Current ACL Repair Techniques

[keno]

I tore my left knee ACL 15 years ago and didn't have it repaired at the time. (I was told at the time that I was too old.) If it's doable without too much down time, I might have it done. I've missed skiing for more than a decade.

I've been recently told that the best current techniques are using cadaver ligament or using hamstring ligament, both arthroscopically I believe.

Has anyone had either of these? What was the nature and duration of the rehabilitation?

Thanks,

keno

[Blastinbob]

My ACL replacement, home for almost 2 weeks, just under a 1 month on crutches, couple months of PT and about 6 months before I was as good as new. When I had mine done patella tendion graft was the thing to do.

[mwos]

Me, :) last year on Feb 28th!

From April to Nov. I biked 2800 miles, did 3 bike tours and I've skied 30 days so far this year. I ski everything, bumps, powder, trees.

My ortho did a cadaver repair. It was his opinion that I'd have less pain down the road with a cadaver. If he did a hamstring it would affect my cycling. Plus, at my age, 58, I'd have younger tissue and a stronger repair.

I was on my trainer 9 days after surgery and riding outdoors at 4 weeks. I was not allowed to use clipless pedals until early June. At the end of May I was strong enough to climb Vail Pass with platform pedals.

Yes, it hurt painwise, but I only took 1/4 of a pain pill a couple of times a day for the 1st day or 2. I don't tolerate pain medicine well so its good that ibuprofin helped me. I was off the crutches after the second day and stopped using the brace within a week. I did lay on the couch for 3 days with my leg elevated, icing frequently and started easy pt the day after surgery. I didn't have a lot of swelling.

I was in physical therapy until early July.

I also tore my MCL, used a brace and had to wait 6 weeks before surgery. Even with PT prior to surgery I lost more than I realized. When I did Brat (Bicycle Ride Across Tenn) in Oct. the 80 mile days made me realize how weak my leg was and that I was not prepared for the kind of riding I was doing. I was subconsciously favoring the rehabbed leg. The same happened to me when I began to ski, the leg did not have the prioproception and strength that it needed. However, since I've been off the bike and doing more leg work I no longer notice that it was injured, it feels just as strong as my uninjured leg. BTW, I do not use a brace for skiing.

My ortho gave me his protocol (timeline) for PT so I was able to see where I was going. For me it helped me to maintain some sanity and set goals. I actually was ahead of his timeline.

While I can't say the experience was easy it wasn't the horrible experience that many of my friends said it was. The protocol for rehab has changed a lot in recent years, making the whole experience a lot easier. My frustration was losing the strength due to the MCL injury and then struggling on my 2 bike tours and the first days of skiing when I thought I was back to normal.

The current thinking is if you want to ski the surgery is the thing to do. Without an ACL you can damage other parts of the knee like the menicus which could be worse.

Kathi

[ThasFACE]

I tore my left knee ACL 15 years ago and didn't have it repaired at the time. (I was told at the time that I was too old.) If it's doable without too much down time, I might have it done. I've missed skiing for more than a decade.

I've been recently told that the best current techniques are using cadaver ligament or using hamstring ligament, both arthroscopically I believe.

Has anyone had either of these? What was the nature and duration of the rehabilitation?

Thanks,

keno

Had mine done two years ago with the patella graft. I was running after a few months and back to full activity in six. As with pretty much all acl reconstructions, I didn't really get pre-injury levels of power and fine motor control fully back until just recently (read: able to play soccer/ultimate/whatever at full speed with quick/powerful cuts). A friend of mine got his done with the hamstring and had a comparatively long and painful rehab. Of course, I have heard of others having great success with the hamstring surgery, so who knows?

From what I have heard, the cadaver surgery has the shortest healing time (provided that the ligament isn't rejected). No matter which surgery you do, though, you should expect to deal with five or six months of serious rehab/gym. It seems to me that the success of the surgery depends mostly on how diligent you are in your rehab.

[93legendti]

Very interesting thread as, thank G-d, my partially torn ACL has lasted 15 years (next month) without any trouble. I avoid tennis and basketball as much as I can. Skiing with a ACT brace worked real well.

[Ginger]

Keno,
One other...Quad tendon.



Surprised no one has mentioned it. My doc does it on older patients, and those with patellar tendinitis in the past (me)

I also had the MCL tear, so the ACL was severed in October, 3 months in the brace, ACL surgery in January, then I think I started PT within the week.

15weeks I was released to go about my business.
Expected actual recovery is 1 to 2 years for the new ACL to revascularize.

Mine was back to "normal" in 1 year. I had a slip and fall and they did an exploratory surgery the following April and my ACL "looked like a normal ACL"


Studies have shown that initial recovery may be faster for cadaver tendons, but overall, the patients wind up in the same place at the same time recovery wise. You don't have the injury site from the graft...

I will tell you that a quad tendon is NOT a pleasant graft site because you can fake it with a hamstring, but every single time you move your leg, you use your quad. And it hurts like someone is sticking a knife in there....every time you shift in bed. It is the only surgery I actually took ALL of the prescribed drugs.

On hamstrings: The tendons they use are supposedly "accessory tendons" In other words, they aren't "really" necessary. But it has been my experience with a removed "accessory tendon" in my ankle that those seem to work with refined movements. Not a big deal with the ankle, but I'm not sure I'd want to mess with my leg.


ANother thing to look in to:
I was recently reading that some doctors were experimenting with a double graft replacement. As the ACL is actually two tendons they're trying to replicate that action by replacing it with two grafts and giving the patient a more realistic knee action...but I read that *after* my surgery.

Now that they've taken a better look at the cadaver tendon industry, I would n't hesitate to go that way. For some reason I had the heebie jeebies about it when I had my knee done. Can you imagine getting a recall on a graft because it was incorrectly harvested?

[Birddog]

I severed my left ACL 36 years ago, and tore the right one about 22 years ago. I have had neither repaired. I also have a "bucket handle" tear in the cartilage in the left knee. After making my decision about repair (some 15 years ago) the Doc said I made a good decision based on the fact that I had already gone so far/long WO it, and was apparently doing OK. It was around that time that I took up cycling again. I ski regularly, and I ski hard and don't limit myself much. I like moguls and black runs as much as I like powderoy and groomers. Occasionally, I get a little tender in the left knee after an especially hard day. The only thing that has ever really bothered me skiing is wind slab or crud, and it's been awhile since that has been a factor. I never have used a brace, I'm convinced that cycling has strengthened the muscles to the point that it really isn't an issue.

Birddog

[93legendti]

I severed my left ACL 36 years ago, and tore the right one about 22 years ago. I have had neither repaired. I also have a "bucket handle" tear in the cartilage in the left knee. After making my decision about repair (some 15 years ago) the Doc said I made a good decision based on the fact that I had already gone so far/long WO it, and was apparently doing OK. It was around that time that I took up cycling again. I ski regularly, and I ski hard and don't limit myself much. I like moguls and black runs as much as I like powderoy and groomers. Occasionally, I get a little tender in the left knee after an especially hard day. The only thing that has ever really bothered me skiing is wind slab or crud, and it's been awhile since that has been a factor. I never have used a brace, I'm convinced that cycling has strengthened the muscles to the point that it really isn't an issue.

Birddog
When I partially tore mine, I saw the surgeon for the Detroit Lions, who told me 1/3 of those with ACL tears need surgery immediately, 1/3 will need it later on and 1/3 will never need it. You are in the lucky 1/3.

[kestrel]

I injured my ACL years ago, but a little over 3 years ago I broke it completely. I got a great Doc, He X-rayed and MRI'ed it, then told me to let the injury heal, then resume riding for at least a month or two and let him know once I'd regained my bike fitness to the pre-injury level. I stayed off the bike for two weeks, then began riding again, once I felt comfortable on the bike, I called him and setup an appt. We decided at my advanced age (58) we didn't want to mess with using my own hamstring, so he did a tibialis donor cadaver replacement. I was on my feet with crutches that day, and putting weight on it the next day. There was also some minor miniscus damage that he stitched, reminding me that would take longer to heal than the ACL replacement. I would classify the pain as mild, nowhere near unbearable, I did stay on the prescribed meds. I stopped using the crutches in 3 or 4 days, and was cycling on a stationary bike at therapy by the next week. The first time I tried the bike, I couldn't get my right leg to circle over the top, so I rocked it for about 4 or 5 minutes. The therapist said to force it over while backpedaling. For some reason it was easier to backpedal than to go forward. The next day I began forcing it over the top and I haven't looked back since. The doctor said once I could pedal the bike, I could quit therapy, so I never went back. His physicians assistant gave me a group of progressive excersizes and I stuck to them faithfully. I rode outdoors 20 miles easy by the end of the third week (clipped in with Looks). I started riding everyday at that point, either outdoors or on a trainer. I didn't try to get back on rollers for about two months, by then it was getting warm enough to be outdoors most of the time anyway.
During the first year, I felt it a time or two, and early morning walks to the mailbox let me know there was something slightly different about my right knee. Minor discomfort, I wouldn't call it pain. Heck the good knee usually hurts more. If I go inactive for more than two or three days, the knee tightens up and it takes a few minutes of stretching to get it back to full range of motion.
All in all I'd say it was the best thing I could have done. He released me for most activity after 6 months, and after a year he said do whatever I wanted to do, the risk of injury was the same or better than the other knee. I can run, play some soccer with my boys, and ride all I want pretty much pain free.

Do a search here and at Bikeforums for ACL replacement and you can find others in the same fix.

[toaster]

I might have to give a castastrophic failure report in a couple of months on a repair done with patella tendon graft done on a fellow cyclist. Against common sense and doctors advice he was on the bike in about a week and did 40 miles first time out. He then followed up that bike ride several days later with a 70 miler with a couple thousand feet of climbing. His knee swelled up both times and still he went on the bike for training rides. Six weeks later he was racing a 45 minute criterium (barely finishing in near last position but still claiming he helped his teammate with some blocking early on).

I don't know what's going to happen. I figure he'll probably end up with a knee replacement.

[stevep]

I might have to give a castastrophic failure report in a couple of months on a repair done with patella tendon graft done on a fellow cyclist. Against common sense and doctors advice he was on the bike in about a week and did 40 miles first time out. He then followed up that bike ride several days later with a 70 miler with a couple thousand feet of climbing. His knee swelled up both times and still he went on the bike for training rides. Six weeks later he was racing a 45 minute criterium (barely finishing in near last position but still claiming he helped his teammate with some blocking early on).

I don't know what's going to happen. I figure he'll probably end up with a knee replacement.

toaster,
hes a dope.
s

[Ginger]

I know others who ski etc without an ACL. The Breg braces are pretty dang good these days, I even raced my mtb with the mine.

My ACL needed to be replaced because when it snapped, the one end jammed up into the front of my knee and I couldn't straighten the leg. It probably should have been operated on immediately, although the torn MCL would not have allowed it to heal correctly...or so I was told.


I have a Canadian friend with a Gore Tex ACL. (I don't think they use those any more...)

[catulle]

I've been recently told that the best current techniques are using cadaver ligament or using hamstring ligament, both arthroscopically I believe.
Thanks,
keno

Can we do a Gram Parsons and get Fausto's ligaments, maybe...?





Seriously now, I hope you get well soon, Keno.

[PK9]

I tore my ACL a coupla years ago and had it replaced with my patellar tendon.

What I learned from my physical therapist (who had done a stint at the Olympic Training Center) was this:

-- If you don't feel a driving need to run and jump, surgery may be not be the right choice for you. By and large you can function quite well without an ACL (and maybe with a brace) if you're just riding. But no fixie for you.

-- Whatever your local specialist does will probably be the best choice. If he/she does patellar, great. If they do hamstring, that may work best.

-- Cadaver will probably be fastest and least painful recovery, UNLESS (a BIG caveat here) your body rejects it. In which case you're in for a world of trouble.

As it happened, my specialist did patellar. I had problems with scarring on the patellar tendon, but was back on the bike in a month. I worked VERY hard and was back on the fixie in about 2-3 months. Took about a year til I was kinda balanced left and right.

My post-surgical knee does pretty well. But, it is NOT the knee I started with. It's not quite as flexible. It's still numb on the skin next to the incision scar and I've taken to icing it after rides as a precaution.

What I've learned is from all this is that you only get two knees: treat them as well as you can given an active lifestyle. I myself NEED to run and jump and surgery WAS the best (if not least troublesome) choice for me.

Good luck.

[Lincoln]

PK9 pretty much hit the nail on the head. Shop for the best doc. you can find and let him do it however he prefers.

Anecdotally, I would say that patella has the quickest rehab back to activity but a higher incidence of long term issues at the donor site. Hamstring is the opposite with a little harder and longer rehab but less long-term issues. I don't know much about cadavers other than they had fallen out of favor for a while and seem to be making a return.

I had mine done a couple of years ago. One of the pluses to living in a ski town (and HQ of the US Ski Team) is that we have a great selection of orthopedic docs (knee specialists in particular) in town. The group that did mine do many of the ski teamers and also did Tiger's a few years back, Eric Heiden and Max Testa joined their group last summer.

My surgeon (Dr. Cooley) prefers to do hamstrings so that's what I got. With hamstrings one thing check out is how they take the graft. The newer technique is to take one longer graft rather than two shorter ones. This is a little tougher to take out but only does half the damage to your hamstring making recovery quicker.

Also keep in mind that selecting a good PT is nearly as important as selecting the doc. If you already know some good PTs then I would ask them to recommend some doctors.