Have you ever felt like your world came crashing down after an injury?
When I tore my ACL earlier this year, it felt like the end of the world. I could no longer run, let alone walk. I struggled with stairs. The future felt quite dim.
Luckily, I started physical therapy. I was no longer helpless to the situation. Each exercise reoriented me away from despair. Instead of a deep pit, my torn ACL became something that could be solved.
Something I could overcome.
What is an ACL?
The human knee is not a paragon of intelligent design. Ligaments, cartilage and bone come together for the purpose of mobility and stability. In day to day use, the ACL is not actually a particularly important ligament. Most people don’t need an ACL to work their desk job or short walks. However, anyone that needs tight-deliberate control of their body (skiers, professional athletes, etc) requires more support.
For these people, the ACL is crucial for maintaining stability of the knee. When you over exert the knee, thus testing it’s control, the ACL is often the first to break. That’s why ACL tears are such a common injury for athletes.
Tearing you ACL
In my case, the ACL ruptured completely. Like any rope, or connective tissue, strain and excessive force can lead to damage. When I fell skiing, my left ski failed to detach. This caused the ski to act much like a parachute – slowing me down abruptly. When my torso fell one way, and my foot the other, it was my knee that bore the punishment.
My ACL ruptured into pink dust: complete detachment.
I felt no snap or crack. So when I was loaded into the MRI machine, my knee covered in heavy sandbags to keep it straight enough for imaging, I was utterly shocked to hear the news. My ACL was gone.
I struggled to walk. I couldn’t bend my knee. But, I had a choice to make. I needed to decide what to do next.
Needs
First and foremost, the primary consideration is patient need. What do you need?
In my case, I have three main requirements:
- Good Performance (I want to go back to Skiing and Running)
- High Success Rate (I don’t want to under go surgery again)
- Easy Rehab (I want to avoid unnecessary pain and shorten the length of rehab)
The Choice
There are three main choices when you tear an ACL. You can choose to do nothing, opt for a replacement from a donor (allograft), or use tissue from another part of your knee (autograft).
Nothing
Doing nothing is a valid choice. You don’t need an ACL to work in an office or walking in the park. Besides some physical therapy, this is by far the easiest and cheapest option – no surgery to recover from. Of course, the main downside is that your basketball days are over – any sort of long distance running, sking, etc are off the table for good. No ACL, no fun!
Allograft (donation)
Organ donation is one of the greatest selfless acts a person can gift to society. A new heart, kidney or liver can forever change a person’s life for the better. Thus, why not donate a ligament?
Allografts are precisely that. Your doctor will take a strip of ligament from a cadaver, and install it in place in the knee.
Advantages
- Faster Recovery
- Less Scarring
- Faster Surgery
- Less Painful
Disadvantages
- Higher Initial Failure Rate
- Risk (though small) of disease transfer
- Long Term Failure is not clear (will this graft last the rest of my life?)
- Not recommended for patients under 30
From my research, most of the issues with Allografts are due to the way they are treated. Use of radiation or chemical treatment can greatly increase the risk of failure.
Autograft (transfer)
Why go somewhere else, when all you need is already in you? Instead of harvesting the replacement ACL, doctors can harvest a piece of tissue from another part of the body. Typically, this will be taken from near the injured knee. Which part of the knee is up to you and your doctor.
There are three main options
Hamstring
Taken from the back of the thigh, one of the more popular choices for ACL replacement is the hamstring.
Advantages
Disadvantages
Patelar
The patelar ligament, found just below the knee, is another great option. Typically, physicians will perform Bone-Patelar-Bone Therapy (BPBT). A small bit of bone will be removed along with the ligament. This allows for stronger attachment to the knee join.
Advantages
- Most Common
- Majority of Scientific Literature/Research
- Strongest
- Highly Recommended for Elite Athletes
Disadvantages
- Most Expensive
- Potentially More Painful
- Pain While Kneeling
Quad
Advantages
- Faster Recovery
- Stronger Remaining Tendon After Harvest
Disadvantages
- Newer Option
- Less Research
Conclusion
As a laymen, lacking any real medical certification or experience, I can not make a definitive recommendation. Ultimately, any patient undergoing ACL replacement should refer to their physicisian for relevant advice. However, based on my needs, the quad autograft seems to meet my demands.
Doing nothing will prevent me from living the active life style I have grown accustomed to. While the Allograft should provide the performance I need with the shortest recover, I find the installation success rate and mixed findings for long term success highly discouraging. That just leaves autograft. Unfortunately, my surgeon does not offer hamstring ACL replacement; many surgeons do not offer all types of replacements.
Of the remaining options, I believe that the shorter recovery, reduced pain, and equivalent success rate makes quad the clear choice for me.
Stay positive, concentrate on your PT, and most of all rely on those around you. You deserve all the support you can get.