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Anterior Cruciate Ligament Reconstruction - Allograft versus Autograft
Andris Levis MF VI
versus
Kristaps Blūms MF VI
Mentor: Dr. Modris Ciems
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Anterior Cruciate Ligament (ACL)
Functions:»Limits the forward motion of the
tibia 1;
»Prevents hyperextension of the knee 1;
»Provides roughly 90% of stability in the knee joint 1
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Incidence of Injury
Annual incidence of more than 200,000 cases with ~100,000 of these knees reconstructed 2;
Most prevalent (1 in 1,750 persons) in patients 15-45 years of age 1;An estimated 70% of ACL injuries are sustained through non-contact
mechanisms, while the remaining 30% result from direct contact. 1
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Indications for surgery
Knee instability 5;Combined injuries (30-50%) 3;ACL reconstruction could prevent further damage 4;High-demand patients 5
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Graft selection(SB BTB)
Allograft
Autograft
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Graft selection
Patient related factors
Surgery related factors
Transplant related factors
Biological factors
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Patient related factorsAllograft
No donor site morbidity 6; No weakening of the flexor/extensor
apparatuses 8; Faster return to activities of daily living 8; Least painful post-operatively 8; Higher IKDC scores 10; Patients older than 45 years 8; Lower demand patients 8; Multiligamentous knee injury
reconstructions 8; Revision ACL surgery. 8
Autograft
Young patients 11
Athletes 12
No difference in Lysholm II and KT 1000 scores 13
More pain – immidiate rehabilitation and activities possible - paradox
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Surgery related factors
Allograft
Smaller incision 8; Reduced operative time 6; Smaller risk of complications under
anesthesia 5; No risk of patellar fracture 9; No need for an assistant.
Autograft
Operative time can be evened with asisstant
Lower cost $4,587 92 min vs $3,849 125 min 14
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Transplant related factors
Allograft
Greater availability 8; Larger cross sectional size 8; Potential graft tissue source for
backup 9;
Autograft Greater avalailabilty in Latvia Lower tear rate
»8,9% vs 3,5% 11
»More than 10% difference in patients less than 18yo 11
At 6 months better AP restraint to AP force, more cross sectional area, twice load to failure strentgh 15
Loses less time zero strenght 17
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Biological factors
Allograft
Low dose irradiation - eliminate bacteria 7;
High dose irradiation - eliminate both bacterial and viral pathogens 7;
The estimated risk of HIV transmission is 1 : 8,000,000. 7
Autograft
Histocompatibility No infection transmission risk Faster incorporation 17
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Bottom line
The surgeon has many choices when it comes to graft selection for ACL reconstruction;
There are certain situations in which one graft may be favored over another;
No graft is perfect; Individual approach is the most important
Future?
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Literature1. Griffin LY. Noncontact Anterior Cruciate Ligament Injuries: Risk Factors and Prevention Strategies. Journal of the American Academy of
Orthopaedic Surgeons. 2000;8:141-150
2. Miyasaka KC, Daniel DM, Stone ML. The incidence of knee ligament injuries in the general population. Am J Knee Surg 1991;4:43-48.
3. Hefzy MS, Grood ES. Ligament restraints in anterior cruciate ligament-deficient knees. In: Jackson DW, Arnoczky SP, Woo SL-Y, Frank CB, Simon TM, eds. The Anterior Cruciate Ligament. Current and Future Concepts. New York: Raven Press, 1993;141-151.
4. Cannon W, Jr, Vittori J. The incidence of healing in arthroscopic meniscal repairs in anterior cruciate ligament-reconstructed knees versus stable knees. Am J Sports Med 1992;20(2):176-181.
5. Johnson RJ, Beynnon BD, Nichols CE, et al. Current concepts review. The treatment of injuries of the anterior cruciate ligament. J Bone Joint Surg Am 1992;74A:140-151.
6. Fu FH, Jackson DW, Jamison J, et al. Allograft reconstruction of the anterior cruciate ligament. In: Jackson DW, Arnoczky SP, Woo SL-Y, Frank CB, Simon TM, eds. The Anterior Cruciate Ligament. Current and Future Concepts. New York: Raven Press, 1993;325-338.
7. Pruss A, Kao M, Gohs U, Koscielny J, von Versen R, Pauli G. Effect of gamma irradiation on human cortical bone transplants contaminated with enveloped and non-enveloped viruses. Biologicals 2002;30:125-133.
8. Shelton WR, Papendick L, Dukes AD. Autograft versus allograft anterior cruciate ligament reconstruction. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. Aug 1997;13(4):446-449.
9. Miller SL, Gladstone JN. Graft selection in anterior cruciate ligament reconstruction. The Orthopedic clinics of North America. Oct 2002;33(4):675-683.
10. Robert H. Miller and Frederick M. Azar. Campbell's Operative Orthopaedics, Chapter 45, 2121-2297.e16
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11. Kaeding CC, Aros BC, Pedroza A, et al. Allograft Versus Autograft Anterior Cruciate Ligament Reconstruction: Predictors of Failure from a MOON Prospective Longitudinal Cohort. Sports Health 2011;3:73-81
12. Pallis M, Svoboda SJ, Cameron KL, Owens BD. Survival Comparison of Allograft and Autograft Anterior Cruciate Ligament Reconstruction at the United States Military Academy. Am J Sports Med 2012;40:1242–6. doi:10.1177/0363546512443945.
13. Chang SKY, Egami DK, Shaieb MD, Kan DM, Richardson AB. Anterior cruciate ligament reconstruction: allograft versus autograft. Arthroscopy 2003;19:453–62. doi:10.1053/jars.2003.50103.
14. Greis PE, Koch BS, Adams B. Tibialis anterior or posterior allograft anterior cruciate ligament reconstruction versus hamstring autograft reconstruction: an economic analysis in a hospital-based outpatient setting. Arthroscopy 2012;28:1695–701. doi:10.1016/j.arthro.2012.04.144.
15. Gulotta LV, Rodeo SA. Biology of autograft and allograft healing in anterior cruciate ligament reconstruction. Clin Sports Med 2007;26:509-524.
16. Jackson DW, Grood ES, Goldstein JD, et al. A comparison of patellar tendon autograft and allograft used for anterior cruciate ligament reconstruction in the goat model. Am J Sports Med 1993;21:176-185.
17. Jackson DW, Corsetti J, Simon TM. Biologic incorporation of allograft anterior cruciate ligament replacements. Clin Orthop Relat Res 1996:126-133.
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