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Allograft or Hamstring ACLR ?

post #1 of 23
Thread Starter 
Had the unfortunate experience of tearing my meniscus and ACL a few weeks back. This is the second time I injured this knee. 6 years ago I tore the MCL and meniscus. Had 40% of the inner meniscus removed due to that injury. Per the latest MRI results, the remaing inner meniscus is trashed and will most likely be completely removed.

As for the ACL - curious about others thoughts regarding the allograft and hamstring aclr. Have friends which have had both types of surgeries. Pretty fimilar with pros and cons of each from speaking with them and internet research. Just interested in others perspectives which may have not been brought to my attention.
post #2 of 23
Bummer. I had the exact injury 7 months ago and am making good progress and will be skiing this weekend (depending on snow of course).

My suggestion is that you let your surgeon use the technique that he feels most comfortable with and has the best outcomes with based upon the condition of your knee.

My doctor (his group are the physicians for all of the professional sports teams in Seattle) prefers to use the hamstring because it works for him. Others in his group prefer the patellar tendon while still others like the allograft. At the same time, they all adapt based upon the patient and circumstance.

At the end of the day, if you trust the doctor, go with his recommendation.

Mike
post #3 of 23
Allograft, baby! Keep all your own equipment and permanently borrow someone else's! The darn surgeons think those hammies are just extra equipment, but Ullr put them there for a reason, and you'll miss your hammie tendon when it's no longer there to decelerate your forward-moving tibia, golldurnit!
post #4 of 23
See reply #1. Each technique works well and each has happy recipients if the individual surgeon is good at it, although patellar is less popular now than in prior years.
post #5 of 23
I was just discussing this with my colleague. The hamstring method utilizing 3-4 strands is supposed to be the strongest method. Knee extension is somewhat limited following surgery.

With the allograft (cadaver) method, infection and rejection are a major concern.

The middle third of the patellar tendon, tends to fibrous over limiting knee flexion (bending) to some extent.

If it were me...probably the hamstring graft.

Look for a surgeon with freakish hygiene, the guys that wear the astronaut suits.

Try not to get caught up in the whole..."well he's the NFL's leading surgeon" thing. Not to say that those guys aren't good but, their clients are highly motivated and usually have better outcomes. This kind of distorts the results in their favor. Teaching (university)hospitals, usually have top notch surgeons. Just don't let a student do it.
post #6 of 23
Quote:
Originally Posted by Johnnys Zoo View Post
The hamstring method utilizing 3-4 strands is supposed to be the strongest method. Knee extension is somewhat limited following surgery.
Just to highlight the point that every person and every surgery is different ... I had a hamstring autograft, and I had 2 degrees of hyperextension the day after surgery. Full flexion took a while to return though.
post #7 of 23
Quote:
Originally Posted by Kuma View Post
Had the unfortunate experience of tearing my meniscus and ACL a few weeks back. This is the second time I injured this knee. 6 years ago I tore the MCL and meniscus. Had 40% of the inner meniscus removed due to that injury. Per the latest MRI results, the remaing inner meniscus is trashed and will most likely be completely removed.

As for the ACL - curious about others thoughts regarding the allograft and hamstring aclr. Have friends which have had both types of surgeries. Pretty fimilar with pros and cons of each from speaking with them and internet research. Just interested in others perspectives which may have not been brought to my attention.
Not a doctor, but been around the block a few times. I would be more concerned about losing the cartilege. Cartilege is what cushions the knee, and without it, you're asking for a lot of pain in the future. Maybe look around for a doctor that repairs cartilege instead of removing it.
As for various ACL replacements, my doctor used my Patella tendon for my replacement with excellent results. I have a lot of friends get the cadaver with excellent results, I don't know anyone that got the hamstring. The big downside of Patella is not the ACL, but where they took the patella, Even if you don't get pattella tendonitis, there's still a lot of tendon pain for a year or two. Cadaver's downside is rejection and infection, but I haven't heard of any first hand. I was told the only reason for the hamstring is the ease of harvest, but longevity and strength are questionable.
post #8 of 23
Thread Starter 
Quote:
Originally Posted by 2-turn View Post
Not a doctor, but been around the block a few times. I would be more concerned about losing the cartilege. Cartilege is what cushions the knee, and without it, you're asking for a lot of pain in the future. Maybe look around for a doctor that repairs cartilege instead of removing it.
As for various ACL replacements, my doctor used my Patella tendon for my replacement with excellent results. I have a lot of friends get the cadaver with excellent results, I don't know anyone that got the hamstring. The big downside of Patella is not the ACL, but where they took the patella, Even if you don't get pattella tendonitis, there's still a lot of tendon pain for a year or two. Cadaver's downside is rejection and infection, but I haven't heard of any first hand. I was told the only reason for the hamstring is the ease of harvest, but longevity and strength are questionable.
Yeah - believe me- Im very concerned with the prognosis of the Cartilege/meniscus. It cant be replaced and he does repair them if an option. Due to the fact that 40% was removed from a prior surgery and that it looks very bad in the most recent MRI, the Surgean believes that removal is the only option. My tennis days, at least singles which I play 3 times a week, may be limited... very depressing...


Appreciate everyones inpout regarding the aclr. This surgeon is comfortable performing both Hamsrtring and Allografts aclr. He does not do Patella. He did say that if it were him he would go Allograft. Although he also said that 2 years ago he would not do Allograft's.
post #9 of 23
Quote:
Originally Posted by faisasy View Post
Just to highlight the point that every person and every surgery is different ... I had a hamstring autograft, and I had 2 degrees of hyperextension the day after surgery. Full flexion took a while to return though.
This senario is more than a bit unusual. Since hamstrings flex the knee, and removing a piece would cause them to tighten, limiting knee extension.

Indeed during surgery and immediately post there is not much tightening YET. I once had an ortho in surgery turn and look at me and said "see it moves" while he was flexing and extending the pt's knee.

Usually after the tourniquets, compression are removed following surgery the knee swells and it moves into a slightly flexed position because of the swelling within the joint capsule.
post #10 of 23
My older son tore his ACL and damaged his miniscus in a FIS downhill when he was 15. He is now almost 22.


We went with hamstring. The surgeon who worked on him studied at the Steadman-Hawkins clinic in Vail. Streadnman is a leading innovator in knee surgery particularly for Wc ski racers and athletes.

I understand his age is a huge factor in his recovery, but he was back racing in 9 months and went on to play Varsity High School football(linebacker) and was a starting pitcher both Junior & Senior High School years. He is currently a senior at WSU and is playing intramural flag football and skis every chance he gets.

As you can see he has done extremely well with the hamstring. He did have some swelling in his knee last week and we went and saw the surgeon. After nothing showed on X-rays they decided to do an MRI which was also normal and his ACL looks great.

It was decided it was a soft tissue contusion, although he could not remeber getting hit or banging his knee on anything.

The downside of the Allograft as has been noted is infection and rejection and in particular our surgeon mentioned AIDS. ya just don't know who that piece of tissue came from for sure.

Patellar he felt was not a good option for a skier. Too many possible issues with the donor site.

A couple of key points ot his recovery!

1. ASAP PT after the injury pre-surgery

2. In a passive constant motion machine beginning the night of or the day after (I can't remeber which)surgery for about 8 hours a day and lots of ice!
post #11 of 23
Quote:
Originally Posted by Johnnys Zoo View Post

With the allograft (cadaver) method, infection and rejection are a major concern.
Can you please provide your literature documentation for the statement that this a "major concern"? (Obviously it's concerning if something should happen to you , but it sounds like this is actually VERY rare!)
post #12 of 23
"the published rate of contracting HIV from these tissue allografts is between 1 in 1.2 to 2 million"
http://www.orthoassociates.com/ACL_grafts.htm
post #13 of 23
Clearant, Inc., (OTCBB: CLRI) the developer of the patent protected CLEARANT PROCESS(R) for pathogen inactivation, announced today results from a one-year clinical evaluation of 70 patients undergoing anterior cruciate ligament (ACL) reconstructive surgery using tissue allograft implants treated by the CLEARANT PROCESS(R), a terminal sterilization technology that virtually eliminates the pathogens that can cause post-operative surgical site infections. The results in 70 patients showed that there was a 0% infection rate; these results demonstrate a far superior degree of safety for patients compared to the infection rate observed for patients implanted with currently available, non-sterile tissue allograft implants treated with low dose gamma irradiation or aseptically processed. The results announced today are consistent with the data from more than 4,000 patients implanted with soft tissue allograft implants using the CLEARANT PROCESS sterilization technology and were reported at the Annual Meeting of the American Orthopaedic Society for Sports Medicine. Of the 70 recipients whose average age was 32 years, 63 patients had excellent outcomes and only 6 had failures (8.6%); these 6 patients were considered to be unusually very active, which could explain the reason for the failures. The results were comparable to the historical average allograft failure rate of 7.3% for non-irradiated, non sterile achilles implants (Siebold, et al, Arch Orthrop Trauma Surg, 2003).
post #14 of 23
post #15 of 23
Man... chill, Thats a research study. The odds of someone actually getting this procedure done are virtually nil. I can't read the other article for some reason Its being blocked.

Maybe I should mention that some have to take immunosuppressant drugs for a while after receiving an allograft. Look that up.

This little summary from about.com, is actually pretty nice.

http://orthopedics.about.com/cs/aclr...clgrafts_2.htm
post #16 of 23
Thread Starter 
Quote:
Originally Posted by Johnnys Zoo View Post
Man... chill, Thats a research study. The odds of someone actually getting this procedure done are virtually nil. I can't read the other article for some reason Its being blocked.

Maybe I should mention that some have to take immunosuppressant drugs for a while after receiving an allograft. Look that up.

This little summary from about.com, is actually pretty nice.

http://orthopedics.about.com/cs/aclr...clgrafts_2.htm

Yes - I have already seen this site. Very good and to the point. However, two surgeons, one very well known and which a friend of mine went to, disagree with the Allograft being weaker?
post #17 of 23
There are all sorts of opinions about these surgeries. Many of them are conflicting.

I have patients that have been told misleading things. (Such as the Aids comment). I think physicians may do this to sway the patients toward a particular type of surgery.

Every so often the ACSM has been known to revise their opinions/research as well.

It is MY experience with rehabing knees, that the hamstring grafts work well with athletic type people.

The other grafting techniques can work well also.

But...when the cadaver grafts get inflammed, they are very problematic. In my experience.

The middle third of the patellar tendon techniques can have motion problems and quadriceps tracking problems. In my experience. With the continual flexion of the knee of skiing. The graft site can be irritated.

The hamstring grafts can appear unstable at first. (my opinion) I think this is because it is primarily tendon tissue, which is more flexible than ligamentous tissue. The tendon tissue is supposed to convert itself to be more like ligament over time.

The information provided ... I would select the hamstring method IF IT WERE MY KNEE.

As someone else said...I would be very concerned about the large piece of meniscus that was removed.

I have worked with some athletes that had old ACL tears and did not know it. Then, they had another knee accident, which required they had surgery. The surgeons would say hmmm....this is an old ACL tear.

FWIW...I have a torn ACL and have chosen not to have it surgically replaced. I have to work and keep my muscles strong to support the knee. I also have a torn medial meniscus. My knee has locked up on me. I manipulated the piece back and the knee has not locked since. That was over ten years ago. Perhaps someday I will chose to have the ACL replaced.

I think the responses to go with what your surgeon is good at, is a good one.:
post #18 of 23
Here are a few articles about ACL reconstruction.

These articles are from medscape.com. If they don't show up just go to the site and register. Its free.

http://www.medscape.com/viewarticle/540965

http://www.medscape.com/viewarticle/408512

http://www.medscape.com/viewarticle/515090
post #19 of 23
Thread Starter 
Quote:
Originally Posted by Johnnys Zoo View Post
There are all sorts of opinions about these surgeries. Many of them are conflicting.

I have patients that have been told misleading things. (Such as the Aids comment). I think physicians may do this to sway the patients toward a particular type of surgery.

Every so often the ACSM has been known to revise their opinions/research as well.

It is MY experience with rehabing knees, that the hamstring grafts work well with athletic type people.

The other grafting techniques can work well also.

But...when the cadaver grafts get inflammed, they are very problematic. In my experience.

The middle third of the patellar tendon techniques can have motion problems and quadriceps tracking problems. In my experience. With the continual flexion of the knee of skiing. The graft site can be irritated.

The hamstring grafts can appear unstable at first. (my opinion) I think this is because it is primarily tendon tissue, which is more flexible than ligamentous tissue. The tendon tissue is supposed to convert itself to be more like ligament over time.

The information provided ... I would select the hamstring method IF IT WERE MY KNEE.

As someone else said...I would be very concerned about the large piece of meniscus that was removed.

I have worked with some athletes that had old ACL tears and did not know it. Then, they had another knee accident, which required they had surgery. The surgeons would say hmmm....this is an old ACL tear.

FWIW...I have a torn ACL and have chosen not to have it surgically replaced. I have to work and keep my muscles strong to support the knee. I also have a torn medial meniscus. My knee has locked up on me. I manipulated the piece back and the knee has not locked since. That was over ten years ago. Perhaps someday I will chose to have the ACL replaced.

I think the responses to go with what your surgeon is good at, is a good one.:

Very fimilar with the knee locking up. My first injury - which prompted the 40% meniscus removol a couple years ago - caused the torn meniscus to lock my knee up on a regular basis. About once a month - sometime less - sometimes more - the knee would lock up and would put me down in some serious pain. I physically would have to lay down on my side wherever this occured, and painfully straghten my knee out. I tolerated this for about 1 1/2 years. When the surgeon scoped the knee at time of surgery he said that the part he removed looked like "crab meat".

Hopefuly that wont be the case this time - although the surgeons first pass via the MRI does not look good. He will scope it at time of surgery and make the final decision then...


Thanks for everyones responses and links!
post #20 of 23
Quote:
Originally Posted by mmckimson View Post
My doctor (his group are the physicians for all of the professional sports teams in Seattle) prefers to use the hamstring because it works for him.
Dr. Engman at Ballard Sports Medicine Clinic/Swedish Hospital by chance?
He replaced mine with my hamstring about 14 yrs. ago and it has been absolutely always awesome! I have never noticed any compromise in my ham. - ever! Our local MD here basically told me I was an idiot for even considering getting it replaced. Something about me not being a real athlete and it only getting prematurely arthritic anyway. All I knew was sometimes my femur would rotate on top of my knee like a gate hinge and I didn't like it at all! Ironically my other knee is getting somewhat arthritic now! (45 y.o.)
Dr. Engman checked my knee and proclaimed it was very cruciate dependant and he recommended the ham. graft as he had the best luck with it - which was fine by me as I don't like the idea of who knows who's old dead tissue being put in me anyway! Seems somehow I have picked up staph somewhere along the way anyway (I've been carved on a few times now - hospitals are great places to get infected!)
In any case, IMO, the importance of rehab and strengthening the knee can not be overstated!

Just my 02.
post #21 of 23

Hmmm.

Seems strange to me that your not even considering Patella. My Dr. (Dr. Cole) has been doing knee surgeries for 20+ years and is considered one of the best in the Midwest. We discussed all 3 options very throughly and he felt a Patella was best for me.

His decision was based on a couple of main factors:

1- I'm still very active.
2- I'm a larger person (225 pounds on a 5'11 frame).
3- My age.
4- My eagerness to return to work as soon as possible.

I believe all but the top 3 were key, and the 4th is controversial and varies greatly between patients.

Dr. Cole agrees with some who have posted here that Patella is not near as common as it once was, but Dr. Cole told me he considered Patella to still be the "Gold Standard" of ACL replacement.

Here were his reasons:

The Hamstring surgery is actually a stronger graft, however it is considered by many to be the 'weaker' of the 2 grafts between Patella and Hamstring. Why? Because the hamstring tissue although stronger, is not grafted with bone. While with the Patella graft, bone is actually fused to bone, giving stronger, more natural attachment to the knee structure.

My Dr. felt that because of my size, especially how large my lower body is (i have very strong, large legs) that messing with the Hamstring for any reason was taking unnecessary risks. He didn't see any large concerns with taking hamstring tissue, just a chance that I may have a loss of strength or flex, compared to and never equal again, to my other leg. He said for a slightly older person with a small to medium frame, he would have considered the Hamstring first.

The Cadaver surgery offers the fastest recovery, and my Dr. was not worried at all about infection or rejection as he said those are extremely rare, but was concerned about the grafts strength and longevity. According to Dr. Cole, the Cadaver graft can be the weakest graft of the 3 grafts, and can often require replacement after 10 years or so.

Dr. Cole said he used the Cadaver graft on mostly elderly people. That was his take on that procedure.

I'm not saying my Dr. is the last word on any of this, nor that my surgery was right and anyone else's was wrong. I'm just throwing my story out there to give you some more information. I did a LOT of research before even going to my Dr., that way we were able to speak on a more lvl playing field about my options. I advise you look at ALL your options of course.

By the way if you look under my name, you can follow my recovery here on the forum, as I am logging my experiences as I go along. I am 1 week removed from my Patella ACL reconstruction.

Whatever you choose to do, I wish you the best of luck friend, and a speedy, successful recovery!
post #22 of 23
Hi, I have a question re: your allograft. How long did you wait to weight-bear? I just had surgery 9 days ago w/ an ACL allograft and feel great. Doc says 25% weight-bear and my PT says to full weight-bear IF you feel comfortable, which I do. I'm only walking in the house....very short distances, am elevating my leg A LOT and doing my PT...riding the bike and doing other exercises. My gait is almost normal and I have 120 ROM. I know I need to protect my graft for the next 6 mos.
Does this sound like I'm doing the right thing? Thanks for any insight!
ReplyQuoteMulti
post #23 of 23
Hi, I have a question re: your allograft. How long did you wait to weight-bear? I just had surgery 9 days ago w/ an ACL allograft and feel great. Doc says 25% weight-bear and my PT says to full weight-bear IF you feel comfortable, which I do. I'm only walking in the house....very short distances, am elevating my leg A LOT and doing my PT...riding the bike and doing other exercises. My gait is almost normal and I have 120 ROM. I know I need to protect my graft for the next 6 mos.
Does this sound like I'm doing the right thing? Thanks for any insight!
ReplyQuoteMulti
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