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Author Topic: Graft Choice in ACL reconstructions - The Place of Allografts  (Read 40305 times)

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Offline The KNEEguru

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Graft Choice in ACL reconstructions - The Place of Allografts
« on: January 26, 2010, 11:00:07 PM »
Ian McDermott has prepared another paper for us - Graft Choice in ACL reconstructions - The Place of Allografts -http://www.kneeguru.co.uk/KNEEnotes/node/2125
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Offline kneelobo

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Re: Graft Choice in ACL reconstructions - LARS choice?
« Reply #1 on: April 19, 2010, 07:05:01 PM »
Hi. I have been diagnosed with a fully torn ACL. Apparently I've had this for over 10years, but I did nothing about it. I just did accupuncture each time it twisted, and wore knee braces and everything was kinda OK for a while, and then over the last 2 years I am not able to function properly in my physical activity.
I am 36years old. Used to play Rugby / Football (Soccer), quite alot from age 18 to 31.
At the moment, I found a surgeon who will do LARS surgery. I got the MRI done, and it confirmed total ACL tear.

On this site found few people with good experiance with this type of surgery, but doesn't seem to be a universally accepted procedure for some reason.

Can anyone confirm if LARS could be an acceptable choice for my condition since I left the injury un-attended for so long.
Bearing in mind, I won't play anymore contact sports, just regular jogging, and weight training.

One surgeon Says its the best,  another says no.  I am confused.
I can't afford to be off work for too long, so this procedure looks very attractive.

Offline tez27

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Re: Graft Choice in ACL reconstructions - The Place of Allografts
« Reply #2 on: April 19, 2010, 07:32:32 PM »
Check out Jays post op diary as he had his acl reconstructed using lars you might find some information on there
Sorry I cant be any more help, I'm still waiting my aclr but think I will be going for the hamstring graft though have to still have the conversation with my o.s about what he thinks will be the right choice for me.
L K injured 25th June 2008
scope Jan 5th 10
diagnosis ACL rupture
fiberous band excised from acl
ACLr July 19th 2010  scope on 24th Sept 2011
ACL has failed incorrect tunnel placement
23rd July 2012 1st stage of a 2 stage ACL revision
10th May 2013 2nd stage ACL revision

Offline LarryAbes

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Re: Graft Choice in ACL reconstructions - The Place of Allografts
« Reply #3 on: April 22, 2010, 12:47:49 AM »
Knee-

I am currently laid up with my 2nd acl surgery. I tore my right knee about 8 years ago play basketball and they used the middle 3rd of my patellar tendon as the graft and it worked out just great for me. At the time I tore my acl, mcl and meniscus and i haven't had a problem since, it feels great.

I just tore my left acl a few weeks ago playing basketball again and had surgery on 4/8. They used the patellar tendon again and it feels pretty good for being 2 weeks out of surgery. I heard good things about the hamsting too, but i have heard some horror stories about cadavers (but you never see people use this nowadays)

good luck with your surgery and my one piece of advice is take the physical therapy very seriously, and really work at it-- if you don't the surgery won't be a success

LA

Offline jamiec123

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Re: Graft Choice in ACL reconstructions - The Place of Allografts
« Reply #4 on: May 18, 2010, 02:45:14 PM »
hi kneelobo

As Tez said, I had my ACL reconstructed by LARS about 8 weeks ago.  So far, so good!  If you want to know anything, feel free to ask!!

Jay
Sep '09 - Torn ACL, Bone Bruising, Medial Ligament Grade 1 strain
Dec '09 - Discovery that ACL stump getting caught in joint
Jan '10 - Scope to trim ACL stump
Mar '10 - ACL Reconstruction (LARS)
June -10 - Swimming and Cycling pain free, awaiting advance to running

Offline Debban

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Re: Graft Choice in ACL reconstructions - The Place of Allografts
« Reply #5 on: June 06, 2010, 01:52:07 PM »
I had my acl reconstructed 2 years ago with an allograft, tibialis anterior tendon. Worked out great. The knee is strong and stable and PT went well.

Offline tony1233

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Re: Graft Choice in ACL reconstructions - The Place of Allografts
« Reply #6 on: July 26, 2010, 09:13:42 PM »
hi guys,

any good stories about allografts ? Particularly about hammy allografts ? I will be getting my ACL reconstruced in 2 weeks using this from a cadaver and I'm just curious as to how it should go !

Thanks,

Tony
09/30/07 Diagnosed with partial ACL tear (left knee)
02/03/10 American Football injury, Diagnosed with ACL & MCL complete tear (right knee)
(R)lateral meniscotomy 08/11/10
(L) Lateral meniscotomy 10/28/11
(L) MCL & Medial Meniscus tear 07/12
(L) injury 01/23/12

Offline jamiec123

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Re: Graft Choice in ACL reconstructions - The Place of Allografts
« Reply #7 on: July 30, 2010, 12:38:36 PM »
Hi,

im 18 weeks post ACLr with LARS.  Ive been running for the past 4 weeks and have even been playing a bit of football (only small sided games with passing, no-one is allowed to tackle me ha ha).

The best bit of advice i can give you is listen EXACTLY to what the dr says.  and make sure you rest it!  The more u keep the leg up and the more you ice it, the quicker it will heal!!

Jay
Sep '09 - Torn ACL, Bone Bruising, Medial Ligament Grade 1 strain
Dec '09 - Discovery that ACL stump getting caught in joint
Jan '10 - Scope to trim ACL stump
Mar '10 - ACL Reconstruction (LARS)
June -10 - Swimming and Cycling pain free, awaiting advance to running

Offline tony1233

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Re: Graft Choice in ACL reconstructions - The Place of Allografts
« Reply #8 on: July 31, 2010, 04:23:03 PM »
Hi jay!

wow, you must be doing well, any footy at 14 weeks is great!  Thanks for the advice Jay, I will keep that in mind throughout the whole process!

Tony
09/30/07 Diagnosed with partial ACL tear (left knee)
02/03/10 American Football injury, Diagnosed with ACL & MCL complete tear (right knee)
(R)lateral meniscotomy 08/11/10
(L) Lateral meniscotomy 10/28/11
(L) MCL & Medial Meniscus tear 07/12
(L) injury 01/23/12

Offline jamiec123

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Re: Graft Choice in ACL reconstructions - The Place of Allografts
« Reply #9 on: August 02, 2010, 11:14:59 AM »
Hi Tony,

Well to be honest, i probably shouldnt be playing in the games, my physio gave me the go ahead to do most other things and ive kind of taken it upon myself to get involved in the small sided games.  I definitely wont be playing competetively for a while!!

Jay
Sep '09 - Torn ACL, Bone Bruising, Medial Ligament Grade 1 strain
Dec '09 - Discovery that ACL stump getting caught in joint
Jan '10 - Scope to trim ACL stump
Mar '10 - ACL Reconstruction (LARS)
June -10 - Swimming and Cycling pain free, awaiting advance to running

Offline tony1233

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Re: Graft Choice in ACL reconstructions - The Place of Allografts
« Reply #10 on: August 02, 2010, 02:15:44 PM »
Ahh!

lol that sounds like a thing that most guys would do anyway ;) I can see myself refereeing hockey twards the end of this season. I'm hoping to be back to being able to play competative by next season, not the begining because it starts in april or may but, I'm aiming for early july. I know I'll have to strengthen my knee immensly in order to achieve this but, I plan on doing that anyway. At what point did you begin training again ? How did they fix your graft on your femur ? Sorry for all the questions I'm just trying to get an idea of how I'll be post Op!

Thanks,

Tony
09/30/07 Diagnosed with partial ACL tear (left knee)
02/03/10 American Football injury, Diagnosed with ACL & MCL complete tear (right knee)
(R)lateral meniscotomy 08/11/10
(L) Lateral meniscotomy 10/28/11
(L) MCL & Medial Meniscus tear 07/12
(L) injury 01/23/12

Offline jamiec123

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Re: Graft Choice in ACL reconstructions - The Place of Allografts
« Reply #11 on: August 03, 2010, 09:44:47 AM »
Hi Tony,

Honestly feel free to ask anything, i know before and after my ops, this forum was invaluable to me!!

Well i started running again at about 14 weeks and since then i have been steadily increasing my training to include more football related things such as mini hurdles, ladders, shuttle runs, weaving between posts, dribbling the ball etc.  The physio had my on an exercise bike as soon as possible, probably about 2-4 weeks.

With regard to fixing the graft, they drilled my femur and tibia and attached the graft using screws.  I believe the idea is that eventually my bone will grow over the screws and make it more natural and solid.

I hope this helps and honestly feel free to ask anything!  Always happy to help!

Jay
Sep '09 - Torn ACL, Bone Bruising, Medial Ligament Grade 1 strain
Dec '09 - Discovery that ACL stump getting caught in joint
Jan '10 - Scope to trim ACL stump
Mar '10 - ACL Reconstruction (LARS)
June -10 - Swimming and Cycling pain free, awaiting advance to running

Offline tony1233

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Re: Graft Choice in ACL reconstructions - The Place of Allografts
« Reply #12 on: August 03, 2010, 10:07:19 PM »
This forum sure is invaluable, I don't know what I would've done without it so far.

so at about 3.5 months I guess I can hope to be at AROUND the point where I can jogg again. We have an arena here with a track around the top of it where I ould go so that sounds like a safe place to do it. I won't be able to benefit from any of those things until the begining of next season beause We'll be under snow by the time I'm ready for that ;).

I was curious about the attachment because my OS is going to attach my tibial attachment with the bio-absorable screw but, my femoral attachment is a combnation of the screw and a "button" . I was just curious if you had any experienc ewith the button or not!

how strict was your protocol ? I found one on here that my PT seems to like but, we're not 100% sure if the OS has her own guidelines or not.  Me and the PT are prepared just in case she doesn't.

Really appreiciate you answering my questions, I'm getting a bit nervous now, only 8 days left til the OP.

tony
09/30/07 Diagnosed with partial ACL tear (left knee)
02/03/10 American Football injury, Diagnosed with ACL & MCL complete tear (right knee)
(R)lateral meniscotomy 08/11/10
(L) Lateral meniscotomy 10/28/11
(L) MCL & Medial Meniscus tear 07/12
(L) injury 01/23/12

orthosci

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Re: Graft Choice in ACL reconstructions - The Place of Allografts
« Reply #13 on: August 04, 2010, 01:01:47 AM »
The trick is to get the ingrowth of blood vessels so that the graft can remodel. You need to pump blood into the knee.  Running is an opening and closing joint jarring motion which is a problem if you have other injuries.  Most ACL injuries have concomitant injuries such as meniscus tears or cartilage defects, neither of which when repaired or resected like running. 

Most of the capillaries that service your connective tissue (the parts that hold joints together) are growth capillaries and when you quit growing, at about age 25, their ability to deliver oxygen to cells diminishes over time.  What that means is that if you are older you have to bend you knee a lot more times than a younger person does in order to get the same amount of oxygen to the cells. This is where stationary bicycling comes in.  Nordic track works also because, unlike running, it is a gliding motion, however, when your torso is parked on a bike, the knee isn't supporting your weight and you can bend the knee a lot without making it angry.

Two rules of pain; if it begins to hurt, stop what you are doing.  If it hurts within 24 hours, you've overdone it.  In either case, reevaluate what it was that you did that was different from the last time that you did PT and back off a bit. Since PT is an activity that you gradually increase both the type and duration over time, when adding a new type of activity or increasing time, do it weekly and not daily, then you don't have the risk of getting an overuse injury - tendonitis for example - in a brand new graft that is neither totally vascularized much less remodeled.

Rehab is a modified more is better model, the more that you bend the knee the better.  No squats, cybex testing, extension against resistance, all of which load the knee and that brand new ligament.  Better to use the bike on low loads and be able at 3 months to put 30 minutes in 2x a day than trying to run the same amount.  What the knee needs is to be vascularized and making it angry so that it hurts will cause inflammation and effusion (swelling) and cause injury secondary to the effusion that you will then have to recover from.

Cryotherapy is your friend.  In addition to being able to assist in the reduction of swelling, it has an analgesic effect that can be used to reduce pain even when the knee isn't swollen.  So whenever you change your routine and the knee lets you know about it whether it be 2 weeks out or 2 months or 6 months or a year, cryotherapy can be helpful to stop the inflammation/pain cycle. 

While the stationary bike and Nordic track are excellent rehab devices, their in vitro counterparts, biking and XC skiing can pose problems depending on how long post-operatively you begin using them.  Unlike when the knee starts hurting and you are on a stationary bike or Nordic track where you can quit and get off, if biking or XC skiing some distance, that option has limits and guys (I'm a man - I can take it) often make the wrong choice and keep going and thus develop a good case of new graft tendonitis.  This is Bad News - don't do it.

Anything that you do that is not low load high rep capable, like biking or NT, really isn't great ACL PT.  Rather it is a recreational activity that has limited physical therapy utility.  The problem in the education portion of this distinction is that Docs often call PT 'exercises' and everyone often calls recreation activity 'exercise'.  You can see how it is easy for people to get confused.  Most ACL PT is designed around a 2 dimensional model because that controls the load on the knee during it's weakening (lowest, weakest point at 4 - 6 weeks) and dominant revascularization & remodeling interval up to about 6 months.  3 dimensional movements, such as rapid direction changes - cutting or jumping and landing, are capable of putting more load on a new graft than it is capable of withstanding without incuring injury. 

For most graft models, the graft doesn't obtain relative strength to the original ACL until about 9 months. It is sort of like being pregnant in reverse, though I don't think that an ACL reconstruction is nearly as bad as giving birth.  However, while a pregnant woman might jog in her first trimester, so may an ACL reconstructed patient jog in the last 3 months, and the middle 3 months are more iffy for either example and are dependent on how careless you are, how uneven the ground is, what other kind of injuries you have, and what your body mass is;  all are factors that should be weighed into the equation when making the decision to run.  Again - it ain't PT.

If you want to do 3D PT, get in the pool.  Same 2 rules of pain, start off slow and see if it is angry the next day or not.  Crawl stroke kick isn't necessarily good because in extension, while the ACL is in the roof of the intercondylar notch, the load, when against the heel, can make the new graft unhappy in a relatively short distance.  It is never a race, use flotation if you don't swim well, and a mask and a snorkel if the chlorine or other pool cleaning agents bother your eyes or sinuses.  Work on symmetry and economy of motion.  No speed or long distances.  The 3D breast stroke kick has the benefit of overcoming proprioreception loss and leg muscle ratio of strength disparity.  Be patient as it will take months.  Plus, rice crispy knees (snap, crackle, and pop) generally will love the pool and so will the rest of your body.

For you Tony, "femoral attachment is a combination of the screw and a "button" ", The button is probably an endopearl, a little bioabsorbable round bead that is tied to the fold in the graft so that the graft can't be pulled past the screw because the interference screw positioned in the tunnel alongside the graft won't let the "button" pass under load.  I've got an Achilles allograft in my knee sized to 9mm inside a 10mm tunnel with a 9mm x 25 mm bioabsorbable interference soft thread screw.  The tibial end has the bone plug in a 12 mm tunnel with a 7 x 25 mm bioabsorbable interference screw.  I'm 21 months out and the knee is stable.

The strictness of your protocol question is telling me that you'd like to do what you want but have your recovery be optimal in spite anything that you might do or not do.  That reminds me of what my doc tells me about his teenage patients who all seem to think that the laws of physics and biochemistry apply to everyone but them. 

It will take longer than you think.  It will take more time than you think.  If you consider that getting it right the first time and investing the time and being careful for about a year (or so) so that you might not have to have it done again then you'll be more likely to have a successful outcome that YOU like the first time around.

Do straight leg raises 500 a day, start now. Tighten the leg, raise it 4 to 6 inches, put if back down, relax it. Do it again, 499 to go.  You can do them standing up, sitting down (gotta scoot forward to be able to keep the leg straight), or laying down.  You can't do them and count them while computering, reading, talking on the phone or watching tv, so don't count them, just do them.  If you do 5 minutes on the hour, that will get you 500  in about 10 hours and then it will just become a normal thing to do instead of trying to do them all at once over 35 to 45 minutes or do.  Follow the 2 rules of pain on this too.  When you can do 500, then do 600, and then 750, and then after a while 1000. They will build you quadriceps muscle back up and keep your graft safe while it is in a weakened state.  More is better, but follow the two rules of pain.

Good luck,
Steve

p.s.  Allografts are where it's at.  Robbing Peter to pay Paul (autografts) is not a particularly good idea since God didn't make us with any spare parts. 
« Last Edit: August 04, 2010, 01:07:54 AM by orthosci »

Offline tony1233

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Re: Graft Choice in ACL reconstructions - The Place of Allografts
« Reply #14 on: August 05, 2010, 02:42:54 PM »
Thank you for the very informational post.

I will be sure to refer to this as time goes on throughout my rehab process. However I know the laws of physics and biochemistry do apply to me, I was just curious as to when Jay started moving on to bigger parts of his rehab, ie. Jogging. I haevn't really been able to jog since january and I really miss it. I'm so out of shape now it's absolutly rediciouls. I just wanted to see when I can hope (around about) to get back at the exercises I really enjoy.

Less than a week from now I'll have my operation completed and will be posting a post-op diary and It'll be interesting to see how my recovery compares to yours, Jay's and everyone elses on the site.

All the best,


Tony
09/30/07 Diagnosed with partial ACL tear (left knee)
02/03/10 American Football injury, Diagnosed with ACL & MCL complete tear (right knee)
(R)lateral meniscotomy 08/11/10
(L) Lateral meniscotomy 10/28/11
(L) MCL & Medial Meniscus tear 07/12
(L) injury 01/23/12















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