OT: ACL repair for athletes

[Stlhuskers]

My son has a ruptured ACL and medial and lateral meniscal tears. He is very active (sports, skiing, running, vball, etc.) and plans to do so again when fully recovered from surgery. Does anyone know the gold standard ACL repair for athletes (allograft vs autograft)? If autograft is selected, is patellar tendon-bone allograft or quad allograft preferred?
Thanks!

​

 

[Laner2]

Can't answer your question. I just want to offer condolences to your son. Tore my ACL, meniscus and partial tear of MCL in 95. They used part of my tendon or ligament for the repair and its still holding up.

 

[RedEB89]

My son has a ruptured ACL and medial and lateral meniscal tears. He is very active (sports, skiing, running, vball, etc.) and plans to do so again when fully recovered from surgery. Does anyone know the gold standard ACL repair for athletes (allograft vs autograft)? If autograft is selected, is patellar tendon-bone allograft or quad allograft preferred?
Thanks!

​

Sorry to hear about your son. If he is young and active autograft is absolutely the gold standard. You can find many “studies” (company marketing) that will state one graft is superior to the other. In my opinion the competence of the surgeon is priority #1. If the surgeon isn’t doing 100 ACLs per year you should probably look elsewhere. BTB patellar autograft is the long thought gold standard for athletes. Quad tendon autograft has recently become a hot choice but has limited long term data. Hopefully the Meniscal tears are repairable as well, almost as important as the actual ACL reconstruction.

 

[HUSKERBILL]

I tore my ACL about 4 months prior to what I assumed might be my last year of football at 25 years old (now 48). Clean, complete, ACL tear. No meniscus damage, etc. I was a 6’2” 258lb fullback that intended to come back for that following season. There would be some pretty good force applied to the graft after given my size and position.

There were 3 choices at the time
Allograft
1. my own patellar tendon and patella/tibia
2. my own hamstring

Autograft
1. cadavaric (donated) tissue derived from an Achilles tendon

procedures
Patellar - takes 1/3rd or the patellar tendon and the attached tips/chunks of the patella and tibia at each end of the tendon.
Hamstring - takes the patients own thin strip of hamstring and quadruples it and sews it all together to make a new “acl”
Cadaver tissue - takes the donated human Achilles and folds it over itself a bunch of times and sees it together to make the new acl.

Pros
Patellar - quickest recovery. Bone to bone healing is super fast.
Hamstring - medium recovery to to fresh tissue but not as fast as bone to bone. You’re basically asking muscle to attach to bone.
Cadaver - slowest recovery due to it being “dead tissue” that my body would need to grow into.

Cons
Patellar - you weaken the knee structure by removing 1/3rd or the patellar tendon. You are now asking 2/3rds of a tendon to support the torque of what a full tendon was supposed to do over the lifetime of the patient. If it ruptures you have to start all over and have a less stable knee.

Hamstring - the hamstring is one of the muscles that helps keep the tibia from sliding forward (the main job the acl does. By stripping a little hamstring, is it less stable? By how much?

Cadaver - slower healing. Greater rupture/reinjury rates by about 10%.

What I did….

I chose cadaver. Didn’t want to weaken my own knee Structure. And figured if it worked i was golden. If I blew it out again I’d just get another cadaver graft and be done with football.

Outcome
Had the surgery. Literally minimal pain. Didn’t take a single Percocet (they gave me 50) when they sent me home. Came back and played my first game 5 months post surgery. Our trainer was also the Milwaukee Bucks Trainer and wrapped my leg prior to ever practice and game. Could barely bend it and get into my stance in the first quarter but was good to go. First play down in Louisville I got submarined (picture helmet to lower legs to take me out) by a LB trying to create a pile in the gap and everything held up fine.

Fast forward 20+ years and it feels great. As good or normal as the other. Glad I got lucky and made it though the season. Feel very fortunate to feel great now.

That was my story and rationale. Good luck with your decision and outcome.

 

[dinglefritz]

Sorry to hear about your son. If he is young and active autograft is absolutely the gold standard. You can find many “studies” (company marketing) that will state one graft is superior to the other. In my opinion the competence of the surgeon is priority #1. If the surgeon isn’t doing 100 ACLs per year you should probably look elsewhere. BTB patellar autograft is the long thought gold standard for athletes. Quad tendon autograft has recently become a hot choice but has limited long term data. Hopefully the Meniscal tears are repairable as well, almost as important as the actual ACL reconstruction.

Spot on. My personal experience with a meniscus has had way worse long term problems for me than my ACL tear. When you lose a chunk of your meniscus you’re headed for a knee replacement. You can get along without a complete ACL. That meniscus is vital. ☹️

 

[HUSKERBILL]

Sorry to hear about your son. If he is young and active autograft is absolutely the gold standard. You can find many “studies” (company marketing) that will state one graft is superior to the other. In my opinion the competence of the surgeon is priority #1. If the surgeon isn’t doing 100 ACLs per year you should probably look elsewhere. BTB patellar autograft is the long thought gold standard for athletes. Quad tendon autograft has recently become a hot choice but has limited long term data. Hopefully the Meniscal tears are repairable as well, almost as important as the actual ACL reconstruction.

Couldn’t agree more with your thoughts about finding the best surgeon as priority #1.

I didn’t have a lot of swelling and our team surgeon wanted to operate 5-6 days after I tore it. I did some research and found that he was an average surgeon and there was another guy I needed to go through for it. I went to that guy and told him my story about wanting to come back quick and how I wanted him to do it vs our team surgeon. I think he liked the ego stroke about me wanting to cine
To him over “our guy” and jumped at it. He said he could squeeze me in two weeks later. I decided it was worth it to wait an extra two weeks.

Couldn’t agree more.

 

[Kenny Fin Powers]

Couldn’t agree more with your thoughts about finding the best surgeon as priority #1.

I didn’t have a lot of swelling and our team surgeon wanted to operate 5-6 days after I tore it. I did some research and found that he was an average surgeon and there was another guy I needed to go through for it. I went to that guy and told him my story about wanting to come back quick and how I wanted him to do it vs our team surgeon. I think he liked the ego stroke about me wanting to cine
To him over “our guy” and jumped at it. He said he could squeeze me in two weeks later. I decided it was worth it to wait an extra two weeks.

Couldn’t agree more.

Rehab will be critical as well. Find a PT that will push him and make sure he works hard at the rehab.

 

[RBigredMax]

I tore my ACL about 4 months prior to what I assumed might be my last year of football at 25 years old (now 48). Clean, complete, ACL tear. No meniscus damage, etc. I was a 6’2” 258lb fullback that intended to come back for that following season. There would be some pretty good force applied to the graft after given my size and position.

There were 3 choices at the time
Allograft
1. my own patellar tendon and patella/tibia
2. my own hamstring

Autograft
1. cadavaric (donated) tissue derived from an Achilles tendon

procedures
Patellar - takes 1/3rd or the patellar tendon and the attached tips/chunks of the patella and tibia at each end of the tendon.
Hamstring - takes the patients own thin strip of hamstring and quadruples it and sews it all together to make a new “acl”
Cadaver tissue - takes the donated human Achilles and folds it over itself a bunch of times and sees it together to make the new acl.

Pros
Patellar - quickest recovery. Bone to bone healing is super fast.
Hamstring - medium recovery to to fresh tissue but not as fast as bone to bone. You’re basically asking muscle to attach to bone.
Cadaver - slowest recovery due to it being “dead tissue” that my body would need to grow into.

Cons
Patellar - you weaken the knee structure by removing 1/3rd or the patellar tendon. You are now asking 2/3rds of a tendon to support the torque of what a full tendon was supposed to do over the lifetime of the patient. If it ruptures you have to start all over and have a less stable knee.

Hamstring - the hamstring is one of the muscles that helps keep the tibia from sliding forward (the main job the acl does. By stripping a little hamstring, is it less stable? By how much?

Cadaver - slower healing. Greater rupture/reinjury rates by about 10%.

What I did….

I chose cadaver. Didn’t want to weaken my own knee Structure. And figured if it worked i was golden. If I blew it out again I’d just get another cadaver graft and be done with football.

Outcome
Had the surgery. Literally minimal pain. Didn’t take a single Percocet (they gave me 50) when they sent me home. Came back and played my first game 5 months post surgery. Our trainer was also the Milwaukee Bucks Trainer and wrapped my leg prior to ever practice and game. Could barely bend it and get into my stance in the first quarter but was good to go. First play down in Louisville I got submarined (picture helmet to lower legs to take me out) by a LB trying to create a pile in the gap and everything held up fine.

Fast forward 20+ years and it feels great. As good or normal as the other. Glad I got lucky and made it though the season. Feel very fortunate to feel great now.

That was my story and rationale. Good luck with your decision and outcome.

Awesome write up huskerbill.

I tore mine nearly 20 years ago and used the hamstring. I believe I have a staple and screw Imin there holding it back together.

FF 20 years - still no pain but gave up basketball probably 10-15 years ago but am still active running/biking/ etc. never have pain. Recovery was 9 months or so at the time but the fear of re-injuring and not “trusting” it lasted longer.

Not sure where you are located but going to an awesome doc is worth it and should be priority.

Not sure how old your son is but I hope he’s not at a milestone (senior year). Good luck with recovery - definitely can bounce back but I’m sure you’re hurting just as much as he is. Hang in there - recovery will be better.

 

[skintight]

HuskerBill is spot on with his statements. I'm a Certified Athletic Trainer and a licensed P.T. worked in D1 setting, Olympic TC setting, Clinical setting. I prefer PTG but the experience and skill of the surgeon is critical regardless of technique and of course the experience of the rehab professional. the addition of other structures damaged plays a huge role in the rehab timeline.

 

[Stlhuskers]

Update at 1 week post-surgery. The knee required both ACL (patella) and medial meniscus repair. The surgery took about 2hrs and was done by a surgeon who does many of these knee injuries. His pain was minimal with the most immediately after surgery. He took pain pills off and on for a couple of days when we (mom and dad) reminded him. Because of the meniscus repair, he was instructed not to put weight on his leg and wear a brace that locks out any flexing unless at PT or doing his home PT. The first PT session was 4 days post surgery and he reached 80 degrees of flex. The brace needs to stay on for 6 weeks.

 

[cruelhalo]

Update at 1 week post-surgery. The knee required both ACL (patella) and medial meniscus repair. The surgery took about 2hrs and was done by a surgeon who does many of these knee injuries. His pain was minimal with the most immediately after surgery. He took pain pills off and on for a couple of days when we (mom and dad) reminded him. Because of the meniscus repair, he was instructed not to put weight on his leg and wear a brace that locks out any flexing unless at PT or doing his home PT. The first PT session was 4 days post surgery and he reached 80 degrees of flex. The brace needs to stay on for 6 weeks.

Sounding awesome.

Blew up my shoulder many years ago (early 90s). Fortunate for me my surgeon was the team ortho for U of Tennessee football team.

Although my injury was shoulder, the toughest element of the healing process besides PT was the pyschological aspect.

 

[Laner2]

Update at 1 week post-surgery. The knee required both ACL (patella) and medial meniscus repair. The surgery took about 2hrs and was done by a surgeon who does many of these knee injuries. His pain was minimal with the most immediately after surgery. He took pain pills off and on for a couple of days when we (mom and dad) reminded him. Because of the meniscus repair, he was instructed not to put weight on his leg and wear a brace that locks out any flexing unless at PT or doing his home PT. The first PT session was 4 days post surgery and he reached 80 degrees of flex. The brace needs to stay on for 6 weeks.

They'll want to get his knee flex to 120 degrees or more. If the therapist is good, he/she will lie like a dog and minimize how much he is really flexing.

Fun fact.......Back when Offutt had Ehrling Bergquist Strategic Hospital (now downgraded to Ehrling Bergquist Medical Clinic). the Marine Corps and Army members stationed there were generally not allowed to have knee surgery there. AF surgeons were not as accustomed to knee repairs as military docs who treated infantry gun bunnies.

 

[Cedric]

My son has a ruptured ACL and medial and lateral meniscal tears. He is very active (sports, skiing, running, vball, etc.) and plans to do so again when fully recovered from surgery. Does anyone know the gold standard ACL repair for athletes (allograft vs autograft)? If autograft is selected, is patellar tendon-bone allograft or quad allograft preferred?
Thanks!

​

I too cannot give any advice, not being any sort of medical professional. I've had two ACL surgeries and came out them OK by carefully following the medical advice I received.

My daughter was a decent college basketball player who needed ACL surgery. After a lot of research we ended up at the Shelburne Knee Clinic in Indianapolis. Doctor Shelburne is amazing, a bit unconventional but very much up in all the latest and best techniques. He has cut on many many million dollar professional athletes. He is constantly giving seminars to other surgeons.

Sorry for your son. Knee surgery is awful. Best of luck