ACL survey results

[Shawn Mcguan]

Dear BIOMCH-L'ers,

I wish to thank everyone who replied to my ACL survey. As you can see
from this compilation, that I am now a member of the very vocal and
supportive ACL victim club. Based on this generous information, other
research, and my MRI revelation that I have also torn both horns of both
maniscii, I have decided to undergo the surgery.

Summarizing all the information I have accumulated:

1. The results are very good, especially with a good surgeon. (My surgeon
will be the noted D.W. Jackson from Long Beach, who is familiar with me
through my 15 year rugby career.)

2. Recovery is fast (6-12 months for full), especially with a good therapist.

3. Autographs seem to be the best. They are more painful, however, the
success rate is higher and the risks lower.

4. Patellar tendon pain is significant. However, most report the pain
dissipates after a year.

Again, I wish to thank all who took the time to respond. With your help,
I feel I am now making a well informed decision. I will keep you posted
on the results.


Thank You !!


Shawn McGuan
Biomechanics Research Scientist
--------------------------------------------------------------------------------
MECHANICAL DYNAMICS INC. smcgu@ADAMS.COM
6 Venture, Suite 100 (714) 727-0430 v
Irvine CA, 92718 USA (714) 727-0477 f
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Dear BIOMCH-L'ers,

I understand that the following message does not conform to the usual
information request subscribers are used to, however, this request
is very dear to me and I believe that the Biomch-L community could give
me a unique point of view and useful feedback.

I am an athletically active 35 year old male, that has
just been informed that I have a total rupture of an ACL. Having much
experience in virtual knee simulation for the purposes of total knee
replacement design, I understand the instability pattern from a academic
and now (ouch!) personal point of view.

The usual orthopaedic surgical procedure is to transplant a piece of the
patellar tendon, to reconstruct the ACL. My concern is, that the mechanical
qualities (lateral stiffness variation, attachment geometry, fanning, etc.)
of the ACL will not be matched exactly by both the patellar tendon
itself and new interface. I am worried about the effects of this disparity
on stability, maniscus stress, ligament/bone interface stresses, etc.

My questions to the community is: Has anyone had this procedure done to them
and what were/are the results (are you happy you had it done?), Does anyone
know the durability of the new mechanism (will I need maintenance?), What is
your biomechanical opinion of this procedure.

Thank you for you attention.

Shawn

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From: SMTP%"asalo@cloud9.net" 20-DEC-1994 14:13:56.32
To: Shawn McGuan
CC:
Subj: Re: Help, opinion on ACL reconstruction surgery


This isn't really in answer to your questions, but I thought I'd put
another idea on the table. A relatively new procedure is also being done
using one of the hamstring tendons (well, a piece of it) as the ACL
graft. I believe it's the biceps femoris tendon. Anyway, as a physical
therapist, I have seen excellent results from this procedure (whose name
of course currently slips my mind) and it is less likely to bring about
the dreaded patellar tendinitis which can occasionally occur s/p ACL
reconstruction using the patellar tendon.

It might be intersting to study the 2 procedures from a biomechanical
standpoint and compare them.

good luck with your surgery - BTW, most patients as long as they are
compliant with their therapy and there are no complications do very well
with ACL surgery!

anna salo, P.T.
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From: SMTP%"saramcc@camtwh.eric.on.ca" 21-DEC-1994 14:25:00.32
To: smcgu@ADAMS.COM
CC:
Subj: ACL reconstruction

Shawn,

Your message was forwarded to me by a friend subscribing to biomech-L.
I work for an orthopaedic surgeon and he uses allografts to repair ACLs.
He is very happy with this procedure as are he's patients. As with any
other surgical procedure there are advantages and disadvantages - from
a biomechanical perspective however, I would think that this procedure
would be preferable. Your 'anatomy' is not disrupted (patella tendon
or I-T band is maintained) and the donated ACL would of course be more
similar to your 'old' ACL. Do they do this procedure in Irvine? Another
advantage is that it can be done orthoscopically.

Best of luck - I hope it works out for you.

Sara McConnell


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From: SMTP%"usoc@uccs.edu" 21-DEC-1994 17:01:35.06
To: SMCGUAN@ADAMS.COM
CC:
Subj: ACL

Shawn,

Sorry, I have no technical information to relieve your concerns, however I too
am scheduled to have ACL reconstruction performed after the holidays. I am
a Biomechanics Research Assistant with the Sport Science & Technology
Division at the US Olympic Training Center, and have been asking the same sort
of questions as you posted.

I haven't found any solid information about the mechanical properties post
surgery, but i have heard a lot of positive feedback from those who've been
through it. Everyone says they are VERY glad they had the surgery. All are
now functioning in athletics without a brace, as if there had never been an
injury

Personal experiences from others are what helped me make the decision to go
ahead with the surgery, but I would be very interested in hearing the responses
you receive from the Biomech-l community. Could you post a summary of your
responses, or send directly to me at dgduis@aol.com, I would greatly apprecitateit.

Thanks much,

Dan Duisenberg
US Olympic Training Center
Colorado Springs, CO 80909
(719) 578-4811 v
dgduis@aol.com
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From: SMTP%"boconnor@indyvax.iupui.edu" 21-DEC-1994 17:24:37.26
To: smcguan
CC:
Subj: Re: ACL Victim in need of advice

Dear Shawn,

I feel a little funny sending you this, sence it smacks of self-promotion
and I can't really offer you any practical advice, but perhaps you might be
interested in some of our work.

My research interests center on the neuromuscular protective mechanisms
1) that protect normal, healthy joints from becoming unstable (and
developing osteoarthritis, and 2) that protect unstable joints from
especially rapid breakdown. We use ACL deficient dogs (produced surgically
by us) and we have come to the conclusion that the tissues of the joints
survive at the pleasure of the neuromuscular system, which, we believe, can
be reprogrammed according to sensation from an ACL deficient joint.

If you are interested in such things (which would at least give you much
food for thought) you might like to read some of our work before you
undergo surgery. If so, I would suggest beginning with a review paper we
wrote last year:

O'Connor, BL and Brandt, KD. 1993. Neurogenic Factors in the
Etiopathogenesis of Osteoarthritis. Rheumatic Disease Clinics of North
America. 19:581-605.

In any event, I wish you a quick and complete recovery.


Brian O'Connor boconnor@indyvax.iupui.edu
oconnor@anatomy.iupui.edu


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To: smcguan
CC:
Subj: Re: acl

>Shawn,
>
>You've just joined the not so exclusive club of physically active persons
>sustaining such an injury. The patellar tendon graft procedure appears
>to be the most overall successful surgical technique to date for this
>problem. There have been hundreds of papers on this topic in recent
>years, and it appears that the graft takes on the characteristics of
>the original ligament over time due to its capacity for adaptation. We
>have tested numerous post-surgical patients with this type of graft over
>the past two years and have been impressed with the extent to which the
>subjects have returned to fairly high levels of activity. You might want
>to read the work of Savio Woo on this topic and the data he reports on
>success rates for various categories of candidates. Good luck!
>
>Louis R. Osternig, PhD
>Dept. of Exercise & Movement Science
>University of Oregon
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From: SMTP%"VI6BOQ71@icineca.cineca.it" 22-DEC-1994 11:26:47.82
To: smcguan@ADAMS.COM
CC:
Subj: Re: Help, opinion on ACL reconstruction surgery

Hallo, I have worked on computer-assisted ACL reconstruction for
only one year but some cases I saw may help you. I know only young
people with ACL reconstruction (and so a short follow-up), and one
of them is in the lab. They are well, they do practice sports (in-
cluding ski and bike), after rehabilitation the knee are not pain-
ful.
In principle you are right. The patellar tendon has not the same
mechanical features of ACL, but after a while its microscopic structure
changes and it becomes like the previous ACL, so that this kind of
implant is nowadays more reliable than artificial ligaments. Not
everything is known about the mechanical properties and requirements
for ACL, but current results with this technique are encouraging (I
am aware of good 10 year follow-ups, but probably other data are
available in litterature).

Bye and good luck, Sandra.
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From: SMTP%"MONTEROSE@helix.mgh.harvard.edu" 22-DEC-1994 16:48:52.36
To: smcguan@ADAMS.COM
CC:
Subj: Re: Help, opinion on ACL reconstruction surgery

I am a physical therapist/bioeng who has worked a lot with ACL reconstructed
patients...I suggest lookiing into literature of Robert J. Johnson, MD form
the University of Vermont...he and his collegues have done a lot of
research in this area....you will never find a "perfect" match in terms
of biomechanical properties for the ACL, however a "close" match
may be sufficient to allow you to remain active...Good luck!
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From: SMTP%"thompson@mail1.ciwemb.edu" 20-DEC-1994 15:45:32.44
To: "Shawn McGuan"
CC:
Subj: torn ACL

Subject: Time:2:44 PM
OFFICE MEMO torn ACL Date:12/20/94

To: Shawn McGuan

Biomechanics Research Scientist
MECHANICAL DYNAMICS INC.
6 Venture Suite 100
Irvine CA, 92718

I received your message from a friend that is a biomechanical engineering
graduate student, . I am not an engineer, but I
guess she felt I am qualified to address your question because I have torn
ACLs in both knees. One has been reconstructed by patellar tendon graft, the
other has not. I tore the ACL in one knee (right) playing basketball 17 years
ago (I am 33 years old), but was not diagnosed properly until 3 years later.
I played basketball in college for two years wearing a anti-derotation brace
from Lennox Hill Hospital on my injured knee and did not have a problem. I
tore the other ACL (left) playing basketball 2 years later. I tried to play
basketball after that, but the left knee would 'give out' on me fairly often.
I would say that if you play a 'cutting' sport, such as basketball, soccer,
etc., if you do not have the knee reconstructed it will go out on you in the
future. If you do more 'straight-ahead' sports, like running or biking, you
are less likely to have problems.

My left knee eventually gave way severely enough (playing softball) that I
tore the meniscus badly. After having most of the meniscus removed AND the ACL
gone, my left knee never recovered reasonable stability, so I had the
reconstruction. I had a great doctor and a great physical therapist (this was
in San Diego), I was walking after three weeks and jogging after 3 1/2 months.
In the reconstucted knee, I have lost some range of motion in flexion and I
have had problems with patellar tendinitis. I do not play basketball any
more, because I'm afraid of reinjuring the knee that is not reconstructed. I
run instead now (it's not basketball, but it's ok) and have completed two
marathons. So... I am happy I had the knee reconstructed, the reconstruction
has some problems (the patellar tendinitis is not trivial), but my knee is
definitely stable. I can also say that my non-reconstructed knee feels
reasonably stable (doctor says likely to be due to built-up scar tissue), and
measures as stable as the reconstructed knee by certain tests.

You may want to try a brace. In my (humble) opinion, the problem with ACL
braces is not so much that they don't work, it's that it's hard to keep them
in the proper position (they tend to slide down when you sweat). I have a
brace from Brace Technologies in Cincinnati that works pretty well, I have
heard good reports for DonJoy knee braces also.

Hope this information is helpful. Good luck.

Catherine Thompson

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From: SMTP%"patton@canaan.eecs.nwu.edu" 20-DEC-1994 16:08:32.11
To: smcguan
CC:
Subj: ACL advice

Greetings, fellow ACL victim!

I assure you, you are not alone. In fact, I would imagine
that you're getting a LOT of replies. I'm 29 years old, and
I injured my ACL skiing 2 years ago, and recently had it
reconstructed (November 4th). I was pretty active before
and after the injury (Running, biking, lifting weights.)
I had the typical medial-third patellar tendon graft, and
no problems in surgery. They say about 4 months of rehab
is expected.

I am now an advocate for the surgery, but for a quite a
while I did not think the surgery was necessary. However,
I think this helped me. For nearly two years, I made it a
point to "beef up." Biking to work, doing the 14 flights
of stairs each morning when I got to work, etc. This was
all in the fear (or hope) that eventually the surgery was
going to happen. Now I'm in physical therapy class with
many other ACL victims, so my perspective (I think) is
well rounded. My experience has led me to the following
conclusions:

* "beefing up" before surgery is good. The
other people who did this also seemed to
have the best luck. This may be simply a
issue of developing new proprioceptive skills
(I think this is a big part of it.) The
bottom line here is that TIME needs to go
by before you have the surgery. (unless, of
course, you have no choice.)
* Continuous passive motion, and very little
else, post surgery for the first 10 days is
good. (I can get you references on this if
you want.)
* The pain was surprisingly not that bad. I was
off pain meds (except for an occasional extra
strength Tylenol) after the first few hours
after surgery -- not to brag or anything.)
* The patellar tendon is what hurt the most
for me.
* People with other capsule problems (meniscus
tears, etc.) have worse luck and slower
progress in therapy.
* People who are active in sports before the
surgery seem to have better luck.
* Pain, and more importantly, swelling are the
enemy. (they shuts down the vasti.) Elevating
the limb, Putting pressure on the joint (ace
bandage), ice, and anti-inflammatory drugs
(naprosyn, advil, etc.) seem to do the trick.
I'm still doing all this now.
* Find the most scientific surgeon (one who is
truly abreast of the latest literature and
does not clink to the conventions of the past
unless they've been proven beneficial). The
best way is to ask physical therapists who see
ACL patients post-surgery, and find out
who has the best success. Academic PT's are
good too because they are also abreast of
the latest literature.
* You can be walking without crutches in a few
days, without your brace in 1.5 weeks,
believe it or not.

In a nutshell, I recommend the surgery. Its not as bas a
some people make it sound. But don't go rushing into it.

I hope this helps, let me know what others say, and feel
free to ask me more questions.

Good luck,




_ _
) . )/)/)
(_/ / / / (

_/_/_/ Jim Patton
_/ _/ _/ _/_/_/_/_/_/ _/_/_/ _/_/ _/ Graduate Student
_/_/_/ _/_/ _/ _/ _/ _/ _/ _/ _/ Biomedical Engineering
_/ _/ _/ _/ _/ _/ _/ _/ _/ _/ Northwestern U
_/ _/_/_/ _/ _/ _/ _/ _/ _/_/ j-patton@nwu.edu
_/ _/ _/ _/ _/ _/_/_/ _/ _/ (312) 549-3263


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From: SMTP%"P.Bate@latrobe.edu.au" 20-DEC-1994 18:41:48.39
To: smcguan
CC:
Subj: Re: Help, opinion on ACL reconstruction surgery

Hi Shaun

re: personal experiences of ACL reconstruction


I ruptured one in 1982, skiing, and had the repair you describe. I got 8
years of low level skiing, rollerblading, bushwalking etc without much
problem, but I never felt convinced the surgery had been worthwhile; I
think if I had just strengthed ++ I would have had about the same outcome.

I now have moderate retro-patellar pain from malalignment of..patella?
tibia?, and constant effusion unless I swim */week and gym static knee
workout 1/week minimum. My knee seems more unstable than when I had the
repair.. I guess its worn out?? I cannot ride my bike for >10 km, or walk
with a heavy pack, or do hot jumps rollerblading now because of the knee
flare-ups and aching...unless, maybe, if I did a lot of gradual training
prior. I avoid stairs, and small spaces like aeroplane and movie seats,
because my knee aches

More objectivelyy, I suggest you do a literature search in
rehabilitation/physiotherapy..there is a lot of long term outcome data for
this op. now, and I think, alternative surgical procedures.


Trish

__________________________________________________ _______________________
Trisha Bate | email : P.Bate@LaTrobe.edu.au
School of Physiotherapy | Phone : 03 285 5259
Faculty of Health Sciences | or : 03 481 1718
La Trobe University | Fax : 03 285 5225
___________________________________|______________ _______________________

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From: SMTP%"rah@csn.org" 20-DEC-1994 18:45:58.83
To: Shawn McGuan
CC:
Subj: Re: Help, opinion on ACL reconstruction surgery

Shawn,
ACL reconstruction is an all too common operation these days. Pros &
cons of patella tendon versus hamstring grafts exist. There is a high
rate of functional return to sports for either graft. There is some
question regarding lack of hamstring function (and protection of
subsequent anterior tibial translation) with the hamstring graft. Most
important is that the surgeon you choose has a high success rate for the
procedure he/she uses. Proper placement of the femoral and tibial
tunnels through which the graft is passed and fixed, is critical for
proper function. If too anterior, there may be impingmewnt of the graft
by the notch between the femoral condyles leading to damage of the graft
and lack of full extension. There are numerous other complications, but
done by someone with a good track record, the success rate is high. No
reconstruction leaves you open to other possible degenerative changes
down the road, es[pecially if you intend to remain active. Amer. J. of
Spts. Med. has numerous articles regarding ACL reconstruction.
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From: SMTP%"mdr5m@uva.pcmail.virginia.edu" 20-DEC-1994 19:31:12.99
To: mdr5m@uva.pcmail.virginia.edu, smcgu@adams.com
CC:
Subj: ACL reconstruction

Hello Shawn,

I read your request today with great interest, as will be apparent in the
text that follows. I am an athetically active 36 year old male, who at age
33 suffered a blowout (complete rupture) of my left ACL as a result of an
injury sustained during my third year in Medical school during the
intra-mural three-on-three basketball playoffs. I think I can relate in a
very personal way to the numerous questions that this event has now created
for you.

To start with I will tell you a little of my background as there are others
with considerably more experience in treating this condition (who, themselves
may not have suffered this injury). I am a second year resident in the
Department of Orthopaedic Surgery at the University of Virginia, doing a one
year post-doctoral research fellowship in the Orthopaedic Biomechanics
Laboratory, after which I will complete my remaining four years of training
as an Orthopaedic Surgery Resident. The research involves using advanced
imaging techniques and analysis to generate a geometric model of the knee,
which will then be analyzed dynamically to study its stability in normal and
pathological conditions and tested against cadaver knees. This research is
partially funded by a research grant from the NIH.

Before going to Medical School I worked at Ford Aerospace Corporation for
seven and one half years up Jamboree Road at the Aeronutronic Division (which
is owned since 1990 by Loral Inc.). My undergraduate degree was in
mechanical engineering from Cal State Fullerton. At Ford, I worked in
Advanced Development Operations in Advanced Mechanical Design where I
designed prototype electro-optical-mechanical guidance and control systems
(among other things) for a variety of missiles, using PDGS, which is a Ford
Motor Company proprietary CAD software. I digress to the extent that I may
show you by way of background why I chose Orthopaedic Surgery as my
specialty.

Now, to the thrust of your question, i.e. What can I/should I expect now?
After much anguish and considerable research, I chose to have an allograft
reconstruction performed. This was after waiting a year and a half,
undergoing so-called conservative therapy, meaning leg strenthening
exercises. First of all, to address the non-operative treatment.

The goal of leg strengthening was return my knee to normal strength after the
disuse atrophy secondary to the knee immobilizer I wore for several weeks.
The role of the immobilizer of course is to reduce pain by preventing
movement. The immobilizer also prevents the inflammatory response from
continuing unchecked as it prevents re-injury or injury resulting from the
new found instability. Also, and very importantly, there are a number of
mediators released during the inflammatory response that can act on your
hopefully undamaged articular cartilage, among these are collagenase and
stromolysin. This is one of the reasons anti-inflammatory medication
(NSAIDs, meaning non-steroidal anti-inflammatory drug) such as Motrin or
Naprosyn are prescribed, to help reduce this response.

In my personal case I began walking without crutches after one week and then
without the immobilizer after two weeks. My rehab program consisted of
walking, the stationary bicycle riding, then bicycling, and after about five
months, running. The reason for this slow pace was that for my initial
physical exam, (by an Orthopaedic Surgeon) took place about three days after
the original injury, by which time my knee had swollen massively, to the
point that the physical exam was not sensitive enough to determine rupture of
the ACL through the normal anterior drawer test or the more sensitive Lachman
test. For this reason, an MRI was suggested, which ultimately was not
conclusive (partly because of scan resolution, and partly due to poor slice
spacing and angulation, which are eliminated with a high density 3D volume
scan). The ligament was diagnosed as a possible partial tear, which was felt
might heal on its own with the aforementioned slowly paced physical thearapy.

Ruptured ligaments, meaning blown, transected, "toast", cannot heal back
together because the knee joint is a synovial joint and as such the synovial
fluid continually washes away any clotting factors which are responsible for
the healing of other ligaments in the body (such as the ankle). The role for
MRI today again is secondary to a good physical diagnosis, and is argued by
some that it is un-needed altogether, though many believe that its most
useful role is to diagnose associated meniscal pathology. The meniscal
tear(s) are significant because unrepaired or resected, can lead to
accelerated wear of the articular cartilage, i.e. traumatic osteo-arthritis.

This is also the natural history of an unrepaired ACL in an active person
which is documented by recent studies published in the American Journal of
Sports Medicine. This is your best source for information on the results of
the different types of ACL repair available. A backup source is the Journal
of Bone and Joint Surgery. It is for this reason that the average active
person, let alone the athletically active, should have this repair done
primarily, meaning right away, as the results of the studies show substantial
wear beginning within the first three years after injury.

As you mentioned, the repair itself will not be anatomic, meaning that the
injury changed your knee forever and whatever is done now is to merely
salvage what's left so that it is "functional". When you realize a number of
professional athletes have had this injury and had it repaired, and they now
continue to play at the professional level, that a repair does not need to be
anatomic (meaning identical) to be functional. The goal is to restore the
original geometry as much as possible, with the hopes that the transplanted
infrapatellar ligament will eventually provide sufficient stability for your
individual case. As you might imagine, because the techniques involved are
somewhat new, there are few long term follow-up studies on any of the newer
methods. And, as you might infer, any injury which has developed a number of
different repair strategies is sufficiently complex and the previous results
must be somewhat unsatisfactory in order for continued development in this
field.

The history of the different types of repair is long and I leave it to you to
research it at your leisure, but to summarize, the accepted state of the art
repair among Orthopaedic Surgeons with Fellowship training in Sports Medicine
is to perform what is called a central third autograft. This consists of
making a vertical incision over the knee from the anterior tibial tubercle to
the patella and removing approximately the central third of the tendon along
with a bony plug at either end so that you have a continuous structure of
bone-tendon-bone (BTB) about ten to twelve millimeters in diameter.
Follow-up studies show that the infrapatellar ligament is repaired by a
combination of collagenous and fibrous tissue and there are published studies
stating that experimentally there is no statistically significant change in
extensor function/strength (I have my doubts about this). The harvested BTB
unit is placed in drill holes made in the distal femur and proximal tibia
that were made using special guides designed for the most anatomic placement.
This has become a source of problems in that improper placement affects
resulting knee motion, as I'm sure you might suspect. The BTB unit is held
in place at either end by interference setscrews that engage their threads
partially in the implant and partially in the native bone. These screws
remain for life, but I have not heard of any problems concerning healing of
the bone to bone other than infection (which you can get with any hardware).
Once the bone heals (about six to eight weeks) the ligament itself is at risk
for failure. Theoretically the screws are stress risers but I have not heard
of any complications or inhibition of function due to this.

The ligament itself undergoes a period of revasculariztion in which capillary
ingrowth occurs and the new ligament is remodeled according to the new
stresses it sees, which falls under the heading of rehab and protecting the
repair from overloads until it gains sufficient strength, hence the need for
sports braces which limit anterior tibial translation, and closed chain
exercises, which prevents the individual from harming the repair by
eliminating activities which can damage it (i.e., no leg extensions allowed
during rehab because they rely on the ability of the ACL to act as a limit
stop during full extension).

Again, the major drawback is donor site morbidity, meaning that it is
possible to iatrogenically damage your extensor mechanism in your quest of
seeking stability. The risk is there, but many take it. Autograft repairs
will heal relatively quickly, some pro players are back with nine months, and
some surgeons will allow full activity after six months. I think this is a
crock, but since there are again no long term studies to prove or disprove
this, it is up to you to believe what you want. Remember, they operate on a
lot of knees, but you have only two, and at 35, a limited amount of time in
which to return to your prior ability. I would double this time period, I
mean what is six extra months versus doing the surgery again (of course, in
my former profession, I was definitely a belt and suspenders kind of guy and
had no design failures, ever).

In my case, the reason I had the surgery was because I wanted to play
basketball again, and I wanted to still be able to leap (37" vertical), as
well as cut. After my conservative rehab, my first game after injury I made
a cut and promptly went to the floor, meaning I ruptured what was left of the
original partial tear, or, more likely, the ligament was toast from day one
and I only found out later because until that time I had not tested it under
real conditions. Fortunatley, my advisor during my fourth year was also a
Sports Medicine trained Orthopaedic Surgeon, and because of the policy of my
medical school, I was able to have the surgery done for free (which is a good
deal because it can cost upwards of ten thousand dollars, and I heard of
eighteen once).

Again, I chose an allograft reconstruction instead of autograft. Everything
is the same as before, but different, as I will try to explain. By
allograft, that means they take the infrapatellar tendon from some dead guy,
saving your own infrapatellar ligament and more importantly, not changing
your extensor mechanism anatomy. The risks with allograft are with
infection, meanining it is possible for someone with HIV or hepatitis B to
have been your donor. I know of one documented case of HIV transimission in
over twenty thousand procedures, which of course is high enough that most
people now choose the autograft. I gambled and won :-). Seriously, unless
you have a reason not to, choose the autograft. Besides healing faster, in
studies done on patients with allografts two years after surgery in which an
elective arthroscopic biopsy was done of the graft, it was found that there
was incomplete vascular invasion, meaning incomplete remodeling of the
ligament. In canine studies, it was shown that allografts regained only
about 30% of the original ligament strength in some cases. Their are
numerous biomechanical papers, as I'm sure you know by Torzilli, Noyes,
Grood, Mow and others.

I believe that the most important aspect of the entire procedure is the rehab
phase, and fortunately, it is the one in which you have complete control.
Ligament laxity occurs immediately post-operatively, and in follow-up studies
even patients reporting excellent functional results from whatever method
(and by excellent, I mean they felt they could do everything they did
before), the one consistent objective finding was of measurable laxity
anteriorly with instrumented testing equipment. The leading tenets of the
procedure today involve examining the patient and ensuring they have full
knee extension pre-operatively, as it is shown if they do not have it
pre-operatively, they will never obtain it.

Initially after surgery, they will put you in a sports brace with stops that
prevent full extension, different schools of though exist as to what amount
of flexion to leave you in post-operatively, which eventually you will remove
and be allowed to extend fully. I feel this is a mistake, especially with
the way physical therapists are trained to help you with the rehab. I think
they are so concerned about a flexion contracture that they force full
extension to soon which only puts an overload on the remodeling ACL limit
stop. In my case, I had about a two degree flexion contracture after the
limit stops were removed from the brace (my right knee hyperextends about
two-three degrees). This was noticeable visibly, but in no way impaired my
walking. I refused to stretch my knee to try and obtain _early_ full
extension, instead, relying on the contracture of the joint capsule to act as
an added constraint to hyperextension, and limit through load sharing the
resutling stress in my ACL.

My rehab consisted of walking only for the first six months (I had the
surgery six weeks before graduation, and then began my intern year in general
surgery). After that I began closed chain exercises with machine weights and
began cycling. After nine months I began running on a track (to prevent
having to compensate unexpectedly for an uneven surface), and at on year
began running on the street, and also began very light open chain exercises.
After starting the open chain leg extensions, my flexion contracture went
from two degrees to zero in about three months. I am now at twenty months
post-op and have about one degree of hyperextension, almost the same as my
right knee. More importantly, I have no measurable difference in anterior
knee translation, meaning, my knee feels tight and absolutely normal. I have
begun playing basketball but only go about 50%, with no cutting or jumping.
My vertical is 30" now and I plan to start full workouts at 24 months, after
which I expect to regain all of it. Again, I'm taking it slow because of the
allograft, but I think the principles are still valid.

Am I happy I had it done? Absolutely!

Durability? Until you blow it out again. It will never be as strong as it
was (especially at age 35), but it can come close. Know what you have and
avoid situations that can endanger it, so that means giving up tackle
football (but not flag football).

Maintenance? A sound exercise program is all. It's a biological repair, so
let nature do its thing so you can do yours. Just don't interfere with
nature too much while it's trying to do the right thing.

Just remember, Bernard King became an All-Star again after having his
repaired (with an older surgical technique, I might add). Danny Manning has
also made All-Star twice since blowing his out during his rookie season. Of
course Derek Smith was never quite as good after his knee blew-out (never
heard of him? Clippers 85', check out his matchups with one Michael J.
Pre-injury Derek could go up with him all the way to the penthouse. Again, I
think that _jumpers_ need to really focus on rehabbing the "right" way.

I know this probably dragged on way to long and it didn't have enough
technical stuff (because no one has done those studies yet), but I hope it
helps out. I spent months in library agonizing over the decision about which
repair before I finally flipped the coin :-).

Good Luck on your surgery, and if you feel it is useful to anyone else you
can post all but the last paragraph.

Humbly yours,

Mark D. Russ, M.D.
Orthopaedic Surgery Resident
Orthopaedic Biomechanics Laboratory
University of Virginia

Box 205
Health Sciences Center
Charlottesville, VA 22908
(804) 971-3847
(804) 924-0269
mruss@virginia.edu

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From: SMTP%"mpwallace@ucdavis.edu" 20-DEC-1994 19:59:01.78
To: Shawn McGuan
CC:
Subj: Re: Help, opinion on ACL reconstruction surgery

Dear Shawn,

I am sure you will get a lot of responses from your question since there
has been and continues to be a lot of research in ACL reconstructions. I
am currently getting my Master's in Bioengineering at UCDAVIS where my
theis work involves evaluating two procedures for locating attachment
sites for the femur and tibia.

Before I try to answer your question. These are the following decisions
the surgeon must make, which are often made on pure hunches.

Graft Type: Bone pattela bone, or hamstring graft (ususally
semitendinosus and/or gracilus
The surgeon I work with in Sacramento uses hamstring graft and
claims the problems such as anterior knee pain for bone-p-bone graft is
avoided. (also you could get a allograft of either type)

Attachment sites of Graft: Femoral attachment site is much more
important for a graft tension profile since it is near the center of
rotation. Tibial attachment site is important to prevent impingment,
which is thoght to be a contributor for failed grafts.
You should ask your surgeon how the address all these issues in their
procedure. Then you can go home read up on it and formulate your own
oppinions. Any decent Medical School libary will have books on the
current research and opinion of ACL reconstruction.

Goood luck.
Mike Wallace

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From: SMTP%"alhkg@ttuhsc.edu" 21-DEC-1994 12:08:43.77
To: smcguan
CC:
Subj:

Dear Shawn:

Being in the field of prosthetic design, you must know that man's
replacement for the original falls short of meeting every quality inherent
to the particular tissue. The ACL is no different. The bone-tendon-bone
allograft (as you described) has been the most successful type of
reconstruction but it is not without its limits. The attachment geometry
is probably one of the most technically important aspects of the recon. and
it varies depending on the skill and preferences of the surgeon.
An attempt at duplicating the helix of the ACL is not made and thus
the isometic nature of the ACL throughout the range cannot be duplicated.
The "straight shot" of the patellar tendon from tibia to femur creates its
own problems, i.e. the graft tends to rub on Grant's notch thus reducing
its life expectancy (this is compensated by reeming out the notch with a
drill).
And of course there are problems with tension in the graft. This
gets to be more art than science as the surgeon places a preload on the
tendon and then makes and educated guess, based on tissue health, age, etc,
on how much more he expects the graft to stretch.
Going without the recon. isn't an attractive option due to the
early degeneration and increased probability of a meniscal tear from the
increased anterior tibial translation / shear that occurs.
Despite all the shortcomings (and there are more) the surgery is
often quite successful. I think the successes are a testimony to our
bodies ability to adapt and modify. Things will never be the same but you
don't have to check yourself into a convalescent center either.
Regarding maintenance, most surgeons would agree that the recon. is
only as good as the effort put into rehabilitation. That's where a good
physical therapist comes in. The attainment of full ROM and strength as
well as compensatory proprioception mechanisms is crucial. Functional
bracing may also be helpful in keeping you out of the Dr's office for a
second go around.
Durability is multifaceted and is affected by most of the above;
some of which you can control, others you cannot.
I wish you luck!

Jackson, D.W. ed. (1993). The Anterior Cruciate Ligament: Current
and
Future Concepts. Raven Press, New York. ISBN 0-7817-0039-6

Hughston, J.C. (1993). Knee Ligaments: Injury and Repair. Mosby, St.
Louis. ISBN 0-8016-6281-8

Strover, A.E. (1993). Intra-Articular Reconstruction of the Anterior
Cruciate Ligament. ISBN 0-7506-1385-8

/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\
Kevin Garrison, PT
Texas Tech University Health Sciences Center
Dept. of Physical Therapy
3601 4th Street
Lubbock, TX 79430
Phone: (806) 743-1169
Fax: (806)743-3249
E-mail: ALHKG@TTUHSC.EDU
/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\/\//\/\

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From: SMTP%"NTUT243@twnmoe10.edu.tw" 23-DEC-1994 16:49:18.05
To: smcguan@ADAMS.COM
CC:
Subj: Re: Help, opinion on ACL reconstruction surgery

Dear Shawn:

I am sorry to hear that you need recieve ACL reconstruction surgery. I
have been a physical therapist in Taiwan and have many patients who receive
ACL reconsruction. Although it is reported that ACL reconstruction has
excellent results by many Orthopedic surgeons, the real situation is not
as good as their reports. You know, their definition for the "excellent"
is quite from ours. Actually some of the patients regreted after surgery
because they got a worse condition as compared with the pre-operation
condition. Therefore, in my opinion, the key points for the high sucess
rate are the technique of the orthopedic surgeon and the rehabilitation
process. I sugget you to look for a skillful orthopedic surgeon and an
experienced physical therapist who encharge your rehabilitation program
then you can get an nearly normal situation after surgery.

With best regards.

Huei-Ming Chai
School of Physical Therapy
National Taiwan University
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rom: SMTP%"kbrowde@andy.bgsu.edu" 28-DEC-1994 12:44:31.66
To: smcguan
CC:
Subj: Re: Help, opinion on ACL reconstruction surgery

Dear Shawn,

I would be very interested in any replies that you receive concerning ACL
reconstruction. I also am ACL deficient (have been for 17 years) and am
considering reconstructive surgery to make sure my knee holds out for the
next 40 years. Thanks!

Kathy D. Browder, Ph.D.
Director, Biomechanics / Motor Behavior Laboratory
School of HPER
Bowling Green State University
Bowling Green, Ohio 43403
Phone: (419) 372-6912
Fax: (419) 372-2877
e-mail: kbrowde@bgnet.bgsu.edu
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From: SMTP%"wec2g@galen.med.virginia.edu" 29-DEC-1994 16:12:46.96
To: smcguan@adams.com
CC:
Subj: I had an ACL reconstruction

Mr. McGuan--

I'm a 24-year old athletically active (except when
classes are really busy..) graduate student in biomed at the
University of Virginia in Charlottesville. I tore my ACL when
I was 18, and had the reconstruction (by way of patellar graft)
done when I was 21. Here's my take on the reconstruction:

The DOWNS:

1) Surgery sucks. I didn't sleep at all for a month
(right after surgery), and rehab lasted about 6 months.

2) I still have pain and soreness in my knee when it is
fully extended. This makes it hard, for instance, to
straighten my leg and do a quad set. With repeated stretching,
I can work out the soreness, but it is usually back the next
day.

3) I wear an Orthotech leg brace for cutting sports,
because I feel more stable in the brace.

The UPS

1) I used to have a VERY noticeable anterior draw. The
doctor got the length of the graft right, though, because this
is gone. (I also can still fully flex my knee, fortunately.
My understanding is that regaining full flexion does not always
occur if the graft is too tight.) In this sense, my knee
noticeably more stable.

2) (A hope, really) My hope is that having a "more
stable" knee for the rest of my life will lead to a smaller
chance of having arthritis and/or degenerative joint problems.

These are the first and main UPS and DOWNS which come
to mind. I don't regret having the surgery. My advice if you
do get it done:

1) Find a doctor that has done a LOT of the(in the
hundreds. Practice makes perfect, and you're outcome is really
a bet that the physician will get the job done right.

2) I can't tell you much about the biomechanical
properties about the scar tissue which was once your patellar
tendon and becomes your ACL; hopefully someone else can.

3) Be dedicated to knee strenthening exercises, even if
you don't have the surgery. This will add stability, and you
will probably notice it.

4) Accept the fact your knee will never be the "same as
normal". I guess I mention this because it was a problem for
me.

Good luck w/ your decision,

Warren E. Carlson