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.

Allograft

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).

Autograft

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.

Synthetics

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 www.uknlr.co.uk for more details.

NIGEL's BLOG - WEEK 4

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.

NIGEL's BLOG - WEEK 3

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. 

NIGEL's BLOG - WEEK 2

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.

NIGEL's BLOG

Autumn news from the Physiotherapy Centre

Breaking News

One of our physio's has damaged his cruciate ligament in his right knee and has undergone surgery to re-construct it.

Here he writes up his experiences and gives some insight into the structure of the ligament, why it may have snapped on him and what the reconstructive surgery involves.

My name is Nigel Howell and I am one of the physio's at the Physio Therapy Centre in Haywards Heath.

I play football twice a week, once on a gym floor and once on astro turf, or at least I used to!

On the day I ruptured my Anterior Cruciate Ligament (ACL), I played a 'one off' game on a '3G' surface, which is a matted surface, resembling grass, which I am not normally accustomed to playing on.

The format was a 'round robin' competition for charity, run by the Purple Carrot Cafe in Hassocks.

Half way into the competition I twisted my knee and I felt as if I had been struck by a fast moving cricket or hockey ball on the outside of my right knee; indeed this was my first irrational thought.

I soon realised that this was not the case and being a physio, I realised that I had probably caused some major internal structural damage to the knee.

I hoped it was not the ACL and I was pleased that there was no immediate and severe swelling, as this is often a sign of a ACL rupture.

After a few moments I got up and realised that I was in big trouble and that my knee felt completely untrustworthy.

Soon after the incident I went to visit a consultant, who authorised a MRI scan.  I went to see him for the results two weeks later and it confirmed what we had both been thinking, the ACL had ruptured.

On a scan the ACL normally looks straight and runs diagonally in the knee, but my ruptured ACL looked 'crinkly' and only ran about half way up.

I knew the options, from experience.

a) Try to rehab the knee, without surgery …. By building up the musculature around the knee and improve control and co-ordination. This works for many people, but, you must wear a brace if you ski or play football as twisting/turning sports can be very difficult.  There may also be an increased risk of osteoarthritis in the knee, as the ACL helps to make the knee joint operate in a normal bio-mechanical way.

b) Opt for the operation, either a hamstring graft or a patella graft, which both have reported advantages and disadvantages.

My consultant offered me the choice but my gut feeling was to go for the operation and the Consultant I saw does the ‘patella tendon’ type of ACL reconstruction.

A week later I was heading to the hospital for the operation!

If this ever happens to you, you do need to think carefully about your options and whether you feel the operation is for you!

This will depend a lot on your lifestyle.

If you don’t do much sport or you tend to do ‘straight line’ sports, such as cycling, running or walking, you may well find that you have enough stability in the knee, after you have done some rehabilitation exercises, which will be directed by your Physiotherapist.

You should not enter into the operation lightly, as it is not a small operation.

If you do opt for surgery, comically you would consider things such as cutting your toenails, before surgery, having good but easy shoes to slip on & off and have a space in your work diary to take a few weeks off and if you drive as part of your work, a month, unless you can negotiate working at home, from two weeks to a month, when you can normally drive again. Even if you are planning to work from home and your work is mainly desk based, you will still need two weeks off work.

Operation options

1) Patella tendon graft.  You have a tendon, which lies just below your knee cap and in fact blends with your knee cap, called the patella tendon.  If you feel directly below your knee cap, you can easily squeeze it between your thumb and index finger.

At its lowest most point, the tendon attaches on the shin bone (tibia) at a place called the tibial tuberosity.

The surgeon cuts into this tendon and takes  a rectangular shape out of the middle of it, ‘a window’.  They also take a plug of bone from the tibial tuberosity and a plug of bone from the knee cap (patella).

The surgeon then goes inside the knee with a camera and removes the remnants of the old ligament with specialised tools and ‘tidies up’ any damage that you are likely to also have done to the meniscus, which are the two semicircular discs, one on the medial side of the knee and one on the lateral side of the knee.  Normally these structures help to deepen a  joint slightly, provide shock absorption between the bone ends of the femur and tibia (thigh bone and shin bone) and help to provide fluid for the joint.

After ‘tidying’ the space within the joint, the surgeon now uses other specialised tools to drill a hole in the femur and one in the tibia, one for each of the bone plugs on either end of the Patella Tendon mentioned above.

With lots of clever techniques, the surgeon then manoeuvres the new ligament into place, inserting the two plugs of bone into the two bony holes, with the attached tendon between them. The two plugs of bone are held in place by small ‘silk screws’.

  This is the new ACL and the operation is complete, once the surgeon has sewn up the ‘portals’, which are the holes made by the camera and small specialised tools. Then an injection is put into the knee containing steroid and analgesics, to help with swelling and pain.

Immediately after the surgery, people have various reactions to the anaesthetic and surgery, some people will feel very queasy and others will feel fine and have a good appetite.

After my operation I felt fine and I was also fortunate enough to have a ‘game ready’, applied to my right leg, which is basically a top of the range cold compression unit, which intermittently inflates and deflates and surrounds the joint with very cold water.  Personally I found this very relieving.

Depending on your surgeon you will either have a brace on for two weeks, six weeks or not at all.

On the day of the operation or at the latest the next day (if your operation is in the evening) you must get up, with crutches and start to put a bit of weight through your leg. You can put maximum weight through it if you wish, with your brace on, if fitted with one.

You can go to the loo and shower, but not bath; you have waterproof dressings over your wounds.

Once the Physio has been and checked that you can mobilise well, including stairs, if you have them at home and the nursing staff have checked that they’re happy, you can go home.

Foot note: You wear a T.E.D.  stocking on your un-operated leg, which will help prevent any blood clots, which can ‘roam’ into your circulatory (blood) system and cause problems, where the moving clots can cause blockages in sensitive areas, such as the lungs, heart or brain and cause problems.

You can now follow Nigel’s blog on his progress ….

Overweight and obese people with knee arthritis tend to report more pain than slimmer people with the same degree of joint damage

Past studies have found that heavier people, especially women, are more likely to develop osteoarthritis and often have more severe osteoarthritis (OA). This study goes a step further. It suggests that people with a higher body mass index (BMI) may have more pain than normal-weight people with the same amount of arthritis-related damage.

Overall, 1,390 participants had already been diagnosed with knee osteoarthritis, 3,284 did not have the disease but were at risk of developing it, and 122 did not have osteoarthritis or related risk factors.

Weiss analyzed X-rays to determine the severity of patients' arthritis and used the health records to gather information on their BMI and pain levels during everyday activities.

She found that patients with a higher BMI reported more pain, even after adjusting for the severity of their joint damage. For each category of arthritis severity, pain scores were substantially higher among obese patients than among normal-weight patients. Scores for overweight patients fell somewhere in the middle.

Even though osteoarthritis is a progressive disease and its effects are irreversible, losing weight should help reduce pain related to the condition, Weiss wrote online June 17 in Rheumatology.

Losing weight could jump-start a healthy cycle, Weiss said: a decrease in body weight could lessen pain, which in turn might make people more likely to take on more physical activity, resulting in even more weight loss.

It might be difficult for a person who is already experiencing a high level of pain to become active in order to lose weight, however. Weiss suggested trying to lose the weight before starting exercise.

"It is easier to lose weight through dietary changes than through exercise. Small changes can sometimes make big differences," she said. "For example, drinking water rather than cola or finding ways to increase activity that will become a habit, like parking further from the store entrance or taking stairs instead of an elevator."

SOURCE: http://bit.ly/1mK8QcO

Rheumatology 2014.

Knee Osteoarthritis (OA): Daily Walking Maintains Function

Patients with knee OA can gain significant benefits and avoid physical function limitations by simply walking more.

"As clinicians, we should be promoting walking in our patients with knee OA. We should have them measure their physical activity with a pedometer, much like people measure their weight with a scale. Those starting on a walking program should get to a target of at least 3000 steps/day and ultimately try to reach 6000 steps/day. This is well below the popular anecdote of 10,000 steps/day, which may be good news to those starting out. It doesn't take much to get to 3000 steps/day," Dr. White told Medscape Medical News. He is research assistant professor, Department of Physical Therapy & Athletic Training, Boston University College of Health and Rehabilitation Sciences, Massachusetts.

Long-Term Study Documents Benefits of Walking in Patients With Knee OA

The researchers measured daily steps taken by 1788 people with or at risk for knee OA who were part of the Multicenter Osteoarthritis (MOST) Study, a large multicenter longitudinal cohort study of community-dwelling adults. Mean age was 67 years, mean body mass index (BMI) was 31 kg/m², and 60% of participants were female.

The researchers measured the number of steps patients walked with an ankle monitor over 7 days. They measured functional limitation at baseline and again 2 years later. The researchers defined functional limitation as walking speed less than1.0 m/s 

The authors reported, "Among study participants who did not develop slow walking at the two-year follow-up (<1.0 m/s), 80% walked at least 5300 steps/day." The minimum for preventing functional decline was between 3250 and 3700 steps/day. Walking an additional 1000 steps each day was associated with a 16% to 18% reduction in incident functional limitation 2 years later.

"Our findings add to the idea that walking is good for people with knee OA. Specifically, walking that occurs during unstructured activities, a few steps here and there, add up and do seem to make a difference in terms of prevention of functional limitation in this patient population. I hope that these findings will lead to clinicians encouraging their patients to use a pedometer to measure their physical activity and work towards the 3000 then 6000 steps/day goal," Dr. White said.

 Physical activity stimulates the expression of lubricin, a lubricant molecule of synovial fluid that is important for cartilage growth and that contributes to the delay of OA development.

More Walking Might Reduce Healthcare Costs Associated With Knee OA

According to Dr. White, data from the National Health and Nutrition Examination Survey showed that 80% of patients with OA have some limitation in movement and that 11% of adults with knee OA need assistance with personal care.

"Our findings strongly suggest that walking does work to prevent the onset of problems with physical functioning in the future in people with knee osteoarthritis," Dr. White said.

Arthritis Care Res. Published online June 12, 2014. Abstract