Allograft Reconstruction of the ACL-Deficient Knee Workup

  • Author: Andrew Turtel, MD; Chief Editor: Carlos J Lavernia, MD, FAAOS   more...
 
Updated: Apr 5, 2011
 

Laboratory Studies

  • The American Association of Tissue Banks has set standards since 1984 for allograft use. Its publication has been revised and updated 6 times, most recently in 1996. It sets the minimum standards for procurement and processing of allogenic tissue. Potential donors undergo a series of examinations in addition to the physical examination, which include medical, social, and sexual histories. Any history of unprotected sex or exposure to a communicable disease results in an automatic rejection, as does other diseases.
    • On physical examination, abnormalities are sought, including signs of infectious disease. Routine blood and tissue cultures are obtained and examined for antibodies associated with HIV 1 and HIV 2, hepatitis, syphilis, and lymphoma. A major concern is the timing of HIV antibody production in an infected individual. This window averages 25 days but can be as long as 6 months. To decrease the risk of missing unconverted donors, many tissue banks do a polymerized chain reaction (PCR) to detect viral antigens. This decreases the window to about 19 days with a confidence level of 95%. It adds approximately $120 to the overall cost of the graft. This decreases the risk of viral transmission.[10, 11]
    • Grafts can be harvested using aseptic or clean techniques. If a clean technique is used, a secondary sterilization process is needed. Heat or high-dose radiation can be used to kill virus particles, but this alters and weakens the collagen structure. Ethylene oxide, although excellent in removing microorganisms, was the culprit in earlier reports of poor allograft outcomes due to chemical residue resulting in synovitis and graft failures. The most common technique is that of sterile harvest, antibiotic soaks, low-dose radiation, and storage by either freeze drying, freezing, or the newest technique, cryopreservation, which may cause less damage to the tissue during processing.[12, 13, 14]
    • What is the risk of viral transmission, and should it cause concern? In 1989, Buck et al calculated a 1 in 1.5 million chance of HIV transmission in screened donors.[15] Later, this was lowered to approximately 1 in 10-20 million based on unpublished calculations by tissue bank workers. Moreover, no cases of transmitted viral disorders have been documented since the advent of the laboratory standards established more than a decade ago.
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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.

Specialty Editor Board

Robert D Bronstein, MD  Associate Professor, Department of Orthopedics, Division of Athletic Medicine, 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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Thomas M DeBerardino, MD  Associate Professor, Department of Orthopedic Surgery, Consulting Surgeon, Sports Medicine, Arthroscopy and Reconstruction of the Knee, Hip and Shoulder, Team Physician, Orthopedic Consultant to UConn Department of Athletics, 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. Consulting fee Speaking and teaching; Genzyme Biosurgery. Inc. Grant/research funds Other; Musculoskeletal Transplant Foundation Grant/research funds Other; Histogenics Grant/research funds None

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

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

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. Richmond JC, Weitzel PP. Bioresorbable scaffolds for anterior cruciate ligament reconstruction: do we need an off-the-shelf ACL substitute?. Sports Med Arthrosc. Mar 2010;18(1):40-2. [Medline].

  18. Borchers JR, Pedroza A, Kaeding C. Activity level and graft type as risk factors for anterior cruciate ligament graft failure: a case-control study. Am J Sports Med. Dec 2009;37(12):2362-7. [Medline].

  19. 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].

  20. 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].

  21. 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].

  22. 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].

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

  24. Spindler KP, Huston LJ, Wright RW, Kaeding CC, Marx RG, Amendola A, et al. The prognosis and predictors of sports function and activity at minimum 6 years after anterior cruciate ligament reconstruction: a population cohort study. Am J Sports Med. Feb 2011;39(2):348-59. [Medline].

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

  26. 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].

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

  28. Reinhardt KR, Hetsroni I, Marx RG. Graft selection for anterior cruciate ligament reconstruction: a level I systematic review comparing failure rates and functional outcomes. Orthop Clin North Am. Apr 2010;41(2):249-62. [Medline].

  29. Mehta VM, Mandala C, Foster D, Petsche TS. Comparison of revision rates in bone-patella tendon-bone autograft and allograft anterior cruciate ligament reconstruction. Orthopedics. Jan 2010;33(1):12. [Medline].

  30. Nagda SH, Altobelli GG, Bowdry KA, Brewster CE, Lombardo SJ. Cost analysis of outpatient anterior cruciate ligament reconstruction: autograft versus allograft. Clin Orthop Relat Res. May 2010;468(5):1418-22. [Medline]. [Full Text].

  31. Barker JU, Drakos MC, Maak TG, Warren RF, Williams RJ 3rd, Allen AA. Effect of graft selection on the incidence of postoperative infection in anterior cruciate ligament reconstruction. Am J Sports Med. Feb 2010;38(2):281-6. [Medline].

 
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Anterior cruciate ligament reconstruction aims to reduce instability episodes in an attempt to preserve the meniscus. When meniscal injury has occurred, the knee becomes degenerate with time.
 
 
 
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