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148 | Breaking Down ACL Graft Types and The Big 3 · The ACL Athlete Podcast

• 0:19
  SPEAKER_00: Welcome everyone to the ACL Athlete Podcast.
• 0:23
  SPEAKER_00: This is the podcast where we talk about everything related to the ACL, whether that's the injury itself, the rehab process, return to sport, and more.
• 0:33
  SPEAKER_00: I'm your host, Dr.
• 0:34
  SPEAKER_00: Ravi Patel, performance physical therapist and coach.
• 0:38
  SPEAKER_00: Between myself and fellow guests and experts, you'll learn through the lens of the patient, the healthcare professional, and the coach.
• 0:46
  SPEAKER_00: The goal of this podcast is to equip you, the athlete, with the education to make the best informed decision about your care and your ACL journey.
• 0:57
  SPEAKER_00: Thanks for joining.
• 0:58
  SPEAKER_00: Now let's dive into today's episode.
• 1:18
  SPEAKER_00: So the main goal of this episode is to share a very simple and general overview about the different ACL graph types that exist in current day ACL surgery and reconstruction.
• 1:30
  SPEAKER_00: I'm not going to talk about the pros and cons or share any opinions about which one's better than the other.
• 1:36
  SPEAKER_00: I'm sure everyone has these questions, and there's a lot of context around this.
• 1:41
  SPEAKER_00: So this is why I just want today to be focused on just breaking these down to understand what are the different types that exist, what are the big three, and what are the categories to just make this super simple for especially any of my ACLers who are going through this process, trying to understand the different graph types, and then what is potentially proposed to you.
• 2:03
  SPEAKER_00: And then for any of my clinical or for any of my coaches out there, for anyone who's listening on the supporting side, to be able to just kind of see what are those different options that you might be working with and what's common in this space.
• 2:18
  SPEAKER_00: So to start this off, we've got two main categories for ACL graft types.
• 2:24
  SPEAKER_00: You have your allograft, which is a cadaver graft.
• 2:28
  SPEAKER_00: So this is something that comes from, yes, a dead body or a cadaver.
• 2:34
  SPEAKER_00: And this is something that is usually taken from the patellar tendon, semitendinosis, which we will talk about, which is a part of your hamstring muscle group.
• 2:43
  SPEAKER_00: Same thing with a gracilis, your quadricept tendon, or Achilles.
• 2:47
  SPEAKER_00: And there might be other ones that also exist and are floating out there, but these are usually the most common ones that are used from a cadaver standpoint.
• 2:55
  SPEAKER_00: So this is not taken from your own body and instead is taken from someone else.
• 3:01
  SPEAKER_00: And then this is what is used as your ACL graft for your ACL reconstruction.
• 3:07
  SPEAKER_00: And then there's autographs, and autographs are taken from your own body, and this is where the big three comes in.
• 3:14
  SPEAKER_00: So the big three are the patellar tendon, the hamstring tendon, and the quadriceps tendon.
• 3:19
  SPEAKER_00: So for the longest time, the patellar tendon and hamstring tendon were the two major ones.
• 3:24
  SPEAKER_00: And of recent years, the quadriceps tendon has become involved in a lot of procedures, and this all comes back to really surgeons' backgrounds, the way that they're trained, maybe the type of graphs that they just love to harvest, and maybe the results that they're also seeing.
• 3:42
  SPEAKER_00: So they take all these things into consideration.
• 3:45
  SPEAKER_00: A lot of times, training and their background is biased based on what it is that they learned in school and residency and into the fellowship and whatnot.
• 3:56
  SPEAKER_00: But sure, there are a lot of things that change within their practices, but these are typically the big three.
• 4:02
  SPEAKER_00: And it's very, very rare for surgeons to do all these particular procedures and do a high number of them, just because there's such a variety.
• 4:12
  SPEAKER_00: Usually they have their particular ones that they cater to.
• 4:16
  SPEAKER_00: You know, they might be like, all right, I like to do the quad tendon.
• 4:20
  SPEAKER_00: There's a lot of people here in Atlanta, a lot of surgeons who love to do the quad tendon.
• 4:24
  SPEAKER_00: Maybe they're more biased towards patellar tendon.
• 4:27
  SPEAKER_00: Maybe they are an older surgeon.
• 4:29
  SPEAKER_00: So then therefore they might bias towards patellar tendon or hamstring tendon since quads is a little bit newer.
• 4:36
  SPEAKER_00: And then maybe they do just cadaver graphs.
• 4:39
  SPEAKER_00: So these are all things to consider with your particular surgeon in terms of graph types.
• 4:45
  SPEAKER_00: And there's episodes and content related to how to best go about choosing your graph type.
• 4:51
  SPEAKER_00: And part of this is also picking your surgeon, and part of this is also what graph types that they are doing most often.
• 4:59
  SPEAKER_00: But the big three here that patellar tendon, hamstring tendon, and quadriceps tendon.
• 5:04
  SPEAKER_00: Let's break these three down.
• 5:06
  SPEAKER_00: So patellar tendon, this is often called the BTB or bone patellar tendon bone.
• 5:12
  SPEAKER_00: And the reason for this is because when you look at the patellar tendon, this is some this is the tendon that is from below your kneecap into this bone called the tibial tuberosity.
• 5:25
  SPEAKER_00: So this is harvested from that middle third, one-third of that patellar tendon.
• 5:31
  SPEAKER_00: So they take the the middle portion of that and they'll take the bone from both ends.
• 5:36
  SPEAKER_00: So they'll take a little bit of bone from your tibial tuberosity, which is just this small little protrusion that is sticking out from where the patellar tendon inserts down on the shin bone, and then you have the top piece where that patellar tendon is starting or its origin on that bottom of the patella or your kneecap.
• 5:58
  SPEAKER_00: And so they'll take a small piece of bone from each side, and these will be bony plugs.
• 6:04
  SPEAKER_00: And so when they go to put this in for your A cell reconstruction, they will actually anchor these bony plugs in at the end.
• 6:11
  SPEAKER_00: And there tends to be a little bit of a quicker formation of bone in terms of that healing and that graph coming into that site.
• 6:19
  SPEAKER_00: You know, pros and cons to everything, but we're not going to talk about that today.
• 6:22
  SPEAKER_00: But this is just something to think about with this surgery, and it's just what's most commonly done with the bone patellar tendon bone.
• 6:30
  SPEAKER_00: For the hamstring tendon, this is what I had actually for my two ACL reconstructions.
• 6:36
  SPEAKER_00: I had my first one in high school.
• 6:39
  SPEAKER_00: That surgeon really didn't have a choice there.
• 6:42
  SPEAKER_00: We really didn't even know that options existed.
• 6:44
  SPEAKER_00: They were just like, you know, we do hamstring tendons.
• 6:47
  SPEAKER_00: And so that's what I got.
• 6:49
  SPEAKER_00: And then in college, I tore my other ACL, and this is where the surgeon recommended a hamstring tendon.
• 6:56
  SPEAKER_00: I knew a little bit more, but this is where there was a suggestion based on since I had a previous hamstring tendon on one side to just kind of do that on the other side.
• 7:07
  SPEAKER_00: You know, that's a conversation for a different day.
• 7:09
  SPEAKER_00: But at the time I was in college, I didn't really know a ton about this world.
• 7:14
  SPEAKER_00: So this is just something where I was just like, all right, this is a reputable surgeon, I'll just go with their suggestion.
• 7:19
  SPEAKER_00: And so the hamstring tendon, getting back to it, is harvested from the medial hamstrings, which is on the inside of the knee.
• 7:29
  SPEAKER_00: So the medial is when you think about your muscle group for the hamstrings, you have some that attach to the outside of your leg of your knee, and then you have some that attach on the inside.
• 7:44
  SPEAKER_00: So the inside ones are semitendinosus and semimembranosus.
• 7:49
  SPEAKER_00: And if you guys want to look this up via anatomy, you can.
• 7:52
  SPEAKER_00: But these insert into the medial side or the inside of the knee.
• 7:56
  SPEAKER_00: And this helps to flex your knee and extend your hip.
• 7:59
  SPEAKER_00: And so this is something where the semitendinosus is what's often taken here, and possibly part of your adductor, which is the gracillis tendon, so that comes to the inside of the knee as well.
• 8:12
  SPEAKER_00: This is just based on the surgeon's preferences, training.
• 8:15
  SPEAKER_00: It might come back to the size of the person where the tendon might not be long enough where they can bundle it in order to make it thick enough for an ACL graft.
• 8:25
  SPEAKER_00: So they might take some of the gracillus in order to do that.
• 8:28
  SPEAKER_00: So essentially, that hamstring tendon is going to be bundled.
• 8:31
  SPEAKER_00: It's going to be taken from the medial hamstrings, which semi-teninosis is the number one, and then maybe combined with gracillus as number two.
• 8:39
  SPEAKER_00: And then we have our quadriceps tendon, often referred to as the quad tendon graft.
• 8:45
  SPEAKER_00: This is harvested from the middle one-third, so similar to that patellar tendon, but this is on the quadriceps tendon.
• 8:54
  SPEAKER_00: So when you look at your quads or your thigh muscle, it comes down to a point where it connects to your kneecap.
• 9:00
  SPEAKER_00: And this is where the quadriceps tendon is found.
• 9:04
  SPEAKER_00: And this is where they will take that middle one-third of it, and sometimes it will be taken with a bony plug off the patella.
• 9:13
  SPEAKER_00: So just like that patellar tendon where there's bony plugs on both sides, you can't get that with a quad tendon just because it's coming from the muscle itself.
• 9:22
  SPEAKER_00: And so, therefore, on one side, there can be bone taken from that patella or that kneecap bone.
• 9:30
  SPEAKER_00: A lot of times it's not taken.
• 9:32
  SPEAKER_00: Again, coming back to the surgeon's preferences, I would say locally here, from what we see, they do not take as much of a bone from your patella, but it just depends.
• 9:43
  SPEAKER_00: I've seen athletes with it before.
• 9:44
  SPEAKER_00: So these are your big three.
• 9:46
  SPEAKER_00: You have your patellar tendon, you have your hamstring tendon, and you have the quadriceps tendon.
• 9:51
  SPEAKER_00: As of right now, this is how we see the autograph for ACL reconstruction.
• 9:58
  SPEAKER_00: One thing I do want to note with these tissues that are taken from your own body is that that's where we call this a donor site or where it's been harvested, where this tendon was taken to be used as your ACL reconstructed graft.
• 10:13
  SPEAKER_00: This specifically needs to be treated as a secondary insult or injury and be managed appropriately.
• 10:21
  SPEAKER_00: I think that this is something that gets missed very often, is that you know, we go into the ACL rehab process and this injury itself or where this has been harvested or that donor site doesn't get managed very well from the get-go.
• 10:35
  SPEAKER_00: And the way that we need to look at this is essentially that patellar tendon and quad tendon, because of where it is taken and the anatomy of it, are forms of tendinopathy or tendinitis in a sense.
• 10:47
  SPEAKER_00: This is an umbrella term, tendinopathy.
• 10:49
  SPEAKER_00: And so this is something that we need to manage in that form, of course, allowing it to heal from that acute trauma and harvesting, but then it needs to be managed and loaded appropriately versus just assuming uh it'll just adhere down and it'll just heal with the process, which it will, but it's something that also needs to be loaded to be built back up, especially after a time of unloading and that graphion taken.
• 11:15
  SPEAKER_00: And for the hamstring tendon, it's a grade three muscle strain or tendinopathy combined, depending on the type of procedure, especially with that gracillus taken, or is it just the semitendinosis taken and the the procedure and the technique?
• 11:30
  SPEAKER_00: But this is a little different because that muscle directly is implicated versus with your quadricept tendon or your patellar tendon.
• 11:38
  SPEAKER_00: With patellar tendon, a direct muscle attachment is not impacted.
• 11:42
  SPEAKER_00: And even with a quad tendon, you still have attachments going with the semitendinosis, they're actually taking that whole tendon.
• 11:49
  SPEAKER_00: So that muscle, the research is very interesting on what happens to that muscle.
• 11:53
  SPEAKER_00: Sometimes it just kind of atrophies and goes away.
• 11:56
  SPEAKER_00: Sometimes it attaches to the semimembranosis.
• 12:00
  SPEAKER_00: That is something that is still kind of out there in terms of the research and what happens to it.
• 12:06
  SPEAKER_00: And this is something that we even looked at with my PT school doctorate, where we did research and MRIs on this, and it was interesting to see just the variety that we saw with people with hamstring tendons and what happened to the remaining semi-teninosis.
• 12:22
  SPEAKER_00: So, this is something to just consider with these donor sites, is just making sure that these can be managed and being treated as forms of tendinopathy or a muscle strain and attacking those sites early and progressively and listening to those areas.
• 12:39
  SPEAKER_00: And that can help with managing the donor site pain and discomfort that we see a lot of athletes come in with later because it has been mismanaged.
• 12:48
  SPEAKER_00: The last thing I'll add here is one additional procedure I wanted to take note that can be done is an LET, which is a lateral extraarticular tenodesis.
• 13:01
  SPEAKER_00: LET.
• 13:02
  SPEAKER_00: And this is where they take part of the IT band and anchor it to the outside of the knee.
• 13:08
  SPEAKER_00: Usually it's indicated for rotational instability, or maybe an athlete has had possible multiple tears.
• 13:15
  SPEAKER_00: So this is something that a surgeon might recommend.
• 13:18
  SPEAKER_00: It's a technique that is done in addition to ACL reconstruction, so not in replacement of, but it's usually an add-on procedure.
• 13:26
  SPEAKER_00: So someone will get an ACL reconstruction with a certain graph type, and then they'll get an LET combined with that.
• 13:32
  SPEAKER_00: And so that is something that has picked up a little bit more steam, if you will, especially more for the right candidates, but just know that this is not the majority of ACL reconstructions.
• 13:45
  SPEAKER_00: So before you go and talk to your surgeon about, hey, I want to do an LET, just make sure that they do that.
• 13:50
  SPEAKER_00: But then the other thing is it needs to be the right person.
• 13:53
  SPEAKER_00: So this is still not indicated for majority, as I said.
• 13:57
  SPEAKER_00: And if they do it, they will likely suggest it based on your case.
• 14:01
  SPEAKER_00: If they don't, then it's something that probably doesn't need to be relevant to your case.
• 14:04
  SPEAKER_00: But again, it's an individual case-by-case basis.
• 14:08
  SPEAKER_00: And this is also something that we tend to see a little bit more outside of the US, but it is still done here in the US.
• 14:15
  SPEAKER_00: It's just more common that we see, especially in Europe and in other parts of the world.
• 14:22
  SPEAKER_00: The US is just starting to do more and more of it based on training.
• 14:26
  SPEAKER_00: But again, it just kind of depends on surgeon preferences and the case that uh warrants doing it.
• 14:33
  SPEAKER_00: The reason that I bring this up is that a lot of times we'll see athletes and they'll say they had an LET done, and I ask them if they know what it is, and they don't.
• 14:42
  SPEAKER_00: And this is something that I think is important because it can help with explaining maybe another area that might be more uncomfortable, maybe their knee is more sensitive or painful.
• 14:52
  SPEAKER_00: So just something to keep in mind and also something to know about your history, especially with an LET being added.
• 15:00
  SPEAKER_00: So that's why I want to bring it up in case these words or letters do come and you know what that looks like.
• 15:06
  SPEAKER_00: And while other procedures do exist in the world of ACL surgeries, the goal here was to discuss the major graph types and understand most importantly where they came from, what are the big three, and being able to just go about making a better informed decision, which is a big part of this podcast, right?
• 15:26
  SPEAKER_00: To help educate you on different pieces of the ACL rehab process.
• 15:29
  SPEAKER_00: And so this is for you to understand the two main categories, which is allograft and autograft, and then from there, the autograft, which is taken from your own body, has the patellar tendon, hamstring tendon, quadriceps tendon.
• 15:44
  SPEAKER_00: One of the things I had mentioned was to just be mindful of that donor site.
• 15:48
  SPEAKER_00: Maybe it's something that you are able to talk to your PT about to just make sure that that's being addressed appropriately.
• 15:55
  SPEAKER_00: And then the additional procedure that has become a bit more common or that is seeing more frequency is the LET with the right cases.
• 16:05
  SPEAKER_00: So that is just something in addition to be aware of.
• 16:09
  SPEAKER_00: Again, this is something that is very general, very simple, no pros and cons here.
• 16:14
  SPEAKER_00: Just laying out the information in terms of what you will see if you go to see your surgeon and you're trying to figure out all right, well, what graph types are available?
• 16:24
  SPEAKER_00: And then from there, it's making a decision based on your specific case.
• 16:28
  SPEAKER_00: And we will do a podcast episode where we break down pros and cons of the graph types and procedures.
• 16:35
  SPEAKER_00: That will definitely be a very filled episode because there's a lot of nuances to it.
• 16:41
  SPEAKER_00: There's no perfect graph type for this, otherwise, the other ones wouldn't exist.
• 16:46
  SPEAKER_00: And so this is why we have to just go with what makes sense for our goals and what the surgeon does and what seems to make the most sense for our own ACL journey.
• 16:59
  SPEAKER_00: I hope that this was helpful, team.
• 17:01
  SPEAKER_00: If you have any questions, you know where to find us.
• 17:04
  SPEAKER_00: This is your host, Robbie Patel, signing off.