ACL reconstuction options: is an Allograft as strong as a patellar autograft?

by Juli
(Ohio)

I'm a 37 year old very active mom and I tore my ACL and MCL. I go back to my dr. In a week to schedule my ACL surgery. He is recommending an allograft for me because of the reduced recovery time and less pain. A friend of mine who teaches athletic training at a university highly suggests I have the patellar bone-tendon-bone autograft because he knows how active I am and says the patellar autograft is much stronger. I'm so confused and reading articles on the web is more confusing. It seems every surgeon has their own preference. I just don't want to have one surgery and regret it later. Is there any evidence of one surgery

being "better" than another?

Comments for ACL reconstuction options: is an Allograft as strong as a patellar autograft?

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May 30, 2015
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Need a 2nd surgery NEW
by: Nick S

I am a 37 old male who keeps in shape and hikes, bikes, kayaks and skis. Back in Feb I clipped a tree with end of ski and tore ACL & MCL. Had the patella autograph 5 weeks later by Dr. Oliver in Fort Collins. She did a fantastic job and I was the model rehabber. I worked super hard and started a running program at 8 weeks out. Things were going great.. I hardly thought about it anymore. And that was where I messed up. At 11 weeks i took my motorcycle out, even though i was advised not to. Went to get off, planted foot, twisted and it popped the ACL again. I couldn't believe i did it. So now i am back to square one. Another patella graph is out of the question.. so its either hamstring or cadaver. I appreciate reading through all the previous comments and stories. Some very good info in there and after taking it all in, i am leaning towards the allograph from a cadaver.

Oct 30, 2014
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soccer after allograft ACL recon NEW
by: shubho

hi physical therapist assistant whose daughter had allograft or others who had allograft,
after 1 year, how has been the return to sports.? i had acl allograft recon after tearing playing soccer.

Sep 24, 2012
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auto vs. allo? which is better and why NEW
by: Anonymous

I am a physical therapist assistant who has 16years experience with many ortho pathologies, my 14y/o daughter recently excperienced an ACL partial tear while playing soccer confirmed with MRI. After 6 months of nonsurgical healing her condition was not improving and a follow-up MD visit it was suggested that she go ahead with ACL reconstruction using a allograft achilles tendon. Reasoning was that with a allograft achilles tendon the MD could reconstruct a dual band ACL which would give max stability and durability much like her natural ACL. Using a autograft patellar tendon would only weaken her knee in high impact demands and require much longer recovery from soreness/pain whereas using a semitendinosuous or hamstring graft would also slow recovery via the trauma and healing from donor site as well as p/o precautions with therapy. Full extenion with hamstring grafts are sometimes more difficult to get back d/t pain/soreness. At best, a single band type of ACL could be used in a autograft ACL reconstruction only giving partial stability at knee extension or knee flexion depending at which position the graft was tightened. I would also like to mention that autrograft surgeries require less surgery time than allograft which is probablly why it is widely used although auto vs. allo are typically reimbursed at the same rate.
As for my daughter who does want to return to high impact sports I was glad that we will be using a allo achilles tendon which by the way is double the size of any autograft and far more stronger with less secondary trauma and faster recovery time unless you have further damage like a collateral ligament or meniscus tear. I hope the info I have written will help anyone with the auto vs. allo decision. good luck and fast recovery.

Sep 24, 2012
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auto vs. allo? which is better and why NEW
by: Anonymous

I am a physical therapist assistant who has 16years experience with many ortho pathologies, my 14y/o daughter recently excperienced an ACL partial tear while playing soccer confirmed with MRI. After 6 months of nonsurgical healing her condition was not improving and a follow-up MD visit it was suggested that she go ahead with ACL reconstruction using a allograft achilles tendon. Reasoning was that with a allograft achilles tendon the MD could reconstruct a dual band ACL which would give max stability and durability much like her natural ACL. Using a autograft patellar tendon would only weaken her knee in high impact demands and require much longer recovery from soreness/pain whereas using a semitendinosuous or hamstring graft would also slow recovery via the trauma and healing from donor site as well as p/o precautions with therapy. Full extenion with hamstring grafts are sometimes more difficult to get back d/t pain/soreness. At best, a single band type of ACL could be used in a autograft ACL reconstruction only giving partial stability at knee extension or knee flexion depending at which position the graft was tightened. I would also like to mention that autrograft surgeries require less surgery time than allograft which is probablly why it is widely used although auto vs. allo are typically reimbursed at the same rate.
As for my daughter who does want to return to high impact sports I was glad that we will be using a allo achilles tendon which by the way is double the size of any autograft and far more stronger with less secondary trauma and faster recovery time unless you have further damage like a collateral ligament or meniscus tear. I hope the info I have written will help anyone with the auto vs. allo decision. good luck and fast recovery.

May 31, 2012
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TORN ACL and TIBIA fracture NEW
by: Kimmie Walstad

Just like Cindy, I too, tore my ACL off and fractured the tibia. I am in Pensacola, Florida. I am 46 and am ACTIVE, ACTIVE, ACTIVE, triathlons, skiing(the reason for the post! lol), jump my horses, kiteboard, running, cycling (thank God for this because it's one sport i can do with no ACL).

Allograft versus autograft???????

Help. I am so confused. I am committed to rehab. I don't need my hand held, but I am also a pessimistic optimist. There are many factors involved with allo vs. auto...cost, hospitals, physicians, hardware reps, laurels, and I have realized as a patient i need to be my own advocate. also, i have learned that doctors do BEST what THEY like and want to do.

i hear "gold standards," among many other thoughts/ideas/beliefs. And, depending on the doctor, you will get different answers to questions.

So......I am searching for more information regarding allo v. auto, hamstring or patellar, etc.

Also, what about "DOUBLE BANDING" with allo?

Kimberly Walstad

May 31, 2012
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TORN ACL and TIBIA fracture NEW
by: Kimmie Walstad

Just like Cindy, I too, tore my ACL off and fractured the tibia. I am in Pensacola, Florida. I am 46 and am ACTIVE, ACTIVE, ACTIVE, triathlons, skiing(the reason for the post! lol), jump my horses, kiteboard, running, cycling (thank God for this because it's one sport i can do with no ACL).

Allograft versus autograft???????

Help. I am so confused. I am committed to rehab. I don't need my hand held, but I am also a pessimistic optimist. There are many factors involved with allo vs. auto...cost, hospitals, physicians, hardware reps, laurels, and I have realized as a patient i need to be my own advocate. also, i have learned that doctors do BEST what THEY like and want to do.

i hear "gold standards," among many other thoughts/ideas/beliefs. And, depending on the doctor, you will get different answers to questions.

So......I am searching for more information regarding allo v. auto, hamstring or patellar, etc.

Also, what about "DOUBLE BANDING" with allo?

Kimberly Walstad

Mar 25, 2012
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Julie NEW
by: Anonymous

My son did the same thing. We live in an Olympic Region with MDs to the athletes. I am very impressed with my son's doctors. All of the conflicting theories were explained. Treat the meniscus first with PT right off, sticthes out 10 to 12 days later. ACL surgery after the stich removal and very good motion, five to six weeks later . Keep knee brace on at night in the beginning 0 to 90 degrees to prevent twisting. Physical theorapy of the knee after initial surgery is very important for you to be prepared for ACL surgery five to six weeks later. The down side of this is you MUST be careful not to twist the knee. Upside, these guys are amazing so you can trust this. Good Luck.

Jan 17, 2012
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Surgeon in Central Florida NEW
by: Anonymous

Hi,

I saw in an earlier post that someone could reccommend an ACL surgeon in Central Florida. If anyone can help, I would greatly appreciate it... I tore my ACL (completely) and fractured my tibia... all in one beautiful stroke!

Thanks.

Christy

Jun 10, 2011
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Stetson/Powell
by: Nancy

I saw the Post "Getting Ready" by: SteveD in Oct 2010 who was scheduled for surgery at Stetson/Powell in Burbank. I was wondering how your surgery went (I hope it went well!). My 17 year old son tore his ACL and will have surgery next month. We are currently seeing Dr. Stephan Yacoubian in Burbank (this is where the emergency room sent us). He seems very good based on reviews, etc., but I've heard better things about Stetson/Powell. Also, who actually did your surgery? Thanks - Nancy

Jan 18, 2011
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Thanks for the comments
by: Jamie

Thanks for the comments. I am about 3 1/2 weeks post op now and I am feeling really good. After talking with my physical therapist, I decided to go with the hamstring graft.

I am seeing my physical therapist once a week now, but doing the re-hab religiously every day, and if not 2-3 times per day. I still have some tightness and swelling that I can feel, but really no pain at all. I just started the stationary bicycle a few days ago, and I gotta tell ya, that has felt so good. It just feels nice for my brain to think I am doing some sort of cardio, even if I am not really getting the heart rate up yet.

I am able to completely straighten my leg, and I am getting very close now to having full range of motion back. Most people cannot believe that I had surgery less than a month ago.

The only issue that I have had,( and it drives me crazy) is that I still have numbness in my leg, just below the knee. Feels like that part of my leg is asleep, and to touch it, or shave my legs is like running your fingers down a chalk board. Anyone else have this issue. Weird and annoying for sure!!

Doc says about 8 more months until I can return to the soccer field. Seems so far off, but I am thankful that things seem to be going in the right direction!!!

Take care and thanks again!!

Dec 18, 2010
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FOR JAMIE..cont'd
by: Anonymous

Most doctors agree that an autograft, or allografdt, both have to undergo the same process of revascularization and ligamentization. THe end product is a ligament-like structure that closely approximates the original ACL. The difference between auto and allo is the amount of time it takes for that process. The autograft will usually heal in 6 months, whereas an allograft (it is believed) takes longer, perhaps as long as 9 months. So, an athlete whose main concern is to get back as quickly as possible might opt for autograft bone-patellar or hamstring, or quad. For someone, who is willing to wait a little longer before returning to full contact sports, an allograft will do just fine. Hoever, there are some doctors now using healing factors, like a fibrin clot from your own blood, or PRP gels, applied to the graft, which results in the allograft healing about as fast as an autograft. But not all doctors are using this technique yet. You can hunt around to see which doctors are. Allografts will also result in much less pain,i.e. there is no extra injury to heal and have to rehab. There are also drawbacks to autografts, such as persistent weakness in the area the graft was taken from, numbness, pain, and serious complications in some cases. In some cases the autograft is too short, causing it to have to be discarded and an allograft used anyway.
Meanwhile, past reasons for being hesitant to use allografts, e.g. risk of infection, transmission of disease, structural integrity, have been dealt with by using newer better methods of sterilization and harvesting. The risk of infection is no different than with an autograft, and the risk of viral transmission is, although not zero, close to it. No ACL graft is used unless organs harvested from the same donor have already been used and proven to not transmit disease.

So, the question of what graft to use is more a question of the individual's comfort level, desire to minimize pain, time to get back to sports,..etc. For a 38 yr old woman, most surgeons would probably recommend an allograft. In your case, since you are very active in sports, it's also a question of how quickly you want to return to full sports activities. SO, don't let anyone scare you or rush you into using an autograft, if that is not what you want.

Dec 18, 2010
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For Jamie
by: Anonymous

The difference between Allograft and Autograft is not the most important question people should be asking themselves. The question of which surgeon to go to IS. By far, the single most significant reason for ACL reconstruction failures in the short term or the long term, is how precisely, i.e. where, the graft is actually placed. This depends upon surgeon technique and skill. Most people settle for the first Ortho they find, who might only do 10-15 operations per year. Best results are obtained with a surgeon who does at least 50-100 per year. The question of what type of graft is usually not that important. The vast majority of ACL reconstructions will be successful regardless of the graft choice, assuming it was correctly placed. The only doctors strongly advocating autografts, usually bone patellar, are Orthos who cater to athletes. This based on ONLY 2 very recent studies, which are not conclusive but do indicate that patients younger than 25 yrs, who engage in contact sports, tend to have fewer ACL reruptures. However, the reasons for this are complex and not necessarily dealth with in the 2 studies.

Dec 08, 2010
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Answer to Jamie- Our experience
by: Anonymous

Jamie,

We had the same confusing stories and a hard time deciding. My son is in excellent shape and had a complete tear in his Acl and had miniscus damage. We choose the autograph/ patellar not hamstirng. Our sports minded ortho recommended not using the hamstring as this will slow your running down a little and you will not be as fast. He plays sports competively and is in college. He worked out and ran all the way up to his surgery date. One would never know he needed surgery. He is now 5 weeks post op. He had an excellent surgery, virtually NO pain and is now driving, working out at the Y and going to PT twice a week. He will be fitted for his functional brace (the second brace you will get after the surgery) Friday. We choose the autograph because of it's longevity, using his own body parts, and a stronger product for athletics later in life. I'm now watching my mother in law in need of a total knee and realized I am so glad we choose this way as he will have a less chance of having trouble later in life. My biggest reccomendation no matter which way you choose, get the "ice MAn" before surgery and have the doc put it in before you come out. Run it for 3 or 4 days contiuously (except when yoy go to PT on day 2 after surgery) It is WONDERFUL and and it really keeps the pain/swelling down. I think it is the reason he had such an easy go of it. Good Luck - it goes really fast- I kept waitng for the bad part and it never happened!

Dec 08, 2010
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Answer to Jamie- Our experience
by: Anonymous

Jamie,

We had the same confusing stories and a hard time deciding. My son is in excellent shape and had a complete tear in his Acl and had miniscus damage. We choose the autograph/ patellar not hamstirng. Our sports minded ortho recommended not using the hamstring as this will slow your running down a little and you will not be as fast. He plays sports competively and is in college. He worked out and ran all the way up to his surgery date. One would never know he needed surgery. He is now 5 weeks post op. He had an excellent surgery, virtually NO pain and is now driving, working out at the Y and going to PT twice a week. He will be fitted for his functional brace (the second brace you will get after the surgery) Friday. We choose the autograph because of it's longevity, using his own body parts, and a stronger product for athletics later in life. I'm now watching my mother in law in need of a total knee and realized I am so glad we choose this way as he will have a less chance of having trouble later in life. My biggest reccomendation no matter which way you choose, get the "ice MAn" before surgery and have the doc put it in before you come out. Run it for 3 or 4 days contiuously (except when yoy go to PT on day 2 after surgery) It is WONDERFUL and and it really keeps the pain/swelling down. I think it is the reason he had such an easy go of it. Good Luck - it goes really fast- I kept waitng for the bad part and it never happened!

Dec 08, 2010
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So darn confused!
by: Jamie

Hello... I am a 38 year old mother of 4, Police Officer and avid indoor soccer player. Until 2 weeks ago, I was playing 4 games a week, and doing kickboxing and step aerobics classes as well. I have a complete tear of the left ACL.

My surgery is scheduled for December 22nd, and I still have not made a decision on which way to go. I am like others on this site who have done so much research that I am totally confused. My surgeon was very surprised at how well I am doing after 2 weeks. ( I started PT at a week following my injury and feel almost like I could go play a soccer game.)

My surgeon said he would recommend either the patellar or hamstring, especially for a first time surgery. If this was the second time around, he said he would surely go with the allograft.

I have heard horror stories for all three, and have no idea what to do. The doc said there was a 1 in 5 chance of problems with the allograft, and a 1 in 20 chance of problems with either the patellar or the hamstring. He did talk about the allograft being a lot less painful, and said I would feel better sooner, however it was not what he would recommend.

If anyone has any advise for a person my age..... I would love to hear it!!!

Thanks!!!

Nov 14, 2010
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Kimberly
by: Anonymous

Thanks soccer gals dad...such a positive note! I'm looking forward to being back in full swing! Surgery went great! but it is SO hard getting around right now....plus it is SLIPPERY with winter just starting! But if i take it slow and stick to my pt i think ill be fine :) these will be the LONGEST 4 months of my life....thanks again! :)

Nov 14, 2010
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20 year old LAcrosse player
by: Anonymous

I wrote back in August and am now updating..

My son finally had his ACL/Meniscus surgery on October 28. We decided to use JOI. The physician we used is a specialist in Knee/athlete patients. Before the surgey we built up the quad muscles and did pre- op PT. He had the surgery two weeks ago. At discharge we had pain meds, sleep meds, nausea meds and antibiotic. We completed the antibiotics, only need the nausea meds twice the first day post op and the pain meds for three days. Never needed the sleep meds. We used patellar autograph for many reasons. Because he is so young and has an athletic lifestyle we choose to use his own body parts and and this will force a slower healing time so it will heal properly. The meniscus tear was in a diificult place to fix but the doctor did an excellent job. The total surgery time was 4 hours. He has had little to no pain and the recovery has been very easy. The Ice Man is the key! (rotating cold water around the wound constantly). Insurance didn't pay for it but he cost was worth it! We started rehab the second day after surgery and have PT twice a week with exercises to do at home.The brace was unlocked at the two week check up and he is now on a bike at PT. He can bend his knee up to 105 degeree anngle, is down to one crutch and has almost no lag time. Still can't drive for another two weeks (but that's ok). At the two week check the xray's show a perfect graft. So far so good!! (the toe relocator last year was more painful and slowed him down more than this!) The key is stay ahead of the pain with the meds at the beginning, use colace to counter act the pain meds side effect, (we switched to Advil on day 4) Use the ice man for the first 48 hours or more and after PT, keep the leg eleveated above the heart for the first two days, and do the PT! WIll updated on week 4 soon

Nov 14, 2010
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20 year old LAcrosse player
by: Anonymous

I wrote back in August and am now updating..

My son finally had his ACL/Meniscus surgery on October 28. We decided to use JOI. The physician we used is a specialist in Knee/athlete patients. Before the surgey we built up the quad muscles and did pre- op PT. He had the surgery two weeks ago. At discharge we had pain meds, sleep meds, nausea meds and antibiotic. We completed the antibiotics, only need the nausea meds twice the first day post op and the pain meds for three days. Never needed the sleep meds. We used patellar autograph for many reasons. Because he is so young and has an athletic lifestyle we choose to use his own body parts and and this will force a slower healing time so it will heal properly. The meniscus tear was in a diificult place to fix but the doctor did an excellent job. The total surgery time was 4 hours. He has had little to no pain and the recovery has been very easy. The Ice Man is the key! (rotating cold water around the wound constantly). Insurance didn't pay for it but he cost was worth it! We started rehab the second day after surgery and have PT twice a week with exercises to do at home.The brace was unlocked at the two week check up and he is now on a bike at PT. He can bend his knee up to 105 degeree anngle, is down to one crutch and has almost no lag time. Still can't drive for another two weeks (but that's ok). At the two week check the xray's show a perfect graft. So far so good!! (the toe relocator last year was more painful and slowed him down more than this!) The key is stay ahead of the pain with the meds at the beginning, use colace to counter act the pain meds side effect, (we switched to Advil on day 4) Use the ice man for the first 48 hours or more and after PT, keep the leg eleveated above the heart for the first two days, and do the PT! WIll updated on week 4 soon

Nov 10, 2010
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Yes you will, rehab, rehab, rehab
by: soccer gals dad

In response to the 25 year old above.
Yes you will. The allograft will do fine if you stick to your rehab. DO NOT OVER DO IT. DO NOT RUSH IT. BE PATIENT. Your knee will feel fine at 3-5 months but it WILL NOT BE READY. Stick to your rehab religiously. Choosing the right doctor is important. Choosing the right physical therapist(PT) is equally important. The PT should be experienced, have a good report with the patient, be firm when necessary. Pt should not be a pushover or a coddler.

Allografts ACL repairs are strong. My daughter is 16, she had an Allograft repair 14 months ago. A small tear in her meniscus was repaired and a tiny bit was shaved. The donated graft was an anterior tibialis, from an ankle and stronger than an acl from what I hear. Either way, the graft is sort of a scaffold for which a replacement ACL grows. It takes at least 4 months for the ACL replacement to revascularize, some say the allograft takes longer.


She was cleared to play 6 months after but we took it slow but she was back on the soccer field, at 8 months she was just about returned all the way. She never has swelling or pain (luckily) - it helps to be 16!!! She is an elite soccer/lacrosse player and is back at full strength.

Nov 06, 2010
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will i be able to play sports again?
by: Anonymous

I am a 25 year old female and I tore my ACL coaching my volleyball team. :( I tore almost all the fibers in my ACL, the back part of my meniscus, and a few fibers of my PCL. I went in for an appointment on Thursday and am already scheduled for surgery on Monday. They are reconstructing my ACL and are going to look at my meniscus while in surgery to see if they should repair it or shave it. I am taking the donor, because I did not want to have any numbness on the side of my knee which I was told would happen from B-PT-B and I didn't want to have more knee pain. I was told that the hamstring graft could be too stretchy...and the surgeon recommended the donor. Now reading about it I heard that it was WEAKER...I don't play professional sports, but I like to play volleyball, disc golf, golf, bowling, soccer and workout...and wanted to do the Insanity Workout...was the donor a bad decision if it is weaker? Also, how long do you have to be inactive for? I am SO sick of not being able to run and jump...:( Plus, I am TERRIFIED for this surgery...

Nov 06, 2010
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Terrified...
by: Kimberly

I am a 25 year old female and I tore my ACL coaching my volleyball team. :( I tore almost all the fibers in my ACL, the back part of my meniscus, and a few fibers of my PCL. I went in for an appointment on Thursday and am already scheduled for surgery on Monday. They are reconstructing my ACL and are going to look at my meniscus while in surgery to see if they should repair it or shave it. I am taking the donor, because I did not want to have any numbness on the side of my knee which I was told would happen from B-PT-B and I didn't want to have more knee pain. I was told that the hamstring graft could be too stretchy...and the surgeon recommended the donor. Now reading about it I heard that it was WEAKER...I don't play professional sports, but I like to play volleyball, disc golf, golf, bowling, soccer and workout...and wanted to do the Insanity Workout...was the donor a bad decision if it is weaker? Also, how long do you have to be inactive for? I am SO sick of not being able to run and jump...:( Plus, I am TERRIFIED for this surgery...I've never had one before....will I be able to play sports again?

Oct 26, 2010
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Be Careful
by: Anonymous

I would be very careful with some of the advice on here. There is a concept called "evidence-based medicine." Some of the cutting edge technologies and procedures being promoted on these comments have great potential, but have not been tested against the scrutiny of time. Short-term research has shown promising, good results, but rarely are these results better than the "gold standard." They are in their infancy, and there is no way to know if their 10-20 year results will be any different than current methods.

Oct 16, 2010
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Getting Ready
by: Michael

An allograft heals slower than an autograft. So, even if cleared earlier than 9 months, I would refrain from contact or cutting type movements until the 9th month. Also, it woud be a good idea if your doctor uses a healing promoter on the graft, such a Fibrin clot, or PRP gel. This ensures the graft will heal throughly and faster.

Oct 14, 2010
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Getting Ready
by: SteveD

Hey everyone! I'm 28 years old and a VERY active soccer player. Well, i WAS active. I recently tore my ACL & MCL while playing. It's been really disheartening as i went from playing 3 times a week to being almost immobile. I've been going through physical therapy to strengthen my quads, hammies and gain my range back. I see my OS bright and early tomorrow morning. During our initial discussion a couple weeks ago he advised i consider going on with an allograft. I'm being treated in Burbank, CA by Dr. Stetson of Stetson/Powell.

All of the OS's there work with top level professionals (Womens National Soccer team) & Olympic athletes so I'm at ease going into this. I've been reading up on the options EVERYDAY and to me it seems the allograft is a great option. I'm confident I'll be back on the field by next summer. I've taking all of your advice and wont rush back. If you have ANY other advice for someone in pre-op I'd be truly grateful. Thanks guys! Hope you all have very positive results in your own rehabilitation.

Oct 13, 2010
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know any good orthopedic doctors?
by: Michael

Your problem may not be a failed or improperly placed graft, it might be a damaged meniscus, or it may be arthritis. You probably want to see a top doctor who will diagnose it properly. If you need a new ACL, I would recommend the double bundle with tibialis allograft. Unfortunately, only some doctors are doing the operation, and fewer still have really mastered it. I don't know of any in Hawaiii. The ones I know are on the mainland (e.g. Thomas Rosenberg in Utah, Freddie Fu in Pittsburgh).

Oct 10, 2010
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know any good orthopedic doctors?
by: Anonymous

I'm 27 years old and I had an ACL autograft procedure 7 yaers ago and it failed so I had to go back to correct the problem a year later.And today I'm still having problems with it and it's putting alot of stress on the good side which is my right knee and i cant afford ruining it,for many years I've been looking to fix my knee problem,but was unsuccessful due to the fact that i had no knowledge of the right steps to take,and at this point i think i know just enough to do it right and i think that right way is to get a revision surgery wiht an allograft. but first I need to find a good or better yet the best orthopedic doctor to do it for me,so can anyone please give me list of doctors that i can talk to? I live in Hawaii and willing to go anywhere for the best doctor as long as he accepts my health insurance which is HMSA-blue cross blue sheild.thanks,akamai from Hawaii

Aug 31, 2010
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Lacrosse Player
by: Anonymous

Thank you for your advice we will see Dr. Kaplan at JOI tomorrow. I have more knowledge now and good questions to ask thanks to this site. WIll keep you posted as to which we we choose and how his procedure and recovery go.. thank you!

Aug 25, 2010
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20 yr old lacrosser player
by: Anonymous

Dr. Xeroagenes does the double bundle also. Whether or not your son wants an allograft (cadaver) will depend on a number of factors, one of which is how quickly he wants to get to sports activities. Allografts heals slower than autografts. Whereas someone with an allograft can be cleared to play as early as 6 months, specially with bone patellar, an allograft should probably not be cleared til at least 8 months. Some doctors will clear you earlier, but the consensus is that you really do need at least 8 months with some super conservative doctors recommending 10-12 months. Every person is different and some people, specially younger ones, will have their graft revascularize and ligamentise faster. But, 8 or 9 months would be my advise. Anterior or Posterior Tibialis is a fine allograft to use with the double bundle. Just make sure it was low dose irradiated (no more than 1.8MeV), and fresh frozen. Most studies I've seen favor fresh frozen over the other preservation methods (i.e. structural integrity, and other factors).

Aug 25, 2010
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20 yr old lacrosser player
by: Anonymous

If you are in North Florida, and can get to the Atlanta area, Dr. Xeroagenes of the Emory Sports Medicine Center is very good.

Aug 20, 2010
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20 yr old lacrosser player response
by: arnh@earthlink.net

Hello,
Sorry about your son's misfortune. Above I mentioned that my 14 year old daughter(at the time), ruptured her acl playing soccer.

Although I did not do as much research before as I did after the surgery, presently we are happy with the decision to go with allograft tibialis tendon.
For what it's worth I will give you some of my pros/cons that I can think of.

Pro: The sterilization process is convincing enough to me that the transfer of disease is near impossible.
Pro: Less pain, less trauma from extracting the graft from hamstring or knee. This also avoids the weakening of the hamstring or patella area and the required additional Rehab on those areasas well.
Pro: Harvesting an autograft from the hamstring potentially weakens it. Weaker hamstrings are part of the reason why girls seem to be more vulnerable to acl injuries - because of this we wanted to avoid a hamstring allograft.
Con: It's commonly believed that the allograft takes longer to revascularize and be assimilated versus an autograft. Because of this the allograft should be treated as "weaker" further out into the Rehab program. So the trade off here is that although you haven't traumatized the patella region or hamstring, the safe return to full sports activity might be delayed to accomodate the full revascularation of an allograft.

My daughter tore in late June 2008, she had the surgery in September, followed the rehab thoroughly, and was cleared for full activity in March. However, we did take it slow even after cleared. It will be a year next month and she is fully active in her sport of soccer.

For now, thats what I got. I can recommend a consult with our DR in Central Florida (where I am). He does general and sports orthopedic surgery. Email me above if interested.

Aug 19, 2010
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20 year old Lacrosse player
by: Anonymous

My son is an extremely driven 20 yr old college lacrosse player and overall everyday- every moment athlete. His right knee has a complete ACL tear with some damage to the MCL.He tore it playing soccer in late July. We had a consultation with an OS who performs about 100 ACL surgeries a year. Before the MRI, he thought it was a bruise not a tear because he experiences no pain and can run, jump, etc.... The OS want to to a cadaver graft but a phone conference with a college football ortho doc recommended Hamstring (son does not want this kind because of speed or (autograph-patellar graft). Another phone conf with a Dr. in Philly said patellar on anyone under 30. We live in North Florida and can't go to Philly. We had advise from a company friend who supplies surgical materials to Ortho's for knee surgery and he recommended Cadaver. We are so confused and our son is taking this semester off from college to have the surgery and recoup. Can you recommend an excellent Doc in this area that possibly does this double bundle? Maybe from JOI or Heekin? We want to address this ASAP so he can begin sports rehab. At least he will have the experience if he follows his path to be an Ortho one day! thanks

Jul 31, 2010
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bilateral tears
by: Anonymous

Sorry, I forgot to address one other question you had... you can not donate your own patellar tendon, if I understand your question correctly. First of all, patellar tendons, like Quads, are subject to weakening (tensile strength) over time. A patellar tendon from a 40 or 50 year old is much weaker than a 16 year old's. Some tissues, like Tibialis, seem to be much less affected by father time, making them superior in my opinion. My son had the Tibialis graft from a 48 yr old man. Second, no licensed doctor will take out any tissue of yours to perform an ACL transplant for the simple reason that a fresh tissue will be subject to the same problems, namely rejection, that any tissue transplant would have. Allografts (cadaver) go through a freezing and sterilization process that effectively kills and removes the sources of rejection (i.e. cells). Your patellar tendon would have to undergo the same procedure which would then render it no better than a cadaver's.
But, this procedure would be both time consuming and very expensive, rendering it impractical. Finally, unless you are wealthy, your insurance company would not pay for it. Believe me, I was very concerned allografts, and I thoroughly research all aspects of donor grafts, including infection, HIV,..etc., including the cases where they did happen, and became convinced that when properly handled, cadaver grafts are quite safe. Just so you know, no soft tissue grafts are ever used unless the organs of the donor were previously used on other recipients. So, if any recipient develops HIV or some other illness, they will throw away the tissue grafts. Nowadays, as compared to the early use of cadaver tissues, infections are extremely rare.

I hope this answers all your questions.

Jul 31, 2010
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bilateral tears continued
by: Anonymous

Having a double bundle performed on two knees simultaneously is a lengthy procedure and I am not sure how many doctors, if any, are willing to do this. You'll need to consult whatever doctor you go to. There are more cons than pros. But, the one pro I see is that trying to do the grueling rehab for one knee, with the other one also damaged, could cause that knee even more damage (because of the missing ACL). Also, your insurance may limit how many therapy sessions you may have in one year, so that might also be a good reason to have both done at the same time, or one shortly after the other, so as to use the therapy sessions available for both. Well, if anyone would do it, it would be Dr. Fu.

How well your daughter's results will be are also predicated on the amount of meniscal damage she may have. The more meniscal injury, the worse the outcomes. But, having no ACL will certainly make matters worse over time (i.e. cause more injury to the meniscus).

Finally, I wrote in earlier posts about the usual reasons for graft failure, doctor's technique being chief among them. You can read about it. I do not know if the Dr. Andrews you refer to is James Andrews, the world famous doctor. But, again, if a graft fails, specially an autograft, there is reason to be concerned that it could be the surgeon's technique and/or skill. So, if you are going to have a repeat ACL procedure, specially a DB, you should try to go to the best possible doctor, all things considered.

One last thing, please have as much physical therapy, for as long as possible. This is the secondmost important reason for success.

Let me know if I can be of further help.

Good Luck to your daughter.


Jul 30, 2010
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bilateral tears continued
by: Anonymous

In terms of the type of graft. It is almost certain that with already one pair of hamstrings gone in your daughter, that the reconstructions will be done with allograft. You can do your own research, but I became convinced that the best kind is one that is 2x or more stronger than the native ACL or Bone Patellar autograft. That is because there is a weakening of the graft once put in, and the stronger and denser the scaffold, the more likely it will survive the rigors of rehab until it is revascularized and ligamentized. Although we were given the option of using the Quad, since my son's forte is speed and agility, I did not want to mess with his extensor mechanism or his ACL stabilizers (Hamstrings). So, we opted for Tibialis Anterior allograft using fresh frozen, low dose irradiated, and no harsh chemical treatments. The methods used by different tissue banks can differ, so, I was happy to learn that the donor tissues used by Dr. Fu met that criteria.
There is one caveat with using allograft. That is, you should be prepared to wait longer to get back to full sports activities - at least 8 or 9 months, instead of the usual 6 with autografts. The reason is that allografts, by most accounts, take longer to revascularize and ligamentize. With young athletes, that is a danger because they feel so good so quickly with allografts, that they believe they can return sooner. This is probably one reason that a study done in 2008 showed a tendency for a higher failure rate with allografts than autografts in younger patients. But if discipline is exercised, there is no reason an allograft will not do as well as an autograft. Doctor Fu uses his own version of a healing accelerant, a Fibrin clot inside and outside of the graft. I don't know if it was this or my son's healing capabilities, but his graft was completely healed earlier than usual, as confirmed by MRI.

Jul 30, 2010
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Bilateral tears
by: Anonymous

Lisa,

Sorry to hear about your daughter. One tear is bad enough, but two? After much research, I, together with my son, opted to have his torn ACL repaired using doubled Tibialis Anterior allograft, and the Double Bundle procedure. He is now 9th months post op and back to regular sports activities. He experienced great range of motion gain quickly, almost no swelling, and no complications. We are very happy with the results. My son is back to running 95% as fast as before the injury and I'm sure he'll get it all back and perhaps be even faster in the next couple of months. We live in New Jersey and we selected Dr. Freddie Fu, head of the University of Pittsburgh Sport Medicine Center. He has done more DB procedures in the U.S. He has pioneered and perfected the techniques used by most doctors in the U.S. that perform the DB. Doctor Thomas Rosenberg in Utah was one of the first to perform a DB, and is also very good. With any operation, specially one still being perfected, the key is to go to the best. Someone who has done the most.
That's why we went to Dr. Fu. I can't say more good things about him and his staff. But, if you can not go to him, there are more and more doctors around the country who learned from Dr. Fu and you may be able to find one near your home.

Jul 25, 2010
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My Daughter has Bilateral ACL tears
by: Lisa Cole

Can anyone help? My 16 yr daughter is a cheerleader. She tore her ACL in Oct 2008 doing a toe touch. She had reconstruction in oct. 2008. In October of 2009 she experienced swelling and pain after a practice a MRI indicated a "change" but our Dr. Said it was "FINE"
Last Monday we took her to see Dr. Andrews for a 2nd opinion on the issue and to address pain in what was the good knee...
Much to our surprise the MRI showed both knees were blown complete tears.. We are trying to determine the best solution. She wants both knees repaired at the same time. We are considering Double Bundle because the singe ACL didn't hold (she never returned to the activity level before the surgery)

Anyone have experience with Double Bundle reconstruction in both knees?
Also, I want then to use my Patella tendons because I have heard you never 100% get over the pain from the Patella graft. I am her mom and much older she has already lost her hamstring in the 1st surgery. I want her to keep her remaining knee ligaments.

If you know anyone who is the top ACL double bundle surgeon that would use a donors ligaments please let me know..

Jun 20, 2010
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Second reconstruction
by: Anonymous

Continued...

In New York, The Hospital for Special Surgery, in NYC, is excellent and they have several really good doctors. Dr. Russell Warren (Giants) is excellent and there are several other outstanding doctors there, including a female doctor who specializes in ACL reconstructions for females only. If you have an HMO, and it doesn't list Warren, Altcheck, or some other doctor in HSS, then do research on the internet on other doctors listed in your HMO. See if they are well known, and if they have published anything. You can even go on college websites and get the e-mails of football coaches or trainers, and ask them about particular doctors in the area. Sometimes they will respond. You may also want to expand your search, HMO allowing, to other states like Connecticut. There are doctors there like Robert Arciero, and John Fulkerson, who are great. In NJ, you have Montgomery (Jets). There also some good doctors in Staten Island. And, if you are willing to go that far, you can go to Pittsburgh like I did, for Dr. Fu, who is one of the very best. In fact, Double Bundle reconstruction is perhaps even better in revision surgery. Finally, if your son will use allograft for his second surgery, he should be prepared to not go back to normal sports activities for 9 months.
Allografts take a litte longer to heal (but they work very nicely).

Good Luck

Jun 20, 2010
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Second reconstruction
by: Anonymous

HiMary,

Sorry to hear about your son. My son was 16 when he tore his. Based on the time frame you mentioned, your son was right at the cusp of when it is considered safe to return.
With professional athletes, whose time is money, it might make sense to attempt to return as soon as possible. It may have been wise and prudent for your son to have waited another month or two before resuming strenuous activities. In addition, if his leg muscles were not strong enough yet to protect and cushion that knee, then the knee could give way during athletic activities and the ACL might tear again. Doctors are supposed to test the strength by having the patient doing one-legged hops, and other tests, to measure the relative strengths of the legs. Most doctors do not allow resumption of activities until the affected leg is at least 90% as strong as the unaffected. Without an independent doctor looking at an MRI it is difficult to know if the problem was caused by a poorly positioned graft. Even though the graft may not be there anymore, most sharp eyed doctors can tell from the position of the bone tunnels whether they were correctly drilled and if it led to an impinged graft. If the tunnels are correct, your son's graft may not have been completely healed yet, and the strenuous activity may have caused it to fail. Or, it may have been completely healed, but he may have been hit or his knee may have turned abnormally and the ACL tore just as it did the first time. You should carefully interrogate your son as to how exactly the second misshap occurred. When the graft is not positioned correctly, it will lead to abnormal forces applied to the graft, and also to knee instabilities. You could ask your doctor if he measured side to side laxity with the KT-1000. A difference greater than 3mm is not good, and greater than 5mm is considered a failed surgery. Anyway, as you can see, there are many reasons why an ACL can retear. Going to another doctor with your MRIs for a second opinion would be a wise thing to do. If the tunnels are well placed, then it may be difficult to tell why it retore.

Jun 19, 2010
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Second reconstruction for 17 year old
by: Anonymous

Hi,

My son had an acl reconstruction using the patella tendon back in November. Never missed a rehab appointment. Doctor cleared him to play May 15. He reteared his acl playing Memorial Day Weekend. Same doctor, recommends allograft this time. We still don't know what caused the autograft to fail. After reading your posting of what can go wrong with the autograft reconstructions, I feel hesitant to have the same doctor do the second reconstruction. We are in NYC and this doctor is basically the only one my insurance allows. However, as playing is so important for my son, we are willing to pay for another surgeon if necessary. Please give me your kind opinion.

Best,
Mary

Jun 18, 2010
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Anterior Tibialis
by: Anonymous

Dear JP,

My philosophy is that when it comes to health issues, you want to go to the best. From Columbus, you are about 2 hrs from Cincinnati. There, you will find Dr. Frank Noyes who is one of the most revered knee doctors. I have read a ton of research material on the ACL produced by him over the last 25 years. I believe he is still practicing at Cincinnati Sportsmedicine and Orthopaedic Center. He does Single Bundle only.
From Columbus, you are 3 hrs from Pittsburgh. There, you will find Dr. Fu, who also been operating ACL for 25 years. You can also find a lot of research material produced by him and his staff. He does both Single Bundle and Double Bundle surgeries. In fact, he is one of the pioneers of DB. I drove my son 5.5 hrs to have his ACL surgery performed by Dr. Fu. He did a wonderful job. If you can afford it, see both then decide. If you have to pick one, you can't go wrong with either one.

Let us know how it goes.

Jun 18, 2010
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Anterior tibialis tendon allograft for ACL revision
by: Anonymous

Hi Friend,

Thanks again for your kindness, patience and help.
Do you have any recommendations around columbus, oh?

Best Wishes and Regards
JP

Jun 18, 2010
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Anterior Tibialis
by: Anonymous

Dear JP,

Looped AT and Doubled AT are the same thing. One tendon doubled onto itself. As long as each strand is individually tensioned, the graft will be more than 2x stronger than the native ACL, and about 1.5x stronger than the Bone Patellar Tendon.

Double Bundle has nothing to do with Looped AT, except to say that it is probably the choice graft to use for a Double Bundle reconstruction.
Anatomic Double Bundle surgery involves creating 4 tunnels instead of one, and two grafts instead of one. Each graft is positioned within the anatomy (i.e. position) of each of the 2 original ACL bundles. Each graft controls slightly different knee motions. One for Translational movement, the other for Rotational. This more closely approximates the physiology of the original ACL, which likewise has two bundles performing the same function. In the standard surgery, Single Bundle reconstruction, 2 tunnels and one graft is used. The doctor tries to fill up as much of the original footprint with a fat graft, usually around 10mm. If your original anatomy is a small ACL, say 12-14mm, a 10mm graft positioned anatomically may do an adequate job of controlling the knee. In larger anatomies, 14-18mm (about 2/3 of population), it may not be adequate and may result in instability, especially Rotational. The Double Bundle uses 2 grafts, usually an 8mm and a 7,6 or 5mm and this can lead to better outcomes. Although, since the operation is fairly new, not enough studies have been done to prove it, and the ones that have been done are about evenly split on the question.

About the 3%...true that the average failure rate is around 4%. But, poor positioning of the graft is one of the reasons ( the most frequent reason) contributing to that. Hence, my concern. There are many doctors, even some very experienced ones, that are performing the reconstruction in a non-anatomical fashion. That is, not positioning the graft within the original footprint, sometimes because the femoral tunnel is not correctly drilled. This results in the grafts being too vertical and hence leading to instability, and/or sometimes also causing impingement leading to graft failure. The doctor should be able to tell you the reason for failure, or at least be able to eliminate graft positioning as a factor. But, human nature being what it is, incorrect positioning sometimes is not admitted unless you go to a different doctor and seek a second opinion. They can easily tell by looking at an MRI. If your insurance allows, get as many second opinions as possible. I would recommend at least 2. If at some point you want some doctor referals, let me know what city you live nearby and I may know of a good doctor there.

Take Care

Jun 17, 2010
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Anterior tibialis tendon allograft for ACL revision
by: Anonymous

Hi Friend,
Thank you very much for the quick response. Your opinion is very helpful in making some decisions.
The doctor treating me is a team physician. He said that the chances for failure are 3%(I am not bow legged or knock kneed).I should digest that I could be in that 3%.
My doctor said that they will use one anterior tibialis tendon and loop it over so it is 2 fold. Is that what you called double bundled or is it different?
I hope the revision works and help me have a normal life.
My surgery is rescheduled to July 22.
I'll keep you posted on my progress.

Best Wishes and Regards
JP

Jun 16, 2010
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Anterior Tibialis Revision
by: Anonymous

To JP:

If you are not sports active, and 31 yrs old, it's questionable why you had an Autograft to begin with. Allograft would've been my first choice. A revision surgery so soon for an Autograft ACL reconstruction most likely indicates either a poorly positioned graft,
some congenital issue with your knees (e.g. knock need, or bow legged not corrected before reconstruction), or some traumatic event after surgery which caused the graft to fail. Other factors such as incomplete healing are rare with Autografts. Bad rehab (or no rehab) could cause problems but probably not graft failure. If you are bow legged or knock kneed, your doctor should consider fixing that before another ACL is placed.

Doubled Anterior Tibialis Allgoraft is a fine graft - about 2x as strong as the native ACL, and studies show it's strength is not age dependent. An 80 yr old AT is just about as strong as a 25 yr old. All grafts weaken as they go through the revascularization process. So, in theory, the stronger the graft going in, the betterr. But, not all doctors ar ein agreement.

The most important factor determining ACL reconstruction success is doctor technique and skill. Do not assume all doctors are equal. In my opinion, you might want to consider going to another surgeon, one that that at least 75-100 reconstructions per year, and who has a good reputation, especially with athletes. Also, rehab is extremely important. Do not neglect it.

Finally, you might want to consider a newer form of ACL reconstruction, where they reconstruct both bundles of the ACL instead of one. It's called Double Bundle reconstruction. Some studies show a 5-10% increase in knee stability. More and more doctors, especially the younger ones, are adopting it. But the operation does require more skill, and it it takes about 30 min loner. Probably the best in the U.S. is Dr. Fu of Pittsburgh.

Good Luck




Jun 08, 2010
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Anterior tibialis tendon allograft for ACL revision
by: JP

Hi,
I(31 year old female) had my first ACL reconstruction(Hamstring autograft) last July and my knee gave in after 11 months. My doctor checked if I had rtheumatiod arhritis and it came out negative(I don't have R.A). He is thinking of using Anterior tibialis tendon allograft for ACL revision this time. Can anyone help me understand if this is a good choice for a revision allograft? Is the tibialis tendon stronger than a 2 fold hamstring?
What are the problems, if any, of using this allograftgraft. How soon can I be out of crutches.I have a year old and a 4 year old. I am a regular person, not into any sporting activities. My revision surgery is scheduled in the first week of July. Your suggestions and opinion is highy appreciated. Please help Thank You.

May 26, 2010
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My Daughter had the allograft
by: Arnold

My 14 year old daughter, a soccer player, tore her ACL and we went with the Allograft. Surgery was September 2009. Everything has been great. She was cleared to return to the field in March 2010. No pain, no swelling at all. I've read much on the theories that the failure rate is higher using the allografts. Hopefully, you come out of this as my daughter did. Rehab, rehab, rehab - that will most likely determine how strong your knee comes back. good luck

Apr 16, 2010
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1 week post op with allograft and doing fine
by: Juli

I decided to go with the allograft and after one week I'm pleased with my decision. My surgeon said the graft he chose was a perfect fit. My surgery only took 63 minutes! The pain has been much less than if I'd had the patellar autograft. I had a femoral block which worked great and was easy to remove by myself 3 days later. I'm managing the pain now with Torodol.

My leg is wrapped from ankle to thigh with an ace bandage and then in an immobilizer brace. I'm doing quad sets, leg lifts and heel slides twice a day until I start PT at 10 days after surgery. I've been able to put 50% weight on my leg since the day of surgery. It makes using crutches much easier.

Thanks for the info about the grafts! I think I'll be able to get back to all of my previous activities after my rehab.

Apr 09, 2010
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I've been in your shoes!
by: Allison Fontana

Hello Julie. My name is Allison and I'm a 44 year old very athletic firefighter. After I tore my ACL I chose to reconstruct using my patellar tendon because I was told it was stronger. I've had nothing but problems. It has been 1 year since my first surgery and I'm facing a third surgery on Tuesday the 13th to deal with scar tissue problems (arthrofibrosis). The second surgery was for the same problem but the scar tissue grew back.
While I am back to full duty on a fire truck, I'm still having problems and pain that I cannot accept long term. It seems that most of the scar tissue has developed around my patellar tendon area. No one knows whether I would have had these probems had I used an allograft, but if I could do it all over again I would use the allograft. Creating a another serious injury to have to recover from in addition to the injuries you already have complicates and delays recovery. I can see if you're very young or a professional athlete that the patellar tendon would be your best choice but other than that I'm not sure. While in therapy I saw many allograft patient funnel in and out, returning to their normal lives, while I sat there making no progress.
I hope this info helps you with gathering info to make your decision. Also, www.kneeguru.co.uk has a lot of good info to sort through. My e-mail is alifontana@bellsouth.net if you have any questions for me. Good luck!

Allison

Apr 08, 2010
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Research on Allograft vs. Autograft
by: Bart - SII

Indeed, information found online for this topic can be confusing. So can the info you get from physicians and other health care professionals. I did a quick search of recent literature and found several articles examining the differences in outcomes for these two procedures. Unfortunately, there was good evidence for both sides.

Autograft and allograft similarly effective in ACL reconstruction, meta-analysis finds. DiMarcantonio T; Orthopedics Today, 2007 May; 27 (5): 48-9

Clinical outcomes of allograft versus autograft in anterior cruciate ligament reconstruction. Baer GS; Harner CD; Clinics in Sports Medicine, 2007 Oct; 26 (4): 661-81


Comparison of revision rates in bone-patella tendon-bone autograft and allograft anterior cruciate ligament reconstruction. Mehta VM; Mandala C; Foster D; Petsche TS; Orthopedics, 2010 Jan; 33 (1): 12

No clinical difference in outcomes between allograft, autograft for ACL reconstruction. Beadling L; Orthopedics Today, 2006 Apr; 26 (4): 9

Prospective comparison of auto and allograft hamstring tendon constructs for ACL reconstruction. Edgar CM; Zimmer S; Kakar S; Jones H; Schepsis AA; Clinical Orthopaedics & Related Research, 2008 Sep; 466 (9): 2238-46

I won't take time to get into each of them individually. Your University friend may be able to get the actual articles for you through their school. Suffice it to say that there are studies that show no significant differences, and studies that show a higher failure rate and lower function with allografts. It can be hard to generalize such results though, because your situation may be different than those in the studies, and there are so many factors to consider when looking at the overall outcome following surgery.

When it comes to graft choice, it is mostly a surgeon/patient preference. While the graft is important, and the surgical procedure needs to be performed correctly, much of what determines the success following ACL reconstruction is the rehabilitation. A comprehensive approach to muscular strength, balance, control, and mobility are necessary to prevent future injury and return of normal function.

I have seen hundreds of ACL patients over 10 years, with almost every graft possible - Auto hamstrings, gracilis, patellar tendon, achilles tendon / allo hamstrings, patellar tendon, achilles, etc. 99% of them were able to return to normal function following their surgery. I worked with great surgeons, but we also had a fantastic ACL rehab program, and a maintenance program that they followed until full release.

It is a difficult decision. Hope this helps a little.

Bart

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