Have you heard about the trial out of Boston Children’s Hospital for a new ACL repair procedure? Dr. Martha Murray and colleagues are pioneering this new technique called BEAR (bridge-enhanced ACL repair). It is based on the the idea that ligaments can heal themselves given the right conditions. For example, the MCL can heal itself in a few weeks depending on the severity of the tear. Up until now, the ACL has always had to be surgically reconstructed because of too much fluid in the vicinity. Identifying this problem and coming up with a way to address it lead Dr. Murray et. al. to pioneer a procedure whereby they place a sponge in the ACL “cavity,” stitch the ACL a bit, and wait for scar tissue to form and create the new ligament, just like the MCL does on its own. 

I first found out about this idea the day after my accident while researching ACL surgeries (waiting in the car while D returned our skis). Fast forward to this week when the team announced their first human trial successes and the start of a second trial. I couldn’t sign up fast enough! And then… I was told that because of my MCL injury, I am not eligible to participate in the trial. 

So. Sad. 

I’m much more bummed about not being able to do it than I imagined I would be! So, back to the plan of giving my MCL time to heal and then surgery to reconstruct my ACL. Sigh. On a happier note, I can’t wait to see what comes of this second phase of their trial. Good luck to Dr. Murray and her team!

Note to self, don’t sleep on my right side with my right leg out. Tried that last night and, while it was so nice to not sleep on my back, I must have forgotten about my leg and when I moved it to shift positions, I totally tweaked my knee and it hurt the worst it has since I injured it. Ouch. I hope I didn’t set myself back. Luckily I was able to fall back to sleep.

Worst night of [lack of] sleep yet. Was awake from 1:30AM to 6:30AM. Read about taxes, painkillers after surgery, and a bunch of other topics that have escaped me. Did some work emails. Made a nice recording of D snoring (don’t kill me!). On the bright side, I guess I got a lot accomplished! 

Accomplishment of the morning: going down stairs without crutches!

[update] Also went up stairs without crutches! 

Learned Today:
* PT location is in network so it is not considered “high-cost.” Confirmed that each visit is the regular co-pay.

A working post with ongoing research about graft options. According to initial consult with Dr. S, I’m likely limited to allograft because of my “petite stature.”

1. ACL Surgery Graft Choice : 5 Professional Opinion Series [link]
   1. [re: autograft v allograft] The risk of re-rupture approaches equal at about age 35.
   2. Allografts (cadaver) grafts are probably a poor choice in an athletic population.
2. Micucci Allograft Presentation [pdf]
   1. Primary ACLRs using nonirradiated allografts may provide superior clinical outcomes than those using low-dose (<2.5 Mrad)irradiated grafts.
      1. QUESTION: Confirm with Dr. S
   2. Bone-to-bone healing is the strongest
      1. QUESTION: Ask Dr. S about this
   3. Allografts heal in the same manner as autograft but at a much slower rate
   4. Tensioning of the graft is more important with allografts
   5. Additional literature:
      1. Autograft versus nonirradiated allograft tissue for anterior cruciate ligament reconstruction: a systematic review. Am J Sports Med. 2014 Feb;42(2):492-9.
      2. Analysis of irradiation on the clinical effectiveness of allogenic tissue when used for primary anterior cruciate ligament reconstruction. Am J Sports Med. 2015 Jan;43(1):226-35.
3. Centers for Orthopaedics, ACL Graft Choices [link]
   1. A very in depth read with lots of info.
   2. Some patients may not be candidates for patellar tendon ACL grafts. These include petite individuals with narrow patellar tendons.
      1. QUESTION: what about hamstring graft in petite patients? (at odds with other research post? look into this more)
   3. A number of efforts are looking at bioengineering ACL’s by culturing progenitor ligament cells on a matrix scaffold. Critical to its success is mechanically loading and stimulating the cells to mature in the correct orientation that would mimic a normal ACL’s cellular geometry. Several research projects are reportedly experimenting with biomaterials that would serve as a suitable scaffold material for this process. Silk is one the materials currently being studied as it seems to be well tolerated by the body, is strong, and it promotes a healthy in-growth response.
      1. QUESTION: Ask Dr. S if I can get a GM silk scaffold!!! Kidding. Sort of.

A working post with ongoing research on the correlation between height and graft choice.

1. Anatomical considerations in hamstring tendon harvesting for anterior cruciate ligament reconstruction. Muscles Ligaments Tendons J. 2012 Oct-Dec; 2(4): 253–257.
   1. When using a patellar – bone – tendon – bone graft, the graft diameter can be reproducibly determined by the surgeon. However, when using hamstring tendons the graft diameter is predetermined by the natural diameter of the tendons of each individual and the surgeon has no influence on that. Hence it is possible to obtain a graft of too small diameter, which potentially could be associated with less mechanical resistance.
      1. QUESTION: Ask Dr. S about patellar graft
   2. Nevertheless there seems to be a consensus that females tend to have small diameter [hamstring] grafts, which may explain reports of postoperative graft laxity more often seen in females.
2. Evaluating the distance between the femoral tunnel centers in anatomic double-bundle anterior cruciate ligament reconstruction using a computer simulation. Open Access J Sports Med. 2015; 6: 219–224.
   1. Even if surgeons are very careful to locate the two femoral bone tunnels anatomically, they sometimes encounter a relatively small footprint area, and thus find it difficult to preserve the stable bony bridge between the two intra-articular apertures.18,19 Based on our results, in cases with relatively short stature (<160 cm for males or 155 cm for females {editor’s note: M, 151cm}), where the ACL footprint size is supposed to be small, femoral tunnel drilling using tibial tunnel-independent techniques, such as the transportal technique or the outside-in technique, might be considered to avoid the overlap of two tunnels and fixation failure.
      1. QUESTION: Talk to Dr. S about this!

It’s been two weeks since the accident. Oddly enough, it feels like much longer.

Today was also my first day cleared and back to work. Dave very awesomely chauffeured and escorted me to and from.  Having not slept very well last night, I was exhausted by 4 o’clock. My leg started swelling up and I gave up on trying to “walk” anymore and just crutched it. One day at a time.

Also made my PT appointment for the first week of April!

FINALLY had my appointment with the orthopedic surgeon this afternoon.

Things I suspected that he corroborated:
* MCL has to heal before ACL surgery
* MCL will take at least 6 weeks to heal (for Grade III); I was hoping for 4
* ACL surgery can be scheduled for any time once MCL heals

Things I learned:
* MCL tears can be categorized above Grade III to Grade IV (or beyond?). So I’m not the worst — yey!
* Because of my height, it is very unlikely that I will be a candidate for an autograft — meaning they likely won’t be able to use my hamstring or patella tendon to reconstruct my ACL. Instead, they will likely have to use a cadaver tendon (ligament?). I need to research both the height correlation and allografts some more.
* For the next two weeks, I should only walk in a straight forward motion; no shuffling from side to side or pivoting. This make walking slightly more frustrating.

Next steps:
* Can’t start PT for another two weeks
* I have to do 4 weeks of PT, twice a week
* I follow up with the doctor in three weeks, i.e. one week after I start PT

I’m a little dismayed that I can’t start PT right away. I wanted to be off and running (no pun intended).

On the bright side, Dave and I had a great lunch after the appointment! Hooray for little things to smile about.

Went to Nordstrom Rack to try and find some pants to go over my brace and I was able to walk ! Aided by the crutches but I’m still really happy. The knee started bothering me afterwards but not too bad! Going to keep trying to put weight on it until the doctor on Tuesday.

UPDATE:
Walked without the crutches!!
(PS – it doesn’t hurt, just feels weird. Like I might tip over?)

Lazy day. Gilmore girls marathon!

Changed the flexion limit to 90° because it was being difficult to bend my knee. So I’ll slowly increase the limit.