Latest / The ACL Athlete Podcast / 275 | Two-Stage Revision ACL Reconstruction Part 1: What It Is and Why It Happens

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275 | Two-Stage Revision ACL Reconstruction Part 1: What It Is and Why It Happens · 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: Ravi 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.
• 1:06
  SPEAKER_00: Before I get into today's topic, I want to tell you about an ACL athlete I'm working with right now.
• 1:15
  SPEAKER_00: She had her ACL reconstructed.
• 1:17
  SPEAKER_00: So she had the normal ACL reconstruction.
• 1:21
  SPEAKER_00: She had her injury, had the surgery after that we normally know about.
• 1:25
  SPEAKER_00: She did everything right.
• 1:26
  SPEAKER_00: She found a surgeon, you know, didn't do a ton of research, just found a surgeon, said that they would do the ACL, you know, went through with the surgery, did her rehab, and, you know, as she progressed along in the process, she was expecting to feel like herself again.
• 1:44
  SPEAKER_00: You know, that's something that all of us feel like, right?
• 1:47
  SPEAKER_00: We have the surgery, we get back to being ourselves over a period of time.
• 1:51
  SPEAKER_00: You go through this, you put in the work, and you come out on the other side.
• 1:55
  SPEAKER_00: But for her, something was off.
• 1:58
  SPEAKER_00: Her knee never felt right.
• 2:00
  SPEAKER_00: There was laxity that shouldn't have been there.
• 2:02
  SPEAKER_00: It just kind of felt a little unstable.
• 2:04
  SPEAKER_00: There was some discomfort that stuck around longer than it should have, um, a sense that the joint just wasn't doing what it was supposed to do.
• 2:13
  SPEAKER_00: So she went back to her surgeon and raised her concerns.
• 2:16
  SPEAKER_00: And she was told essentially, you know, there was nothing wrong, that she just needs to keep rehabbing and it'll get better, that everything looked fine from his perspective.
• 2:26
  SPEAKER_00: And that she just needed to keep working at it.
• 2:29
  SPEAKER_00: So she kept doing it, she kept working on it.
• 2:31
  SPEAKER_00: Months and months went by, and the knees still didn't feel right.
• 2:35
  SPEAKER_00: And here's the thing about being told you're fine when you don't feel fine.
• 2:39
  SPEAKER_00: And it's so messy in this ACL rehab process because there's so many different factors.
• 2:44
  SPEAKER_00: It could be the rehab, it could be, you know, the surgery, it could be your body adapting to things, it could be things that change over time, it could be life circumstances.
• 2:54
  SPEAKER_00: There are so many different factors that play into the overall success or lack thereof in this process.
• 3:01
  SPEAKER_00: And so it's challenging when you're told you're fine and you don't feel that way.
• 3:06
  SPEAKER_00: So after a while, you start wondering maybe it's just you, right?
• 3:09
  SPEAKER_00: Maybe you're not working hard enough, maybe you just have a low pain tolerance, maybe to push through things, but then your knee gets flared up.
• 3:17
  SPEAKER_00: Maybe this is just what your knee feels like now.
• 3:20
  SPEAKER_00: You know, you've had surgery and injury, and so this is what you should accept.
• 3:24
  SPEAKER_00: That doubt is one of the most challenging things and damaging things that can happen to an athlete going through this process because it's not the knee that's the problem at that point.
• 3:36
  SPEAKER_00: It's the story you're being told about it.
• 3:38
  SPEAKER_00: And that's really important here.
• 3:40
  SPEAKER_00: We eventually got connected and she had heard about, you know, specializing in ACL.
• 3:46
  SPEAKER_00: And so I evaluated her and I was able to look at her particular case, her history and everything.
• 3:53
  SPEAKER_00: And there were some things that just kind of seemed off in terms of just the way that the tunnels were drilled, when I looked at the op report, when she was noting the pain she was feeling, just some lack of range of motion issues, some stiffness, just her overall sensations that she was feeling was feeling off to me based on testing, assessing some things.
• 4:15
  SPEAKER_00: She had some pinpoint locations that were also giving her issues.
• 4:19
  SPEAKER_00: So we were dealing with a multitude of things, right?
• 4:23
  SPEAKER_00: And so I had suspected that she had a hardware-related issue.
• 4:27
  SPEAKER_00: I had suspected that maybe that the ACL, based on the post op report, wasn't necessarily sitting in the right place.
• 4:35
  SPEAKER_00: And so it was just a challenging situation.
• 4:38
  SPEAKER_00: And so with that, I referred her to a surgeon, and that surgeon was sharing essentially that there was a little bit of an issue, right?
• 4:50
  SPEAKER_00: And basically saying that the original reconstruction had been done with a tunnel positioning that was more vertically aligned, and it should not have been that way, basically.
• 5:01
  SPEAKER_00: And it was non-anatomic.
• 5:03
  SPEAKER_00: That's why the knee felt a bit unstable.
• 5:06
  SPEAKER_00: That's why the knee felt a little bit wrapped off and not in the, you know, best ability.
• 5:12
  SPEAKER_00: And the ACL had been rebuilt, but it just hadn't been rebuilt in the right way.
• 5:18
  SPEAKER_00: And for many of you listening, you're probably like, I didn't know that it could be drilled or put in vertically.
• 5:24
  SPEAKER_00: So there's different tunnel techniques that exist in the ACL react process.
• 5:29
  SPEAKER_00: And so there's transtibule, there's more anatomical base.
• 5:32
  SPEAKER_00: And so, based on training and how much surgeons, you know, go deep in this area of their surgical practice, or maybe they were just taught old beliefs.
• 5:43
  SPEAKER_00: Usually transtibule is a little bit more of an older kind of vertical alignment.
• 5:47
  SPEAKER_00: And the anatomical is supposed to mimic essentially where that ACL was when it got injured, right?
• 5:53
  SPEAKER_00: Where anatomically it was put for your physical, you know, biology, right?
• 6:00
  SPEAKER_00: And so this is something that was a little hard.
• 6:03
  SPEAKER_00: So she had a hardware issue, and then her A cell laxity was an issue.
• 6:07
  SPEAKER_00: And so the other thing, too, is that her tunnels had widened as well.
• 6:11
  SPEAKER_00: And so she was just dealing with some complications with this process.
• 6:16
  SPEAKER_00: And it eventually led to her having to have a revision of her knee.
• 6:22
  SPEAKER_00: And that's what it ended up coming down to, based on her goals and what she wanted to get back to doing, the issues that she was dealing with.
• 6:28
  SPEAKER_00: Um, it made sense based on just, you know, a number of conversations and and consults to essentially move forward with the risk revision in order to really provide a viable solution for this person.
• 6:43
  SPEAKER_00: The path forward was going to be more complicated than just like, you know, a simple redo, if you will.
• 6:49
  SPEAKER_00: It requires what was a two-stage procedure, a two-stage reconstruction.
• 6:55
  SPEAKER_00: And that's what today's episode is about: a two-stage ACL reconstruction, why it happens, who ends up facing it, and what to expect going into it.
• 7:07
  SPEAKER_00: And we're gonna make this into a two-part series just to be able to dive into the details because there's a lot to unpack here.
• 7:14
  SPEAKER_00: And while it might happen to a smaller subset of ACLers, it happens.
• 7:18
  SPEAKER_00: And I don't think that there's enough clear information out there.
• 7:21
  SPEAKER_00: So I want to make this super practical for my ACLers, for my clinicians, coaches who are listening to, because it might be something you might be a little more unfamiliar with.
• 7:30
  SPEAKER_00: So my goal is to make sure you feel educated about it.
• 7:33
  SPEAKER_00: So we're gonna split this into two parts to go a little bit deeper into it.
• 7:37
  SPEAKER_00: And in part two, we're going to get more into the research, what the studies actually say about outcomes, and what the surgery itself looks like in detail and what that recovery looks like.
• 7:48
  SPEAKER_00: Because it is a lot.
• 7:50
  SPEAKER_00: And I want to make sure as athletes, as clinicians, as coaches who are working alongside them that we have the details to be able to map this out appropriately.
• 8:00
  SPEAKER_00: So let's get into it.
• 8:02
  SPEAKER_00: So, what is a two-stage ACL reconstruction?
• 8:07
  SPEAKER_00: And usually this can also be thought of as revisions.
• 8:10
  SPEAKER_00: Basically, we are revising a previous ACL reconstruction or surgery.
• 8:16
  SPEAKER_00: Most people have this mental model of ACL surgery that goes something like this: you tear your ACL, you have surgery, your surgeon drills tunnels in the femur and the tibia.
• 8:25
  SPEAKER_00: That's your thigh bone and your shin bone.
• 8:27
  SPEAKER_00: They put a graph through that, through those tunnels, fixes it in place.
• 8:31
  SPEAKER_00: Usually there is a button that is used, and usually there is also a tibial screw that is used.
• 8:38
  SPEAKER_00: Again, different procedures, different techniques, different hardware can be used, but that is a very common process with this.
• 8:45
  SPEAKER_00: And then you rehab your way back, right?
• 8:47
  SPEAKER_00: One surgery, one recovery, and you're good to go.
• 8:51
  SPEAKER_00: That model is accurate for a lot of people, I would say majority of people, but there's this subset of athletes for who the path that that is is not going to be directly available.
• 9:04
  SPEAKER_00: Either the first surgery failed in a way that left behind structural damage, or the original tunnels were positioned incorrectly, or the tunnels have widened so significantly over time that there isn't enough solid bone left to hold that new graft in place securely.
• 9:24
  SPEAKER_00: In those cases, a single-stage revision going back in and just replacing the graft isn't always the safest or most effective.
• 9:36
  SPEAKER_00: And so that's where the two-stage reconstruction revision surgery comes in.
• 9:43
  SPEAKER_00: Here's how to think about it.
• 9:44
  SPEAKER_00: Imagine you're renovating a house, you want to put up new walls, new floors, new roof.
• 9:49
  SPEAKER_00: But when the contractor gets in there, they find out that the foundation is compromised.
• 9:53
  SPEAKER_00: You guys know I love a good house analogy.
• 9:55
  SPEAKER_00: The concrete has cracked, the structure underneath isn't stable.
• 9:59
  SPEAKER_00: If you just build on top of that, everything you put up is going to be a risk.
• 10:04
  SPEAKER_00: So what do you do?
• 10:05
  SPEAKER_00: You fix that foundation first, you let it set, let it cure, let it become solid, and then you build on it, right?
• 10:14
  SPEAKER_00: And that's exactly what a two-stage ACL reconstruction is.
• 10:18
  SPEAKER_00: Stage one is the foundation work.
• 10:19
  SPEAKER_00: The surgeon goes in, removes the old graft, the hardware, cleans the damaged bone tunnels, and fills them with bone graft.
• 10:30
  SPEAKER_00: I kind of like to think of this as like a putty that they put into there.
• 10:33
  SPEAKER_00: It's helpful to kind of visualize that.
• 10:35
  SPEAKER_00: The goal of stage one is that entirely structural.
• 10:40
  SPEAKER_00: The goal of stage one is entirely structural.
• 10:43
  SPEAKER_00: It's not about the ligament yet.
• 10:45
  SPEAKER_00: It's about restoring the bony environment so that stage two can be done correctly.
• 10:50
  SPEAKER_00: So they usually go in there, they'll clean up that knee.
• 10:53
  SPEAKER_00: I've seen situations where you know there's a meniscus-related issue that they find in the knee when they go in to revise it.
• 10:59
  SPEAKER_00: So then they may repair it, they may clean that up a little bit.
• 11:03
  SPEAKER_00: They just want to make sure like the entire joint itself looks pretty good and is in a good spot.
• 11:09
  SPEAKER_00: And then they're going to also fill in those holes to make sure that that foundation is super solid.
• 11:17
  SPEAKER_00: So that way when they go in, they are able to drill the holes appropriately and almost start from scratch, in a sense.
• 11:25
  SPEAKER_00: And so here's the thing athletes need to understand about stage one.
• 11:29
  SPEAKER_00: You leave that surgery with no ACL graft in place.
• 11:32
  SPEAKER_00: The old one is out, the new one isn't in yet.
• 11:36
  SPEAKER_00: And that is very intentional.
• 11:38
  SPEAKER_00: That's by design.
• 11:40
  SPEAKER_00: But it's something that needs to be understood going in because it changes how you think about the period between surgeries.
• 13:51
  SPEAKER_00: Stage two is the reconstruction itself.
• 13:54
  SPEAKER_00: So now you can kind of think about a typical ACL reconstruction.
• 13:57
  SPEAKER_00: Months later, once imaging confirms that the bone has healed and the tunnels have consolidated, the surgeon goes back in and performs the actual ACL reconstruction with a new graft.
• 14:08
  SPEAKER_00: New tunnels are drilled into solid healthy bone, new fixation.
• 14:13
  SPEAKER_00: It's all done right, hopefully, right?
• 14:16
  SPEAKER_00: Two surgeries, one goal, a knee that is actually built on a foundation that it can hold, right?
• 14:22
  SPEAKER_00: And so in certain situations like this, the other thing I want to share is that usually it is a two-stage procedure.
• 14:30
  SPEAKER_00: There are situations where maybe a surgeon can go in and repair maybe a widened tunnel without having to completely remove the ACL.
• 14:40
  SPEAKER_00: So there are different techniques that exist, and it's all going to be based on surgeon expertise, opinion.
• 14:46
  SPEAKER_00: What is the graft quality like?
• 14:48
  SPEAKER_00: Is it still thick and good and strong and in there?
• 14:51
  SPEAKER_00: And the tunnel is just creating issues and it's too wide.
• 14:54
  SPEAKER_00: And so things like this can occur.
• 14:56
  SPEAKER_00: So then, therefore, that is where you have to get the opinions and figure out what is going on.
• 15:01
  SPEAKER_00: I wish it was so straightforward, but at this point, I've consulted so many complicated ACL cases all across different injuries, different sports, different age ranges, genders.
• 15:14
  SPEAKER_00: You name it, y'all.
• 15:15
  SPEAKER_00: Like I promise you, at this point, I've seen it and heard of it.
• 15:18
  SPEAKER_00: And the thing is, is that there can be a lot of complicated cases that exist out there when you're talking about a one ACL tear, two ACL tear, three ACL tears, and yes, four ACL tears, it happens.
• 15:31
  SPEAKER_00: And so the thing is, is that can make things a bit messy.
• 15:35
  SPEAKER_00: So then we got to figure out, you know, what do these revision surgeries or solutions look like?
• 15:41
  SPEAKER_00: Now, why does this happen?
• 15:43
  SPEAKER_00: This is the part I want to spend some real time on because understanding why a two-stage is necessary is what helps athletes make sense of what they're facing.
• 15:54
  SPEAKER_00: It's not random.
• 15:56
  SPEAKER_00: There are specific reasons a surgeon looks at a knee and says a single stage revision isn't enough.
• 16:03
  SPEAKER_00: The common reason is the tunnel widening, and that's the biggest thing here.
• 16:08
  SPEAKER_00: When your original ACL reconstruction was done, the surgeon drilled tunnels in your femur and tibia to seat that graft in there.
• 16:16
  SPEAKER_00: Over time, those tunnels can expand.
• 16:19
  SPEAKER_00: And there are a few reasons this might happen: mechanical stress of the graft, biological responses to certain grafts, fixation methods, the position of the tunnels themselves, you know, where they were drilled, because the angles and the positioning is important.
• 16:36
  SPEAKER_00: Hamstring grafts, for example, tend to produce more tunnel widening than patellar tendon grafts.
• 16:41
  SPEAKER_00: You know, the patellar tendon grafts themselves have bones on each side of them.
• 16:45
  SPEAKER_00: And that's one of the reasons why some people will, you know, claim it's the gold standard or the one that a lot of surgeons will like.
• 16:55
  SPEAKER_00: And because there's bones at the both ends of them.
• 16:57
  SPEAKER_00: And so then therefore it incorporates into those tunnels much better and much faster because that bone can heal faster versus it being just a soft tissue graft with no bone on each end, right?
• 17:09
  SPEAKER_00: It's not a failure of the surgery itself, though, in every case.
• 17:13
  SPEAKER_00: I think that's important.
• 17:14
  SPEAKER_00: It's just a you know biological reality that can happen in situations like this.
• 17:19
  SPEAKER_00: The problem comes when the widening is significant.
• 17:22
  SPEAKER_00: Most surgeons draw the line somewhere between maybe 12 to 14 millimeters in a tunnel diameter.
• 17:29
  SPEAKER_00: When you cross that threshold, the walls of the tunnel are too thin and the bone is too compromised to hold a new graph with secure fixation.
• 17:39
  SPEAKER_00: You can't just drill a new tunnel like you have, you know, some plywood, and you're like, okay, let me move this over a little bit because of a especially a widen, kind of degraded one next to it and expect it to hold, right?
• 17:52
  SPEAKER_00: That's like trying to do that hole super close to another hole that you've drilled.
• 17:57
  SPEAKER_00: You know, there's potentially impact that that can kind of cross over.
• 18:00
  SPEAKER_00: And so the only thing that's important to consider too is the bone quality just isn't there.
• 18:05
  SPEAKER_00: And that's where a stage one becomes necessary to rebuild that bone stock back before stage two can happen.
• 18:13
  SPEAKER_00: The second major reason is tunnel positioning or bad positioning, if you will.
• 18:20
  SPEAKER_00: And this is what happened with the athlete's story today.
• 18:23
  SPEAKER_00: Her original surgeon drilled the tunnels in a non-anatomic position.
• 18:28
  SPEAKER_00: It was more vertical than they should have been, what we call it typically like a transtibule, which meant the graph was working in a direction that didn't necessarily replicate the natural ACL, which is why the knee felt unstable even after reconstruction.
• 18:43
  SPEAKER_00: When a revision is needed and the tunnel, the new tunnel, needs to go in a different, more anatomic position.
• 18:51
  SPEAKER_00: There can often be overlap with the old one.
• 18:54
  SPEAKER_00: When that overlap is significant enough, you can't safely drill the new tunnel without compromising the fixation.
• 19:01
  SPEAKER_00: The old tunnel has to be filled, allowed to heal, and then a new anatomic tunnel goes in through the solid bone.
• 19:09
  SPEAKER_00: And there are other reasons the two-stage becomes necessary too.
• 19:13
  SPEAKER_00: Hardware from the original surgery that can't be removed without damaging the surrounding bone, significant stiffness in the knee that needs to be addressed before reconstruction, alignment issues in the joint that needs to be corrected first, active infection in most serious cases.
• 19:29
  SPEAKER_00: And while y'all think that that doesn't exist, I have seen a case that y'all would never believe with infection.
• 19:37
  SPEAKER_00: As much as this person tried to keep it clean and safe, it was quite a journey over the course of about six months, I would say, of infection with ebbs and flows, controlling it, eventually having to get the hardware taken out.
• 19:52
  SPEAKER_00: You know, it was earlier in the process too.
• 19:55
  SPEAKER_00: So it was something that was a bit complicated.
• 19:58
  SPEAKER_00: And when I say I've seen a lot, y'all, I've seen a lot.
• 20:01
  SPEAKER_00: This active infection really did impact about six months of rehab for someone.
• 20:06
  SPEAKER_00: Separate case here, but that was also another, you know, thing where, you know, the the bony restoration of that joint was important.
• 20:14
  SPEAKER_00: But tunnel widening and tunnel malpositioning, if you will, are the two biggest ones that play into this.
• 20:20
  SPEAKER_00: And of course, yes, like an ACL tear happens, reinjury happens, then that could be a part of that tunnel widening and tunnel malpositioning, right?
• 20:29
  SPEAKER_00: They're the reasons most athletes end up facing this decision.
• 20:32
  SPEAKER_00: And now I want to come back to the athlete story for a second, because there's something here I think needs to be named directly.
• 20:39
  SPEAKER_00: She went to her original surgeon multiple times and was told nothing was wrong, that her knee looked fine, that she should just keep working at it, and that experience of raising a concern and being dismissed is something I hear about more often than it should be.
• 20:55
  SPEAKER_00: Not every surgeon is equipped to manage complex ACL cases, even simple ACL cases.
• 21:02
  SPEAKER_00: Like you just don't want the catch-all of all surgeons to be able to do an ACL case.
• 21:07
  SPEAKER_00: I don't want a general orthopedic surgeon doing my ACL case.
• 21:11
  SPEAKER_00: No offense, y'all.
• 21:12
  SPEAKER_00: I want someone who is literally so obsessed with ACLs doing my ACL case, who is so obsessed with knees doing my ACL case because they are going to stay on top of things.
• 21:23
  SPEAKER_00: They have worked on perfecting things because they're so obsessed with it.
• 21:27
  SPEAKER_00: I don't want the surgeon who is also good at hips, good at shoulders, good at ankles, because they're likely not amazing at every single thing.
• 21:35
  SPEAKER_00: There are usually one to two things that people are really good at.
• 21:39
  SPEAKER_00: And this is one of those things where I say you are an inch wide and a mile deep.
• 21:46
  SPEAKER_00: This allows you to go deep into ACL world and know this stuff.
• 21:51
  SPEAKER_00: And that's where I'm saying, you know, there are a lot of surgeons who are not equipped to handle complex ACL cases.
• 21:57
  SPEAKER_00: And this applies across PTs and rehab as well.
• 22:00
  SPEAKER_00: Not every surgeon is also going to look at tunnel widening on an X-ray and know what they're seeing, to be honest.
• 22:07
  SPEAKER_00: I wish that they did.
• 22:08
  SPEAKER_00: And not every surgeon is going to refer out when a case exceeds their expertise.
• 22:12
  SPEAKER_00: And this is something, man, I need to do an episode on this.
• 22:17
  SPEAKER_00: And I think the same thing could be said about physical therapy.
• 22:20
  SPEAKER_00: Um, I think that there's so much ego in terms of trying to be the solution and being able to solve every problem.
• 22:29
  SPEAKER_00: And I think that that's really important.
• 22:31
  SPEAKER_00: And even for cases for us, like I'm not here to say I'm gonna save the day in every single situation.
• 22:36
  SPEAKER_00: And I'm gonna also make sure you get to the right places and make sure you have that solution or we're evaluating different solutions.
• 22:43
  SPEAKER_00: And you can ask any of our athletes, any of our team members, we are searching for the perfect solution for you to make sure it's the right choice.
• 22:51
  SPEAKER_00: I think that that is the case, and also surgical expertise is that sometimes surgeons need to also say, I think that I need to refer you to a colleague or here, go see this person.
• 23:02
  SPEAKER_00: And we have surgeons around here and we know that do this, right?
• 23:05
  SPEAKER_00: And I respect it so much because then they're like, I need to do right by this patient, versus feeling like, oh, I can save the day, right?
• 23:13
  SPEAKER_00: Sometimes it's helpful to have a different lens in the process and a different expertise to be able to see a different viable solution, right?
• 23:24
  SPEAKER_00: The damage that happens in an ACL deficient or unstable knee while an athlete is waiting for answers is just not a neutral, if you will, right?
• 23:35
  SPEAKER_00: And every giving away episode puts stress on the meniscus.
• 23:39
  SPEAKER_00: Every month of instability puts stress on the cartilage.
• 23:43
  SPEAKER_00: Now, some people can get by, but you know, if there are people who are not copers in this process, then that is something that's challenging.
• 23:50
  SPEAKER_00: The longer the gap between what's actually wrong and when it gets addressed, the more complex the problem can become.
• 23:57
  SPEAKER_00: Her case was harder to solve when the second surgeon saw her than it would have been earlier.
• 24:03
  SPEAKER_00: And that was on Honestly, a real cost.
• 24:04
  SPEAKER_00: And I wish that she could have had it done earlier, but she felt like you know she had evaluated all things.
• 24:09
  SPEAKER_00: So if your knee doesn't feel right after surgery, trust that.
• 24:14
  SPEAKER_00: And I want you to be thorough in that evaluation.
• 24:18
  SPEAKER_00: Now get a second opinion.
• 24:19
  SPEAKER_00: It might be a second opinion from a surgeon, a second opinion from a physical therapist.
• 24:24
  SPEAKER_00: Make sure you're doing your due diligence first.
• 24:27
  SPEAKER_00: You're you're doing all the right rehab stuff in terms of listening to your PT and your surgeon.
• 24:31
  SPEAKER_00: But again, like not everyone is expertise in this.
• 24:34
  SPEAKER_00: Some a lot of times it's more general than it is more expertise.
• 24:38
  SPEAKER_00: So you need to find someone who can help you get the second opinion, third opinion, fourth opinion, and especially who specializes in this space.
• 24:47
  SPEAKER_00: And especially if you have a complicated case who understands complex cases, because that's going to be really important.
• 24:54
  SPEAKER_00: For us, like we are not a starting point for a lot of people.
• 24:58
  SPEAKER_00: We'd love it because then therefore it's a smoother process for the person.
• 25:02
  SPEAKER_00: But a lot of times, y'all, we get people who are coming in, you know, three months, six months, nine months, twelve months out from their first, second, third ACL.
• 25:11
  SPEAKER_00: It might be multi-ligament, it might be meniscus ACL, it might be multiple revisions, bilateral ACLs.
• 25:20
  SPEAKER_00: We've had people who have come years and years out that had never gotten it back, who have been dealing with pain issues for years and months.
• 25:27
  SPEAKER_00: You guys name it.
• 25:28
  SPEAKER_00: And the thing is, is that that's essentially like what I just generally expect whenever people I talk to for consultations and start working with us remotely or in person.
• 25:39
  SPEAKER_00: I'm expecting the hard cases.
• 25:40
  SPEAKER_00: And if you looked at our cases remotely and in person, it is crazy how much complexity is across the board.
• 25:48
  SPEAKER_00: But the thing is, is that we love those things.
• 25:51
  SPEAKER_00: We want to be challenged by that.
• 25:53
  SPEAKER_00: There's a lot of people who don't necessarily engage in that or have experience with it.
• 25:57
  SPEAKER_00: And I think that's really important.
• 25:59
  SPEAKER_00: And there's a real cost to that.
• 26:01
  SPEAKER_00: If your knee doesn't feel right, just make sure you get some opinions.
• 26:06
  SPEAKER_00: The right answer might be that everything is actually fine.
• 26:09
  SPEAKER_00: And that's okay.
• 26:10
  SPEAKER_00: That's awesome.
• 26:11
  SPEAKER_00: But the right answer might also be that it isn't.
• 26:14
  SPEAKER_00: And you deserve to know which one is true and be thorough in your approach to do so.
• 26:21
  SPEAKER_00: So who ends up needing this procedure?
• 26:25
  SPEAKER_00: I want to give you this clear picture of athlete population that typically faces the two-stage because I think it helps people understand that this isn't just random bad luck.
• 26:34
  SPEAKER_00: Most athletes who go through a two-stage have had at least one prior ACL reconstruction, often more.
• 26:42
  SPEAKER_00: They tend to be active athletes in sports that involve pivoting and cutting, soccer, basketball, skiing, lacrosse, football, ultimate.
• 26:53
  SPEAKER_00: But this isn't exclusive to competitive athletes.
• 26:57
  SPEAKER_00: I work with recreational athletes, our team does weekend warriors, active adults, and the profile can apply across the spectrum.
• 27:04
  SPEAKER_00: The ACL does not discriminate.
• 27:08
  SPEAKER_00: The path to needing a two-stage usually involves one or more of these a failed primary ACL reconstruction that either retore or never felt stable.
• 27:19
  SPEAKER_00: A first surgery done at a facility that wasn't equipped for the complexity of this injury, a graph choice or a surgical technique from the first surgery that led to significant tunnel widening over time, or a combination of several of these things stacking on top of each other.
• 27:36
  SPEAKER_00: And the other thing I want to add too is that you could have done everything right, and so could have the surgeon, and this can still happen.
• 27:42
  SPEAKER_00: So I don't want to kind of throw fault at different people.
• 27:45
  SPEAKER_00: Just know that usually these players are happening, and it's something that we just kind of have to weigh and figure out okay, what could have contributed to this?
• 27:56
  SPEAKER_00: And also, you know, what is going to be the game plan more importantly for us to make sure that this doesn't happen again.
• 28:02
  SPEAKER_00: What these athletes almost universally have in common, though, is that they did the right thing.
• 28:08
  SPEAKER_00: They got the diagnosis, they got the surgery, they went to rehab, they tried, and something still went wrong.
• 28:14
  SPEAKER_00: That matters to say out loud because a lot of these athletes carry guilt and self-blame about where they ended up.
• 28:22
  SPEAKER_00: Can't tell you how many conversations I have, and it breaks my heart because these people feel like they have worked and worked and worked, and especially working with professionals who might not be super encouraging and might just blow it off or saying, like, oh, well, I did my job, like it's on you to do this, or sorry, I don't know.
• 28:43
  SPEAKER_00: That sucks, man.
• 28:44
  SPEAKER_00: And you feel gaslit by this.
• 28:46
  SPEAKER_00: And and it happens so much in healthcare, and I think it's really important to call out.
• 28:50
  SPEAKER_00: The message I want to land here is that this isn't a character flaw on your part.
• 28:55
  SPEAKER_00: It's a just clinical reality of what happens, and it's one that can be addressed.
• 29:00
  SPEAKER_00: People think that they get to these points and they're like, I can't get there.
• 29:04
  SPEAKER_00: And I can't tell you how many times we have had people tell me on the phone in conversation, like feeling stuck, feeling like they've just been, you know, spinning their wheels and that they're just like, I don't know if I'll ever get there.
• 29:16
  SPEAKER_00: And they get there.
• 29:18
  SPEAKER_00: But we got to make sure there's the right team, right testing, right, you know, comprehensive understanding of your story to create the best solution possible to address the problem.
• 29:31
  SPEAKER_00: Is it gonna be fast?
• 29:32
  SPEAKER_00: Probably not.
• 29:33
  SPEAKER_00: I wish it was, but we're dealing with human biology.
• 29:36
  SPEAKER_00: We can't predict the future.
• 29:37
  SPEAKER_00: We don't have a magic eight ball here to say, like, okay, here it is.
• 29:40
  SPEAKER_00: Yeah, we say nine to 12 months, but y'all, it ranges.
• 29:43
  SPEAKER_00: It ranges so much upon people's lives and so many other just complexities that exist in this process and what it is to just be a human, right?
• 29:53
  SPEAKER_00: And so I think that that's really important to just share here, but just knowing that it's something that can be addressed no matter where you are, how complex your case is, there can be a solution.
• 30:08
  SPEAKER_00: Now, what to expect going in?
• 30:10
  SPEAKER_00: If you're facing a two-stage or you're working with an athlete who is, there are a few things that need to be understood clearly before the surgery.
• 30:17
  SPEAKER_00: First, this is a long process.
• 30:19
  SPEAKER_00: ACL rehab in general is a long process, but this is longer.
• 30:23
  SPEAKER_00: You're looking at a minimum of 14 to 24 months.
• 30:26
  SPEAKER_00: I know that pains me to say, hear, do, but from stage one all the way through to let's say return to sport, return to performance, you're looking at a long timeline.
• 30:38
  SPEAKER_00: I'm not saying that to discourage you.
• 30:40
  SPEAKER_00: I'm saying it because one of the most damaging things that can happen to an athlete navigating this is expecting a shorter timeline and feeling like they're feeling when the biology just doesn't cooperate.
• 30:52
  SPEAKER_00: And knowing the real number up front allows you to plan around it mentally and practically.
• 30:57
  SPEAKER_00: Knowing it's a long game process, we're not trying to win this thing in the first month or two.
• 31:01
  SPEAKER_00: Playing the long game is so important.
• 31:04
  SPEAKER_00: And also knowing what to expect.
• 31:06
  SPEAKER_00: If you do a job and you are expecting to get paid 100 bucks and you get paid 20 bucks, you're gonna be real mad.
• 31:14
  SPEAKER_00: And that's what's important here is that we need to let you know are you getting paid 20 bucks?
• 31:18
  SPEAKER_00: Are you getting paid 100 bucks here?
• 31:20
  SPEAKER_00: At least you know what that is, so then that way you know up front what it is, so then that way you know how to plan and what to expect for the process.
• 31:31
  SPEAKER_00: Second, the interstage period is unlike anything, you know, in the standard ACL rehab, if you will.
• 31:37
  SPEAKER_00: The window between stage one and stage two typically runs, I would say around three to six months between that bone graft being put in and the ACL reconstruction happening.
• 31:48
  SPEAKER_00: It could be longer depending on how well the bone graft incorporates.
• 31:54
  SPEAKER_00: It could be shorter, usually rarely less than three months, just from a bone healing standpoint.
• 31:59
  SPEAKER_00: But during that period, your knee has no ACL.
• 32:02
  SPEAKER_00: You're mobile, you know, you're doing rehab, but you have real restrictions.
• 32:07
  SPEAKER_00: It doesn't mean that you just kind of chill, right?
• 32:09
  SPEAKER_00: You're prehabbing, you're rehabbing really hard, building up that knee, but we're not doing things to compromise the knee or testing that ACL, right?
• 32:17
  SPEAKER_00: Like we're not trying to drive your car and to high speed traffic.
• 32:21
  SPEAKER_00: We are, you know, doing stuff in the neighborhood, maybe on the, you know, kind of city highway, if you will, but nothing in high speed traffic.
• 32:29
  SPEAKER_00: So no cutting, no pivoting, you know, no contact stuff.
• 32:32
  SPEAKER_00: We're pretty controlled about plyometric stuff and we got to assess risk reward, right?
• 32:37
  SPEAKER_00: The biggest thing is getting your knee in a good place, getting it healthy and strong, and making sure that all the surrounding musculature is as strong as possible going into it.
• 32:47
  SPEAKER_00: And you're doing all that while you're waiting for the bone to heal, which is a different kind of patience than anything else in this process.
• 32:53
  SPEAKER_00: We're going to cover the interstage period in detail in part two because it deserves its own conversation.
• 33:00
  SPEAKER_00: But the third point I want to share about what to expect going in, and I want to be direct about this, is that this is going to be emotionally heavy.
• 33:10
  SPEAKER_00: This rehab process in general is emotionally heavy, and most people do not understand this.
• 33:16
  SPEAKER_00: Most, you know, people who have not torn their ACL don't understand this.
• 33:20
  SPEAKER_00: And this is not to say, like, you know, it's it's something that you're lacking, but it's just one of those things that until you walk in these shoes, you just don't get it.
• 33:31
  SPEAKER_00: And it's hard to really share that with people.
• 33:33
  SPEAKER_00: And I know my ACLers understand this.
• 33:38
  SPEAKER_00: This is just an emotional journey overall, but especially doing something like this, you've already probably gone through one ACL injury and a reconstruction.
• 33:46
  SPEAKER_00: Now you're gonna go through another one, and it's gonna be longer.
• 33:50
  SPEAKER_00: And the reason I'm saying it's gonna be emotionally heavy is not because you're a weak person, right?
• 33:55
  SPEAKER_00: It's just genuinely hard.
• 33:57
  SPEAKER_00: You've already been through this once, you already know what this process costs, and now you're facing a revision of it that's more complex and takes longer.
• 34:07
  SPEAKER_00: The research actually backs this up.
• 34:09
  SPEAKER_00: Studies published in 2025 found that psychological readiness scores in revision ACL patients are significantly lower than the primary ACL patients.
• 34:19
  SPEAKER_00: Not marginally lower, significantly.
• 34:22
  SPEAKER_00: That's not a reflection of the individual athlete, that's a documented, measurable response to a documented, measurable reality.
• 34:29
  SPEAKER_00: You like that, didn't you?
• 34:31
  SPEAKER_00: What it means practically is that the mental piece of this needs to be taken as seriously as the physical.
• 34:39
  SPEAKER_00: That doesn't matter if it's a revision or not, but especially in this.
• 34:43
  SPEAKER_00: We're going to get into that in part two as well.
• 34:47
  SPEAKER_00: And where we're gonna leave it here is that the athlete I told you about at the start of this episode is currently in the middle of stage two rehab.
• 34:57
  SPEAKER_00: She's not at the finish line yet, but she's getting there.
• 35:00
  SPEAKER_00: She has a knee, she understands, a surgical plan that made sense from the start, a team behind her that she trusts.
• 35:06
  SPEAKER_00: And for the first time since this whole process began, she knows exactly where she is, where she's going, and what the next step is.
• 35:14
  SPEAKER_00: That shift from confusion and the self-doubt to clarity and direction, that's what's getting the right diagnosis and the right team in your corner can do.
• 35:22
  SPEAKER_00: It doesn't make the process shorter, but it makes it much more doable and much more confident because you know that you have the GPS here.
• 35:32
  SPEAKER_00: You know exactly where you're going, you know what the estimation of that is.
• 35:37
  SPEAKER_00: But most importantly, you can feel confident in that roadmap.
• 35:39
  SPEAKER_00: And I think that's so key is that in this ACL rehab process, there's so many of you who don't know what the next step is, don't know what this looks like, don't know where you are.
• 35:51
  SPEAKER_00: And the the similarity or the comparison I make to this is that you get in your car, you type into the GPS where you want to go, but you don't know where you're starting.
• 36:02
  SPEAKER_00: And so then it makes it really hard for it to calculate because it has to have at least two points for us to be able to know, okay, this is what I estimate, how long, this is the turns we got to make, and this is what it's gonna look like, right?
• 36:15
  SPEAKER_00: But it's really hard when you don't know those things.
• 36:18
  SPEAKER_00: And I can't tell you how many athletes who come to us that I'm not saying we get them, you know, perfectly to a good place in their perfect set amount of time.
• 36:27
  SPEAKER_00: We have to navigate through the complexities of their process and what they had been dealing with before, maybe take steps back.
• 36:34
  SPEAKER_00: And maybe it takes longer because of life, or maybe they have a flare-up, whatever happens.
• 36:39
  SPEAKER_00: The thing is, is that they always know where they are and where they're going.
• 36:43
  SPEAKER_00: And that is so important in this process.
• 36:45
  SPEAKER_00: And I can't tell you how much people share the anxiety that has left them, the clarity that they have, and just knowing that they have someone who knows this process that's in their corner that they can lean on, right?
• 36:57
  SPEAKER_00: Ask questions, know exactly what this is gonna look like.
• 37:01
  SPEAKER_00: And that alone makes, you know, a 12-month, a 18-month, a 24-month process so much better because you're gonna have to walk that journey anyways.
• 37:11
  SPEAKER_00: You might as well do it knowing you have confidence in your team, your physical therapists, and who is in your corner.
• 37:17
  SPEAKER_00: And so that is something that we hope to provide for any of you who are interested.
• 37:23
  SPEAKER_00: So please reach out to us.
• 37:24
  SPEAKER_00: We would love to be helpful, especially if you're feeling doubtful in this process.
• 37:29
  SPEAKER_00: You can find our information in the show notes.
• 37:31
  SPEAKER_00: We can point you in the right direction, or even just clarity on what the next steps can look like for yourself.
• 37:37
  SPEAKER_00: But before we sign off here, I do want to share in part two, we're gonna cover some of the research.
• 37:42
  SPEAKER_00: You know, what studies like Mitchell and colleagues have found, the Mars group, the 2025 meta-analysis by Sutton and colleagues, basically sharing outcomes after a two-stage reconstruction.
• 37:52
  SPEAKER_00: We'll break down what the stage two looks like and the road back looks like, and what the interstage period requires from you know the athletes and clinician side and what both groups need to walk away from this, knowing exactly how to be confident and what it is all about.
• 38:10
  SPEAKER_00: And if this episode resonated with you, share it with an ACL or a clinician, you know, a supporting role here who needs to hear it.
• 38:18
  SPEAKER_00: And as I shared, if you're in a situation where you need some assistance, please reach out to us.
• 38:23
  SPEAKER_00: All the info is in the show notes.
• 38:25
  SPEAKER_00: We work with athletes navigating exactly this complexity every single day.
• 38:32
  SPEAKER_00: And uh we would love to help anyone who is interested.
• 38:36
  SPEAKER_00: And if you have any questions in general, please reach out to us.
• 38:40
  SPEAKER_00: Otherwise, I will see you in part two.
• 38:42
  SPEAKER_00: This is your host, Robbie Patel, signing off.