please give advice an graft selection, im freaking out.

[knee-will-be-great]

Dearest Kneegeeks (including but not limited to Dr. Mark) !!!

(#1, accept my apology for one of the key on my keyboard not working conitently....)

(#2, I am absolutely fascinated with this interesting thread.)  A an over 45-year old who is in top hape, who drives 228 kilometre (137 miles) every day to/from work - and who has more energy and get up and go (and who is more active than most of my friends and colleague 10 to 15 years my junior), I can state without hesitation that I have had 4 ACL repalcements; the firt being an autograft in 1976, (uing a emitendinoi repair; thi did not lat more than one to two year - a I wa an etremely active teenager).  Thereafter, I had a Bone-Patellar Tendon Bone Allograft (without a HTO) in 1993.  Thi failed le than one year later becaue of being bumped trongly on the ide of my knee; hearing the rrip wa impreive mind you.  Thereafter another ACL allograft in 1995, although I do not know the nature/origin of the harveted cadaver material.  Thi ACL allograft lated until the 2000' when a rrrrrrip occurred owing to forces outside of my control.  I learned, later, that the allograft could not have been properly poitioned owing to the fact that my knee wa in a varu poition relative to the healthy knee - owing to the fact that I had had a medial meniectomy in 1976; thereafter uffering oteoarthritic change.  I apparently needed an HTO prior to an ACL replacement for the ACL replacement to work / be attached properly.

I am pleaed to tate that after a HTO (2006) and, 18 month later, a third ACL allograft (2007), I am very fine and fit; I did have ome etenion iue (5 to 8 degree) owing to the fact that the HTO wa poitioned in uch a way a to tilt my tibia relative to the fit left-leg twin.  Moreover, arthritic change contributed to thi.

________________

I would have liked to have had an autograft but it wa out of my deciion cope - (my orthopaedic urgeon sees me, I believe, as a de facto "A Personality"who pushes herelf (and the os is correct on his assessment).  I am cloe to half a century young now, am fit as a fiddle, and could not think about how life would have manifested without a (3rd) allograft and a much appreciated HTO.  Hope there will not be any more allograft, but I can handle same - if necessary owing to injury or progressive looseness refractory to the inherent nature of the allogaft.  Too bad for me that the bed knee happened; would have like to have done the iron man (woman) at 50 year of age - in Hawaii

I do get a sense that the allograft may be considered for the so-called more "sedentary" (not in this case <me>) over 45-crowd member, but have not focued my attention of reearching thi.

________________

In any event, an ACL replacement is, I find a definite necessity for active, healthy individuals - so that they can continue being active and non-sedentary and not focus their minute-by-minute modus vivendi on how to balance their bodies on top of a unstable knee / et of knees.

Cheer from Knee-will-be-great ........... 

[crumpet]

KWBG:

Yes... I very much appreciate the open discussion (even if its bit heated).  Its a shame that this graft business is shrouded in such secrecy as are many things medical. One would think since there are so many recons done in any give year...there would be better "intelligence" on the topic.   

Forgive me for asking...in case you have already posted this.  How is you new graft going?  Have you experienced any laxity or instability with it? You have had so many grafts now...its too bad they hadn't all been placed properly, so you could give a us a review on how each one conducted itself!:) 

KWBG...you don't have to win the ironman race to convince me that you are made out of some pretty darned tough stuff.

~C:)

[knee-will-be-great]

The new allograft - doing fine - very fine !!! 18 mo. and counting.

KWBG!!!

[abknee]

http://www.springerlink.com/content/d708148n750p3543/

Hamstring tendons actually regrow back!

[fergy]

KWBG - good for you!!!  I'm glad to hear that things are going well for you.

I too am no spring chicken (age withheld out of modesty - hee hee) but I'm very active.  I am a semi-pro dancer - I do exhibitions of 1960s style dancing.  The pivoting, jumping, and cutting I do when I dance would put any soccer player to shame ( no offense Feeny!  )  I also love roller skating and had just bought a pair of quad (traditional) skates right before my accident - grrr  My activity level is hard to explain to people who cannot imagine someone at my age doing the things I do. 

I do wonder if my doctor based her graft recommendation on my biological age rather than my activity level (she recommended achilles tendon allograft).  But there were other considerations, including my petite stature.  And she didn't recommend patella based on her experience with hearing patients complain of patellar pain years later. 

I must admit I am a little concerned - not about the long term stability of the graft but how long this thing takes to incorporatel.  I have dance gigs in March, June and July of next year and given the nature of my dancing, I doubt I'll be able to do them.  And if I have to cancel another gig - it could mean I don't get invited to others...

Anyway, after reading a number studies, I've come to the conclusion that the reason why there isn't a lot of solid studies about graft choice in the literature are a difficult area of study because of all the variables: surgeon skill, patient compliance, other factors about the patient, rehab protocol, length of time needed to follow subjects, bias factors - the list goes on.  What would be interesting to see is a long term study that with patients from the same surgeon and rehab protocol, using different graft types. 

[abknee]

There is a shortage of grafts for acl operations. Also you do not know how old the person was who you got the graft from - I assume everything else being equal a graft from a younger person would be stronger than the graft of an older person, but that maybe initially but after it is incorporated into your body how much of a significance is that?

The only real way to prevent future acl injury that is not an accident is to reduce the number of cutting, pivoting movements by changing the way you perform or strengthening your whole body.

[fergy]

Abknee, perhaps you don't have access to the full study (I do). The study was a literature review of previous studies in this area.  According to the author - it is clear hamstring tendons can regenerate into a "tendon-like structure", as the author puts it.  But the author also points out that there are many unanswered questions about the mechanism of this regeneration, and the restoration of hamstring function. 

Fast forward to the conclusion of the study: "In conclusion, despite the initial enthusiasm, the literature review still reveals unanswered questions about the tendons regeneration phenomenon and surgeons must be more sceptical [sic] about its clinical significance.  Further, long-term studies are needed to clarify issues such as the exact mechanism of the tendons regeneration, the end time of the maturation process, the mechanical properties of the neotendons and the physiological role of the phenomenon in the matter of restoring the function of hamstring muscles."

Some abstracts don't always provide the full picture of a study. It's important to read the entire study and have some knowledge of medical terminology to understand these studies. 

[abknee]

Just noticed you had an achilles tendon allograft (same as me) one day after me.

I know the hamstrings do not fully regrow back but it was an interesting article.

As to graft choice - from what I have been reading about contralateral BTB if there is good chance of the patella regrowing? then it must be no1 choice assuming there are no other issues.

I suppose in the future if we get gene therapy we could perhaps treat the allograft so that it incorporates better. I do feel that fixation methods have improved to an extent where there is little significant difference using a bone harvest or not. The main benefits I see is that the bone harvest speeds up incorporation into the body.

[fergy]

There's no way I could change my performance to avoid those kinds of movements.  1960s dances embodies that kind of movement, so that's not an option. 

My body was pretty darned strong before the accident so I'm not as concerned about that.  Much of my concern has to do with  the psychological factor.  I don't know if I'll get past the concern that something could happen to be able to perform as I used to.  That's the thing that might end my career, if not my knee.

[abknee]

As to the psychological factor - when I first played soccer after my first acl op I wore a heavy knee support - well 10 minutes into the game I was hit hard on the knee by a bad tackle (i thought oh no) I stayed on the ground but I felt no pain and the knee felt fine. I got up tenderly and ran for a bit and felt fine. I took off the support and played hard as if my life depended on it. It was the best thing that could have happened as I then knew I was fine and back!

But as its your career I would play a bit safe (where would you be with a second acl op? even further behind) Realistically you should be at full strength 8 months post op is what my Surgeon informed me. Looking at around June?

[fergy]

Unfortunately, I can't wear a brace performing... and unlike athletes, I wear vinyl boots from the 1960s that are made for looks, not support or comfort! 

My OS said 8 months too - but again, I'm not sure she has any idea about how I dance. I have read 12 months for an allograft to fully incorporate, perhaps longer - so even if I'm ready, the graft might not be ready to take the stress from wild dancing in bad shoes Darn it,  I should have brought her a video of my dancing.  I hate the "woulda shoulda coulda" game but I can't help kicking myself not impressing upon her about my dancing style and how important it is to me to get back to my dancing ASAP.   I just wish there was something I could do to make the healing go faster...

Well, no point in worrying about it - anything can happen between now and then, both good and bad.  I'll try to avoid thinking about the bad and focus on the positive.   

[abknee]

Allografts is a trade-off between less pain and mobility early vs a delayed return to sports.

The allograft is in your knee now - thinking about whether it was the correct graft choice is pointless. Concentrate on your physio and training and think that your legs need to be x2 as strong as before. I did so many heavy squats and leg work my legs were like steel when I came back.