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ACL reconstruction surgery-- or not?
Old 12-21-2008, 10:43 AM   #1
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ACL reconstruction surgery-- or not?

Anyone aware of any evidence-based research or meta-studies between those who've had their ACLs rebuilt and those who have not?

The way our family schedule's shaping up, I have a "window of opportunity" to rebuild my left knee this summer. If it goes well then maybe I'd do the right knee a couple years later. No hurry.

But I don't feel the anticipation of taking in a high-mileage car for body & fender work-- it's more like the resignation of turning myself in to the authorities to confront the inevitable. Or for you submariners, it feels like the workup for an inspection.

I tore both my ACLs seven years ago but didn't figure it out until two years ago when I sprained my left knee yet again. That also tore cartilage which keeps me from fully straightening the joint, but it's not noticeable in my stance or gait. The good news is that I've stopped stretch-stressing my joints and I've tremendously strengthened the remaining ligaments & muscles. I've returned to taekwondo with much better technique, control, & balance. Custom-fit orthopedic braces keep me stable during sparring and heavy lifting (yardwork, weight training). Bicycling and elliptical machines are OK now. Even without braces I have full squatting mobility with no swelling, but I'm still working on single-leg squats and other exotic quad tortures exercises. Lunges, long walks, and an infrequent two-mile run are fine.

I can cope with the status quo as long as it doesn't get worse. I'm nearly pain-free (ibuprofen) but if I curl up in a chair then I stiffen up as if a metal sleeve was clamped around the joint. When I go down tall/uneven steps, my left knee bends to a point where it just stops supporting my weight, "gives out", and drops me down on my right foot. I stay safe but I struggle for control and I still can't tell if it's weakness or a lack of mechanical leverage. Same thing with hopping on my left foot (skipping rope on mats)-- it's much weaker than my right and it's taken a long time to develop the musculature to overcome the lack of ligament. These little whining issues make me wonder if delaying surgery might cause irreversible damage. Of course the surgery might cause even more irreversible damage.

A couple orthopedic surgeons and a couple more sports physicians have recommended ACL reconstruction. The theory is that without an ACL my knees will lose stability, leading to bone-on-bone osteoarthritis and total knee replacement. But unlike most injured athletes, I have months to prepare for the surgery and the physical therapy. Today my knees are much stronger than when I tore the ACLs.

I'm waffling. Can things get worse? Evidence-based medicine doesn't seem to show whether ACL reconstruction delays osteoarthritis. There's not much evidence for lifestyle/exercise preventing it, either, but that's a lot less trauma than arthroscopic surgery. OTOH I've only heard from one person who has elected to forego the surgery, but they seem to be built to run dozens of miles a week. I don't have enough cartilage for that lifestyle. I haven't talked to any patient who felt that the surgery went especially well, and several have said they wish they'd skipped it.

Surrounded by doctors & surgeons who tend to see solutions in terms of surgery, it's hard to feel as if there's a choice. But Dr. Jolie Bookspan has a different perspective. Her blog has started a three-part article on ACL surgery: What Works Better Than Knee Surgery? (Warning-- includes a gross photo of an old-school post-op knee incision. Put down your beverage and swallow that mouthful before clicking the link.) She feels that surgery is just asking for more trouble.

I've learned that allograft tendons are probably better than cadaver ligaments. I've learned that pre-surgery physical conditioning is key, as is minimizing post-op swelling and starting physical therapy. I've learned all sorts of details about side effects and recovery. What I haven't learned is whether any of it is necessary in the first place.

Let me know if you've seen any compelling evidence to motivate me for elective surgery...
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Old 12-21-2008, 12:08 PM   #2
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Knee1 Forums

I dunno, Nords, I think ACL replacements and rehabs have advanced to the point where it's a no-brainer, about like using index funds. The incisions are very small now, they send you home that afternoon, and you're in rehab slowly walking backwards on treadmills a few days later.

You'd think you'd get at least two weeks of laying on the couch atrophy'ing and sending your wife to Blockbuster, but nope...

Edit: Don't be frightened by what you read on the Knee1 forums...as the moderators there occasionally point out, the posters are pretty a self-selected group - the folks who have surgery, rehab normally, and return to their normal activity don't register at 3:00am to post introductory threads that read "11 weeks post-surgery, WTF?!?!?!?!??"
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Old 12-21-2008, 12:26 PM   #3
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Nords, you are right to question everything, and in this case you and Dr. Jolie are right to be skeptical!

Go to the New England Journal of Medicine and check out this study, published just 3 months ago:

NEJM -- A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee

I think you can get a free trial if you sign on, and then you can read the whole article.

Here's a news story on it:

globeandmail.com: Arthroscopic knee surgery ineffective: study

Since this was not a metaanalysis, I searched the Cochrane database for "knee" and this page came up: nothing about ACL surgery, I'm afraid.

Search Results: knee

I hope this is helpful. Sounds like you are doing a great job with exercise.
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Old 12-21-2008, 12:42 PM   #4
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Mead, that report from a few months back pertained to (probably far too common) meniscus repairs...whittling on loose edges of knee cartilage.

Nords is considering the replacement of a ligament in the center of the knee, a whole 'nuther can of fish...
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Old 12-21-2008, 01:26 PM   #5
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Mead, that report from a few months back pertained to (probably far too common) meniscus repairs...whittling on loose edges of knee cartilage.

Nords is considering the replacement of a ligament in the center of the knee, a whole 'nuther can of fish...
Correct, CB. And osteoarthritis surgery is likewise a different deal altogether from Nords' issues. The evidence is likely not applicable.

Nords, I'll keep my eyes open on this for you. It's out of my scope of practice but I have contacts. My gut says to defer surgery unless your current limitations are significant to cut into your lifestyle in a meaningful way, or you are reliant on potentially dangerous amounts of NSAIDs.
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Old 12-21-2008, 01:57 PM   #6
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Anyone aware of any evidence-based research or meta-studies between those who've had their ACLs rebuilt and those who have not?
Hi Nords,

I will do a little research and see what I can find out. I'll post links to studies which may be helpful - you can read them and see what you think! I don't have time to do an indepth analysis, but you seem to be pretty good at that!

Here's the first one I found:

15-Year Follow-up of Neuromuscular Function in Patients With Unilateral Nonreconstructed Anterior Cruciate Ligament Injury Initially Treated With Rehabilitation and Activity Modification: A Longitudinal Prospective Study -- Ageberg et al. 35 (12): 21

<snip>
"Conclusions: Good functional performance and knee muscle strength can be achieved and maintained over time in the majority of patients with ACL injury treated with rehabilitation and early activity modification but without reconstructive surgery."

FYI, doesn't look like they examined incidence of onset of OA later on, so this still doesn't answer your question, but it is food for thought.
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Old 12-21-2008, 02:12 PM   #7
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Next: "A decision-making scheme for returning patients to high-level activity with nonoperative treatment after anterior cruciate ligament rupture"

SpringerLink - Journal Article

<snip>
"Of the 39 rehabilitation candidates 28 chose nonoperative management and returned to preinjury activity levels, 22 of whom (79%) returned to preinjury activity levels without further episodes of instability or a reduction in functional status. No patient sustained additional articular or meniscal damage as a result of rehabilitation or return to activity. The decision-making scheme described in this study shows promise in determining who can safely postpone surgical reconstruction and temporarily return to physically demanding activities. Continued study to refine and further validate the decision-making scheme is recommended."

Note: One of the authors of this study, Lynn Snyder-Mackler, PT, is one of the PT gurus for ACL rehab. I'm sure she has the latest, greatest info on surgical vs. non-surgical candidates for rehab and could likely point you to studies regarding onset (or not) of OA. This article was written in 1999, so I'm sure there is more current research out there. She currently is a professor at the University of Delaware. Here's her page there: Lynn Snyder-Mackler's cv Note all the studies listed that she has done on ACL rehab. I think if anyone can answer your question about outcomes regarding OA (surgery vs. conservative rehab), she can.

Good luck!
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Old 12-21-2008, 06:03 PM   #8
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I shredded my knee in a skiing accident at 23 and had this reconstructive two years later, in 1991. In my case it was definitely a good thing.

I guess my question to you would be: do you have instability in the knee that prevents you from doing what you want to do? Does it give out or "pop out of place" on you more often than you find acceptable? If so, I'd likely do it. If it's not giving you a lot of problems and it doesn't significantly impact your desired lifestyle and activities, I'd focus more on rehab and exercises that strengthen the muscle mass around the "bad" knee -- those can give you added stability as well.
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Old 12-21-2008, 07:57 PM   #9
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I worked in Sports medicine for several years and saw a lot of ACL repairs with excellent results but most of them were younger than you . We did occasionally do patients over forty but it was pretty rare . I've read several articles that state age is now longer an issue in ACL reconstruction but that is something I'd ask the Orthopedist . How many older patients have they done and what were the results ? Plus what are their results with an older injury ?
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Old 12-21-2008, 08:39 PM   #10
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Nords, I'll point out that you are in the small group who, no matter which way you decide, WILL DO the recommened PT work. Therefore, you will increase the odds for a good outcome significantly.

Years ago I was going to Lenox Hill's sports medicine clinic - when I went in for the second time, I really shocked the doctor when I said "Yes, twice a day" when he asked if I was doing the recommended exercises. I don't know what the average compliance rate is, but I was a statistical outlier !!

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Old 12-21-2008, 09:51 PM   #11
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I had ACL reconstruction 3 years ago at age 48. I had tore my ACL playing basketball about 6 months earlier. I probably messed my knee up more by not getting it diagnosed earlier. My orthopedist said that many folks my age did not get it repaired, but gave up certain activities. After a 6 month rehab I was playing basketball again, but not full-speed. I cannot trust my knee the first two years after. But if I ride my bike hard 20 miles a day and keep my legs strong, then I trust my knee more in this 3rd year. If I slack off, I need to work back up to full strength before I try certain basketball moves.

Since you appear to be motivated to stay in shape and perform the necessary rehab exercises, I myself would recommend that you do the surgery. Whatever you do, do not overdo the rehab, but follow doctors orders.
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Old 12-21-2008, 11:44 PM   #12
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Quote:
Originally Posted by Cb View Post
Edit: Don't be frightened by what you read on the Knee1 forums...
My emotional reaction? Holy freakin' crap, too late.

Rationally, I agree that it's pretty straightforward. I guess the question is controlling the surgery/postop risks (if possible) and whether there's any clear long-term degradation without the surgery. Your continuous passive motion machine and cryo cuff look pretty standard with this group.

I need to dig through that board to see if there's a no-surgery discussion.

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Nords, you are right to question everything, and in this case you and Dr. Jolie are right to be skeptical!I hope this is helpful. Sounds like you are doing a great job with exercise.
Thanks for the links, Meadbh, up to now I'd just read about the study. Oddly enough I thought that loose cartilage was keeping me from fully extending the left knee, and I'd hoped that'd be fixed during the surgery. I'll have to ask about that.

Quote:
Originally Posted by Rich_in_Tampa View Post
Nords, I'll keep my eyes open on this for you. It's out of my scope of practice but I have contacts. My gut says to defer surgery unless your current limitations are significant to cut into your lifestyle in a meaningful way, or you are reliant on potentially dangerous amounts of NSAIDs.
Thanks, Rich, no real limitations ("Doc, it hurts when I do a 540-degree spinning hook kick!") and only 800 mg ibuprofen before heavy exercise. Rarely more than 4-5 doses a week or more than two in a row. Always after a meal with lots of water.

At this point I'm not sure there's a detectable difference between "seven years before reconstructive surgery" and "20 years before reconstructive surgery".

Quote:
Originally Posted by Moemg View Post
I worked in Sports medicine for several years and saw a lot of ACL repairs with excellent results but most of them were younger than you . We did occasionally do patients over forty but it was pretty rare . I've read several articles that state age is now longer an issue in ACL reconstruction but that is something I'd ask the Orthopedist. How many older patients have they done and what were the results ? Plus what are their results with an older injury ?
Funny thing there too. The grumpy old surgeon told me that I'd be lucky to walk with full mobility and taekwondo was out of the question. I later learned he does a lot of geriatric patients & car accidents. He reduces expectations as much as possible.

The younger surgeon who does UH's volleyball & football players thought it'd be no big deal, no problem with taekwondo. He's probably the #1 or #2 guy on the island, although his new associate has at least as good a rep.

Reading this thread again, I think my reluctance about the surgery is the definite (perhaps small) risk of adverse results versus the disputed possibility of avoiding even worse results.

Quote:
Originally Posted by mews View Post
Nords, I'll point out that you are in the small group who, no matter which way you decide, WILL DO the recommened PT work. Therefore, you will increase the odds for a good outcome significantly.
Years ago I was going to Lenox Hill's sports medicine clinic - when I went in for the second time, I really shocked the doctor when I said "Yes, twice a day" when he asked if I was doing the recommended exercises. I don't know what the average compliance rate is, but I was a statistical outlier!!
The grumpy old doc handed out the world's most boring PT exercises and had the same advice, but later admitted that they say so with the hope that once a day will be more assured of happening. Kinda like dentists advising "Brush twice after every meal".

You're right, one of my issues will be pushing the PT too hard.

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Originally Posted by LOL! View Post
My orthopedist said that many folks my age did not get it repaired, but gave up certain activities. ... If I slack off, I need to work back up to full strength before I try certain basketball moves.
Since you appear to be motivated to stay in shape and perform the necessary rehab exercises, I myself would recommend that you do the surgery. Whatever you do, do not overdo the rehab, but follow doctors orders.
I've spent some time with a taekwondo national team conditioning coach who came back from a horrible car accident-- multiple knee ligament tears & two surgeries. He's really focused on quads, squats, & lunges and I know many interesting ways to do them now. They're far more difficult than anything I see in a PT clinic, too.

Although a year ago I once tweaked one knee out of alignment and caused a couple days of swelling & pain that sent me to the doctor for help, it's the only time since my diagnosis that the lack of an ACL caught me by surprise. Since then I'm much stronger/stable and I'm not sure that the ACL is necessary any more. Like you, I think keeping up with the exercises will keep the knee stable enough. But that also might be rationalizing away the surgery.

That Knee1 forum really highlights the pain issues, which is probably causing most of my foreboding. I may have an extraordinarily high tolerance, but that doesn't make me look forward to the experience!

Dr. Bookspan has a great summary of the situation: "Now that I am fine again and back to martial arts, which I love, I want to have someone plunge a knife in both knees, because strangers claim I might, not definitely known, but might have trouble sometime undetermined in the future. I want to definitely have pain and reduced mobility, with no guarantee that I will be made better."

And thanks for Dr. S-M, SG. I'll track her down too.
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Old 12-22-2008, 02:10 PM   #13
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OK - I'll come clean - I tore my ACL skiing over Thanksgiving weekend and my ACL reconstructive surgery is 9 Jan - the consensus is if I want to ski again, I have to get the surgery...I want to ski again.

I've read a lot of stuff on blogs over the last few weeks - keys seem to be:

1) Keep as much strength as possible in the legs before surgery - I am doing the exercises shown given to the post-op patient daily - it's amazing, my quad has already atrophied. I've fallen twice and exacerbated the damage and it is not very stable, so I am motivated to get the wurgery.

2) Keep up with the PT afterwards - it's like the heart patients I used to see - they had them on treadmills the day after they had their transplants....brutal, but necessary. Interesting thing is each OS and PT have different protocols - this should be interesting.

3) It is important that the acute pain phase not become a chronic pain phase - so getting off the pain meds is important, but not too soon - it's a balance and I'm sure it is different for everyone and their biochemistries.

4) For high impact sports which rely on the knee stability a good rule of thumb is that you won't be doing that for at least a year after the surgery (i.e. skiing).

5) The 6-10 week point after surgery is the most vulnerable as you will feel like all is well when in fact the graft is still healing - you will feel like you are your old self, but you mustn't overdo it.


Nords - I believe you would be someone who would have to moderate your 'overdoing'
PT - however, having the discipline to do it is the most important for long term prospects.

The weirdest thing - the number of people who have had this surgery, other knee surgery or hip replacements who are skiing with my club amazed me - they'd all gone through it and yet were able to come back - made me feel better.

I am having this done on the German economy - should be interesting - the surgeon does two of these a week - they told me I will get a hamstring autograft and that here they have me in a 0 degree immobilizer for two weeks - in the beginning the extension to normal is most important with flexion being second. My husband will be taking time off to nurse me for awhile - other aspect is they keep my in the hospital for three days - I'm thinking that may be a good thing as they can manage the pain medication, bandage changing/etc over the more acute post-op phase.

Merry Christmas and Happy New Year to me!!!! and to you all - I do enjoy reading the info here and have since I first came here (2004).
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Old 12-22-2008, 04:31 PM   #14
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...Your continuous passive motion machine and cryo cuff look pretty standard with this group.
In the first few days after surgery, I slept with my CPM going all night. The cryocuff is important becaue the swelling is what I found to cause the pain. Keep the swelling down and no pain.

Quote:
I've spent some time with a taekwondo national team conditioning coach who came back from a horrible car accident-- multiple knee ligament tears & two surgeries. He's really focused on quads, squats, & lunges and I know many interesting ways to do them now. They're far more difficult than anything I see in a PT clinic, too.
PT was not that painful once past the swelling stage. It is more time consuming than anything else. One certainly didn't need pain pills just because you were doing PT.

Quote:
That Knee1 forum really highlights the pain issues, which is probably causing most of my foreboding. I may have an extraordinarily high tolerance, but that doesn't make me look forward to the experience!
I have a high tolerance for pain as well. When I was younger, I would let the dentist drill without numbing my mouth. I've had 4 episodes of kidney stones and the ACL is a balmy walk in the park compared to that. I still have almost all the vicoden from my ACL, but admit I used some of those pills at the onset of a kidney stone.

I will write about something I found remarkable. My ACL was replaced with a hamstring tendon. Although that tendon is now missing, the tendon on the opposite side of the knee has grown much much thicker (compared to other leg) since the surgery. In effect, my knee has remodelled itself noticably.

Also once people see you with a knee brace, they will start talking to you about their ACL surgery. I met many people with good outcomes, but also many people with bad outcomes or who had to have the surgery redone with a tendon from a cadaver after they messed up during re-hab. Get a great surgeon.
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Old 12-22-2008, 07:45 PM   #15
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DH had this done 8 years ago. He was operated on Friday at 10.00 a.m. and I picked him up in the drive thru at 2.00 p.m. the same day and took him home with crutches.

By Monday he was back at work without crutches. He managed to get thru the whole process without any painkillers as one Percocet convinced him he would rather suffer pain than the side effects of medication.
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Old 12-23-2008, 06:20 AM   #16
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Good luck. I had an ACL repair in 1995. The thing feels pretty stable now, though my Physical Therapist figures they made it too tight -- I can't flex my leg nearly as much as in my other leg. That only really bothers me when I try to kneel with my heals touching my rear (which, unfortunately, is part of protocol in one of my martial arts). On the plus side, I no longer get pain from Osgood-Shlatter's in that knee because of them removing part of my patellar tendon (and bone) and using that to rebuild my ACL.
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Old 12-26-2008, 02:40 PM   #17
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I've learned quite a bit through everyone's links, thank you! Cochrane Reviews seems like a great place to start a search.

The most interesting thing I've learned is that there's no hard evidence whether ACL repair is necessary, although there are a number of reasons why it could be a good idea:
Exercise for treating anterior cruciate ligament injuries in combination with collateral ligament and meniscal damage of the knee in adults
Surgical versus conservative interventions for anterior cruciate ligament ruptures in adults
Exercise for treating isolated anterior cruciate ligament injuries in adults

Dr. Bookspan notes in her blog that a study in "Arthritis & Rheumatism" determined "Two to five years after treatment, patients had similar muscle strength and function whether they had training alone or with surgery." The study concludes, "Reconstructive surgery is not a prerequisite for restoring muscle function."
Anterior Cruciate Ligament (ACL) Surgery Unnecessary

Of course it'd be good to read the 20-year followup to that study.

I saw a sports physician about the surgery and gave him no indication which way I was leaning. In fact I gave him plenty of opportunity to recommend the surgery but asked him if there would be any impact from delaying it further. He checked my knees over, asked questions about pain & posture & range of motion, and said that reconstruction wasn't essential as long as there wasn't further injury. He said that I'm functioning at an obscenely higher level than most of the ACL patients he sees.

There still doesn't seem to be clear evidence that loss of an ACL will lead to osteoarthritis-- although repetitive injury can hasten the process. There also doesn't seem to be clear evidence that ACL reconstruction avoids osteoarthritis or that it makes any other significant difference. It is clear, however, that strong quads/hamstrings are necessary for the stability & good biomechanics that avoid repetitive injuries and the cartilage grinding that leads to osteoarthritis.

I've decided that I'm going to defer the surgery and keep working on my strength & balance. Sort of the same logic behind "I'm going to ER, but I can always get a job" with the same benefits & potential pitfalls.

Deserat, if you're going to take up skiing again then I'd strongly recommend a snowboard set of carbon-fiber custom-fitted orthopedic braces. They're pricey-- $1500-$2000 a pair-- but that's cheap insurance. The newer models only weigh 24-32 ounces each, slip on & off with Velcro straps, and give you a tremendous sense of confidence. At first my knees were rattling around in mine like castanets, but it gave the muscles a chance to heal & strengthen without repetitive injuries. Today I only need them if there's a chance of very heavy loading or surprise movement.

Of course the best alternative would be cross-country skiing, but I feel I've already made enough of a compromise by forsaking judo in favor of taekwondo...
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