ACL Repair- Part Deux (Comparing Allograft and Autograft Experiences)

**SnowTigress** · 03-02-2007, 01:51 AM

So I survived my second ACL surgery this morning....went patellar tendon this time (cadaver/allograft last time 4 years ago).

I know there is a lot of discussion on the board about which way to go so I thought I would start a thread to give a play by play of what it's like to get your ACL fixed, and relay the similarities/differences of the two graft types as time goes by. I do not volunteer for a third go to include the hamstring graft perspective!

First off, I went with patellar tendon this time becuase I am young (28), have a healthy patellar tendon, and the doc thinks my cadaver graft failed. Apparently the thing was totally gone. Next to dislocation I had the highest grade instability and have been skiing/running/playng soccer/windsurfing on it like that for a while without knowing it!
So I don't have anything to report in terms of rehab or stregth yet, obviously, but there have definitely been some interesting differences in the process so far.

I have not yet had the infamous "more pain" from the patellar tendon that I was warned of. I am only about 12 hours out and my femoral nerve block is still in full swing. That wasn't part of the game with the first surgery...I kinda like it.

I also like the "Gameready"...a cold wrap coupled with a cooling machine that really stays cold. It replaces the old cooler that they gave you with the small cuff that just went around the knee and got warm after a bit.
And finally I love the Hemovac...a tube that sucks the blood and other fluids out of the knee joint. Kinda gross to watch it fill up deep red, and then have to have someone empty it out for you, but nice to know that junk isn't trapped in the knee.

They gave me the continuous passive motion (CPM) machine same day and formal PT will begin day 6 after sutures removed.Until then I can start doing staight leg raises (if I can get full extension) when the block wears off. Doc said no full weight bearing at all for first 2-3 days due to the block and pain meds.

To be continued!

**divegirl** · 03-02-2007, 07:29 PM

Good luck with this!!!

**lhs** · 03-02-2007, 08:36 PM

hey! great to see you out and typing...
i'll be the first to agree that percocet is wayyyy better than vicodin.
just to round out the comparisons, it sounds like your experience this time around was pretty similar to my hamstring graft- CPM machine the same day, PT after a week. its really cool that they have the procedure so dialed that they really can get you going again almost immediately.
good luck with the healing!

**drmark** · 03-03-2007, 09:57 AM

I have done a few thousand autografts and at least a few hundred allografts.

The issue of post op pain and recovery period has also been studied in the peer reviewed literature.

My results, as well as the reported results in the literature, have not shown any signifigant difference in the amount of post op pain, disability, or time on crutches.

All of these issues are multifactorial, and depend mainly on how the guy who is holding the knife conducts him/herself.

For example my opposite patella autograft patients are not given crutches after this surgery, all have a normal gait the night of their surgery. Without CPM, our patients will have 140 degrees of flexion by the third day. My colleague (who probably shouldn't be doing ACL surgery) puts everyone in a large brace, on crutches, and attempts to substitute a CPM machine, for hands on PT after installation of an allograft. Some of his patients never walk normally again. Most will, but it takes at least three months. The graft type makes no difference.

**SnowTigress** · 03-03-2007, 03:00 PM

Hi Dr. Mark,
I appreciate your experience and feedback for this process. How great that you are implementing differnt treatment and post-operative care options to help your patients have less pain! It's been interesting reading your remarks.
Your comments become less powerful, however, when you see only one way to do things and you criticize your surgeon colleagues in a public forum. It's quite likely that you are an excellent surgeon, with great results. There are, however, many other excellent surgeons with wonderful results out there that have completely different perspectives on treatment.

Before my surgery I actually did read over your entire website and printed out your "roadmap" to show my PT group and the surgeons working on my case. They did not agree with your protocol to weight bear right away (for various reasons) and since they are the ones treating me, I go with what they say. That's not to say that your protocol is not good.

The surgeon who performed my recon is very well respected in the SF Bay Area, especially among athletes, and from what I can make of her incision marks, etc, she does really clean work. I had my dressings removed today and there is virtually NO swelling. Do I have some pain? Yes. Mostly due to the hemovac tube which has now been removed. Do I think all of your patients are completely pain free and able to skip down the block the night after surgery, no way.

It is good to have your input in Gimp Central, we're all here to gain insight and share info, but your advertisement of your particular techniques being superior to every other technique is a bit much.

**crons** · 03-03-2007, 05:22 PM

bravo, tigress, bravo!! i couldn't have said it any better....

**drmark** · 03-03-2007, 06:16 PM

Snowtigress is correct. Most PTs and orthopaedic surgons will disagree. This plan defies tradition and the conventional wisdom that most problems should be treated with rest and immobilization. The published results with accelerated rehabilitation date back to the late 1980s and have been published extensively by my friend and teacher, Dr. Donald Shebourne. He has done in excess of 7000 ACLs that way, and has reported considerable positive long term followup. Perhaps you should Google him or Accellerated ACL Rehab to learn more on this subject. I don't believe that I said that accellerated rehabiliation is better. On that issue, the oberver can make his or her own decisions.

Regarding weight bearing after ACL surgery, its not just with little ol' me that they are disagreeing. The American Orthopaedic Society for Sports Medicine asked a respected scientist and researcher, Bruce Bennyon, to write a review article about ACL issues. I have posted a reproduction on this issue. Please review the earlier reproduction from the 2005 American Journal of Sports Medicine review article that I have posted.

I don't believe that I said that our patients are pain free and able to skip down the block. Our average case takes narcotic pain meds (vicodan or darvocet) for six days. If you have visited our webisite, you seen videos of such patients walking without crutches, drains still in place, while still in the hopsital. Certainly, this issue is easily verified.
If you haven't seen it, here is the link

http://sandersclinic.net/postsurgery/index.html

While we will certainly disagreee on nearly every issue, I am delighted to know that you are not a proponent of cadaver tissues. The reasons that cadaver tissues are incompatable with young extreme athletes could fill this entire website.

Last, I have pulled the American Journal of Sports Medicne reprint from another post on this website and here it is again:

Immediate Versus Delayed Motion
Our review identified 5 RCTs comparing immediate to
delayed knee motion during the initial stages of rehabilitation,
and there appears to be reasonable consensus that
immediate motion is beneficial for the healing ACL graft
and soft tissue structures that span the knee.47,50,86,92,95
Haggmark and Eriksson were among the first to perform
a prospective RCT of rehabilitation after ACL reconstruction
with a patellar tendon graft.35,47 Patients were
treated with a dorsal plaster splint during the first week
after surgery and were then randomly assigned to continue
rehabilitation during the following 4 weeks while wearing
either a hinged cast that allowed knee motion or an ordinary
cylinder cast that prevented knee motion. All of the
patients were followed up during a 1-year interval; those
treated with standard cast immobilization had significant
atrophy of the slow-twitch muscle fibers of the vastus lateralis,
whereas those treated with the hinged cast and
early motion demonstrated no changes in the cross-sectional
area of the slow- or fast-twitch fibers. Haggmark
and Eriksson47(p55) noted that “there appeared to be no difference
in the end result of the surgical procedure” and
that treatment with the hinged cast “facilitated an early
return to sports.”
A prospective RCT that compared immediate to delayed
range of motion after ACL reconstruction was carried out
by Noyes et al.86 Subjects in the immediate motion program
began continuous passive motion of the knee on the
second postoperative day, whereas those in the delayed
motion group had their knees placed in a brace at 10of
flexion and began continuous passive motion on the seventh
postoperative day. Subjects in both rehabilitation programs
reported similar rates of joint effusion, hemarthrosis,
soft tissue swelling, flexion and extension limits of the
knee, use of pain medications, and time of stay in the hospital.
Continuous passive knee motion immediately after
ACL reconstruction did not lead to an increase in anterior
knee laxity during healing.
Rosen et al95 carried out a prospective RCT of rehabilitation
after arthroscopically assisted ACL reconstruction
with a central third BPTB autograft performed by the
same surgeon. After surgery, subjects were randomized via
a lottery system to 1 of 3 programs: early active motion,
continuous passive motion, or a combination of both. This
work extended the research of Noyes et al86 by showing
that continuous passive motion during the first month
after ACL reconstruction, compared with early active
motion, produced similar range of joint motion and KT-
1000 arthrometer measurements of A-P knee laxity.
Richmond et al92 reported the results of a prospective
RCT that compared the effects of continuous passive knee
motion for 4 to 14 days after arthroscopically assisted ACL
reconstruction with a BPTB autograft. They found similar
values for knee range of motion and lower limb girth
between treatment groups.
More recently, Henriksson et al50 described a prospective
RCT of rehabilitation after ACL reconstruction with a
BPTB graft performed by 1 of 4 surgeons using the same
technique. After surgery, subjects were randomly assigned
to rehabilitation protocols consisting of cast immobilization
or early range of motion training with a brace.
Subjects in both groups underwent similar supervised
rehabilitation, and during the first 5 weeks, all rehabilitation
exercises, with the exception of range of motion exercises,
were the same for both treatments. Follow-up measurements
made after 2 years included 88% and 92% of
subjects in the brace and plaster cast treatment groups,
respectively. The researchers found that rehabilitation
with the use of a brace and early range of motion training
after ACL reconstruction produced equivalent knee laxity,
knee motion, subjective knee function, and activity level in
comparison to rehabilitation with plaster cast immobilization
for 5 weeks. There were, however, differences in terms
of strength. At 2-year follow-up, subjects in the brace
group had a larger strength deficit of the knee flexors
(5.9% loss compared to the contralateral, normal side) in
comparison to subjects in the plaster cast group (0.9%
loss). As well, there was a strong trend for subjects in the
brace group to have a strength deficit of the knee extensors
(11.1% decrease compared to the contralateral side) in
comparison to patients in the plaster cast group (3.8%
decrease).
Of the 5 RCTs reviewed above, only Rosen et al95 adequately
described their method of randomization, and only
Haggmark and Eriksson47 and Henriksson et al50 had minimal
loss of patients at follow-up; no author stated
whether the investigators were blinded at follow-up.
After ACL reconstruction, it is clear that extended immobilization
of the knee, or limited motion without muscle
activity, is detrimental (inferior structural and material
properties) to the structures that surround the knee (ligaments,
cartilage, bone, and musculature).4,10,62-65,70,84,112
There is little doubt that early joint motion after ACL
reconstruction is beneficial; it leads to a reduction in pain,
lessens adverse changes in articular cartilage, and helps
prevent the formation of scar and capsular contractions
that have the potential to limit joint motion.24,65

Immediate Versus Delayed Weightbearing

Two prospective RCTs have compared immediate versus
delayed weightbearing rehabilitation programs after
ACL reconstruction, and both have reported that immediate
weightbearing programs produce similar clinical,
patient, and functional outcomes to delayed weightbearing
programs.60,106

Jorgensen et al60 performed a prospective RCT to evaluate
the effect of weightbearing on the results of ACL reconstruction
with the iliotibial band graft. After surgery, subjects
were randomized to undergo rehabilitation with
either immediate weightbearing or nonweightbearing for
5 weeks followed by a gradual return to full weightbearing
during the first 9 weeks of healing. Evaluation 2 years
after surgery revealed no differences between the groups
with regard to A-P knee laxity and patient activity level
(evaluated with the Tegner and International Knee
Documentation Committee [IKDC] scores).
In a subsequent prospective RCT of ACL reconstruction
with a central third BPTB autograft, Tyler et al106 compared
rehabilitation with immediate weightbearing to
delayed weightbearing for 2 weeks. Only 2 subjects in each
treatment group were lost to follow-up. At a mean followup
of 7.3 months, there were no differences between the
treatments with regard to knee range of motion, vastus
medialis oblique function, and A-P knee laxity (clinical
examination and KT-1000 arthrometer measurement).
However, patients treated with immediate weightbearing
had a decreased incidence of anterior knee pain.
Authors of these RCTs did not describe their method of
randomization, and they did not mention if the subjects or
investigators responsible for the follow-up measurements
were blinded to the treatments that were studied.
The findings from these investigations indicate that
immediate weightbearing after ACL reconstruction does
not produce excessive loads that permanently deform the
graft or its fixation and suggest that immediate weightbearing
may be beneficial because it lowers the incidence
of anterior knee pain. After ACL injury and reconstruction,
the effect of weightbearing on the healing response of
injured articular cartilage or meniscus repair is currently
unknown.

**Vinman** · 03-04-2007, 09:15 AM

My thoughts on graft choice after doing rehab with many ACL and undergoing 2 ACL reconstructions myself (soccer related ~14 yrs hamstring graft and ~8 yrs patellar tendon graft)

I am for weight bear as soon as tolerated, for some that may be day 1 for others it should be no later than day 2 or 3 with active ROM and active quad sets being done ASAP. The only caveat to this is where the meniscus has been repaired. The repaired meniscus needs to be protected a bit more than the meniscus that is partially excised so crutches may be needed a bit longer here. All of this is independant of graft choice.

As for choice of graft. There are pluses and minuses to each one. Graft choice and which is best really depends on the person, their activity level and what they personally want after surgery.

All three graft types have their pros and cons. Most orthos will say the patellar tendon is the "gold standard" when it comes to graft choice. It has good fixation with a bone block at each end and is very strong. The draw backs are taking a section out of the only tendon that can forcefully extend your knee and possible side effects like patellar tendonitis and pain when kneeling later on. Also probably the most painful of the three choices.

As for the hamstring, it is a good choice, it is strong but tougher to get good fixation due to the fact there are no bone blocks. you avoid the patellar tendon issues, but they can also stretch out over time for some people who are naturally very flexible. middle of the road as far as pain goes.

the allograft is also a good choice, strong, less pain involved overall but has the downsides of slight possibility of disease transmission, tissue rejection and "yuck" factor for some people as far as having a piece of another person implanted into them. Also this one takes much longer to revascularize then an autograft( upto a year for allogroaft ~4 months with autograft). This can be an issue for some who are looking for a faster return to high levels of activity.

So really there is no bad choice, just options all with pros and cons.

Of my personal experience, my 2 rehabs were very different. 1st one ~14 years ago took a bit longer but this also involved meniscus 2 repairs. It was at the time fairly accelerated. I was back to competitive soccer in about 8-9 months.

Second surgery, no meniscus repairs. off crutches on day 3 over all was quicker mostly because I knew what to expect and how to go about making things quicker( quad sets and AROM on day 1, full extension by day 5.)

ok have to cut this short to go change a diaper......pheeeewwwww!!!!

**drmark** · 03-04-2007, 01:35 PM

Other than avoiding deep squats, there is no need to change the rehab when meniscal repairs are performed.

The intrarticular enviornment after ACL reconstruction lend itself to meniscal healing (lots of blood, and potential to form scar tissue)

The need to get the knee going in my opinion trumps the meniscal issues.
My experience is that the vast majority of meniscal repairs will heal without signifigant changes in the rehab when combined with ACL reconstruction.

Meniscal repairs performed in the absence of ACL reconsturction are an entirely different far less reliable.

**watersnowdirt** · 03-05-2007, 01:26 AM

I have nothing medical to add, just a good old fashioned....

FEEL BETTER, GIRL!!!

**Natedogg** · 03-05-2007, 01:29 PM

Originally Posted by watersnowdirt

I have nothing medical to add, just a good old fashioned....FEEL BETTER, GIRL!!!

Same here. Hope to see some MTB, windsurfing, etc pics ASAP!!

**SnowTigress** · 03-05-2007, 02:43 PM

Update Post-Op Day 4:

Pain: I dont love taking meds. But they do the trick and keep me nice and comfortable.
This autograft experience IS more painful that the allograft, but not unbearably so.

Stiffness: I have not had as much stiffness this time. I've retained complete extension, presumably due to the very minimal amount of swelling...thanks to the hemovac, anti-inflamms (toradol, vit I, etc), ted stocking, elevation and icing. The cpm is comfortable to 65 degrees today (they started me at 45 and have had me up it between 5-10 degrees/day). Only stiffness I feel is when trying to engage my VMO (ie. trying for quad set). ..PT says I gotta loosen the patella so it can glide better.

Weight Bearing: No pain to weight bearing at all. Just feels wobbly/unsure (despite having brace on and locked at O degrees) and that scares me.
Morale: Now that the hemovac tubes, pain pump out, I feel better, less hindered. Better mobility = increased morale. It really sucks to have to go through this a second time due to tissue rejection....time off work, relying on others, time away from fun.

Thanks to all you guys who've called/emailed/texted in support. Much appreciated!

**Vinman** · 03-05-2007, 03:05 PM

It sounds like you are doing just fine, don't worry too much about the wobbly feeling, that is likely just caused by your muscles not really being up to the job right now. Get to work on being able to fire your quad effectively and that should subside.

**'ofeina** · 03-07-2007, 11:22 AM

Hiya Tigress!

I hope that you are feeling better real soon!!!!!

I totally feel your pain and have had two ACL reconstructions too!
1) 2001 - broken tibia, completely blown ACL partially torn MCL
HAMSTRING REPLACEMENT

I had to wait for about 6 weeks for my tibia to heal the point that my doctor felt comfortable doing the ACL surgery. For about 4 of those weeks I was on crutches & then felt generally pretty great. I was lucky that it was such a clean break, right along the almost fused growth plate. Then I had a hamstring replacement which was a bit rough. The anestisia made me really sick and I had considerable pain for several days following. Rehab fluxuated in pain, intensity & emotional stability. Generally, I would say that it was an arduous process. Within 3 months I was feeling good to do most day-to-day activities and was swimming competativly within 5 months. Within 6 months I was skiing and back in tip-top ski form by 7.5 months. I actually had my best racing season ever that year... it was real sweet.

Fast forward 4 years...
2) Complete re-tare of ACL
ALLOGRAFT REPLACEMENT

Goofing around at club ski team race (where I literally beat all of the boys w/o trying)... get in the back seat a bit & make an athletic recovery. I feel the knee pop & finish the last 3-4 gates on one ski. Get through the finish line - atleast I won my last race- and sit down & start crying. Not cause it hurt or anything... but because THAT SUCKS. (and, okay, it hurt a little...)

I finally get around to seeing the doctor 3 days later & he sends me in for an MRI that comes back inconclusive... because of the couple of metal screws from my fisrt surgery. He told me that people can hurt their knees without tearing their ACLs. Itold him that mine was torn... even though we had a great realtionship (too many injuries...) and he even wrote me a letter of reccomendation for college, it really destroyed my trust in him...

I ended up visiting the doc back at school & having a KT2000 that demonstrated that my ACL was completely detached. Such a bummer.

From there, I did my homework & went to a couple of different docs... figured it might be worth stepping up from the rural area that I lived... I ended up deciding on a great doctor in NYC. He was the Giant's team physician for 27 years & gave me plenty of time to askquestions and to thouroughly explain teh procedure to me. We decided on an allograft -really, pretty much my only option, as taking from both the hamstring & patella would severely weaken the knee. My doc wasn't very impressed with the job that my previous surgeon had administered. Everything about my 2nd surgery was better; easier & faster recovery... less pain... no overnight stay or problems with anastesia... had a CPM machine that I used, like, all the time, as well as this awesome ice machine that constantly put cold icewater from a cooler over my knee... oh and this little shocker thing like they use in PT. Use the CPM machine- it sucks while you are doing it, but makes a WOLRD of difference.

The allograftcame from a short 50-something male... kinda creepy to think about, so I don't. :-)

Nearing two years on the 2nd surgery & my knee feels great! I occasionally have pains when I have a long hard day in the pow or am doing a lot of pivoting (think soccer)... but generally no issues.

Overall: I think that the allograft was the better surgery for me... I feel more stable & confident with it. I also had a better doctor... so it is challenging to differentiate the two!

Wow, that was long winded. apologies.

FEEL BETTER HUN!!!! You've got all my good vibes coming your way. Let me know if you need anything, seriously.

**SnowTigress** · 03-07-2007, 11:57 AM

Ofeina-
Great account. Sounds like your first experience was horrible...and drawn out!

Glad to hear the graft still treating you well. I have friends that have had both knees done in cadaver and are charging!

Guess my knee joint welcoming committee didn't get the memo to be nice to the foreigner graft!

I'm crossing my fingers the patellar graft will do the trick for me!

Getting sutures out today and starting PT. Yippee!

-Tigress

**drmark** · 03-07-2007, 05:35 PM

Its difficult to compare allografts vs. autografts when they are done by a different operator.

The most likely cause of failure of any graft is putting it in wrong. A well postioned allograft is way better than a poorly positoned autograft.

Allografts vs. autografts, all done by the same guy lead to better comparisons.

**Huckwheat** · 03-07-2007, 07:59 PM

Hey SnowTigress.....hope the recovery goes smooth. At least you arent missing the best season around

Did you end up skiing at all? I know we had a conversation about it.

DrMark....I read your disclaimer....and especially in light of those fact around liability and internet advice, we really appreciate you coming on here. There is a wealth of experienced knee patients on this board, and it is great to hear professional opinions mixed in! Thanks for contributing.

**Natedogg** · 03-07-2007, 08:56 PM

Originally Posted by Huckwheat

we really appreciate you coming on here. There is a wealth of experienced knee patients on this board, and it is great to hear professional opinions mixed in! Thanks for contributing.

I havent read everything you posted since I have no frame of reference to *really* understand this stuff, but I agree--it seems pretty cool that you would be on here. Buuuuut, how the heck do you have all this time to write these long responses?? I thought doctors are overworked and never have time to eat lunch or take a leak, nevermind surf TGR?!?

Originally Posted by SnowTigress

Pain:
Morale:

I hear that there are some wacky docs (or wanna-be docs) who gas people for these reasons... Maybe you should try it?!?

**drmark** · 03-07-2007, 09:06 PM

There is a long waiting time in between surgeries and I usually have my lap top. Writing these responses usually only take a few minutes or so.

**Natedogg** · 03-07-2007, 09:11 PM

Originally Posted by drmark

There is a long waiting time in between surgeries and I usually have my lap top. Writing these responses usually only take a few minutes or so.

Right on. My GF is a PA for a pedi-ortho and they go a million miles an hour 12 hours a day. High turnover rate in that place, I tell ya.

**SnowTigress** · 03-07-2007, 09:55 PM

Originally Posted by drmark

The most likely cause of failure of any graft is putting it in wrong.

That makes sense. ^^

I realize you're not a fan of allo when auto is an option. But when allo is the only option, what's in the current literature about efficacy of different types of cadaver tissue they use (ie achilles vs. patellar tendon vs. other)? In my first surgery (2003) they used cadaver achilles tendon. Surgeon of recon #2 said today that she found a remnant of the 1st achilles graft when removing the old screws...said it looked "like gristle"...ew!
Has there been a documented prob with using achilles?

But like you mentioned above, surgeon #2 did say she felt that the femoral attachment was placed too far anteriorly for me, so she moved it back...she thought other than poor tissue/tissue rejection, that could have been the cause of failure #1.

Anyways, I'm pleased to have minimal stiffness/swelling/pain this time around and awesome extension, pretty good flexion (90) on day 6 post-op. Sutures out today and everything looks/feels great!

Not much difference between the two knees today!

**SnowTigress** · 03-07-2007, 10:10 PM

Originally Posted by Huckwheat

Hey SnowTigress.....hope the recovery goes smooth. At least you arent missing the best season around

Did you end up skiing at all? I know we had a conversation about it.

Hey Huck! Thanks! Yeah, I got a coupla really fun days in, last one being a pow day, so I'm stoked. Thanks for the advice on that. I ended up getting a sweet Townsend carbon fiber custom brace and it reminded me to be careful.

Congrats to you and the Mrs. on the lil tyke on the way!

**drmark** · 03-07-2007, 10:10 PM

Sorry, Tigress, but an anteriorly placed graft is really bush league work. Especially in the 2000s. You have to wonder if the attending doctor was even in the room, or the residents did it unsupervised.

There is not much difference between the Achilles and the Patella tendon allografts. At least the results are comprable.

My choices of graft in descending order
1. opposite patella tendon
2. same sided patella tendon
3. opposite quad tendon
4. same sided quad tendon

So there is two graft sources per knee. To date, I have not had do do someone's 5th revsion. Most days I am revising failed allografts. I guess there is no choice but allograft for the 5th operation provided the previous four were autografts. I am hoping that I never am faced with such a problem, but by the time four ACLs have failed, the patient is likely to be in need of a total joint rather than another ACL.

**SnowTigress** · 03-07-2007, 11:12 PM

Originally Posted by drmark

Sorry, Tigress, but an anteriorly placed graft is really bush league work. Especially in the 2000s. You have to wonder if the attending doctor was even in the room, or the residents did it unsupervised.

Maybe so. As a patient, you do your homework and go with the guy you think will do a good job for you. That means talking to friends who've had surgery there, reading reviews, and talking to that guy himself. In the end, surgeons are people and can make mistakes. We're also assuming Dr. #2 is correct in her judgement of the placement.
I still believe Dr. #1 is an excellent surgeon and would recommend him as an option to other folks. Round two I went with someone my PT recommended because she's seen and rehabed hundreds of her patients and there's consistent evidence of really clean, solid work. So far so good.

**upallnight** · 03-07-2007, 11:39 PM

oh, man, snowtigress--sorry to hear you had to go through another surgery. sounds like your attitude is a great one and i wish you the best during your recovery.