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Author Topic: Achilles tendon Allograft - long term prospects?  (Read 3187 times)

Offline abknee

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Achilles tendon Allograft - long term prospects?
« on: November 20, 2008, 09:21:41 PM »
I have just had an achilles tendon (bone plugs) surgery on my right knee on 30/10. I decided to go the allograft route as I already had my hamstring from both legs used for an acl and mcl recon in my left knee (9 years ago).

I could have had a patella tendon autograft in my right knee but I had osgood schlatter which would have made the harvest quite tricky.

Now after reading what Dr Mark has said regarding allograft failure rates do I once I am fit give up playing active sports? I am 32 and I was hoping to get back to playing soccer perhaps late next year.

After being through 2 knee injuries I am now thinking is it time I changed my lifestyle and stop playing the sports I love? The thing is how do you know you will not re-injure your acl? You don't no matter how much strengthening and fitness you do.
April 98 - MCL + ACL full rupture Left Knee from horror tackle in Soccer
April 99 - MCL + ACL recon using hamstrings from both legs
December 05 - Bad tackle on Right Knee
July 07 - ACL rupture confirmed on Right Knee - and meniscu tear
Oct 08 - Planned ACL Allograft Recon and Meniscus repair

Offline crumpet

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Re: Achilles tendon Allograft - long term prospects?
« Reply #1 on: November 20, 2008, 09:49:39 PM »
ABknee:

Ya know...I'm not one to know a lot yet, but from what I understand the recent study said that it did NOT include the failure rate for the achilles allograft.

It would be interesting to hear if Doctor Mark is referring to his experience here or if he has seen reports of a high number of achilles allograft failure. 

FWIW...By all accounts that (I've read thus far)...the achilles allograft is considered the best of all allograft choices.

I don't know what sports you love, but I strongly am starting to believe that some sports are more ACL friendly that others, and you never know...you may find a new "love" if you look hard for it.:) I love watching contact sports but, I'd run away from something like that...even before I was ever injured, so I'm not probably the best person to ask on that one!:) LOL

Good luck!!!!

~C:)




acl issue

drmark

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Re: Achilles tendon Allograft - long term prospects?
« Reply #2 on: November 21, 2008, 12:46:29 PM »
That study used bone patella bone allografts not achilles allograft.

In medicine, a physican must constantly make decisions based on imperfect information.  The best available information is what I base my practice decisions on.

To my way of thinking, it defies common sense to believe that one dead tendon treated with caustic chemicals or radiation to kill deadly germs, can be very much different from the next.

Offline abknee

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Re: Achilles tendon Allograft - long term prospects?
« Reply #3 on: November 21, 2008, 01:52:17 PM »
So drMark would you ever use an allograft in an ACL surgery? I understand that Carson Palmer had an achilles tendon allograft with an mcl repair as well as further injury to his knee and has made a comeback but I cannot say how well he is playing as I do not follow NFL from here in the UK.

Jimmy Bullard - a premier league soccer player tore his PCL, MCL, ACL and dislocated his knee, he had surgery done by Richard Steadman - I have been looking on the net but I cannot find what type of grafts were used - drMark would you have in indication of what were used as Jimmy Bullard is now back playing as good as before.

DrMark - thank you for your replies - you must be a busy man and I as well as everyone on this forums appreciate your candid responses.
April 98 - MCL + ACL full rupture Left Knee from horror tackle in Soccer
April 99 - MCL + ACL recon using hamstrings from both legs
December 05 - Bad tackle on Right Knee
July 07 - ACL rupture confirmed on Right Knee - and meniscu tear
Oct 08 - Planned ACL Allograft Recon and Meniscus repair

Offline feeny

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Re: Achilles tendon Allograft - long term prospects?
« Reply #4 on: November 21, 2008, 02:19:18 PM »
Heya -

To my knowledge there have been plenty of successes and even amazing successes using allografts.
One that I know of first hand is Alisa Camplin - won a medal in the freestyle jumping at the winter olympics less than 4 months after undergoing ACLr. She was practically in the bed next to me when I had mine done:

In her preparations for the Turin Winter Olympics, Camplin incurred a serious knee injury in October 2005, requiring a knee reconstruction. To speed the healing process, she used the relatively uncommon practice of using donor tissue in the knee, and returned to limited training only 11 weeks after the surgery. She finished fourth at a World Cup event in Lake Placid to secure her place in the team.
On 22 February, in a night competition that was marked by a thick fog that disturbed competitions to an extent, Camplin registered a score of 94.99 in her first jump, the fourth best. In the second jump, she received a 96.40, which temporarily placed her second, a silver medal. She was, however, eventually dislodged by China's Li Nina, finishing third behind Switzerland's Evelyne Leu, who won the event, and Nina, who took silver. She also benefited from the unexpected fall of China's Xinxin Guo, who had received the highest score in the first jump and was expected to secure a place in the Olympic podium — at which time Camplin, who was already third then, would have gone out of the medal zone. She was selected to be the Australian flag-bearer at the Opening Ceremony.


Full story on Alisa at wikipedia: http://en.wikipedia.org/wiki/Alisa_Camplin.

Same surgeon did mine using a hamstring autograft. No complaints yet and hoping to keep it that way. I may not have won any medals, but at about the same time Alisa was winning - I was just up the road in the alps snowboarding again in a similar recovery time frame to her.

Abknee - you may never injure your ACL again (and I hope not) - whether you play sports or not. The decision is entirely yours - and I have only been through one of these things... but my attitude is we have to live our lives, right?
Sep-05 ACL rupture, Medial mensical tear, MCL rupture
Oct-05 Had it all repaired (hamstring graft, meniscal rivet)
-and then-
4.5 Months post-op Snowboarding like a demon
7 Months post-op Successful return to indoor soccer (YEH!)

Offline abknee

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Re: Achilles tendon Allograft - long term prospects?
« Reply #5 on: November 21, 2008, 02:27:22 PM »
From a post by Soccergirl

For comparison here is tested failure point of different graft options  (in newtons)
Autografts
i. Patellar autograft- 2375 N
c. patellar autograft- 2950 N
Quad bundle Hamsting- 4550 N
Quad tendon w/o bone plug- 2353 N
                    w/ bone plug-  3360 N
Allografts
Anterior Tibialis- 4122 N
Posterior Tibialis- 3594 N
Patellar tendon - 2090 N
Quad Bundle hamstring- 3900 N
Achilles- 5670 N

http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=44111.0

However I don't know what a typical achilles tendon graft will be like post chemical treatment and post vascularization and attachment, however if no one tries something new we will never learn so its unfortunate for those that take the risks but that is how we progress?

I think what I may do is contact my Surgeon and see if I can find out the age of the person whom I received my graft from. In the UK there is no private market for grafts. Everything is handled by the National Tissue Service (part of our great NHS).

April 98 - MCL + ACL full rupture Left Knee from horror tackle in Soccer
April 99 - MCL + ACL recon using hamstrings from both legs
December 05 - Bad tackle on Right Knee
July 07 - ACL rupture confirmed on Right Knee - and meniscu tear
Oct 08 - Planned ACL Allograft Recon and Meniscus repair

Offline feeny

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Re: Achilles tendon Allograft - long term prospects?
« Reply #6 on: November 21, 2008, 10:35:47 PM »
One thing I have never fully understood is how important graft strength is over time.
My limited (and probably flawed) understanding is that it impacts the type of rehabilitation possible in the weeks and months after surgery - a stronger graft / adequate fixation technique means that more aggressive rehabilitation is possible...

What I have never really understood - is given appropriate protocol for different graft types - in the medium term future - say three years after surgery - will the graft choice make any difference at such a point to the overall strength of the knee?

...My understanding was very little if any at all - I believe the graft to be essentially a "scaffolding" upon which the body then builds new tissues that perform the structural functions required. What I have never been able to understand, is once the new tissues have formed, over time, how can the initial graft choice itself have any significant impact on the outcome - other than through the additional rehabilitation options that may be possible via stronger graft choices and fixation techniques?

And I would have "guessed" that a big part of the failure rate of the allografts in young people would be as much to do with young people trying to do far too much too quickly after such a procedure - i.e. possibly caused by protocols that have not yet caught up with such techniques - together with the difficulty of getting young'uns to properly follow such protocols... - as anything else? I haven't read the article - but I wonder what the failure rates are of other graft choices in the same populations - and whether it is significantly different - I would also be interested to see what this failure rate was when the older procedures were first adapted (and hence less understood!).
Sep-05 ACL rupture, Medial mensical tear, MCL rupture
Oct-05 Had it all repaired (hamstring graft, meniscal rivet)
-and then-
4.5 Months post-op Snowboarding like a demon
7 Months post-op Successful return to indoor soccer (YEH!)

Offline ATsoccergirl

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Re: Achilles tendon Allograft - long term prospects?
« Reply #7 on: November 21, 2008, 11:39:40 PM »
Just to clear up a few points, the achilles allograft only has bone plug which comes from the calcaneous of the cadaver. 

When looking at the failure points, which was quoted from one of my previous posts, a newton is roughly equal to 1/4 of a pound of force.  Most people find newtons a little too abstract to really mean anything. 

I have had an achilles allograft almost 4 years ago, in fact it's the only type of allograft my surgeon will use.  It's strong and also the widest graft available.  He specifically use the achilles allograft on me so that I could return to soccer and I returned at 4 months post-op.  I was in a car accident 2 years where my knee hit the dashboard.  The OS I saw following the accident was quite amazed that I completely tore my PCL yet my ACL was intact and I had no anterior laxity. 
1999 LR, 2002 ACL/PLC recon, reversal of LR, 2004 ACL revision, 2006 Car accident torn PCL and small fractures resulting in bone chips in my knee.  Torn MCL 3 times.  Wicked screws under IT band and Pes Anserine.  June 2008-Hip Arthroscopy.

Offline crumpet

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Re: Achilles tendon Allograft - long term prospects?
« Reply #8 on: November 21, 2008, 11:55:21 PM »
Soccergirl:


Wow...Very sorry to hear about that awful accident, but its so cooooooool that the ACL held up.

Excellent!

Do you see that ABknee?  Should warm your heart.:)

YEAH...feens...I've seen that theory. Too much activity too soon for the graft choice -- sounds entirely plausible, and totally avoidable.:)

How does one sigh up for a "young" achilles instead of an old one?

~C:)


 
acl issue

Offline abknee

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Re: Achilles tendon Allograft - long term prospects?
« Reply #9 on: November 22, 2008, 01:18:43 AM »
I don't think you sign up - it depends on what's available at the time and when you want your surgery scheduled - it's something you can perhaps find out post operation.

Soccergirl - I was advised to wait 8 months before returning to soccer so your 4 months is amazing to say the least.

Just wondering does anyone know when the acl is under the greatest strain? Ie is it when the knee is straight, bent?

April 98 - MCL + ACL full rupture Left Knee from horror tackle in Soccer
April 99 - MCL + ACL recon using hamstrings from both legs
December 05 - Bad tackle on Right Knee
July 07 - ACL rupture confirmed on Right Knee - and meniscu tear
Oct 08 - Planned ACL Allograft Recon and Meniscus repair

drmark

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Re: Achilles tendon Allograft - long term prospects?
« Reply #10 on: November 22, 2008, 02:49:29 AM »
We have no clue how strong the ligament grafts are after they are treatd with the chemicals and implanted inside the knee.  Since few ACL patients die, and those whose ligaments fail have the ligament grafts excised piecemeal, we don't get to check their ultimate strength to failure.  As I said before, we have to make deisions based on imperfect information.

I have used one allograft in the past ten years, and the paitent did well.  Most of my practice is revision ACLs, and I know that I much more frequently revise allografts cases than auto PT cases.  Since everyone has two expendable1/3 patella tendons, and two mid quad tendons, I have not had to resort to any allogrfts in my revisons.  My patients all expect alot of my work, and they are all too important to me to excessively tempt Mother Nature by using expesive implants that could be responsible for disseminating deadly diseases that we haven not yet isolated (I was a medi student the late 70s when the homosexual and hemophilliacs started to die off and we had now idea why.  Had we been big into allografts back then, we would have wiped out millions of healthy kids.  I continue to be afraid for my patients that such a thing will happen again in my lifetime) or poteintially have a higher failure rate.  (The failure rate of 25% may not be a big deal to a participant on this website, who believe he/she will  be amongst the lucky, but with me doing 100-200 ACLs per year, I know that I can't consistantly be lucky and between 25 and 50 people will be hating my guts every year  That would make every afternoon in the clinic into a miserable experience for me.)

As far as the big names mentioned earlier, we know very little about how this famours guy or that famous guy is doing with their knee.

A study was done on Olympic bound athletes.  They were asked if a pill was available that would enhance perfromance and win them a gold, but would cause premature death in five years was available, would they take it.  Over 50% said they would.  What does that tell you about their decision making process?


Now lets mention some famous American athletes
OJ Simpson....
Michael Vick.......both in prison and jail
Roger Clemens.....heading to an indictment and probably prison
1/2 the Dallas Cowboys pro football team .....on probation or one form of adult superision or another

These guys don't make the best decisions in their lives.  Do you think that they make  the smart health care decsions?


Very few pro athletes are smart enough to lean stuff about their knee from one another, as on this board
Just because one of these gorillas have this or that, do that automatically make it the smart thing to do?
« Last Edit: November 22, 2008, 03:31:45 AM by drmark »

Offline abknee

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Re: Achilles tendon Allograft - long term prospects?
« Reply #11 on: November 22, 2008, 01:31:18 PM »
In respect to disease transmission I was at first very sceptical about going down the route of an allograft but luckily I know quite a few Transplant Surgeons and I discussed it with them and their point of view was simple I had greater chance of getting knocked down in the street than getting an infection as they dealt with these issue day in day out and in the UK they are extra cautious in the way they treat donors. They transplant livers and kidney everyday and in their 25 year careers have never come across a transmission of a serious infection. Obviously this is statistics and I do appreciate the point regards the only safe way is autograft.

Unlike these pro sportsman I will accept that if I feel my knee will not be up to the stresses of soccer that I can go and play another sport - triathlon is what I have my eyes on (I am 32 but fit when not injured!!).

April 98 - MCL + ACL full rupture Left Knee from horror tackle in Soccer
April 99 - MCL + ACL recon using hamstrings from both legs
December 05 - Bad tackle on Right Knee
July 07 - ACL rupture confirmed on Right Knee - and meniscu tear
Oct 08 - Planned ACL Allograft Recon and Meniscus repair

drmark

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Re: Achilles tendon Allograft - long term prospects?
« Reply #12 on: November 22, 2008, 01:44:18 PM »
There is a huge difference beween livers and kidneys and tedons for ligament repairs.
With the kiney and liver patients, its either transplant or death.

With the knee igaments, these patients are perfectly healthy and the IS an alternative.

Offline ATsoccergirl

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Re: Achilles tendon Allograft - long term prospects?
« Reply #13 on: November 22, 2008, 02:29:00 PM »
There has been a few cases of disease transmission from an allograft, but it generally occured when the grafts were not coming from reputiable sources. 

So people are aware that junk like this is going on, there are some scams out there were people are being contacted by someone claiming to be a lawyer asking for money so that they can join a class action lawsuit against the tissue bank where their graft came from.  If you are or have been contacted by someone making this claim, you need to call your OS immediately because your medical records may have been compromised.  When I was contacted by them, it was apparant that they had way more info than they should.
1999 LR, 2002 ACL/PLC recon, reversal of LR, 2004 ACL revision, 2006 Car accident torn PCL and small fractures resulting in bone chips in my knee.  Torn MCL 3 times.  Wicked screws under IT band and Pes Anserine.  June 2008-Hip Arthroscopy.

Offline subail

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Re: Achilles tendon Allograft - long term prospects?
« Reply #14 on: November 22, 2008, 05:14:19 PM »
I know this is the cruciate section.

Having said that I ruptured my patellar tendon and as a result of previous surgeries I was unable to have my hamstring used as a graft. My surgeon opted for an Achilles tendon allograft. I have suffered no ill effects.

Sure, I've read a couple of horror stories about wire breakage and bits floating up to the heart and killing people. I have a wire cage encircling my knee. Will I worry about the likelihood of that happening....No! The chances are slim.... :D  So, will I worry that I may catch something from a graft....No!

I think sometimes we involve ourselves in too much navel-gazing!

Yes, it's important to be circumspect but I trusted my very well qualified surgeon to make the decision. In my case as well there weren't many options....

The opinions expressed here are my own....take from them what you wish...
Dislocation of left patella and as a result left patellar tendon rupture in the medial section and torn at both ends.
3 Previous surgeries-semitendiosis tenodesis
Reconstruction surgery on left knee October 10 '07
TKR on right knee May 25 '10.....successful!
Limited ROM

 















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