In my previous post, I highlighted the importance of doing your own research in the essence of making the best of your consultation with your doctor, which will the only assessment you have before choosing the doctor you are going to go with.
If this is your first ACL reconstruction operation, you might be wondering what exactly does reconstruction actually mean. My sesame street description of this as follows:
When you tear your ACL completely( and I say completely cause there are some cases when the ligament can be 50% torn and the surgeon might have other options), naturally, you cannot stitch these loose ends together again. The only option is to completely replace it with another ‘wannabe’ ligament called a graft, which either can come from your own body or from a donor. There are 3 options that you could choose from, all with their own set of pros and cons.
The choices you will have, in accordance with your doctor’s advice, will depend on factors such as your record in physical setbacks, age, and activity participation level going forward. These are your options:
Hamstring Graft – The hamstring muscles are the group of muscles on the back of your thigh. When the hamstring tendons are used in ACL surgery, two of the tendons of these muscles are removed, and “bundled” together to create a new AC.
– Hamstring autografts generally have the least post-operative pain associated with it.
– Easier rehabilitation in regards to quadriceps activation occurs.
– Most patients have a quicker return to Activities of Daily Living (ADLs).
– The incision used to harvest the hamstring graft(s) is the same incision used to drill and place the fixation hardware.
– The fixation is not as strong initially so caution is advised with rehabilitation.
– General hamstring weakness is noted.
– Return to full athletic participation is generally slower, usually 6-7 months.
– There is no hamstring activation for at least the first four weeks in order to allow the harvest site to scar and heal down.
– There is an increase incidence of hamstring strain / tenderness.
Pateller Tendon Graft – The patellar tendon is the structure on the front of your knee that connects the kneecap (patella) to the shin bone (tibia). The patellar tendon averages between 25 to 30 mm in width. When a patellar tendon graft is taken, the central 1/3 of the patellar tendon is removed (about 9 or 10 mm) along with a block of bone at the sites of attachment on the kneecap and tibia.
– A bone-patellar tendon-bone autograft is one of the strongest grafts concerning the initial fixation. This is due to the fact that there is bone on each end of the graft that is going into a tunnel in the bone.
– Physicians have the most experience with using this type of graft.
– Return to full athletic participation is typically quicker, usually within 5-6 months
– B-PT-B autografts are generally the most painful of the grafts post-operatively because harvesting the middle third of the patellar tendon along with a bone fragment from the distal pole of the patella and the tibia tubercle.
– Has an increased chance for patellar tendonitis.
– Because of the bone fragment harvested from the distal pole of the patella, there is an increased chance for a patella fracture.
– Initial rehabilitation / activation of quadriceps is more difficult because one third of the connective tissue allowing for quadriceps activation is removed and used.
– There is an increased incidence of patellar tendon pain and discomfort with kneeling.
– There is an extra incision where the graft is harvested from.
Allograft – Most commonly used in lower demand patients, or patients who are undergoing revision ACL surgery (when an ACL reconstruction fails). Biomechanical studies show that allograft (donor tissue from a cadaver) is not as strong as a patient’s own tissue (auto graft). For many patients, however, the strength of the reconstructed ACL using an allograft is sufficient for their demands. Therefore this may be an excellent option for patients not planning to participate in high-demand sports (e.g. soccer, basketball, etc.).
– No harvest morbidity occurs because the graft is donor tissue.
– Allow for the fastest return to Activities of Daily Living (ADLs).
– Allografts are the least painful post-operatively.
– Allows for a smaller incision on the medial tibia.
– Potential risk of viral transmission (HIV, hepatitis). The chance of HIV infection from donor graft tissue is 1 in 1.8 million.
– Return to full athletic activities is generally within 6-7 months.
– Though small, there is a chance for some type viral transmission. As with any surgical procedure, that chance is there. There are also other risks involved with any surgical procedure. Dr. Lowe or his representative will discuss those risks with you.
In 2010, after my first encounter with ACL tears, I honestly was not given an option from the doctor, but also because I was not educated enough on the injury for me to realize what other choices I may have had. In any case, my first surgery was performed using a hamstring tendon. It survived for two years. I was back to my normal sports activity and I felt secured with it. Since they take a piece of your hamstrings tendon, you must be sure that you need to strengthen your hamstring after your operation cause it’s now minus some artillery. I felt some pain in it sometimes, if I was performing hamstring focused exercises but nothing out of the ordinary.
Now that I have summarized your options on your graft selection, there are still a lot of bits of pieces that you need to know, regarding the graft positioning and the complications that may arise in your surgery if this is indeed a revision surgery.
See you in the next post.