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Author Topic: ACL reconstruction--need to choose patellar or hamstring autograph  (Read 8869 times)

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Offline PeterB

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Hi everyone,
  New guy here; I'm glad I found this site.
 
I'll try and keep this as short as possible. On 19 December 2009 I ruptured the ACL in my left when I fell downhill skiing. (I'm 40, by the way, and in good health and have no other knee issues). The ACL tear was confirmed with an MRI. I plan to get it reconstructed fairly soon, and have been doing a bunch of reading on this topic. I have definitely decided to stay away from an allograph.

The big decision I have to make (like everyone who is facing an ACL reconstruction) is whether to have the autograph donor tissue taken from the patellar tendon or hamstring tendon. I have read about the pros and cons of each method, but am still confused about which way to go. It seems to me that in years past, the patellar tendon method was considered the "gold standard" (it was actually described that way on a website I visited) and was favored by high demand athletes, etc.

But the impression I get is that in recent years the tables have turned and the hamstring method has gotten a lot more popular.

If anyone cares to opine about this issue, I'd love to hear it.

I have interviewed one surgeon already (here in the Twin Cities of Minnesota) at a clinic called Minnesota Orthopaedic Specialists. The surgeons at that clinic only do the hamstring method. This guy I spoke with has good credentials, did his ortho residency at Mayo Clinic, etc. He said he has personally done about 100 of these operations. Does that sound like enough experience to be comfortable with this guy? I checked his background and it's clean.

Anyway, sorry for rambling. If anyone can help me out in my efforts to make this decision, I'd be grateful.
Thanks.  ;)
-Peter

Offline Kaputt_Knee

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Re: ACL reconstruction--need to choose patellar or hamstring autograph
« Reply #1 on: March 05, 2010, 05:23:54 AM »
Sorry to see you here but you have found the best resource on the Net at least.

I've had both repairs, so at least I can give you the benefit of that.

My advice is quite definitely shop around until you find a surgeon who tells you "I'm going to do this or that" and you answer "when". Then you will know that you have found the right person for you.

Your surgeon should instil you with confidence that he/she will get you back into action in the way you want to regardless of your age. What they then choose to use is what they are best at doing. Despite all the arguments, there are advantages and disadvantages of both autografts. These are summarized in some excellent articles here in the Information Hub, written by Drs Grelsamer and Noyes and rehab protocols by senior physios at specialist knee clinics

Start here: http://www.kneeguru.co.uk/KNEEnotes/node/1762

Rehab protocol: http://www.kneeguru.co.uk/KNEEnotes/node/775

Dr Noyes' excellent article on ACL revisions: http://www.kneeguru.co.uk/KNEEnotes/node/155 Essential reading to help you avoid this particular problem.

After you've done some reading by all means come back and ask away!

I'm based in Germany and the processes and operations are way different in every country. Common to all - go into the operation as fit and as mobile as possible and stay focused on positive outcomes by being realistic in your expectations and milestones.

good luck with your choices

Sue ;)



1989 big trauma R. knee - sorted
1990-2004 3ACL recons and 20+ arthroscopies -RK
3/06 LK ACL torn!
4/06 ACL recon, kneecap broken
09 &10/06- 2x meniscus trims
3/07 - Notch Plastic & Lateral Release
14/8/08 complete revision ACL plus LCL/PLC recon
6/2/09 returned to skiing! Whoopee

Offline PeterB

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Re: ACL reconstruction--need to choose patellar or hamstring autograph
« Reply #2 on: March 06, 2010, 06:26:56 AM »
Sue, thanks for the reply.

Having just found and read some informative articles/postings on the internet, I now feel more inclined to go with the hamstring autograft. Frankly, I don't like the sound of the various complications that can arise as a consequence of harvesting material from the patella tendon. In particular, it concerns me when I read that some people experience pain/discomfort when kneeling after having an ACL reconstructed using patellar tendon graft. I enjoy various activities that involve kneeling such as tent camping, and I don't relish the thought of having kneeling issues. Or patella-related issues, for that matter.

I think, broadly speaking, that a hamstring graft sounds like it might be the better option for me. Various commentators have speculated that the hamstring graft may not ultimately be quite as strong as a patella tendon graft. That may be true, but then again, I'm not a high-demand athlete. I'm a recreational downhill skier, and a pretty tame one at that. (After my reconstruction and rehabilitation, I plan on wearing a sturdy knee brace when skiing just as a precaution against re-injuring the knee). I enjoy hiking and non-technical mountain climbing, and I ride a bicycle and run stairs as my main forms of conditioning exercise. It seems to me that I'm not putting a great deal of stress on my knees.

So anyway, that's where I'm at right now on this issue.
-Peter


Offline PeterB

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Re: ACL reconstruction--need to choose patellar or hamstring autograph
« Reply #3 on: April 03, 2010, 05:42:39 AM »
Got an appointment for a surgical consultation 6 April 2010 at the Mayo Clinic (Rochester, Minnesota, USA) with one of the top knee surgeons in the United States.  :)  I'm very hopeful that this will be the person I'll feel comfortable with to fix my ACL. I'll let you all know how it goes.

Offline Silkncardcrafts

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Re: ACL reconstruction--need to choose patellar or hamstring autograph
« Reply #4 on: April 03, 2010, 07:19:38 AM »
Hi there,

Definitely find a surgeon that does a lot of ACL reconstructions. 100 operations is not a lot. My OS is a well known knee surgeon in Australia and overseas and does about 200 ACL recons a year. I think his preference is for the hamstring graft, but it depends on the patient I think.

Good luck !!

Don't be afraid to get more than one opinion if you need to.
11/1996 - RK LR
07/1997 - LK LR
11/1998 - LK MPFL Reco
12/2005 - RK LR Repair
07/2006 - LK MPFL Repair
11/2006 - LK LR Repair
22/05/08 - LK Trochleoplasty
11/02/10 - RK Trochleoplasty
07/03/11 - RK Chrondroplasty

Offline PeterB

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Re: ACL reconstruction--need to choose patellar or hamstring autograph
« Reply #5 on: April 05, 2010, 05:13:38 AM »
Thanks. No, I'm not afraid at all to get a 2nd opinion. I know the ACL has got to be reconstructed. It's just a matter of finding a surgeon that instills confidence. I don't think one can go wrong with the staff at the Mayo Clinic. I'm so happy to finally get the appoinment to meet with this fellow. If the meeting goes well I'll get the surgery scheduled for as soon as possible.

Offline Kaputt_Knee

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Re: ACL reconstruction--need to choose patellar or hamstring autograph
« Reply #6 on: April 05, 2010, 05:55:27 AM »
I was reading an article by my surgeon in a local newspaper this weekend and he quotes the following statistics just for Germany:

80,000 plus ACL tears per year which apparently works out to be one every one every 6.5 minutes!

approx 80% will be repaired - age never comes into the question. Health and quality of life are the criteria used.

He does more than 300 a year, a lot being revisions of poorly placed ones like mine.

He uses only human tissue - predominantly autografts taken from the hamstring tendons. He was able to harvest my semitendinosis and gracilias tendons for a second time (my first surgeon started down that path and obviously made a mistake of some sort as he reverted to a patella tendon graft in the end). so in the 2.5 years between the two ops my hamstring tendons had regenerated/repaired or what ever it is they do!

The important thing was that he listened to me, read my history and then discussed with me what HE was going to do to solve my problem. I was almost 58 when he operated, but the age question never came into the scenario. He asked me what my aim was, and he told me that he would do everything possible to ensure I could achieve this but I would have to work hard at the rehab. He believes in early mobilisation and the physios were working on me within 24 hours of my operation. I was back skiing 5.5 months later.

I'm up early today as I'm off skiing for the day - it's a holiday here so why not, I ask myself!!!!

I've been through this procedure more frequently than anyone else here - either I'm a klutz or just damned unlucky - doesn't faze me and I don't care. I'm still skiing, sailing, paragliding (took it up post ruptured ACLs) mountain walking and being generally disgraceful for my age  ;D

You'll get loads of opinions here - a lot from people who have never had this procedure as they feel they have some experience to offer however irrelevant. In the end this is a virtual world from which you can learn but the reality is choose someone to work on your knee that you trust. You will know when you've met them believe me!

Good luck with the search. If I can help with any other questions, just ask away!!! I'll be back this evening (with luck!  ;) )

Sue  8)
1989 big trauma R. knee - sorted
1990-2004 3ACL recons and 20+ arthroscopies -RK
3/06 LK ACL torn!
4/06 ACL recon, kneecap broken
09 &10/06- 2x meniscus trims
3/07 - Notch Plastic & Lateral Release
14/8/08 complete revision ACL plus LCL/PLC recon
6/2/09 returned to skiing! Whoopee

Offline BadKneeDay

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Re: ACL reconstruction--need to choose patellar or hamstring autograph
« Reply #7 on: April 06, 2010, 12:39:57 AM »
**Personal Opinion**  Like other things, we all have one!  But, here's mine.  I was unfortunate that my ACL tear was work related and I did not get to choose my doctor.  It took him two and a half years to even diagnose my ACL tear.  At the pre-op he told me that he would be using an allograft.  I wasn't educated and said whatever.  Went home, did some research.  Decided that I wasn't comfortable with the allograft.  Went in for surgery the next morning (I was told I would have surgery on Tuesday, surgery Wednesday) and told him I wasn't comfy.  He said he would use the patellar tendon, no problem.  So long story short... I have numbness along the left half of my knee along the tendon, it is extremely uncomfortable to kneel, if I do I have to pad it and try to balance to keep the weight off of it, and now I have scar tissue behind the tendon, the screw blew out of the back wall of the femur, and I also have more scar tissue behind the knee cap that has to be removed.  Of course this is all a fight with worker's comp... took me 5 months to be approved to see another doctor (of my choosing) and no telling how long until they approve the surgery that he says I need. 

The new doc says that he does 250 ACLs a year and that 10-15 patients develop scar tissue problems... although most are diagnosed shorty after surgery (mine took 16 months) and don't cause as many long term problems.  From my reading it seems that patellar tendons seem to have a higher incidence of complications.  I encourage you to keep researching while you wait for your appointment, being informed will help the doctor help you to make the right choice for your lifestyle.  Don't agree to anything you aren't comfortable with! 

Offline Snowy

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Re: ACL reconstruction--need to choose patellar or hamstring autograph
« Reply #8 on: April 06, 2010, 05:28:43 AM »
I asked the same question when I found out about my ACL tear, and got a lot of helpful opinions from many folk over on the skiing forums who have already been through ACL reconstruction. Since then I've also been researching the various options like crazy. Based on what I've heard and read, I'm 99% certain that a hamstring graft is the way I want to go.

However, this is very much a personal opinion based on my particular situation. I have a long history of patellar tracking problems and chronic anterior knee pain, which would make me a really bad candidate for the patellar graft. I'm not  convinced by allografts; there are definite advantages (not having to heal a harvest site as well as the knee joint) but most research seems to indicate the failure rate is higher, which seems like a bit of a risk to me. Long-term, it doesn't sound as though there's a huge difference between the strength of a hamstring and patellar graft. My PT also recommended the hamstring graft.

That said, every situation is different...my feeling is that a good OS will talk through the pros and cons of each with you, and not push you into a certain choice just because it's the one they're most personally comfortable with.

Good luck with your decision!
Mar 11: R Biceps femoris tear (skiing)
Jul 10: ACLr (hamstring autograft)
Mar 10: L ACL rupture (skiing)
Feb 06: L partial ACL tear (kickboxing)
Dec 03: R bone edema (motorbike)
Jan 01: R patellar chip (motorbike)
May 93: R ACL sprain (hockey)
Ongoing: bilateral PFS and OA

Offline PeterB

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Re: ACL reconstruction--need to choose patellar or hamstring autograph
« Reply #9 on: April 07, 2010, 04:54:54 AM »
Thanks for the feedback Snowy.

Got home just a little while ago from Rochester (it's about 75 miles away). The meeting with the knee surgeon I selected went very well. Unlike the other surgeon I saw, this guy seemed much more accessible and experienced. Doesn't hurt that he's also a professor of orthopaedics who has done hundreds and hundreds of ACL reconstructions using all the different graft choices, including roughly 450 hamstring grafts. He discussed all the pros and cons of the various graft choices. He had no problem at all with my preference for hamstring, so hamstring it will be; I'm going to schedule surgery with him. I think he was even impressed with all the technical questions I asked regarding the fixation techniques that are currently in use (bio-absorbable interference screws, etc. etc.)

I was impressed with everyone I dealt with at Mayo today, from the staff at the admissions desk to the physical therapist.

After all the medical things were finished I had dinner and drinks with a girl I know who lives in Rochester and drove back home. So all in all it's been a splendid day and I'm feeling all lot more positive about my knee situation.  :)

Offline crankerchick

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Re: ACL reconstruction--need to choose patellar or hamstring autograph
« Reply #10 on: April 07, 2010, 01:58:32 PM »
I don't think a person has to have gone through ACL reconstruction to have an opinion worthy of consideration on the topic. Some non-acl folks such as myself are just interested in the topic and do just as much research on the subject as someone who has gone through it. I can say that I know what my doctor prefers, and that is autograph patellar tendon, for the reason that time frame for bone to bone healing is more certain than for tendon to bone healing in the case of the hamstring graft. My doc does hundreds of reconstructions per year. I don't think 100 in a year is a lot.

As for kneeling after patellar tendon reconstruction, i personally think based on what i've read that this has a lot to do with the one holding the knife and also the rehab that comes after the surgery. Me and my physical therapist were discussing this the other day. With good technique and proper rehab, patella tendonitis and kneeling should be a non-issue.

That said, it's a very personal choice and I think what is more important then which graft to do is choosing a doctor that you are comfortable with, with tons of experience, that is comfortable using the graft you choose. Also take into account the after surgery protocol and rehab protocol. Things can vary widely in terms of whether a doctor issues braces, crutches, etc after surgery and their time frame for rehab milestones. I think it is important to choose the surgeon that most matches up with your goals for the process and is well skilled at the graft that you are choosing.

Good luck with your surgery. Even though I have my opinion on what is the best graft to choose, I think a good outcome can be had with any graft provided the surgeon is skilled at what he is doing, the graft matches up with the desired activity level of the patient, the proper rehab protocol is implemented, and the patient does their part in following the rehab protocol.
« Last Edit: April 07, 2010, 02:04:00 PM by crankerchick »
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Offline PeterB

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Re: ACL reconstruction--need to choose patellar or hamstring autograph
« Reply #11 on: April 14, 2010, 03:16:53 AM »
As for kneeling after patellar tendon reconstruction, i personally think based on what i've read that this has a lot to do with the one holding the knife and also the rehab that comes after the surgery. Me and my physical therapist were discussing this the other day. With good technique and proper rehab, patella tendonitis and kneeling should be a non-issue.

Good point. My thinking, though, is that I'm not happy with taking the risk--however small it may be--of ending up with kneeling issues by going with a patellar tendon graft. I'd never be able to forgive myself if I ended up that way by going with the patellar tendon graft. From what I can tell, the debate of patellar tendon versus hamstring isn't going to end anytime soon. And the final analysis seems to be they both do a good job of replacing the ACL.

My surgery is scheduled for 11th May. I've been busy doing the exercises the physical therapist instructed me to do to get the leg strengthened before surgery. He gave me several big rubber-band things to be used for the exercises, one of which gets hooked over a door-handle and then around the knee. In this way the hip and upper leg muscles can be worked. It looks pretty foolish, but is effective. Then there's the squatting, leg extensions, stepping up on to a pile of books repeatedly with my bad leg, etc.

Not looking forward to all the pain and inconvenience the surgery will bring, but so far I haven't had too much anxiety about it. My parents graciously offered to drive me back from hospital and to let me convalesce at their house for a week or so. And also to arrange to hire a car with automatic transmission for me to use until I can drive my own car again (manual gear change). :P

The tips I've read on this board about what to expect after the surgery have been very helpful. One thing I very much intend to do is buy a pair of crutches at the secondhand store before the surgery (they're practically free) so I can practice hobbling around on them, and build up associated strength so I don't have to suffer too much after the surgery. :-*

Offline PeterB

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Re: ACL reconstruction--need to choose patellar or hamstring autograph
« Reply #12 on: May 23, 2010, 06:08:43 PM »
I'm back!  Had my ACL recon surgery (hamstring) 11th May. So I guess that was 12 or 13 days ago. Everything went very well. Surgeon told me there was very minor miniscus damage that he cleaned up whilst he was rummaging around in the knee.

The recuperating process is coming along nicely. Had to do lots and lots of icing and elevating to get the swelling down. I can't tell you how sick I am of reading, watching television, and listening to the radio. I'm well past 90 degress bend, and the stiffness in the knee is decreasing a little bit each day. I know I have a long road ahead of me and I will have to be careful of my knee for a long time to come, but the worst is definitely behind me.

Back to work tomorrow to sit in front of a computer all day--something I have not missed at all for the past two weeks.






Offline PeterB

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Re: ACL reconstruction--need to choose patellar or hamstring autograph
« Reply #13 on: June 20, 2010, 05:36:19 AM »
Hi everyone,

  I hope that you are all making progress in getting your knee problems sorted out. It's a tough boat to be in. I have empathy for you all.

  22nd June will be 6 weeks since my ACL reconstruction (hamstring autograft). Making steady progress. Little bit each day. Doing all the exercise the PT told me to. Squats, heel-slides, leg-lifts, calf and hamstring stretchs, etc. ect.. I love riding my stationary bicycle. It really limbers up the ol' knee. It's a constant battle against stiffness.

  Today I decided it's time to transition from crutches to a cane. Lacking a store-bought cane, I fashioned one out of materials at hand. I used an ice-axe I found in the closet with the leg from one of my crutches lashed to it to provide necessary length. Looks a bit odd, but works really well. Photo below:

http://img.villagephotos.com/p/2009-6/1342206/iceaxecane.JPG

Hobbling around on a cane feels pretty spooky at the moment; I imagine I'll get used to it soon enough.

Next appointment at Mayo Clinic is 28th June for an X-ray, follow-up visit with surgeon, and further consultation with my PT.

Regards,
-Peter

Offline tez27

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Re: ACL reconstruction--need to choose patellar or hamstring autograph
« Reply #14 on: June 20, 2010, 11:05:29 AM »
Peter thanks for the update I wondered how things were going for you, I am having my aclr on the 19th July also using the hamstring graft, wee question how is the walking going you said that you are now moving from crutches to cane, have you needed the crutches as long as 6 weeks, I have been told a max of 3 weeks needing crutches, and some people you hear of are off them before then, I am freaking out a bit about the inactivity and even though I am kinda on the old side to have this surgery 48 i need to get back to my normal life asap.
Hope your recovery contiues well take care
Tez     
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