eMedicine Specialties > Orthopedic Surgery > Knee

Allograft Reconstruction, ACL-Deficient Knee: Treatment

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

Updated: Jul 8, 2008

Treatment

Surgical Therapy

A major advantage of allografts is that there are a greater variety of tissues available for reconstruction. Bone-patellar tendon-bone has been used most commonly, and although some advocate its use in primary cases, most are used in revisions. Its popularity stems from its 2 bony attachment sites, which ease fixation. Achilles tendon is also available, but it is used more commonly in posterior cruciate ligament (PCL) reconstruction due to its size, length, relative ease of insertion, and accommodation to being split into 2 bundles as part of an increasing trend for PCL reconstruction. Hamstring, tensor fascia lata, and other tissues, such as anterior and posterior tibial tendons, have also been used with varying success.16 Rene Verdonk of Belgium has reported good success in revisions with these tibial tendons with up to an 8-year follow-up.

Following proper thawing or rehydration and implantation, the incorporation of both autograft and allograft follows a similar sequence. The original structure acts as a scaffold for revascularization, cell repopulation, and remodeling. However, the timing of events varies, as the remodeling and maturation process is prolonged by as much as 50% for allografts. Grafts are weakest during this vascularization and maturation period. This has implications for the stresses that these tissues can withstand in the postoperative period.

Once remodeling is complete, implanted allografts appear histologically similar to native ACL. However, this does not necessarily translate into strength or stability. Shino4 showed histologic maturity at 18 months, while Arnozky17 showed dog allograft histologically resembling normal ACLs at 1 year. Using a goat model, Drez18 and Jackson9,12 independently showed similarities with native ACL at 26 weeks. Although it is now understood that the goat model is not applicable to humans regarding time of incorporation, Drez showed the maximum load-to-failure of allografts to be 43% of the native ACL, and Jackson showed this failure to be 27% of native ACL versus 62% for autografts.

Complications

Infection following any surgical procedure is certainly one of the accepted, yet feared, complications. Recently, however, significant publicity has surrounded 3 infections and subsequent deaths following orthopedic allograft transplants.19

The strain level that damages grafts and the strain level necessary for graft development are not presently known. Proper graft placement certainly plays a critical role. Specifically for allograft, the hydration status or how well thawed a graft is must be considered. If the graft is not allowed to fully recover from its frozen or freeze-dried state, postoperative tensioning and strain characteristics may drastically change soon after surgery.

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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