Reconstructive ACL Surgery: Is it worth it?

Posted on December 5, 2011

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A lot of things in life are beneficial. Traveling for a year, a college education, working late on a Friday night, etc. Whether or not something is beneficial is rarely the right question though. The right question is, is that thing worth it?

There is a term from economics called opportunity cost. Opportunity cost accounts for not only the cost of what we choose to do, like traveling for a year, but the cost of what we could have been doing instead.

By traveling for a year you are now a year behind your peers in the corporate world. That 4 (or more) years of college education costs a lot of money and a lot of time. What if you don’t end up in a field related to your degree? Or you could have been working and made money those 4 years, rather than only spent it. Working late on that Friday night might have been the night you could have been out with your friends and met your future spouse. Is lessening your chances to meet your husband/wife worth that extra night of work?

I know I’m being extreme here but it helps get the point across.

With that in mind, let’s make this specific to reconstructive ACL surgery. I’ve gone over the benefits (link); now I’m going go over the costs. We know that the surgery benefits those that are looking to get back to a very high level of activity, is getting back to that high level of activity worth the costs of the surgery though?

(Remember, out of all the research I went over in the beneficial post none of it exemplified a benefit in the general population. Between the research and experience with my own leg, I don’t think the surgery is worth the agony if the most difficult thing you like to do is hike. Not at all.)

The first cost I’m going to look at is the most obvious…What does this surgery cost financially?

 

Cost of surgery

Surgery is expensive, and ACL surgery is no exception. To the tune of $25,000 to $50,000 dollars. The numbers jump around but the average person pays about $2,000 dollars for their ACL surgery. How much you personally pay for this obviously depends on your insurance status.

Everyone is going to view this differently. $2,000 dollars to one person might be nothing while it might be the world to someone else. If you have crappy or no insurance, $50,000 dollars is a down payment on a house. Is your weekly flag football game worth that?

That’s the most obvious financial cost. A cost less talked about, but just as important, is physical therapy. PT revolves around $60 per session. I’ll get into this more later but, just for number’s sake, I have a client whose brother is in the NFL. A few years ago he tore is ACL. Want to know what his rehab looked like? It was every, single, day…for over 6 months.

6 months x 30 days per month x $60 per session = A crap load of money.

Obviously most people aren’t in the NFL, therapy every single day for months and months might be excessive, and again, everyone’s financial and insurance situation is going to factor in here. My point is don’t think you can go to one month of physical therapy, because that’s all your insurance provides, and you’ll be fine. You won’t.

If you can pay for the surgery, or your insurance covers it, but you can’t pay for the physical therapy, or your insurance doesn’t cover that, you need to seriously contemplate this decision. Having the greatest surgeon in the world won’t matter if your physical therapy isn’t on par. More on this soon.

Next, the opportunity cost. Some of us out there, and I’m one of them, don’t get paid if we don’t work. If you have a physical job you’re guaranteed to have to take some time off of work after this surgery. Not only do you have to account for the cost of the surgery, you need to account for the loss of money you might incur by not working. Or how you may be giving up your vacation days in Maui.

There’s no magic number for how much time. Some surgeons don’t want their patients weight bearing for at least a few weeks. (My surgeon wants me to wait 6 weeks. Haha.) Some want them walking as soon as possible. Some people’s recovery takes longer than others. Some people’s idea of a physical job involves a lot of standing where some people are carrying a hundred pounds around.

For most people their leg won’t be back to full strength for at least 6 months, if ever. With the leg hopefully being 85% as strong at roughly 4 months post surgery.

This is critical. Depending on your profession, are you able to take off however much time you need to take off? Are you able to get disability coverage? If these are big issues, you might not want to get the surgery. Or at least maybe not at a certain time.

Trying to return too soon just gives you a greater chance of effing the whole thing up. Leading to going through the whole thing again.

Remember, you don’t need to account for a couple weeks. You need to account for the recovery your leg is going to take over the course of a few months.

Of course, the surgery has to go well first…

 

Risks of surgery

I have no idea why, but so many people are so nonchalant about surgery. I don’t know about you but surgery scares the shit out of me. General surgery involves your typical risks such as infection (this happened in Tom Brady’s ACL surgery), blood clots, the surgeon is having a bad day and screws up. Oh yeah, and that death one too.

Specific to reconstructive ACL surgery, it has around a 2% complication rate. Pretty small…but things do happen. Some common things related to the surgery depend on the graft chosen. Choosing a cadaver carries risk of transmitting disease or infection. A patellar graft runs the chance of fracturing the patella (fun, fun.) A hamstring graft seems to be pretty complication free.

You have the whole fun of anesthesia. Some people respond better, or worse, than others.

And then there’s the chance the damn thing doesn’t work either. ACL surgeries have a 90-95% success rate. Far from perfect.

For some this may not matter. For those on the fence though, it may sway them off.

Remember, this is all for a surgery that will HOPEFULLY return you to a 15% higher level of activity than if you don’t have it. This isn’t like you have a tumor you need removed so you don’t die.

 

Your age

First, for the “age is just a state of mind” crowd: Who is your favorite 60 year old in the NBA? No, there aren’t any. Glad we agree age does matter

Yes, I wrote a post Age is not an excuse. Age is not an excuse to be out of shape and weak. It very well may be an excuse to not have a surgery primarily designed for, and practiced, on young athletes.

Also:

1) Your risks of complications with surgery go up the older you are.

2) Success rates in anterior cruciate ligament surgeries are better the younger the person.

3) Your desired level of activity is more important than your age. However, for those who aren’t very active right now and are young, you don’t know what your desired level of activity is going to be in 15 years. You might take a liking to a recreational sport you never imagined playing.

I have a client who is obsessed with softball. She travels all over the country going to tournaments, plays multiple times per week, the whole nine. She didn’t start playing until she was 40.

Point being: The younger you are the more likely the surgery is of higher value to you. Sure, if you’re 50 you probably aren’t going to take a liking to a sport you haven’t already tried. You might be more than ready hit up the pro shop and start shopping for golf clubs. If you’re 25 though, there are a lot of years ahead of you. It’s hard to know for sure what your desires will be.

 

The most important factor: Are you committed to the recovery?

I’ve met with multiple surgeons so I can speak on this well. Other than being the told the first few weeks or so are “pretty rough,” barely anything has been said to me regarding the recovery from this surgery. If your experience has been or is similar, don’t let this fool you into thinking this is some easy recovery.

One person I know who had this surgery told his surgeon how he was a construction worker. The surgeon’s response, “Oh, well, the tools we use will look very familiar to you then.” If you’re not catching on, this surgery involves using a power drill to drill holes in your legs. Ala it is a painful recovery. Bringing us to the fact:

You are not in the NFL

“But Tom Brady or such and such NFL player got this surgery and look at how good he is now!” Guess what, you don’t play in the NFL. Back to my client’s brother who is in the NFL. It was 9 months before he played in another football game. Through at least the first 6 months his therapy, as previously mentioned, was every single day. As not mentioned, it was every single day, for about 6 hours per day.

While I could argue that’s overkill, the point is that you do not have 6 hours a day to devote to rehabbing your knee. You are not that committed, you do not have that much time, your knee likely does not make you millions of dollars. You simply do not have the incentive an NFL player has to get back on the field. Nor do you have the resources, or their recovery ability.

Most ACL rehab guidelines say that a return to full activity can be attained at 6 months. However, ask people who have had this done and many aren’t getting back til closer to 9 months, if not a year. And many aren’t feeling themselves again til more like a year and half after the surgery. Some people even say how years after the surgery they still have to be diligent with exercising their leg or it will atrophy very quickly.

Are you committed to the idea of at least a year of work? Work that you don’t get paid for? Work that you can’t take off of? (Because if you do you are only hurting your long-term outcome.) You’re going to make all your physical therapy appointments? You’re going to do your exercises on your own? Even when life is bitching at you?

Especially in the first 8 weeks or so, we are talking about an every single day obligation. How many of you already have trouble getting to the gym 3 days per week?

If we’re talking optimal conditions, we’re talking at least a month of therapy before the surgery too.

I’m not trying to scare anyone. Just please recognize the amount of work and effort that will go into this. (At least if you want to have a good outcome. If you’re just looking to be able to hike, well, you probably don’t need the surgery anyways.) If you think you are going to get cut open and be alright in a couple of weeks you are really out of the loop. Or delusional.

There is plenty of research on the best ACL rehab protocols. You know when the best ones start their rehabilitation? When the person wakes up. No, not in the morning. When the person wakes up from the anesthesia used in their surgery. That’s how soon.

And you might be thinking, “Well, that’s probably for NFL players or something so I won’t need to be that diligent.” It’s not though. Starting your rehab that quickly helps assure the person that they will be able to regain full range of motion. The loss of knee extension is a huge factor in arthritis rates after ACL surgery. The longer people take to regain that range of motion the higher their chances of never getting it back go.

 

One quick note on timing

When you get the surgery can help put a lot of the above factors in your favor. For example, I know one person who tore his ACL 3 months before his wedding. He was pretty aware of how extensive the rehab process was. So, he decided to wait until after the wedding before getting his surgery.

This is a great move. Rather than run the risk of getting side tracked with wedding stuff and having a suboptimal rehab, he simply pushed the whole thing back. While this caused him to have an extra 3 months before he could get back to some of the activities he loves, it set him up for a much better recovery and a much better long term outcome.

For some of you maybe your business has slow and busy seasons, maybe you have a 4 day weekend coming up and you can add a couple of vacation days to it, etc. So, give a lot of consideration as to when you get the surgery. Not just the day of, but the months that follow.

 

Wrapping up

 At the end of the day this surgery is most beneficial for people in high impact sports playing at a high level. However, just because you play those sports now doesn’t mean you need to continue to play them.

Everyone needs to weigh issues like their age, the risks of surgery, how committed they are to the long rehab process, before they decide to get the surgery.

Maybe you’ll just keep hiking but give up your weekly recreational basketball league so you don’t have to pay 5,000 dollars, risk getting an infection, go through the pain of surgery, miss a month of work, miss time playing with your kids, go through 9 months of physical therapy, all so you can do 15% better than if you didn’t get the surgery…and have a 10% chance you won’t be satisfied with the whole thing anyways.

For certain people that 10-15% of activity, or their chosen sport, means everything. For others, their playing basketball is what they do because the treadmill is boring.

How much is that extra 10-15% of activity worth to you?

 

Next up is my decision on what to do with my leg and my reasoning behind it.

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Check out my ACL rehab resource: The most important phase of ACL rehab

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