Choosing ACL Graft Tissue

[Over_Under_Or_Throug]

January 8th I tore my ACL and meniscus. I’m tentatively scheduled for surgery February 16th. They won’t know if they can repair my meniscus until surgery. I am having ACL reconstruction done though and have the lovely choice of what tissue to use. I’m looking for experiences to try and help with my choice. If you’ve had surgery, I’m sure you know the options. My doctor and physical therapist keep saying cadaver due to less pain, quicker healing. The cadaver tissue worries me because of the higher threat of infection and possibility my body won’t except it. My non-horsey “athletic” friends keep saying patellar tendon, but the doctor and physical therapist are concerned about pain and stiffness later. I’m leaning towards the hamstring tendons. I know “Providence” recently had the hamstring graft done:

Returning to the saddle following ACL surgery.... - Chronicle Forums

Any help would be appreciated.

[equestrianerd]

My mom and I both had our ACLs reconstructed the same summer (her surgery was 2 weeks before mine). She did the graft option, I did the hamstring.

My rehab sucked, but then, I think rehab in general sucks from ACL reconstruction. (“Sucked” as in, was painful, not out of the ordinary…taking a chunk of tissue that’s not meant to be used the way it’s now being used takes some getting used to. My mom didn’t fare any better, but she had “faster” progress because her surgeon was very aggressive with regard to post-surgery rehab and mine was very conservative, so her PT team was having her bend her knee much farther/sooner than mine was…end result was the same, though, both our knees are recovered. :))

My thigh was a little sore from the hamstring, but it wasn’t a big deal after a few days (especially compared to my knee, which was quite sore for a few weeks!). My surgeon recommended the hamstring option to me because I said I would be much more likely to be squatting (at the barn to do wraps, etc) than I would be doing lateral movements (apparently soccer players frequently do the patellar option so that it doesn’t affect their lateral ability). I was told squatting would be more painful if I did the patellar option, and this appears to be the case judging my mom and I (8 years post-surgery)…she says her knee gets stiff more than mine (which may also be due to age), and she has more discomfort doing things (like squatting) than I do.

My knee still aches a bit when it’s especially cold/wet out (and I live in England, go figure ;)), but otherwise it’s been night and day how well it’s been since the surgery (knock on wood). I resumed riding 2 months after surgery (with surgeon’s permission), and while it hurt for a while (I wasn’t allowed to use stirrups for the first month to avoid extra strain on my knee ;)), I didn’t have any issues.

Sorry if this is rather incoherent - just jotting down random thoughts about our experiences. Hope it helps.

[LauraKY]

I had the cadaver. It’s now 5 1/2 years post surgery and it still aches when the weather changes. I had a Johns Hopkins sports medicine orthopod do the surgery. He insisted on 3 months of PT before surgery and 9 months after. It works as well as it ever did, but I’m unconsciously very careful with that knee.

Rehab sucks. Good luck whichever way you go.

[medical_mike]

Why the extra concern???

Cadaver grafts are not the problem they used to be. They are used as an alternate for several reasons…IME the most common reason is concern harvesting your patellar tendon will create problems with kneecap/tendon structure/function.

There are +/- to all techniques. My suggestion is search www.pubmed.org for “ACL surgery” or like phrase.
The abstracts and some articles are available so you can see what the science is.

Regards,
medical Mike
equestrian medical researcher
www.equicsion.com

[vineyridge]

I had ACL replacement surgery in 2002 with a cadaver graft. I’ve been very satisfied. The only pain I ever have had after very good PT is when the weather changes. Knee is completely stable and I can do anything with it.

I think one reason they didn’t even suggest hamstring was because of my age–well over fifty at the time.

[amastrike]

I had the hamstring graft, and it was absolutely fine. A little sore for a week or so, but since I wasn’t going to be running laps or doing acrobatics anyway, it didn’t matter :lol:. Personally, the idea of a cadaver graft squicked me out, so I would have declined had it been suggested.

[Leather]

I had a patellar graft done about 20 years ago.

At the time, hamstring and donor grafts were not options.

The most pain/problems I’ve had with my knee have been from the graft site. I can’t kneel because of it.

I’ve had friends that have gone the hamstring graft route with no problems.

If I had it to do over again, I’d go hamstring or donor.

[mambo9]

I torn both ACLs

Well I can tell you both sides of the equation as I blew out both my ACLs playing soccer- (Not at the same time but about 7 years apart.)

I tore my left ACL and meniscus in 1993. They scoped my meniscus in 1993, but I actually waited, for personal reasons, till 1996 to have the ACL repaired. I went to a very reputable orthopedic surgeon (Who operated on a lot of the professional athletes in my city) and we went the hamstring route… Holy cow was that a painful recovery. Not only is their trauma to your knee, but you also are having trauma to the hamstring. It was a good 6 month rehab- till I was fully healed. I wore the brace for a little while, but was back to riding and playing sports again within 8 months.

In 2000 I tore my right ACL playing soccer- again. This time I went to a different surgeon, as I was in a new city, and we opted for the Cadaver graft! Like you I was worried about the body rejecting it or disease, but he assured me everything would be fine… Guess what- he was right!
The rehab on the knee with the cadaver graft was sooo much easier and I recovered a lot quicker. Within 6 months I was back to playing sports full force.

They both are also sore after a good long ride or if you squat for some time, but I can deal with it.

Both knees feel strong and sturdy and one is not better than the other. Besides the scars (The hamstring knee has a huge ugly scar compared to the cadaver knee which has 3 little incision scars.) you would never know the difference.

Now if I was to do it again(God forbid) I would do the Cadaver graft. The Physical Therapy is tons easier and you bounce back a lot quicker. Well, I did at least.

[ridingagain]

I had ACL surgery in 1986 - ski injury in CO - and had the top doc in the country at the time do mine - I had the hamstring replacement. 10 months of serious rehab, but umpteen years later I can pretty much do anything I want without pain or stiffness (except maybe a lot of pounding on pavement). Hasn’t affected my riding at all.

My 16 yr. old son just had the same injury and repair last spring - he had to do the hamstring one because he hadn’t finished growing. The good news…his recovery was much quicker than way back when I had mine - and he is 100% now.

No matter which option you choose, I highly recommend one of the electric icing machines for your first month post op. I forget what they're called, but you can rent them.  Really helped my son with the pain and swelling.

Make sure you have someone with you at all times, the first week to help you out. It is serious surgery and the recovery is tough. You will get some hard core pain relievers, and don’t try to tough it out without them.

Good luck and let us know how you do!

[TimelyImpulse]

I had my right ACL done with the patellar tendon in 2003. (Soccer injury) My surgeon believed in the “get on your feet, off your ass, and back in gear…FAST” method of PT. Immobilizing cast off in 3 days, and no crutches after 1 week. I was also given a passive motion machine to use for the 1st week after surgery.

PT sucked. I cried the 1st time I was able to pedal the exercise bike once around, backwards. The first year post-op, when I squatted, it felt like my knee was going to explode. Not a great feeling, but it’s pretty much back to normal now. I still have a numb area, about the size of a deck of cards, across my knee, and a long scar across the front from the tendon removal.

I was ooooged out at the thought of the cadaver piece back then, but might opt for it when I have to get my left one done (OTTB did learn to stand for mounting after that incident), especially if it is a shorter recovery.

The more you use it, the better it gets, IMO.

Ice is your friend. And don’t pull out the stitches if you think they look “done.” They’re not.

[amastrike]

Mambo9, I’m willing to bet your hamstring graft site hurt so much because of how long ago you had it done. Mine was done at the end of July, and the pain was minimal. It felt like a sore muscle for a few days-week, and it hasn’t bothered me at all since.

OP, FWIW, I started PT 2x/week 6 weeks post-surgery, and was discharged from PT after 2.5 months. The knee still isn’t 100%–I can’t squat, like TimelyImpulse said, it feels like it’s going to explode. Kneeling is tricky, too, and going down stairs is a bit iffy. But on the whole, it’s pretty great. It feels very stable and I’m comfortable on it. No matter what graft option you go with, the results are 100x better than not having it fixed at all!

[bird4416]

I tore my left ACL in a riding accident. I think my surgery was in 2004. I opted for the patellar tendon repair and haven’t had any issues. I healed fine, have minimal scarring and the knee works fine. It gets sore some when the weather changes but not bad. It feels kind of weird if I have to be on my knees for some reason but not really painful.

[system]

I had my acl, lcl, and meniscus done a couple years ago. They used a cadaver for my lcl, and my patellar for my acl. I am all healed up, minor stiffness if I do too much. It was a 12 month recovery.

[SonnysMom]

2004 cadaver graft, clean up mcl & meniscus. I was riding 6 months to the day after the surgery. Jumping small gymnastics within 2 weeks. I have a spot on the outside of the calf that has disturbed skin sensation. It isn’t fully numb it just feels weird sometime.
When it is cold I get a bit stiff. My quad gets a bit sore sometimes too.
My surgeon does not like doing the patellar graft since too many of his patients then can’t comfortablel kneel.
I was too heavy at the time to do hamstring.
My surgeon is very picky about which company he gets the cadaver grafts from. That particular company irradiates the tendons/ligaments to help prevent infection. If my memory is correct since tendons & ligaments don’t really have much blood in them there is less chance for infection.
I have an over active immune system. To the degree that my body was attacking my own liver and colon. I was treated for about 2 years with predinsone & Immuran which is an anit-rejection drug. These drugs were used to supress my immune system so my body would stop attacking the liver/colon. I had been off the meds for about 4 years prior to the ACL reconstruction.
Even with an over active immune system there was no hint of my body rejecting the graft.
My particular surgeon does many of the ACL reconstructions and has never had anyone reject a cadaver graft.
My surgeon does not do the continuous passive motion device. If I ever need ACL reconstruction that is one thing I would insist on having prescribed. Other people that I know that had the ACL surgery and the CPM device had an easier PT.

[TSWJB]

cadaver graft!

i had the cadaver graft and it has held up very well for me. i had it 8 years ago and when i slipped on ice and twisted around, my ankle snapped not my ACL.
you have less scarring and less pain after surgery. and my dr assured me that the banks were safe. well i was home from surgery that night and NBC news did a thing that night on what everyone having a common knee surgery should know. they had said the banks were contaminated. i freaked! but i was fine. since then they have new controls. its should be very safe.
i had the front of my knee opened up when they banged an IM rod down my knee about a year ago. that has caused me problems with my pateller ligament. i would leave it alone if you can. plus hamstring can cause issues with healing since they are damaging your hamstring taking the graft.
why not use someone elses graft! mine is perfect 8 years later!

[pharmgirl]

Mr. pharmgirl had ACL reconstruction and did the allograft (cadaver). He signed off on both options just in case the surgeon didn’t like the condition of the cadaver tendon, but he said it looked fabulous so they went with it. He was also sent home with a CPM machine. I think this was in 2003 maybe?

His rehab was tough, and it is a long road regardless, but that knee gives him no problems whatsoever. He plays basketball, tennis, and doesn’t even use a brace and he says it feels completely stable (probably helped that he had very strong quads to begin with, but still).

We have seen several people since his surgery have ACL reconstruction, and they have gone the autograft route (patellar or hamstring, not sure who had which), and they were much slower in their recoveries. At least one didn’t get a CPM machine, so I don’t know how much that had affect, but they seemed to be in more pain post-op, take a lot longer to really get into rehab, and one or two say they still feel like it bothers them some.

[stolensilver]

I had my ACL and medial meniscus repaired in November 2009. I had a hamstring repair.

The rehab was sore and very hard work, 4 hours, 5 days a week. But after 3 months I was back at work 2 days a week and 2 weeks after that I was back at work full time. I started riding at Christmas, just 6 weeks after the operation. It did hurt, especially doing rising trot but it was bearable.

The most important thing after an ACL repair is to get your full range of extension back. I spent hours with my leg propped up on a table and a bag of frozen peas on my knee.

I’m in the medical profession and the best advice I can give you is to take the surgery your surgeon recommends. Some surgeons get better results with hamstring repairs, some with patellar grafts, others with cadaver grafts. The research doesn’t show much difference in outcome between hamstring and patellar grafts (don’t know about cadaver grafts) but if your surgeon gets better results with a patellar graft then have one of those!!! Same if his/her results are better with hamstring grafts.

Whichever repair you have the rehab is long and fairly painful but it works out in the end. I’ve been left with a numb patch over the front of my knee and down the outside of my shin. Kneeling is still uncomfortable but bearable. Squatting is the same. My hamstrings are still weaker on the operated side but the whole knee is pretty good.

FWIW a colleague ruptured one ACL and had it reconstructed. They later ruptured the other ACL and chose not to have that one reconstructed. They don’t find any difference in function between their knees and they are very active, running 8-10 miles a day and doing a lot of cycling. They say the rehab from having no surgery was a lot quicker and less painful than having the surgery. Just something else to consider.

[Providence]

Over Under Or Through - Please feel free to send me a PM with any questions you may have.

My rehab is going well. My physiotherapist is very pleased with my progress. I don’t notice any pain in my hamstring where the graft was taken from. I hope to be riding again in a few weeks! I can’t wait!

[dwblover]

My father is a doctor and my brother had to have the same surgery done. My father insisted that he use cadaver and he did. Everything healed up great. The reasoning was that when they use your own tissue THAT incision site is much more painful then the actual ACL site. He has had many patients with this over the years and all who used their own wished they had gone with cadaver. Best of luck to you!

[Over_Under_Or_Throug]

UPDATE Post Surgery

Thank you all for your responses!!

So I had my surgery just under three weeks ago. Went with hamstring graft even though my surgeon recommeded cadaver and prefers patellar in younger patients (at 30 I’m apparently not part of that group anymore ). So far so good. They prescribed the gameready (ice compression machine) and CPM for first three weeks. I second everyone that says ice is your best friend!! I iced every hour for about the first week and did the CPM religiously 4 - 6 hours a day. Also was proactive with pain meds. so didn’t think the pain afterwards was all that bad. I’m currently at about 120 degrees flexion and almost full extension. Pain in my hamstring is minimal, almost like a sore muscle and sometimes a little cramping. Knee is still sore and slightly swollen. As of right now I’m happy with my choice. Was told I could go off crutches at one week and cleared for no more brace at two weeks. I still wear it when I go to the barn (only to visit right now - no work/riding yet) and if I’m going to be in a busy place where I could trip or get run into.

Physical therapy was excruciating the first day, which was one week after surgery. Took about 8 mins out of 10 to just be able to do a full backward rotation, but now it’s not problem. Just hop right on the bike.

Follow up appointment in two more weeks.