[geo_skier]

I’m a 37 Male, and reader of TFTNA and veteran of the Free Ride Plan. Typically I am 5000-6000 ft/day backcountry skier, around 30 days a season, with 10 more at the resort. Though the mountains are 3+ hr away from where I live. My other activities are day hikes, and training for skiing. I don’t climb and haven’t played other sports in years. Six weeks ago I got into a ski mountaineering accident tearing my ACL and MCL on my left leg and have a high grade partial ACL tear and MCL tear on the right. I curious about other people’s experience with the various reconstruction options. I had no idea of all these choices before.

I’ve met with two surgeons, both seemed good and were recommended. Both have recommended the patellar graft. They talked about this autograft vs using a donor allograft. They thought I was close to the line on this, but I should go with my own tissue. Neither wanted to use a hamstring tendon and were dismissive of it. From my research this seemed consistent for athletes. I’ve been surprised to see lots of skiers, younger than me, have gone with the hamstring autograft. I am missing something for backcountry skiers vs other athletes? Hamstring seems like the shortest recovery time, but is weaker and more likely for re-injury. I was also told that the hamstring adds knee stability so it was that surgeons last choice for an active person.

On another note – the first surgeon was hopeful I would only need one reconstruction but that was early and he wasn’t able to do all the tests on my ligaments due to soreness. The second (2 weeks later and after prehab started) believes I will need both knees. Only time will tell on that. He recommended 2 months between surgeries to just get it over with.

Topic

[Pete Dickinson MS,PT]

Pete Dickinson MS,PT on March 7, 2019 at 8:30 pm #17760

Sorry to hear about your recent injury and ACL/MCL involvement. Ligament instability of the knee starts to become a safety issue in the backcountry as movement limiting incidents can then occur. My time rehabbing our US Ski Team Downhillers has given me some background with this injury. Graft selection is an important consideration, but the main issue is picking the right surgeon and trusting his judgement. I never recommend pushing for a surgery that the surgeon’s experience doesn’t favor. That said, the autograft patellar tendon compromises your quad, not a good outcome for a ski athlete. Dealing with subsequent chronic patellar tendonitis is no fun. The hamstring autograft is a great option, as is the allograft donor tissue. You have been getting some odd advice as the hamstring graft has nice outcomes for all patients. Speed of rehabilitation is individual, all the ACL surgeries need to respect the graft fixation time limitations, then its a matter of gradually progressing without getting into trouble with yanking on the graft with the wrong activities (ie: skiing, early running). I also agree that you need 3 months between surgeries to have a good leg to stand on for the 2nd surgery.
Best,
Pete

[Anonymous]

Anonymous on March 7, 2019 at 11:26 pm #17766

If you have not already done so, you might want to check our Brian Harder’s blog, http://www.skimolife.com/. Over a series of 5 posts, he detailed he experience with ACL reconstruction for skiing. All the the questions you ask, and more, are detailed therein. Good luck–it’s a long road, but I think you’ll come out the other end stronger.

[dmburch]

dmburch on March 17, 2019 at 8:36 pm #18560

Hi Geo_skiier, I am a fellowship trained sports medicine orthopedic surgeon. Like Pete, I am truly sorry to hear about your injury. My personal preference for ACL reconstructions is the patellar tendon autograft. The primary function of the ACL is to control front to back and rotatory stability to the knee. Graft selection is controversial, but the gold standard is still the Patellar tendon (B PT B). The bottom line is the hamstrings grafts have more laxity post op, this no one disagrees about. In my hands my collegiate athletes return to their previous level of sport. It is true that there is more post op pain at the front of the knee, and strength recovery is a bit longer, but these dis advantages are outweighed by the advantages in a person with high demands. I would recommend post op bracing for skiing as well. I dont help take care of USSkiing but am a USOC doc, as well as the head team physician for several colleges and a G-League basketball team.
Regardless of which you select, the post op rehab is critical. Follow your surgeon and therapists instructions. Best wishes. Dan

[Pete Dickinson MS,PT]

Pete Dickinson MS,PT on March 19, 2019 at 3:00 pm #18634

Thank you dmburch for your surgeon perspective on this condition! My post exposed my biases gained from the treatment room. Since the patellar tendon autograft is considered a ‘gold standard’ I was able to see countless sport specific outcomes to this choice. While great in cutting sports due to it’s strength, it takes out the middle third of the patellar tendon leading to tendon pain with sports that load that area (think skiing, biking). I remember ski legend Marc Giradelli sitting at the start of many races packing snow on his patellar tendon due to his chronic pain at the end of his career (post ACL).
The “bottom line” might be laxity oriented in D1 Football, but this isn’t the whole story. Laxity was common in post ACL even in B-PT-B due to the demands of sport and training, in my alpine team experience. In light of the graft choices available, the advantages outweigh the disadvantages for the knee extensor loaded sport participant to consider non B-PT-B grafts.
All this being said, pick the surgeon, not the graft. Your surgeon of choice will have what works for him based on his skills and experience.
Respectfully,
Pete