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

[SnowTigress]

thanks UAN!
good to get some ++ energy back into this thread!

[Kellie]

Bummer to hear you had to go back under the knife, but I'm sending positive healing vibes your way!!!

Best of luck, keep that great attitude, and keep us posted

[altagirl]

Good luck with the healing and rehab!

I'm still very happy with my allograft. And, being in the odd (and unfortunate) position to compare the two...

I had a hamstring graft ACL in the left knee. It's held up, though I tore the meniscus on that knee a few years later.

I had an allograft ACL in my right knee. Again, the graft held up, and I tore the meniscus in that knee about 18 months later.

Comparing the pictures of the two grafts 18 months plus post-op - in my personal, non-medical opinion - the allograft looks stronger and healthier. My surgeon (who did the three most recent surgeries, but not the hamstring graft) said the hamstring graft is still functional, but looks like it stretched a bit. In the photos from my partial menisectomy on that knee later, the graft looks intact, but had little fibers sticking out. The allograft, on the other hand, is still totally solid and the photos of it are pretty cool. It looked quite dead ("gristle" isn't too far off) in the photos I have of it when it went in, and 18 months later it's smoothed out and alive looking, with nice little blood vessels grown all over it.

My surgeon let me start skiing at 5 1/2 months post-op. I definitely was taking it easy, and started out with XC skiing and such first. Maybe that was high risk, but it worked out well.

Anyway - good luck with your rehab!!

[Huckwheat]

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 your reason for being anti-allograft is strictly because of the "possible" risk of infection (on some type of disease that hasnt been found yet)?

That seems pretty slim to me. Also, I am just surprised your views are so strong, when so many other docs are running wild with Allografts.

Regarding strenghts of the grafts also surprised, as so many docs that do tons of skiers are so Pro-Allo (to your credit you did say "how it was put in" is most important). I am biased though.....since I am part dead person.

[drmark]

Two reasons to hate allografts
1. the revision rate is 4 to 5 times higher
2. if you think the infection thing is minor, why is it that in every field of medicine everyone Sh1ts in their pants before a transfusion is given? At every hospital a special consent for blood transfusion is necessary. With most elective surgeries, patients predonate their own blood so a transfusion won't be necessary.

Having said that sports orthopedic guys are charging right in when no one else will go. What can possibly be a reson for this?

Interestingly, allografts are purchased for about $2000 from the supplier. The surgical center usually owned by the docs mark it up to $4000. Heck, I can't sell a guy his own patella tendon. Like in everything else, follow the money.

I won't expect you to agree with anything I would say. I think knee braces are a complete waste of time and money, unless you are the one selling them.

[SnowTigress]

UPDATE POST-OP 2 WEEKS

Pain: None really...except when the PT manipulates the scar tissue at the graft site to break it up to improve patellar gliding.
Stiffness: Much less thanks to CPM and PT ROM exercises. Really helps to massage the fluids around, especially just above patella. Makes quad sets and straight-leg-raises easier. Big difference here compared to allograft is the heavy scar tissue building up at graft site this time (feels pinchy with big flex of quad). PT says goal now is to work on this stuff, break it down, so it doesn't cause problems down the road.
Got a bit of tightness in the calves and lateral quad...feels good to rub those out too.
Weight Bearing: Yesterday after PT I seriously felt like I could skip down the hall...
Morale: Happy because it feels like it's going by a lot faster and smoother this time around! Good to have the hardest part behind me!


Thanks AG and K for the ++!

[Buzzworthy]

Awesome report. I am following closely as you can imagine.

Keep it up!!

[Natedogg]

I talked to the pedi-ortho GF today about this... I was bragging that I was learning lots of info about allo and autografts. In reality this stuff goes way over my head. I can't remember the arguement for/against what, but she says the dead peeps stuff is the preferred tissue of choice for older folks.

But that's not my point... She said to keep an eye out for this: http://www.childrenshospital.org/new...blevel196.html

[drmark]

Those are animal experiments. They are still experimental for animals, and far from being ready for human use.

[SnowTigress]

Hey Nate!
Very cool article! Hope it proves useful for humans in the future...would nice to avoid more acl recons!

Thanks for sharing!

[Vinman]

Dr. Mark:

What kinds of technology is on the horizon for joint replacement? I have a pretty shitty knee (articular cartilage wear wise from my multiple ACL injuries and have a badly worn trochlear groove.

I know right now there is no way to repair this kind of damage short of replaceing the knee.

Do you think there might ever be some kind of stem cell based tech that might allow new growth of articular cartliage? I know the carticel stuff is basically the first step in this kind of tech but for me this is not an option due to the location of my wear.

There is one doc in Cali doing some paste grafting of articular defects know anything about this type of repair?

sorry for the topic hijack.....

[drmark]

You might have gathered that I a "old school" in all areas except rehab.

First and foremost what is your range of motion? Is it equal to the other knee? If not, you need to get it there. Strength too.
This come straight from Shelbourne who thinks that all articular surface surgery is an absolute waste of time. He published on a few thousand ACL cases and proved that the most important determinant of a good result was full motion, especially in extension. Stability was an added bonus. Stable knees with flexion contractures did way worse than unstable knees with physiological hyperextension. The short story is that the whole game is about hyperextension equal to the other side.

I believe in getting the basics right, before charging into new kooky and spooky procedures that evidence based medicine has shown to work as good as at 25,000 dolllar placebo.

[altagirl]

Two reasons to hate allografts
1. the revision rate is 4 to 5 times higher
2. if you think the infection thing is minor, why is it that in every field of medicine everyone Sh1ts in their pants before a transfusion is given? At every hospital a special consent for blood transfusion is necessary. With most elective surgeries, patients predonate their own blood so a transfusion won't be necessary.

Having said that sports orthopedic guys are charging right in when no one else will go. What can possibly be a reson for this?

Interestingly, allografts are purchased for about $2000 from the supplier. The surgical center usually owned by the docs mark it up to $4000. Heck, I can't sell a guy his own patella tendon. Like in everything else, follow the money.

I won't expect you to agree with anything I would say. I think knee braces are a complete waste of time and money, unless you are the one selling them.

I think the important thing would be that MY surgeon doesn't have any significantly higher revision rate for allograft patients. The two surgeons I've used both felt there were a lot of valid reasons for using either and they tailored their recommendations to the individual patient.

And as someone who's had torn MCLs from lateral impacts that could have been easily prevented if I had been wearing my knee brace... I'm going to keep on wearing them.

I appreciate that you believe so strongly in what you're doing and I do think your method is a great idea for someone with a healthy patella/patellar tendon in the opposite knee, etc. But that isn't everyone.

[Vinman]

yeah ROM is limited to about 120 deg knee FLX depending on the day. I had a scope this fall to clean out some loose bodies and old meniscal damage. I can ski without pain due to the few "islands of cartilage" that are keeping the patella off the bone surface of the trochlear groove. Strenght is good to very good and so is proprioception. I really don't have pain unless I go beyond 120-130 deg FLX. I do get a pretty good effusion with activity and have given up triathlon because of the art. cart. damage....

contemplating a "grease and lube" injection as well

basically just looking for info on stuff that might be a few years away. As I know that I am already a future candidate for a replacement. And would prefer to not have one too soon since I am only 35.

[altagirl]

You might have gathered that I a "old school" in all areas except rehab.

First and foremost what is your range of motion? Is it equal to the other knee? If not, you need to get it there. Strength too.
This come straight from Shelbourne who thinks that all articular surface surgery is an absolute waste of time. He published on a few thousand ACL cases and proved that the most important determinant of a good result was full motion, especially in extension. Stability was an added bonus. Stable knees with flexion contractures did way worse than unstable knees with physiological hyperextension. The short story is that the whole game is about hyperextension equal to the other side.

I believe in getting the basics right, before charging into new kooky and spooky procedures that evidence based medicine has shown to work as good as at 25,000 dolllar placebo.

So what do you recommend for patients with healthy ligaments but articular cartilege damage/problems/arthritis?

[drmark]

Exercise to get both knees to symmetrical motion and strength. (this is key)

Stationary bike one hour per day, everyday. Get up to your target heart rate for your age

Nutriex Sport visit www.nutriex.com

stop smoking

weigh what you did when you got married for the first time, or were discharged from the Service.

avoid doctors as much as possible except socially.

[amyzilla]

I think the important thing would be that MY surgeon doesn't have any significantly higher revision rate for allograft patients. The two surgeons I've used both felt there were a lot of valid reasons for using either and they tailored their recommendations to the individual patient.

And as someone who's had torn MCLs from lateral impacts that could have been easily prevented if I had been wearing my knee brace... I'm going to keep on wearing them.

I appreciate that you believe so strongly in what you're doing and I do think your method is a great idea for someone with a healthy patella/patellar tendon in the opposite knee, etc. But that isn't everyone.

Well said, AG.

[Buzzworthy]

Exercise to get both knees to symmetrical motion and strength. (this is key)

Stationary bike one hour per day, everyday. Get up to your target heart rate for your age

Nutriex Sport visit www.nutriex.com

stop smoking

weigh what you did when you got married for the first time, or were discharged from the Service.

avoid doctors as much as possible except socially.

Well, I stopped smoking almost 2 years ago to the day, I weigh 20 pounds less than when I got married (out of shape BIG time then), and will be doing the gym thing with the family now with my goal of biking and swimming a lot. Once allowed to ride on road, git the MTB out, for the road. No roadie in garage unfortunately.

Doctors are getting harder to avoid too. That part sucks.

[Natedogg]

Those are animal experiments. They are still experimental for animals, and far from being ready for human use.

If you call five years 'far' I guess... At least that's what the GF cites, and she works with Dr. Murray...

Hey Nate!
Very cool article! Hope it proves useful for humans in the future...would nice to avoid more acl recons!

Thanks for sharing!

You bet! I'm keepin' an eye out for ya, little lady!

[drmark]

Its important not to be the first human who has a new procedure. Its better to sit back and watch what dire new and previously unheard of complications occur to someone else.

When I was 30, I charged into every new thing. At 50, I am more careful. I am not a pessimist, just an experienced optimist.

[Natedogg]

Its better to sit back and watch what dire new and previously unheard of complications occur to someone else.

Agreed.

8798776875

[altagirl]

Exercise to get both knees to symmetrical motion and strength. (this is key)

Stationary bike one hour per day, everyday. Get up to your target heart rate for your age

Nutriex Sport visit www.nutriex.com

stop smoking

weigh what you did when you got married for the first time, or were discharged from the Service.

avoid doctors as much as possible except socially.

I haven't tried the vitamins you recommended, but I do take glucosamine, chondroitin, bromelain, , etc. Looks like a good idea though, since I'm buying a lot of those things separately and it might make more sense to get them all in one pill.

My extension is identical (to about +8 hyperextension), and flexion is maybe a degree or two short on my left knee (though both touch my butt), and I'm not noticing any strength difference. Just that my left knee is starting to get more and more sore on the medial side where most of the meniscus is gone.

I generally do spin class 4-5 times a week, but it wouldn't hurt to do more.

Never smoked.

And I weigh less than I did when I got married and when I was discharged from the Service.

Almost never take NSAIDs anymore. The Army fed them to you like candy and it messed up my stomach. I haven't taken anything for more than about 2-3 days in years - which is often against my doctor's advice, but when the pain in my stomach is far exceeding any possible pain in my knees, back, or whatever else, it just isn't worth it. The stuff I've read on how they're bad for your cartilege doesn't make me want to take them either.


Do you consider the elliptical trainer as about equivalent to a stationary bike?

[drmark]

Altagirl, you are the perfect woman!
An eliptical trainer works as good as a bke, but the bike is a non weight bearing exercise.

[altagirl]

Altagirl, you are the perfect woman!
An eliptical trainer works as good as a bke, but the bike is a non weight bearing exercise.

Heh... well, I try. I have a hell of a lot of things I'd like to improve on.... Anyway, I guess what we're saying here is that my knees would probably feel a lot worse if I wasn't doing all of those things...


I'm also putting yoga on the list of things that make my knees feel better. Particularly because it keeps my IT bands from getting too tight. And tight IT bands create a multitude of painful issues with my knees.

Not to mention, my chiropractor had been working on a "dish" in my spine for years and we'd pretty much determined it wasn't going away and given up. (spot where it was flat where it should be curved between my shoulder blades, resulting in occasional shooting pains in my shoulders, etc.) I went back in after my recent car accident and he was shocked how much better it was. I've been doing yoga for about 6 months and it finally got that spot back to a normal curvature. So yay for yoga!

[Natedogg]

I haven't tried the vitamins you recommended, but I do take glucosamine, chondroitin, bromelain, , etc. Looks like a good idea though, since I'm buying a lot of those things separately and it might make more sense to get them all in one pill.

Speaking of pills--and I guess I could look this up--but I just thought to ask... what is your guys' (gals) views on popping pills (sorry for thread hijack, ST). I dont think about it much and try to stay away from every pill I can. I will endure bad headaches before I take an Advil or let mucous drip out of my nose before I take an antihistamine. Ive always considered it 'cheating' to take a pill (although there are circumstances where its fine [ie., Yassis situ]). I know Im probably being stupid about it, but I can endure, so I do. (The Dude abides) Besides, it seems like our society looks for pills to help with every friggin thing in our life, and I want no part of that (damn, I sound like a organo-eating tree-hugging puss bag).