Wednesday 19 November 2014

Bone-Patella Tendon-Bone ACL Graft.

Which Graft should you consider for ACL reconstructive surgery?

This is an often debated question and the literature has many references to which is most appropriate for an individual.

The broad categories include

Autograft (Patients own tissue)
Allograft (Harvested tissue from a donor)
Synthetics (Manufactured material)

I will not drag open the debate but simply point each individual to the internet for interest and to discuss with their surgeon, the most appropriate graft for their reconstruction. Ultimately it is the patient’s choice.

My reasons and beliefs for my choice of graft are set out below.


I reserve this for revision surgery in my practice but will also offer autograft in revision should the patient prefer (sometimes using he opposite limb to harvest the graft). Allograft is expensive, has a slightly higher risk of failure in young people and possibly has a higher risk of infection. However there is no donor site morbidity (discomfort and some loss of function associated with autograft harvest from the patient).


This must be the graft of choice for first time ACL reconstruction. Typical grafts include, Bone-Patella tendon-Bone (BTB), Hamstring, and quadriceps tendon.

I choose BTB as my graft of choice as I have most experience with this graft. My harvest technique through small cuts and tunnelling out the graft allows a reduced level of discomfort on kneeling and ache at the front of the knee (a common complaint from patients who have a long midline incision to harvest the graft).
The fixation of BTB is very strong and if a patient is unlucky enough to suffer a rupture of the graft, there is good bone and not tendon within the placement tunnels making revision surgery easier.
Perhaps more importantly in professional footballers, there is now growing evidence of a reduced failure rate with BTB compared to Hamstring. This is perhaps the most compelling reason to use BTB over Hamstring.
It is important to understand that this is a personal choice and has worked well for my patients.


These can be used to augment an auto or allograft but rarely used at present as the main choice.

Will we ever know which is the most appropriate? In the UK now, a registry has recently been set up to record outcome after ACL reconstructive surgery. In time this should give us more evidence of the best graft choices in a set of circumstances and in any one particular surgeons hands. Visit for more details.


Work is becoming easier towards the end of week 4 and I am looking forward to being able to stop wearing my brace, as I feel it is becoming too much of a ‘security blanket’.

Robin likes his ACL patients to wear the brace, which limits the amount of bend you can get in the knee to 90 degrees, for four weeks after the operation.

Surgeons vary with this, some not liking their patients to wear a brace at all and others advising two weeks of wearing it, but Robin stresses that the research shows that in the long run, the wearing of the brace for four weeks, increases the long term stability of the knee, but this may be more for only the type of re-construction I have had (patella tendon-see above).

The brace runs from the thigh to the ankle and you tighten it with straps and it does give you a lot of support and confidence. The down side is that your muscles don’t have to work as hard and so you lose more tone and bulk, which you need to compensate for, by doing plenty of exercises.

Another down side is that when you put the brace on in the night, for example if you need the loo, the velcro makes a terrible noise, when you take the brace off again, waking anyone in the vicinity!

On the Thursday of this week, so four weeks post op, I remove the brace and I do feel much weaker than I have done!

But I also feel much freer and I go for my first swim.

I am careful not to do any kicking movement but I am an ok swimmer and love the feeling of being able to do front crawl, with my legs just dragging behind me.

It feels fantastic, a re-gained freedom, something I can do. I also enjoy just gently bending and straightening the knee, with my back to the pool wall.

I am feeling that things are improving but I am very aware of the fact that ACL re-constructions are very vulnerable at the four to six week period, as the blood supply is starting to reduce in the graft, before the graft becomes re-vasularised, after about the six week period.

As I got into the water and out, I was very aware of this and wore a pair of wetsuit shoes, to help me grip and I moved very carefully.    

Pain is not really an issue now and I am improving all the time, with my Physio, with Ali, although swelling around my knee cap, is still a big problem, which is worse in people who have had the patella tendon graft and not really an issue in people who have a hamstring graft.


I hobble onto the train and walk up through the park, with my crutches,( of course) and go to work, for the first time, since the operation.

Over the weekend I have been able to do a short amount of walking, without my crutches, but only indoors.

I deliberately have a very light day, with only four or five patients and I have gone in to work a bit later than normal.

My feeling is one of happiness, to be back to work and I am glad I have broken in lightly and for me it would have been harder to leave work for longer. I am pleased to be back and have found it a little easier than I expected.

My second day back at work ,is extremely tiring and I realise that I had been existing on adrenalin, by the end of the day, although it is a light one, I am shattered. If you can take three or four weeks off work, after an ACL, do so!!!!!!!!!!!!!!!!

I struggle through the week, but I am helped massively by Alison Orchard, as I start my Physiotherapy with her, in earnest and she gets me through the week.   
The physio involves her helping to mobilise my knee cap and get me used to the scar being palpated and helping me achieve closed chain exercises, which basically means exercises, where you have your foot on the ground, as you are not meant to do any open chain exercises, where your foot is off the ground.

With the physio, I improve, achieving more flexion (bend) of the knee and extension (straightening) but I am still struggling with swelling. 


Rest is helped by terrific weather and the Ryder cup! but my nature still inclines me to try and do more than I probably should!

I manage to get carefully down onto Hove beach, with, I must say, some pretty expert usage of crutches, so all my teaching of how to use crutches, which I have dispensed to patients over the years, has come in handy!

I lie on the beach in the sun and as i’m dosing I hear a woman say to a man, ‘how did he get down on the beach’ and i’m not sure if it’s an accusation or a compliment!

The pain is lessening, although I am still having to take codein and paracetamol four times a day, and sometimes more at night.

My wife is having to do a lot of driving, to make up for my inability to drive and I am extremely grateful, for all the extra things which she is having to do. Never underestimate the effect that surgery or illness, have on those around you!

I am trying to walk as normally as possible, with the aid of the crutches and I am still using my ice compression unit, a few times a day. I also do my exercises three or four times a day,

Friends are great and I go out to a few cafes, with them, but I feel so tired and sleep a lot in the day, which seems less uncomfortable than my attempts to sleep at night, when I fidget and disturb my poor wife.

It is, however, now possible to spend a bit of time lying on my side, as I can now bend my knee about thirty degrees and this is a huge improvement. I tend to use a ‘neck’ pillow for this as the shape seems ideal.

The swelling is still bad but I understand that this varies between patients, but the pain in my shin, which was the worst, is lessening, especially when I first get up, after having it elevated.

It is getting easier to shower but I still feel very vulnerable about slipping over!

On the Wednesday I visit the nurse at my GP practice and she removes the dressings and checks the wound and on the Friday I visit Robin (the surgeon) and he is satisfied with the progress.

I am never bored and relish the time to catch up on some reading.