eMedicine Specialties > Orthopedic Surgery > Knee

Allograft Reconstruction, ACL-Deficient Knee

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

Updated: Jul 8, 2008

Introduction

Multiple techniques are available for reconstruction of the anterior cruciate ligament (ACL). Controversy certainly exists as to which autograft is best and which methods of placement and fixation should be used.

Instances exist in which autograft is not available because of multiple reconstructions or combined ligament injuries. In addition, after discussing the advantages and drawbacks of the various graft materials available, patients may choose not to use autograft material. In these situations, other graft sources must be considered. This article deals with the grafts available and is aimed at providing the reader with an increased confidence in choosing from various materials. This article does not cover surgical indications or techniques, as other articles in this publication address these issues.

For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center. Also, see eMedicine's patient education articles Knee Injury and Knee Pain.

History of the Procedure

The supremacy of free bone-patellar tendon-bone autograft was briefly challenged in the 1970s and 1980 by proponents of artificial ligaments in the form of Gore-Tex and Proplast. Poor experiences with these nontissue substitutes led surgeons to choose other graft materials, including allografts. This trend was accelerated after Jackson and others developed the technique of arthroscopically assisted ACL reconstructions during the mid 1980s.1

Problem

The obvious issue is, What is the better choice when both autografts and allografts are available to the surgeon and patient?2 See Indications for a discussion of the advantages and disadvantages of autografts and allografts.

Indications

Certainly, the use of autografts presents some disadvantages. One is the need to add an incision to sacrifice important tissue. The other is the imposition of iatrogenic hardships, including patellofemoral symptoms, especially with bone-patella tendon-bone grafts that can hinder rehabilitation and can contribute to range-of-motion loss, arthrofibrosis, and patella baja. Reported cases of patellar tendon rupture and patellar fracture also cause concern. For hamstring constructs, 2 strand grafts are neither as strong nor as stiff as desired, and 4-strand grafts can affect knee-flexion torque when both semitendinosus and gracilis are harvested.3

Overall, concern with soft-tissue fixation continues to be a challenge, although advances are being made in this regard. Allografts would appear to be a rational choice. Their benefits include the sparing of autogenous tissue and the morbidity associated with their harvest, small incisions, shorter surgical times, and a larger choice of tissue types and sizes. This is especially important in revision cases in which bone may be deficient.

Shino4 and Noyes independently reported good results using allografts in the 1980s, as have Yoldas5 and Lawhorn in 2003.6 So, why is the allograft not the universal choice? Offsetting the list of allograft benefits is a litany of potential disadvantages, which include a potential for disease transmission, delayed incorporation, and decreased ultimate strength relative to autograft counterparts . Allografts also add another thousand dollars or so to the cost of a reconstruction. The actual surgical technique, including tunnel placement, tensioning, and fixation methods, should be similar for autografts and allografts. Therefore, the 3 major clinical factors to consider in assessing allograft use are potential disease transmission (see Workup), ultimate graft strength (see Treatment), and additional cost of the  allografts.7,8,9

Relevant Anatomy

See Surgical therapy.

Contraindications

While no true contraindications seem to apply to the use of allografts, some reports indicate that chronic instabilities tend to do better with autografts.

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

  1. Jackson DW, Grood ES, Arnoczky SP, et al. Freeze dried anterior cruciate ligament allografts. Preliminary studies in a goat model. Am J Sports Med. Jul-Aug 1987;15(4):295-303. [Medline].

  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].

  4. Shino K, Inoue M, Horibe S, et al. Maturation of allograft tendons transplanted into the knee. An arthroscopic and histological study. J Bone Joint Surg Br. Aug 1988;70(4):556-60. [Medline].

  5. Yoldas EA, Sekiya JK, Irrgang JJ, Fu FH, Harner CD. Arthroscopically assisted meniscal allograft transplantation with and without combined anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. May 2003;11(3):173-82. [Medline].

  6. Lawhorn KW, Howell SM. Scientific justification and technique for anterior cruciate ligament reconstruction using autogenous and allogeneic soft-tissue grafts. Orthop Clin North Am. Jan 2003;34(1):19-30. [Medline].

  7. Bolano L, Kopta JA. The immunology of bone and cartilage transplantation. Orthopedics. Sep 1991;14(9):987-96. [Medline].

  8. Bullis DW, Paulos LE. Reconstruction of the posterior cruciate ligament with allograft. Clin Sports Med. Jul 1994;13(3):581-97. [Medline].

  9. Jackson DW, Simon TM, Kurzweil PR, Rosen MA. Survival of cells after intra-articular transplantation of fresh allografts of the patellar and anterior cruciate ligaments. DNA-probe analysis in a goat model. J Bone Joint Surg Am. Jan 1992;74(1):112-8. [Medline].

  10. Bottenfield S, Caspari RB, Hurwitz RL, Asselmeier MA. HIV transmission via allograft organs and tissues. Sports Med Arthroscopy Rev. 1993;1:42-46.

  11. Simonds RJ, Holmberg SD, Hurwitz RL, et al. Transmission of human immunodeficiency virus type 1 from a seronegative organ and tissue donor. N Engl J Med. Mar 12 1992;326(11):726-32. [Medline].

  12. Jackson DW, Windler GE, Simon TM, et al. Intraarticular reaction associated with the use of freeze-dried, ethylene oxide-sterilized bone-patella tendon-bone allografts in the reconstruction of the anterior cruciate ligament. Am J Sports Med. Jan-Feb 1990;18(1):1-10; discussion 10-1. [Medline].

  13. Langer F, Czitrom A, Pritzker KP, Gross AE. The immunogenicity of fresh and frozen allogeneic bone. J Bone Joint Surg Am. Mar 1975;57(2):216-20. [Medline].

  14. Rihn JA, Irrgang JJ, Chhabra A, Fu FH, Harner CD. Does irradiation affect the clinical outcome of patellar tendon allograft ACL reconstruction?. Knee Surg Sports Traumatol Arthrosc. Sep 2006;14(9):885-96. [Medline].

  15. Buck BE, Malinin TI, Brown MD. Bone transplantation and human immunodeficiency virus. An estimate of risk of acquired immunodeficiency syndrome (AIDS). Clin Orthop. Mar 1989;(240):129-36. [Medline].

  16. Ozer H, Selek HY, Turanli S, Atik SO. Failure of primary ACL surgery using anterior tibialis allograft via transtibial technique. Arthroscopy. Sep 2007;23(9):1026. [Medline].

  17. Arnoczky SP, Warren RF, Ashlock MA. Replacement of the anterior cruciate ligament using a patellar tendon allograft. An experimental study. J Bone Joint Surg Am. Mar 1986;68(3):376-85. [Medline].

  18. Drez DJ Jr, DeLee J, Holden JP, et al. Anterior cruciate ligament reconstruction using bone-patellar tendon- bone allografts. A biological and biomechanical evaluation in goats. Am J Sports Med. May-Jun 1991;19(3):256-63. [Medline].

  19. Centers for Disease Control and Prevention (CDC). Update: allograft-associated bacterial infections--United States, 2002. MMWR Morb Mortal Wkly Rep. Mar 15 2002;51(10):207-10. [Medline].

  20. Indelicato PA, Bittar ES, Prevot TJ, Woods GA, Branch TP, Huegel M. Clinical comparison of freeze-dried and fresh frozen patellar tendon allografts for anterior cruciate ligament reconstruction of the knee. Am J Sports Med. Jul-Aug 1990;18(4):335-42. [Medline].

  21. Shelton WR, Papendick L, Dukes AD. Autograft versus allograft anterior cruciate ligament reconstruction. Arthroscopy. Aug 1997;13(4):446-9. [Medline].

  22. van Arkel ER, de Boer HH. Survival analysis of human meniscal transplantations. J Bone Joint Surg Br. Mar 2002;84(2):227-31. [Medline].

  23. Beynnon BD, Johnson RJ, Fleming BC, Stankewich CJ, Renström PA, Nichols CE. The strain behavior of the anterior cruciate ligament during squatting and active flexion-extension. A comparison of an open and a closed kinetic chain exercise. Am J Sports Med. Nov-Dec 1997;25(6):823-9. [Medline].

  24. Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med. May-Jun 1990;18(3):292-9. [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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