EpicSki › The Barking Bear Forums › Ski Training and Pro Forums › Fitness, Injury, and Recovery › ACL Reconstruction: Patellar or Hamstring Graft?
New Posts  All Forums:Forum Nav:

ACL Reconstruction: Patellar or Hamstring Graft?

post #1 of 54
1/28/09 at 5:09pm
Thread Starter 
Just got my first serious injury ever, a complete tear of my Right ACL after 5 awesome days of skiing Aspen/Snowmass . Was coming through some steep trees and didn't hold the landing of a quick turn jump and fell down the slope, hyper-extending the knee. I know that I jumped and didn't make it, but I dont know exactly how I inured it.

Getting to see my MRI results tomorrow with my Ortho Doc. My PT from the same clinic saw the MRI and said it was a complete tear with no damage to anything else in the knee, which I haven't read is common. Can someone explain how that happens?

Anyway, since surgery is most definitely needed at this point, I wanted to see if there's any preference between getting an autograft from the Patellar Tendon or from the Hamstring Tendon.

My PT told me my doc prefers to do Patellar Tendon, being the majority opinion these days. I've read the pros of being bone-to-bone graft, leading to quicker and simpler recovery, with the major con for me being pain behind the knee cap while kneeling; seems like 1 in 2 chance of that developing. Can you verify this?

Besides a passion for skiing, I'm a motorhead and spend a lot of time in the garage wrenching of my motorbikes and car and there's a lot of kneeling involved. Also, I'm planning for an extended motorcycle trip through South America and in order to repair tires in the wild, force from kneeling is integral to the process . So, I'm thinking getting a Patellar Tendon is really going to bother me for my motorcycling.

Regarding the Hamstring, while it's pros are that it performs just as well or better than the Patellar, while having higher tensile force, the major cons are that it is a tissue to bone healing for the graft and devices are needed to anchor it.

Do you know of any other cons to Hamstring tendon grafts? Want to see if I should just stick to Patellar or really pursue the Hamstring.

I read that laxity over time was an issue earlier, but now they've got that figured out with the quad pre-tensed design.

What do you think are some of the better anchors for this kind of graft?

Some pictures:
Getting ready to ski some trees near the Buckskin run in Snowmass:


At Highland Peak, after having hiked to the summit to ski the awesome Highland Bowl, whoop:


Frame capture of the area that I fell; the International run area near Ruthie's Lift on Aspen Mtn:


I shot tonnes of video of me and my French skiing buddy and I'm going to compile and post them here along with a full Trip Report. This is just a quick clip to show the area that I fell in:


I'm know I should be good to go for another epic ski trip next year (maybe Jackson Hole), but this year is sadly over too soon. Hoping it doesn't interfere with the whole motorcycling season coming up.

Thanx for any input
Reply
post #2 of 54
1/28/09 at 5:39pm
Hamstring or Patellar? That is a good question. It all depends on your Doc. We have one of the best ortho docs in the country here (Mark Aiken) and he perfers the Patellar. Others will disagree. Your other question, which goes along with the Patellar tendon surgery about knelling on your knee. It will be awhile, it stays pretty tender. Also kinda numb. I'm almost a year out on mine and still am alitttle hesitant to put full weight on it. PM me if you want to discuss more. You will do fine and will figure out ways around the knee to do your work.
Reply
post #3 of 54
1/28/09 at 5:52pm
I'm 9 1/2 months since Hamstring Autograft. So far this year I've skied 7 days...hammered hard, skipping lunch most days. Going back asap.

My Doc partners with a US Ski Team Doc...they do ONLY hamstrings...I hope that tells you something.

Tiger Woods...hamstring.

No way would I ever consider anything but a hammie. The hardware is exotic...very expensive, like 3g's per bolt. NO PROBLEMS either with the knee or the hamstring since surgery.

Hope this helps a bit. I wish you well.
Reply
post #4 of 54
1/28/09 at 6:17pm
Allographt is what I just had done 3 weeks ago. faster recovery and just as good as anything else
Reply
post #5 of 54
1/28/09 at 6:56pm
Quote:
Originally Posted by JamminSki View Post
My PT from the same clinic saw the MRI and said it was a complete tear with no damage to anything else in the knee, which I haven't read is common. Can someone explain how that happens?
It happens all the time and it's really good news for you. Most often the skier is in the back seat falling in a way that emulates the drawer test orthos do. Then all it takes is for a ski to catch an edge causing a little twist and the ACL tears.

Any time a skier falls on their rear-end in steep moguls they should be thankful they didn't tear an ACL.

Quote:
Anyway, since surgery is most definitely needed at this point, I wanted to see if there's any preference between getting an autograft from the Patellar Tendon or from the Hamstring Tendon.
I've had a patellar tendon autograft and while my knee repair is perfectly stable and strong now, I had some complications including pretty severe tendonitis in my patellar tendon that I still have to this day to some degree. It's still slightly tender after 10 years and I can't really kneel on it.

FOR ME, I'd never have a patellar tendon autograft again.
FOR ME, I'd do an allograft, which is from a cadaver.

BUT, I'M NOT A DOCTOR and you should make darn sure you pick the most skilled surgeon possible, preferably one who is a knee specialist as opposed to a run-of-the-mill ortho (no offense intended). And once you make that pick you should probably follow his advice.

Quote:
... Patellar Tendon, being the majority opinion these days.
Up here most ACLs are done as allografts.

Good luck and sorry about your injury...
Reply
post #6 of 54
1/28/09 at 7:10pm
Quote:
Originally Posted by breckview View Post

Up here most ACLs are done as allografts.

Good luck and sorry about your injury...
ditto thats why I went that route
Reply
post #7 of 54
1/28/09 at 7:21pm
I'm know the technology has greatly changed, but 8 years out with a patellar graft, everything is stable but it is still "weird" kneeling. There's a dead spot and it's not good.....
Reply
post #8 of 54
1/28/09 at 7:30pm
Quote:
Originally Posted by breckview View Post
I've had a patellar tendon autograft and while my knee repair is perfectly stable and strong now, I had some complications including pretty severe tendonitis in my patellar tendon that I still have to this day to some degree. It's still slightly tender after 10 years and I can't really kneel on it.
I'm about 6 years out from patella tendon ACL replacement, and have been kneeling on it for 5 1/2 years. There is no pain from kneeling, only a numb spot that eventually shrinks to about the size of a quarter and can be ignored. Usually, the ACL is fine, but the pain from where they remove the patella tendon is the issue. Ideally, with proper PT, back to skiing hard at 6 months out, I was at 5 1/2 months, but had patella pain for that entire year. though my wife had the same surgery and had NO ill affects after PT. From the second year until now, I've had no knee pain at all.

Quote:
FOR ME, I'd never have a patellar tendon autograft again.
FOR ME, I'd do an allograft, which is from a cadaver.
I was told that the hamstring was used purely because of the ease of harvest for the surgeon. It is not as strong, not as precise and it's longevity was questionable.
If I had to do it again, I would go allograft also. If that was not possible, or my surgeon of choice didn't do cadaver, I would use my patella tendon again.

Quote:
BUT, I'M NOT A DOCTOR and you should make darn sure you pick the most skilled surgeon possible, preferably one who is a knee specialist as opposed to a run-of-the-mill ortho (no offense intended). And once you make that pick you should probably follow his advice
.

good advice, plus pick out a good physical therapist and schedule your PT before the surgery and good luck.
Reply
post #9 of 54
1/28/09 at 7:33pm
My hamstring procedure has been great...12 years now. This surgery was relatively new then. Do your research, get comfortable with a doc and personally with the procedure. Be confident you've chosen the right procedure (they're probably all good) and the doc. Mentally you want to be "right" on the backside. I think it's key to be confidnet during rehab and for that first time you ski without the brace.
Reply
post #10 of 54
1/28/09 at 9:08pm
Thread Starter 
Quote:
Originally Posted by breckview View Post
It happens all the time and it's really good news for you.

FOR ME, I'd never have a patellar tendon autograft again.
FOR ME, I'd do an allograft, which is from a cadaver.
Ok, good to know snapping the ACL only is common.
Yeah, if you're still having kneeling issues after 10 years, don't think I can go Patellar Autograft route.

Regarding Allografts, just the fact that there's a chance of disease infection (worst case HIV), even if it's only 1 in 2 million chance, I think that's still too high of a chance for me to gamble on my body. I know there's great success rates in allografts, and have been reading about irradiation techniques and improving sterilization and pre-screening of donor for diseases, etc, but all the articles still seem to say that there's no one comprehensive way to eradicate infections from a donor tendon. But I guess I need to research more into allografts.

But yeah, the flip side is dealing with the possible pain from a Patellar graft or the many possible unknowns in a Hamstring graft.

Actually I read that harvesting the Hamstring tendon is more tricky than the Patellar tendon, due to possible damage to the other Hamstring tendons in the area.
Reply
post #11 of 54
1/28/09 at 9:11pm
Thread Starter 
Quote:
Originally Posted by 2-turn View Post
I'm about 6 years out from patella tendon ACL replacement, and have been kneeling on it for 5 1/2 years. There is no pain from kneeling, only a numb spot that eventually shrinks to about the size of a quarter and can be ignored.

I was told that the hamstring was used purely because of the ease of harvest for the surgeon. It is not as strong, not as precise and it's longevity was questionable.

good advice, plus pick out a good physical therapist and schedule your PT before the surgery and good luck.
Good to hear that. Yeah, you must be the 50% that doesnt have any knee pain If I go this route, I'm definitely hoping to add to this side of the statistic.

Yup, already going to PT and know the importance of going in prepared for the surgery to have better success in rehab.

Quote:
Originally Posted by EWA113 View Post
Mentally you want to be "right" on the backside. I think it's key to be confidnet during rehab and for that first time you ski without the brace.
Yeah I know being mentally sure of the decisions made are important in the final outcome after rehab. Good to hear the hammie is doing well.
Reply
post #12 of 54
1/29/09 at 11:48am
Thread Starter 
Can someone recommend an ACL reconstruction specialist in the Chicago area who does both Patellar and Hamstring grafts?

My regular ortho referred me to someone who does both, but he's not in-network, so trying to figure out how to find other specialists in this area.
Reply
post #13 of 54
1/29/09 at 2:42pm
YES! (Maybe not patellar though)

Num had hers done in that neighborhood....allow me to search awhile and/or PM Num for a name.
Reply
post #14 of 54
1/29/09 at 3:09pm
Quote:
Originally Posted by JamminSki View Post
Ok, good to know snapping the ACL only is common.
Yeah, if you're still having kneeling issues after 10 years, don't think I can go Patellar Autograft route.

Regarding Allografts, just the fact that there's a chance of disease infection (worst case HIV), even if it's only 1 in 2 million chance, I think that's still too high of a chance for me to gamble on my body. I know there's great success rates in allografts, and have been reading about irradiation techniques and improving sterilization and pre-screening of donor for diseases, etc, but all the articles still seem to say that there's no one comprehensive way to eradicate infections from a donor tendon. But I guess I need to research more into allografts.

But yeah, the flip side is dealing with the possible pain from a Patellar graft or the many possible unknowns in a Hamstring graft.

Actually I read that harvesting the Hamstring tendon is more tricky than the Patellar tendon, due to possible damage to the other Hamstring tendons in the area.
Your chances are probably higher of dying of infection as a result of the extra incision when going patellar or hs.
I own a PT clinic and treat acl's all the time. Go allograft.
The healing is much much much faster. No loss of strength. Faster rehab.
Reply
post #15 of 54
1/29/09 at 3:10pm
Quote:
Originally Posted by JamminSki View Post
Can someone recommend an ACL reconstruction specialist in the Chicago area who does both Patellar and Hamstring grafts?

My regular ortho referred me to someone who does both, but he's not in-network, so trying to figure out how to find other specialists in this area.
From my experience (surgery in Nov '08), many Docs seem to have their own personal preference...I ended up picking my Doc because he was the only one in the area who does double bundle reconstruction (which intuitively seems superior to me than the traditional single graph technique although there is not long term data yet) and I felt comfortable with him.
Reply
post #16 of 54
1/29/09 at 3:23pm
Quote:
Originally Posted by MEfree30 View Post
From my experience (surgery in Nov '08), many Docs seem to have their own personal preference...I ended up picking my Doc because he was the only one in the area who does double bundle reconstruction (which intuitively seems superior to me than the traditional single graph technique although there is not long term data yet) and I felt comfortable with him.
Double bundle is very new. They started that technique because the acl is actually a "double bundle". Please post you progress from time to time. Haven't treated any yet myself. The thinking is you get more directional stability but from what I've read and it's not that much you aren't any less likely to re-tear. You may limit excessive wear though. But who knows? I guess we will in the years to come.
What graft did they use?
Reply
post #17 of 54
1/29/09 at 4:30pm
oops
Reply
post #18 of 54
1/29/09 at 4:34pm
In my case...QUAD was done.

A relatively small segment of hamstring tendon was excised, it is then surgically sliced in two, folded over and cut at the ends.

This equals 4 strands of hamstring tendon, which are then sutured together to make one.

The 4 segmented tendon is threaded through the tunnel and secured in place.

Over time---8 months to 24 months...the tendon fuses into a single, living, stout LIGAMENT.

Those are laymans terms...its working beyond my wildest dreams for me.

As for the hamstring tendon...no apparant change. It recovers from the harvest just fine.

No bones sawed on, no bones aching from the sawing.
Reply
post #19 of 54
1/29/09 at 4:59pm
Quote:
Originally Posted by ski=free View Post
Your chances are probably higher of dying of infection as a result of the extra incision when going patellar or hs.
I own a PT clinic and treat acl's all the time. Go allograft.
The healing is much much much faster. No loss of strength. Faster rehab.
Ditto the allograft. I chose cadaver because there's that much less to heal. Of course, I was 62 years old when I had it done (5 years ago), and my surgeon said that at my age I'd die of something else first even if I caught a virus from the donor! I did my PT RELIGIOUSLY, including a passive motion machine that I began at 6 a.m. the morning after late afternoon surgery, and after February operation, I was on my road bike by May, and skiing in December.
Reply
post #20 of 54
1/29/09 at 5:18pm
I've got two patellar grafts, 8 and 12 years out. No more numb spots, kneeling is fine but was weird for awhile - like a few years. Really, though, what's the big deal with kneeling? Get kneepads and it is not a problem.
Btw, arthroscopic meniscus work is worse in the long term. Not much you can do about it, but a "clean up" means they're removing stuff that was good for you before. For me it was even worse in the first week which is a little bizarre.
Maybe soon they'll invent the "tune up" or "lube job" that adds beneficial material.
Reply
post #21 of 54
1/29/09 at 5:26pm
Quote:
Originally Posted by ski=free View Post
Double bundle is very new. They started that technique because the acl is actually a "double bundle". Please post you progress from time to time. Haven't treated any yet myself. The thinking is you get more directional stability but from what I've read and it's not that much you aren't any less likely to re-tear. You may limit excessive wear though. But who knows? I guess we will in the years to come.
What graft did they use?
I haven't treated any double bundles either but we did have an inservice from an OS on a research study they did on double vs single bundle ACL reconstruction. Their study showed no difference in functional outcomes between the 2. What have you read?
Reply
post #22 of 54
1/29/09 at 5:39pm
Quote:
Originally Posted by Bucki78 View Post
I haven't treated any double bundles either but we did have an inservice from an OS on a research study they did on double vs single bundle ACL reconstruction. Their study showed no difference in functional outcomes between the 2. What have you read?
Exact same. From what I remember there may be a tad more rot stability or less rot laxity to be more specific but functionally there seems to be no difference and thats the name othe game right?
Reply
post #23 of 54
1/29/09 at 6:25pm
Hey Jammin, sorry to hear your situation. I missed this thread until pointed this way by Snowfan. I live in Chicago and just this summer had an ACLR using a 4 strand hamstring (and gracilis) autograft.

My doctor, who I'd definitely recommend, is named Chadwick Prodromos. He runs an ortho clinic, the Illinois Sports Medicine and Orthopedic Clinic in Glenview and also has an office in Chicago. He only does hamstring grafts, and on the site he explains his reasoning, as well as comparing the various types of grafts.

He's full of information and dedicated to passing it on to patients, a trait I really appreciate in a guy I pay to cut me open Here's the patient's comprehensive guide to the acl and here's the main knee page with links to various bits of information.

Feel free to pm me or ask here if you have any questions.
Reply
post #24 of 54
1/29/09 at 7:03pm
Quote:
Originally Posted by JamminSki View Post
Can someone recommend an ACL reconstruction specialist in the Chicago area who does both Patellar and Hamstring grafts?

My regular ortho referred me to someone who does both, but he's not in-network, so trying to figure out how to find other specialists in this area.
Check out the Midwest Ortho group at RUSH. They do great work on all levels of patients. I had a significant procedure done in Sept 07 and I was so pleased with my MD. He is a world specialist in his field. I would look into them.
You can PM me with questions.
Reply
post #25 of 54
1/29/09 at 11:10pm
Nurseflash, glad to hear you had a good experience with them. When I was trying to pick an ortho, the final two I was deciding between were Charles Bush-Joseph (with Midwest Orthopedics at Rush) and my current ortho (mentioned above). Bush-Joesph seemed to be an excellent ortho
Reply
post #26 of 54
1/30/09 at 12:04am
Here's a summary taken from a recent review article: Clinical outcomes of allograft versus autograft in anterior cruciate ligament reconstruction.
Baer GS, Harner CD.
Clin Sports Med. 2007 Oct;26(4):661-81. Review.

BPTB=patellar



ACL reconstruction is one of the procedures most commonly performed by sports medicine physicians today. Good-to-excellent results in terms of knee stability, patient satisfaction, and return to athletic activity are reported commonly to be around 90% [107]. Although BPTB grafts traditionally have been considered the reference standard, donor-site morbidity has led to an interest in alternative graft choices. Commonly used autograft options to BPTB include hamstring tendons and, to a far lesser extent, quadriceps tendon grafts. Allograft options include BPTB, Achilles tendon, anterior and posterior tibialis grafts, hamstring tendons, and fascia lata grafts. With successful clinical outcomes achieved with both autograft and allograft tissues, the choice of graft material becomes one of surgeon and patient preference. Autograft tissue offers the advantages of no risk of disease transmission, a high success rate, and no immunogenic response. These benefits must be balanced with donor-site morbidity, difficulty of graft harvest, additional operating room time associated with graft harvest, and the limits and unpredictability in graft size and quality. Allograft tissue has the advantages of lacking donor-site morbidity, smaller incisions, decreased operative time, easier and less painful rehabilitation, and larger and more predictable graft sizes. The major disadvantage of allograft reconstruction is the risk of disease transmission; although with current screening, processing, and sterilization techniques the risk is extremely low, it should not be overlooked. Additionally, when using allograft tissue, one must be aware that allograft tissue may generate a low-level immune response. It also has been shown to have delayed incorporation time, and the cost for the allograft tissue itself is greater. Overall, no graft choice can match completely the characteristics and function of the native ACL. The ideal graft choice should have biomechanical properties similar to those of the native ACL, have low morbidity, incorporate quickly, and be able to restore functional stability to the knee over the long term while taking into account individual patient factors, including patient preference, activity level, prior surgery, comorbidities, and goals.
Reply
post #27 of 54
1/30/09 at 9:33pm
Quote:
Originally Posted by num View Post
Nurseflash, glad to hear you had a good experience with them. When I was trying to pick an ortho, the final two I was deciding between were Charles Bush-Joseph (with Midwest Orthopedics at Rush) and my current ortho (mentioned above). Bush-Joesph seemed to be an excellent ortho

Brian Cole did my work. There are 2 guys in the US who do what I needed to have done and he is one of them. The other guy and Cole do some research work together. So, it was a great place for me to be!

Reply
post #28 of 54
1/30/09 at 9:34pm
Quote:
Originally Posted by mrzinwin View Post
Here's a summary taken from a recent review article: Clinical outcomes of allograft versus autograft in anterior cruciate ligament reconstruction.
Baer GS, Harner CD.
Clin Sports Med. 2007 Oct;26(4):661-81. Review.

BPTB=patellar



ACL reconstruction is one of the procedures most commonly performed by sports medicine physicians today. Good-to-excellent results in terms of knee stability, patient satisfaction, and return to athletic activity are reported commonly to be around 90% [107]. Although BPTB grafts traditionally have been considered the reference standard, donor-site morbidity has led to an interest in alternative graft choices. Commonly used autograft options to BPTB include hamstring tendons and, to a far lesser extent, quadriceps tendon grafts. Allograft options include BPTB, Achilles tendon, anterior and posterior tibialis grafts, hamstring tendons, and fascia lata grafts.
Overall, no graft choice can match completely the characteristics and function of the native ACL. The ideal graft choice should have biomechanical properties similar to those of the native ACL, have low morbidity, incorporate quickly, and be able to restore functional stability to the knee over the long term while taking into account individual patient factors, including patient preference, activity level, prior surgery, comorbidities, and goals.

BPTB = Bone Patellar Tendon Bone


Edited by nurseflash - Sat, 31 Jan 09 05:35:34 GMT
Reply
post #29 of 54
1/31/09 at 11:32am
Thread Starter 

 -


Edited by JamminSki - Sat, 31 Jan 09 19:33:35 GMT
Reply
post #30 of 54
1/31/09 at 11:33am
Thread Starter 
Quote:
Originally Posted by ski=free View Post
Quote:
Oiginally Posted by JamminSki View Post
Ok, good to know snapping the ACL only is common.
Yeah, if you're still having kneeling issues after 10 years, don't think I can go Patellar ograft route.

Regarding Allografts, just the fact that there's a chance of disease infection (worst case HIV), even if it's only 1 in 2 million chance, I think that's still too high of a chance for me to gamble on my body. I know there's great success rates in allografts, and have been reading about irradiation techniques and improving sterilization and pre-screening of donor for diseases, etc, but all the articles still seem to say that there's no one comprehensive way to eradicate infections from a donor tendon. But I guess I need to research more into allografts.

But yeah, the flip side is dealing with the possible pain from a Patellar graft or the many possible unknowns in a Hamstring graft.

Actually I read that harvesting the Hamstring tendon is more tricky than the Patellar tendon, due to possible damage to the other Hamstring tendons in the area.
Your chances are probably higher of dying of infection as a result of the extra incision when going patellar or hs.
I own a PT clinic and treat acl's all the time. Go allograft.
The healing is much much much faster. No loss of strength. Faster rehab.

 So sounds like disease transmission through allografts in much much lower these days? Yeah, I definitely want faster healing, cause I dont want to waste away the whole summer as well as this winter.

Reply
New Posts  All Forums:Forum Nav:
  Return Home
  Back to Forum: Fitness, Injury, and Recovery
EpicSki › The Barking Bear Forums › Ski Training and Pro Forums › Fitness, Injury, and Recovery › ACL Reconstruction: Patellar or Hamstring Graft?