Author Topic: ACLr - Quadricep tendon autograft (Read 3049 times)

Hockey98 · « **on:** April 25, 2012, 12:53:30 PM »

Hey guys,

I am currently one week removed from acl reconstruction and meniscus repair on my left knee. My procedure was performed at UPMC in Pittsburgh by Dr. Freddie Fu. I was starting this thread to not only shed some light on my recovery process, and perhaps provide some information to anyone looking to use Dr. Fu, but also to gain some feedback on my progress from those who have already been down this road.

Most of my story can be found in a separate thread that was started a couple years back when I was originally slated for reconstructive surgery. That thread can be found here: http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=53949.msg572334#msg572334

In terms of my progress thus far:

To say I am frustrated would be an understatement. I still have absolutely no quad control and the burning sensation when I stand is still very much prominent. I need someone to physically lift my leg up for me to help move from the couch to a seated or standing position. I have not yet graduated to crutches and am still utilizing a walker, which better allows me to lift myself up as I move and provides much better balance. I have reached 65 degrees of flexion on the CPM, however when the machine falls into extension I feel as if I don't achieve those last couple of degrees. This, coupled with the fact that prior to surgery my meniscus was locked in the joint preventing full extension, have causes considerable difficulty in my post-op recovery and achieving any sort of quad control. I am sure that the quad tendon autograft compromised things further. I am currently a graduate student obtaining my Masters degree at a local university and have already missed two entire weeks of class, and anything more will undoubtedly prove disastrous to my grades. Essentially, I am looking to see if anyone else has had such progress in the immediate aftermath of the surgery. Any questions about my procedure I would be happy to answer.

Kaputt_Knee · « **Reply #1 on:** April 25, 2012, 01:19:49 PM »

Get in contact with EmergRN as she had an ACL REVISION using a quad tendon graft done in Vancouver last November. She is the most recent, still active member who had this particular graft. She may pop by of her own accord as well. She is also having a few issues with her rehab, but they may not be exclusively a result of the choice of graft.

Good luck, it does get better but how quickly is always hard to generalise. so far I've avoided having my quads harvested but that may be the only source of autograft if I mess up my ACLs again!

Sue

Hockey98 · « **Reply #2 on:** April 25, 2012, 06:21:30 PM »

Thanks Sue!

I found that member's profile but for some reason cannot figure out how to send a message! So much for my presumed computer literacy. Dr. Fu seemed certain that the graft side morbidity would be less than that of the other options, so that is why I agreed to go with that option. I am sure this extension is going to be a real challenge. I feel as if those last few degrees of hyperextension are really being prevented by swelling at the moment more than anything else, but that being said, my operative leg still feels as if it's not under my control.

Kaputt_Knee · « **Reply #3 on:** April 25, 2012, 06:38:39 PM »

You need 20 posts to be able to send PMs. You can easily get the last 7 or so you need by answering some the fun questions in the Who's who section in Games Room (right at the bottom of the Home page index).

Sooty I thought you had enough posts already.

emergRN · « **Reply #4 on:** April 25, 2012, 06:50:42 PM »

I saw Quad tendon graft...and here I am..lol!

Don't be frustrated! I was comparing everything to my first ACLr with hamstring autograft, and the quad graft is a different monster all together. The rehab is MUCH slower. I was freaking out because I could not lift my leg. My surgeon told me that I could I'd be superwoman.

It took me almost a month before I could get in the front seat of a car, and even then, I had to lift my leg in. I used to have to sit in the back seat, and have someone lift my leg for me. Snowy can attest to this. I had no strength what so ever. I am almost 6 months out now, and I still have a lot of quad weakness, but I am having troubles that may have nothing to do with my graft.

I did figure out how to get in and out of bed by myself fairly quickly. Put your good leg under your bad one, and use your stomach muscles and just swing it up. It's hard to explain. Don't try this without someone present the first time. If you drop your leg, it will hurt like h***! I didn't have the meniscus repair that you have had, so I am sure that this will change things somewhat.

All I can tell you at this point is to try to remain patient. Ice and elevate as much as you can. Do your ankle pumps. I would say that heel slides are an impossibility, but you have a cpm. Try to do you quad contractions to get those babies woken up. When I started PT, we had to use E stim quite a bit. I even had to take the unit home with me, and use it for 15 minutes twice a day.

I will also tell you that the SLR's are going to be a real challenge when the time comes. Things really won't start progressing too much until you start PT. Even then, do not expect things to move fast. It will be baby steps. It took me three PT sessions using the recumbent bike, with my foot strapped in because I had no quad strength, to gain enough flexion to get all the way around. It hurt, but I remember that being a happy day!

I will not lie. This is a frustratingly slow recovery. It wasn't what I was expecting. Then again, I also had three knee surgeries in 14.5 months. You are only one week out right now. I think it helps to look back even a couple of days, and you will see that there are small improvements. The pain is a little less, you have a bit more flexion, getting around is a little easier..etc.

Take the small victories at this point! They all count in the end! Feel free to ask away! If I can be of any help, I would be more than glad to answer any questions you may have.

W

Hockey98 · « **Reply #5 on:** April 25, 2012, 07:10:32 PM »

Thank you for your response!

That is very disconcerting considering my surgeon (his fellow, to be exact) told me I would be able to return to school two days ago! Meanwhile, I am still at home struggling to complete even the most mundane task. I have begun to use my good leg to assist me in some things, but there is still a pretty significant amount of pain in the leg and it is much easier at this point to have somebody actually help me with it. The pressure and burning pain I have upon standing is getting more localized, and I suppose that is a positive sign. All of the pain now is directly beneath the joint on the medial size of the knee, extending into the calf. I am sure this is from the extensive repairs done to my meniscus and the two large incisions just above that area.

I have always been a very active person, and I hope that that works in my favor in regaining some control of the quads relatively quickly. Prior to reinjuring the knee I was typically free-squatting 315 pounds for sets of 10, however in the week leading up to the surgery full extension was not possible at the meniscus was stuck. This, I'm sure, has a hand in the considerable weakness I am experiencing.

My plan is to get back to school on Monday (4 and a half days from now). Actually, this isn't so much a plan as an absolute necessity. The likelihood is increasing daily that my 5 hours of class time will be a codeine-fueled daydream, but hey, at least I'll be there!

emergRN · « **Reply #6 on:** April 25, 2012, 07:18:19 PM »

You are probably at the point now that when you stand, you will be experiencing "blood rushes". These will disappear in time. I hope your quads do bounce back fairly quickly.

I am assuming that you have someone to drive you to school?

W

Hockey98 · « **Reply #7 on:** April 25, 2012, 07:23:53 PM »

I will have to see where I am on Monday, but if the pain is still as significant as it is now and mobility hasn't improved any then yes, I will certainly require a chauffeur. However, I would much like to have at least gained some level of independence by that time - enough to drive up and be able to get into and out of my car on my own. This may be a bit ambitious, but we shall see.

Also, I was given an electrical stim machine that I have been using for the past two days. It has three different settings: one that is meant to help retrain my quads (this setting actually contracts the muscle for 20 seconds with a 10 second rest, and is not super comfortable), one that is meant to reduce pain and swelling and one specifically for pain control. During the contraction setting I am supposed to attempt to contract my quads for the 20 seconds that it is on but I have yet to make any progress on that front. Still going to keep plugging away though.

emergRN · « **Reply #8 on:** April 25, 2012, 07:28:55 PM »

It sounds like you have an estim/tens unit. Which leg did you have surgery on? I am hoping that you say left!

W

Hockey98 · « **Reply #9 on:** April 25, 2012, 07:49:01 PM »

Oh yes, left leg, and my car is an automatic transmission, so I'd like to think that there wouldn't be too much of an issue there. I am currently sitting outside on my porch, which is a huge milestone for me right now! However the trip back up, including the three minute walker-assisted trek to the door (which should really only take 5 seconds) and crab-walking up the steps with someone holding my leg up the entire time is sure to quickly bring me back down to earth.

emergRN · « **Reply #10 on:** April 25, 2012, 07:53:23 PM »

Slow and easy! I will just caution you not to do too much too fast. I crutch walking around Whistler Village three days post op. When I got home on 7 days post op, I crashed! I did too much too soon! I thought I was fine at the time!

W

Hockey98 · « **Reply #11 on:** April 25, 2012, 08:22:35 PM »

I will certainly do my best to heed that warning. I have been cooped up inside for an entire week now, with crutching pretty much totally out of the question and the walker my only means of movement, and even that is very slow and painful. That being said, it may be hard to contain myself once I am finally able to get up and around on my own with the crutches

Hockey98 · « **Reply #12 on:** April 29, 2012, 10:20:49 PM »

Couple more days in the books now, and luckily some progress to report. I can finally get off and onto the couch on my own, using my good leg as support to swing it as you suggested. That is obviously a huge step for me. The burning sensation, while still present, isn't nearly as debilitating as it was a few days ago, and I am able to get around pretty good now with the crutches...no more geriatric-style walker! I also managed to get in the car today and drive a couple miles to Office Max and crutch my way to purchase a posterboard. The true test is going to come tomorrow when I attempt to return to school and sit through 3+ hours of class - which will be by far the longest I have been out without my leg elevated at any point.

I have reached 90 degrees on the CPM machine, and that is the farthest I am allowed to go until at least the 1-month mark as they don't want to stress the meniscus repair. However, when I get on the machine I usually have to ease my way back up to 90, sometimes starting as low as 40 degrees until the knee loosens up a bit. I have tried some heel slides and usually can't get anything moving without at least a little outside assistance. I have topped out at maybe 25 degrees on those, as the knee just feels very heavy, tight and awkward. I have regained a very small amount of quad control, but the contraction is very weak.

All in all, I guess those are some good steps since my last post 4 days ago. Still a looooong way to go. Wish me luck for class tomorrow. Two presentations and some extended sitting periods are going to be pretty taxing, both mentally and physically.

emergRN · « **Reply #13 on:** April 30, 2012, 12:06:39 AM »

You have made some really significant progress since your last post. Glad to hear it! Good luck with your classes tomorrow! Ice like crazy and elevate when you get home!!

W

Hockey98 · « **Reply #14 on:** May 05, 2012, 01:04:30 AM »

Well, a few more days in the books. Class on Monday wasn't too bad, however I had to return to school Wednesday and Thursday and during this time stayed at my apartment just off campus. I didn't really have a lot of help at this point and as a result wasn't able to pack most of the stuff I wanted to take for the night - namely my cryocuff. So two consecutive days on my feet (or crutches, I should say) for upwards of 5 hours and no ice made for some excessive swelling. It's been wonderful to relax at home and keep the knee iced since I got home last night, however the swelling in the knee seems like it is going to be my big problem right now...

My heel slides are suffering badly from the amount of swelling still in the knee, and this was the case even before my two days without ice. Once I reach a certain point the pressure in the knee is pretty extreme, and there's simply no moving past that point. I have been keeping elevated and iced but the residual swelling is very stubborn.

emergRN · « **Reply #15 on:** May 15, 2012, 09:35:44 PM »

I have been checking to see if you have posted! How is it coming along?

W

Hockey98 · « **Reply #16 on:** May 16, 2012, 05:36:38 AM »

Hello! Things are coming along, albeit quite slowly. Pain is essentially gone, save for the scar from my meniscus repair which is constantly rubbed by my brace, although this is more a nuisance than any real pain worth mentioning. Range of motion is improving somewhat, but swelling is really limiting what I can achieve. I measured out at 0 extension and 85 flexion today at therapy. I was just cleared today to begin 50% weight bearing, which I hope will help move some of this stubborn swelling out. Quad strength is the only thing I can see considerable improvement in, as it has been returning rapidly in the past week. Thursday at my most recent post-op visit I was unable to achieve a single straight leg raise and have since been busting my ass on them - I pulled off 40 today in therapy with a 3 pound weight on my ankle. I also got to get on the exercise bike today for the first time, but was barely able to make it the whole way around, and it was with a fair amount of discomfort. Looking at the big picture I suppose I have come a long way at this point, but of course I'd like to be further ahead. I was going to post a picture on here of how it's healing up but I can not figure out the image posting on this forum. Thanks for inquiring about my progress and I'll be sure to update more frequently.

emergRN · « **Reply #17 on:** May 16, 2012, 10:42:26 AM »

That is most excellent. You will be amazed at how quickly you progress on the bike. I can't believe how good your quads are coming back. This graft source knocked the crap out of my quads, which I had really built up pre op! Can I ask how big your quad tendon graft was? Mine was 1.1cm x 10.5 cm. I am trying to figure out if graft size can be correlated with the loss of quad strength. It should be on your OR report!

W

Hockey98 · « **Reply #18 on:** May 16, 2012, 11:37:41 PM »

I will see if I can find the exact size for you at my next post-op visit, but I can tell you that my scar is pretty small. Even my therapist commented on the size of it, saying it was the smallest she had ever seen for a quad graft. Also, if you recall from an earlier post I was unable to get the double bundle procedure because my knee was too small, so there is a very good possibility that my graft was, in turn, small.

emergRN · « **Reply #19 on:** May 16, 2012, 11:46:24 PM »

My Quad harvest site scar is only an inch! They don't need to make a big incision to get the graft out. When you get the report, I would love to know the size of your graft because I am having a much harder time getting my quads back than you are, and I am much further along post op! I am trying to figure out if the amount of tendon harvested has a direct impact on rehab. Just a thought!

W

Hockey98 · « **Reply #20 on:** May 24, 2012, 03:59:55 AM »

Pretty much the last week of "boring" therapy is done, just one more day tomorrow. I call it boring because thus far my time there has been limited to quad sets, straight-leg raises, heel slides...stuff I can (and have been...religiously) doing at home. Next week I am allowed full weight bearing and, while this should add some interesting new concepts to my therapy program, I feel like there is no way I am going to be able to walk on this knee. I have been primarily locked in extension for the better part of 5 weeks and have only been putting even partial weight on it for the past week and a half. Occasionally I have sort of tested the knee a bit, applying more weight and unlocking the brace for a more normal walking gait, but....it just feels so weak. I have progressed to 105 degrees of flexion and you were certainly right about the bike. The knee still feels very awkward and takes quite a while to get loose enough to feel even somewhat normal, but flexibility-wise the bike has gotten much better.

I'll update after my (second) first steps next week.

Hockey98 · « **Reply #21 on:** May 30, 2012, 06:35:00 PM »

I began walking again yesterday at therapy, albeit very carefully. Everything still feels very weak and while the knee itself isn't buckling my lack of quad (and hamstring) control allow my knee to bend in ways that I don't intend while I am walking. I have to focus intensely on walking properly and making sure I am at full extension before my heel hits the ground, otherwise my knee will bend forward a bit and give that buckling sensation. My numbers in terms of flexion have not improved greatly. I am at 107 degrees now, compared to 105 at this point last week. Different tasks are becoming much easier though, such as standing up and lifting my leg into the shower. Along with walking, now that I am at full weight-bearing I am allowed to do wall squats, which already seem to have strengthened my quad somewhat. No change in size as it still looks like linguine, but the strength seems to have made a bit of a jump since I have been bearing weight.

Hockey98 · « **Reply #22 on:** June 09, 2012, 01:37:00 PM »

Walking has gotten much better at this point. Completely off the crutches for about a week now and the feeling of instability has also vanished. Had another post-op two days ago and I unfortunately was unable to obtain my operative report, however I inquired about whether the size of the graft taken could have an impact on the speed with which strength returns and was told that it certainly can. Prior to my next visit (one month from now) I will call down there and see if they can have the report prepared for me so I can get an exact size for you.

Everything else on my end has been improving steadily. Still some stiffness, range of motion is still improving slowly and most notably swelling has finally gone down.

emergRN · « **Reply #23 on:** June 12, 2012, 11:54:14 AM »

It all sounds like it is going very well! That is great! Keep up the good work! I will be checking in on your progress!

W

Hockey98 · « **Reply #24 on:** June 19, 2012, 03:18:33 PM »

Summer classes have really ramped up, so unfortunately I will be unable to go to formal therapy for the next two weeks. That being said, I have access to tons of therapeutic exercise modalities here on campus, and have been swimming religiously for the past three weeks. After spending two weeks in the pool my flexion jumped up from 107 to 125, so I was extremely happy about that. Strength doesn't seem to be making any rapid improvement, nor does the size of my leg - at all. Pretty disheartening, but I'm quite aware there is still a long way to go.

A question for any of you out there who dealt with the post-op paranoia: I was walking my dog around at a local high school and walking down a short decline (about 35 or so degrees) I felt a little bit of movement in my knee. Nothing painful, but certainly alarming. Any chance such a simple thing could have stretched the graft any? I've been worried about it since the weekend and don't see the doc for another couple weeks.

emergRN · « **Reply #25 on:** June 19, 2012, 03:25:32 PM »

I think what you are feeling going downhill is most likely due to weak muscles. Yes..the paranoia is perfectly normal. I think it is our brain's way of making us protect that graft! Way to go on the swimming, and the improvement with your flexion!

W

Hockey98 · « **Reply #26 on:** July 05, 2012, 02:22:30 PM »

Just got back from another post-op visit. Dr. Fu seems to think that everything looks very good. My kt-2000 score on my reconstructed leg produced a 6 today, compared to a 5 last time. I was a little concerned with that, especially considering my "knee-moving" incident I mentioned in the previous post, but they assured me it is nothing to be concerned with. I was able to obtain a copy of my operative report for you. It definitely made for an interesting read.

Here is what I got from my operative report regarding my graft:
"The graft dimensions were 8cm of soft tissue length, 16mm of bone block length, 10mm depth, and 10mm in width"

emergRN · « **Reply #27 on:** July 08, 2012, 02:02:43 PM »

I didn't have a bone block, but the diameter of your bone block is just slightly smaller than my soft tissue graft. I will have to look up the length of mine, but it was longer than 8 cm. I just had an arthroscopy done 10 days ago, and I can now say that the trouble that I was having had nothing to do with my graft! That actually looks really good! I had a meniscus tear, and I had a lot of damage under my patella. The cause is speculative. Anyway, a lot of the quad inhibition I was having was due to patellar pain, and not my graft harvest site.

So...How are you progressing now?

W

Hockey98 · « **Reply #28 on:** July 09, 2012, 10:14:13 PM »

That's great to hear your graft is in good shape! I had been having some slight pain in my patella and my therapist opined it may be due to the lack of quad strength allowing my patella to fall slightly out of the groove. Perhaps that could have been a culprit in your case? I hope everything is uphill from here on out with you.

I am doing well, still a few instances where I feel a slight buckling sensation, but knowing that the graft is secure I guess I can mark that down to weakness. My OR report stated that my ACL was completely ruptured off of its femoral insertion, so I've reasoned that I can't possibly be less stable now, from a ligamentous standpoint, than I was prior to surgery. Strength is still returning slowly and I am actually able to see a tiiiiiny bit of quad definition now, so hopefully this atrophy becomes less evident in the coming months. I have made it a goal in my head to return to the ice by November 20, which would be exactly 8 months from my surgery date. I have been working literally every single day to achieve this goal; it will just be a matter of Dr. Fu granting me clearance to lace up the skates. Getting anxious just talking about it!

emergRN · « **Reply #29 on:** July 10, 2012, 12:00:24 AM »

Good luck with your goal! Patellar tracking was certainly part of the culprit, and probably being pushed to do some closed chained exercises that irritated my knee greatly. My goal is to ski Whistler next winter. If I am going to do that I am going to have to crack at it!

I am exactly 8 months post ACL revision today!

The buckling is probably from your quads. I like to call that Bambi syndrome!

Be careful with your rehab. I will tell you that if you get a lot of patellar pain, then slack off on that exercise and find something else to work that muscle group. I have done both the hamstring graft and now the quad! This quad business is not for the faint of heart. I thought the hamstrings were hard to rehab until I had this done. The quad graft is much more difficult to get over, no matter what the literature says.

You are doing great, and I am very happy for you. I will continue to check in. There aren't many of us who have had this graft source on here.

W

Hockey98 · « **Reply #30 on:** July 25, 2012, 01:42:02 PM »

Just hit the 3 1/2 month mark yesterday and the knee is finally starting to feel pretty good. Rehab has really ramped up to the point where I am lucky to be out of there within 2 and a half hours. Strength has been still making pretty decent progress. Monday night after rehab I did a 1-hour spinning class and that, combined with the extensive therapy session previously in the day had the knee pretty sore that evening. My calf has come quite a way in terms of the atrophy that I experienced, however my quad is still smalllllllll as hell. Seeing Dr. Fu again in 2 weeks to assure that everything is looking good from his standpoint, and I hope then to be cleared to go back to work.

Hockey98 · « **Reply #31 on:** August 23, 2012, 06:01:18 PM »

About 4 1/2 months out of surgery now and everything with everyday life has essentially returned to normal. The knee isn't quite where I'd like it to be, but I am making progress. Atrophy is still pretty significant, and my therapists have assured me that this will be the area that will be the most painstakingly arduous. I visited the doc about 3 weeks ago and everything looked good on his end. My healthy knee measured a 4 on the KT machine compared to a 5 on my involved knee, so it is certainly stable. There is still a tiny bit of swelling, but it has resolved to the point where I can very quickly tell that certain movements are increasing swelling in the knee. I have begun some jogging-like movements in rehab, but have yet to break into a full-on jog. Going to keep plugging away though. Next doc appointment is in the middle of November, and I hope to get the all-clear to begin at least skating at that point. We'll see how it goes.

Hockey98 · « **Reply #32 on:** October 20, 2012, 12:42:45 AM »

Been about two months since I have posted, so I figured I'd provide an update. I hit the six month mark two days ago and am not exactly thrilled with where I am at this point. I had hoped to be essentially back to normal by now, save for whatever deficits I needed to make up in terms of strength, but that is far from the case. Strength and atrophy are certainly my two largest obstacles at this point, however I am still having pain when in complete flexion and actually have a very painful and pronounced bump on the medial side of my tibia which I was just informed is the remnants of one of the screws that fixed the graft in place. This bump, when touched or pressed on, is very sensitive and makes the skin above my shin muscle tingle something fierce, which is quite odd. Apparently if this issue doesn't resolve itself by my year anniversary I will need to get what remains of the screw removed via another surgery.

I have yet to begin any sort of cutting or real running, and have only very recently started to jog somewhat comfortably. I had, up until about three weeks ago, a pretty awful looking jogging stride. I think it was due in large part to the fact that I just don't really trust the knee yet, even for something as simple as jogging. I see Dr. Fu again in a couple of weeks, and hope then to get the o.k. to really ramp up my rehab and am really hoping for a quick follow-up appointment that may clear me to get back on the ice, provided I see some serious improvement from my more intense rehab. Fingers crossed.

Hockey98 · « **Reply #33 on:** December 15, 2012, 04:00:21 AM »

I am now just about 8 months out of surgery and beginning to get very frustrated with my progress. I still have way more pain than I think I should have at this point, mostly as a result of scar tissue around my graft side, a lot of grinding and grating going on when I bend my knee, and I feel like the knee is still extremely weak. I can't determine whether this sense of weakness is a result of the atrophy that I still have or if the knee itself is unstable. Clinically, by all measurements (kt-1000, lachman, pivot shift) my knee is stable. However having not truly tested the knee in any sort of cutting scenario, and having only attempted landing from a jump on the knee VERY seldomly I can't tell whether it is actually unstable, it just feels funny because of weakness, or if I am just being paranoid. I can, however, actually see noticeable movement in my tibia in relation to my femur when relaxed and I pull the tibia forward, much more so than my uninjured knee.

I see Dr. Fu again on January 17th and plan to return to the ice that day to at least begin skating, so long as everything tests out okay at the office visit. I hope that this jump in activity will break up some of the troublesome scar tissue and hopefully give me some confidence in the stability of my knee so that I can stop worrying about it.

Has anyone here had a sense of instability following surgery? Was is actually unstable or did it just take a while to trust it? I am beginning to worry that I may be one of those cases where the knee just never feels right.

Hockey98 · « **Reply #34 on:** January 15, 2013, 10:47:08 PM »

So I have somehow managed to develop grade III arthritis under my kneecap. My appointment was moved up to Jan 10th, at which point they did an MRI to try to determine what was causing my continued pain. I wasn't informed of this immediately following the MRI at the doctors office, however my therapist was informed after a more detailed examination of the images and told me of it today. Needless to say, I am pretty bummed out about it. And very caught off-guard. I had resigned to the fact that I would develop arthritis in my injured knee and likely need some sort of treatment for it down the road, but I am only 9 months out of the operation.

I see the doctor again in two weeks, and hopefully then we can determine a course of action for this.

What have any of you on here done to ease the pain or curtail the symptoms associated with arthritis?