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ACL Grafts: Which is Best? A Strength Coach’s Perspective

Written on November 15, 2010 at 3:53 am, by Eric Cressey

A few weeks ago, I came across this recent study of different ACL grafts.  It found that there was no difference in follow-up success rates at two-year mark between hamstrings and patellar tendon grafts.  The patellar tendon group did, however, exhibit more anterior knee pain – which isn’t a surprise because it’s not uncommon to see longer term tendinosis in athletes with patellar tendon grafts even after their “rehabilitation period” is over.  That said, I would be interested to see what would happen if they:

a) evaluated those patellar tendon graft subjects who received soft tissue treatments as part of their rehabilitation versus those who didn’t (my experience says that the anterior knee pain goes away sooner when manual therapy is present) .

b) evaluated those who went to effective strength and conditioning programs immediately post-rehabilitation versus those who didn’t (my hunch would be that those who continued to activation/strengthen the posterior chain would have experienced less anterior knee pain).

c) looked at performance-based outcomes at ~12-18 months in the hamstrings group, as these folks have more “intereference” with a return to normal training because of the graft site (you want to strengthen the posterior chain, but can’t do that as soon if you are missing a chunk of the hamstrings).  My experience has been that patellar tendon patients can do a lot more with their strength and conditioning program sooner than those who have hamstrings grafts.

It’s not to necessarily say that one is better than the other, as they both have their pros and cons – but I think this study potentially casts patellar tendon grafts in a less favorable light when the truth is that hamstrings grafts can have just as many complications down the road.  Above all else, the best ACL grafts are the ones that the surgeon is the most comfortable using – so pick your surgeon and defer to his expertise.

As an interesting aside to this, I remember Kevin Wilk at an October 2008 seminar saying that 85% of ACL reconstructions in the U.S. are performed by doctors that do fewer than 10 ACL reconstructions per year.  So, don’t just find a surgeon; find a surgeon that does these all the time and has built up a sample size large enough to know which ACL graft site is right for you, should you (unfortunately) ever “kneed” one (terrible pun, I know).

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7 Responses to “ACL Grafts: Which is Best? A Strength Coach’s Perspective”

  1. Daniel Iaciofano Says:

    Nice post Eric.

    As someone who has had an ACL reconstruction using the hamstring for the graft site I agree. There are pro’s and cons to both. My surgeon exclusively worked with ACL tears year round, it’s very important to find a guy who is a specialist in ACL’s.

    Dan

  2. Keith Says:

    Any experience and comments (aside from longer recovery times)with ITB grafts? This is what I elected to have. I was lucky to get a good surgeon that worked with me from diagnosis through to surgery

  3. Tom Says:

    Hi Eric,

    Interesting post as always. I am a physical therapist and work with 2 surgeons that perform a ton of ACL reconstructions every year. I would say graft selection within our group is pretty evenly divided between Patella tendon, hamstring, and allograft. The graft selection is usually dependent on the patient’s age, activity demands, and some other factors. Our surgeons are very proficient with all graft types and our outcomes are good (we follow for approx. 1 year)regardless of graft selection. For what it’s worth, we typically begin isolated posterior chain training within 6 weeks post HS graft. Earlier with the others. We start mini squat progressions immediately post op (within a few days)with everyone. Since I’ve begun reading your blog I’ve eliminated isolated knee curls and the sort from my programs and have been using SL Hip Lifts, deadlift variations, and other more functionally based CKC exercises to train the posterior chain. Do you have any thoughts on a logical progression of posterior chain exercises that would be appropriate for these patients to systematically activate and progress the posterior chain? I find my athletes pick things up pretty quick, but many of our weekend warriors look awful doing simple hip lifts and modified SL RDLs (poor mobility and activation patterns everywhere being the culprit..which we try to address). We are limited with length of care by insurance benefits, so while we emphasize activation and mobility impairments immediately, people sometimes run out of visits before their mobility is adequate to move on to some of the more difficult (and beneficial) exercises. I’d love your input on posterior chain progressions for the previously untrained or deconditioned. Thanks for the info you provide us all.

  4. jakers Says:

    Anterior knee pain is real from a patella graft. Graston was part of my rehab and has largely alleviated it but there are a few positions while kneeling that I\’m not going to maintain for very long. (Like less than half a second)

    One complication that I wasn\’t made aware of pre-surgery was that when taking the graft from the patella it can be broken. It\’s a known 1 in a thousand complication. Just my luck it was my surgeons 750th acl procedure. Two more screws in my knee cap to hold it back together and 3 months in brace waiting for it to heal before I could begin PT. Probably put my recovery behind by about 6 months.

  5. Matt Says:

    Great advice! My personal experience is obviously anecdotal, but thought I would share. I have had ACL reconstruction on both knees, at the time of my injuries I was playing college football so I was very interested in the pros and cons of the hamstring and patellar tendon grafts. After driving myself mad trying to make the best decision I ultimately decided to go with my Doctor’s preference, the hamstring graft. Two year later I tore my R ACL, new doctor, so I went with the patellar tendon graft. Both surgeons did great job, I am currently very active without complication.

  6. Matt Biancuzzo Says:

    Great stuff as usual Eric. As you said, it comes down to surgeons preference and I especially like you bringing up finding a physician who does multiple ACL repairs per year. I think that has a lot to do with recovery and other complications down the road. I have dealt with more hamstring grafts than patellar and don’t really see a glaring positive for one over the other. I do whole-heartedly agree that with proper posterior chain strengthening and manual work on the hip flexors, quad, quad tendon, and patellar tendon that anterior knee pain can be greatly reduced with patellar grafts.

    Tom, I definitely understand your frustration and am glad I have not had to deal with visit limitations from insurance coverage due to the settings I have worked in. One thing I have found great success with when trying to instruct those who are less athletic than others is to quickly and aggressively train the uninjured limb with those higher skilled/more difficult exercises. By doing that, they can neurologically pick up those movement patterns and know how the exercises should feel so when they are ready to progress to those exercises on the injured/surgical limb, it should be a quicker progression.

  7. ZW Says:

    Mr. Cressey –

    Your commentary on autograft choices for ACL surgery was particularly interesting to me personally. Currently, I’m taking a years leave of absence out from med school to serve as an ACL research fellow here in Pittsburgh. I’d like to add a few points I’ve learned from my experience.

    1. In addition to the BTB and the hamstring autografts, surgeons here are starting to shift to the quadriceps tendon (harvested without a bone block) as their go-to graft in ACL surgery. This has become so popular over the last year or so that the quad will be included as a major arm of a large, NIH sponsored randomized-controlled trial scheduled to kick off here in January (we’ll be comparing anatomic single-bundle and anatomic double bundle reconstructions for much of the next 7 years or so). The basis for using it is that the tendon is thicker than the other options available. At a diameter of approximately 8-10mm, it is able to reproduce a large percentage of the footprint of the native bony insertion sites. Additionally, the mechanical properties benefit from a greater cross-sectional area. I was originally skeptical myself because the procedure is very painful early on, but patients seem to recover very rapidly from the pain and seem to have an overall similar recovery to patients with the other grafts. This graft may not be optimal for the high-performance athlete because it removes a chunk of a pretty significant tendon in the knee, but the surgeons here seem optimistic that the quad may be able to reduce re-tear rates in younger athletes (our greatest at-risk group statistically) because of its size. Additionally, I’m very interested to see what happens to their quad function over time and whether these patients will be affected by greater scar formation because of the size of the incision into the quad. Just wanted to put it on your radar.

    2. In terms of the paper you discussed this AM by Magnussen et al, there are limitations in the outcomes measurements they used to look at differences that they didn’t discuss. The IKDC scores in particular aren’t really helpful because they group outcomes A & B (normal and nearly normal) together as non-failed reconstructions and don’t report the breakdown. If you look at the IKDC form (you can find it in the original paper for IKDC guided ACL assessment: Irrgang et al, KSSTA 1998, 6:107-114), A & B aren’t really similar. Historically they are grouped together because that paper couldn’t find a statistical difference between A&B states but I would bet that this is more of a function of cautious testing that didn’t stress the knee to its limits at the time of exam. Surgeons don’t like to push that envelope because no one wants to risk damaging a patient for assessment purposes. However, I am confident that you’d notice the difference between an A and a B knee at the levels of performance you see in your gym. I don’t know if examining A & B separately would cause a different conclusion in this paper because many of the other outcome measurements seem pretty even at a quick glance, but we also know that the clinical exam doesn’t correlate strongly to subjective complaints, which is why the IKDC exists in the first place. I think its a shame that this has been propagated through the literature. The surgeons at Pitt are moving away from reporting “normal” and “near normal” as one outcome here as well, and that movement is headed up by the three original authors of the 1998 KSSTA paper that are still attendings here. They all agree that more sophisticated assessments must be developed to accurately reflect the patient experience. Finally, the 5 year follow-up isn’t long enough to capture the magnitude of the clinical effects caused by osteoarthritic changes from the patellar grafting. As you no doubt understand, the time horizon for these changes are really 2-5 times the length of this follow-up period. I am similarly interested to see how proper posterior chain training (which I would bet my massive student salary that close to zero of these patients have had) can alter both these changes radiographically and symptomatically. Unfortunately, the OA process may be an unalterable cascade triggered by the initial grafting insult, and the field just doesn’t understand that process enough yet.

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