eMedicine Specialties > Orthopedic Surgery > Knee

Allograft Reconstruction, ACL-Deficient Knee: Follow-up

Author: Andrew Turtel, MD, Clinical Adjunct Professor, Department of Orthopedic Surgery, Beth Israel Medical Center
Contributor Information and Disclosures

Updated: Jul 8, 2008

Outcome and Prognosis

Long-term published clinical studies comparing allografts to autografts are few. Indelicato20 and Shelton21 all showed generally good results in comparison of the tissues. In another study, an overall trend of fewer patellofemoral symptoms and better range of motion with allografts was noted. Shelton described a trend of increased pivot glide with allograft, which was not statistically significant. Although happy with their allograft results, they all remained cautious with their outlook, echoing the sentiments of Beynnon that it may take years to see a pattern for overall failure for any graft type.22

Beynnon theorizes that the initial and 2- to 3-year outcome studies may not accurately assess longer-term results.23 He showed that reestablishing AP stability is not a predictor of future graft behavior. Using strain gauges in autograft reconstructions, he showed that strain characteristics established at the time of surgery was a more powerful predictor of long-term results. Grafts that varied most from normal strain patterns in the early postoperative period showed long-term failure. This is disturbing when recent bench studies have shown that tensioning allografts in the human cadaver knee to fully achieve AP joint stability increased forces in the graft at all angles of flexion.

Authors have long proclaimed dangerous strain and shearing in terminal extension. Of particular note, the good results that  Indelicato20 and Shelton21 achieved all predated the era of accelerated rehabilitation protocols popularized by Shelbourne.24 In fact, the allograft protocols included limited arcs and crutch weightbearing for up to 12 weeks.

With all of this in mind and knowing that allografts take longer to remodel and mature, the following question remains: Should there be concern with allografts in general and specifically in relation to recent trends in accelerated rehabilitation? Although Shelbourne has not suggested this, should his autograft axiom be applied? It allows activity based on the status of rehabilitation and not on graft biology. Alternatively, should these patients be restricted as is commonly done in grafts without bone plugs due to fixation concern? This question is especially important with the potential earlier aggressive rehabilitation and return to activity that allografts allow due to the decreased morbidity compared with autografts.

Future and Controversies

The risks of disease transmission would seem to have become infinitely small, but, as evidenced by fatal infections noted already, this risk has not been reduced to zero. It is imperative that the surgeon constantly monitors the source of his or her grafts and has a very specific protocol of response in the face of an adverse surgical outcome when infection is a possible diagnosis.

With a supply of safe graft materials, other than a national graft shortage or insurers or the hospital denying coverage for the additional costs, strength and long-term results become the main concern.

The information above indicates the need to protect these grafts from aggressive early rehabilitation. Protection may include limited weightbearing and stresses placed across the joint. However, no data are available to support this protocol, and prospective comparative studies are needed. For primary cases, weighing the risk of outright allograft failure due to tissue weakness against the morbidities of autograft harvest still leaves the surgeon with a difficult decision. No clear answer exists.

Far from ideal, allografts offer a material off the shelf with a relatively good record. Although prospective long-term results are unknown, many patients have done well clinically with this procedure as a primary reconstruction. However, with improved soft-tissue fixation, tripled semitendinosus without gracilis and Quad tendon grafts are becoming more appealing, as they offer strong autograft materials without the problems associated with patella tendon. For revisions and situations in which no autograft material is available, it offers hope where none might otherwise exist.

 


More on Allograft Reconstruction, ACL-Deficient Knee

Overview: Allograft Reconstruction, ACL-Deficient Knee
Workup: Allograft Reconstruction, ACL-Deficient Knee
Treatment: Allograft Reconstruction, ACL-Deficient Knee
Follow-up: Allograft Reconstruction, ACL-Deficient Knee
References
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References

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  2. Eriksson E. Auto- or allograft for ACL-reconstruction?. Knee Surg Sports Traumatol Arthrosc. Jun 2007;15(6):689. [Medline].

  3. Edgar CM, Zimmer S, Kakar S, Jones H, Schepsis AA. Prospective Comparison of Auto and Allograft Hamstring Tendon Constructs for ACL Reconstruction. Clin Orthop Relat Res. Jun 25 2008;[Epub ahead of print]. [Medline].

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Further Reading

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Keywords

allograft reconstruction, ACL injury, ACL pathology, ACL reconstruction, ACL reconstruction materials, knee reconstruction, anterior cruciate ligament

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Contributor Information and Disclosures

Author

Andrew Turtel, MD, Clinical Adjunct Professor, Department of Orthopedic Surgery, Beth Israel Medical Center
Andrew Turtel, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Robert D Bronstein, MD, Associate Professor, Department of Orthopedic Surgery, University of Rochester School of Medicine
Robert D Bronstein, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, and Medical Society of the State of New York
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Thomas M DeBerardino, MD, Associate Professor of Orthopaedic Surgery, University of Connecticut Health Center
Thomas M DeBerardino, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, and American Orthopaedic Society for Sports Medicine
Disclosure: Arthrex, Inc. Grant/research funds Other; Arthrex, Inc. Honoraria Speaking and teaching; Genzyme Biosurgery. Inc. Grant/research funds Other; Musculoskeletal Transplant Foundation Grant/research funds Other; Histogenics Grant/research funds None; Arthrex, Inc. Consulting fee Speaking and teaching

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Carlos J Lavernia, MD, FAAOS, Adjunct Clinical Professor, Department of Orthopedic Surgery, University of Miami School of Medicine; Medical Director, Orthopedic Institute at Mercy Hospital
Carlos J Lavernia, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Hip and Knee Surgeons, Arthritis Foundation, Biomedical Engineering Society, Florida Orthopaedic Society, and Orthopaedic Research Society
Disclosure: Zimmer Stock Implant Designer

 
 
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