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

**Buzzworthy** · 02-08-2008, 01:52 PM

Week shy of 10 months post op ACL allograft.
Been boarding 1-2 times a week, all in pow (man I got lucky this year). Pow does put more strain on my knee muscles and tires me out more, but the ACL is solid.

Solid enough I was getting 5' off the ground yesterday and did not think twice about it.

And I don't air anymore, or so I told myself this year.

I still have two 9mm screws in and they are bothersome, but not enough to get them out while the snow is so fantastic. Gettiing them out spring most likely.

I have yet to ski again though. Mental mind fack as that is how I lost it.

edit: age 33.

**drmark** · 02-08-2008, 01:54 PM

Altagirl,

The purpose of the ACL is to protect the menisci, and the purpose of the menisci is to protect the articular cartlage.

I would have serious doubts about the integrity of any ACL replacement if the knee continued to need to be pruned of its other vital parts.

**altagirl** · 02-08-2008, 01:57 PM

Originally Posted by drmark

Altagirl,

The purpose of the ACL is to protect the menisci, and the purpose of the menisci is to protect the articular cartlage.

I would have serious doubts about the integrity of any ACL replacement if the knee continued to need to be pruned of its other vital parts.

Well, in that case, my hamstring graft isn't any better, because I've had the same thing done in that knee.

And yes, I'm sure you'll just tell me I should have had patellar grafts done, but with my trashed patellas, I'm not adding to the arthritis and issues I already have with them.

Not to mention, there are plenty of people out there with intact original ACLs and meniscus tears. I'm just not buying that theory.

**drmark** · 02-08-2008, 04:29 PM

I dont remember telling you that you need to have patella tendon grafts for your ACL.

Here are the odds.
15% failure rate for allografts which usually leads to further meniscal/articular cartlage issues
06% failure rate for hamstring repairs which also leads to further meniscal/articular cartlage issues.
<1% incidence of new meniscal tears in stable knees every year even in elite athletes.

That means that if a person such as yourself sustains a meniscal tear on the reportedly well reconstructed knee, there is a 5x (for the hamstring side) or 15x (for the allograft side) greater chance that it is related to an undiagnosed or underreported ACL graft issue than a fresh new traumatic meniscal tear.

Do you really think that you are so unlucky?

That is just the arithmetic speaking.

**thebentwoods** · 02-12-2008, 03:55 PM

DrMark - I asked you a question at the top of page 4 in this thread. I was hoping you might have some insight on whether it seams the west coast is being more accepting of the allograft than the rest of the US.

Also, I have firmly decided to use an autograft. I like the hamstring (will be very fine with patellar too). I am wondering why you like the patellar and quad better. I can understand the patellar - everyone like it - but many websites only give a brief mention about the quad. Why do you make it your number two choice?

**thebentwoods** · 02-12-2008, 04:01 PM

Another two questions

1. If a surgeon is thought to be good at ACL repairs - about how many per year/month would you think they would be doing? I know there are other factors - but its one of the factors.

2. It looks like the PCL is just a mirror to the ACL. If the femor moves so much that the ACL tears - why does the PCL not tear with it?

**drmark** · 02-12-2008, 04:13 PM

I do about 100+ per year. I know people that do twice that number and screw most of them up. I am certain that there are those that do 10 a year and do them all well, but that is pretty uncommon.

The PCL is not a mirror image of the ACL. The only thing they have in common is the C and L.

**thebentwoods** · 02-15-2008, 05:06 PM

Patellar Autograft in March! Looking forward to it. The Dr. said that our region does a lot of hammies (Sacramento). He suggested it was because the Dr. who developed (or helped develop) the use of that graft was from this area. He said I'd have to find another Dr. if I wanted that choice. I'm glad he was decisive.

**altagirl** · 02-15-2008, 05:16 PM

Originally Posted by drmark

I dont remember telling you that you need to have patella tendon grafts for your ACL.

Here are the odds.
15% failure rate for allografts which usually leads to further meniscal/articular cartlage issues
06% failure rate for hamstring repairs which also leads to further meniscal/articular cartlage issues.
<1% incidence of new meniscal tears in stable knees every year even in elite athletes.

That means that if a person such as yourself sustains a meniscal tear on the reportedly well reconstructed knee, there is a 5x (for the hamstring side) or 15x (for the allograft side) greater chance that it is related to an undiagnosed or underreported ACL graft issue than a fresh new traumatic meniscal tear.

Do you really think that you are so unlucky?

That is just the arithmetic speaking.

I'm sure you're trying to tell me that both my surgeon and the other orthos who have checked out my knee are just lying to me for whatever reason and telling me that my ACL is just fine. I'm just not seeing it, or seeing why they would not tell me, hey, your ACL is overstretched or something and needs to be replaced. Especially considering that your typical justification for the allograft is that they're a bunch of criminals trying to make more money - why don't they want my money this time?

And I don't know where your numbers are from, but I've met plenty of people who have meniscus tears unrelated to anything else. I guess I just live in a world of anomalies...

**drmark** · 02-15-2008, 05:51 PM

I can't be sure of what what other people's intentions are, but from your story you either have a functional instability (could be ACL or could be posterolateral, or some other instability the docs couldn't find) or you are one of the most unlucky people in the world.

A reasonable person would find the former idea much more acceptable than the latter.

(And by the way, fear causes one to try to cover their mistakes to avoid liability and fear always trumps greed, but thats Machiavelli and is another story)

**thebentwoods** · 03-12-2008, 09:26 PM

Got my patellar autgraft today. I hated the drowsy feeling. It just went away. On to healing......

**Luiggi** · 09-01-2009, 03:10 PM

SnowTigress, Altagirl and DrMark,

This thread has been really helpfull for me. I completely torn my ACL playing soccer early this year and have recently decided to get surgery (yeah I know, kinda late). Living without doing sports at all is such a drag!!

Anyway, I got the option for an allo or autograft and I'm thinking on the second one mostly because of Dr Mark's input and experience and some other homework I've done. My current doctor is completely fine with either option for me. I'm 28yrs and planning to continue doing sports, big time... My surgery will be in about a week or so (haven't got the exact date yet), I'll try to update my experience here, so wish me good luck!!!

Any pointers/suggetions for a begginer like me? How's everyone doing???

**ThrindelSev** · 08-16-2010, 01:13 PM

Greetings,

In line with Dr. Mark, I must say that I always refer other athletes to the Patellar Autograft.

Perhaps some of you are familliar with Dr. James Andrews. For security reasons, I am not going to mention my name, but I am an athlete. I blew out my ACL playing football.

Dr. Andrews and Dr. Nielson suggested that the Patellar was the 'gold standard' and that it was 1,000+ newtons stronger (resistance) than the normal ACL tendon. (This is in comparison to the hamstring graft, which is -1,000 newtons weaker compared to the strength of the original tendon. That's a +2,000 newton difference.)

They also said that the hamstring was harder to fix to the bone.

They said that they do not do allografts for several reasons:

1. You could get the tendon from a 60 year old, and thus a weaker, older graft.
2. They have seen many cases where the allograft "loosened" over time. Think of it as a elastic band that lost its ability to contract.

They iterated that the patella autograft is substantially more painful in terms of tendonitis under the kneecap. I can agree with this. They are basically causing more trauma to an already injured knee. I don't know if I would have liked to have my graft harvested from my other knee, however. I would rather have on nagging pain in one knee instead of oddities in both. They agreed and we did the same knee patellar autograft.

When I went back for my checkups, they were astonished at how "tight" it was locked in. They marched me around Andrews Institute and showed me off to other doctors. I was bearing weight 2 days post-op. I had to be careful because I needed 30% of my meniscus shaved/repaired as well.

They put me on an accelerated PT program. I got full extension in 2 months. Those of you worried about flexion and extension, don't sweat it. Everyone is different. You just really have to "push" and fight through the pain during your PT. Due to the size of my hamstrings, my flexion is only around 138, but its the same for both knees, so I am not too worried bout that.

I had surgery on March 3rd. As of today, I am about 80-90%. I can jog for extended amounts of time. I can also sprint. The 'tightness" I used to get (when suddenly standing after sitting for a long period of time) is gone.

I noticed the greatest improvement in my patellar pain once I started doing leg presses, quad extensions, and free-weight squats in the gym. The first few squats were incredibly painful, but a week or so later, I have noticed awesome games in strength and the pain has all but vanished.

I am only doing half squats with around 225lbs on the bar. I don't go down to a full 90 quite yet. I'm slowly working into it. My goal is to start full cutting drills at six months. The Doctors said that I can make this a six month thing, considering how well my body has responded. I'm looking to start playing ball again this January.

Thanks to all the medical professionals who dedicate their lives for our well-being. Dr. Mark, I appreciate your insight on these boards, and I appreciate the sacrifices you have made to the medical community, and to athletes such as myself.

Kind Regards,

#42

**splat** · 08-16-2010, 01:19 PM

Looks like you're healing up very well. Count your blessings.

**Dexter Rutecki** · 08-16-2010, 02:04 PM

Get well soon, Ronnie Lott!!

**ska21** · 08-16-2010, 11:30 PM

Get well soon, Ronnie Lott!!

Na Dude, It's Johnny Utah, bra. Former Ohio State quarterback gone FBI agent.

**damagedgoods** · 08-17-2010, 12:52 PM

DR Mark currently I have a PCL completely torn, ACL completely torn, 1/2 my median menscus removed and all of my lateral menscius removed. I am only 33 and I know having the menscius removed opens me up to all sorts of long term knee damage. Currently the doctors want to put donors in for all of the ligaments but I have read countless studies about the extremely high failure rates for people that are under 40. I also have read how the studies show people that are very active will likely experience failure.

I cannot think of many jobs that are as damaging to the knee as being in the navy(as I am). Really only a few come to mind marines, army, construction worker. In any case the navy has to be in the top 5% of jobs that are knee unfriendly. Even firemen probably do not run up and down latter wells 4 or more times a day in 6-7 story buildings made of steel and stand for 12 to 17 hours a day. I am not trying to be dramatic but that is a good summary of my previous job.

So Dr. Mark or others what do you think of my chances or returning to sea duty? Also do you think I should argue for using my own ligaments for the surgery since they have a much lower chance of failure as opposed to donors ( I cant use my own ligaments for all of the injuries but some good material is better than all bad material IMO). Right now there seems to be resistance of using my own tendons because they say there is not enough material to cover all of the injuries.

**drmark** · 08-17-2010, 01:25 PM

If I was going to be operated on by a newly minted Navy Orthopaedist, I would have them do the lateral meniscal allograft, and an allograft ACL, probably have them skip the PCL.

Thats not what I would do, but it is what I would reccommend the young medical officer to do.

**Steeze Clown** · 08-20-2010, 12:47 PM

heyy DR MArK im totally hijacking this thread but I have 2 questions for ya, I had a hammy graft done by DR McConkey up in Squamish BC, he kills it.

In December I will be 7 months post op, is it realilistic to think i will be able to ski hard around this time? what about the end of the winter?

And how much does age effect recovery im 20?

**drmark** · 08-20-2010, 06:00 PM

You really need to direct this question to the man that intalled the new ACL

**damagedgoods** · 08-24-2010, 04:05 PM

Well a few of the Navy surgeons have been surgeons for 10 years or more and they have experience. Only one has experience in a meniscus transplant and seems weary of doing it. I am greatly concerned about the high failure rate of an allograft. From the other posts that I have read you seem to despise allografts why recommend them now? I suspect you fear the quality of surgeon and do not want to damage a good knee.

Since my laterial meniscus and 1/2 median mensicus where removed I have had marked increased pain going up and down stairs as well as a high degree of pain going down hills. If feels like my knee wants to pop out sometimes going downhill.

What type of surgery would you do and why would you recommend the navy doctors to do a different type, is one easier than the other? Would it be a good idea to use material from my good knee for some of the surgery? As for as I understand it the PCL is actually 2 seperate ligaments is this correct? Given the high failure rates of allografts in my age group do you really think they have a chance of holding up? I was an active wrestler for many years and would like to continue with other sports like boxing if my knee ever returns to normal/semi normal capactity. I also really think the narrow and steep stairs on the ship will cause significant problems for me. Your thoughts please.

Also Dr. Mark thank you I have read alot of your posts and you are providing a valueable service.

**drmark** · 08-24-2010, 04:47 PM

The vast majority of Navy Orthopaedists are young men fresh out of training working of an educational comittmement. They need to stay out of trouble, and take the simplist approach considering their lack of experience.

I would first check you alignment to see if an osteotomy was necessary. Then I would reconstruct the ACL with an autograft, and probably never touch the PCL. I would also consider a lateral meniscal allograft.

**damagedgoods** · 08-26-2010, 04:54 PM

Thanks Dr. Mark so far what they have done was replace the PCL with an allograft but only one of the ligaments was put in. At the moment they think it has streched out some and when they go in for the ACL the plan is to rework the PCL at the same time, 1st surgery was on Feb 22nd of this year. I just wanted to hear a second opinion after reading through this forum, also some doctors seem to downplay the failure rate of allografts.

There also seems to be some some questioning if my right knee has a streched out LCL or not since my left knee also has quite a bit of play in it. The test they did was an X-ray to see the space and then XRay again while pulling on it. As for myself when i pull on my knee i feel it move more than my left knee and when i shake it back in forth it definitely moves so i am uncertain why the doctors say its not moving much more than my left one.

Lastly apparently my ACL has been damaged for years but caused me very little trouble since I participated in wrestling and jujitsu at a high degree of competetion with little problems, obviously my luck ran out. The doctor who did the surgery said it was damaged for years along with the meniscus. Since my knee gave so little warning before falling apart and the doctors seem suprised that both knees move so much when being pulled on i am considering on insisting on an MRI on my "good knee" to find if it is also having problems but just does not have symptoms.

Your thoughts please.

**xxxxestwwgz** · 01-24-2011, 03:20 AM

hi
i hope i enjoy my stay here

pls be nice to me

thanks!

**GS828** · 07-24-2011, 11:38 AM

Originally Posted by damagedgoods

Thanks Dr. Mark so far what they have done was replace the PCL with an allograft but only one of the ligaments was put in. At the moment they think it has streched out some and when they go in for the ACL the plan is to rework the PCL at the same time, 1st surgery was on Feb 22nd of this year. I just wanted to hear a second opinion after reading through this forum, also some doctors seem to downplay the failure rate of allografts.

There also seems to be some some questioning if my right knee has a streched out LCL or not since my left knee also has quite a bit of play in it. The test they did was an X-ray to see the space and then XRay again while pulling on it. As for myself when i pull on my knee i feel it move more than my left knee and when i shake it back in forth it definitely moves so i am uncertain why the doctors say its not moving much more than my left one.

Lastly apparently my ACL has been damaged for years but caused me very little trouble since I participated in wrestling and jujitsu at a high degree of competetion with little problems, obviously my luck ran out. The doctor who did the surgery said it was damaged for years along with the meniscus. Since my knee gave so little warning before falling apart and the doctors seem suprised that both knees move so much when being pulled on i am considering on insisting on an MRI on my "good knee" to find if it is also having problems but just does not have symptoms.

Your thoughts please.

Interesting, I am in the same boat sort of. All the years of BJJ/Wrestling/Judo have put so much wear and tear on my knees. I am currently in the process of having a second ACL surgery (in under 1 year) on the same knee unfortunately.