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ACL and MCL injury - To have surgery or not?

Poll Results: Surgery for ACL and MCL tear?

 
  • 100% (4)
    For Surgery
  • 0% (0)
    Against Surgery
4 Total Votes  
post #1 of 45
Thread Starter 

On 30th December I tore 2 ligaments in my knee, the ACL (Anterior cruciate ligament) and the MCL (Medial collateral ligament).

 

Age 19, I'm a serious skier and am devastated that this has wiped me out for the season and also for my water sports come the summer season. I've seen the doctor who is suggesting surgery, but i've heard a lot of stories against surgery - knees never being the same again etc. I presume that not having surgery would have the shortest recovery period, but I want my knee to return to full mobility/performance. 

 

I've rested my leg for almost 2 weeks, in a brace there is little pain and i'm beginning to do exercises to strengthen my thigh muscles and continuing to ice it regularly to reduce swelling. I am due to start physio in February and the doctor wants to see my in 6 weeks (21st Feb) to see progress/decide on surgery - surgery isn't possible at this stage due to the swelling. 


Any advice to sway me one way or the other?

Calling Doctors/knee specialists/physios/anyone with experience.

 

Thanks!

Serena

post #2 of 45

Your presumption that no surgery would provide the shortest recovery time could not be further from reality. Leaving your lower leg dangling for the rest of your life guarantees it will never be "the same".

 

Get it fixed.

post #3 of 45

Sorry about your injury, but welcome to Epic.

 

I voted for surgery, but there are some arguments that can be made for the other side- http://www.epicski.com/t/69400/acl-recovery-without-surgery.  Lots of ACL threads and info on the site http://www.epicski.com/search.php?search=acl

 

I am almost 8 months post-op my 2nd blown ACL on my right leg- which first sustained a blown achilles (no surgery).  Some will say that a year or two post op and the knee feels as good as your other one.  I would say my results have been reasonably good, and I skied at a relatively high level for about 180 days between the two falls/surgeries, but my knee has never felt quite as good (but actually seems more stable this the second time around).  Part of my situation might be a weakening of my calf/ability to jump due the achilles- this affects me playing basketball, but has almost no affect skiing (at least the first time, haven't skied yet after the second one).

 

It seems like they are still learning about exactly what is best in terms of length of time for rehab (and many other issues), but I would tend to err on the side of taking a bit longer as it takes some time not only for you to build back up your muscles, but also for the ACL graft to fully incorporate (which likely varies depending on type of graft, each individual, etc.)  You are young, so losing one summer season and taking it slow early next winter is likely worth the trade-off if it means a better long term prognosis.

 

Good luck and be sure to see a doctor who has a good track record and experience with ACLs- especially among active patients like yourself.

post #4 of 45
Thread Starter 

Thanks very much for your comments guys. 

 

Mefree30 - you said that you went through with the surgery, did they use your tendons/carbon fibre etc? Roughly what was your length of recovery period after the op? 

Sorry to hear about your basketball. Many thanks, Serena

post #5 of 45

Serena, I am not a dr and I don't know your situation but I am just a couple days over 3 weeks with a detached ACl, Why wont you be able to waterski this summer? IMHO, you are not seeing the big picture here. You are a active person who is involved in high impact and high stress sports.  TRANSLATION: you need as much performance out of your body as you can get. So if you don't do the surgery, you will have to most likely wear a brace when you are skiing. You will be at higher risk for future injury of the knee and potentially increase the likelihood for arthristis. I for one don't want the risk for a weakened knee to give out in the middle of a high speed turn or on a steep line. I don't want to have to wear a brace or wonder if what I am doing will cause a blowout. (enven if it's stable I will wonder)  If you get going on surgery, you should be back up and in decent shape (maybe not competing) in 4 months with a high degree of recovery in 6.  (I plan to ski this August in SA).  Don't get devistated, get organized and focused. Not being mean here, you need to get over it and move forward. The injury is done you can't go back,  I would get busy finding out as much as you can about rehab and recovery and get that surgery lined up with the best possible doctor you can find and even find where you are going to do the rehab. it's critical. Then in a few months, it will all be in the past and you will be back doing all the things you like to do.  I haven't once read a credible story about a failed ACL reconstruction where a person was worse than not doing the surgery.  icon14.gif

post #6 of 45
Quote:
Originally Posted by beanielp View Post

Thanks very much for your comments guys. 

 

Mefree30 - you said that you went through with the surgery, did they use your tendons/carbon fibre etc? Roughly what was your length of recovery period after the op? 

Sorry to hear about your basketball. Many thanks, Serena


I had a cadaver graft both times, but different doctors feel differently about this.  The advantage of the cadaver is that you don't weaken anything else, BUT the 2nd doctor said that they now think it takes longer for a cadaver graft to get to full strength (if it every incorporates 100%).  With younger patients, I think most Drs go with autografts- either the patella or hamstring.  Both have advantages and disadvantges- patella is a tendon, so it might attach better and be stronger BUT there may be more pain on your knee from the harvest site for a while.  Tends to be less pain with the harvest site with the hamstring BUT the hamstring is a muscle that you want to be strong to protect your ACL (but they only take a bit that presumably you can rebuild).

 

Having an extensive meniscus repair, I am taking things much slower the 2nd time around- the first time the knee felt decent after 3 or 4 months and only a bit longer the second time BUT I firmly believe that some healing/strengthening continues for 12 to 24 months post op.  I would listen to what your dr and PT tell you, but 6-9 months to be at a reasonable level of activity if you go autograft and 9-12 if you go cadaver might be good time frames based on what I know.

 

As far as basketball goes, while I currently have no lift of that leg and am past NBA prime in terms of age, I think the knee is solider than the first time around and am hopeful that I will regain some strength/lift/sping- not to where it was pre-achilles, but hopefully not to far from where it was pre-ACL.

 

post #7 of 45

I picked neither - why? Because you should listen to your DOCTOR. See/get 2nd/3rd opinions from other orthopedists that specialize in athletes/knees if you want another opinion, not anonymous people in an internet forum.

post #8 of 45
Quote:
Originally Posted by MEfree30 View Post


I had a cadaver graft both times, but different doctors feel differently about this.  The advantage of the cadaver is that you don't weaken anything else, BUT the 2nd doctor said that they now think it takes longer for a cadaver graft to get to full strength (if it every incorporates 100%).  With younger patients, I think most Drs go with autografts- either the patella or hamstring.  Both have advantages and disadvantges- patella is a tendon, so it might attach better and be stronger BUT there may be more pain on your knee from the harvest site for a while.  Tends to be less pain with the harvest site with the hamstring BUT the hamstring is a muscle that you want to be strong to protect your ACL (but they only take a bit that presumably you can rebuild).

 


Incorrect. We harvest the patellar graft from your tibial tuberosity to the knee cap and this piece of tissue connects bone to bone, therefore, by definition it is a ligament. The "hamstring" is a group of muscles but we harvest a piece of tissue that connects muscle to bone, therefore, by definition it is a tendon.

 

 

post #9 of 45

Get the surgery. I blew an acl in high school football, did the rehab and surgery, and was back to wakeboarding in July (8months). I was pretty careful wakeboarding that year but the knee felt great. Ive never had an issue with it skiing other than some soreness for the first year after surgery, after that no issues whatsoever and its stronger than my other knee thanks to my physical therapist. Here are my recommendations to you. First off find a great ortho surgeon in your area, a couple hours drive is worth it. My surgeon worked on Kobe Bryant, Ndamukong Suh, and others, well worth the two hour drive. Then ask him who in your area is a good physical therapist. Don't commit to one doctor just because you've already been there. You will do an insane amount of therapy before and after surgery to get the knee back into shape, but its well worth it.

Keep stretching and working on your leg before surgery, the better flexibility and strength you have before surgery, the better it will be afterwards.

post #10 of 45

beanielp,

 

I blew my acl March 10, '08, then had a hamstring autograft 4 weeks later. Back to skiing 7 months after that and have been totally satisfied with my knee. The situation caused me to get in better shape and focus on improving my skiing. I went in debt for the surgery and it was well worth it and would NEVER consider not having it repaired should it happen again.

post #11 of 45
Quote:
Originally Posted by Velobuff View Post




Incorrect. We harvest the patellar graft from your tibial tuberosity to the knee cap and this piece of tissue connects bone to bone, therefore, by definition it is a ligament. The "hamstring" is a group of muscles but we harvest a piece of tissue that connects muscle to bone, therefore, by definition it is a tendon.

 

 



Yes, it appears I was incorrect about the hamstring graft not being a tendon, but doesn't it depend on how the patella graft is harvested if it is a tendon or ligament.  This seems to say it is a tendon. http://www.kneeguru.co.uk/KNEEnotes/node/2125 (at least when done the way this doctor does)

Autografts

The most common way of performing an ACL reconstruction in the UK is to use autograft, ie. the patient's own tissue. The two main options here are:-

  • Patellar tendon: a strip is taken from the middle of the patient's patellar tendon, at the front of the knee, along with a small block of bone at either end.
  • Hamstring tendon: two long strips of tendon can be taken from the patient's hamstrings, at the back of the thigh.

 

I agree that it is generally worth listening to doctors as opposed to random people, but what about when doctors disagree and/or have their own biases and/or shortcomings?  I think you have to be able to separate the wheat from the chaff both with MDs and random postings on the internet.  Getting multiple opinions, like you said, helps you do this, but so does being able to ask some of the right questions (which a forum like this might make you aware of).

 

As an aside, What do they call the guy who graduates last in his med school class?  Some self education is a good thing, IMO.

 

In "Fooled by Randomness" an example was given of a medical question for which only 1 in 5 doctors got the correct answer. Question: ~if an illness/disease occurs in 1 in 1,000 people and a test for said illness/disease has a 5% false positive rate, what is the chance that a randomly selected person has the disease if the test comes back positive? 

 

Makes you definitely want a doctor who has good diagnosis skills and isn't just relying on a test.

 

 

 

  

 

 

  

 

post #12 of 45
Quote:
Originally Posted by MEfree30 View Post





Yes, it appears I was incorrect about the hamstring graft not being a tendon, but doesn't it depend on how the patella graft is harvested if it is a tendon or ligament.  This seems to say it is a tendon. http://www.kneeguru.co.uk/KNEEnotes/node/2125 (at least when done the way this doctor does)

Autografts

The most common way of performing an ACL reconstruction in the UK is to use autograft, ie. the patient's own tissue. The two main options here are:-

  • Patellar tendon: a strip is taken from the middle of the patient's patellar tendon, at the front of the knee, along with a small block of bone at either end.
  • Hamstring tendon: two long strips of tendon can be taken from the patient's hamstrings, at the back of the thigh.

 

I agree that it is generally worth listening to doctors as opposed to random people, but what about when doctors disagree and/or have their own biases and/or shortcomings?  I think you have to be able to separate the wheat from the chaff both with MDs and random postings on the internet.  Getting multiple opinions, like you said, helps you do this, but so does being able to ask some of the right questions (which a forum like this might make you aware of).

 

As an aside, What do they call the guy who graduates last in his med school class?  Some self education is a good thing, IMO.

 

In "Fooled by Randomness" an example was given of a medical question for which only 1 in 5 doctors got the correct answer. Question: ~if an illness/disease occurs in 1 in 1,000 people and a test for said illness/disease has a 5% false positive rate, what is the chance that a randomly selected person has the disease if the test comes back positive? 

 

Makes you definitely want a doctor who has good diagnosis skills and isn't just relying on a test.

 

 

 

  

 

 

  

 



icon14.gif

 

I have been mis-diagnosed and undiagnosed so many times I have lost count.  I refuse to grant automatic respect and trust to anyone just because they got through school.

 

post #13 of 45

Enjoy your free internet diagnoses by wikipedia MD's guys :)

post #14 of 45

Oh my, the amount of information that gets around is crazy. At your age you should strongly consider an ACL reconstruction because there is some evidence that an ACL deficient knee may be more vulnerable to meniscus damage in the future. Also, if you are into sports, which you are, that risk is even higher. However, this scientific evidence is really not all that conclusive but rather it is more suggestive. Keep in mind that NO ONE NEEDS an ACL to survive. It's really a personal choice.

 

Even without an ACL you're going to develop arthritis and meniscus damage because it's unavoidable as we age. Again, at your age I would strongly consider a reconstruction because of the years of abuse that your knees are still going to endure. Most doctors would undoubtedly recommend  a reconstruction in a 19 year old because of the many more athletic years to come for a young person. 

 

I'm not a doctor but I have had 4 ACL reconstructions and I'm in medical school (I rarely mention this). Last year I did a million page (maybe a few less pages) research paper on the necessity of ACL reconstruction (my interest came from my own reconstructions) and in the end the evidence suggests that you go with the reconstruction if your knee is unstable. There is no documented medical rule that states you cannot ski or play other sports without an ACL. You don't need to have surgery just because you are disappointed that you have a broken body part. You need surgery if it causes you enough problems to interfere with your life. Remember, people live without gallbladders, spleens, and wisdom teeth and most of them do just fine.

 

The END

 

 

 

 

post #15 of 45

In my opinion...Do it!  I would do it again, no question about it.  Find the the doc you're very comfortable with and go.  I blew my knee skiing 15 years ago when I was 29, I had my ACL replaced my hamstrings and it has been great.  It's not automatic though, it's what you make of it, it takes work but at your age you'll heal quick and bounce back super fast.  I had my surgery in May and was skiing the next season, not a 100% full on but skiing nonetheless.  The surgery changed my life in many ways as I was super bummed to be down with an injury having been a skier my entire life.  I have since committed 100% to being strong and fit and now at 44 have never skied (sp?) better, faster, stronger longer and my knee doesn't bother me one bit.  I do try to keep my skis on the snow more now though.  It's but a bump in the road, you'll be a fine.  A bummer, but what are you going to do... Don't rush any of it.  Good luck.

post #16 of 45
If the doctor recommends surgery, then do it. It's not like your knee would get worse compared to right now.
post #17 of 45

I'm not a doctor but...

 

Get surgery.  You're very young.  Fix your knee if you plan on being athletic in your life for many years to come.  Notice how *every* athlete ever gets the surgery?  There's a reason.  You can get by without it but if you want to do more than get by...

post #18 of 45
Quote:
Originally Posted by beanielp View Post

On 30th December I tore 2 ligaments in my knee, the ACL (Anterior cruciate ligament) and the MCL (Medial collateral ligament).

 

Age 19, I'm a serious skier and am devastated that this has wiped me out for the season and also for my water sports come the summer season. I've seen the doctor who is suggesting surgery, but i've heard a lot of stories against surgery - knees never being the same again etc. I presume that not having surgery would have the shortest recovery period, but I want my knee to return to full mobility/performance. 

 

I've rested my leg for almost 2 weeks, in a brace there is little pain and i'm beginning to do exercises to strengthen my thigh muscles and continuing to ice it regularly to reduce swelling. I am due to start physio in February and the doctor wants to see my in 6 weeks (21st Feb) to see progress/decide on surgery - surgery isn't possible at this stage due to the swelling. 


Any advice to sway me one way or the other?

Calling Doctors/knee specialists/physios/anyone with experience.

 

Thanks!

Serena


Partial tear or complete tear?  Makes a difference in your decision.  

 

post #19 of 45
Quote:
Originally Posted by BadGalSkier View Post

Oh my, the amount of information that gets around is crazy. At your age you should strongly consider an ACL reconstruction because there is some evidence that an ACL deficient knee may be more vulnerable to meniscus damage in the future. Also, if you are into sports, which you are, that risk is even higher. However, this scientific evidence is really not all that conclusive but rather it is more suggestive. Keep in mind that NO ONE NEEDS an ACL to survive. It's really a personal choice.

 

Even without an ACL you're going to develop arthritis and meniscus damage because it's unavoidable as we age. Again, at your age I would strongly consider a reconstruction because of the years of abuse that your knees are still going to endure. Most doctors would undoubtedly recommend  a reconstruction in a 19 year old because of the many more athletic years to come for a young person. 

 

I'm not a doctor but I have had 4 ACL reconstructions and I'm in medical school (I rarely mention this). Last year I did a million page (maybe a few less pages) research paper on the necessity of ACL reconstruction (my interest came from my own reconstructions) and in the end the evidence suggests that you go with the reconstruction if your knee is unstable. There is no documented medical rule that states you cannot ski or play other sports without an ACL. You don't need to have surgery just because you are disappointed that you have a broken body part. You need surgery if it causes you enough problems to interfere with your life. Remember, people live without gallbladders, spleens, and wisdom teeth and most of them do just fine.

 

The END

 

 

 

 


agree with most of what you say in that you give a pretty balanced presentation that indicates she has a decision to be made with the scientific evidence being suggestive, but not conclusive...don't understand "The END" part??  Are you saying that is all you have to say or suggesting she needn't look further?  

 

Hopefully, more research will be done and there will be stronger evidence suggesting not only YES or NO on surgery, but what surgical methods yield the best results (with breakdowns by age, etc).  Bad doctors wouldn't want this, but being a numbers guy, what I would really like to see is a National/International database which logs info on all surgeries/major medical treatments and give the patient a way to post follow-ups/status reports (or requests certain info on a periodic basis).  Enough ACL surgeries have been performed that we should have more than just suggestive evidence as to which graft choice/surgical technique (there is more than just one being used) is best.  

 

People can point to patient confidentiality issues, but my guess is that the real thing stopping this is doctors/hospitals-  the good doctors are already busy, so there is no upside for them and the rest are concerned about the negative affect of ranking in the bottom half of results obtained.

 

 

I felt very comfortable with both my ACL surgeons going into the operation, but when consulting with the 2nd doctor who uses a different technique than the first, he said that they have had numerous friendly discussions/debates about which method is best.  If two intelligent, well educated doctors who perform hundreds of these things can't come to an agreement, how is an uninformed patient suppose to make a rational choice?      

 

In the long run, a central database is going to be a better, quicker, and more efficient way to optimize health care than trying to study things ex-post-facto, not just for ACL surgery, but for prescribed drugs and other treatments as well.     

 



Quote:
Originally Posted by huhh View Post

If the doctor recommends surgery, then do it. It's not like your knee would get worse compared to right now.

I voted for surgery because she is 19 and active BUT

Have you had knee surgery?  Surgery will likely increase stability BUT surgery does trauma to the knee (including drilling holes in your bones, swelling and muscle atrophy), even when it is very successful.  If the OP said she had to rely on her knee in a life and death situation in Feb or March, I wouldn't advise having the surgery now.  

 

 

post #20 of 45

I blew out my knee in October playing lacrosse on field turf (ACL tear, partial MCL tear, menicus damage) at age 43 and my overriding goal was to be able to return to skiing at the same level as I was before (without giving up moguls, etc.).  Given my goal, my doctor thought surgery was the clearly the way to go.  I had a hamstring graft and that has had a lot of lingering soreness, but knee is coming along great.  I'm not rushing anything, but working hard in rehab, and my goal is to ski in 2013 being in much better fitness than I ever have been before. 

 

I didn't look around for a famous doctor, and maybe I should have, but was friends with surgeon (was able to see him at his house 30 minutes after injury) and he does several ACL's a week, so I chose access over someone who has operated on professional athletes.  And I am someone who go to Tiger Woods' eye surgeon if I ever did that.  You should research whether it you think a star surgeon is likely to affect your ultimate athletic outcome - I really don't know and would be interested to hear others' thoughts.

post #21 of 45

If I only had a nickel for every time a "doctor" told me something that turned out to be wrong or only partially correct.  icon14.gif Doctor Velo,  I would recommend you read through some of the bullshit many of us here have had to deal with due to our "doctors". I for one have gained tremendous information and knowledge that has helped me sort through the half-answers, standard couch potato treatment protocols and other medical advice that most doctors allot in their 10 minute, "medical practice by MRI treatment". In fact, funny  you should bring this up; I put together a self-rehab program based on info gleaned from folks here and showed it to the doctor; he was impressed and approved the regiment.

 

Personally, I think if doctors would just be honest with their patients and just tell them if they don't know how to treat athletic people. It would save a lot of us a lot of time.


Since I just had one ortho tell me he didn't think my ACL was even torn only to find out it's gone, and now he thinks I don't need surgery because there are and I am quoting the MRI report "few fibers remain in tact" and he feel my knee feels "pretty stable".  So should I listen to him or the other ortho who deals with pro- and olympic level skiers and bull riders on the pro-rodeo circuit says my knee is in no way stable enough to handle the stress's I put on it?

 

 

Quote:
Originally Posted by Snowfan View Post



icon14.gif

 

I have been mis-diagnosed and undiagnosed so many times I have lost count.  I refuse to grant automatic respect and trust to anyone just because they got through school.

 



 

post #22 of 45


Great post and such pearls of wisdom; unfortunately its posted on the internet so it has to be wrong......  (its a joke Dr. velo)

 

I do have a question: this is a bit of the "chicken and the egg".  Would you be proactive and fix the problem based upon a higher risk of re-injury for people who ski and mtn bike, trail run and such or wait till a knee that may seem good blows out?  I pose this in total seriousness.

Quote:
Originally Posted by BadGalSkier View Post

Oh my, the amount of information that gets around is crazy. At your age you should strongly consider an ACL reconstruction because there is some evidence that an ACL deficient knee may be more vulnerable to meniscus damage in the future. Also, if you are into sports, which you are, that risk is even higher. However, this scientific evidence is really not all that conclusive but rather it is more suggestive. Keep in mind that NO ONE NEEDS an ACL to survive. It's really a personal choice.

 

Even without an ACL you're going to develop arthritis and meniscus damage because it's unavoidable as we age. Again, at your age I would strongly consider a reconstruction because of the years of abuse that your knees are still going to endure. Most doctors would undoubtedly recommend  a reconstruction in a 19 year old because of the many more athletic years to come for a young person. 

 

I'm not a doctor but I have had 4 ACL reconstructions and I'm in medical school (I rarely mention this). Last year I did a million page (maybe a few less pages) research paper on the necessity of ACL reconstruction (my interest came from my own reconstructions) and in the end the evidence suggests that you go with the reconstruction if your knee is unstable. There is no documented medical rule that states you cannot ski or play other sports without an ACL. You don't need to have surgery just because you are disappointed that you have a broken body part. You need surgery if it causes you enough problems to interfere with your life. Remember, people live without gallbladders, spleens, and wisdom teeth and most of them do just fine.

 

The END

 

 

 

 



 

post #23 of 45
Quote:
Originally Posted by Finndog View Post

I do have a question: this is a bit of the "chicken and the egg".  Would you be proactive and fix the problem based upon a higher risk of re-injury for people who ski and mtn bike, trail run and such or wait till a knee that may seem good blows out?  I pose this in total seriousness.



 


FWIW, I skied some this year with my PT, a former Dutch soccer player in his 40s with many numerous surgeries to one of his knees and a PT buddy of his, a good skier in his 50s who is pretty sure he has a partially torn ACL that he is actively trying to avoid having surgery on until it is 110% necessary.  OTOH, my PT thought it was a no-brainer for me to get my completely torn ACL redone if I wanted to stay as active as I have been.   Both are intelligent guys who have seen lots of blown and repaired ACLs (and watched doctors do the operations).

 

post #24 of 45
Quote:
Originally Posted by MEfree30 View Post


agree with most of what you say in that you give a pretty balanced presentation that indicates she has a decision to be made with the scientific evidence being suggestive, but not conclusive...don't understand "The END" part??  Are you saying that is all you have to say or suggesting she needn't look further?  

 

Hopefully, more research will be done and there will be stronger evidence suggesting not only YES or NO on surgery, but what surgical methods yield the best results (with breakdowns by age, etc).  Bad doctors wouldn't want this, but being a numbers guy, what I would really like to see is a National/International database which logs info on all surgeries/major medical treatments and give the patient a way to post follow-ups/status reports (or requests certain info on a periodic basis).  Enough ACL surgeries have been performed that we should have more than just suggestive evidence as to which graft choice/surgical technique (there is more than just one being used) is best.  

 

People can point to patient confidentiality issues, but my guess is that the real thing stopping this is doctors/hospitals-  the good doctors are already busy, so there is no upside for them and the rest are concerned about the negative affect of ranking in the bottom half of results obtained.

 

 

I felt very comfortable with both my ACL surgeons going into the operation, but when consulting with the 2nd doctor who uses a different technique than the first, he said that they have had numerous friendly discussions/debates about which method is best.  If two intelligent, well educated doctors who perform hundreds of these things can't come to an agreement, how is an uninformed patient suppose to make a rational choice?      

 

In the long run, a central database is going to be a better, quicker, and more efficient way to optimize health care than trying to study things ex-post-facto, not just for ACL surgery, but for prescribed drugs and other treatments as well.     

 

I voted for surgery because she is 19 and active BUT

Have you had knee surgery?  Surgery will likely increase stability BUT surgery does trauma to the knee (including drilling holes in your bones, swelling and muscle atrophy), even when it is very successful.  If the OP said she had to rely on her knee in a life and death situation in Feb or March, I wouldn't advise having the surgery now.  

 

 


The inherit problem ACL reconstruction data is that 90% of the doctors who perform them do not do them properly (incorrect tunnel placement, impingement, etc...) If it was possible to document only reconstructions that were done anatomically, a database would be helpful. I doubt there will ever be conclusive evidence due to the fact that nearly every orthopod thinks they are capable of doing an ACL recon. This is the biggest problem with orthopedics right now. Just because certain procedures are in a surgeon's so called "scope of practice" does not mean that they should be performing them. My orthopod has told me on more than one occasion that the reason he is so backed up all the time is because he spends half his O.R. time revising poorly performed operations.   

 

A poorly reconstructed ACL is absolutely useless and often makes things worse. Many people have reconstructed ACL's that are not even functioning as the native ACL (due to poor surgical technique). In this case the person would have been better off not to even have the ACL reconstructed.

 

Sorry about "the END" thing. I'm not quite sure why I put that. Just ignore it. 

 

Finndog, 

 

If you are under the age of 30 I would strongly consider ACL reconstruction. Over age 30, it becomes more of a pros and cons situation. If I was over the age of 30 I would leave my knee alone if I was not having any problems. I'm 29 and if one of my ACL's blows again I'n not fixing it unless it becomes so unstable that I can't ski. If the muscles around your knee (quads and hamstrings) are strong enough they can compensate for the missing ACL. Anyone who tells you that you need an ACL reconstruction to prevent further damage is full of crap. There is hardly any conclusive evidence to support this. However, in an ACL deficient knee I would wear a functional knee brace when participating in sports. Again, the evidence for the use of knee braces is controversial at best but they may give a slight protective advantage and they are not harmful, so why not?

 

Likewise, hardly anyone needs a PCL reconstruction. The PCL is virtually useless and yet so many doctors tell people they need one. PCL reconstruction generally has a poor track record (due to the position of the ligament being behind the ACL) and thus should almost never be considered. 

 

 

 

 

post #25 of 45

Saying 90% of orthopedic surgeons do ACL surgeries wrong is a pretty strong claim.  But just like there are few good lawyers and many bad ones and clients can rarely tell the difference, I am sure that is true to some extent for doctors. 

 

So how does one identify a "good" orthopedic surgeon?  Surely it must be based on some outcome-based evidence and not just on who works on famous athletes (who operated on Adrian Peterson is only relevant if Adrian Peterson rationally and empirically chooses his orthopedic surgeon and, if so, how?).  Any idea what that emprical evidence is?  I haven't seen anything like that in the ACL rehab research and it's PT's who should be able to tell the difference between "good" or "bad" ACL surgeries based on outcomes, but then I'm not a PT professor (I just a professor send me ACL articles).

 

post #26 of 45

Badgirl but I am 47 and more active and in better condition than most 30 year olds. I am hearing conventional "diagnosis by couch potato" in your thinking. Whats the magic of 30? I already have had one surgery for torn meniscus and have some fraying of the horn and a buckled PCL with no intention of slowing down. THe knee is unstable and will undoubtedly wear more quickly and risk other damage to knee. So what would be the "con" to having the knee repaired vs hamering it and having to wear a brace for another 25 years? There are many here in there late 60's even early 70's out there still skiing, running and riding at a high level.  BTW- Feel free to have this discussion with Dr. Sisk, in Steamboat, he is one of the surgeons to the US ski team. I am sure you guys can have a fun discussion http://www.exploresteamboat.com/marketplace/businesses/dr-michael-sisk-orthopaedic-surgeon/

 

Quote:
Originally Posted by BadGalSkier View Post


The inherit problem ACL reconstruction data is that 90% of the doctors who perform them do not do them properly (incorrect tunnel placement, impingement, etc...) If it was possible to document only reconstructions that were done anatomically, a database would be helpful. I doubt there will ever be conclusive evidence due to the fact that nearly every orthopod thinks they are capable of doing an ACL recon. This is the biggest problem with orthopedics right now. Just because certain procedures are in a surgeon's so called "scope of practice" does not mean that they should be performing them. My orthopod has told me on more than one occasion that the reason he is so backed up all the time is because he spends half his O.R. time revising poorly performed operations.   

 

A poorly reconstructed ACL is absolutely useless and often makes things worse. Many people have reconstructed ACL's that are not even functioning as the native ACL (due to poor surgical technique). In this case the person would have been better off not to even have the ACL reconstructed.

 

Sorry about "the END" thing. I'm not quite sure why I put that. Just ignore it. 

 

Finndog, 

 

If you are under the age of 30 I would strongly consider ACL reconstruction. Over age 30, it becomes more of a pros and cons situation. If I was over the age of 30 I would leave my knee alone if I was not having any problems. I'm 29 and if one of my ACL's blows again I'n not fixing it unless it becomes so unstable that I can't ski. If the muscles around your knee (quads and hamstrings) are strong enough they can compensate for the missing ACL. Anyone who tells you that you need an ACL reconstruction to prevent further damage is full of crap. There is hardly any conclusive evidence to support this. However, in an ACL deficient knee I would wear a functional knee brace when participating in sports. Again, the evidence for the use of knee braces is controversial at best but they may give a slight protective advantage and they are not harmful, so why not?

 

Likewise, hardly anyone needs a PCL reconstruction. The PCL is virtually useless and yet so many doctors tell people they need one. PCL reconstruction generally has a poor track record (due to the position of the ligament being behind the ACL) and thus should almost never be considered. 

 

 

 

 



 

post #27 of 45

I`ve actually got some time on my hands this morning which is a wonderful thing.

 

If your knee is unstable then definitely have the surgery. Age is not an issue if your knee is preventing you from participating in the things you enjoy in life. I was using the age of 30 for someone who has a torn ACL but is asymptomatic, meaning they show no signs of instability. If you are 55, have a torn ACL and love to ski but your knee is too unstable then have surgery. If your knee is not unstable then there really is no indication that surgery is necessary. 

 

Skiing is not nearly as taxing on the ACL as cutting and pivoting sports like soccer and basketball. Many people will find that they can ski no problem without an ACL but soccer is almost impossible. So the activities you participate in also have some bearing on whether you truly need an ACL. In your case it sounds like you should go ahead and have the surgery. Of course then there is the issue of allograft vs. autograft but I`ll stay out of that for now. 

 

I agree that saying that 90% of orthopedic surgeons that do ACL`s do them wrong is a bold statement. Perhaps I should have said more like 75%. Regardless the percentage is outrageously high. Higher than it should be. However, remember that even a surgeon who only does 3 ACL`s a year and does them poorly will be included in that 75-90% so in truth the numbers really are that high. A surgeon that only does 3 a year should not be doing them in the first place.

 

On the other hand consider 5 surgeons who do ACL reconstructions. Lets say one surgeon does 100 a year (which a common for a highly skilled ACL surgeon) and does them all correctly while the other 4 do a combined 25 a year and they are done poorly. So out of 5 docs only one is truly competent in performing ACL recons. That leaves the other 80% being done at sub par levels.  

 

I`m not saying that the docs that do poor ACL`s are poor surgeons in general. I`m just saying that they are not skilled enough in performing this particular procedure. 

 

When looking for an ACL surgeon you should ask how many the doc does per year (30 should be the absolute minimum and I would still avoid them). You should be seeking a sports-specific surgeon (many do only knees). I would also ask when he last attended a conference on ACL surgery as the techniques are constantly changing. If he says 10 years ago or never run away as fast as you can. Also, put them on the spot by asking how ACL surgery has advanced or changed in the last 5 years. An experienced doc should have no problem giving you specific examples on things like fixation methods and rehab protocols.    

 

 

post #28 of 45

Well, my mother-in-law interrogated my surgeon and found out he's done about 2 ACL's a week for years, so I feel better now.  She also told him he looked too young smile.gif , but he's 40 and I am sure he was flattered.  It was funny because this all took place a few feet away while I was in a chair watching the kids play lacrosse on the same field where I had been injured a week early.

post #29 of 45
Quote:
Originally Posted by BadGalSkier View Post


The inherit problem ACL reconstruction data is that 90% of the doctors who perform them do not do them properly (incorrect tunnel placement, impingement, etc...) If it was possible to document only reconstructions that were done anatomically, a database would be helpful.


 



Quote:
Originally Posted by BadGalSkier View Post

I agree that saying that 90% of orthopedic surgeons that do ACL`s do them wrong is a bold statement. Perhaps I should have said more like 75%. Regardless the percentage is outrageously high. Higher than it should be. However, remember that even a surgeon who only does 3 ACL`s a year and does them poorly will be included in that 75-90% so in truth the numbers really are that high. A surgeon that only does 3 a year should not be doing them in the first place.

 

On the other hand consider 5 surgeons who do ACL reconstructions. Lets say one surgeon does 100 a year (which a common for a highly skilled ACL surgeon) and does them all correctly while the other 4 do a combined 25 a year and they are done poorly. So out of 5 docs only one is truly competent in performing ACL recons. That leaves the other 80% being done at sub par levels.  

 

 

 


BadGal- A lot of what you are saying makes sense, but I am going to nit-pick a few things regarding the lack of benefit of a centralized database:

 

1.  A centralized database, accessible to the public, is a great way to verify that a surgeon is as experienced as he says he is. 

2. Would help to identify surgeons who don't know how to do a particular procedure

3. Would help to identify which specific techniques work best.

4.  Using your own analysis (which intelligently differentiates between the % of surgeons doing incorrect procedures and the % of incorrect procedures, most are done correctly, but even if they were not, a database would have the above benefits (and more)

 

post #30 of 45

You are correct that a centralized database would provide some helpful information and this would be true for any surgical procedure. A database such as the one you propose would provide mostly qualitative data rather than quantitative data which is fine. However, a database that documented only anatomically correct reconstructions would be most helpful in advancing surgical techniques.

 

One other thing I wanted to mention was that there is no empirical evidence to suggest that a double bundle (meaning a separate anteromedial and posterolateral bundle) reconstruction has any advantage over a single bundle reconstruction. In fact evidence suggests that the double bundle technique may carry more risks such that the surgeon must drill 4 holes and place 4 screws instead of 2. This exponentially increases the risk of bone fracture (since the holes are drilled so close together in the femur an tibia) and infection. Also, revision surgery becomes much more difficult when you have to deal with 4 screws and holes instead of 2. Some surgeons who do double bundle recons will only do them on males because of their larger bone mass.

 

Anatomically, the ACL is 2 distinct bundles, but it has not been proven that both bundles are necessary for stability. Experiments on cadavers show some reduction in tibial translation with the double bundle technique but this has yet to show truth in live subjects.

 

The double bundle technique is something that has hardly been studied and at the moment is still experimental. It's kind of like the new ACL fad. Many surgeons refuse to do it because there is no evidence to suggest that it is worth the extra risk and difficulty. Personally, I opted against the double bundle technique because the single bundle method has such a good track record. This is not to say that the double bundle technique is bad but people getting it are really just guinea pigs. If there was convincing evidence that showed the double bundle technique to be significantly superior to the single bundle technique than I would have considered it.

 

Of course, there is always going to be compelling arguments on both sides of the fence, however, I prefer to err on the side of caution and go with what has been scientifically proven to be effective (at least in the case of ACL reconstruction).         


Edited by BadGalSkier - 1/15/12 at 9:05pm
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