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Bill and any others out there who might have some insight....
Have any of you heard that the use of the hamstring tendon in ACL replacement is frowned upon due to the elasticity of this particular tendon? I have been told by several PT/ATC's that this procedure is rarely done anymore and that it is the last option after 1)cadaver ACL(gold standard) 2)patella tendon 3)artificial ligament - gortex?
The examples given to me were the athlete who has this procedure done and re-injures the knee and has it deemed another tear upon manipulation while the MRI shows the ACL still intact but badly stretched. I have an athlete who just busted her behind to get back to 100%+ in around 5 months only to have it injured yesterday in practice....I will be PISSED if their preliminary diagnosis (maybe re-torn ACL) is actually a stretched hamstring tendon ACL replacement that is still intact.
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Robert dos Remedios, MA, CSCS,
HCC (Hartman-Cosgrove Certified)
Director of Speed, Strength & Conditioning
College of the Canyons, CA http://www.canyons.edu/departments/pe/strength
"NO CHAMPION HAS EVER ACHIEVED HIS OR HER GOAL WITHOUT SHOWING MORE DEDICATION THAN THE NEXT PERSON; MAKING MORE SACRIFICES THAN THE NEXT PERSON; WORKING HARDER, TRAINING, AND CONDITIONING HIM / HERSELF MORE THAN THE NEXT PERSON; ENJOYING HIS / HER FINAL GOAL MORE THAN THE NEXT PERSON"
From talking to a number of different orthopods - including a few that are friends of mine - (I have bad knees and have had both operated on and take an undue interest in the structure and function of that particular joint), they have said that the choice to use either a cadaver's (called allograft), patellar or hamstring is dependent on a number of different factors since apparently neither the hamstring nor patellar use method are universally considered better than the other. The factors:
-what the surgeon is comfortable with. Most surgeons prefer one or the other simply because they do more of one or the other. I.E. their own expertise and experience. This is probably the overriding factor in the majority of surgeries since many patients will not seek out the different alternatives for replacing the tendon.
-often the hamstring tendons (2 are usually 'bundled' to make a 'new' ACL) are preferred because of the lack of patellar pain in recovery (they need to remove the bone as well as part of the patellar tendon, where with a hamstring graft they only need to remove part of the tendon). In addition, the chance of patellar fracture or patellar tendon rupture is higher after using the patellar tendon since part of the bone is gone as well as part of the tendon.
-The preference of the patellar tendon over the hamstring is that you are grafting bone to bone and the strength of the resultant structure will be much stronger than a hamstring graft, which also must be held in place for a longer period of time during recovery to allow full healing. In addition, sometimes there are complication with the hamstring stability post-surgery (i.e. pulls/tears). Also, the patellar tendon resembles the ACL in more respects than the hamstring tendon does (as far as types and volumes of loads encountered).
-As you mentioned, the preferred method nowadays is allograft from a cadaver. Obviously you have the exact same 'part' being replaced, and the older problems of disease transmission are minimal. In addition, if for some reason the allograft were to fail, you could still go back and harvest either the patellar or hamstring tendons for another try.
Of course, all of this doesn't answer your question, so I called my friend (an orthopod). Here is what he said: there was a study published in the Journal of Sports Medicine [I think that's what he said it was anyway] that showed that patellar replacements were stronger than hamstring ones. His comment though was that the strength will really depend on the thickness of the tendons and that is obviously a very individual matter. He hadn't heard of a stretching of the hamstring tendons being a problem, but did say that for the rare surgeons who offer both techniques, people invloved in aggressive sports play are usually given the patellar graft (due to strength of bone to bone healing) and less active people are usually given the hamstring graft (because the healing time and pain are apparently shorter).
My friend said there is no current widespread use of synthetic grafts in the US.
Hope that helps. As with most things, the answer is usually far from clear cut, and there is always some marketing involved [img]smile.gif[/img] (in this case, what the surgeon has a preference in doing).
One final comment: obviously the experience of therapists like Bill who are on the front lines of the healing and recovery long after the surgeons have departed may be different. My post was from the viewpoint of the orthopedic surgeons. Also, all three procedures are still widely performed in the US.
In 13 years of PT, I've probably seen a small handful of ACL reconstructions that used the hammy tendon. This [Indy] is the birthplace of the modern ACL reconstruction protocols(Dr. Shelbourne)at Methodist Sports Med. so they all tend to follow the master using patellar tendon grafts. Rehab has much better outcomes. Of course, I say that because the docs here just use them more frequently.
In most cases of hammy tendon use it was the result of do-overs where the patellar tendon has already been harvested. These cases usually did not intend to return to high levels of sport in my experience.
I have only seen failed synthetic grafts in clinic prior to getting their second surgery. Actually one was a surfer-dude from Hawaii who moved to Carmel, IN so his kids could see the change of seasons [what?!?]. I think he was hit on the head by his board too frequently.
Sorry to hear about your V-baller. Any idea what her stability was like before the injury (KT1000)?
Quick story...my first year in clinicals I got to assess a football player with complaints of knee pain. Showed no instability but was found to be missing ACLs in both knees and by the description from the surgeon, he hadn't had them for a long time. He had the biggest hamstrings I have ever seen. Seems he'd been substituting for the ACLs with some serious hammy strength.
Thanks guys.....I talked with a friend over @ UCLA and she gave me similar info.
In the case of my athletes, her pateller tendon was too thin and the risk of tendinitis would have been very high (that's why they went with the hamstring graft).
I will let you know what happens after the MRI....she was walking around campus with a little limp but felt "strong" so who knows??!?!
__________________
Robert dos Remedios, MA, CSCS,
HCC (Hartman-Cosgrove Certified)
Director of Speed, Strength & Conditioning
College of the Canyons, CA http://www.canyons.edu/departments/pe/strength
"NO CHAMPION HAS EVER ACHIEVED HIS OR HER GOAL WITHOUT SHOWING MORE DEDICATION THAN THE NEXT PERSON; MAKING MORE SACRIFICES THAN THE NEXT PERSON; WORKING HARDER, TRAINING, AND CONDITIONING HIM / HERSELF MORE THAN THE NEXT PERSON; ENJOYING HIS / HER FINAL GOAL MORE THAN THE NEXT PERSON"
I was pretty careful not to be TOO aggressive in her rehab. Kind of followed the University of Oregon 'aggressive' protocol. We kept a pretty close eye on her to make sure we weren't going too hard and possibly setting her up for tendinitis etc.
We actually just finished testing the day before her practice injury and she exceeded all pre-surgery strength tests, VJ, agility, speed etc. Also was performing (quite well) aggressive, multiple movement chaotic-style drills since early August (about 3.5 mos.). This was an ACL only injury.
__________________
Robert dos Remedios, MA, CSCS,
HCC (Hartman-Cosgrove Certified)
Director of Speed, Strength & Conditioning
College of the Canyons, CA http://www.canyons.edu/departments/pe/strength
"NO CHAMPION HAS EVER ACHIEVED HIS OR HER GOAL WITHOUT SHOWING MORE DEDICATION THAN THE NEXT PERSON; MAKING MORE SACRIFICES THAN THE NEXT PERSON; WORKING HARDER, TRAINING, AND CONDITIONING HIM / HERSELF MORE THAN THE NEXT PERSON; ENJOYING HIS / HER FINAL GOAL MORE THAN THE NEXT PERSON"
Irregardless of the source of the graft in an ACL reconstruction, the collagen composition of the graft changes over time. Allo or autograft, hamstring or patellar harvest. While the 'feeling' of security doesn't necessarily diminish, the strength of a graft does decrease over time. Cross-sectional micrografts of grafts show an average decrease in the diameter of the collagen fibres that compose the graft (i.e. instead of a small number of larger diameter fibres, there is a large number of small diameter fibres). While the overall diameter of the graft itself doesn't change, this fibrous conversion (which is performed by the patient's fibroblasts, though no one understands why, even in an autograft) does affect the physical properties of the graft.
Ultimately, all the collegen in the original graft is replaced by the new stuff that is laid down, and further changes are just normal turnover--so there is an 'endpoint' so to speak to how much the graft will actually change.
Hello All, as we all know the new ACL reaches its weakest point at the end of 6 weeks. Are there any precautionary measures/active measures that one can take to keep the new ACL safe? My OS has me on a brace for 3 months. I have been told that I can stop wearing at night at the end of 6 weeks. however besides the standard precautions ie. wearing a brace, using crutches till you are FWB without limp etc, is there anything else I can do to keep the ACL safe?
Hello All, as we all know the new ACL reaches its weakest point at the end of 6 weeks. Are there any precautionary measures/active measures that one can take to keep the new ACL safe? My OS has me on a brace for 3 months. I have been told that I can stop wearing at night at the end of 6 weeks. however besides the standard precautions ie. wearing a brace, using crutches till you are FWB without limp etc, is there anything else I can do to keep the ACL safe?
Thanks,
Gaurav
Just be careful. The main reason 6 weeks is the 'danger zone' is twofold. First the new tendon is at it's weakest as it begins to build into its new job and second is that you're finally starting to feel better/normal again and might try to do something. Just follow your surgeons/PTs protocol and you'll be fine.
To the original discussion, IIRC my surgeon was trained under the person in Indy. He explained to me that if I wasn't going to go back to sports then a hamstring graft would be okay since the recovery could be faster and have less pain, but it would be a weaker fix. His preference was the patellar graft which is what I got (why fix it at all if I wasn't going to do sports anymore?).
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"Only those who will risk going too far can possibly find out how far one can go." -- T.S. Eliot
"We are what we repeatedly do. Excellence, therefore, is not an act, but a habit."-- Aristotle
Hello UConJulie, yes I will be. I am already 10 days post op. My PT tells me that wearing the brace at all times should keep me safe. In general my OS and PT have advised me to
a) Use the brace for the next 3 months + wear it at night for the first 6 weeks post op.
b) Use crutches till the PT says I'm ok to stop using them.
c) My PT has restricted my activites and am following his instructions strictly.
Given that the graft is re vascularizing over 12 weeks and is at its weakest for the first 6 weeks I was just wondering if there was something I could do at my end.
Regards,
Gaurav
PS : They used a Patellar Tendon for my reconstruction.
Gaurav, check here for info on when I had my ACL done last year. I kept a decent log of my recovery and had lots of questions similar to your answered.
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"Only those who will risk going too far can possibly find out how far one can go." -- T.S. Eliot
"We are what we repeatedly do. Excellence, therefore, is not an act, but a habit."-- Aristotle
Most orthopods have very established post-ACL rehab protocols. As long as you're doing what you're told, there's nothing else you need to worry about. Chances are, if your surgeon has been practicing for a few years, the PT that works for them has it down pat. Recovery is very predictable in a vast majority of cases, regardless of where they took the graft.
Just found out this forum through Google search, and I wish I found this earlier before I went through an ACL Reconstruction. I'm at my 6th day now post Ops and quite feeling better now from the operation. Not until I've read this thread and kinda made me sad on all the insights I've read regarding the use of Hamstring as Graft, as this is the one that was used for my reconstruction. The choice between the Patellar-Tendon and Hamstring Tendon Graft were indeed presented to me by my Ortho, but was advised that the main difference will be mainly as to how big the incission on the knee will be.
The reason I went through the reconstruction is to bring back myself to a more active lifestyle, and that is mainly in sports activities. Sad that I didn't manage to chose the stronger fix...
FonB, I wouldn't worry about it. The one person I know who did the hamstring fix has had no limitations in her activities. She never played soccer again out of choice, but has since run marathons, lifts daily, etc...
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"Only those who will risk going too far can possibly find out how far one can go." -- T.S. Eliot
"We are what we repeatedly do. Excellence, therefore, is not an act, but a habit."-- Aristotle
FonB,
No worries...I've gone through ACL (Cadaver) reconstruction. Both times, It took about 4 months of rehab and I was back doing everything I had been doing. Both were baseball related injuries. One thing to keep in mind....don't rush the rehab. Take your time. You knee may feel better, but believe me!! it will take double the time to recover if you rush through and re-injure your knee. Take the time to do it right. Good luck!
Thanks for the advice guys, it's realy quite comforting!
Though I must say, seems I become a bit pharanoid about my actions lately after coming across on these threads. I went back to my braces now when cruching, though my Ortho says that I should already practice walking without it. Prankly, I already felt good on my 5th day post Ops that I manage to walk without cruches and brace but still ofcourse limping. But now, seems I feel I maybe rushing things and afraid to mess-up my rehab.
1 quick question. During this "danger zone" weeks, is it possible to re-injure the graft without me knowing it? Because on my 5th day post ops, there were these instances that I heard a crackling sound (just like when you crunch your knuckles) when standing and during my thigh strengthening exercises. There were no twisting, no over-extension of knee, no pain and no swelling whatsoever but fear is creeping on me that I already lost the graft. Thus this make sense?
My appology for the negative aura, just need to let this out of my system. And I'm really thankful for this medium to express it.
You can get crepitus in the joint (that's the crunchy noises) for any number of reasons post-op. If you did nothing traumatic to the knee, then you didn't tear the graft.
5 months post-op, I stepped into a deep hole that hit me at the knee level, and fell forward onto the ground, completely hyperextending my knee. I did not tear my graft. So, just doing quad sets and standing around wouldn't tear it.
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Life's a Journey ... Enjoy the Ride!
Well, I'm on my 1st week now post Ops. Still feeling some swelling on the knee, but pain is manageable. I'm just consuming my Antibiotics until Saturday, no more pain killers. I just apply ice when feeling some stings, and after doing Quad/Hammy exercises. Wounds seems healing OK, no liquid things coming out
I still wear my braces when going down stairs, going to the toilet and while sleeping. But for most of the day in my room, I take them off and just sits/stand/walk around only on bandage. I could feel more my Quads/Hammy now, I guess the exercises is truly beneficial. I'll meet with my Rehab Doctor by Saturday, and I'm glad I've got some tips from this forum on what to discuss with him
But still have some complain though When resting on my bed, I always have this stress feeling on my upper leg up to the hip, up to right across the lower back, that's really discomforting. What I do is make some Quad sets, or bring down my feet to the floor and sit on the bedside with my knee bending 90 degrees, just to relax my leg muscle.
Actually, this discomfort always wakes me up early in the morning ( 1am, 2am.. ) and disrupts my sleep ( I sleep with my Braces on ). Am I doing something wrong? Or this is just some muscle reactions given that I'm on rehab?
Ortho says that I should already practice walking without it. Prankly, I already felt good on my 5th day post Ops that I manage to walk without cruches and brace but still ofcourse limping. But now, seems I feel I maybe rushing things and afraid to mess-up my rehab.
My PT explained the main thing you're fighting early on is swelling. So you don't want to do too much and have your knee swell up. Do the exercises prescribed (ask what you can do on days you aren't in PT) and keep icing. Also, the reason they want you wearing your brace is to protect the knee not just from you, but from other people. You can walk around right now, but your knee isn't strong enough to protect itself against someone bumping into you. Additionally, as my PT put it, if you're crossing the street and a car is coming and without thinking you naturally jog a bit to cross more quickly == Bad bad bad
Quote:
Originally Posted by FonB
1 quick question. During this "danger zone" weeks, is it possible to re-injure the graft without me knowing it?
I asked my surgeon the same question and he said 'no'. If you pull your graft out, you're most likely going to really feel it. Now I've read that if you don't follow all his protocols you can stretch it and it makes a 'loose' fix, but someone else will have to comment on that.
Quote:
Originally Posted by FonB
My appology for the negative aura, just need to let this out of my system. And I'm really thankful for this medium to express it.
I completely understand. It was only a year ago that I was in your same position. Now I'm leaving on Sat. for a surf trip to costa rica. You'll be surprised how fast things will heal, especially with how eager you are to work.
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"Only those who will risk going too far can possibly find out how far one can go." -- T.S. Eliot
"We are what we repeatedly do. Excellence, therefore, is not an act, but a habit."-- Aristotle
Yes, you can "stretch" your graft ... but again, it is unlikely from what you have described. Surferguy () has some great input and advice since he just went through this. And it is normal to be apprehensive and worried about every single thing. Do your exercises, ice, elevate, wear your brace when out and about and any other time you might stress the leg (remember the muscles aren't all working properly just yet) ... and rest. You'll be fine!
That feeling is likely just some muscle protective spasming ... what exercises are you currently doing? (Please list/describe.)
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Life's a Journey ... Enjoy the Ride!
Wow, I truly love this Forum!!! I'm glad I came across about this
I really appreciate your help good people!
Thanks for the advice EastCoast! Actually, I always read through to one of your Threads "ACL TEAR". It was really enlightening ( It's how I found out about this forum ) Cheers to you man!
Seems your right about the spasming UConnJulie, I'm managing right now by massaging my legs and doing some stretching. It eases the discomfort and relaxes my muscles. I'm icing a lot lately, but mainly on the upper part of the knee only. I'm a bit cautious icing directly over the wounds
Here's the exercises adviced to me by my Rehab Doctor to do:
PTs are usually excited to get someone who is gungho. They want you to get better as much as you want to. Just make sure to pay attention to swelling and let the PT tell you how much you can do and when. You can ask your PT, but mine told me to ice and elevate as often as I wanted to. Just pay attention to icing so that you don't give yourself frostbite lol.
The first week is the hardest and then things really start moving. Remembering back, I had surgery on Oct 29th and was wakeboarding again the following May.
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"Only those who will risk going too far can possibly find out how far one can go." -- T.S. Eliot
"We are what we repeatedly do. Excellence, therefore, is not an act, but a habit."-- Aristotle
It's my 9th day post Ops now.Everythings Up and Up so far, ongoing rehab.
Not until yesterday, around 5pm when suddenly rashes came out of my body. I'm not sure if I could post this in this thread, but I'm hoping someone might have experience this also post Ops and could shed some light into it. Or maybe I could be directed to the right thread
It started in the face then progresses downward. My face was very red and red spots seen at my neck, chest and back. There were some on the legs but I consider the redness on the operated leg was due to the bandage I'm using. I get that a lot when bandaging my legs for a very longtime. Wounds seems normal. I have no shortness of breath, no chest pain, no fever, no difficulty swallowing, just hot sensation and itching on my ear. I went to the ER around 11pm and have a shots of Anti Inflamatory and AntiHistamine. But nothing change up to when I woke up this morning. I've attached some pictures for you to see...
I'm really lost how did I get it. Can't recall any food I ate that might cause it. Actually, I didn't notice it until my housemate point it to me that my face were with rashes and red. Now, I'm just thinking if this still have a relation to my Ops. Would it be possible for a late allergy reaction to the AntioBiotic? I'm taking it for 8 days now continously. Is there a chance of being allergic to the implant? (the screws that is..to much exaggeration?)
Well, I'm going back to my Ortho later today and have my follow-up check-up. And maybe visit a Derma also for this rashes. Just mad a post first and solicit some opinions while waiting for the doctors appointment.
Thanks in advance.
It's my 9th day post Ops now.Everythings Up and Up so far, ongoing rehab.
Not until yesterday, around 5pm when suddenly rashes came out of my body. I'm not sure if I could post this in this thread, but I'm hoping someone might have experience this also post Ops and could shed some light into it. Or maybe I could be directed to the right thread
It started in the face then progresses downward. My face was very red and red spots seen at my neck, chest and back. There were some on the legs but I consider the redness on the operated leg was due to the bandage I'm using. I get that a lot when bandaging my legs for a very longtime. Wounds seems normal. I have no shortness of breath, no chest pain, no fever, no difficulty swallowing, just hot sensation and itching on my ear. I went to the ER around 11pm and have a shots of Anti Inflamatory and AntiHistamine. But nothing change up to when I woke up this morning. I've attached some pictures for you to see...
I'm really lost how did I get it. Can't recall any food I ate that might cause it. Actually, I didn't notice it until my housemate point it to me that my face were with rashes and red. Now, I'm just thinking if this still have a relation to my Ops. Would it be possible for a late allergy reaction to the AntioBiotic? I'm taking it for 8 days now continously. Is there a chance of being allergic to the implant? (the screws that is..to much exaggeration?)
Well, I'm going back to my Ortho later today and have my follow-up check-up. And maybe visit a Derma also for this rashes. Just mad a post first and solicit some opinions while waiting for the doctors appointment.
Thanks in advance.
I'm worried about a drug eruption. What antibiotics are you taking?
At start, I'm also guessing the antibiotic. Though having the fact that I'm already taking it since operation and 8 days straight post Ops, kinda make me wonder. I'm taking Cefuroxime Axetil(Zegen) 500mg capsule by the way.
Anyway, just visited my Ortho yesterday to have clear this issue and him too doubt the antibiotics cause this. My wounds were not irritated nor with redness. And rashes somewhat concentrated on the face that just progress downward like hives. He made me stop the antiobiotic though( still have 4 pcs to drink for 2 days ). And then referred me to an Allergologist and Derma.
Allergos diagnosis?Acute Urticaria.Game me several meds that I'm taking since yesterday (PREDNISONE 30mg, FEXOFENADINE HCI 180mg, BENADRYL TAB 50mg, RANITIDINE 150mg and DESONIDE LOTION). Also passby with the Derma and just gave me soap for my face(GLYCERINE SOAP). Well, face swelling quite subside now but still with rashes and redness. And the itch?Itching like hell Well I guess I'll just need to suck it up to overcome this.
Visited my Rehab Doctor also yesterday, and already templated my program. Though I'm still with the Home Exercises for the next week (Straight Leg Raise and Heel Slide) and be back to him by Saturday.
I didn't manage to ask him about the other Home Exercises I've seen on this forum, didn't want to come out as if I'm over playing him
Anyway, I'll just maximize the benefits on the 2 exercises he referred
Ok, have a great day guys/gals!! Have some scratching to do..hehehe, just kidding
When resting on my bed, I always have this stress feeling on my upper leg up to the hip, up to right across the lower back, that's really discomforting. What I do is make some Quad sets, or bring down my feet to the floor and sit on the bedside with my knee bending 90 degrees, just to relax my leg muscle.
Well I guess I'll just need to suck it up to overcome this.
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