Episode 175 | ACL Graft Types – Why You Might Not Have a Choice For Surgery

What is up team and welcome back to another episode on the ACL Athlete Podcast. Today we are diving into this topic: “ACL Graft Types – Why You Might Not Have a Choice For Surgery.” Before we dive in to this episode, I want to provide a very quick overview if you’re new to the world of ACL’s and graft types. An ACL graft is essentially the new ligament or really it’s a tendon when it goes into the knee, but it is what’s going to become your new ACL ligament. It goes in as a tendon and it is harvested either from yourself, which is an autograft, or it is an allograft which is from a cadaver. The cadaver itself can be a variety of options; including the big three, which is the patellar tendon, the quad tendon or the hamstring tendon. That is usually your three choices for autograft and allograft, it can be those three from a cadaver, or it could be an Achilles tendon. I’ve seen some other options out there. But usually because of the research and especially with the consistency of the thickness of the graft that we want, usually is pulling from those different areas in terms of becoming your new ACL graft. 

Now that we have those basics out of the way, the thing is when you have your ACL injury and you are a candidate for ACL reconstructive surgery which is where most people go and the direction that they’re going in. Then you are going to be thinking about the graft that you’re going to get. I have had the opportunity to consult with over hundreds of ACLers over the years, here locally in Atlanta, as well as all over the world, Europe, Australia, Asia, South America, Africa, countries I didn’t know even existed, literally all over. And the way that it’s handled is very different from the healthcare systems to the medical training and on. There’s a lot of factors that play into this whole process. 

What I want to do today is share something that I’ve noticed more in this space, given this unique experience that I have, being able to essentially pull from different regions of the world, talking with different athletes, knowing how different surgical procedures go in different parts of the world. It’s something that I don’t really think is really mentioned. We talk a lot about making your choice and exploring the graft types and different surgeons and whatnot. But I think that there’s something that doesn’t really get mentioned often whenever athletes are going to make this decision and consulting with surgeons, and that’s what I want to dive into today, specifically. 

So what happens is you’re often not given a choice with ACL grafts. Now let me explain what I mean by this. I think that this will shed some light and I think hopefully it’ll create a little bit of a light bulb moment for you guys as you’re listening. In general, if you ask the surgeon, if you ask the PT, if you ask athletes, ACLers who have had this surgery and are listening, you get such differing opinions and answers based on experience, as well as geographically where people live. These are all things that play into it, aka that will also play into the surgeon that they go with, which will ultimately also factor into the graft that they get. 

While surgeons aren’t often on Reddit threads or Facebook groups, if you go into these places, don’t do it. But if you do, then this is something where you will often see the question: What is the best ACL graft? It’s such a broad question, but everyone and their mother is going to add their opinion. I had the hamstring graft because my surgeon recommended it and I had the best results with it, and then someone else is going to come in and say, the hamstring graft is the worst. It has a higher reinjury rate, all this stuff. It’s all anecdotes or they might pull a study reference here, there. But everyone has their own perspective because it’s an N equals one perspective, especially if you’re someone who is not working with the majority of these types of athletes. If you’re not a PT, seeing a high volume of these athletes; if you’re not a surgeon who is working lot with these athletes; if you are especially the ACL or you’re going to have your own perspective. I have my own perspective about hamstring grafts because I’ve had to myself. But it’s very unique because I’ve actually worked the least with hamstring grafts. I’ve actually worked the most with quad grafts as a coach and as a clinician working with ACLers. But I worked with quite a number of hamstrings, quads, patellar tendons, allografts, combo, multi-ligament reconstructions. These are all perspectives that we are going to speak from, in terms of when we are making opinions or suggestions or recommendations. This is something that is really tough—ACL graft choice.

My goal today isn’t to talk about all of these and say which one’s the best. In all honesty, it is a very difficult choice and it is so specific to each person and the context that they are in. This is something that you have to take within your specific case. I want today’s focus to be on this topic of why your choice might not exist. I’m going to break this down even a little bit further so then that way we can understand what it is that we’re trying to gain from this episode today. 

As I had mentioned, I don’t think that there is a lot of discussion around your options or much less given a choice, even if you ask your surgeon and here’s why. Surgeons are the ones who are guiding this process because they’re the ones who are going to be doing the surgery. Of course, it sounds like I’m calling out surgeons, but it’s not calling them out. It’s just really just explaining this process from my perspective. The surgeons are who we are focused on because they are doing the surgery. This is where they are doing that process, so therefore the conversation is with them typically. Sure, you might get other opinions from your physical therapist. We help athletes navigate this process if they are pre-surgery and make some recommendations based on their goals and also surgeon and all these different factors that play into it. But in the day, it’s the conversation for you as the athlete and the surgeon in terms of what it is that you’re going to use as your graft. This is where I want to bring up our biases and our lenses. Every human looks through certain biases through different lenses based on experiences and whatnot. I do that as a physical therapist, as a coach, as a husband, as a father, brother, all these things, all these life experiences. But especially if we are talking about professionally, like I look through certain lenses as a physical therapist and performance coach. 

With that said, a surgeon also has their own lenses and biases that they’re going to look through. This is something that we want to make sure that we think about, okay, well, where is this coming from? A lot of it is their education and training, mostly residency and fellowship and afterwards. Who did they train under? And what were their opinions about particular graft types? What was the graft type that they did the most of during residency and fellowship. This strongly influences the surgeons practice and the graft that they potentially use when they go off to join a sports medicine team or go off and do their own practice. I’m not speaking absolutes here. This is not all surgeons and this is not all healthcare providers. This is, of course, just speaking in general, that this is a very common route to go because of your training. You’re going to bias through this lens because that’s the experience that you’ve gained because it’s been passed down from someone else or a group and it’s something that you’re comfortable with. This is going to influence the surgeon’s practice and the graphs that they potentially use. This is something that the surgeons they will stick with it. And then there are some of those who might change due to experience, change the technology or maybe its research that comes up and is updating their practice. This is something that I want us to dig a little bit deeper on. 

Let’s take the surgeon that was trained on the patellar tendon graft, that’s their go-to graft. If you’re someone seeking a quad tendon as an ACLer, do you think this surgeon is going to recommend it even if you ask for it? It’s possible and maybe they’re trained on each one, maybe they know how to do both of those. There are surgeons that exist that do a variety of them. But the thing is a lot of times surgeons have their go-to grafts. They do quads. They do the patellar tendon or the hamstrings, or they’re big on cadavers. They are that person. Rarely are they seeing a high volume of each one? They all have their preferences. 

When I talked to surgeons, a lot of times they do have their own preferences even here in Atlanta. Quad tendon is a very big one that has really taken over, I think even in the general surgeon community here in the States, that I think this is something and again, like not saying that’s the best one. There are a lot of factors that could play into it. It’s of the newer of the big three. But it’s something even someone had mentioned the thought of, oh, well, it’s actually the easiest to harvest as well. I’m not going to make any comments on this. I think the biggest thing to consider here is that everyone’s got their own perspectives and their biases that they lean towards. They’re rarely going to see a high volume of all of these, just because they’re all different techniques. Usually when you’re in the world of ACL and doing decent amount of volume, you’re not going to be amazing at all those different techniques. You might be able to do them, but you might have a bias towards a certain type. This could be also based on how you see athletes who report, your surgical technique, how people are progressing along the way, all this stuff embeds into their experience which embeds into what they’re recommending for athletes they’re seeing. 

There might be certain categories of athletes,they’re young youth athlete, they might have a go-to tendon for that. If they are a recreational athlete, they might have a go-to tendon for that. If they’re 45 or an older, a lot of times surgeons will recommend allografts, that’s just like a blanket across the board. Although, I think that there should still be caution and I think there should be conversation around it. And age not being just the only factor, but also goals and the context of the athlete. This is something that you want to make sure you factor in. When you’re having the conversation around graft options, this should first informally be coming back to a place of your goals, history, age, gender, etc., all factors that play into this decision. And of course, what options are on the table with the surgeon. Usually they have one graft that they recommend is probably the one they do a lot of and are known for. Even if you’re hoping for a patellar tendon, for example, they might have said hamstring.

I think what’s not mentioned here is that this bias influences their opinion and nudging you in that direction. I heard it from ACLer so many times where they talk to their surgeon and they say this graft is best because of X. They give some sort of reasoning behind why that graft choice is better for you. And while it may be true, it might not be true. It’s also the one they like, so they’re of course going to try and recommend it. They’re oftentimes isn’t another option on the table and so that’s where this title comes into play. Is that they might just say like, really this is the graft choice you need to get. And there’s not really a discussion around the other options that exist. A lot of times, because they probably just don’t do the other graft types or maybe they just really love one particular graft type and that’s their expertise and that’s what they’ve been doing for so long. Now that’s not necessarily a wrong thing, of course, but I think that this is something to just consider because a lot of times what we talk about is you want to assess what your options are. But the thing is that sometimes you just don’t get those options. Because as soon as you pick a surgeon, you’re going to be essentially forced into a particular type of graft because that is their background and that is the graft that they recommend. If you think one’s best, but really it’s their bias and preference for what they think is best. You have to do your homework. I’m not saying that what they’re recommending is wrong. Don’t get me wrong here. So I’m not saying that the surgeons are wrong in the sense of like recommending their graft. It can almost eliminate these options and choices that can make it a little bit more simple for you. I don’t think that that is a bad thing, but I think it is bad whenever we don’t do our homework or we just kind of go with the graft type and don’t really doour due diligence to look at some information to assess other options.

And then we have athletes who later on are like, man, I wish I had never gotten this graft if I had known this. Some of that could be picked up by just doing the proper research, whether it’s on the surgeon, whether it’s on the graft type, whether it’s on your sport specifically, or getting some different opinions. This is something that I want to really encourage with this episode, because you have to understand your options as well as the surgeon who have had the reps and the credibility. That is the thing that’s important. 

You want to make sure the surgeon has had good repetitions of ACL’s and you want to make sure that they have really solid credibility. If the surgeon’s only done a handful of ACL’s in the year [?]. But if they’re doing multiple ACL reconstructions weekly, like some of these Atlanta surgeons are, I have some trust in them. And that also goes along with  their philosophy. Do they do return to sport testing? Do they do strength testing? Do they rush athletes to surgery? What is communicated to these athletes as well plays a big role in the relationships and trust I have with certain surgeons, especially locally here in Atlanta. This is something that I do think is important to think about. And while it seems like a lot, do your due diligence. And if that’s one thing you take away from this podcast in general, if you’ve been listening to it for a while, do your research, educate yourself. That’s why this podcast exists is to help you to sift through all the noise because there’s a lot of BS out there in the space. I want you to make sure you do your check on me as well and make sure that what I’m saying is true and honest. This is something that I think we always have to have a little bit of skepticism with anything we encounter, especially with medicine. It’s just one of those things where nowadays we have to just make sure we educate ourselves as best as possible and find reputable sources. 

As I mentioned, it might seem like a lot to do. But this is something that I want you to think about from a different lens. Think about if you were going to buy your house, you’re going to buy a car, you’re going to do the research. You’re going to invest in something where you’re going to spend a lot of money. Of course, when money is associated, we definitely do our research or aesthetic is also played into it. Then we’re going to do our research a little bit, do some reviews, shop around if you will, just to make sure it is the right thing. Because it’s a perception thing, but then it’s also something that you’re going to be maybe living in or driving around and it’s important to you. It is something that has a little bit more of a high cost to it. 

Now let’s transfer this over to your health. I feel like we owe it to ourselves with our health, especially to invest in it and to be able to do our due diligence like anything else, especially similar to buying a house or a car, or the college that we’re going to go to, another good example. We do our research and we make sure that we make the best choice. Don’t just go with whatever your first option is, that is typically not always the best idea. You just want to get some information first and then make a good decision. 

And so make sure you ask the surgeon the questions that are important. If you want to know what those are, then you can check out earlier podcast episodes I’ve done on questions to ask your surgeon. There’s two part series to that. You can check out our blog on the ACL Athlete website. We also have a free ebook you can download that is available on our resources page on the website. We will also link it in the show notes for this episode, in case you were someone who is looking to ask the right questions to your surgeon. And the thing is, if you are nervous to ask your surgeon these questions, politely just say, Hey, I have some questions. Do you mind if I ask them, it will really give me some peace of mind. And if they are taken aback by any of them, then I would almost question their true commitment and really like, why is it that it is affecting them in a way for you to ask these questions. 

I know the healthcare system makes us feel rushed and we got to hurry and ask our questions within the 5-10 minutes we got. Look, you are deserving of that time, you are making a very important decision and if you need to take the next 15-20 minutes to take that surgeon’s time do it. I think this is very important because you can often get rushed through this process. It is a very big decision and you want to be fully at peace knowing you have evaluated, asked all your questions. This is something that I can say from experience, in terms of being an ACL, being in the medical system so many times, dealing with my parents who are immigrants and having to help them navigate a lot of healthcare issues, working with clients and athletes, having to help them navigate these situations, it is not easy. I’ve been at fault for this to like kind of rush through some things at times, but that’s where we audit our process and we make sure, hey, we make time for our athletes and have conversations and make sure that they feel fully addressed and all questions are fully answered. If we don’t know the answer, then we find out the answer and get back to you. If you’re anyone who has ever talked to me in any form or a consultation, you know that every single time at the end of that call I ask, are there any more questions? I’m not going to put a cap on that because I think that you need to make sure you feel fully educated and understand what you are getting into. I think that that is also very important for consulting with your surgeon and making these decisions. 

The thing that is going to be important with this podcast episode is that you just need to know that there might be a bias. That can be okay, as long as you’re on board with the game plan. If you were someone who had intentions of a different graft, but a surgeon persuaded you or changed your mind otherwise, then I would look a little deeper to see if that’s maybe the right thing to do or maybe because they just don’t do that graft. That’s the thing that you want to make sure you have researched that might be best for you in your specific situation. 

The last point I’ll make here is get a few opinions. Even though they might be the go-to surgeon in the area, they’re the ACL guy or girl,they are the pro-team sport surgeon, etc. Get two to three opinions. See what perspectives these docs have. I say this with finding a PT, this goes for finding a house. You’re not just going to go to the first house and buy it after you’ve toured it. You’re going to make sure that you tour a few houses at the minimum, if not multiple houses in order to make the best decision of what feels right for you, location, all these factors that you’re going to play into the decision of purchasing a home. 

The same thing with a college, the same thing with a car, insert anything else you’re going to invest: time, money, energy into same thing here with your health and with your particular case. Even if you feel locked in with your first surgeon, just go get a second opinion anyways, just to see what someone else might have to say. And then that way, okay, cool. I really liked my first surgeon and I think that this is the person I’m going to go with for X, Y, and Z reasons. 

I just wanted to come on to today’s episode and share this perspective because I don’t really think it gets discussed very much. I know in this space you might be like, okay, I hear, yeah. Go talk to my surgeon and ask them these questions. But a lot of times when I’m talking with ACLers, they don’t really get these options. They’re just kind of told here’s your graft. You might get another option if the surgeon is really forward, they will say like, I don’t really do that one. A lot of times you’re coming into this, not really knowing anyways, because you’re just trying to rely on their professional. The thing is that the professional has a certain lens they look through. This is where I just want to share some caution because you need to do the research and understand your context and then be able to make a decision based on multiple opinions, even though they are that go-to person. And sometimes you honestly just don’t have a choice, even though options exist out there. That’s the thing that can be so tough. And it comes back to the surgeon, their preference and of course, your consent with that as well. But as always, you guys know advocate for yourself, especially if your gut tells you it doesn’t feel right or what you were expecting. And that’s the thing that I want to make sure we hammer home with this episode. And again, not saying all surgeons are like this, it’s just more of just the nature of human beings and we all have our own lenses we look through, our own training, all the things. And so that’s where we just need to make sure we evaluate our options, make sure that we find different options and opinions and then make the best informed decision we can once we do that.

And final thing I’m going to note here, don’t go off and be giving your surgeons really hard times. Still respect them. Of course, they are part of your team and just hear their perspective and get that information, take it in as data. Once you get those differing opinions, you can make a well-informed decision about what route you want to go in. Of course, they’re going to have their own preferences and that’s okay, it’s just not discussed. I think that’s the thing that I want to share today because I think a lot of times people go in thinking, oh, well, you know, I might do this graft or I’d like to hear my options. But then they are just told, hey, you’re going to go with this quad graft. This is something that just like, okay, yeah, you’re the professional. Let me trust you. But I think that there are some people who end up getting certain grafts or going with certain surgeons because it was what was convenient. It sounds ideal based on the way that they explained it and they didn’t get multiple opinions on this. I think that’s where things can go wrong in a sense because then therefore, they’re just looking through that one lens of what that surgeon preferred.

This is where doing your research, doing your due diligence in terms of this process is so key because it can make a huge difference, not only in the short term, but also the longterm. And also, potentially not looking back in hindsight and being like, man, I should’ve done something different. You want to feel very confident in that decision like any other big investment you’re going to do. But this is for your health and the long-term abilities of your body with athletic abilities, all the things that are going to be so important to you here in the short term, but also in the long term. 

If you have any questions, team, please reach out. You know where to find us on all the channels. If you have not listened to recent episodes, you can go into the show notes and you can ask us a question and this could be something that we will table for some Q and A’s coming up, as well as any other podcast topics. And if this podcast has been helpful to you, I asked for two things: One is that if you would leave us a five-star review because that helps us to reach more and more ACLers just like you. And also to send us a message, we do not get your phone number whatsoever, but you can send us a text saying how this podcast has been helpful for you. That is super awesome. And we have been loving the messages we have been getting from people who have been tuning in. So again, thank you all so much for supporting us until next time. This is your host, Ravi Patel, signing off.