Snow... one last question about torn ACL

[S_Man99]

I had an MRI done and have seen an orthopedic surgeon and both have confirmed an ACL tear, and a slight tear in my meniscus. My Marine recruiters want us to do the Initial Strength Test (which involves a mile and a half run) and go on a short motivational run with them coming up next week. I would like to participate in both of these to keep my condition up before going in for surgery within the next few weeks. Would doing either of these two things damage my knee more then it already is? Would you recommend not doing this?

[snow85]

i'm sure your doctor will have a say in this.

when i had my first acl, the doctor put me on crutches for two weeks prior to my surgery. no running, jumping, cuttting, pivoting, no sand, no nothing. i also had a fractured femur, so that might have been why, but it didn't bother me, and i was uber pissed because like you, i didn't want to lose strength or conditioning going into the surgery. those very well may have been the worst two weeks of my life up to that point in time. they don't want you do cause any additional injury before your surgery.

on the other hand, the 2nd time around, the doc said that i'll have it when i have it, and he's letting me train for ironmans. it *REALLY* is situationally dependent, and you need to just call up your doc and ask him/her.

just so you know: if you're having the patellofemoral graft, no matter what you do now, you'll lose so much strength and actual mass that you'll probably want to kill yourself. that's the very best reconstruction you can have, and that loss is normal. however, you're going to have to work harder than you've ever worked to bring that leg back to pre-surgical standards. as far as mass: my entire thigh on the surgical leg probably lost about 1/2-3/4 its mass, and that was within 24 hours of the cuttting. the muscle is a different shape, and the bones are actually different shapes after the surgery. my legs aren't symmetrical anymore, but you probably couldn't tell that just by looking. for a while though, my clothes didn't fit, i had to look at that every day.... it was depressing to say the least.

once you start rehab, you have to go at the rate they tell you to go. if you push too hard, yes, you'll build strenght and mass, but strength and mass acting on that new graft will damage it. it's a set program, so follow it religiously. i blew through mine, because i didn't lose any of my cardio, and my legs were insanely strong to begin with. the challenge was keeping my cardio from falling off, but i had to watch the lifting, and was cut back.... either 2 or 3 times on that. i reached a point where they told me that they would no longer increase my weight in the rack because if i could lift xxx pounds, there wasn't any reason why that would continue to rise, and at that point, they were more concerned with the health of the graft than the strength of the legs.

you need to go in a strong as you can, but you can't make these massive gains before it happens. that's actually counterproductive. talk to your doc and see what he says. if you do the test, spedifically have them note that you're doing it with a torn acl/meniscus. if you score is crappy, do it again later. i don't know what the Marine standards are, but the Navy would totally let you re-test later. participating in these won't keep up your conditioning, so if that's what you were told, then i would be careful. if you want to condition, you'd be much better off getting in a pool.

talk to your doctor, lemme know how it goes.

S

[S_Man99]

He said that the "gold standard" these days is to do the patellofemoral graft, but that they are both pretty much the same. The patella graft is supposed to hurt more after surgery for a few weeks, and the hamstring is supposed to take a little longer to get back in shape, but they both even out in strength and durability after a month or so. Would you recommend getting the patellofemoral graft or the graft from the hamstring? Those were the two options I was given.

[snow85]

i refer you to my post:



just so you know: if you're having the patellofemoral graft, ....that's the very best reconstruction you can have,


i had it, i LOVED it, it was excruciatingly painful. for mine, they took the middle third of my patellar tendon, but i think they may now take the medial third-- which both require taking bone from the patella and from the tibia. yes, they use a bone saw, albeit a small one.

they're NOT the same. hamstring grafts not only don't stand up as long-- you can go a lifetime w/o damaging an PT graft no matter how hard you are on it, but there are a lot of problems with the HS graft, including reinjury, and the HS not ever fully adapting the way it should, aka it's weaker, doesn't function the same, develops a lot of scar tissue, and there's not much you can do about it. i, personally, would never have that done. in fact, my ortho refuses to do it to me this time around.

if i could, i would have a second PT graft, but b/c i've already had one on the injured knee, i can't have another one taken from the same leg. my very ethical doctor won't take the one from the other leg because he'd make an otherwise healthy knee unhealthy. but, if i could....

the PT graft will leave you with a long incision in your leg. i, in fact, still have some stitches in my scar that never dissolved. you'll probably have some surface nerve damage, and your physical therapists will have to make sure that you don't overload your newly weakened tendon, and develop PTF or Chondromalacia. TELL them if you start to experience any pain or difficulty. a week or so out of surgery, you'll know if you are or not. the main reason for this is that the tendon is 1/3 weaker than it was before your surgery. it has to work harder to keep your bones in place because it's smaller, and you can easily rupture it, sending your patella flying up into your quad. ouch! don't be that guy. the tendon will eventually regenerate.

i was in a constant motion "machine" literally, right out of my surgery. it kept my leg moving through a pre-set range of motion for several weeks, so that it would be easier to regain mobility, flexion and extension. you'll be more concerned with the extension than the flexion, it's the harder of the two to retrain. some orthos will put you in a demobilizer, but i attribute my strong recovery to that immediate, constant motion. that's really up to your doc. also, i started physical therapy the morning after my surgery, and i believe that it also helped my recovery.

however, this is a very personal decision, one that you need to reasearch, and thoroughly discuss with your physician and your parents. if you're still not sure, go to CU's athletic dept, and ask who their team doc is. make an appt with him and get a second opinion. that's what i would do.

in fact, the doctor that i used 12 years ago is not the same ortho that i'm using today, but my ortho knew me when i had the first one done, has done other surgeries for me, and KNOWS:

1. how i recover
2. how i deal mentally
3. how i train/ my level of focus (my best friend tells me i'm "crazy")
4. my personality when it comes to my physical activity/rehab/life

he's awesome and i wouldn't want another doc. but then again, i've known him for 12 years. you need to thoroughly discuss your future plans with your doctor, and see what he says. also, if you're going to continue boarding, he should know that too, and what kind of shredder you are. all this stuff's important.

lemme know how it goes, and if there's anything else i can tell you.

S

[S_Man99]

Snow,
I've seen one surgeon and he has recommended the pateller graft. My dad is making me go see another surgeon just to hear another opinion. This second surgeon says he uses tendons from cadavers. What are your thoughts on that? Do you think that will work out alright or better or worse?

Also, how long did it take you to recover from your surgery?

Thanks
S_Man

[snow85]

um, well, let's see:

the first time, i did the patellar tendon graft. while it tears up your knee for a while, i liked the fact that it was MINE. (i was a few months shy of 16.) i know how i take care of my body, so... there's that. people who have muscular, strong legs probably have better recoveries because their muscles are easier able to support their weakened joint. however...


now, i will be having a cadaver graft and that's freaky. yeah, yeah, yeah, i've heard my doc who insists on it this way, and even HE agrees that it's freaky. but it's still a good graft, 2nd to the patellar tendon graft. complications include disease and death from said diseases... it depends on how the graft is harvested and if it's actually been in an autoclave, etc. the extreme heat/sterilization actually weakens the tissue, so you have to know what tissue bank your doc gets them from, and what their rep is re: integrity of the tissue and disease rate. (things like hepatitis, HIV, etc. you can research this.) the others aren't sterilized *as much*, but the graft is almost "living" when you get it, so they can't really kill it in the autoclave. it's injected with all kinds of stuff to sterilize and clean it. that particular doc can tell you all about that.


either way, that amount of tendon that they take is TRIPLE what you initially had, so they tend to last a bit longer, and ideally, vascularize and grow stronger and stronger, until they've assimilated with your own tissue, and essentially become part of you. my initial recovery... i was running at 10 weeks, and back playing in a brace at 5 months. that's actually really fast. i rehabbed for... 3 hours every AM before school and 4 every afternoon. when i started practicing again, i practiced from 1PM until 9ish at night. this is a little crazy, and might not be necessary for everyone. do NOT go back at 4 months, even if your doc says you can. the grafts, biologically, do not heal in that amount of time. while you'll feel fine, you're really not, not quite yet. typical recovery is about 6 months, so i would say between 5 and 8 is average. most athletes/active people recover in about 6.

with the cadaver, your recovery is a full 12 months, sometimes longer. because the tissue is not your own, it's much weaker and is in that weakened state much longer than the patellar graft tissue. rejection is big risk with any transplant-type surgery, and that's almost what a cadaver ligament is. almost. it's really fresh, let's just put it that way.


you know-- if you really don't know, a 3rd opinion is NOT a bad idea. honestly, i would do it. always, always. surgery is a big thing, so you want to make sure you're doing the right thing for you. get as many opinions as it takes for you to feel comfortable going under the knife. it's very sharp, so you want the right guy doing the right thing, right.

let me know what happens. thanks for keeping me posted.

S

[S_Man99]

I'm planning on going with the second surgeon. My dad's friend did a lot of work with him earlier in his career and highly recommended him. He is also the Denver Nugget's team physician and was the team physician for the Broncos and Avalanche back in the 80's until the mid 90's. He told me the recovery time table was anywhere from 4-6 months, and that it all depends on my mental strength and motivation to get back out there and rehab it. He did mention the slim possibility of disease from using a graft from a cadaver, but that it was a very small probability. He told us all the cadavers he uses are checked for previous cancer, HIV, hepatitus, etc. and if anything is found, they are not used. He also assured us that he wasn't going to be taking a 50 year old man's tendon and putting it in my knee.

All in all, this second surgeon was a lot more convincing, and sounded a lot more confident then the first, and after looking at all of his credentials, made me feel more comfortable to go with him. I'll keep you posted on how surgery goes and rehab and all that... Looks like I should have surgery within the next week or so. Thanks for taking time to talk, and share your experiences and opinions.

S_Man

[snow85]

He is also the Denver Nugget's team physician and was the team physician for the Broncos and Avalanche back in the 80's until the mid 90's


this really doesn't matter. i worked with a collegiate athletic trainer who was a total POS,. (the track team where i was turned out many, many carribbean and african olympians, and of course, the football guys who went to the NFL combine.) i actually quit because after two athletes had major surgeries that didn't correct their injuries, i was tired of working for a guy who was too arrogant to realize that he was causing them more harm by not paying attention to what was really going on. that guy was fired a year after i left because the parents of those athletes sued the school. before that, when i was in school, i was misdiagnoesd by a different collegiate athletic trainer, and then the team doc for the san antonio spurs. the doc i have now is the one who said: whoa. you know what? you're completely asymptomatic, but what you're describing is X. let's do an MRI before we resort to exploratory surgery. he fixed me.

on the other hand, this is the guy who did my first surgery:

Undergraduate University of Texas
Austin
Microbiology
1973

Graduate University of Texas Graduate School of Biomedical Sciences
Houston
Nuclear Medicine
1975

Medical University of Texas Health Science Center
Houston
M.D.
1978

Residency University of Texas Health Science Center/Hermann Hospital
Houston
Orthopaedic Surgery
1978-1983

Fellowship J. Richard Steadman, M.D., Fellowship
South Lake Tahoe, California
Sports Med.- Arthroscopic/Knee Ligament Surgery
1983

Fellowship Princess Margaret Rose Orthopaedic Hospital
Edinburgh, Scotland
Prosthetic Reconstruction of the Hip and Knee
1984

looks good, right? but none of these are reasons why i chose him. this guy is super-duper ****y, and had a reputation for liking to cut. those aren't good reasons either, no matter how confident he is when he's talking about slicing and dicing me. you have to remember that 90% of all sports injuries are non-surgical, so anyone who jumps too quickly is someone to look out for. i heard many, many warnings about this guy. it doesn't matter how confident he sounds. that really has no bering on how good he is. at a certain point, they're the same, with personal preferences, which is what it seems like you're up against. however, my first doc did relate to me in terms of his own son, who was also an athlete. my athletic trainer, whom i still trust implicitly and knows me very well, told me that this guy is the best around. additionally, he tailored everything to me: i had an atypical brace that would allow me to waterski, but i was told that i would have to wear it for any and all types of skiing. he said that at some point, i might not want to wear it for soccer, but i would for softball. the brace was titanium (with my name engraved), and a special type of polyeurethane, so it was lightweight and didn't absorb sweat or water. aside from the entire thing being measured to my thigh and calf, the hinge was custom made to fit my particular knee, (they actually sent it back twice), which hyperextends well past 181 degrees.

my current doc:

involved in U Arizona Med. (orthopedics), and the Skeletomuscular Transplant Foundation. because i'm in houston, i have my pick from the best physicians in the world. i only care what his credentials are to an extent. beyond that, i don't care if he's operating on Presidents of the United States. (he may very well have.) both of my parents have seen this doctor for knee injuries-- my dad actually had both knees replaced by someone else, and went to my guy as a follow-up. when he did, my doctor told him something contrary to what his doc told him re: rehab and training-- and my doc told him why he felt that way. my dad did a bit of extra research, and concluded that my doc was right. (of course he is, that's why he's my go-to guy!)

i trust him because i've done the independent research. every question i've had, i've not only gotten straight answers, but honest ones, and ones that consider all factors, not just his personal preference. he did however say "you're going to have to get it through your pretty little head that you have to do this again, and soon. let me know when you're ready."

it sounds like your doctor, mostly serving professional athletes, is very, very aggressive. mine is the same, but he respects the complications of the procedure and the fact that an allograft (cadaver) is a more biologically sensitive, risky procedure. your given recovery time would make me pause if he said that to me, and i'm having the same thing done that you are. in fact, not only was i pre-med in school, but i worked in a physical therapy clinic, was an athletic trainer, AND am still a highly competitive athlete, who has already had an ACL, and that time-span worries me. it would worry me for the PT graft as well. personally, i wouldn't do it with that doctor.


He told me the recovery time table was anywhere from 4-6 months, and that it all depends on my mental strength and motivation to get back out there and rehab it.

no, it doesn't. i was the most motivated athlete my docs/therapists/trainers had ever seen, and as health-care providers, it was their RESPONSIBLITY to slow me down and make sure that i was healing properly. hell, i could have been back playing after 1.5 months, if it had been up to my determination, rehab, and motivation. in fact, i at 6 weeks when i was told that i couldn't run yet. i was so totally *PISSED*. but, that's what they're there for. next, i tried everything in the book to talk them into releasing me at 4 months. they said NO. any graft, but especially a cadaver graft, simply doesn't heal that quickly. it will *seem* fine, *feel* fine to you, but you don't know what's going on inside and you could easily rupture it again. in fact, one of my PTs was a volleyball player in college, and re-tore her ACL playing in a brace. that's pretty common, which is why you have to let them heal. your mental state and muscular physical state are NOT going to align with your rate for biological healing, cellular growth and repair. it's not gonna happen. being motivated will help you avoid some complications due to muscle atrophy, weakness, and imbalance, but the surgical site isn't going to heal any differently unless you damage it.

if you really think that you're going to rehab more than me though (6+ hrs/day on top of going to high school), then i'll be worried because you could easily be doing additional damage. my butt was under a microscope, and had to strength test before and after sessions, cardio test, weigh in and out, and all sorts of other things to make sure that i wasn't doing additional damage. the ONLY reason that they were so, so committed to my recovery was becasue i was insanely motivated, and they really liked me and didn't want me to end up going to a sports psychologist over the whole thing. (frustration w/ not being able to play and train (read: rehab) at a level that i wanted to be at.) typically, your medical team won't be like that, and mine wasn't like that with other patients. i wouldn't recommend that extreme for anyone, just a team that would be willing to trek all those extra miles. they DID pull me back a few times because mentally and physically i was going stronger and faster than _medicine_ had proven the graft, at that stage of developement, could go. i almost definitely would have ruptured it had i been left to my own devices. but, as health care providers, reigning me in and essentially managing my passion, drive and ambition were part of their job. later on, when i broke my wrist and then a month later my nose, they all amost cried because i had worked so hard and was sidelined again.

yes, donor parts are screened, but it's not like looking at a person and saying 'yes, he has brown eyes.' in fact, the reason why i'm stressing it to you is because in the past few years, there seem to have been several reports of people contracting diseases from organ transplants. the problem is that physicians don't know that there's a risk with using a particular harvesting company until people start getting sick. that can take months. also, you're going to have to carefully watch for rejection of the graft. you may be put on additional medication to manage that.

biomechanical stability is a huge factor. you have all sorts of torque and torison forces to contend with... this isn't just sewing a rope back together. what your doctor apparently hasn't told you is that any graft other than a PT graft is medically considered to be a "Salvage Procedure." that's the medical term, not mine. you'll see it over and over again if you research. remember, you're still young, very young, compared to professional athletes, and for various reasons, an allograft is just easier for them.

think about things. honestly, at your age and with your injury, i wouldn't recommed a cadaver graft. i don't know why you would settle for a medical procedure that has proven to less than the best when you've got the rest of your life to live. if, on the other hand, you get a 50 year old athlete's body part, because he died in a car accident, and it's healthy, good, and strong, why not take it? i would.

really, really need to research what you're getting into.

here are some places to start:

http://www.orthoassociates.com/ACL_grafts.htm
"Most surgeons do not routinely recommend using an allograft for a primary, first time ACL reconstruction..."

http://www.medscape.com/viewarticle/408512
"Of greater concern is adequate functioning of the graft itself. Animal work by Jackson[1] demonstrates that allograft ACL reconstruction results in a slightly increased AP translation, less stiffness, and more abnormal-appearing histology than comparable autograft material. For this reason, Chang[2] and Noyes[3] have both concluded that the patellar tendon autograft be used as the first choice in humans...."

www.aaos.com (american academy of orthopedic surgeons)

www.jbjs.com (journal of bone and joint surgery)
http://www.ejbjs.org/cgi/reprint/76/7/1019?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=anterior+cruciate%2C+allograft&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT

www.ajs.com (american journal of sports medicine)

http://ajs.sagepub.com/cgi/content/abstract/0363546506295083v1

http://ajs.sagepub.com/cgi/content/abstract/23/2/173?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=ACL+Allograft&searchid=1&FIRSTINDEX=20&resourcetype=HWCIT

http://ajs.sagepub.com/cgi/content/abstract/21/6/825?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=ACL+Allograft&searchid=1&FIRSTINDEX=30&resourcetype=HWCIT

http://ajs.sagepub.com/cgi/content/abstract/28/3/370?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=ACL+Allograft&searchid=1&FIRSTINDEX=30&resourcetype=HWCIT

http://ajs.sagepub.com/cgi/content/abstract/21/5/738?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=ACL+Allograft&searchid=1&FIRSTINDEX=30&resourcetype=HWCIT


these are just places to start. if you have any more questions, let me know.

S