OT: Hamstring vs Patella ACL

Submitted by a non emu on March 24th, 2010 at 5:37 PM

Since I consider MGOBOARD my own personal oracle, I've come to you guys to help me decide.

I tore my right ACL and meniscus playing basketball last week. It is pretty stiff at the moment, and I just managed to start hobbling around without crutches. I've seen a couple of doctors, and the first one will either do a Patella, or an Allograft (graft from a cadaver), and the second one will only do a hamstring graft, and claims the long term outcomes are actually better with a hamstring graft since I won't have to deal with with tendonitis, and (possible) life long pain at the site of the graft. However, stuff I've read online indicates that the Patella actually holds up better and that the re-rupture rate is lower as well.

Two years ago, I had surgery on my left knee to fix a torn ACL (have I mentioned yet that I hate my knees?), and used the Patella graft that time around. I have to say that although the knee has never felt unstable since, I still have a constant low grade ache that I haven't managed to shake off. Additionally, I cannot kneel for any length of time on my left knee.

So, I am confused. The stronger graft, but long term pain, or the hamstring with long term hamstring weakness, and the potentially weaker graft? Added to this, the allograft, which sounds appealing due to it being minimally invasive, and having a quicker recovery schedule. But tempered against a small risk of infection, and again, possibly a weaker graft.

Anybody have experience with the hamstring, or the Allograft? Any problems since? Help me decide, oh MGOBOARD!


el segundo

March 24th, 2010 at 5:54 PM ^

I had the patellar tendon autograft. But mine was 23 years ago, so I can give you some information based on fairly long term experience.

I did have tendonitis in my patellar tendon about three years after the surgery, and it took a long time to resolve -- about two or three months. But that's the only time I had any tendonitis problems. My knee is more difficult to kneel on, even today. I also don't have full extension on the leg with the repaired knee. Over the years, that has led to a slight limp when I try to run hard. But I'm not sure that's a function of having the autograft as opposed to another procedure. It may be a function of ACL reconstruction generally.

I'm a little surprised to hear that the type of tissue used for the graft makes a long-term difference in the stability of the repair. When I had my operation, I was told that the tissue in the graft would be "transmogrified" (that was the actual term the doctors used) over about three months, so that it was converted from tendon tissue to ACL tissue. I would think this is true with any kind of graft, so I don't see how the original tissue source would make a difference in that way. But then I'm a doctor of philosophy, not of medicine.

For what it's worth, I did not have a choice about what kind of procedure to have. When mine was done in 1987, I was told that the FDA had ordered a temporary halt to all allografts from cadavers because there was no way to be absolutely sure of preventing AIDS transmission through the graft. Obviously, that's not a problem anymore.

From your name, I imagine you might be in the Ann Arbor area (unless "emu" refers to the bird instead of the school). If so, what doctors have you seen? I had my procedure done by MedSport, and the attending physician for my surgery, Dr. Wotys, is still there, I believe. My surgery was very successful, but I subsequently developed some doubts about Wotys, which I can share, if they'd be relevant to you.

a non emu

March 24th, 2010 at 6:15 PM ^

Thanks for the reply. They don't do transmorgification(!) anymore. The grafting and the graft attachment are done during the same operation. It is a little concerning that you still have trouble kneeling. I do have full extension in my left knee now. But it is a little stiffer than my other knee and I don't have quite the same degree of flexion in my left knee.

And the emu in my name has nothing to do with EMU the university (I went to UM) :) But I did have my first surgery at MedSport, in the down time I had between graduating, and starting work. I had the surgery with Dr. Bruce Miller. I would recommend him for anyone else in the area that needs an ACL reconstruction. Oh, and the PT team at MedSport is awesome. I really wish I could go back there for PT. Unfortunately, I live in Boston now and MedSport is out of the question.

el segundo

March 24th, 2010 at 7:41 PM ^

As I understood it, "transmogrification" refers to the process that the graft tissue undergoes in the time immediately after surgery. The tissue used as the graft is dead, regardless of where it comes from. When it's screwed into the bone ends, scar tissue forms around the screws, and that scar tissue permits the healing process to begin. The tissue in the graft is replaced, molecule by molecule, with ACL tissue that is generated at the root of the old ligament. This process of tissue transformation is transmogrification. I think it's part of every ACL reconstruction.

In my surgery, the graft and graft attachment were done in the same procedure. The big difference between my procedure and what's done today is that, in my surgery, the doctors opened up the whole joint. I have a big scar over my patella and another almost-as-big scar on the side of my knee. Now everything is done arthroscopically.

Anyway, don't be too put off my my trouble in kneeling. First of all, I can kneel, but my surgical knee just tends to get sore sooner if I'm kneeling on a hard surface. Second, I had to wait more than four years between tearing my ACL and the surgery because, at the time of the tear, there wasn't a reliable procedure to fix it. (Or, at least, my doctor, who was in NH, did not know about it). I got my ACL fixed after I came to Ann Arbor for grad school. Between the injury and the surgery, I did a fair amount of damage to the joint and had some arthritis even back then. I'm sure that contributes to some of my lingering knee problems.

Finally, you're right about the PT people at MedSport.


March 24th, 2010 at 10:56 PM ^

Torn ACL in 1985 (age 13); patellar graft in 1989. 6" scars each over my patella and lateral knee joint capsule. I could care less (couldn't care less?) about the scars.

It rarely bothers me during normal activity. Sometimes there's a phantom pain, but it's gone in a day, and it's very infrequent. I keep to low-impact sports (mostly) - cycling, swimming, maybe a little hockey (i said mostly). I've felt it sway a bit a couple of times, but never really feared for its stability. If I do anything other than walk, I'll wear a brace, though I've been told by some that it's not strictly necessary. Many doctors have commented that my result was excellent.

I have excellent range of motion, both flexion and extension; It does get a bit stiff when I kneel or squat; I minimise that.

Knock on wood I never have to replace it again, but I would think a hamstring would be an option. What's the risk of rejection with an allograft? Do you have to take immunosuppresives?


March 24th, 2010 at 6:34 PM ^

Patella graft about 5 years ago and wish I would have gone the other route. I have a lot of scar tissue and have never regained flexability in it. It is very stable though. The doctor told me they actually use an achilles tendon for the cadaver. It isn't as flexible but is more durable in the long run. I do wish I would have gone the other way at this point though.


March 24th, 2010 at 6:35 PM ^

I tore my ACL and meniscus 2 years ago playing basketball, it was on the landing of a dunk in warm ups (embarrassing). I had a patellar graft and still dont feel 100%. There is still a low grade ache/stiffness. I am playing basketball recreationally but definitely will never dunk the ball again and still feel like I cant really load that leg in cutting, sprinting and jumping like I used to. No tendinitis, but i also cant kneel much at all. If I were to do it again, I would try the hamstring graft, good luck.


March 24th, 2010 at 6:52 PM ^

I really hope that we get those injured players back for fall camp. Michigan can't afford to lose any more starters. What happened to our old strength training?

Jeffy Fresh

March 24th, 2010 at 7:50 PM ^

I am an orthopaedic resident about to go into sports medicine fellowship. I can tell you that you will get many varying opinions from different orthopods depending on their training. Many studies have been done on this very topic, yet none are very conclusive. Some say patellar tendon will lead to better stability but higher risk of knee pain, others say they are equivalent. There has been no consensus in our literature, hence the varying opinions depending on who you go see. All in all patient satisfaction tends to be the same. A lot of the old school guys swear by bone-patellar tendon-bone. This may be just from their comfort as this was the more common way years ago. If you hate your knee pain now in your previously operated leg, hamstring may be more up your alley. Again, unfortunately you will get a ton of varying opinions, and it comes down to what you were trained to do. Good luck, and sorry to give you a non-answer. In 2 years I will try to convince you to do whatever I am trained to do in my fellowship.


March 24th, 2010 at 8:55 PM ^

I went patellar both times (once per knee). Once was Fall '96, the other was Spring '02 (in a snowball fight). I lift, play all kinds of sports, wrestle, and basically do everything except go jogging, for impact reasons. Soreness and pain happen from time to time, but overall both knees are pretty happy considering what they've gone through.


March 24th, 2010 at 10:42 PM ^

I tore my ACL and medial meniscus about 8 years ago. They used a hamstring graft on me. I don't really have much knee pain at all, and I feel like most of it (from overuse or being cramped up too long or the weather) is more attributable to the meniscus anyway. From what I can tell I have not lost mobility in that knee as compared to the other.

I also don't notice my hamstring being any weaker. They don't take out any muscle, just a part of the lower tendon. I'd never heard about that side effect but I guess it would possibly make sense. Jeffy Fresh could probably say more about that.

2 cool things about going the hamstring route is that when I flex my hamstring I can feel (with my fingers) where the tendon is missing. Also, I was not knocked out during the surgery but only under local anesthetic. When they took out the tendon I felt it. It didn't hurt, but it felt weird. The best way I can describe it is that if you were wearing baseball sliding shorts and had a wet spaghetti noodle stuck in them against your leg and then somebody pulled it out.

Personally (and unscientifically) I feel like the knee should be messed with as little as possible whereas the hamstring is a lot larger and can take it. I understand the draw of an allograft because then you keep all your tendons intact but how do you know that person doesn't have sucky tendons?


March 24th, 2010 at 10:51 PM ^

I tore my ACL in the left knee playing basketball 8 months ago and had the hamstring graft. It feels great and I have been back on the court for about a month and a half now. I have full range of motion and relatively no pain at all. It has only been 8 months so I can't really testify to long term effects but i am more than pleased with my results. I would recommend it to anyone who is researching their options. Good luck to you.