Lafayette Special

After eating and drinking too much at the new restaurant Lafayette yesterday, I felt I had some penance to do, and coordinated with K for a morning workout. We headed to the fencing room and did the following.

2 times:
- Lunges (about 30 feet - guesstimate)
- bear walk (30 feet).

While walking, throw a 10kg medicine ball forward from your side (twisting motion), alternating left and right (the other guy walks backward and throws it back). 2 times 30 feet.

On your back, do a situp holding the 10kg medicine ball above your head, then trhow it to other guy who is standing up, he throws it back. 15 times.

Situp position with trunk raised (45 degrees) and feet held by something, holding a medicine ball, twist from side to side. 80 times (twisting on one side counted as once). We had a 5kg and a 6kg ball, so we exchanged after every 20.

10 Arianes on each foot (total 20, see description of an Ariane here).

10 minutes slow paced rowing.

Good workout. I looked much worse than K after the lunges and bear walks, but by the end of the workout we seemed in similar state. He rows much faster than I do even at a slow pace, but the good thing is that he taught me some technique.

Profundus

Warm-up:
burpees, situps
dynamic squat stretching

3 rounds (95# bar):
6 deadlifts
6 barbell rows
6 hang power cleans
6 thrusters
6 pushups

Ran through a few rounds of a complex posted up at CF Sunnyvale, untimed as I haven't replaced my watch yet. Right forearm strain still tweaky, so didn't push it - HPCs in particular tend to be problematic.

Quick anatomy lesson: the flexor digitorum profundus controls finger flexion at the distal interphalangeal (DIP) joint, while the flexor digitorum superficialis handles flexion at the more proximal PIP. I'm pretty sure I have a profundus strain, as ring finger PIP flexion is fine but DIP flexion produces pain in the mid-forearm, near where the tendon inserts into the muscle.



Rest is really the only treatment, so I'm avoiding climbing for a few weeks (sorry, G).

A bestiary of RNA

A nice blurb in the NYTimes on The Promise and Power of RNA.

ACL Reconstruction

Mark arrived at my door today to announce that he wanted to join the ACL surgery club and had therefor gone and torn his ACL during a rousing game of football (that's soccer to the ignorant Americans). So, in light of this I went to look for the review articles I had read on ACL reconstruction and found that since my surgery a complete review issue was released by Clinics in Sports Medicine. I've included the important articles from that first, as it's the most recent source. But I will start by pointing out that it is clear from my reading that surgeons have their preferred methods and sometimes the conclusions drawn form the data are, by and large, opinion applied to completely inconclusive results. While I did not read any outright contradictions of the data—there was considerable wiggle room used in interpretation.

I will summarize my reading of the articles here and then group the articles by topic and relevance. I haven't read all of these articles as I couldn't find my original list and I read a bunch of them on paper hand haven't confirmed which was which.

First, Bone-Patellar-Bone autograft reconstructions are the oldest and probably the best under most valid statistical measures of knee function recovery but have the highest rate of associated long term post-surgery (anterior) knee pain. This anterior knee pain can also slow recovery as the time to full knee mobility is highly correlated with recovery time and the extra pain associated with the BPB autograft increases this time. Further, all the recent reviews I read suggested that the current generation of alternative allo and auto grafts had statistically indistinguishable results from the BPB autograft, though at least two meta-analyses showed at least one measure that was statistical better for each of the primary auto-grafts (PBP and hamstring) and the allograft comparisons appear to be the same. The primary worry cited in the allograft comparisons is the small (order ~1:400,000 chance) that you will receive an infection from the allograft and in one report I found the median surgical infection rate for this category is 0.36% suggesting that this should probably not be a primary concern (Am J Infect Control 31 (2003)). The other concern is a very small rate of rejection due to improper treatment but the rates were similarly very low (~1:100,000 if I remember correctly). There is a major advantage to the allograft as it allows for faster transition into recovery (less additional trauma) and it can be harvested to maximize match between the grafts bio-physical characteristics and that of the native ACL. A recent class of surgeries appears to be destined to be the new gold standard: the double bundle reconstruction. This actually locates two separate graft attachment points on the femur and tibia. These dual bundle reconstructions appear to be capable of both better duplicating the natural ACLs construction and reducing rotational laxity—a problem with current grafts (but least with the BPB graft).

Below I am grouping and categorizing the reviews. I would remember that the graft comparison reviews (especially the conclusion/discussions) appear to be slightly biased towards the particular surgeons favorite technique.

Clinics in Sports Medicine Review Issue

• Clinical outcomes of allograft versus autograft in anterior cruciate ligament reconstruction
• Allograft safety in anterior cruciate ligament reconstruction
• Soft tissue allograft and double-bundle reconstruction
• Primary anterior cruciate ligament reconstruction using contralateral patellar tendon autograft
• Bone-patella tendon-bone autograft anterior cruciate ligament reconstruction
• Biology of autograft and allograft healing in anterior cruciate ligament reconstruction

Allo vs Auto Graft

• Allografts in the treatment of anterior cruciate ligament injuries
• Should allografts be used for routine anterior cruciate ligament reconstructions?
• Anterior cruciate ligament reconstruction: allograft versus autograft

Additional ACL Surgery Procedures

• Cryotherapy after ACL reconstruction: a meta-analysis
• Bracing after ACL reconstruction: a systematic review

ACL Graft Comparisions

(Orrin Sherman's review first)

• Anterior cruciate ligament reconstruction: which graft is best?
• A comparison of autogenous patellar tendon and hamstring tendon grafts for anterior cruciate ligament reconstruction
• Hamstring tendon autograft better than bone patellar-tendon bone autograft in ACL reconstruction: a cumulative meta-analysis and clinically relevant sensitivity analysis applied to a previously published analysis
• Anterior cruciate ligament reconstruction, hamstring versus bone-patella tendon-bone grafts: a systematic literature review of outcome from surgery
• ACL reconstruction: a meta-analysis of functional scores
• Reconstruction of the anterior cruciate ligament: meta-analysis of patellar tendon versus hamstring tendon autograft
• Hamstring tendon autograft better than bone patellar-tendon bone autograft in ACL reconstruction: a cumulative meta-analysis and clinically relevant sensitivity analysis applied to a previously published analysis

Structure, Double Strand and Partial Tear

• Partial rupture of the anterior cruciate ligament
• Review article: anatomic double bundle anterior cruciate ligament reconstruction
• Anterior cruciate ligament anatomy and function relating to anatomical reconstruction

One Nasty Complication of BPB Grafts

• Indirect patella fractures following ACL reconstruction: a review

Injury Fate and Recovery Rates

• Fate of the anterior cruciate ligament-injured knee
• Return to play after anterior cruciate ligament reconstruction
• A review of ski injuries resulting in combined injury to the anterior cruciate ligament and medial collateral ligaments

Arthroscopic orientation

Orientation is tricky because the scope gets pretty zoomed in on a particular area, and it's hard to get a sense of the entire anatomical layout. Sweet images, though - Eric, you now have evidence you're as good-looking on the inside as on the outside...

Here's a step-by-step guide to a patellar tendon ACL reconstruction with images, it's helpful for identifying anatomy and instruments - ignore the bloody tendon harvesting.

Maybe this will help a bit:

What training wrought...

Just because I know you all want to see this...

Hard to see landmarks here. (I don't have a good photo of the old ACL).

Note the drill...

A new ACL.

I'll post some more thoughts later and a bit on ACL reconstruction but I can now say that I have a brand spanking new (old) ACL. And, more important, my return-to-training clock has started...