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ACL Reconstruction: Questions for prospective orthopedic surgeon

post #1 of 53
Thread Starter 

I'm coming up with a list to ask the doctor about the surgery and his/her skills as an orthopedic surgeon.

 

From my background (biomechanics) and all the research I've been doing, I feel like I have a good handle on what it is all about; however, I just want to hear the OS answer the following questions.

 

  1. Show me the injury on the MRI. (Pet peeve--the orthopedic I saw only read the radiologist report and there is a lot of variability in interpretations).
  2. What can you tell me about the health of the cartilage from the MRI/X-rays? (I did not have any weight-bearing x-rays. Also questions on contralateral knee and ankle.)
  3. What graft do you prefer to use for my situation and why?
  4. When is someone a candidate for non-operative treatment and would it be just postponing the inevitable for me?
  5. Where will the surgery be performed (i.e. hospital, surgery center)?
  6. How many ACLR surgeries do you perform weekly? (I'm hoping for someone that does at least 1-2/week).
  7. What should I expect after surgery?
  • Will I have a CPM?
  • Will I use a brace post-surgery & during rehab?
  • Recovery time (start working at home vs return to work)
  • When can I start formal physical therapy?
  • What is your rehabilitation protocol?
  • How do you determine readiness to return to sports (qualitative and/or functional testing)?

    8. Why should I choose you to perform my surgery? (Great question from my physical therapist!)

    9. Should I buy an early bird season pass in April? ski.gif

 

I can deal with a little cockiness/arrogance. But I know I won't be able to deal with someone that won't take the time to answer questions or pushes me off to an assistant.

post #2 of 53

Wow, great questions.  OS in Idaho here.  I won't go into all of your questions, but just try to hit on some points.

 

First off, please don't ask your surgeon to sell himself (why should you do my surgery?).  He's not a used car salesman, don't treat him like one.  He/she is a professional, and has worked extremely hard to have the privilege to do what he/she does.  If, after talking through the procedure, you have a good understanding and trust the surgeon, then proceed.  If not, then find another surgeon.

 

Also, keep in mind, there are NO right answers to a lot of your questions.  Graft choice, fixation devices, CPMs, rehab, etc. is surgeon dependent.  We all do what we works best for us.  If there was an absolute right answer, we would ALL DO IT.  The bottom line is the surgeon uses what works best for them, and lots of different things work.

 

Going over MRI's with patients is tough.  Some really want to see it, others just see a lot of grey and black.  I agree that interpretations can vary, but not very often when it comes to ACLs.  What really matters more than the MRI, is are you having instability symptoms, and does that correlate with the exam?  Honestly, it doesn't matter what the MRI shows (in the positive).  If you aren't having symptoms, why have the surgery, right?

 

As for how many ACLs each surgeon performs, another difficult answer.  Certainly, two a year is not ideal.  However, is 20 enough? 30?  In the military, I did over 50-60 a year, now operating in a ski town, I do 20.  Does that mean I don't know what I'm doing?  I would say I do, but you might disagree.

 

Finally, release to full activities is a really controversial subject.  You are talking about full graft incorporation, and no amount  of rehab, graft choice, or fixation will change the physiology on this.  I feel very strongly that 10 months is a minimum, and prefer twelve.  There is a reason Derek Rose is waiting for the playoffs to suit up (and it's not that he can't dunk off his operative leg).  I prefer that you have 90% strength in quads and hams as contralateral side, but not an absolute.

 

Not sure any of this was helpful, but hopefully gave you a little more to think about.

post #3 of 53
I agree about the last question, I would find that a bit offensive if I was a doctor. What sort of hardwear (metal, bio absorbable, screws, endo buttons), and why? How do you determine where to drill the tunnels and place the insertions? Ideally you want someone who can explain how they try to customize the tunnels and insertions to make the reconstruction as close an anatomical match to your anatomy as possible, versus one size fits all. You can also ask double versus single bundle, although most docs still do single, and there are good arguments for both method. It can be helpful to ask if they track their graft failure rate. If allograft, you can also ask what type, since it varies. My preference for me for allograft bone-patellar-bone, but there's no right answer. You should also find out how they handle other damage that might become obvious during surgery, like meniscal damage or damage to the posterolateral corner.
post #4 of 53
Thread Starter 

My last 2 comments were tongue and cheek. That doesn't come out well over a forum.

 

Doc, sorry--I didn't mean to offend you.

 

I know that I would be asking open-ended questions that have no one answer--I want to hear the options and why. For the first OS he said, "It's not unheard for someone your age to have ACLR." (Yikes, I'm only 45.) But, I have negatves: female, older, overweight. Concerned about ability to kneel and have more pain with surgery if patellar tendon is used.

 

Valli,,

Thanks for the question about hardware, procedure, graft placement and bundling. Plus, I'm also anxious about what would happen if he found something else going on in there, how would he proceed. A worry for me it being totally non-weightbearing and not having a support system.

 

Thank you so much, Bert and Valli.

 

Still might have to as the last question--when will I be able to try the slopes gently!

post #5 of 53

As I understand it, the question about the number of specific procedures a surgeon has performed relates to experience.  How many is enough? That depends on the surgeon.  Some surgeons, though, are just starting out.  They've attended an ACL workshop in Bermuda given by a top surgeon.  Being smart, having survived medical school, and having established a boatload of professional self-confidence, they know what they need to do, but they haven't developed the thoughtless reflexes of an experienced OS -- reflexes that allow the surgeon to concentrate on variables.  

 

What you want is a guy like Bert12.  Might he make a mistake?  Of course -- every surgeon will screw up sometime in his career.   But is he likely to?   No. 

 

A friend of ours, a spine specialist in Portland, Oregon, used professional contacts at Dartmouth to get recommendations of local surgeons.  He found us a guy in town who does ACL reconstructions regularly.  My wife's surgery was a complete success. 

 

Once you've got an experienced surgeon, become concerned about follow-up PT -- that can get routine awfully fast, it seems.

post #6 of 53
Thread Starter 
Quote:
Originally Posted by lakespapa View Post

A friend of ours, a spine specialist in Portland, Oregon, used professional contacts at Dartmouth to get recommendations of local surgeons.  He found us a guy in town who does ACL reconstructions regularly.  My wife's surgery was a complete success. 

 

Once you've got an experienced surgeon, become concerned about follow-up PT -- that can get routine awfully fast, it seems.

 

I'm working on getting recommendations from other doctors.

Luckily, I do have a PT--she worked with me on back issues at a Physical Medicine and Rehabilitation clinic.

post #7 of 53
Quote:
Originally Posted by lakespapa View Post

Once you've got an experienced surgeon, become concerned about follow-up PT -- that can get routine awfully fast, it seems.

 

  A great comment / question I got yesterday was the following:

   Why do we do different activities every session, my last rehab just had me follow the circuit every time?

 

   A good PT is always assessing & modifying to ensure both progress & motivation.  If you are not getting this level of care, start looking elsewhere.

 

 

Quote:
Originally Posted by rx2ski View Post

 

Luckily, I do have a PT--she worked with me on back issues at a Physical Medicine and Rehabilitation clinic.

 

 A point of consternation with peers that I have is that some will not admit when they are not the proper "fit" either by skill, background or sport knowledge. 

 Insist that your PT is a skier & rehabs skiers.  Your knee will thank you!

 

 I would ask your OS about this as well.

post #8 of 53
Thread Starter 
Quote:
Originally Posted by iriponsnow View Post

 A point of consternation with peers that I have is that some will not admit when they are not the proper "fit" either by skill, background or sport knowledge. 

 Insist that your PT is a skier & rehabs skiers.  Your knee will thank you!

 

 I would ask your OS about this as well.

 

I'll ask him for his advice. 

 

I've known this PT (actually a DPT) for awhile and one of the things I like about her is that we don't always do the same thing. She makes sure I don't over or under do it. She knows I work my butt off with the standard exercises at home and want to reserve PT time for things I can't do at home. She assesses my progress and we do more interactive things. Also, there are no PTAs there--only PTs. I actually arrive about 20 minutes early for my appointments now to warm up on the bike and do Bosu exercises. Then I have 45 minutes with her one-on-one. 

 

She is a skier herself and a fitness trainer. I had grabbed the JOSPT article on sport specific rehab for Alpine Skiing and return to sports and she wanted to take a look at it. It's always nice to have the PMR docs associated with that clinic readily accessible on site, if needed.

 

I have found another place for down the road that offers a ski conditioning with knee injury prevention--all ATCs, PTs, certified trainers, etc..

 

As always, I appreciate your advice. I'm glad we have a PT on the board.

post #9 of 53
Quote:
Originally Posted by iriponsnow View Post
. . .

 A point of consternation with peers that I have is that some will not admit when they are not the proper "fit" either by skill, background or sport knowledge. 

 Insist that your PT is a skier & rehabs skiers.  Your knee will thank you!

. . .

In this case, rx2ski is lucky that she lives near big ski mountains so finding a PT who skis is not that hard.  For those who live in the flatlands, still possible to get good rehab if the PT is willing to listen and do a little research about what helps for ski conditioning.

 

I liked my PT because he was quite willing to give guidance and suggestions for what I could do on my own after a certain point.  Note that I did PT as a coper who opted against surgery.  I also found a personal trainer willing to learn what helps a skier, as well as someone finishing up knee rehab.

post #10 of 53
Thread Starter 
Quote:
Originally Posted by marznc View Post

In this case, rx2ski is lucky that she lives near big ski mountains so finding a PT who skis is not that hard.  For those who live in the flatlands, still possible to get good rehab if the PT is willing to listen and do a little research about what helps for ski conditioning.

 

I liked my PT because he was quite willing to give guidance and suggestions for what I could do on my own after a certain point.  Note that I did PT as a coper who opted against surgery.  I also found a personal trainer willing to learn what helps a skier, as well as someone finishing up knee rehab.

 

A benefit of living in the Boulder/Denver area!

 

Since I have my own numbers/technical/measurement slant, I might go to another clinic that has a KinCom just for some strength testing pre-surgery. That way I'll know my starting point, quad/ham ratio, and comparison to my good leg and get retested 8-9 months after surgery--before I try to ski again. Gosh, I'm a geek!

post #11 of 53

The only real question of relevance is how many do you do a week?

 

Frequency is the single biggest metric of successful outcomes for surgeons.

 

The number you are looking for is 10 a week or more. 1 or 2 a week is a hobbyist or semi-retired.

 

And go for the allograft (cadaver tendon) vs. the painful weakening of your hamstring for an autograft (piece of your own tendon).

post #12 of 53

Sorry to respectfully disagree, but on this you are way wrong (and not by a little).

 

Nobody, and I mean nobody, is doing ten ACLs a week.  Their residents and fellows might be doing them in the surgeons name (at a training program).  A private practice sport guy might do four to five in a week when busy. Think about it.  Ten a week is 500 a year.  That is more cases than the average orthopedic surgeon performs in TOTAL.  Come on.

 

Allografts.  Admittedly a popular choice.  The problem is that the failure rate is significantly higher (depending on the study, as high as 20%).  Not a wrong choice, just a bad choice in my opinion.  The data shows that in the short term, allograft patients do better (first 6 - 12 weeks).  By 6 months, not so much.  By 24 months, failure rate is higher in allograft group in every study.  Tell me which one you want in your own knee.

 

Really not trying to flame, but it does get a little old reading things on this and other boards that really aren't based on reality.

post #13 of 53
Thread Starter 

I looked at how the studies classifed low, medium, and high volume surgeons. But that is definitely not the only factor. I'd much rather have a surgeon with 10-15 years experience doing medium or low volume than a "high" volume surgeon that's only been out of medical school a few years.

 

I've had surgery a couple of times going straight from the ER. It's actually odd to have a choice. But seeing how my luck of the draw wasn't the best when I broke my ankle, I'm glad this isn't how it was in the 80s where the normal routine was to get you into the OR very quickly.

post #14 of 53
Thread Starter 
Quote:
Originally Posted by Eagles Pdx View Post

The only real question of relevance is how many do you do a week?

 

Frequency is the single biggest metric of successful outcomes for surgeons.

 

The number you are looking for is 10 a week or more. 1 or 2 a week is a hobbyist or semi-retired.

 

And go for the allograft (cadaver tendon) vs. the painful weakening of your hamstring for an autograft (piece of your own tendon).

 

I'm going for quality over quantity. Yes, I have an idea of numbers in my head, but years of experience is just as important.

 

For a surgeon to be doing 10/week would mean he/she would never have any time to actually see patients to assess them before surgery and do any follow-ups. 

 

If all things were equal, I'd jump at the chance for an allograft. But, allografts do have a higher failure rate. Nobody looks forward to pain. But it's kind of a cost/benefit analysis. My MRI shows a lot of scarring and I've never had surgery. Going into surgery the OS might have one plan, but once he gets in there, who knows what he might find.

 

I've actually known people that had the autograft from their patellar tendon come from the opposite knee since it was their second surgery--that had to hurt.

 

Ironically, I found out via FaceBook that two friends I used to compete moguls with in the late 80s have also blown their knees within the last month. We were a few that had escaped knee injuries back in the day.

 

I'm just hoping to get this all worked out to have surgery in April and work towards a goal of groomers in January 2014. My 2014 New Year's Resolution will be to give up moguls! Those dang things just call to me!

post #15 of 53
Quote:
Originally Posted by rx2ski View Post

 

I'm going for quality over quantity. Yes, I have an idea of numbers in my head, but years of experience is just as important.

 

For a surgeon to be doing 10/week would mean he/she would never have any time to actually see patients to assess them before surgery and do any follow-ups. 

 

If all things were equal, I'd jump at the chance for an allograft. But, allografts do have a higher failure rate. 

 

Number of surgeries, frequency, is the major factor.  "Quality" is impossible to know as there is no compilation of stats.

 

New docs starting out have been through years of residency, have the stats on latest techniques and know the latest tools.  Old school is good but new school has advantages also.

 

10 a week is light.  Takes a good surgeon, about an hour for an ACL, 5-10 a day on their surgery days is typical for good ortho's.   Two days surgery, three days in the office for new and followups.

 

Allograts increased failure rate is due to the excellent results, people feel better sooner and put stress on it too soon, starting athletic activity, before the tissue has a chance to grow around it and the metal implants that secure it.  It is also typically used in younger patients to spare the other tendons that are cut in autograft procedures and younger patients push them early.

post #16 of 53

I had the autograft hamstring and it was not a big deal.  I had one major cramp during rehab exercises.  The PT massaged it out the next time I saw her, and I eased off on those exercises for a few days.  It hurt a lot for a few hours and hurt some for about 4 days.  Not a deciding factor in the big picture.

 

My opinion is that you should go with whatever your surgeon thinks is the best choice.  You want him doing what he believes in and is best at.  If  you have strong opinions on graft type that don't match your surgeon's, get a dfiferent surgeon.

post #17 of 53
As far as the stats on allograft failure, my understanding is a lot of it depends on age and activity level, as well as a willingness to carefully follow rehab protocol. One of the top doctors I met with says he only does allografts now, and he treats a lot of US Ski team athletes and professional snowboarders. Often times an allograft procedure allows you to feel better faster, and then young athletes in particular will try to return to high demand activities too quickly. He said if they follow the correct rehab protocol he has not found graft failure rates to be higher with allograft. The other factor is that with each decade of age your own tissue has less resilience, so different doctors have different recommendations for switching to allograft, although if you are 40 or over they all seem to recommend allograft. As far as total number, I've read studies saying that doctors develop more competence after they've done at least 60 ACL reconstructions, but I wouldn't care if they are doing 2 or 10 per week. They are probably doing other procedures ss well, and you want them to spend some time with you. Surgery is hard work, and most docs I've met do 2-3 days of surgery and use the other days for patient care.
post #18 of 53
Quote:
Originally Posted by valli View Post

 ...and he treats a lot of US Ski team athletes and professional snowboarders.

 

Haven't heard much about snowboarders tearing ACL's. It's not in the mechanics of snowboarding the way it is in the mechanics of skiing.

post #19 of 53
Quote:
Originally Posted by Eagles Pdx View Post

 

Haven't heard much about snowboarders tearing ACL's. It's not in the mechanics of snowboarding the way it is in the mechanics of skiing.

Not as much, but it certainly happens.

post #20 of 53
Quote:
Originally Posted by segbrown View Post

Not as much, but it [ACL tears snowboarding] certainly happens.

 

I wonder how since the snowboard design acts almost like a preventer for the mechanics of ACL tear.  Possibly a collision where someone hits them exactly in the back of the knee?

post #21 of 53
The surgeon I met with had an X Games snowboarder who crashed and tore her ACL and posterolateral corner, and was back winning at the XGames less than 10 months later. She has her story up on his web page.
post #22 of 53
Quote:
Originally Posted by valli View Post

The surgeon I met with had an X Games snowboarder who crashed and tore her ACL and posterolateral corner, and was back winning at the XGames less than 10 months later. She has her story up on his web page.

 

I'm sure crashing into things at high speed or from heights in extreme competition like X Games could result in an ACL or any number of injuries. It is not common in snowboarders, almost exclusively skiers.

post #23 of 53
Thread Starter 
Quote:
Originally Posted by Eagles Pdx View Post

 

I wonder how since the snowboard design acts almost like a preventer for the mechanics of ACL tear.  Possibly a collision where someone hits them exactly in the back of the knee?

 

Generally, it's from collisions or landing air in the back seat. The other primary time is getting off the lift--if you have only one boot in and you have a problem getting out of the unloading zone you might have the snowboard steer the other way. Snowboarders are more likely to injure wrists, head, and shoulders.

post #24 of 53
Quote:
Originally Posted by rx2ski View Post

 

Generally, it's from collisions or landing air in the back seat. The other primary time is getting off the lift--if you have only one boot in and you have a problem getting out of the unloading zone you might have the snowboard steer the other way. Snowboarders are more likely to injure wrists, head, and shoulders.

 

Snowboarder landing in back seat won't tear an ACL, the legs are on the "wrong" position on a snowboard to create than kind of torque on the knee.

 

Indeed, wrists, shoulders or head are the most common snowboarder injury.

post #25 of 53
Thread Starter 
Quote:
Originally Posted by Eagles Pdx View Post

 

Snowboarder landing in back seat won't tear an ACL, the legs are on the "wrong" position on a snowboard to create than kind of torque on the knee.

 

Indeed, wrists, shoulders or head are the most common snowboarder injury.

 

Landing in the back seat from a large air onto the flats may cause it.

post #26 of 53
Quote:
Originally Posted by rx2ski View Post

 

Landing in the back seat from a large air onto the flats may cause it.

 

No...the mechanics just aren't there.  Snowboarder will land on his butt, the bindings rotate, the board does not create the leverage on the knee.  It's why ACL's are all from skiing.

 

The sole example was a boarder in a race who crashed into the netting or other race equipment on the course.  I'm sure it is possible to be on a snowboard and get an ACL injury but it will not be from mechanics of the snow board.  Again this is why we see no snowboarder ACL's and it is a common injury for skiers.

post #27 of 53
Quote:
Originally Posted by Eagles Pdx View Post

 

No...the mechanics just aren't there.  Snowboarder will land on his butt, the bindings rotate, the board does not create the leverage on the knee.  It's why ACL's are all from skiing.

 

The sole example was a boarder in a race who crashed into the netting or other race equipment on the course.  I'm sure it is possible to be on a snowboard and get an ACL injury but it will not be from mechanics of the snow board.  Again this is why we see no snowboarder ACL's and it is a common injury for skiers.

 

I realize you are being contrary just because you're an ass and that seems to be your MO on this board, but for others who might be reading: ACL injuries happen, but not often, and they do happen on bad landings. One of my best friends tore hers at Steamboat about 4 years ago. 

 

Knee injuries, more specifically Anterior Cruciate Ligament (ACL) tears, are much less common in snowboarding than in alpine skiing.  However, an ACL injury is a season-ending injury and the most common injury requiring surgery in snowboarding.  ACL injuries are more prevalent in advanced/expert level snowboarders and are most often the result of a fall after a jump.  The mechanism of injury for ACL tears in snowboarding is different from alpine skiing.  ACL tears in snowboarding are thought to be due to a “quadriceps induced” injury, where there is an imbalance between the quadriceps and hamstrings.  This can occur when you land flat off of a jump without much of a bend in the knee.  Therefore, properly scoping out the landing before hitting a jump or a cliff, as well as adding hamstring strengthening to your dry-land training can go a long ways in preventing ACL injuries in snowboarding.  Additionally, undergoing jump and landing retraining with a licensed physical therapist can further prevent injury.

http://excelptmt.com/2011/01/acl-injury-prevention-for-snowboarders/

 

 

Wrist injuries accounted for 27.6% of all snowboard injuries and 2.8% of skiing injuries, and ACL injuries composed 1.7% of all snowboard injuries and 17.2% of skiing injuries.

http://ajs.sagepub.com/content/early/2012/01/19/0363546511433279.abstract

post #28 of 53

as discussed in another thread (with links to Steadman studies)  this info is not exactly accurate in the sense that a high % of the failures are due to improper technique by the surgeon and lack of experience;  nor does it address double bundles in the study.  Another key factor is the age of the patient. Allografts are not recommended for young highly active patients. I believe my OS does not use them on very active patients below 30.   the gap in time from 6 months to two years is a clue here. 6 months?  really?  At 6 months an improperly attached AC is not experiencing the loads and stresses they will experience one rehab is complere.  Lets look at the failure rate of properly performed surgeries at a year and out. If a ACL is reattached at the incorrect angle or not securely attached, it will fail for sure under stress.  You Also have to look at how a failure is determined. I think part of the flaw in the study is that unless someone has exploratory surgery it is extremely difficult to determine if the allograft itself or the surgery or if the patient simply stressed and detached the ACL again. It is not accurate to simply say that if a patient detaches their ACL its a failure due to an Allograft vs a Autograft alone. If it was that clear-cut, it wouldn't be used so commonly. Both my OS (who is a surgeon for the US ski team and pro football team) and my PT who is a ACL specialist feel a double bundle Allo when properly installed is strong and durable.  

 

Also you would have to look at the rehab history of the patient and if they successfully completed rehab. Many failures are due to people who don't put the time and work into their rehab. IF a person is not committed to the work; don't do the surgery

 

Have your ACL done by an experienced surgeon who does a couple hundred per year and uses the correct drill angles and attachment protocols and the failure rate is no more or only marginally more than any other methodology.  You also failed to mention that a double bundle is demonstrably more stable than singles. The bottom line is that any time any surgery is being done by a surgeon who does literally 5-10 per year (which is the average!), the failure rate will be higher; find an experienced surgeon with a proven track record.  Ask the right questions, how many surgeries has he/she done, what is their failure rate what protocols are they using, etc.  Dont blame the allograft, blame the surgeon/pt and/or patient

Quote:
Originally Posted by Bert12 View Post

Sorry to respectfully disagree, but on this you are way wrong (and not by a little).

 

Nobody, and I mean nobody, is doing ten ACLs a week.  Their residents and fellows might be doing them in the surgeons name (at a training program).  A private practice sport guy might do four to five in a week when busy. Think about it.  Ten a week is 500 a year.  That is more cases than the average orthopedic surgeon performs in TOTAL.  Come on.

 

Allografts.  Admittedly a popular choice.  The problem is that the failure rate is significantly higher (depending on the study, as high as 20%).  Not a wrong choice, just a bad choice in my opinion.  The data shows that in the short term, allograft patients do better (first 6 - 12 weeks).  By 6 months, not so much.  By 24 months, failure rate is higher in allograft group in every study.  Tell me which one you want in your own knee.

 

Really not trying to flame, but it does get a little old reading things on this and other boards that really aren't based on reality.


Edited by Finndog - 3/25/13 at 11:13am
post #29 of 53
Thread Starter 
Quote:
Originally Posted by segbrown View Post

 

Wrist injuries accounted for 27.6% of all snowboard injuries and 2.8% of skiing injuries, and ACL injuries composed 1.7% of all snowboard injuries and 17.2% of skiing injuries.

http://ajs.sagepub.com/content/early/2012/01/19/0363546511433279.abstract

 

Thanks, I wasn't in the mood to dig out the studies to support this. Although rare, it can definitely happen.

post #30 of 53
Quote:
Originally Posted by segbrown View Post

ACL injuries composed 1.7% of all snowboard injuries

 

As you see, the mechanics are just not in play in snowboarding, extremely low injury rate and as your reference noted limited to advanced expert end of the spectrum.

 

My original comments seemed to parallel your reference.

 

 

Quote:
 
Originally Posted by Eagles Pdx 
 
I'm sure crashing into things at high speed or from heights in extreme competition like X Games could result in an ACL or any number of injuries. It is not common in snowboarders, almost exclusively skiers.
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