> Yes it does.
> What would you say accounts for different outcomes with
> patients with similar injury using the same type of graft?
> I just ran into two people, one a friend who had a patella
> autograft two years ago and after the initial week had no
> pain, no kneeling pain and no tendonitis and said he barely
> did his PT. The second individual also had a patella
> autograft and said the pain was unbearable for two weeks,
> and severe for 4 more weeks and difficult through 5 months
> of PT which he said he did religiously. He said he still
> has kneeling pain 1.5 years later and occassionally his
> knee is sore. Two different doctors (FYI neither of them
> Dr. Sanders , nor did they use the contralateral knee for
> graft.)
> I know indivuals are different but I wonder if the skill,(
> e.g. maybe placement of graft,) doesn't have a bigger
> impact on outcome and/or pain then the studies suggest.
> BTW: since I think skill is important wouldn't go to a
> surgeon who can't supply any patients for me to talk to-a
> doctor we visited recently acted surprised at this request
> and still can't provide any to talk to. (as many of you
> know Dr. Sanders has lots of patients willing to share
> their experience-I'm out of state but had one talk to me
> for about an hour.) I think that is a telling sign right
> there.
As a clinical researcher, I understand and applaud your efforts to try to determine the major variables that affect the results of ACL reconstruction. However, this is difficult to determine even with large patient population due to the multitude of variables that must be taken into consideration. In my experience, these include:
1a. The operative technique (not just the "skill" of the surgeon, but the technique itself). For instance, the surgeon I work with does a meticulous dissection of the patellar tendon region, always bone grafts the defect in the patella at the end of the procedure, and loosely closes the defect in the patellar tendon. That combined with a carefully monitored rehab program has resulted in less kneeling pain in our hands than that reported by some authors.
1b. The ability of the surgeon to place the ACL graft in the anatomically correct position - or where the native ACL used to reside. Many surgeons have trouble accomplishing this goal if they used a single-incision endoscopic technique - a point which has been well-established in recent literature. A vertically oriented (nonanatomic) graft may work in some knees, but in many will not provide suitable stability and results in a positive pivot-shift.
2. The presence of severe bone bruising or visible, large articular cartilage defects seen at surgery. These pre-existing problems affect the outcome of surgery, regardless of all other variables.
3. The extensive loss of meniscus tissue. So goes the meniscus, so goes the knee. That is why we attempt to repair meniscus tears whenever possible, instead of resecting major portions of this vital structure.
4. The presence of other ligament ruptures, which require operative repair.
5. Pre-existing patella pain or patellar instability.
6. The rehabilitation program, which we believe must be initiated the day following surgery and include immediate knee motion, patellar mobilization, and quadriceps exercises. The program should be progressed as tolerated by the patient and according to the presence of articular cartilage defects or additional major operative procedures. Exercises and modalities should be used and modified as required to avoid overuse or tendinitis complications.
7. The chronicity of the injury - how much time has passed between the initial injury and the operation. Our studies have shown much better results if the procedure is done fairly soon (within 4-6 weeks) after the injury than if the patient waits for many months or years.
8. Restoration of normal knee motion and good muscle strength, elimination of pain and swelling before surgery.
9. Graft maturation.
10. Patient motivation and compliance.
11. Other variables inherent in individual patients that cannot be predicted at this time, such as a genetic/anatomic predisposition to recurrent ACL injuries.
The combination of all of these factors is what really influences the outcome of this operation and that is why patients have differing outcomes with what appears to be the same operation. I hope this helps!
SueBW
