Some of you may have heard that I recently tore my ACL skiing. It happened on a late spring day when the snow condition was poor, I was out of practice (haven’t skied for 3 years), and on top of that I started the day following my husband who’s an expert boarder doing ski jumps. It was only after the accident that I learned that the obstacle course at Snoqualmie accounts for greater than 30% of injuries at the resort, and that it alone probably kept the ski patrols in business.
After the fall I was taken directly to Evergreen Hospital’s ER, where the doctor took an x-ray to check that I didn’t break a bone but decided that he’d skip the MRI because “the swelling didn’t look that bad”. However, after a week of icing and ibuprofen my knee was still very weak and wobbly that I decided to go to OrthoWashington in Kirkland for a 2nd opinion. The doctor there also thought that it was probably just a light sprang and he ruled out any soft tissue damage, but prescribed the MRI nonetheless just as a precaution. In fact, during the time I was waiting for the MRI results to come back my knees felt good enough that I’ve started running again, and except for the occasional funny feeling of my knee bones not sliding against each other in a funny way whenever I slip, I generally felt fine. You can understand then how shocked I was to learn that in fact my ACL has completely ripped. Apparently it is not uncommon for people with a detached ACL to feel fine, as long as there’s no side-way movement. This is also the danger of having a ripped but undiagnosed torn ACL – without the ACL acting as a stabilizer for the knee, it is possible to injury other tendons in the knee as well such as the meniscus. Unless one plans to swim or run in a straight line for the rest of one’s life, for us active folks the doctor generally would recommend surgery as the solution because unfortunately the ACL is not one of those tendons that can grow back on its own. The lesson learned here is that if you experience quite a bit of pain when the accident happened, take a MRI. It is quite common for doctor’s to not diagnose soft tissue damage correctly and a number of people had similar experience.
For most of us that have experienced tendon injury that requires a surgical fix, the tricky part then is deciding how to get it done because there are so many options. In the case of ACL, the first major decision to make is whether to use one’s own tissue to do the repair (Autograft) or somebody else’s (Allograft). The jury is out on which one works best, and in general all the options can have good outcomes, assuming the surgeon is competent and the rehab instructions are followed. What I can tell you is that after the injury I contacted a bunch of athletes that have had the injury, and it seems that the majority of people elected the autograft. Also quite a few people mentioned that allograft could take longer to re-vascularize, and one has to be very careful not to re-injure the joint during this period, so depending on when you want to be active again, this may be a consideration.
If you are interested in understanding more about the pros and cons of the approaches, here are some good links:
http://www.acl-repair.com/a-scientific-look-at-autograft-versus-allograft-acl-resconstruction
http://en.wikipedia.org/wiki/ACL_reconstruction
http://www.tetongravity.com/forums/showthread.php?t=111222
If you are considering allograft, by all accounts the risk of infection is extremely low, but here are some examples of when things do go wrong:
http://www.usatoday.com/news/health/2006-11-22-tissue_x.htm
http://www.msnbc.msn.com/id/13208662/
Now, if you decide to go down the autograft route, you have a choice of using either part of the patella tendon (which is very strong, stronger in fact than the original ACL) or your 'semi-tendinosis' (which is a half-muscle, half-sinew ligament in your upper leg and which can be taken without problems, since it's redundant unless you're an Olympic sprinter). The patella option gets you back on your feet faster (hence it is what most athletes use), the other one has the advantage that it won't affect your knee any further (since the semi-tendinosis sits elsewhere). On this note, I consulted a friend of mine who is an orthopedics professor at UW, and he told me that if it were his knee he would elect the patellar tendon autograft sice it is the most resilient, though regardless of the type of surgery (allograft or, patellar tendon autograft or hamstring autograft) the alignment and strength of the quadriceps can change, so one should consider rehab to be an ongoing, lifelong issue.
If you are interested in seeing how the surgery is performed, here's a great article my sister sent me that probably contains more information than you'll ever need to know. I definitely plan to watch my own surgery as it happens - hey, now that I can't actually do crazy things for a while, I'll take all the thrills I can get!
My story isn’t quite finished, as I haven’t had my surgery at this point, but what I do know if that I would be volunteering a lot at races instead of doing them, which is a bit of a bummer but hey, at least I know I have something to look forward to once my knee heals!
Recommended Doctors (and quotes from people recommending them)
Dr. Lawrence Holland at Orthopedic Physicians at Swedish in Seattle
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I had meniscus clean-up/ACL reconstruction using a section of my patellar tendon was done in 1991 by Dr. Lawrence Holland in Seattle. The repaired knee is the better of mine – very solid, no issues. I run, bike to work 3x week & play basketball.
Dr. Roger Larsen from UW Sports Medicine
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I also highly recommend Dr. Roger Larsen from UW Sports Medicine. He is very good and I called even the prince from Israel flew all the way here with a team of doctors to learn from Dr Larsen. I knew about it because that happened just a few days prior to my second ACL surgery and it was the nurses at the UW hospital who told us about it.
I had allograph done on both my knees (yes, I have both ACLs torn… lol) and they work great. According to the doctor, allograph is getting more popular these days. And there are plenty in the bank to share so you don’t have to worry about saving it for the needed (doc said there is enough for 3 ACLs for every person in America).
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I had ACL reconstructive surgery about 20 months ago. I’m very active and competitive with running and triathlons, so I also thought carefully about which path to go down. I was seriously considering the allograft or the reasons you mention. I didn’t want to weaken my hamstring. However, I was finally convinced that the hamstring strength wouldn’t be a problem. Almost all younger, competitive athletes (UW athletes, US ski team, etc.) who end up having this surgery are doing hamstring tendon autografts now. I think the risk of infection of an allograft is pretty small, but I think the risk of the graft being weaker or stretching slightly over time is very real.
I’ve been very happy with my hamstring autograft. There was certainly some additional pain and weakness in the hamstring, but it progressed much quicker than the knee itself did. So by the time I was ready to get active, with additional hamstring strengthening exercises that I generally did as part of my training anyway. I’m now running and certainly faster than I did before my surgery. So I would definitely recommend the hamstring tendon autograft. The one caveat is that you should find a surgeon that specializes in the type of surgery you decide you want. I used Dr. Roger Larson from UW sports medicine, and he had done research and written numerous medical papers about perfecting that exact type of surgery. I would recommend him as well.
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I more recently had an ACL reconstruction and micro-fracture surgery performed by Roger Larson of UW Sports Medicine. He's done surgeries for 10 people I know and is the current surgeon recommended by the Huskies trainers.
Jason Boyer, OrthoWashingon, Kirkland WA
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I saw Dr. Boyer on Friday. He works in Dr. Bramwell’s office. He spent a lot of time with me (over an hour) answering all my questions. He said that no matter how many surgeons I see, there is not going to be an obvious correct answer for what to do. He offered allograph as an option, and said that recent studies have shown that the revision rate for allograph is not as high as it once was. His recommendation though was to do bone-patellar-bone due to my activity level. In his fellowship he did mostly BTB surgeries. He emphasized, however, that all the options can have good outcomes, assuming the surgeon is competent and the rehab instructions are followed.
Dr. Steve Bramwell, OrthoWashington, Kirkland
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Dr. Steve Bramwell in Kirkland...he's done multiple knees/elbows/shoulders for friends and family, and is the former team doctor for the Huskies football team.
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Dr. Bramwell suggested allograft and talking to his pre-opt nurse that’s the type of surgery he’s been doing for the last year or so. If you are interested in allograft, he might be a good option.
Dr. Charlie Peterson, Swedish Hospital, Seattle and Mercer Island
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I have had 3 ACL surgeries over the last 20 years...I've hurt myself each time playing basketball. I had autografts each time. My doctor is Charlie Peterson. He has an office on Mercer Island and also works out of Swedish (206-292-7550 Capitol Hill and 206-373-8330 Mercer Island).
Dr. Bruce Rolfe, Evergreen Hospital, Kirkland
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My favorite there is Dr. Bruce Rolfe. He sub-sub-specializes in knees and other lower limb problems, but he not only fixed my knee but also did an excellent repair job on my shoulder.
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I'll second Dr. Rolfe as I had the exact surgery 3 weeks ago. I was back on my bike 4 days later. Not to mention that Dr. Rolfe is an avid biker himself. When Dr. Bruckner repaired my hip, the recovery instructions were handed to me by the PA in the form of an eleventh-generation copy of a sheet of paper saying, in essence, "do nothing for a month. Then, start walking, slowly, around your bed -- once a day."
Overall, for a knee, I'd go with Dr. Rolfe. Among the reasons are that he is willing to adjust his recovery instructions to your preferred activity, your fitness, and the progress of your healing instead of using the one-size-fits-all approach that Proliance surgeons (or their liability insurance?) seem to like.
Dr. Rolfe and the partner in his practice, Dr. Takemura (physical med. & rehab), fortunately have more realistic views of active recovery.
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I have gone with Dr. Rolfe twice (one for a removal of meniscus tear and the second one for an ACL reconstruction). I couldn’t be happier with the services of Dr. Rolfe. He also operates on Seahawks players as well (http://kneefootankle.com/about/)
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I just had my left knee ACL reconstructed with Dr. Bruce Rolfe at the Kirkland Knee, Foot and Ankle center three weeks ago. He's awesome! I was on the exercise bike within the same week.
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