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What can you tell me about ACL reconstruction surgery? I'm just starting to look into the details as I'm probably going to have this operation. I understand all about the two different graft choices. What's the latest skinny on these?

No matter what type of graft is used, surgeons agree that the results are better when the reconstruction mimics the natural anatomy. The graft tissue is placed inside the knee using tunnels that are predrilled through the bone. Screws hold the graft in place until it is incorporated into the tunnel and healing takes place. Studies have shown that nonanatomic reconstructions just don't produce the same good-to-excellent results of anatomic techniques. And, it is absolutely necessary to match the length of rehabilitation with the type of graft used for each patient. For example, allograft tissue (from a donor bank) takes longer to heal within the bone tunnels. Rehab is extended to allow for that delay. Patients who intend to return-to-play in a competitive or high-intensity sport must also be given additional time to train. And the surgeon and rehab therapist must take into consideration that high-level athletes will put the graft to the test with running, jumping, quick turns, and sudden stops. It's clear now from several decades of surgical treatment that every patient must be evaluated individually. There is no "one-graft-fits-all" choice for anterior cruciate ligament (ACL) repairs. First, is the patient male or female? Women are more likely to experience graft failure with hamstring autografts (tissue taken from the patient). Next, what sport is involved? Many patients participate in multiple sports year-round. The surgeon must consider each graft type based on the activity and intensity level. Autografts involve donor site morbidity -- in other words, problems that develop where the tissue was taken from or harvested. Bone-patellar tendon-bone (BPTB) autografts present the greatest donor site problems. There can be pain when kneeling -- that's the main difficulty after the reconstruction has taken place. Fracture of the patella (kneecap) and loss of knee extension are two other possible complications of autograft BPTB. You can see why this might not be the best choice for someone who isn't fully invested in the rehab program or who has a low threshold for pain tolerance. But the bone-patellar tendon-bone (BPTB) graft provides a good, stiff ligament needed to maintain knee stability. It is less likely to stretch out and more likely to heal well compared to the hamstring graft. The autograft has a better track record in these two areas compared to a BPTB allograft. These features of the BPTB graft make it a better choice for the active young adult who is eager to get back into strenuous sports activity. Now what about that hamstring graft choice? We mentioned it is the strongest graft material. There are fewer problems at the donor site. But it takes longer to heal compared with the BPTB graft. Athletes must rehab a full month longer (at least). The rehab program must pay close attention to getting full hamstring strength back. And the risk of graft stretching and losing tension is greater with a hamstring graft. Studies also show that graft failure is more likely with the hamstring graft. There's more joint laxity (looseness) with this type of graft. Women already have greater knee laxity than men so the hamstring graft may not be ideal for them. Finally, there's nothing more disappointing than a graft failure in a young athlete eager to get back into action. Allografts seem to have a higher failure rate in this patient population. It is suspected that the reason for this is the sterilization process used to make sure the graft doesn't harbor any infections or other diseases. There are risks and benefits with any soft tissue graft. As each patient faces the decision of choosing one over the other, conversation with the surgeon is important. Selecting the graft type is a personal choice based on each patient's needs, activity level, goals, and preferences. The decision will be influenced by surgeon experience and preference as well.


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