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  1. #1
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    ACL graft indecision

    TLDR; for those of you who have experience with an ACL reconstruction what graft did you get? Anyone know of any professional mountain bikers who have shared about this experience?



    I've done a little reading and I'm still undecided. Cadaver graft sounds nice on account of not messing with other ligaments or tendons in my body but takes longer to heal. Using my petallar ligament sounds nice on account of shorter recovery time but I'm a little worried about the strength of the knee cap and the petallar ligament. One story about a dude going down on his knee cap six months post op and breaking the Petalla are enough to make me ask some more.

    Using hamstring tendons isn't as enticing.

    I do a lot of advanced yoga and telemark skiing. I can touch my wrists to the floor when reaching for my toes. Apparently there's more lost using hamstring tendons. Yet the idea of leaving the petallar ligament alone makes it worth considering.

    The surgeons I've spoken with all recommend the petallar ligament. All were able to understand why I'd want a cadaver ligament and cautioned me that it takes longer to heal and studies show it ruptures more. One was very well-read on the matter and agreed with me when I pointed out that studies that showed that a cadaver graft is more likely to fail have not controlled for a prolonged recovery time needed for a cadaver graft. He also pointed out that whether or not it has been irradiated seems to effect long term success.


    I was hoping to have scheduled the surgery by now but indecision and decent riding has kept me at bay. Tore it at the end of May backcountry skiing on Mt. Shasta.

  2. #2
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    I went with the Allograft, recovery hasn't been to bad. I'm three weeks post surgery as of last Friday, my decision was based on my age. Being over 30, means I heal slower. Allograft causes less damage, less scar issue to deal with. All of them will take time and work to get back to normal. From what I've read, the early tears tend to happen when a tear would have happened anyway, it's just the nature of people that tear ACL's. Short of chanting your activities, you'll always have the risk.

    It's amazing, even three weeks post how much better I can walk after the tear. Keep in mind I got my surgery two weeks after my tear.
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  3. #3
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    ACL graft indecision

    Iíve had both knees reconstructed with a patellar graft. One in 1990 and the other in 1996. I still ski, snowboard, and bike. Iíve had no issues.


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    Last edited by gcohen; 10-08-2017 at 04:26 PM.

  4. #4
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    I had my right ACL done 14 years ago (in my late 30's) with patellar tendon replacement. Rehab was longed due to swelling (I shredded my ACL, strained my MCL and the doc had to trim up my meniscus). I have no issues with 1/3rd less patellar tendon (had some numbness for a year or so) and the replacement ACL feels stronger that my original.

    I know of others who have done cadaver and hamstring variants- some said their hamstring was not the same after.

    If I blew one again, I'd probably go with cadaver replacement for giggles and less recovery time.
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  5. #5
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    Quote Originally Posted by edubfromktown View Post
    I had my right ACL done 14 years ago (in my late 30's) with patellar tendon replacement. Rehab was longed due to swelling (I shredded my ACL, strained my MCL and the doc had to trim up my meniscus). I have no issues with 1/3rd less patellar tendon (had some numbness for a year or so) and the replacement ACL feels stronger that my original.

    I know of others who have done cadaver and hamstring variants- some said their hamstring was not the same after.

    If I blew one again, I'd probably go with cadaver replacement for giggles and less recovery time.
    So part of what you're saying is that a cadaver graft heals faster than a patellar ligament graft on account of how long it takes for the patella to heal? I understand that the reconstructed ACL heals faster when using your own tissue (autograft) versus using cadaver tissue (allograft).
    Last edited by ehigh; 10-09-2017 at 07:16 AM.

  6. #6
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    Quote Originally Posted by ehigh View Post
    So part of what you're saying is that a cadaver graft heals faster than a patellar ligament graft on account of how long it takes for the patella to heal? I understand that the reconstructed ACL heals faster when using your own tissue (allograft) versus using cadaver tissue (autograft).
    I can say my rehab seems to be going a lot faster than a Co-worker that did the Patella graft. I'm a few weeks from being done with my brace, he's been in one for going on five months. We used the same surgical group, but different surgeons. I also damaged my knee way more than his.

    Allograft is a cadaver by the way. I will say I make a lot of jokes related to the cadaver graft, my wife doesn't think it's nearly as amusing as I do however. I think a lot of people think the allograft is a lot weaker than it really is. When I really dug into the reading, that tended to be what it boiled down to.

    Outside of the graft, just do everything they tell you. After your surgery, PT sucks, but it's worth it. I can see improvements daily. I've started walking three to five miles a day on top of the exercises. It aches, but I've almost completely recovered my range of motion. Don't bend your knee when you're resting your leg too! The PT to get it back flat SUCKS. Mine doesn't need much, but it's probably the most painful part of the whole process. Thankfully it's quick.

    I rode a lot before the surgery, 50-100 miles a week. After my accident, I dropped almost 15 lbs in weight which I'm sure was all leg muscle. Be prepared for that, it's amazing how much smaller my right thigh is vs my left.

    The hardest part of this whole process honestly was sleeping in a locked leg brace for two weeks. As a side sleeper and a person with bad sleep apena, I had real issues trying to sleep with it. For the first week I may have gotten four hours of sleep a night. Once I figured out how to sleep, it was better. The first night I went without it however, I slept for a solid 13 hours.
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  7. #7
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    I've had both my ACLs redone, the first one was an autograft and the 2nd an allograft. I was only given a choice for the second one, and after the experience with the patellar tendon, it was rather easy to go with the cadaver tendon the 2nd time. In both cases I was put in a Continuous Passive Motion machine for about 3 days after surgery. That alone helped a lot in getting me up and moving quicker than some it seems, and I'd recommend asking the docs about it, if it hasn't been brought up already.

    A run down of my experience with each one...

    Right knee, a patellar tendon graft. Surgery went well, they used a big coarse thread titanium screw to hold the bottom of the tendon in my tibia instead of a bone plug. This makes a difference for recovery time since a bone plug has to have time to fuse to the tibia. The joint and tendon were super stiff afterwards. They sent me home with a pain pump in the knee, but the tube pulled out the first night, and made little difference. Not a ton of pain. The CPM machine did its job getting range of motion going, I think I was in it constantly for 3 days, and during the day for a few more. Yes, I slept with a machine slowly bending my leg at the knee for 3 nights. The angle was slowly worked up as the stiffness and strain on the tendon allowed. I want to say it took a good 5 days to be able to hobble around the house without much help from crutches, and not that long afterwards where I was off them totally. Rehab consisted of getting the range of motion back and building up some strength, though my legs have always been pretty damn strong. I found tendonitis in the patellar tendon to be the worst thing involved with this one. It was there during rehab, and for about a year after surgery doing anything strenuous. I was off work (mechanic) for about 8 weeks since the doc didn't want me around anything hard enough to break my kneecap.

    Left knee was a cadaver tendon. Surgery was fine, this time with a bone plug holding the tendon and filling the hole in the tibia. Because of this, I was off work quite a bit longer, 12 weeks IIRC. No patella to worry about breaking though. The CPM was a breeze this time around, not having to fight stiffness in the patellar tendon. I was in it the standard 3 days, getting up to 90* quickly. I was also walking easily the 3rd day, and even though I had the crutches with me on the follow up on day 4, doc asked me why I even had them. Rehab was easier this time around without tendonitis, though the pace was a bit slower while the bone plug fused. So far, no durability issues with the cadaver tendon, and my joke is I'm .5% zombie :P

  8. #8
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    Quote Originally Posted by ehigh View Post
    So part of what you're saying is that a cadaver graft heals faster than a patellar ligament graft on account of how long it takes for the patella to heal? I understand that the reconstructed ACL heals faster when using your own tissue (allograft) versus using cadaver tissue (autograft).
    I was looking at it from the perspective of recovering from two procedures: harvesting 1/3rd of the patellar tendon plus bone plugs on each side and installing the new and improved ACL versus installing a harvested cadaver replacement ACL.

    I had a lot of knee swelling for a few weeks after the injury and then again post op (surgery was ~6 weeks after the injury IIRC). Some may have been due to the injury (I was in a full/locked out straight leg brace for two weeks post op that was very uncomfortable!). I also had a lot of numbness on the front of my knee for more than a year.

    Your mileage may vary.
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    I really appreciate everyone that has gotten back to me on this. These stories about these experiences are priceless.

    I'm starting to waver towards the cadaver graft again. I went in feeling strongly about getting the cadaver graft when I spoke with the third surgeon I've seen to talk this over. The way he put it is that I'll be "testing" the limits of the graft and that's worth considering.

    It wasn't until the end of August that I finally figured this knee pain might be more than some cartilage or meniscus damage. So I went 3 months assuming this would get better on its own. I've been contemplating options since. Doing an autograft is sounding less and less appealing. When I was told I'd get an allograft if I tore the reconstructed ACL I had to ask why not just start with that. And the doctors have said that isn't a bad idea for someone who is concerned about that. I'd say 1/3 of the surgeons I've spoken with have a lot of experience with this procedure which is a bit of a bummer. I watched a video in the operating room on an ACLR autograft operation to get psyched about it all. Gore doesn't usually bother me but I have a bit of a hard time stomaching the idea of regretting which graft I get.


    Thanks again everyone who has posted.

  10. #10
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    Quote Originally Posted by ehigh View Post
    I'd say 1/3 of the surgeons I've spoken with have a lot of experience with this procedure which is a bit of a bummer. I watched a video in the operating room on an ACLR autograft operation to get psyched about it all.
    I think I watched that, haven't been able to look at a raw steak since.

    My surgeon pretty much does nothing bout ACL/MCL/Miniscus. So far I've been really happy. I got the impression they do 4-5 knee surgeries a week. Go online, you'd be amazed what you can learn about your doctors lol.
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  11. #11
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    Watching that video made me wish I was a surgeon. Looks kind of fun. Some of the work I've seen done on a bicycle takes longer and looks more complicated. Like rebuilding the upper legs on a Talas fork, mess it up and it could be catastrophic but follow the procedure step by step and in less than an hour it's done.

    You wouldn't happen to be in California? Limited options around where I'm at. I'm actually paying out of pocket for this procedure and have considered going out of the county. Anything besides using Google, Health Grades, and Yelp that you'd recommend using to read about doctors?

  12. #12
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    Oklahoma, https://www.ratemds.com/ok/claremore/ and Healthgrades. Sports doctors tend to be the best.

    I'm lucky in that I have really good insurance. I knocked part of my teeth back at the end of last year, so my deductible and out of pocket was met this year. In total, this whole venture ran me $100 for the ER visit.

    I will say younger doctors might also be a better option. The older ones tend to have older ideas.. part of what happened to my co-worker.
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  13. #13
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    Thought I'd also add, look into PT as well. It's just as important to find a good place for PT as it is to find a good surgeon.
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    Thanks again for the advice. I ended up flipping through the Teton Gravity Report forums and found out they've had a "ACL Class of" thread going for years for people to check in and discuss how it's going/gone. Figured I'd mention it for anyone here that ends up in a similar situation. The number of people discussing it there is sort of priceless. Still seeing plenty of reasons against each option. A non-irradiated cadaver ligament is still sounding pretty good. The chance of having to stay off that knee for an extended period of time sounds like crap and the chance of forever being at 95% strength in my hamstring doesn't sound much better. Still undecided.

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    I was up on mine after three or four days. Mostly due to the femoral block didn't want to wear off. I took a few three mile or more hikes over the weekend without to much issue too, which seems to have really surprised my PT. I think everyone's different. It all depends on how much you're willing to put into it. I want to get back to where I was, so I put everything I can into it.
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    I figure I'll drop my in-progress notes in here. I went with the hamstring. I had pain/recovery in the hamstring which I guess I knew but I was focused on the knee so much it surprised me.

    I went with that as I figured it was the larger place to take from. I didn't want to risk any cadaver rejection issues/not knowing what you're getting.

    I'm just over 2mo post-surgery. I've just hopped back on the bike in the last couple of weeks for fairly flat bits. It's amazing how much you can work on pedaling without bothering the knee much. I've been in PT with a guy that was a month ahead of me I feel like I've about caught up to him in recovery. He had the patella graft but it's also his second replacement.

    I don't feel like I can give a final result as I'm still held back. I'm regaining strength and it'll be another 6mo before I can go all out without fear (though I'm sure I'll keep some fear in reserve).

    Definitely get PT going. I started PT 5 days after surgery and go 3 times a week ever since. It's made such a world of difference. Also get one water cooling machines post-op. It is amazing. I'd pay cash out for the damn machine if this ever happened again.

    Good luck on the recovery and it's heartening to see all the folks on the other side. I should have poked around the forums here a lot earlier.

  17. #17
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    Quote Originally Posted by ehigh View Post
    Thanks again for the advice. I ended up flipping through the Teton Gravity Report forums and found out they've had a "ACL Class of" thread going for years for people to check in and discuss how it's going/gone. Figured I'd mention it for anyone here that ends up in a similar situation. The number of people discussing it there is sort of priceless. Still seeing plenty of reasons against each option. A non-irradiated cadaver ligament is still sounding pretty good. The chance of having to stay off that knee for an extended period of time sounds like crap and the chance of forever being at 95% strength in my hamstring doesn't sound much better. Still undecided.
    LUKE, use the FORCE

    Whatever you decide, hope it goes well.

    Main thing to remember is don't push too hard on the recovery (everyone recovers at different rates so don't compare your progress to others) and be damn careful getting around.

    I read about one guy who was like a week post-op ACL replacement, fell down a flight of steps (trying to negotiate with crutches), shredded his newly installed one... and the other ACL!
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    I'm seven weeks post op today, my recovery is going as well or better than expected for me. I started PT Two weeks post op, going three times a week. It still gets sore and swells pretty good, however it doesn't slow me down anymore. My leg is still weak, some of the exercises they have me do makes it shake like a leaf. With that in mind, my day to day isn't noticeable outside of a bit of soreness after standing from sitting for a long period.

    I'm thinking about taking my bike out for a spin around the neighborhood. Every time I bring it up I get a worried look from my PT/Wife however. The most pain from the whole endeavor came from the PT trying to get movement back into my kneecap, otherwise it hasn't been bad.

    Do the exercises they give you, invest in some good ice packs if not the water machine, and recovery isn't bad at all. I was able to take ~900 steps at Walnut Canyon in AZ five-six weeks post op without to many issues. Now I'm mainly working on getting my balance back.
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  19. #19
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    28 years on a patella tendon graft here. I'm getting a TKR in a couple of days but the joint is still stable and the graft is the only good thing about my knee. I got another 25 years of telemark skiing in, ~100 grand canyon river trips, lots of backpacking and canyoneering, and lots of mtn biking. In short, it never held me back from being active and lots of opportunities to tear it.

    Never had a problem with the knee cap or the petalla tendon itself after the graft was harvested. Good luck with your choice.

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