ACL injuries from football are very common

The patients who opt for surgery are required to wear knee braces after surgery temporarily to provide support to the knee and helps in regaining the lost strength. But some former ACL surgery patients have chosen to continue using a knee brace for athletics, even after they have 100% recovered. According to the survey conducted by aclsurgery.us of 187 ACL surgery patients, 31% (58) said they still wear a brace, though they’ve fully recovered. 33% (62) said they sometimes wear a brace, and 36% (67) said they never use a brace. This means that approximately 2/3 of the people who have had ACL surgery still feel they need for a brace. And with the variety of braces in the market, how does one choose?

Knee Brace Survey

Different types of knee braces are specially made to suit the needs to ACL surgery patients. However, the best and the most widely recommended one is the braces with hinges and metal supports. The hinged knee brace covers the major portion of the leg i.e. from the portion above the knee to middle of the calf. It is specially designed to provide comfort to the injured ligaments as well as to prevent strain on those parts during the movement.

Some of the companies who specialize in the manufacturing of knee braces for ACL surgery patients are Donjoy, Breg, McDavid, Ossur, ProCare, etc. Out of these, Donjoy is the most popular as well as widely used brand for ACL braces. There are many models available in each of the above-mentioned brands and the price varies from brand to brand and model to model.

We will compare two knee braces: Donjoy Custom Defiance knee brace, and Breg custom LPR ligament knee brace which are specially meant for ACL surgery patients.

Donjoy Custom defiance knee brace:

Pros

• It offers maximum comfort to the injured ligaments due to its custom fit feature.
• Over 40 different choices in colors and graphics.
• Mechanism to control the flexing and extension of the knee.
• Manufactured by most trusted and widely used brand.
• Wide range of supporting accessories.

Cons

• Higher price than competing brands

Breg Custom LPR ligament knee brace:

Pros

• It is designed with light weighted aerospace aluminum in order to stabilize injured ligaments.
• Provides great protection as well as comfort to the knee.
• Comes with airframe padding, which allows the moisture and heat to move away from the skin.

Cons

• Absence of Mechanism to control flexing and extension.

Even though it is listed at $950 it can be availed at a special price of $759 from braceshop.com.

You can also find many affordable braces on following websites:-

• braceshop.com,
• betterbraces.com,
• dme-direct.com, etc

While you can save money ordering online, it comes at a risk, however, as it may not fit as precisely as you want. And the fit is key to protecting your knee and avoiding future injury. So, the best way to buy the right knee brace is to try on different braces in order to determine the comfort and support abilities of each brace. This is best done in a major metropolitan area where you can drive to a variety of brace carriers. It may take a little effort, time and money in travelling around to find the best brace for your knee, but if protecting your knee is a high priority, it may be a wise investment.

There are three primary choices of grafts for ACL surgeries: patellar grafts, hamstring grafts, and allografts (cadaver grafts). There is much speculation and debate about which graft and fixation is the best. Surveys show that the hamstring graft is the most popular choice currently for most people, but that the most serious athletes in competitive sports still choose patellar grafts, known for being the strongest, most reliable graft, but not necessarily the most pain-free.

The best advice before surgery is to wait at least six months to allow the swelling to abate, with full range of motion to return and pre-surgical strengthening exercises preparing the way. After surgery, the need to work with a physical therapist and/or athletic trainer is crucial. It will also take a full year for the proprioception to return which is the balance and agility factor, so important to keep from re-injuring the knee.

Out of 400,000 ACL surgeries a year, about 18,000 to 35,000 fail is some way. The most common failures are permanent stiffness; lack of full extension and range of motion; instability and a pain and/or grinding. The reasons for failure include going back to sports too soon; not completing proper post-operative care with a brace or cast; and several possible surgical errors. The graft may have been misplaced, non-anatomically correct, too vertical or too tight. The rehabilitation program may have been poorly designed or the patient had lack of motivation to succeed. Whatever the reason, the condition is called “arthrofibrosis” and this failure will lead to post-traumatic arthritis.

Some patients had successful surgeries and rehabilitations, but end up reinjuring the knee either playing the same sport that caused the original injury or from other activities involving twisting motions of the knee. Whether through carelessness or by accident, the resulting knee injuries will be more complicated, less stable, and require even longer rehabilitation. Most professional athletes are forced to retire after reoccurring knee injuries.

People can tear their ACLs in a variety of ways. It can occur from high impact sports like motocross or karate, or doing mundane things like walking down stairs or hopping out of bed. Videos actually show athletes tearing their ACLs, not for faint of heart, but give you an idea of how it happens and what it’s like.

How most people tear their ACL
(From December 2010 survey)

Basketball 11.8%
Football 11.8%
Skiing 13.7%
Soccer 23.5%
Other 39.2%

The ‘other’ group contained random activities, such as:

Wrestling
Motorcycle accident
Netball
Ultimate Frisbee
Snowboarding
Kickboxing
MMA fight
Floor hockey
Motocross
Jujitsu
gymnastics
Wrestling
Training with marines
Jumped off truck tailgate
Badminton
Taekwondo
Hockey

We look forward to hearing your story on how you hurt your knee…

Narrow down by graft or fixation type
Doctors tend to have distinct areas of expertise and tend to do procedures they’re comfortable with. It’s uncommon for a surgeon to perform both patellar grafts and hamstring grafts, for example, it’s normally one or the other. So, when you choose your doctor, it essentially decides what type of graft and fixation technique. Therefore, it’s best to make sure you have already chosen what graft you want first. This will then narrow down prospective surgeons.

Narrow down by location
Another way to narrow it down is by location. How important is it that you have the surgery as close to where you live as possible? On surgery day, you’ll need to have someone drop you off and give you a ride back. It may not be feasible for some to drive 2 hours or more to a big city. So, this may limit the pool of surgeons as well.

Narrow down by expertise
You can narrow surgeons down by expertise as well. Make sure they are board certified with the state and have all the normal credentials. Maybe the surgeon has a few feathers in his cap from special research or techniques he or she has pioneered. Some people want reputable surgeons that are on-staff surgeon for a professional or college sports team. Pro sports teams likely would do extensive research and choose only the best surgeon for their team, so you could piggyback off their selection criteria.

Narrow down by reputation (websites)
Another option is to search for a doctor’s reputation online. Several sites exist, but there are none that are 100% adopted by everyone yet. You probably want to avoid sites like angieslist that require payment upfront and have no guarantee of any kind of useful content. The best site for the time being seems to be: http://www.healthgrades.com Go there, type in a doctor’s name and see if it has any info.

Narrow down by choosing ‘preferred providers’
Your health insurance company may have a preferred providers list on its website that are guaranteed to successfully process payments through your insurance company. This is an important step as you don’t want to risk having the surgery and find out the provider is ‘out of network’ because of some technicality, forcing you to spend thousands more dollars.

Hopefully this list helps you fine tune your list of candidates for performing your ACL surgery. If you have additional criteria that helped you decide, please share below in the comments.

To give you a ballpark of costs, in December 2010, fifty one people who have had ACL surgery reported their costs. This was the exact cost out of pocket to them, not what insurance covered. You will notice that several paid nothing $0 and the highest was $17,500, the overall average cost being $2,339.43.

ACL SURGERY OUT OF POCKET COSTS

1 $100.00
2 $3,000.00
3 $3,000.00
4 $3,000.00
5 $500.00
6 $500.00
7 $2,000.00
8 $3,000.00
9 $500.00
10 $17,500.00
11 $800.00
12 $80.00
13 $-
14 $100.00
15 $4,500.00
16 $1,200.00
17 $1,000.00
18 $2,000.00
19 $2,000.00
20 $-
21 $1,360.00
22 $6,000.00
23 $1,500.00
24 $160.00
25 $6,000.00
26 $-
27 $50.00
28 $950.00
29 $1,500.00
30 $1,000.00
31 $15,000.00
32 $-
33 $-
34 $-
35 $3,000.00
36 $1,500.00
37 $1.00
38 $-
39 $150.00
40 $5,000.00
41 $2,000.00
42 $7,000.00
43 $500.00
44 $1,500.00
45 $10.00
46 $850.00
47 $2,000.00
48 $8,000.00
49 $500.00
50 $2,000.00
51 $7,000.00

More information upfront will help you make a smart decision about whether or not to have ACL surgery. If the surgery proves to be a financial burden currently, remember that there is no risk in waiting as far as the surgery or your knee is concerned as it is. It assumes that you won’t engage in sports or activities that put your knee at further risk. If you postpone, you’d really have to take it easy and be careful, while strengthening the muscles around the knee.

For more info on costs, see the end of this post on ACL surgery advice…

If you had ACL surgery, please comment below and share how much you paid so others can benefit. Thanks!

I’m currently scheduled to have my 2 titanium screws removed from my my incision, just below my knee. It isn’t the bioabsorbable screw, as that is not wise to remove, being deep into the bone. The surface area with the 2 screws is sensitive, but is only minor pain- probably a 2 on a 10 point scale. With my insurance deductible met, I’m tempted to have the screws removed, but I don’t want unnecessary risk.

The purpose of the screws being there is to hold your graft (replacement ACL) in place. After healing for a year, the screws are no longer necessary, as the graft has healed in its place. [see a company that makes the screws]

Below is what I have learned so far about having your ACL surgery screws removed (hardware). These responses are from an experienced arthroscopic surgeon who is the staff doctor for a professional basketball team.

1. Do you recommend me having screws in my knee (near incision) removed?
   Answer: only remove them if you have pain in that area. Don’t remove them for other reasons, such as thinking someday in the future they may become a problem, or that you might get arthritis (not true).
2. What are all the risks of having the screws removed?
   Answer: So, the surgery itself is not risky, but the risks are the same as for any surgery, including infection (that may lead to death), and fasciitis (damage to nerves, vessels, and tissue).
3. What are all the risks of leaving the screws in (not having surgery)? (arthritis, pain, etc?)
   Answer:  None. There is no known risk of leaving in the hardware. In years past, it was more common to remove hardware, but is done less and less in recent years as techniques have improved. There is no risk of arthritis, despite what some people believe. Arthritis only exists near a joint, and the screws are not at the knee joint, but below at the place of incision.
4. What % of the surgeries (for removing screws) have complications?
   Answer: None the surgeon is aware of.
5. Of all the ACL surgeries you have performed, what % have had their screws removed?
   About 1% to 5% have their screws removed due to pain it causes- from doing about 100 ACL surgeries per year for many years.
6. Of all ACL surgery patients who have had their screws removed, what % noticed improvement (less pain) and were satisfied?
   Answer: Most all who had pain in that area had reduced or no more pain in that region.
7. How long is the procedure to remove screws?
   Answer: Short, only about 15-20 minutes, but additional time for preparation, such as anesthesia, prepping the leg (shaving hair, cleaning, sterilizing, etc), and recovery. The surgery is a relatively simple procedure, as its near the surface. The only thing covering the heads of the screws are skin and a little fatty tissue, including nerves and vessels. That part is cut and the titanium screws (and washers) are removed using a regular hand-held screw driver (not a drill). Then the incision is sewn back together and its done. There is no endoscopy or any other procedure needed.
8. Does the procedure require anesthesia and will the patient be asleep?
   Yes. The initial unscrewing of the screw from the bone would be painful without anesthesia. You need to be completely asleep for it. It’s also possible to have partial anesthesia so you’re not 100% asleep.
9. Will the screws being removed make the fixation any weaker?
   No. After a year goes by, the graft has fused into the bone where it should not be weaker without the screws.
10. What is the typical recovery time after the screws are removed?
    You can walk the same day, but crutches are recommended for the first day or two. You will be sore in that area. No pain medication is needed post surgery. After 1 week, you should be able to resume normal athletic activities.
11. Is there any advantage (timeliness) in having screws removed sooner vs later? (such as years into the future?)
    No, there is no advantage at all. Your body will respond in the same way, whether 1 year after surgery or 10, or 20 years. If there’s no pain causing you to need to take out the screws, don’t take them out. Simply wait and see if it becomes a problem and is painful and if so, then take them out down the road, since there’s no disadvantage in waiting.
12. What are the exact billing codes used for this? (codes you may give your insurance company to determine whether your plan covers it or not)
    20680 – hardware removal
    plus billing codes for the surgeon’s fee, the anesthesiologist, any assistants

An additional questions that would be nice to ask:
What % of ACL patients have a problem with their screws unscrewing on their own?

So, has anyone had their hardware removed (screws, etc) after having ACL surgery and what was your experience (do you recommend it)?

• Yoga is an excellent way to build strength and balance prior to surgery- something that I reaped the benefits of post-surgery, because there’s a lot of hobbling around in crutches and balancing on one leg while reaching down and picking up things
• Wait a while before the surgery. It took 6 months for my swelling in my knee to go completely down where I regained most of my motion back and was able to do strength exercises. The surgery is said to be more successful after all the swelling subsides. Just be careful in the mean time to not reinjure yourself, and it will be worth the wait.
• Ice machines are good if you have people around to help maintain it. They run out of ice quite often, every 1-2 hours. So, unless you have people helping you with it, you won’t get much rest constantly getting up to fill the machine with new ice and drain out the old. Crushed ice is worst, regular size ice is mediocre. The longest lasting is homemade ice in 16oz cups- denser- and still fits in container- it may last 3-4 hours each batch. There’s also an electrical shock hazard on the Game Ready ice machine I had. Water from the drainage may leak onto the AC outlet underneath. What were the product designers thinking?
• Try to avoid hopping on one leg with the other one dangling within a week after surgery. I suspect this and other extra movements led to me having some extra pain and internal bleeding- which they had to manually drain with a needle 1.5 weeks post-surgery.
• A wheelchair is not a bad idea, as an alternative to get around in your home.
• For rehab, it’s better to listen to your body (pain level) and let that dictate the speed of recovery rather than follow a physical therapist’s recovery timeframe to a T. It’s ok to take the exercises slow- there’s no rush.
• It’s nice to have a cart on wheels. One that’s not tippy. You can put dinner plates on it, and roll items from the refrigerator to the table, or for moving your heavy ice machine around, etc. Otherwise, it’s a challenge moving objects around the house with crutches.
• Don’t try to touch toes to put on/off socks- I may have pulled my hamstring doing that.
• Don’t pay your bills too soon! Wait until absolutely everything is resolved between your providers and insurance company first. You don’t want to start paying bills you don’t owe. There’s a degree of negotiation between the provider and insurance company and it’s best to postpone paying until everything is settled and knowing that you’re not getting jipped- it puts you in a better position to negotiate in case your insurance didn’t cover something they were supposed to.

Post ACL Surgery Timeframes:

• Same day: went home and used crutches to get around
• 1.5 weeks – stopped using the ice machine full time, much of the swelling gone
• 2.5 weeks – started driving (very carefully) and went completely off pain pills.
• 3 weeks – less dependent on the knee brace- went without it- and start walking.
• 3.5 weeks – able to climb/descent stairs
• 4 weeks – started walking without crutches, able to use stationary bike and do light squats

Insurance companies will harass you and will try to find any loophole possible to not cover your benefits. As tedious as it is, it’s best to speak to the billing department of each of your service providers in advance and get price quotes and take good notes with who you spoke to, dates, billing codes, time spent on each procedure, etc. Then speak to the insurance company and ask them based on this scenario what your coverage will be. They are trained to be extremely vague about everything, so it takes some work. Take detailed notes on everything.

How much does ACL surgery cost?

I got a couple quotes (before insurance coverage) and here’s the range…

Surgeon fee – $1,350 – $2,200
Facility fee – $810 – $9,300 (huge range!)
Anesthesia – $748 – $845
Implant fee – $500

Other fees:
Full knee brace – $490
Ice machine rental (2 weeks) – $300 (not covered by insurance)
Prescription pain medicine – $100
Crutches – $30

Get more info on ACL Surgery Costs…

If you are having a hard time with the cost aspect of ACL surgery, there’s nothing wrong with shopping around and choosing a different doctor. You can even travel to a larger metro area if its important enough.

Insurance issues

My insurance is supposed to cover 80%, but with the deductible, 20%, and some things not covered, when it’s all done it’s supposed to be $2,000 – $3,000 to me. That’s a little too vague of a price range for my comfort, but that’s part of the billing game.

It’s 5 weeks out and my insurance company is playing the game, saying initially that my benefits are denied, while requesting an ‘incident report’ form to be filled out. Basically, they’re trying every possible scenario to get out of paying, fishing for someone else to be potentially liable for the incident. I think they’ll have to pay though, according to the conditions of the plan.

Provider issues

The providers are also a little tricky in the way they bill. For example, they quoted me only the surgeon’s fee each time I asked about billing with no mention of any other weird fees. But now that it’s over, they decided to bill separately for one of the assistant’s time too. I would have wanted him out of the room if it were up to me- it would have saved $490.

The providers also quoted me one rate and billed another- higher $ of course. They also said the prices will be going up after the new year, which may be reflected in my bill. There’s really no guarantees of anything and the patient is in a very poor position for negotiation.

I hope this information helps someone. I wish I had this kind of info beforehand.

Remember to also read everything on this site and read the ACL surgery tips and comments from other people.

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Learn about the decision of which graft to get: Patellar vs Hamstring

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1. PATELLAR GRAFT – the old-school gold standard and choice of many athletes.
Pros: The patellar graft is strong, as the graft from the knee tendon includes bone which ‘fuses’ into your knee nicely. It also resembles the size and length of the ACL (anterior cruciate ligament) that is needed and is technically easier for a surgeon to do this. Fast recovery.
Cons: May give you knee pain. Many people complain that kneeling or bending the knee causes pain that wasn’t there before.
Summary: Patellar graft may be the best choice for young people who are engaged in professional or high-impact sports and are willing to risk having knee pain for perhaps the rest of their life. It may not be a good choice for a working man, such as a carpenter, who bends their knees a lot, crawling in tight spaces, or walking up and down stairs all day.

2. HAMSTRING GRAFT – considered a newer technique that claims comparable strength to the patellar graft, but without the knee pain.
Pros: Less or no knee pain, comparable strength to patellar.
Cons: Slightly weaker hamstring muscle- 90% of normal strength. Some people complain that the hamstrings stretched out and no longer becomes tight. May take longer rehab.
Summary: Hamstring graft is the best choice for someone middle of the road, who does physically active sports, but not professionally or extremely competitive. This person is not as much in a time-crunch to recover, and the priority is in not having knee pain.

3. ALLOGRAFT (graft from a frozen cadaver) – the doctor likely takes a patellar graft from the cadaver to use in the knee of the patent.
Pros: Fast recovery from surgery, as you don’t sustain any injury by having a graft taken out of your own body.
Cons: Weaker- a low percentage of patients have the allograft break, requiring a 2nd ACL surgery. Has a slight risk of getting a disease transmitted through the blood & body part from someone else.
Summary: Allograft is the best choice for someone aged 45+ or someone who does not plan to do any substantial physical sports, and is willing to take the risk of implanting someone else’s body part.

Note: Doctors generally specialize in either patellar graft only or hamstring graft, and generally don’t perform both. So, when you choose a doctor, you’re also choosing what graft you want. To change grafts, you likely have to change your doctor completely. Because of a higher technical skill involved in the hamstring graft, it may mean you will find more competent doctors performing it.

Reputable doctors may contradict each others’ opinions. One may say patellar graft is best, the other may say the hamstring graft is best. Online research suggests there’s no strong winner on either side, but perhaps a slight leaning towards the hamstring graft.

Doctor A says:

• Hamstring graft is the most popular choice for professional athletes today
• There’s less risk of graft complication
• No knee pain with hamstring graft, where as, the patellar commonly results in a lifetime of pain when kneeling
• Hamstring graft is stronger than the patellar, because of 4 dense strands bound together, instead of just 1 with the patellar
• Neither grafts ‘grow back’, so better to go with the hamstring, since it’s a very large size and taking such a small portion of it only results in a hardly detectable loss of strength 5% – 10%, but it’s easily regained through basic physical therapy
• The drilling hole in the bone can be smaller when using the hamstring graft, because of the efficient configuration of the 4 strands in the hole. A smaller hole, results in a stronger bone
• Patellar grafts can loosen/weaken the knee and lead to patella arthritis
• Patellar grafts are ‘old school’ – a thing of the past. This surgeon used these grafts years ago, but not since the advancements in hamstring grafts, which are now superior
• Tiger Woods had a hamstring graft
• Hamstring grafts are the best

Doctor B says:

• Patellar graft is a larger and stronger tendon that’s 10mm, instead of a 8mm hamstring graft
• Patellar graft is the most popular choice among athletes today
• An annual survey of hundreds of orthopedic surgeons shows that patellar grafts are most popular
• Patellars are the ideal size and length
• The hamstring is too small, too long, and requires a more technical procedure with greater opportunity for error
• The hamstring may stretch/loosen and may not fasten to the bone correctly over time
• The patellar actually grows back and regenerates itself in 8 months, where as, the hamstring will be gone forever and be noticeably weaker
• Tiger Woods only got a hamstring graft only because the surgeon he chose invented his own hamstring graft technique which he wanted to promote
• Patellar grafts are best

As you can see, there’s good reason to hesitate when making a choice with potential long-term health ramifications.