Patella Tendon (Autograft)
This means taking a strip of the tendon from the front of the athlete's own knee (autograft), and is the most popular choice for this surgery. This technique has been utilized for the longest period of time in the largest number of patients, and is considered the gold standard for ACL reconstruction.
Advantages: Strong graft, with bone attachments at each end, which allows the graft to be fixed very solidly at the time of surgery and which allows healing to the body in the shortest period of time (bone to bone healing) of 4-6 weeks.
Disadvantages: Requires taking tissue from the body. This may cause donor site soreness in a small percentage of patients. To avoid this we utilize a unique method for harvesting the patella tendon graft. This method utilizes a round oscillating tool, which takes a circular graft and leaves the patella with a smooth defect. This makes the patella much less prone to any post surgical problems, and we have not found this to be a problem in many hundreds of patients.
This is a newer method, that is gaining popularity. We recommend this technique for patients who for whatever reason are not a candidate for usage of the patella tendon.
Advantages: For some surgeons, this may result in a lower incidence of donor site discomfort.
Disadvantages: Hamstring tendons do not come with bone attachments, and it takes the body 12 weeks to heal the hamstring graft (3 times as long as the patella tendon). This means that in the early postoperative period the graft is at risk for injury for a longer period of time.
This means using tissue from a cadaver. This is an attractive option in cases where multiple ligaments are injured and additional tissue is needed for surgery, or for revision cases where the patient's own patella tendon has already been utilized.
Advantages: No need to take tissue from the patients already injured knee. May be a good idea in the older patient whose own tissue may be weaker than the usually young donor.
Disadvantages: This method has lost popularity recently because of some reports that it is more likely to stretch and fail than an autograft. This is partly due to the weakening of the graft caused by the need to irradiate it to prevent disease transmission. Unfortunately, even after irradiating the donor graft tissue, the risk of transmitting disease is still possible, although rare.
ACL Tightening (Shrinkage): We are currently performing a study utilizing a new technique which tightens the partially torn or stretched ACL. This is not applicable to the completely torn ligament. Surgery is done arthroscopically with no incisions. Recovery time is dramatically faster than with a reconstruction. So far, we have been impressed with the ability to tighten the ligament at the time of surgery (average 50% reduction in laxity). We are following these patients closely to determine if they will stretch.
After-care: Patients are sent home with a knee brace for the first day. Range of motion is started as soon as the wound is checked. Early goals are to obtain range of motion and to reeducate the muscles. Weight bearing is begun immediately with crutches. The brace is utilized for three weeks or until the quadriceps are strong enough to support the limb. Crutches are discontinued after 1-2 weeks. Stationary bicycling is begun as soon as the patient can achieve 100 degrees of flexion and can get around on the pedal (usually 2 weeks). Outdoor bicycling and jogging are allowed at 3 months. Return to twisting cutting and jumping sports is delayed for 6 months since this is how long it takes for the graft to biologically heal. Prior to returning to sports, the patient is expected to have regained 90-95% of their muscular strength.
Prognosis: ACL reconstruction is a highly successful operation. 90-95% of patients can be expected to return to full sports participation with 6 months and with aggressive rehabilitation.