Latest / The ACL Athlete Podcast / 289 | Why Your Surgeon's Favorite Graft Might Not Be Right For Your ACL Surgery

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289 | Why Your Surgeon's Favorite Graft Might Not Be Right For Your ACL Surgery · The ACL Athlete Podcast

• 0:18
  SPEAKER_00: Welcome everyone to the ACL Athlete Podcast.
• 0:22
  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.
• 0:31
  SPEAKER_00: I'm your host, Dr.
• 0:32
  SPEAKER_00: Robbie Patel, performance physical therapist and coach.
• 0:36
  SPEAKER_00: Between myself and fellow guests and experts, you'll learn through the lens of the patient, the healthcare professional, and the coach.
• 0:43
  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.
• 0:54
  SPEAKER_00: Thanks for joining.
• 0:55
  SPEAKER_00: Now let's dive into today's episode.
• 1:00
  SPEAKER_00: What is up, team, and welcome back to another episode on the ACL Athlete Podcast.
• 1:07
  SPEAKER_00: So if you have talked to more than one person about ACL surgery, you probably heard a line like this.
• 1:14
  SPEAKER_00: This was actually something that I heard from an athlete this past week.
• 1:18
  SPEAKER_00: And when we were talking through graft types, they're like, oh well, isn't it the best graft is the one your surgeon is good at.
• 1:26
  SPEAKER_00: And maybe this is something that your physical therapist said.
• 1:30
  SPEAKER_00: Maybe it is something that you saw on a Facebook group or Reddit or whatever forum or place where people comment.
• 1:37
  SPEAKER_00: You will also hear opinions, especially if people are like, which is the best graft?
• 1:42
  SPEAKER_00: Be careful going down that rabbit hole, especially in forums, because everyone will either have a very strong opinion about their graft one way or another.
• 1:50
  SPEAKER_00: They'll either be like, I had an amazing recovery, and it's Bertha with the allograft, who should have had a more straightforward process, if you will, compared to maybe, you know, John John with the quad tendon and L E T and meniscus repair, right?
• 2:06
  SPEAKER_00: But a lot of times people start thinking about just the graft itself, and they'll insert their opinion.
• 2:12
  SPEAKER_00: And the opinion is valuable.
• 2:14
  SPEAKER_00: It's just really hard because it's trying to compare all.
• 2:19
  SPEAKER_00: Imagine lining up all these different fruits, but none of them are the same.
• 2:23
  SPEAKER_00: They're all different.
• 2:24
  SPEAKER_00: It's not orange to orange, it's like orange, watermelon, pineapple, apple.
• 2:28
  SPEAKER_00: Even though they are all sweet, you know, they're all very different.
• 2:33
  SPEAKER_00: And that's very similar in this process of comparing graph types, especially because every person's context is so different.
• 2:42
  SPEAKER_00: And I will say this once, and I have said it repeatedly before, is that no one ACL journey is the same ever.
• 2:51
  SPEAKER_00: And so this is really important here because people will share their opinion about graph types.
• 2:57
  SPEAKER_00: And most importantly, people are trying to make decisions about their graphs, especially what should they pick.
• 3:04
  SPEAKER_00: And so I think what has happened in the space is that people are getting more educated, whether it's through AI or whether it is through ACL resources, whether it's people online, whether it's through this podcast, whatever it is, you're trying to educate yourself and you will consistently see now where people will say, Well, oh, it's the best graph that the surgeon is good at, you know, the volume that they do it at.
• 3:27
  SPEAKER_00: And we put this even a part of our questions to ask your surgeon and different ways to, you know, be able to audit and to figure out is this the surgeon that you want in your corner, right?
• 3:40
  SPEAKER_00: You do want them to be picking the one that they are best at.
• 3:45
  SPEAKER_00: And this is something that can be a bit of a challenging thought, but I think you know, it's something that you have to make sure you sit with properly and go through the proper filtering.
• 3:56
  SPEAKER_00: But here's the thing though, and I'm not gonna say it's not wrong, and that's something that's really important, but it's just not the whole answer.
• 4:05
  SPEAKER_00: And the gap between that not wrong and the whole answer is where you know a lot of athletes end up with a graph that was fine for their surgeon, but wasn't right for them.
• 4:18
  SPEAKER_00: And that is really, really important to stress here.
• 4:21
  SPEAKER_00: So today I'm not just gonna tell you what is the best graft.
• 4:24
  SPEAKER_00: That's not my goal with today.
• 4:26
  SPEAKER_00: That is a different episode for later.
• 4:28
  SPEAKER_00: And I am going to make sure today that you have something that is more useful than just a single graft answer.
• 4:37
  SPEAKER_00: And I want to give you a way to think about it, to make this decision through a framework.
• 4:42
  SPEAKER_00: And you guys know I'm very big on not just saying, like, oh, well, this is a dumb thing, like, or this is wrong, and then just leave it at that.
• 4:49
  SPEAKER_00: Like, I want to leave you with something practical to help make a decision, actionable takeaways, practical application.
• 4:55
  SPEAKER_00: That's the goal with this episode.
• 4:56
  SPEAKER_00: So when you're sitting in that consult room with the doc, um, you're talking with maybe your physical therapist if you're lucky enough to do that before you have the surgery, you know what you're actually being told and what you are not being told.
• 5:10
  SPEAKER_00: It's really important here.
• 5:12
  SPEAKER_00: And graph choice is one of the important decisions in your ACL rehab surgery process.
• 5:19
  SPEAKER_00: There are a lot of important decisions.
• 5:21
  SPEAKER_00: My bias, and I'm gonna share that here, your number one decision is going to be the rehab provider you work with, your physical therapist and the person who's gonna get you through this.
• 5:31
  SPEAKER_00: Number one by far.
• 5:32
  SPEAKER_00: They're in the throws with you, and they're gonna be the ones who are gonna really be guiding you through this.
• 5:37
  SPEAKER_00: And I have seen the best surgeons who have said it's not the graph that really makes the difference.
• 5:43
  SPEAKER_00: It's more so the rehab and the work that they put in that is gonna make the difference.
• 5:47
  SPEAKER_00: And I've seen this across every single graph.
• 5:50
  SPEAKER_00: We have at this point worked with over hundreds and hundreds of different surgeons all across the world, different techniques, different philosophies, different trainings.
• 5:58
  SPEAKER_00: And we can compare across a lot of these surgeons as well as the graph types.
• 6:04
  SPEAKER_00: And again, we're only really coming down to four different graph types in reality.
• 6:08
  SPEAKER_00: It's an allograft, it's a quad graft, it is a hamstring graft, or it is a patellar tendon graph.
• 6:15
  SPEAKER_00: That is what exists for the most part.
• 6:17
  SPEAKER_00: Yes, there's the bear, there's ACL repairs, there are other things that are ongoing that are being investigated.
• 6:22
  SPEAKER_00: But for majority of ACL surgeries, what is happening is one of those four graphs.
• 6:28
  SPEAKER_00: And if it's an autograph, it's gonna be that patellar tendon, quad graft, or hamstring.
• 6:33
  SPEAKER_00: And if it's an allograph, it can be a mix of those things and some other potential cadaver options.
• 6:38
  SPEAKER_00: Now, the next thing, yes, you picking your provider is gonna be number one, your rehab provider.
• 6:45
  SPEAKER_00: Then, yes, of course, your surgeon, and then yes, your graph type is gonna be a part of that very important decision making.
• 6:53
  SPEAKER_00: Now, let's talk about why go with that surgeon that is good at that particular graft.
• 7:00
  SPEAKER_00: You know, that's what they're good at, if you will, became that default device in the first place.
• 7:05
  SPEAKER_00: Because I really don't think it just came out of thin air, right?
• 7:09
  SPEAKER_00: People were talking about this, and I think this is something for us to tease out.
• 7:13
  SPEAKER_00: Most surgeons train heavily in one graft, maybe two, if we're talking to you know, someone further along in their careers, or maybe they changed along the way, so they know a few techniques, but rarely is it more than that.
• 7:30
  SPEAKER_00: Yes, they can do a cadaver, anyone can, because the technique has not changed that much.
• 7:35
  SPEAKER_00: But in terms of autographs, this is where usually surgeons will sit in one camp of the three.
• 7:41
  SPEAKER_00: Now, sometimes they can do two.
• 7:43
  SPEAKER_00: It's rare that they're really good across all three.
• 7:46
  SPEAKER_00: I don't really see that a lot, and usually they have one that is their go-to.
• 7:51
  SPEAKER_00: And any physical therapist you talk to who works with surgeons can verify that.
• 7:56
  SPEAKER_00: And it's not necessarily a criticism on their part, they're niching down into being like, okay, this is what I've trained on.
• 8:03
  SPEAKER_00: And remember, residency and fellowships matter a lot here.
• 8:08
  SPEAKER_00: Who you get into residency and fellowship is going to influence your clinical practice and the way that you are going to decide what graph you go with.
• 8:17
  SPEAKER_00: Now, you may change along the way, but the thing is that a lot of times that is influenced by who your mentors and who you learn from.
• 8:25
  SPEAKER_00: So if someone is a quad graft heavy person, there's probably going to be a strong chance that a fellow going through surgical fellowship that they are going to pick up doing the quad graph because that is who their mentor had told them, you know, this is what I do, this is what you're going to learn.
• 8:42
  SPEAKER_00: And that's what they have exposure to.
• 8:44
  SPEAKER_00: So just know that that is something, it's not necessarily a criticism.
• 8:48
  SPEAKER_00: It's just the way the game goes of getting into this space, and it's just how the training process is.
• 8:56
  SPEAKER_00: And the thing is, is you're also not just going to be amazing at all the different things.
• 9:01
  SPEAKER_00: You're not just going to be the master of all the different techniques.
• 9:04
  SPEAKER_00: You're going to be the master of one, maybe two different techniques, and you're going to go all in on those things.
• 9:10
  SPEAKER_00: And that's what most surgeons do.
• 9:12
  SPEAKER_00: You become excellent at that, and then you build your reps around that and your outcomes around that.
• 9:17
  SPEAKER_00: Now, again, people change, and there are some who are more open to change, and there are some that are just set in their ways.
• 9:24
  SPEAKER_00: And no matter what, they will stick around with that unless their outcomes are horrendous.
• 9:30
  SPEAKER_00: And so now put yourself in the room.
• 9:33
  SPEAKER_00: You're hearing about graphs for the first time in your life.
• 9:36
  SPEAKER_00: If you're an ACLR, maybe it's another, you know, a second time, which you'll probably do a little bit more research, maybe a third.
• 9:42
  SPEAKER_00: But let's just say it's your first time hearing about graphs.
• 9:46
  SPEAKER_00: You feel scared, you know, you're anxious, you're processing the injury that derailed your season, or your activity and lifestyle and fitness, or your year, or honestly your identity as an active individual.
• 9:59
  SPEAKER_00: And across from you is someone who's super confident, super smart, went to medical school.
• 10:05
  SPEAKER_00: Yeah, that's a one that we typically view as high praise, right?
• 10:10
  SPEAKER_00: And who has a very clear answer for you in most cases.
• 10:15
  SPEAKER_00: I've talked to so many people who tell me they kind of semi-blacked out in some of these evaluations or consults with surgeons.
• 10:22
  SPEAKER_00: They don't necessarily remember half of what was said, especially if it's more technical jargon.
• 10:27
  SPEAKER_00: They just remember kind of nodding along and it's like, okay, it sounds good, right?
• 10:32
  SPEAKER_00: So you take a confident expert with a genuine bias, they may not even realize they have.
• 10:38
  SPEAKER_00: You know, they fully feel invested in their kind of guidance and opinion, which is fair, it's everyone's opinion, right?
• 10:46
  SPEAKER_00: And you put them in front of someone who is overwhelmed and just wants answers, wants it to be fixed, and a good enough decision can come from that.
• 10:55
  SPEAKER_00: Not because anyone really did anything wrong in this case, but it's just because of what the experience is.
• 11:01
  SPEAKER_00: And I can vouch for this because I did this as a high school athlete.
• 11:06
  SPEAKER_00: You know, I was 15 when I had my first ACL.
• 11:10
  SPEAKER_00: So I can vouch for this.
• 11:11
  SPEAKER_00: I kind of blacked out.
• 11:13
  SPEAKER_00: I honestly don't even really remember it.
• 11:15
  SPEAKER_00: And then my second one, I remember it just being technical, you know, medical jargon to me of like, this is why you do we're doing this, right?
• 11:22
  SPEAKER_00: And I was in college during that time.
• 11:25
  SPEAKER_00: But the thing is, just because that is what happens in this process of just kind of going through this almost transactional feel when that expertise meets urgency and when that urgency meets fear, it's really challenging in this situation.
• 11:40
  SPEAKER_00: So I want to give you a way to picture this because I think it will stick with you longer than me just, you know, rambling on about it.
• 11:48
  SPEAKER_00: If all you have is a hammer, everything looks like a nail.
• 11:52
  SPEAKER_00: And I know that is a cliche thing.
• 11:54
  SPEAKER_00: It's not a knock on the person who is holding the hammer.
• 11:57
  SPEAKER_00: A surgeon who is excellent with one graft is going to see that graft as the right call for most of the patients in front of them.
• 12:04
  SPEAKER_00: I'm not saying all, but I have seen this enough at this point over thousands and thousands of conversations and reps that there tends to be this bias towards what graft that I do tends to be the one that I am going to suggest.
• 12:22
  SPEAKER_00: It's rare that I ever find someone walk out of that door and they say, I don't think that this is the right graph type for you.
• 12:28
  SPEAKER_00: I can't do this, I'm gonna refer you somewhere else.
• 12:31
  SPEAKER_00: Rarely ever happens.
• 12:32
  SPEAKER_00: I've never really seen it that much because hey, at the end of the day, like there is a possibility of it working, but again, it has to be the right person.
• 12:42
  SPEAKER_00: But when you do one technique and someone walks in needing help and you feel like you can help them, guess what?
• 12:49
  SPEAKER_00: I'm not gonna say it's a wrong technique, but it might not be right for that person that it is going to be done on.
• 12:55
  SPEAKER_00: And this is a skill here in terms of their confidence and their ability to do this graft.
• 13:03
  SPEAKER_00: And so they truly believe in it.
• 13:05
  SPEAKER_00: And it's not dishonesty.
• 13:06
  SPEAKER_00: I'm not here to say like these surgeons are necessarily being dishonest.
• 13:11
  SPEAKER_00: It's just we all have a bias of a lens we look through.
• 13:15
  SPEAKER_00: It's just our training, it's just who we are as human beings.
• 13:18
  SPEAKER_00: It's just a natural tendency, and it's hard to be very neutral about every case, especially when you are naturally a surgeon and you're here to help someone, it's gonna be easier to justify the option you have.
• 15:36
  SPEAKER_00: I just for example, I'm a physical therapist.
• 15:39
  SPEAKER_00: My main goal is to avoid people having surgery naturally.
• 15:42
  SPEAKER_00: Now, ACL is a little different, but in this space, it's it's almost like our bias to almost not push people towards further intervention and we hold people out for too long sometimes because we want to avoid the knife and surgery or like an injection because we're like, no, no, no, the human body can tackle this.
• 16:01
  SPEAKER_00: And so I'm gonna call out my own profession's bias by also saying that we sometimes hold on too long because sometimes we do need to refer people to further medical intervention and we drag things out sometimes.
• 16:13
  SPEAKER_00: So that's our bias.
• 16:15
  SPEAKER_00: And so every profession has a bias.
• 16:18
  SPEAKER_00: It's just one of those things that's just really challenging in this case, especially when someone is presenting this option that they have.
• 16:25
  SPEAKER_00: And yes, now the saying a surgeon only sees a hammer sounds like a cheap shot.
• 16:31
  SPEAKER_00: Like it's almost like I'm trying to, you know, call them out directly.
• 16:36
  SPEAKER_00: And certain people, yeah, I think that they take it way too transactional and it becomes almost this non-human like exchange, and I hate it.
• 16:47
  SPEAKER_00: And sometimes there are situations where it's really, really challenging based on what we hear from athletes or interactions we have.
• 16:54
  SPEAKER_00: But I'm not saying this across most searches.
• 16:57
  SPEAKER_00: I think that they're trying to do right, they're trying to help people, and I am not trying to take a shot at anybody.
• 17:02
  SPEAKER_00: I'm saying it because it is true.
• 17:04
  SPEAKER_00: Naturally, when you have typically one or two solutions, you're gonna try and fit that into the box of the solution.
• 17:11
  SPEAKER_00: But the main thing here is that you deserve to walk into that room understanding exactly the situation and whether it's gonna work for you or not.
• 17:22
  SPEAKER_00: So here is the actual framework I want you to walk away with today.
• 17:27
  SPEAKER_00: There are two filters in this decision, not just one.
• 17:32
  SPEAKER_00: And if you follow this, if you're someone who is about to have ACL surgery, then I really hope that you take it through this lens.
• 17:42
  SPEAKER_00: And if you're someone who has already had surgery and you're listening to this, then I want you to just kind of think through this.
• 17:47
  SPEAKER_00: And if this feels like it aligned with the conversations you had and the thought process, and if you're after the fact and maybe it didn't, then that's okay.
• 17:57
  SPEAKER_00: But I think it's important to be able to have this process in order to make the best decision for your case.
• 18:06
  SPEAKER_00: So filter number one, what graft is right for you specifically?
• 18:12
  SPEAKER_00: We're not focused on what the surgeon does best, we're focused on what is the right one for you.
• 18:19
  SPEAKER_00: Filter number two is the surgeon actually skilled and has high volume in that specific graft.
• 18:28
  SPEAKER_00: So we need to focus on you and what's best for you versus fitting you to the box that the surgeon wants you to fit into.
• 18:36
  SPEAKER_00: We need to make sure that you have all options available.
• 18:40
  SPEAKER_00: Let's figure out the one that is best for you.
• 18:43
  SPEAKER_00: And I'm gonna kind of make this similar to let's say someone has cancer, they're assessing their options, and you have one surgeon who's like, you know, this is the best situation for this, but maybe it's not necessarily the best for you.
• 18:57
  SPEAKER_00: For them, they think it is, but then you're assessing different options and you find out that that might not be the best one, but they're good at that thing, but then you have someone else who is really good at the thing that is best for your particular type of cancer.
• 19:12
  SPEAKER_00: This is no different, and I know I seem so dramatic in this, but y'all, this is the real deal here.
• 19:19
  SPEAKER_00: Like it is serious, like this is the decisions we need to make, and the degree of importance that it needs to be made.
• 19:25
  SPEAKER_00: It needs to be fit to you first, and then we gotta find out who is going to be the person who is going to be best to do that.
• 19:33
  SPEAKER_00: Here is the problem in most consults, you only ever get filter two explained to you.
• 19:41
  SPEAKER_00: You rarely ever see what is the right one for you.
• 19:44
  SPEAKER_00: Now, I'm not saying again, all, but a lot of times I see filter number two is the surgeon skilled in it, and the volume that they do is typically the main lens that is look through versus what is going to be the right thing for you.
• 19:58
  SPEAKER_00: And it's rare that I shared earlier that they say this isn't the right one for you.
• 20:03
  SPEAKER_00: Let me refer you to someone else.
• 20:05
  SPEAKER_00: Rarely ever hear that.
• 20:07
  SPEAKER_00: But you hear about their experience of the graft, you hear about their outcomes, you hear their confidence, and you walk out thinking that was essentially the whole decision, and it was not.
• 20:17
  SPEAKER_00: And you also might be like, Yeah, let's do that.
• 20:20
  SPEAKER_00: And you're feeling good, you're feeling the momentum of that of that exchange.
• 20:24
  SPEAKER_00: And it was only half of it, though.
• 20:27
  SPEAKER_00: And the half that comes first, the one that actually determines whether filter two even matters for you, almost never gets discussed unless you are the one who brings it up.
• 20:37
  SPEAKER_00: Now, there are some surgeons where we have seen incredible bedside manner and incredible detailed discussion.
• 20:45
  SPEAKER_00: Like we had someone the other day who was like, Yeah, my surgeon spent 30 minutes with me.
• 20:49
  SPEAKER_00: We're like, What?
• 20:50
  SPEAKER_00: In what world?
• 20:51
  SPEAKER_00: And I'm not saying you need 30 minutes, but you also need more than five minutes.
• 20:56
  SPEAKER_00: Okay.
• 20:56
  SPEAKER_00: And the thing is that there needs to be a conversation around your case, your life, your goals, all the things.
• 21:02
  SPEAKER_00: And I'm gonna kind of break this down of the important areas that need to be evaluated for seeing what's right for you, but there needs to be more detail input here.
• 21:12
  SPEAKER_00: And I will say the good surgeons are the ones who will ask these questions and take the time to understand.
• 21:17
  SPEAKER_00: And also, most often will give options.
• 21:22
  SPEAKER_00: Now, I completely get it.
• 21:24
  SPEAKER_00: People lean on us to help make decisions.
• 21:27
  SPEAKER_00: So I'm not here to say just give options and then leave it up to the to the person.
• 21:31
  SPEAKER_00: Now, you can still insert your opinion.
• 21:34
  SPEAKER_00: I would just say that the opinion is very biased because of maybe their specialty or what they typically do.
• 21:40
  SPEAKER_00: So I think that's something to just be aware of, but it's something that I think is good to potentially have options.
• 21:47
  SPEAKER_00: And there might be situations where it is only a one specific thing that is going to be ideal for that person.
• 21:54
  SPEAKER_00: And I get that.
• 21:55
  SPEAKER_00: And so maybe that recommendation might be correct.
• 21:58
  SPEAKER_00: But the thing is that we need to make sure we start with getting to the detail of you first, the patient, the person who's having the procedure done, because it has such a domino effect of things later down the road.
• 22:11
  SPEAKER_00: And so what we find often is more so that the patient, the person who's having the surgery has to bring it up versus being asked these questions.
• 22:20
  SPEAKER_00: And so a quick note before we move on.
• 22:24
  SPEAKER_00: This applies whether you're on your first ACL reconstruction, second, third, whatever it is.
• 22:29
  SPEAKER_00: It applies if there's a combined procedure involved, something like an LET alongside the reconstruction or another multi-ligament.
• 22:36
  SPEAKER_00: Revision cases do get more nuanced since what tissue is already used and what your tunnels are, the bone stock looking like, the options can potentially narrow or they reduce down because you've exhausted one, right?
• 22:51
  SPEAKER_00: Or maybe it's the other knee, and so maybe you have still some options, but we need to look at your history, and that's going to be an important nuanced conversation.
• 23:00
  SPEAKER_00: But that all in and of itself is genuinely its own conversation, and I'm not trying to cover it in full today of you know the second, third ACL, but just know that the two filters still hold regardless of what number ACL this is for you.
• 23:18
  SPEAKER_00: Now, filter number one.
• 23:21
  SPEAKER_00: Let's actually build this out.
• 23:23
  SPEAKER_00: What determines the right graph for you?
• 23:26
  SPEAKER_00: And I'm gonna keep this simple on purpose.
• 23:28
  SPEAKER_00: We could spread thin.
• 23:29
  SPEAKER_00: I'm not trying to overwhelm you with 12 different variables to make a best decision.
• 23:34
  SPEAKER_00: You need the ones that weigh the heaviest.
• 23:36
  SPEAKER_00: If you're looking at the pie, you're looking at most of the pie, and these are the ones that actually influence the recovery and move the needle.
• 23:44
  SPEAKER_00: Age is number one.
• 23:46
  SPEAKER_00: This can influence the younger athletes all the way up to yes, older athletes.
• 23:51
  SPEAKER_00: And you'll typically have the associations of autograph, higher cutting sports, pivoting sports, and younger athletes versus allograph older athletes.
• 23:59
  SPEAKER_00: It can span the entire spectrum.
• 24:02
  SPEAKER_00: We have seen it, and so the thing.
• 24:04
  SPEAKER_00: Is is yeah, generally allographs are for older athletes.
• 24:07
  SPEAKER_00: But again, we've seen it in younger, it just has a range and it really depends.
• 24:13
  SPEAKER_00: But in reality, if you're getting back to cutting pivoting sports, you're younger, the research shows clearly that allographs have a higher failure rate in younger athletes and people who are higher activity patients compared to an autograph.
• 24:27
  SPEAKER_00: That is a lot of what the data shows.
• 24:29
  SPEAKER_00: Now, I'm not going to get into the deep, deep layers of age because we have seen it across work for a bunch of different ages and different graph types.
• 24:37
  SPEAKER_00: But age is going to be a factor discussed.
• 24:41
  SPEAKER_00: Goals, sport, position, or activities.
• 24:47
  SPEAKER_00: Those are all going to be huge factors in this.
• 24:50
  SPEAKER_00: This defines how much your knee actually needs to do.
• 24:54
  SPEAKER_00: A soccer player who is cutting and pivoting has different demands on their knee than someone who wants to get back to hiking or skiing, lifting weights, for example.
• 25:02
  SPEAKER_00: It could be the same knee and same age, even if we compare, you know, people across completely different answer depending on what you are asking it to do.
• 25:12
  SPEAKER_00: So we need to really dissect what are the goals of the person, what is their sports activities, and if it's a sport, what is the position that they play?
• 25:22
  SPEAKER_00: All those things factor into decisions of what we are going to decide, what is best for this person.
• 25:29
  SPEAKER_00: The next one is previous injury history.
• 25:32
  SPEAKER_00: And I mean this broadly.
• 25:35
  SPEAKER_00: Has this knee had a prior injury, surgery, ACL, or otherwise?
• 25:41
  SPEAKER_00: It could be a meniscus, could be some cartilage-related stuff going on.
• 25:45
  SPEAKER_00: Have they had previous history of a lot of patellofemoral issues, just knee pain and issues prior to the ACL?
• 25:51
  SPEAKER_00: Has your other knee had an ACL tear?
• 25:54
  SPEAKER_00: Does the tendon they would be harvesting from have its own history of pain or previous injury, like patella or hamstring tendinopathy, quad tendonopathy?
• 26:06
  SPEAKER_00: Is there a chronic fat pad issue that they're dealing with at the patellar tendon area?
• 26:13
  SPEAKER_00: All these things are going to really influence like a basketball player with a chronic history of patellar tendinitis.
• 26:19
  SPEAKER_00: We might have to think twice about using a patellar tendon, even though a lot of surgeons would be like this would be the best route right now for this person.
• 26:27
  SPEAKER_00: But if you have a tendon that has been through a lot, then we need to make sure that the integrity of that tendon has been held up.
• 26:34
  SPEAKER_00: But then also we think about the aftermath of, well, they've already been dealing with a lot of tendonitis in the past.
• 26:40
  SPEAKER_00: If we take a piece of that tendon, what's going to happen to that tendon after?
• 26:44
  SPEAKER_00: You think it's going to rebound better or is it going to have a harder time?
• 26:47
  SPEAKER_00: And in some cases, there are also autoimmune-related things, even connective tissue like LR down loss or having hypermobility that is going to factor into these decisions.
• 26:59
  SPEAKER_00: For example, there are a lot of people who have hypermobility that end up having an ACL injury, usually to a magnitude that doesn't match what the injury was.
• 27:10
  SPEAKER_00: Like they jump over a puddle and they tear their MCL, ACL, meniscus, and bruise the joint.
• 27:16
  SPEAKER_00: It just doesn't make sense.
• 27:18
  SPEAKER_00: And we see the connections with these particular athletes.
• 27:22
  SPEAKER_00: The thing is that the graph that they choose is so, so important.
• 27:27
  SPEAKER_00: And there are certain ones that show a higher rupture rate, and there's certain ones that have a better longevity and likelihood.
• 27:35
  SPEAKER_00: And I will say if you are in that category and you are thinking about surgery, I would lean towards a patellar tendon unless there is some limitations on that.
• 27:44
  SPEAKER_00: Again, context-dependent.
• 27:46
  SPEAKER_00: And I can't say this blanket, but I would say in a case like this, we have had people who have had hamstring.
• 27:52
  SPEAKER_00: And there has been some research to show that that's not necessarily the best positive outcome compared to a patellar tendon, for example.
• 28:00
  SPEAKER_00: All of this is going to shape what is even available to use and what is wise to take for your particular graft and for the surgery.
• 28:10
  SPEAKER_00: Occupation and hobbies, or even let's say school and hobbies, right?
• 28:15
  SPEAKER_00: Whatever area of life you're in, context-wise, but these are going to really be important, especially the ones that are knee intensive.
• 28:23
  SPEAKER_00: I want you to think about wider than just your job title, whether there's flooring, plumbing, construction, anything where you're on your knees for work.
• 28:31
  SPEAKER_00: But also think about gardening, yoga, a preschool teacher, anything in daily life that has you kneeling.
• 28:38
  SPEAKER_00: We have park rangers who we work with.
• 28:40
  SPEAKER_00: Like it's crazy the wide array of things that people are needing to be able to do with their knees with occupations or with hobbies and activities.
• 28:49
  SPEAKER_00: So if you're constantly kneeling, you're squatting constantly, this is a factor almost nobody brings up on their own in a consult.
• 28:58
  SPEAKER_00: And it really, really bothers me later because you have someone who loves, loves, loves yoga, and they had a patellar tendon history and they have a patellar tendon done.
• 29:09
  SPEAKER_00: And I'm not saying it's the wrong thing, but I'm saying this person obsesses and loves yoga, and that wasn't asked about.
• 29:17
  SPEAKER_00: And they ended up now having so much sensitivity based on her particular case that she has trouble kneeling.
• 29:24
  SPEAKER_00: And that's really hard for someone who loves yoga, but that could have been avoided if good questions were asked and it was filtered correctly.
• 29:31
  SPEAKER_00: It genuinely influences the donor site discomfort because you are going to have a byproduct of that in some shape or form after getting an autograph taken.
• 29:41
  SPEAKER_00: Now, it doesn't stay consistent with every case, and people think that just because you get that, that they'll have donor site pain forever.
• 29:49
  SPEAKER_00: It can be managed with the right programming and rehab.
• 29:52
  SPEAKER_00: We can't fix 100% of them because there has been a structural change there.
• 29:57
  SPEAKER_00: But I will say there is a large portion of rehab that influences whether that recovers and the pain and discomfort.
• 30:04
  SPEAKER_00: But it's also going to be influenced, especially where that's taken and the choice we have, and also especially based on goals, hobbies, occupation, activities, school, things like that, where there may be some more knee-intensive things.
• 30:19
  SPEAKER_00: So we got to factor that in.
• 30:21
  SPEAKER_00: The next one is skeletal maturity.
• 30:23
  SPEAKER_00: This is the last one.
• 30:25
  SPEAKER_00: I'm naming five here that I feel like are the heaviest weight.
• 30:28
  SPEAKER_00: If you're an adolescent athlete with open growth plates, this can override everything else on this list because there are certain factors that we have to influence.
• 30:37
  SPEAKER_00: It can force a physial sparing technique, regardless of what else is going on.
• 30:44
  SPEAKER_00: This one belongs, you know, near the top, I would say, especially for someone who has these constraints of skeletal maturity.
• 30:51
  SPEAKER_00: It can't necessarily be just a preference because we don't want to influence those growth plates if they're open.
• 30:57
  SPEAKER_00: So that can influence, do we get a patellar tendon, which have been awesome because bone is harvested from that?
• 31:03
  SPEAKER_00: But we can't take that if there's still open growth plates.
• 31:06
  SPEAKER_00: So guess what?
• 31:07
  SPEAKER_00: We might have to take a quad graft or a hamstring graft or figure out what other techniques are available to us based on the age of the athlete.
• 31:15
  SPEAKER_00: And I know that usually people think that teenagers and on have this injury, but this happens to the eight-year-old, the 10-year-old guys, and especially with how often sports are played right now in club, we're seeing it younger and younger.
• 31:29
  SPEAKER_00: Before it was like, yes, the frequency of female athletes and between the ranges of 13 to 18, especially.
• 31:39
  SPEAKER_00: But we're seeing this in 10-year-olds.
• 31:43
  SPEAKER_00: Yeah, 10-year-olds.
• 31:44
  SPEAKER_00: It sucks.
• 31:45
  SPEAKER_00: And the thing is, is that we have to be considerate of those things.
• 31:50
  SPEAKER_00: We have to be considerate about playing too many sports and not enough recovery and just letting kids be kids.
• 31:55
  SPEAKER_00: That's a side tangent, but we also need to make sure that we are considering these things for the whole spectrum.
• 32:02
  SPEAKER_00: And all these factors will play into that.
• 32:04
  SPEAKER_00: I'm excited for the bear because I think that that could be a potential option for some of these athletes.
• 32:09
  SPEAKER_00: But again, it's not necessarily going to solve all problems and it's not like it has a hundred percent success rate.
• 32:15
  SPEAKER_00: So we have to factor in a lot of different things for this.
• 32:18
  SPEAKER_00: And so I'm gonna put skeletal maturity on here.
• 32:21
  SPEAKER_00: So these are five factors.
• 32:23
  SPEAKER_00: And again, not because there isn't nothing else to ever factor into this, but because these are the ones that actually move a graph decision for most people, the heavily weighted.
• 32:33
  SPEAKER_00: And I would rather you walk in with five clear questions on this than 15 that you can hold in your head.
• 32:41
  SPEAKER_00: Um, and also just because of time.
• 32:44
  SPEAKER_00: But these are the things, especially, and just to repeat these age, goals, sport, position, and activities, previous injury history, huge occupation and hobbies, or school that especially can have knee intensive related movements on them or pressure, skeletal maturity is the last one.
• 33:05
  SPEAKER_00: So here's where I land this.
• 33:07
  SPEAKER_00: It's a no one size fits all.
• 33:09
  SPEAKER_00: And I'm not trying to dodge this actual question of like what's the best graft or what's out there.
• 33:14
  SPEAKER_00: It's really the honest answer here.
• 33:17
  SPEAKER_00: It really depends.
• 33:17
  SPEAKER_00: There's no one size fits all.
• 33:20
  SPEAKER_00: Because when you understand these two filters, that is going to really help to be able to make a better decision.
• 33:26
  SPEAKER_00: I'm not gonna hand you a single best graft today because that question does not have one honest answer for every person listening to this.
• 33:35
  SPEAKER_00: What I am handing you instead is how to find your specific graft.
• 33:40
  SPEAKER_00: So here's what I want you to actually do with this before your surgery consult, or if you have already had one and something feels off, ask your surgeon two things.
• 33:51
  SPEAKER_00: Why is this graft right for me specifically?
• 33:55
  SPEAKER_00: Not just why do you like doing it, why is it right for me specifically?
• 33:59
  SPEAKER_00: And they need to know your age, your goals, your context.
• 34:03
  SPEAKER_00: And I know that it's shared sometimes, but sometimes it is just not considered.
• 34:07
  SPEAKER_00: So I think that this needs to be truly taken into consideration of why this graph is right for me specifically and asking that, not just what they like doing or they have expertise in.
• 34:20
  SPEAKER_00: And what would you have recommended if I were not the kind of case you usually see?
• 34:27
  SPEAKER_00: I'm gonna repeat that again.
• 34:29
  SPEAKER_00: And what would you have recommended if I were not the kind of case you usually see?
• 34:34
  SPEAKER_00: So just curious to kind of see where they go with that.
• 34:37
  SPEAKER_00: Again, be careful with that last one because they, you know, sometimes they can feel like you're trying to criticize them.
• 34:42
  SPEAKER_00: But these will help you in getting through the filter one and two, or just even two for all honesty.
• 34:50
  SPEAKER_00: But this is something that I think has so much value in it, y'all.
• 34:54
  SPEAKER_00: And I this is a long overdue podcast episode that needed to be done.
• 34:58
  SPEAKER_00: And I know I'm getting longer on you guys, but I'm probably just having way too much to say, and I probably need to revisit that.
• 35:04
  SPEAKER_00: But I also don't want to cut you short because I think that sharing the context of this is really key, being able to understand what it is that factors into a graph selection.
• 35:15
  SPEAKER_00: And with information, overload these days, too much information at our fingertips, it's so hard.
• 35:23
  SPEAKER_00: I get so many console calls where people are overwhelmed, and it's more so about the information they're taking in.
• 35:29
  SPEAKER_00: They're listening to podcasts, they are getting hit by every ACL specialist and quotes on Instagram and YouTube, and everyone's got all these resources, and especially with AI, they're doing these research reviews, and I'm saying do your due diligence, but there's also challenges with going on Reddit forums and Facebook groups, and I'm not faulting anyone on this.
• 35:54
  SPEAKER_00: I do not blame anyone, and I'm not gonna sit here and say that don't do that.
• 35:57
  SPEAKER_00: Like I need you to just do what you feel like is gonna help you in this process, but I also need to share with you that sometimes more information isn't always better.
• 36:08
  SPEAKER_00: And I think connecting with actual true experts, people who have the social proof, who have the reps, who can show you, who can talk to you, who can ask you good questions, and to be able to say, like, okay, all right, these are the things I know about you, and be able to dive in deeper and then also see what options are available.
• 36:27
  SPEAKER_00: And yeah, if you're, you know, in a rural area and they only take your insurance there and the surgeon's good and that's the only graph they do, even though it's a different one that'd be better.
• 36:39
  SPEAKER_00: You just gotta kind of weigh that and decide like, is that gonna be the best thing for your situation?
• 36:43
  SPEAKER_00: And in some cases, it might be okay.
• 36:46
  SPEAKER_00: And in other cases, I think it's important to try and get another opinion.
• 36:50
  SPEAKER_00: It might be a pain in the butt and it might be annoying to call and get another schedule, it might impact the timeline, it might cost you a little bit out of pocket, whatever it may be.
• 37:02
  SPEAKER_00: But you are getting something so permanent done to you.
• 37:06
  SPEAKER_00: And again, I am going to equate this to getting cancer because in reality, y'all, like this can really change the trajectory of your life, this rehab, and people don't get it.
• 37:18
  SPEAKER_00: You just don't get it.
• 37:19
  SPEAKER_00: And many of you listening to this on the other side of it are nodding your heads because you're like, I now get it.
• 37:25
  SPEAKER_00: And we're talking to people who are months, years, long time out with good resources, who are struggling, struggling, and it could be a number of different things, and sometimes it can almost come back to they could have evaluated more options, been a little bit more detailed in what options existed, and being able to figure out another opinion.
• 37:51
  SPEAKER_00: But the thing is, is that I am not faulting any single person in this because I think it comes back to our medical system and the process, and I think that this world in general is very challenging.
• 38:04
  SPEAKER_00: And I understand I'm sitting in the seat of someone who has a lot of experience and expertise, but I understand that this is new for people, so you only get what you get exposure to, and it's really hard to tease that out, especially for someone who's not in this space.
• 38:19
  SPEAKER_00: So I'm not faulting anyone for that, and I think that's very, very important here.
• 38:23
  SPEAKER_00: So if you had a graph that you potentially regretted or wish you did differently, I hear you, and I don't want you to feel like that was a poor decision.
• 38:32
  SPEAKER_00: I think that that was something that I think was intentional for the way it played out, and just know that there is something that can be done to improve this.
• 38:40
  SPEAKER_00: We just got to audit and see is it a rehab thing, is it a biology thing, and then make a plan from there.
• 38:49
  SPEAKER_00: But if you're someone who is deciding on the graft, I really hope you use this.
• 38:54
  SPEAKER_00: If you do, please send me a message, or if you have any thoughts about this episode, I would really appreciate it.
• 39:00
  SPEAKER_00: This is your host, Robbie Patel, signing off.