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

[altagirl]

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).

FWIW - I take vitamin/supplement type pills regularly, but almost never take antihistamines, cold medicine, pain killers, anti-inflammatories, etc. I try to eat well, but figure vitamin supplements and such are probably good for me vs. things that are suppressing my body's natural reactions, especially since they all seem to have side effects I don't like.

[Buzzworthy]

I don't like to take a lot of pills, but when pain like this is involved, I will take the pills. But I do not go overboard, as I have an addictive personality and don't want to start any problems with potential addication. I am just being careful about it.

[SnowTigress]

I'm with Buzz. I'll take the advil for pain and inflammation since I only need them occasionally. No rules against comfort for me!

An issue I am encountering with the PT graft that I don't recall with the allograft is the rebounding stiffness I wake up with each morning. I spend each day working on my ROM, loosening up the patella (mob-ing), massaging any spots of fluid build-up and doing all the quad sets, straight leg raises, etc... as directed. I feel great on the way to bed...really limber and strong. But in the AM, my patella feels like someone super-glued it in place and the front of the knee feels very tight. I understand that this is due to scar tisssue that is being built up in the donor site. It's an annoying case of 2 steps forward, one step back.

The other thing that sucks (and it sucked last time too), is sleeping.The leg has this dead-weight feeling to it that drives me nuts.

[Natedogg]

Sorry for taking this thing offtrack. My bad. Glad to hear everything is going well!!

stoked on squats and spin

Uhhhh, right. Whatever gets you back in the saddle faster.

[SnowTigress]

Pain: None really...except after standing/walking around for multiple hours, gets a bit swollen and tired, start limping more.
Stiffness: Minimal. Full extension still, 120+ degrees flexion. Feels good to go around full circle on the bike and work out the kinks in bending.
Weight Bearing: No problem. Even ok on stairs. Can stand on one (bad) leg with good stability. No brace, no crutches for last 2 weeks. Not wobbly at all.
PT Activities: Heavy focus on quad strength in extension with solid straight leg raises (at home 3x/day), cycling, hamstring and glut work, shuttle and squats (for quad strength in flexion). Still struggling a bit to loosen up scar tissue that prevents clean gliding of patella, but progress each day. Cycling helps this a lot. *Didn't have this as much with allograft.
Morale: Stoked. I am mobile (walking slowly!) and even made it up to Tahoe for the KW Comp festivities. Fun! Getting this graft really was not as bad as I thought it would be. If it means a potentially stronger outcome, it is totally worth it (so far...).

Was told the 6th-8th weeks are when you're really vulnerable because you feel great, but it's right about when the bones from your leg are fusing with the bone chunks on either end of the graft. You have to be super careful not to push too hard til you cross the 8 weeks mark.

Will report back then!

[steved]

All the Best of luck SnowTigress.....next season has to be a better one than 06/07....

[SnowTigress]

I can't believe it's been that long since the surgery! Been MIA on TGR for a while and thought I'd drop in with and update and say hey!
Knee is really strong. Graft is tight. Doing a lot of spinning, eliptical, glut, quad and hamsting work. Focus is on stablization using the whole muscular complex of the legs and torso, taking stress of hip flexors and joint. Feeling really tight and sore all the time from all the stregth training...but in a good way! I finally got back on my mtn bike with WaterSnowDirt and we did a mellow ride in Pacifica. I still ate shit and flew head first into some poison oak (scratch, scratch), but the knee was fine and I was stoked to be out there again!!
I have only one complaint at this point. The area around one screw is a inflammed and my PT thinks it's because of over-strengthening the quads vs. hammy. Working on balancing that out. So far so good. So far I have also avoided any patellar tendonitis. Woo hoo! I think PT is absolutely amazing. Such a delicate balance.
Though I can skip up stairs an jog briefly, I am still dreaming of trail runs, tennis and soccer. But PT urges me to wait for some time. She wants to make sure I am super strong and the whole joint has has its fair time to heal. Dont need a third acl surgery! I keep hearing about re-tears through her. At least 3 of her patients who had surgery around the same time as me are getting back out and doing stupid stuff too soon and coming in to the office in tears...back to the OR!! It's one thing to train aggressively to gain strength in the muscles and reduce swelling, but you can't force biological processes. It really does take a full year for everything to heal. And I'm gonna take it slow and steady....I wanna be skiing when I'm 90!! I've got 61 years to go!
See ya'll in 2008! Shout out to Walt Sob and Hemas who are in the same boat. Hang in there friends...and thanks for the posi vibes Steve!

- Tigress Over and Out

[Natedogg]

Been MIA on TGR for a while and thought I'd drop in with and update and say hey!

No shit! Shes baaaaaaaaa-aack.

[SnowTigress]

so we are 6 months post op.

all is great except I am growing a second knee cap where the screw is coming out. it's ginormous and really friggen painful. surgeon took one look and said, "wow, you're having a really bad reaction to those!" no kidding.

screws (that's right, 2 of em) out next thurs. looking forward to being painfree and DONE with the knee saga! should be simple IV sedation, unscrewing and 2 weeks of nothing too strenuous. Then I'm home free! Yahoo!!!! (Fingers crossed!)

[SnowTigress]

Today was a great day.

Got some painful hardware removed finally, bringing this ACL-redo drama closer to the end. It had been many weeks of discomfort due to a few screws that had decided to start coming out of my tibia. They were causing all kinds of inflammation and adding to the scar tissue build up. Yuck! So they put me under once more (interesting how we went from discussion of a simple local anesthetic and possible iv sedation to full on general anesthesia...I’m not complaining, just weirded out by the huge discrepancy between talk and action ), and took those puppies out.

Before: seriously swollen, painful and gross…we’re talking fluid build up above and below the knee…and it jiggled when I walked. Hot. I know.

Swelling

Look mom: two kneecaps!


After


Putting these under my pillow tonight...just in case there's a screw fairy.
Got a bit of pain, but nothing intolerable. Vitamin V is helping me out some.

Visions of trail running, mtn biking and skiing dancing in my head. Also planning on hitting the hills harder with the roadie. No more restless, painful leg! Ooh, and dont forget backpacking...and climbing....and windsurfing. Yayyy!

Cheers!

[hemas]

Today was a great day.

Visions of trail running, mtn biking and skiing dancing in my head. Also planning on hitting the hills harder with the roadie. No more restless, painful leg! Ooh, and dont forget backpacking...and climbing....and windsurfing. Yayyy!

Cheers!

That's great to hear...

And great that they let you keep the screws... They are mucho expensive (I think my screws were over 250 € a piece).

As for climbing, I've been at it since 4.5 months post-op... Just be careful, don't do any absurd problems/routes (where ya have to really twist yer leg) and don't book a lot of airtime...

Funnily enough, I'm more or less to my original leisure climbing shape, OS 5.9's and occational 5.10 as well as flashing V2's... Heck, I've even managed to nearly flash a V3/V4 (I think it was pretty soft for the grade), and got it on the 2nd go.

Henkka, still missing an inchand some from my quad... But it's getting better and better all the time.

[SnowTigress]

thats great to hear henkka! glad you are doing so well!! thanks for checking in!
yeah, climbing will not be for a while for moi, but it will be one day. i do not plan to go in for a 4th knee surgery thank you very much!
and you're right on the screws...VERY expensive!! Gonna find something creative to do with mine!

[hemas]

and you're right on the screws...VERY expensive!! Gonna find something creative to do with mine!

Necklace...

[SnowTigress]

good idea, walt.

so how YOU doin'?

we gotta road bike soon! Moss Beach to pescadero and back, baby!! that's a good 70 miles! I'll be good to go in about 3 weeks. Gimme a ring!

[Steve.N]

Tommorow will be 4 weeks post op for me. I'm doing really well in my opinion, I've got full extension and can bend to 124°. My only problem seems to be swelling right below the patella and the outer side of the knee.

[SnowTigress]

I still keep getting better every day! I did 45 miles on the coast yesterday, but with almost 5k climbing -- Tunitas Creek Road is my new proving ground for the next few months. I'll send you the map. Let's ride in October!

or you could always come sample some of our nice hills oer here in Berkeley! good for the quads. good for the soul.

[jmk]

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.

By way of introduction: I am an anesthesiologist. I just tore my ACL on Sunday playing soccer and now must face real surgery related to sports for the first time in my life (I played collegiate soccer and have been knocking around competitive soccer since - also like to ski, bike, etc.). Total bummer! However, I am researching the allo vs autograft question. The argument you presented does not meet any standards for validation: I would never question the money issue you raise - I am sure there is truth there. However, you have cited no reference when you mention the revision rate being 4 to 5 times higher with autograft. Moreover, when it comes to the infection question, you don't address statistics at all, relying on the scariness of infection as evidenced by "everyone sh1ts their pants before giving a transfusion" which is just a bit inflammatory don't you think. After all, I give blood not uncommonly in the OR and have no problem with it at all if my patient needs it. The transfusion related infection rate is very low indeed. I can get the figures for you if you want.

That all being said, I am still avidly reading this board for the wonderful input from all. Thank you all very much for your insight. I am not looking forward to the rehab after surgery. One question: I am planning to take one week off of work (9 days) to recover before going back. Is that enough? I think I will be fine. I would love to know from all of you who have had this surgery what you think. Thanks in advance.

[Mofro261]

That all being said, I am still avidly reading this board for the wonderful input from all. Thank you all very much for your insight. I am not looking forward to the rehab after surgery. One question: I am planning to take one week off of work (9 days) to recover before going back. Is that enough? I think I will be fine. I would love to know from all of you who have had this surgery what you think. Thanks in advance.

I am a 3-time ACL loser, 2 hamstring autografts in the distant past and then an allograft this May. I was conflicted as well on whether to go for a allograft or a patellar tendon graft this last time. But my Surgeon, who was highly recommended by my primary physician and my PT person, wanted to go with the allograft due to my age (30's), my fondness for running, and for the initial recovery time being shorter.

And while I do think the initial recovery was shorter, the overall return to sports is a few months longer, 9-12 months as opposed to 6-9. I have been very vigilant at rehab 1.5-2hrs a day, and at 6 months I'm just returning to running. Granted, my doc has a slightly conservative return to activities program. But if you are an avid soccer player that's something to keep in mind.

I had surgery on a Wednesday and was back at work the following Wednesday and realistically could have gone back on the Monday, so I think 9days should be sufficient. But nine days out your mobility will obviously be restricted and if you are on your feet a lot at work you may want to consider a few more days. Other factors could be secondary damage in the knee- meniscus etc.

Good luck on whatever you choose.

[Vinman]

a week to 10 days is pretty sufficient to get over the inital pain and begin to regain quad control. This could well be very different for you but on average this is typical. For you, if you would be able to sit in the OR instead of being on your feet it would better, if you do plan on getting back to work quickly, so that your knee does not swell.

2x ACL recon for me and work in the sports medicine profession as a certified athletic trainer. I was off crutches after 3 or 4 days after my second surgery(hamstring graft 1st, patellar tendon 2nd) and back to work after about 10 days.

[ikkin]

i just had allograft acl recon october 3rd and took two weeks off from work, but i honestly felt pretty good after one week so i think 9 days will be perfect. good luck. i'm a soccer player too, also played in college, and i know what a bummer it is to lose out on that- not to mention the ski season. rehab isn't too bad so far, so don't worry too much about that. it's really just putting the time in more than anything else. not incredibly painful.

[jmk]

Thanks very much to those who responded. Your input is very helpful. I really appreciate it. Again, great blog..

[Dexter Rutecki]

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 was just with my ortho this morning discussing the imminent revision of my shredded, reconstructed ACL. I'm having the surgery in the spring so I can ski with the little girls this winter, but he indicated that allograft would likely be his preference (I had assumed I'd go with the hamstring, as both patellas have already been spoken for). He told me to do my own research and we'd discuss it, but it seems that his preference is to do the allo. Is it true that the revision rate is that much, or even appreciably, higher for allografts? And has that stat been controlled for other factors that could explain it?If so I'd definitely go hamstring, although I've been worried in the past by reports of it being more prone to stretching. And what are the infection/rejection risks? I'll be checking all this out over the next few months, but I was wondering who might have good info already to start with.

edit: to chime in on jmk's question, I'm also a two time ACL recon person (soon to be three, dammit), and for the last one I was back at work in four or five days, but I was able to keep my leg up for a good portion of the day and didn't have to stand too much. Anything over a week should be good for most people, unless you have to stand/move around a whole lot, then you might need more time.

[0BernhardFranz]

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.

Could not find it either I checked studies after studies.So I would go ALLO as it is saving you the extraction operations.Saving one or two extraction operations is not like saving two bagels for tomorrow or anything, oh no, you can even die of it.

See about surgeons. I BMX jumped ca. 500 000 times as kid.Now I am save.But say you did something 4 times you might not be good at it but need many many uses to be good at it.Same with surgery.So if a surgeon did one procedure 4 times and another 1000 , he might be better with it.Though many things can be transfered from procedure to procedure like sewing skin etc. .Looking for a doc with many OPs of that particular kind improves yor chances.At UNI clinicum you can go to hell my doc ma says as doctroral students are trying out their craft.Sure can get to old with to many procedures.

[thebentwoods]

Dr. Mark,

Do you see any indications that the western US is more accepting of the allograft while the rest of the US says the allograft is a weaker option? I can't validate it or not and was wondering if you've noticed any pattern like this.

I sure am having a tough time deciding on graft choice. My doctor says he does 95% allograft - due to people's choice. However, I believe that based on a statement like that - people will go with the flow and choose the allograft. I just don't know to how much degree is an allograft "weaker". I am pretty convinced I want to go the autograft route. I will leave it up to the Dr. which type of autograft he does the best.

[altagirl]

I just had my right knee scoped again (repaired meniscus tore and locked again after 2 years), but the allograft in that knee is still looking solid - I think that puts it at something like 3 1/2 years (and two meniscus injuries) on the allograft, but the ACL is holding up well.

I'm still happy with mine FWIW.