone to catastrophic failure, so the risk of donor site complications is worth going with an autograft (Hamstring or "B-T-B").
"Use of autografts have been shown to decrease retear rates substantially in the younger population,"
Cadaver grafts re-tear more....3x as much actually.
If you are riding MX...stay away from Allografts plain and simple. If a doc tries to convince you...he does not understand what is involved in MX...at any age. He is trying to talk you into the procedure that he is most comfortable with instead of admitting he is not the doc for you. Go somewhere else.
The question is B-T-B Patella vs Hamstring. What it came down to fore me was simple.. Hamstring grafts re-fail 2x as often as P-T-B Patella grafts. End of story. Either Patellar or Hamstgring are far better than an Allograft.
DO NOT TAKE ANY DOCS WORD WITHOUT CHECKING THE FACTS. GO READ THE PAPERS YOURSELF, especially the on I cite here. Then grill the docs you talk to.
Final summary from the above referenced paper:
The surgeon has many choices when it comes to graft selection for ACL reconstruction. There are
certain situations in which one graft may be favored over another, such as in the young, athletic
population where autograft tissue should be used. However, there is good literature that excellent
results can be achieved with each type of graft, and thus the surgeon must inform his or her patients
of the advantages and disadvantages of each graft and help them make an informed decision. In
summary, BTB autograft is generally accepted as the “gold standard” due to its biomechanical
profile and reliable, fast bone-to-bone healing; however, hamstring tendons offer certain theoretical
advantages in those that do a lot of kneeling, pre-existing patellofemoral pain, patella alta, or in those
with open physes. Quadriceps tendon grafts have several advantages, including a large crosssectional
area and associated bone plug, but more long term, prospective studies must be done to
determine its incorporation properties and ensure its long-term survival compared to patellar tendon
and hamstring autografts. Allograft tissue is an excellent choice in many revision situations, in the
older recreational athlete, and in those with low demands but need to return to work faster with less
pain and dysfunction immediately post-operatively.
I had the cadaver and the meniscus shave 30% on inner and outer sides by the Fondren Clinic in Houston, Tx.
I have to do pre PT because my knee was mechanically locked and wouldn't straighten out and it took months before the surgery could be done because of major swelling. I had blood pooling up in my foot coming from my knee and I was having my knee drained every 2 weeks. Post PT is the key to a good recovery, unfortunately since I had to wait to have surgery and couldn't straighten my leg the Quad muscle died off very quick so when it was time for Post PT I had hardly any quad left.
Mines probably 80% and could use some arthritis removal from under the knee cap which is common for older people a few years after ACL construction.
I race fine with mine at 48 now but I sure wouldn't want to stab it straight into the ground on accident.
Jason
Pit Row
I'm a physician assistant for Ochsner Sports Medicine Institute in New Orleans, and I also work trackside with asterisk. It's cool to see all the debate here, because as others mentioned, there's often debate in the medical community as to what graft is best for certain patients.
I agree with StartedTooLate that a BTB autograft is likely the way to go for our community. The surgeon I work with places the incision slightly lateral to attempt to prevent the tenderness that develops over that scar. I think a lot of runners, soccer players develop tendinitis status post BTB auto's, but that's strictly empiric talk.
If you need anything, feel free to email me. Arden.ballard@ochsner.org
As for the OP, people wait and get their acl's repaired later on all the time. Prehab, good surgeon and good, consistent physical therapy (and self-dedication) will bring you back better than new!
If using the patella tendon for repair will lead to arthritis, it is going to do so on which ever knee you pull it from. Contralateral has no bearing...unless you want to choose which knee is subject to some unknown risk...
As for a general study on arthritis following ACL repair, here is a study...
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2532071/
I am sure if you google, you can find plenty more. But without even reading the papers, if you understand ACL anatomy, and how they are repaired, any type of repair is going to increase the risk of arthritis. But not as much as not getting it repaired. See this paper...
http://www.hindawi.com/journals/aorth/2015/928301/
"Deficiency of the ACL results in suboptimal kinematics as effective transfer of loads relies on mechanical stability. ACL insufficiency causes deterioration of the physiologic roll-glide mechanism culminating in increased anterior tibial translation as well as increased internal tibial rotation [31]. It results in increased mean contact stress in the medial and lateral compartment posterior sectors under anterior and rotational loads, respectively [36]. With muscular fatigue or poor neuromuscular control, patients experience combined anterior and rotatory instability as a subluxation of the tibiofemoral joint. Ultimately, failure of a primary restraint such as the ACL necessitates recruitment of secondary structures (e.g., menisci) in order to resist external forces and to stabilize joint motion. The higher loads borne by secondary structures may render them more susceptible to degeneration or secondary failure (Figure 1)."
If a structure is designed with 4 load bearing members, and you take one out, the loads are going to re-distribute to the other members. In your knee, that is the meniscus. ACL repair is pretty reliable. Meniscus repair is not. The moral is...don't tear your ACL. I highly recommend that route. If you do tear it, either stop being active, or get it fixed. If you are going to get it fixed, dont use a cadaver graft unless you want to take 12-18 months off.
I was that guy that my jaw dropped when I read the MRI report. Got it all fixed from DR. Cambell in VA, Beach. He refused to use cadaver parts, for some reason he recommended hamstring for moto. The fear of rejection was the reason behind not using cadaver parts.
My knee is 95% from what it was, very pleased I finally got it fixed. Now I will say in my case, my repaired leg when contracting the hamstring is noticeably weaker to this day, my surgery was 10 years ago.
I had both my ACL's replaced in the same surgery so an opposite knee graft was not an option. One of my ACL's had been gone for 20 years and the other was a new tear. Like some here have said every one is different. I rode and raced for 20 years with no ACL in the one knee and for years it was fine. Would buckle occasionally here and there for the first couple of years but after that my body must've compensated and it was perfect for 15 plus years.
The tear in the other knee I thought would be the same so I wasted 2 years off the bike rehabbing and strengthening it only to have it give out the first ride every time I would test it. Knowing what I know now I simply would've rehabbed the knee for a month or two and then got it repaired ASAP.
Since the Sanders technique is an opposite knee graft I figured I might as well get them both repaired anyway.
The thought of having a perfectly good knee messed with to fix a damaged knee freaks out a lot of people, myself included. But after having a patella graft done then you realize why they do it that way and its the best way. They know what they're doing!
I was back riding in under 4 months having them both done at the same time, if I only had one repaired doing the opposite patella graft I would been back much much sooner.
After all of my research I made my mind up that having my ACL reconstructed in Houston with Dr. Mark is the way to go. The one thing I did not research, whether or not his office takes my insurance and unfortunately they don't. So now I'm back to looking for a top-notch orthopedic surgeon preferably in Texas. I have already visited with one surgeon but they are pushing for an allograft and so because of this and all of my research, not sure I can really trust this surgeon. Very few recommend an allograft for active adults under 45 and especially for your first reconstruction. So that being said, any suggestions on excellent surgeons? I emailed Dr. Mark with the same question but have not heard back. Just very disappointed that I'm not covered at his office otherwise I'd have already made arrangements to fly to Houston for a consult.
Main down fall is is isn't US FDA approved. Europe it is approved.
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