The WAITING ROOM => GENERAL KNEE QUESTIONS and comments (good for new threads) => Topic started by: chippie100 on August 26, 2010, 11:59:10 PM

Title: possible 3rd knee reconstruction
Post by: chippie100 on August 26, 2010, 11:59:10 PM

does anyone have any information/opinions regarding 3rd ACL reconstruction on the same knee

im a 36 year old male self-employed carpenter and have been for 20 years . i first injured my knee when i was 17 playing rugby i had a  complete rupture and cartilage tear which i managed to carry on and play on for around 4 months with knee giving way around 15 times or so.

i had a reconstruction using my hamstring tendon through an open surgery at 18 . my sciatic nerve was damaged during this operation and i spent 6 days in hospital in a full brace then i was  fitted with a donjoy gold point when the stitches came out at 10 days.

 i wore this brace for 3 months solid during day to day activities and physio. then the next 3 months physio with out . i was given the all clear to resume playing but re injured the knee at around 8 months from the reconstruction at rugby training , the turf gave way as i changed direction.

i was put in plaster for 1 month by local A+E dept. . i then was seen again by my surgeon who set me up for a scope and i woke to another reconstruction this time a synthetic graft was placed along side the damaged hamstring graft followed by 6 months rehab again . i stopped playing rugby .

 now around 16 later i started to get some knee pain and my knee felt lax saw GP and was referred to a surgeon after X-rays and MRI scan it is felt the synthetic graft has broken down which has left me with a very lax ACL.

  first opinion is a scope to repair any damaged cartilage and asses knee under anesthetic then to remove both damaged grafts and to use bone grafts to fill holes and remove staples and screws then after 6 months use my hamstring tendon from my good leg and try again an ACL repair . i also have a fair bit of wear to my knee cap from my femur sliding forward
my questions are as follows

   1. Is surgery my only option ?
   2. Is the hamstring tendon the best graft to use ?
   3. Has anyone had this done or heard of it being done with any success ?
   4. I have just got into mountain biking and this is giving my quads and hamstrings a good work out . Is this safe to carry on with ?
I didn't ask these questions when I saw the surgeon as my world started to fall apart as he spoke and couldn't think properly.
Thanks for taking time to read this. I have 2 more surgeons to see and would like to be more prepared when I do see them.

regards to all

Title: Re: possible 3rd knee reconstruction
Post by: Snowy on August 27, 2010, 06:51:17 AM

So sorry to hear about your knee woes. I just had my first ACL reconstruction, and can't imagine going through this again - never mind a third time.

I'm afraid I can't answer your questions, but I would highly recommend you talk to Knee Geek members kaputt_knee (5 ACL reconstructions) and clarkey_vl (4 reconstructions). They are both amazing ladies who have been through a great deal and are more than willing to share their stories. Kaputt_knee is an inspiration - she skied 50+ days last season and is retaking her ski instructors certification this year - and clarkey_vl is currently in active rehab from her 4th reconstruction. Of course every experience is different, but it may help to talk to people who have first-hand experience of failed synthetic grafts, bone grafts, and multiple reconstructions.

I wish you luck - you've been through so much already, and it sounds like you still have a long road ahead of you. I hope that it leads you to a successful outcome in the long run.

Title: Re: possible 3rd knee reconstruction
Post by: Kaputt_Knee on August 28, 2010, 10:16:50 AM
Hi Chippie,

can you say where you had the artificial graft put in (hospital)? I've calculated that the op was around about sometime in 1996, which means you probably have a Goretex or Dacron graft. Do you know which type it was? The carbon fibre grafts were introduced in the 1970s and the Dacron and Goretex ones came along in the 1980s. It would also be interesting to know the name of your surgeon if you can remember. The fact they used the artificial graft to support the stretched hamstring shows that they were thinking outside of the box for that particular period.

I had a carbon fibre one put in in 1989 but it snapped within a year, I then had one of the newer ones (still not sure which one) inserted in 1991 which also snapped very early on. In 1992 they finally put in a patella tendon graft. All three replacements were done via open knee surgery. The patella tendon graft has been a huge success, although I have stretched it a wee bit which has led to some meniscus tears (all quite minor I believe and taken care of arthroscopically by shaving the tear away).

The main problem with revisions of all types of artificial fibre grafts is the size of the tunnels used to place them. This is true also for the LARS ligaments that are being used today. The tunnels are much larger than those used for autografts or allografts and these have to be filled before any new graft can be inserted. This often involves a 2-stage revision surgery. The first removes the artificial graft and fills the tunnels with bone tissue (often harvested from the illiac crest - part of the pelvis). You then have a period of non-weight bearing while the new bone beds in and bonds with the bone of the tibia and femur. The NWB period varies from person to person and the surgeon's own protocol. Once the bone is settled, they go in again and do a standard AL replacement.

Let me know if you have any questions. I think the patient's attitude to the challenge is very important to the rehab and success of the outcomes. Concentrate on the negatives and the chances are that things will go pear-shaped. Be realistic and concentrate on the positives, using small milestones to mark your progress, the chances are that you will return to the activities you were enjoying before the knee decided to pack in!

Sue  ;)
Title: Re: possible 3rd knee reconstruction
Post by: chippie100 on September 01, 2010, 11:07:40 PM
thank you kay and sue for your replies

sorry about the delay in replying to you guys as i am working away from home and dont have access to

Internet .

First its good to know 3rd 4th and 5th acl reconstructions can be done .

my first acl and 2nd were done by malcolm macnicol in Edinburgh . the synthetic graft was described to me

as  gore-tex shoe lace like material, the consultant at good hope, sutton coldfield said synthetic grafts cause

scaring and irritates the knee joint and they went out of vogue a few years ago but are now coming back into

fashion . from what i can make out the patella tendon graft is the strongest and i felt given a choice thats what

I would like to try, your feed back sue backs up my theory .

i see the 2nd surgeon tomorrow 2/9/2010 so i guess i will know exactly what im up against if his diagnosis is

the same as the surgeon at good hope . i am really hoping some kind of tidy up operation can be performed

along side a muscle strenghthening program can give me a stable knee but i know its a major doubt that would

be enough.

i will keep you up to date as things unfold



Title: Re: possible 3rd knee reconstruction
Post by: Kaputt_Knee on September 02, 2010, 07:40:05 AM
Hi Craig

no problems about anything!

When you talk to the surgeon make sure you ask about knee sensitivity and how can it be avoided. I have had both patella tendons used and it makes it incredibly uncomfortable for me to kneel. I'm about to work on a 42m2 parquet floor in my lounge and it is going to be difficult as I cannot kneel for longer than a few seconds.

If you are no longer in active contact sports why not ask about the hamstring alternative as a means of preventing this.

I have read of other surgeons who work on the hyper-sensitivity to make sure it is not a major problem. For me I think it is too late and the only kneeling I would have to do is in church these days and as I am not a regular attendee, not a major problem.  ;D I think the "Big Boss" knows what you're thinking so whether you are on your knees or not is irrelevant!  ::)

I'm glad to hear that the artificial graft was one of the Gore-tex ones as as far as I know they have not been involved in the disintegration incidents - those were the carbon-like fibre ones which luckily for me snapped shortly after implantation.

Let me know how the appointment goes and what your options are. A young fit (you say that you are an MTBer) active guy such as yourself should really not have any problems once the remains of the artificial graft are out. Whether he does a full recon or not often depends on what they see once they are inside the knee. Again a question about whether the operation will be successful using arthroscopic techniques or if it is possible that you will have to have open knee surgery to ensure all the graft is out.

It helps sometimes to write out all your questions just to reassure yourself that you have covered all your worries helps. Many surgeons are happy to see this list appear and will do their best to answer as many as they can. It means that you are preparing for the operation as much as they are in a sense.

Sue  ;)
Title: Re: possible 3rd knee reconstruction
Post by: chippie100 on September 02, 2010, 11:15:27 PM
hello again

I have seen the surgeon today and we talked through the condition of my knee , my requirements as far as work and lifestyle and about how much time is involved in recovery from all of the options .
First of all he thinks my knee is not as lax as he was expecting as per the MRI report and images he viewed and the NHS surgeons report . He agrees the graft may have completely broken down but is unsure and feels a scope of the knee is required to assess this to be 100% sure . 
We talked about how necessary it was for me to have a third ACL as I dont take part in any contact sport or play any twisty turny type sports .
We then talked about what would be involved in a 3rd ACL . The tunnels drilled into the femur are very large and the hole in the tibia looks really big so bone grafts would be a necessity to allow any more work .
He had a very strong view on where to take any graft from and his favored is the hamstring tendon as I need to kneel at work and taking the patella tendon graft can be very very painful also he was thinking of using a donor for the bone grafts All in this could take up to 18 months and more if things dont take too good .
i then asked if i had any chance of avoiding surgery and working on conditioning the muscles needed, quads and hamstrings and he feels this alone would not be enough he wants to go in and tidy up the knee, he can sees small tears in the cartilage and if the synthetic graft is damaged or broken down he wants to clean this up too and to give it a flush out, he thinks this would stop me working for about 2 weeks . also getting a chance to asses the knee under anesthetic would give him a chance to be sure what my knee requires and what it will require in the future . so i am booked in to have a scope and tidy up on the 10th of december . big bonus is mtb is the best thing i could be doing in his opinion along with shoe cleats to keep my leg motion linear on the bike and i have been told to give my legs a good thrashing as much as possible to help build muscle and it will be the main aim in trying to give me a stable knee .
if this doesn't work out we will revert back to a 3rd graft i think .
another bonus was the possitivity of the surgeon and his understanding of my position and what i need my knee to be able to do

i will keep you posted on how things shape up building up to and after surgery and how well things go


Title: Re: possible 3rd knee reconstruction
Post by: BlueTopaz_ZA on September 03, 2010, 03:40:14 PM
Hi Craig

It seems you now have some much needed direction, as well as the recovery period afterwards to make the critical decision re the ACL revision.

I am on my 2nd ACLr to my Left knee, and I can only state my immense admiration for anyone who undergoes 3rd, 4th and more reconstructions!
In my case we used my hamstring first time around, and this time around we used donor ligament.

I agree with your OS that he needs to go in anyway as MRI can only tell them so much. My OS found lots more damage than we originally anticipated - I almost chickened out of the surgery altogether - thank goodness we went ahead as there was alot of cleaning up to do. If I had not had anything done, I would have seriously compromised the health of my knee long-term.

I wish you a speedy recovery after the scope, and best of everything for your rehab.

Title: Re: possible 3rd knee reconstruction
Post by: Kaputt_Knee on September 03, 2010, 03:47:48 PM
We then talked about what would be involved in a 3rd ACL . The tunnels drilled into the femur are very large and the hole in the tibia looks really big so bone grafts would be a necessity to allow any more work

That's what I've read about reconstructions using artificial ligaments - makes revisions an absolute nightmare.

Craig - it sounds like you have someone who is listening to you and is prepared to look first and make informed decisions in line with your needs.

The idea of an exploratory arthroscope is probably the best solution in order to evaluate a really difficult situation. The number of times I've read or heard people saying that the surgeon found way more damage when they went in and so the plan was changed is incredible. An exploratory arthroscope is no big deal and will allow him to plan the best outcomes for you.

Keep us posted on what happens.

Sue  ;)
Title: Re: possible 3rd knee reconstruction
Post by: kpoppy on September 03, 2010, 05:14:11 PM
Hi Craig-

Your topic caught my eye as I scanned through the board.  You will certainly find some good info on this site, as well as differing opinions, preferences, and experiences of patients and surgeons.  The more you learn about what is possible, the better.  My situation is both similar and potentially different to what you are experiencing.  But I thought it might be helpful to you. 
I just had my 3rd ACL reconstruction 6 weeks ago.  I also needed staged procedures due to enlarged tunnels.  My bone grafting procedure was in January of this year.  It is definitely essential to find a physician that has done a lot of these procedures, as it is highly complex.  I have met pts who have had the bone grafts in the tunnels fail and their only option became a total knee replacement.  You are the same age as me, so way too early for that.

Some of the things my surgeon (who has specialized in and has researched knees for 30+ yrs) prefers when possible are the following: 1. autograft bone graft (supplemented with allograft tissue if needed) to fill in the tunnels (30mm x 30mm was taken from my iliac crest + allograft bone)  2. patellar autograft from same or opposite knee (he uses bone plugs, not just bone shavings, to fill in the defects to allow kneeling- which I can attest that even at 6wks post-op, very little tenderness present).  Also because the patellar autograft has bone at both ends for optimal fixation of the new ACL.  Whereas I'm sure there are other successful scenarios, all these things, as explained to me by my surgeon, gave me the best chance at a successful outcome based on his research and clinical outcomes.  And so far, in my case, all is progressing as planned. 

On another note, I became an avid cyclist too (road bike) when my knee problems seemed to become chronic.  I've done a lot of other sports, but cycling definitely builds the leg muscles fantastically.  However, care should be exercised to avoid resistance at high knee flexion angles if patellar issues are present, as it increases the patellofemoral compressive forces, leading to breakdown.

Keep up the research.  Knowledge is power.

Best wishes,
Title: Re: possible 3rd knee reconstruction
Post by: chippie100 on December 11, 2010, 09:09:15 PM
hello guys

just had my scope on friday and and my 2nd ACL graft has broken down, it had torn apart and was in a bit of a mess .the surgeon has removed what was left of the graft some of which he thinks was getting caught in the joint and giving me the pain and hyper-extension on occasions . the cartilage that i still have was a little bit ragged this has been trimmed and tidied up. my surgeon feels my knee is in ok condition and my quads are in good condition and i could cope without a 3rd ACL op . but as i am a carpenter i need to have a solid stable knee so we are aiming for the 3rd op as and when i can fit it in around work. so the first stage is removal of old fixings and to drill out and bone graft the bone tunnels . this will be left to settle then my good leg will have the hamstring tendon harvested and then 3rd time lucky i hope !!!!!!!....
at the moment i am using a cryo cuff for the first time  and my knee feels good. it is ok to walk on after fridays work . also surgeon doesn't know what synthetic graft was used in 2nd reconstruction it wasn't dacron what ever it was it lasted 15 or so.

thanks for the postings so far i will add to this as i progress from this op and look forward to the next ones