ACL Reconstruction Patella Tendon Graft Choice
Patella Tendon Graft Choice
Patellar tendon graft can be taken from the same knee (ipsilateral) or the other knee (contralateral). The traditional and by far in a way the most common practice is to take ipsilateral patella tendon grafts. The advantages of this are:
* Surgery only on one knee
* Only one wound/scar
The disadvantages of this are:
One knee has to achieve two contradictory rehabilitation goals. These two goals are
1. Strength
2. Motion.
The primary aim during the initial rehabilitation protocol is to reduce swelling and regain motion. If strengthening is attempted at the same time this will cause the knee to swell and therefore motion loss will occur. It is contradictory. The end result is that the rehabilitation has to be slower in order to sequentially achieve both of these goals.
The other option is to take the graft from the other knee (contralateral PTG). The advantages of this are:
* Each knee has only one rehabilitation goal to achieve.
The ACL reconstructed knee does not have disruption of the extensor mechanism by taking the graft and therefore it is not significantly weakened. The only thing it has to achieve is to reduce swelling and get the motion back. Strength is not a key issue in the early stages.
The other (donor) knee that has the graft taken from it has an immediate weakening effect on the extensor mechanism. There is no violation of the knee joint and therefore no swelling occurs within the knee and therefore there is no loss of motion. The graft knee therefore only has to regain strength and motion is not an issue.
The end result of being able to split the rehabilitation goals is that rehabilitation is achieved much quicker as strength in one leg and motion in the other leg can be achieved simultaneously rather than sequentially.
* Another advantage of having surgery on both knees is that you do not, in essence, have a good leg, which means that when you attempt to walk you cannot offload onto the good leg and try and limp, which means you are more likely to walk with equal weight distribution on both legs resulting in a more normalized gait pattern. This once again accelerates rehabilitation.
* Having a scar on the knee will result in permanent numbness around that scar. Attempting to kneel with a scar present does feel awkward and unusual. When only one scar is present on one knee the brain has a normal knee to compare against, meaning that it accentuates the strangeness of the sensation. However, if both knees are operated on with similar scars the brain does have a normal to compare against and therefore although it feels unusual it does not feel as strange as with only one scar.
Disadvantages of a contralateral patellar tendon graft are:
* Surgery on both knees and having two apparent "bad" knees.
Having surgery on both knees is not more painful than having it on one knee and in fact in a study I have done, it has actually shown that people having ACL reconstruction in both knees at the same time use less painkillers than people having one ACL reconstruction.
Having a bad knee, whether it is one or two knees, is all down to the rehabilitation. If the graft leg is rehabilitated appropriately it will return to being a normal knee. However if the graft leg is ignored then there is no doubt that it will be a bad knee. This is also true if the graft is taken from the same knee (ipsilateral), except in this situation, it is much harder to rehabilitate the donor site in isolation.
Donor site in contralateral PTG
Contralateral patellar tendon harvest has led to a problem in its own right that was not apparent with ipsilateral surgery. This problem is that of the donor site. In ipsilateral surgery the donor site was never an issue in its own right because it was part of the injured knee that was being rehabilitated in total. However, when the graft is taken from the other leg it became apparent that the graft leg had to have a rehabilitation programme in its own right.
The donor (graft) knee rehabilitation programme has now been developed and fine tuned into the following stages:
* The first month following the surgery is all about healing the patellar tendon defect. This is done by undertaking low resistance, high repetition work using initially a series of Therabands and then step downs. After the first month, if you look at the patellar tendon of someone who has undergone contralateral patella tendon harvest it would be seen that their tendon is almost twice the size of the other side indicating that the tendon has healed and increased in size.
* After one month the emphasis on the graft harvest leg is all about regaining strength and this is done by traditional strengthening methods of high resistance, low repetition work.
Therefore, a well devised rehabilitation programme is now undertaken for the graft leg from the day of surgery all the way through the whole rehabilitation programme.
Origin of Contralateral PTG ACL reconstruction
The initial experience with contralateral patellar tendon graft harvest came from revision surgery when the ipsilateral tendon had already been harvested and therefore the tendon from the other side was used. Revision surgery has always been thought to have been salvage surgery in the sense that the results are not as good as primary ACL reconstruction, but this has certainly not been my experience with it.
The originator of the contra-lateral technique was Dr Donald Shelbourne, whose experience was exactly the same and therefore led him to use contralaterals for primary ACL reconstruction due to his findings of the rapidity with which people who had contralateral grafts got going and the ease with which their rehabilitation was carried out and performed compared to ipsilateral patients.
Providing the graft site is rehabilitated appropriately, patients with contralateral harvests have fewer problems, have easier rehabilitation, progression and return to functional activities is quicker, return to training is quicker, return to is sports quicker. Revision patients who had contralateral surgery actually preferred their contralateral ACL surgery and found the rehabilitation easier than primary ipsilateral surgery, which is very unusual for any revision operation in any field of surgery.
Conclusion
It is therefore my opinion, that the benefits of contralateral patella tendon harvest far outweigh any potential disadvantages.
The rehabilitation and return to play times following contralateral PTG can be speeded up by anything between 4 to 8 weeks quicker return to each stage of the rehabilitation programme including return to full sport which in motivated individuals can be as quick as 4 months from surgery.
This is now my graft of choice for primary ACL reconstruction.
