Tuesday, January 29, 2008

Choices

I'm a bit of an obsessive research junkie so naturally I spent every waking moment for two weeks drowning myself in the details of every available source of ACL related information on the internet. My objective was certainly not to become an ACL expert, but rather to become aware enough to be able to ask good questions. The fact is, doctors are the single best source for the latest and most accurate information on ACL injury (if you don’t believe me, ask any doctor). But conversations with doctors are typically much more productive if the patient already has a basic foundational understanding of the problem and the available treatment options. There are hundreds of ACL related sites on the internet and many of them contain marginal or outdated information. The key to doing internet research on the ACL is to find and stick to a few, good sources. ACLSolutions.com and the Orthopedics Associates of Portland for example both have excellent comprehensive sites.

If you are for some reason more inclined to break your leg than your ACL, then essentially the only thing you will need to decide is which color cast goes best with your shoes. ACL injury treatment, on the other hand, is much more complicated and requires some decisions to be made. The first and most basic is whether or not to have surgery at all. A torn ACL alone is far from life threatening. Although physical activity sans ACL has to be limited, the knee can be strengthened to compensate to some degree for the retired ligament. Some studies have apparently shown accelerated degeneration in knees without a functioning ACL due to increased play in the joint, but clearly the effect would depend on activity level. For me, surgery was a relatively easy choice because I want to remain active in ways that do require the stability that the ACL provides.


The second decision is to repair the existing ACL or reconstruct with new tissue. At least for now, this is almost a non-option as repair is very rare, with a short track record, and it requires near perfect injury conditions. There are also only a handful of doctors performing ACL repair. I happened to find one of these doctors, and I spoke to him about it. Although I was a reasonably good candidate for possible repair, after considering the possibility for a day I decided that I really needed to go with the surest option.

Within reconstruction, there are various treatment details to consider and all have their own risks and benefits. The four key options are as follows:
Graft Source: Graft tissue is either “harvested” from another part of the patient’s body (autograft) or graciously donated by a dead person who no longer needs it (allograft). The main concern with allograft tissue is the risk of disease transmission, extremely rare and potentially fatal. Donors are carefully screened and grafts are cleaned to the best extent possible, but complete sterilization by any current method does too much damage to the tissue.
Tissue Type: This is somewhat dependant on graft source. The most common autografts are patellar tendon and hamstring tendon. Allografts can come from various tendons including patellar, achilles, and tibialis.
Attachment: This is somewhat dependant on tissue type, but generally, holes are drilled through the tibia and the femur and the graft tendon is attached at the tibia with an interference screw. At the femur end, the graft can be attached in various ways including an interference screw, routed over a horizontal press fit pin, or run through a rope with a button on the end.
Hardware: Titanium used to be the standard for screws and pins, but it seems that new bioresorbable plastic screws have become more popular.

There are other details to consider but in general, I found that even the most personable surgeons will begin to tire of any discussion with a patient that goes much beyond the four listed above. Placement of the femoral tunnel is critical to the function of the knee, but the conversations I initiated with doctors regarding this topic were not very productive.

I formed some opinions on these different options before I went out to visit as many surgeons as my insurance company would tolerate. Thoughts from that tour next…

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