The ACL Repair Blog Firsthand accounts of ACL surgery and recovery

Saturday was a momentus day for me in that I took my trucker out on the road.  My girlfriend and I rode about 10 miles round trip from our place in Eastlake (Seattle) to Ballard for sandwiches.  It felt fantastic.  I had no knee pain and my legs felt quite strong.   Of course, the route was completely flat and largely on bike paths which helps.  I’ll definately need to get some miles in before i have the confidence to hit the roads with my former gusto.

Yay for bikes!

Hey all, I just upgraded the wordpress install on the old ACL blog. If you see anything funny going on let me know. Thanks!

This is mostly from a review on ACL reconstruction: Spindler, KP and Wright, RW. 2008. Anterior Cruciate Ligament Tear. New England J of Medicine.

1. Weight bearing right after surgery does not cause harm.

2. Using passive motion machines is not any better than not using them.

3. Use of a brace is no better than not using a brace.

4. Exercises bending the knee (like squats) are better than exercises that extend the knee.

5. Motivated people can do just as well at home as at Physical therapy (But are any of us that motivated that we can do as good as a professional?)

This has come up a lot in this blog in the posts and comments.

What is better autograft (hamstring or patella) or allograft (from a cadaver)?

As a biology graduate student I have access to scientific publications and some experience in assessing the published information. There are no official published guidelines for doctors, just scientific articles. Here is what I have found from articles comparing allograft to autograft:

1. There is a lack of randomized trials to compare auto- vs allograft. Randomized studies are very important in science. Think about your doctor. He or she has an opinion on which is better. So the graft you get may be biased by that opinion or, if you decide opposite that doctor’s preference, the surgery itself may be biased. Randomized trials would be if you went to the doctor and picked a surgery (allo- or auto-) out of a hat. These have been done comparing patella tendon versus hamstring but not allo- versus auto-.

2. Failure rate for allograft is significantly higher (9 of 158) than autograft (2 of 167) in observational studies. The review (first citation) recommends autograft, especially for young athletes.

3. Greater chance of deep infection with autograft (2 out of 170) versus allograft (4 out of 628). Significant difference, but all in all, risk was low, maybe too low in this study to tell if there is really a difference.

4. Allografts take longer to revascularize

Additional interesting information I found:

0. There is really no difference in results from patella or hamstring, but patella causes a little more pain. I know this wasn’t auto- vs allo- but still relevant.

1. ACL reconstruction in patients over 50 can be as successful as in younger patients

2. 175,000 ACL reconstructions were performed in 2000

3. Osteoarthritis occurs in 50 % of patients that tear their ACL 10 to 20 years after injury.

4. 60-70% of ACL tears also damage meniscus cartilage.

5. Non-operated ACL tears are more likely to cause further cartilage damage than ACL reconstruction.

6. 15% of patients need additional cartilage or scar tissue surgery after ACL reconstruction (I did for my first knee).

7. Means of graft fixation (how they attach the graft) does not affect outcome

8. Risk of tearing a graft is about 3% after 2 years, the same as your ACL in your other knee (which is what happened to me after 5 years).

I will post later about differences in rehabilitation.

Citations:

Spindler, KP and Wright, RW. 2008. Anterior Cruciate Ligament Tear. New England J of Medicine Katz LM,

Battaglia TC, Patino P, et al. 2008. A Retrospective Comparison of the Incidence of Bacterial Infection Following Anterior Cruciate Ligament Reconstruction With Autograft Versus Allograft. Arthroscopy.

Dahm DL, Wulf CA, Dajani KA, et al. 2008. Reconstruction of the anterior cruciate ligament in patients over 50 years. JOURNAL OF BONE AND JOINT SURGERY-BRITISH VOLUME

As my physical therapist sees me getting stronger and stronger, my exercises seem to be getting more and more ridiculous, mostly in the name of ‘balance’. I have thrown a ball repeatedly against a bouncing backstop while standing on one leg an a tippy board. I have done squats on the Total Gym standing on a circular piece of inflated rubber. I did Tai Chi like toe pointing while standing on my repaired leg. And I have laid on my back rolling my hamstrings on a giant inflatable ball. But this week takes the cake for oddity (although I actually liked this one). I got to ‘jump’ while doing leg presses (with 50 lbs). It felt like I was in the water and jumping. But it was still fun to leave the ‘ground’ and I had to control myself to not go too ‘high’.

While my recovery may not be ‘picture perfect’ like some other people I could name, I am recovering and that is what’s important. I appear to be regaining some feeling in my nerve-damaged shin which gives me hope for a close-to-complete nerve recovery (although it may take forever). I went for a walk down to the pond today which is a steep downhill, and steep up with no problem; it felt great. I do still have pain in my meniscus area sometimes although it doesn’t make much sense because it was shaved and should have no flappy painful cartilage. Regardless, it feels great to feel mended and takes a lot of self-control to not overdo it (especially since my quad is still weak and may take a year to match my other quad). I have to make sure to ask the doc when I see him for the (final?) time in two weeks when I can go back to activities. I worry that I will not be able to play sand volleyball this summer but better to not play than another surgery.

As I was on the bike on the trainer in the garage last night i noticed how much more comfortable it is for me now. I’ve been doing some intervals and have found that i only feel pain at my peak resistance.

I hadn’t spent much time on a trainer before this injury, so it’s interesting to see how it affects my form. When i first got on the trainer i noticed how much i was trying to sway side to side. Hopefully this time on the trainer will help me stop doing that as it seems like a big waste of energy.

I’m probably still a month away from hitting the streets on a bike, but i’m getting really antsy about it. I’m hoping to start adding some miles to my morning commute once i’m riding again. The spring is a fantastic time for bikes! Soon i’ll be loading up the trucker and going camping.

I’m also thinking i might be well enough to do some easy hiking. At the moment i’m thinking i may go out for a flat stroll on sunday.

It’s been 8 weeks since my surgery and I’m feeling great. In fact, yesterday my PT told me I was having a “picture perfect” recovery. I’m walking without a brace all the time, still riding a bike on the trainer and doing ever more ambitious PT exercises.

Although I must say, if this is picture perfect I really do feel for those of you that are having a harder time of it than I am. This stuff is no fun!

I’m also curious about this Russian Stimulation they’ve been doing at my physical therapy appointments. I’ve been reading a little (and promise to do a recap blog on that reading … PROMISE!) and I still don’t totally get it. What I do know is that it feels like I got the best, most focused workout ever after I’m on that thing for 20 minutes.

I hope my other ACL survivors are doing well, please leave a comment and tell me about your knee!

Today I’m seven weeks post-op for my ACL repair.  At this point physical therapy and self discipline seem to be the name of the game for me.  I’m going to PT once a week now, and a typical routine looks like this:

1. 8 minutes on a stationary bike to warm-up
2. 8 minutes on a device they call the “total gym”, which basically facilitates diagonal squats.
3. Lunges.  Straight ahead, 45 degrees ahead, 90 degrees, 45 degrees back and straight back.  Left and right. These are the most tedious part.
4. Wall squats, usually with a ball between me and the wall.
5. Balance Exercises - there are several of these, i’m bad at all of them.
6. Toe raises
7. Russian Stimulation
8. Ice.

It all seems to be working because my leg feels quite strong, with my quad coming back to life. I’ve been riding my bike on a trainer at home.  As of this week i’ve began turning up the resistance and doing some intervals.  It helps so much to be clips in w/ bike shoes for me.

In other news it’s been a pretty bad snow year here in the Pacific Northwest, so i haven’t had to spend too much time lamenting my inability to ski this winter.

My surgeon sent me home with with a video of my surgery on DVD.  Did other people get that?  It’s really cool to hear his commentary while he was working on me, but some of the visuals are a little hard to stomach!

Did you get sent home with a video, or any other cool perk for that matter?

Maybe I complain to much, but PT is in some ways torture. Unlike Henry, I am still going to PT twice a week, often for an hour and a half of hard work. Because I was using one crutch for 6 weeks, my left leg is noticeably thinner than my right and definitely weaker. It turns to jelly after a dozen step-ups. But my PT is all about working me hard. The doc said my ACL is super-tight (i.e. strong) and he used some new technique, drilling on an angle, to make it tighter. Course he’s only been doing it for a year, but he thinks its a great technique. I wondered why he didn’t tell me before the surgery. 

I am riding the stationary bike for 40 minutes a day with as much resistance as is comfortable when I don’t go to PT as well as assorted leg lifts and wall slide. My PT has me doing all sorts of exercises that fall into two categories: muscle strengtheners and balance. I much prefer the muscle ones because I just feel that they are working me to get my muscle back (obviously). The balance ones just make me nervous. I worry that I will tweak my knee in a bad way and it is not worth the risk. My PT thinks that the balance exercises strengthen other muscles than the squats and leg press etc. I agree but still, stepping on a half rubber ball, rolling my hamstrings along a big ball, and doing squats on a tilty board are just not my thing. And I dislike them the most because they are more nerve-racking than the boring quad strength ones. And those are really boring. Of course, having a weak quad is the most dangerous thing just now and I need to get stronger.