Allograft Reconstruction of ACL-Deficient Knee Treatment & Management

Updated: Mar 25, 2022
  • Author: Bart Eastwood, DO; Chief Editor: Thomas M DeBerardino, MD  more...
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Approach Considerations

Certainly, the use of autografts for reconstruction of an anterior cruciate ligament (ACL)-deficient knee 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–patellar tendon–bone grafts that can hinder rehabilitation and can contribute to range-of-motion (ROM) loss, arthrofibrosis, and patella baja.

Reported cases of patellar tendon rupture and patellar fracture also cause concern. For hamstring constructs, two-strand grafts are neither as strong nor as stiff as desired, and four-strand grafts can affect knee-flexion torque when both semitendinosus and gracilis are harvested. [20]

Overall, concern with soft-tissue fixation continues to be a challenge, though 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 where bone may be deficient.

Shino et al [21] and Noyes independently reported good results using allografts in the 1980s, as did Yoldas et al [22] and Lawhorn et al [23] in 2003. Given these results, it is reasonable to ask why the allograft is not the universal choice.

Offsetting the list of allograft benefits is a litany of potential disadvantages (eg, potential for disease transmission, delayed incorporation, and decreased ultimate strength relative to autograft counterparts). Allografts also add significantly to the cost of a reconstruction. The actual surgical technique, however, including tunnel placement, tensioning, and fixation methods, should be similar for autografts and allografts.

Therefore, the three major clinical factors to consider in assessing allograft use are as follows [24, 25, 26] :

  • Potential disease transmission
  • Ultimate graft strength
  • Additional cost of the allografts

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

The 2014 guideline on the management of ACL injuries formulated by the American Association of Orthopaedic Surgeons (AAOS) recommended that practitioners use either autograft or appropriately processed allograft tissue in patients undergoing ACL reconstructions, on the grounds that the measured outcomes are similar, though with the caveat that these results may not be generalizable to all allografts or all patients (eg, young or highly active patients). [4]

Hybrid grafts (a combination of autograft and allograft) may be considered a viable alternative in selected patients. [27, 28]


Procurement and Processing of Allografts

Since 1984, the American Association of Tissue Banks has set the minimum standards for procurement and processing of allogenic tissue. [29] 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 do 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) assay 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. The assay decreases the risk of viral transmission. [30, 31]

Grafts can be harvested with 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, though 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 commonly used technique has consisted of sterile harvest, antibiotic soaks, low-dose radiation, and storage by means of freeze-drying, freezing, or cryopreservation, which may cause less damage to the tissue during processing. [32, 33, 34]

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. [35] Later, this figure was lowered to approximately 1 in 10-20 million on the basis of unpublished calculations by tissue bank workers. Moreover, no cases of transmitted viral disorders have been documented since the advent of the established laboratory standards.

Roberson et al systematically reviewed proprietary processing techniques for allograft tissues in ACL reconstruction and demonstrated no significant differences in patient-reported outcomes or biomechanical properties between the various techniques, with the exception of the Tutoplast process, which had an unacceptably high failure rate (45% at 6 years). [36]


Surgical Considerations

A major advantage of allografts is that more different tissues are available for use in reconstruction. Bone–patellar tendon–bone (BTB) [37] has been employed most frequently; although its most common application has been in revisions, some advocate its use in primary cases. The popularity of this allograft stems from its two bony attachment sites, which ease fixation.

Achilles tendon is also available, but it is used more commonly in posterior cruciate ligament (PCL) reconstruction because of its size, length, relative ease of insertion, and accommodation to being split into two bundles as part of an increasing trend for PCL reconstruction.

Hamstring, tensor fasciae latae, and other tissues (eg, anterior and posterior tibial tendons) have also been used, with varying degrees of success. [38] In Belgium, Verdonk reported good success in revisions with the tibial tendons at a follow-up of up to 8-years.

Preshaped allograft bone dowels are gaining popularity as an option for two-stage revision ACL reconstructions. [39, 40]

After proper thawing or rehydration and implantation, the incorporation of both autograft and allograft follows a similar sequence, with the original structure acting as a scaffold for revascularization, cell repopulation, and remodeling. [41] However, the timing of events varies, in that 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. One study reported a higher graft failure rate with younger patients and with allograft, with a multiplicative effect when combined. [42]

Once remodeling is complete, implanted allografts appear histologically similar to native ACL. However, this histologic similarity does not necessarily translate into comparable strength or stability.

Shino et al [21] showed histologic maturity at 18 months, whereas Arnozky et al [43] showed dog allograft histologically resembling normal ACLs at 1 year.

Using a goat model, Drez et al [44] and Jackson et al [26, 32] independently showed similarities with native ACL at 26 weeks. Although it is understood that the goat model is not applicable to humans regarding time of incorporation, Drez et al showed the maximum load-to-failure of allografts to be 43% of native ACL, and Jackson et al showed this failure to be 27% of native ACL vs 62% for autografts.

The risks of disease transmission via allograft would seem to have become infinitely small, but, as evidenced by fatal infections previously noted, this risk has not been reduced to zero. It is imperative that the surgeon constantly monitor the source of the grafts and develop a very specific protocol for response in the face of an adverse surgical outcome when infection is a possible diagnosis. [45]

With a supply of safe graft materials, aside from the possibility of a national graft shortage or insurers or of the hospital denying coverage for the additional costs, strength and long-term results become the main concern with allograft use.

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.

Although admittedly not ideal, allografts offer an off-the-shelf material with a relatively good record. There remains a need for prospective long-term data, but many patients have done well clinically with this procedure as a primary reconstruction. In a case-control study that evaluated long-term patient-reported outcome measures (PROMs), return-to-sport rates, and revision risk after ACL reconstruction (autografts, 76%; allografts, 24%), Randsborg et al found that improvements in International Knee Documentation Committee (IKDC) scores were sustained 7 years after the procedure, a 70% return-to-sport rate could be expected, and there was a 26% chance of subsequent knee surgery within 9 years. [46]

With improved soft-tissue fixation, tripled semitendinosus without gracilis and quadriceps tendon grafts are becoming more appealing, in that they offer strong graft materials without the problems associated with patella tendon grafts. For revisions and situations in which no autograft material is available, this offers hope where none might otherwise exist.

Administration of platelet-rich plasma (PRP) has been suggested as a means of augmenting ACL reconstruction; however, a systematic review and meta-analysis by Davey et al found no clinical, biochemical, or radiologic improvements in postoperative follow-up when PRP was used with allograft ACL reconstruction. [47]  

Anatomic allograft ACL reconstruction infused with bone marrow aspirate concentrate (BMAC) has also been described. [48]  A double-blind randomized controlled study (N = 80) by Forsythe et al found that BMAC augmentation of BTB allografts during ACL reconstruction yielded greater signal intensity scores on MRI at 3 months, which were suggestive of increased metabolic activity and remodeling and, potentially, accelerated ligamentization. [49]



Infection following any surgical procedure is certainly one of the accepted, though nonetheless feared, complications. However, significant publicity surrounded three infections and subsequent deaths that occurred after orthopedic allograft transplants. [50]

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