Analysis of Outcomes of Anterior Cruciate Ligament Repair With 5-Year Follow-up: Allograft Versus Autograft

doi:10.1016/j.arthro.2005.04.112

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 21, Issue 7, July 2005, Pages 774.e1-774.e15

https://doi.org/10.1016/j.arthro.2005.04.112 Get rights and content

Purpose: To prospectively compare outcomes of primary anterior cruciate ligament (ACL) reconstruction with either Achilles tendon allograft with soft-tissue fixation or standard bone-patellar tendon-bone autograft with interference screw fixation. Type of Study: Prospective comparative case series. Methods: A group of 41 patients who underwent soft-tissue allograft reconstruction and a group of 118 patients who underwent autograft bone-patellar tendon-bone reconstruction were included in the final results. Patients were evaluated preoperatively and postoperatively at 1 to 2 weeks, 6 weeks, 3 months, 6 months, and then annually for 5 years. Objective measures of outcome included KT-1000 measurements, range of motion, ligamentous integrity, thigh atrophy, and International Knee Documentation Committee score. Subjective evaluations included patient completion of 5 questionnaires documenting functional status, pain, and health-related quality of life: (1) the short-form McGill Pain Questionnaire, (2) a patient subjective assessment of knee function and symptoms, (3) a patient subjective assessment follow-up, (4) a knee pain scale, and (5) the RAND 36-Item Health Survey. Mixed models analysis of variance was used to compare the outcomes of the treatment groups using baseline values of the study variables as a covariate. Results: Autograft patients reported significantly more pain on the bodily pain subscale of the RAND-36 than the allograft group at 1 week (P = .0006), 6 weeks (P = .0007), and 3 months (P = .0270). Autograft patients reported more pain than allograft patients on the McGill Pain Scale visual analog scale at 1 to 2 weeks (P < .0001) and 6 weeks (P = .0147). Patient assessment of function and symptoms showed that a higher proportion of patients reported normal or nearly normal knee function in the allograft group than in the autograft group at 3 months (33% v 14%, P = .0558, respectively). Fewer activity limitations were reported by allograft patients than autograft patients at 6 weeks (P = .0501), 3 months (P = .0431), and 6 months (P = .0014). After reconstruction, the allograft group displayed significantly more laxity in KT-1000 measurements at all time points than the autograft group (P = .0520). These measurements decreased over time for both groups (P < .0001). Conclusions: Five-year follow-up of patients undergoing ACL reconstruction with allograft versus autograft were compared objectively and subjectively. Both groups of patients achieved similar long-term outcomes. Overall, the allograft patients reported less pain at 1 and 6 weeks after surgery, better function at 1 week, 3 months, and 1 year, and fewer activity limitations throughout the follow-up period. Level of Evidence: Level II, prospective cohort study.

Section snippets

Methods

From November 1994 through May 1999, 352 patients underwent unilateral ACL reconstructions; 219 of these patients were eligible to participate in the study. ACL reconstruction surgery was performed by 3 surgeons at 1 institution: 1 surgeon performed arthroscopic reconstruction using allograft and the other 2 performed arthroscopically-assisted reconstruction using BPTB autograft.

Patients were excluded from the study if they had previous injury or surgery on the affected knee, multiple

Results

At the time of surgery, it was determined that 18 of the 219 patients enrolled in the study were ineligible for participation (12 who did not sustain an ACL rupture, 5 who had multiple ligament injuries, and 1 patient who had a nonstandard surgical procedure). A final review of patients revealed an additional 25 patients who were excluded from the study (17 patients with previous knee arthrotomies, 6 patients who were age ineligible, 1 patient with a head injury, and 1 patient who developed a

Discussion

Reconstruction of the injured ACL has been performed using a variety of autograft and allograft ligament substitutes. The use of autologous BPTB has been considered the gold standard and the first choice of many surgeons for a variety of reasons.17, 18 Multiple studies have shown good results using this method.6, 19, 20, 21 Autologous tissue avoids the perceived risk of disease transmission that is associated with allografts. Although the composite risk of harvesting and processing tissues from

Conclusions

Reconstruction of the ACL using either BPTB autograft or freeze-dried Achilles tendon allograft was successful for establishing knee stability that was maintained for up to 5 years. Allograft patients reported fewer role limitations due to physical health problems compared with autograft patients from 6 weeks to 6 months postoperatively, and better overall physical functioning at 1 to 2 weeks, 3 months, and 1 year. Significant differences on the Rand-36 pain subscale, the Knee Pain

Acknowledgment

The authors thank Monte Hunter, M.D., of the Department of Orthopaedic Surgery, Medical College of Georgia; Gloria Hairston, E.M.T.; and Denise Tickle, P.T., for their assistance in carrying out this study.

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Preserving the hamstring tendon insertion during ACL reconstruction with an autograft: Systematic literature review
2023, Revue de Chirurgie Orthopedique et Traumatologique
Les tendons des ischiojambiers (droit interne et demi tendineux DIDT) sont utilisés de façon fréquente comme autogreffe dans la reconstruction du ligament croisé antérieur (rLCA). La cicatrisation de la greffe passe par un lent processus biologique de ligamentisation. Dans le but de favoriser ce processus certains auteurs ont proposé de laisser pédiculés les tendons DIDT.
Laisser les tendons des ischiojambiers pédiculés à leur insertion tibiale permet une meilleure incorporation biologique initiale et une fixation mécanique tibiale supplémentaire avec des avantages cliniques.
En janvier 2022, une revue systématique de littérature a été réalisée par deux auteurs indépendants dans les moteurs de recherche Medline, Pubmed et Embase. Les mots clés étaient « pedicular » or « pedicled » or « preservation of tibial attachment » or « hamstring tibial insertion » et « ACL reconstruction ». L’analyse des données a été faite séparément.
Seize articles ont été analysés. Laisser les tendons des ischiojambiers pédiculés dans la reconstruction du LCA améliorait l’incorporation biologique dans la phase postopératoire initiale selon les études cliniques avec analyse IRM et fournissait un avantage mécanique pour la fixation de la greffe au tibia selon les études biomécaniques (montage jusqu’à 65 % plus rigide). Il n’y avait pas de différence sur les scores cliniques et fonctionnels avec une technique où les tendons DIDT sont détachés de leurs insertions tibiales.
La principale conclusion de cette revue systématique de littérature était que la préservation de l’insertion tibiale des ischiojambiers dans la reconstruction du LCA semblait améliorer la ligamentisation de la greffe avec des avantages biologiques et mécaniques (montage jusqu’à 65 % plus solide) par rapport au détachement des tendons. Les résultats cliniques et fonctionnels étaient comparables aux autres techniques. Des études prospectives avec large cohorte seront nécessaires.
IV ; Revue systématique de la littérature.
Preserving the hamstring tendon insertion during ACL reconstruction with an autograft: Systematic literature review
2023, Orthopaedics and Traumatology: Surgery and Research
The hamstring tendons (gracilis and semitendinosus) are often used as an autograft for anterior cruciate ligament (ACL) reconstruction. Healing of this graft involves a slow biological process called ligamentization. To encourage this process, some authors have proposed preserving the insertion of the hamstring tendons.
Leaving the tibial insertion of the hamstring tendons intact will provide better early biological incorporation and superior tibial mechanical fixation resulting in various clinical advantages.
In January 2022, a systematic literature review was carried out independently by two authors of the Medline, PubMed and Embase databases. The keywords used were “pedicular” or “pedicled” or “preservation of tibial attachment” or “hamstring tibial insertion” AND “ACL reconstruction”. Each author's data was analyzed separately.
Sixteen articles were analyzed. Preserving the hamstring tibial insertion during ACL reconstruction improves the graft's biological incorporation during the initial postoperative phase according to clinical studies with MRI analysis and provides a mechanical advantage at the graft's tibial attachment according to biomechanical studies (construct up to 65% stiffer). There was no difference in the clinical and functional scores when compared to the conventional technique in which the hamstring tendons are detached from their tibial insertion.
The main conclusion of this systematic literature review was that preserving the hamstring tibial insertion during ACL reconstruction appears to improve the graft's ligamentization with biological and mechanical advantages relative to detaching the hamstring tendons. The clinical and functional results were comparable to other techniques. Prospective studies with large cohorts are still needed to confirm these findings.
IV; Systematic review of literature.
Achilles Tendon Allograft Preparation Technique for Anterior Cruciate Ligament Reconstruction: A Technical Note
2021, Arthroscopy Techniques
Several factors associated with graft preparation for the surgery of the anterior cruciate ligament (ACL) like the wrong thawed, prophylaxis, bone cuts, excessive bone removal as well as positioning problems like a tunnels-graft mismatch, insufficient harvesting of the donor's tendon, size graft limitations (length and diameter), uncontrolled rotation of graft in their longitudinal axis, over or under tensioned graft, fixation mistakes, bone defects, secondary arthrofibrosis or morbidity of the donor site, and others factors importantly affect the outcomes of the ACL surgery. In this sense, the Achilles tendon Allograft is an advantageous technique where many of the previous limitation factors described can be controlled during an appropriate preparation. However, to obtain the maximum potentialities of the graft a detailed knowledge of the preparation is required. Hence, we aimed to describe how to prepare the Achilles tendon Allograft to control the graft's length and diameter, bone removal, and fixation requirements.
Pain Management Strategies After Anterior Cruciate Ligament Reconstruction: A Systematic Review With Network Meta-analysis
2021, Arthroscopy - Journal of Arthroscopic and Related Surgery
To systematically review randomized controlled trials (RCTs) evaluating various pain control interventions after anterior cruciate ligament reconstruction (ACLR) to determine the best-available evidence in managing postoperative pain and to optimize patient outcomes.
A systematic review of the literature was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. A study was included if it was an RCT evaluating an intervention to reduce postoperative pain acutely after ACLR in one of the following areas: (1) nerve blocks, (2) nerve block adjuncts, (3) intra-articular injections, (4) oral medications, (5) intravenous medications, (6) tranexamic acid, and (7) compressive stockings and cryotherapy. Quantitative and qualitative statistics were carried out, and network meta-analysis was performed where applicable.
Overall, 74 RCTs were included. Across 34 studies, nerve blocks were found to significantly reduce postoperative pain and opioid use, but there was no significant difference among the various nerve blocks in the network meta-analysis. Intra-articular injections consisting of bupivacaine and an adjunct were found to reduce reported postoperative pain scores up to 12 hours after ACLR, with significantly lower postoperative opioid use.
Nerve blocks and regional anesthesia are the mainstay treatment of postoperative pain after ACLR, with the commonly used nerve blocks being equally efficacious. Intra-articular injections consisting of bupivacaine and an adjunct were found to reduce reported postoperative pain scores up to 12 hours after ACLR, with significantly lower postoperative opioid use. There was promising evidence for the use of some oral and intravenous medications, tranexamic acid, and nerve block adjuncts, as well as cryotherapy, to control pain and reduce postoperative opioid use.
Level II, systematic review and meta-analysis of RCTs.
Tendon and ligament tissue engineering
2020, Principles of Tissue Engineering
Tendon and ligament are the major stabilizers in musculoskeletal system. Tendon/ligament injuries are common, especially in young generation. Loss of tendon/ligament support leads to tremendous functional disability. Thus restoration of tendon/ligament function after injury becomes crucial. However, the self-repair or regenerative capability of tendon/ligament is low due to their hypocellular and hypovascular nature. Therefore tissue engineering approaches to enhance tendon/ligament repair and regeneration or replace a nonrepairable tendon/ligament has indeed shed light on the future in this field. In this chapter the typical tissue-engineered tendon/ligament approaches with the basic elements and cutting edge technologies are discussed.
Lateral ankle ligament anatomic reconstruction for chronic ankle instability: Allograft or autograft? A systematic review
2020, Foot and Ankle Surgery
To investigate if there is any evidence in favour of autograft or allograft use for anatomic reconstruction of lateral ankle ligaments in patients with symptomatic chronic ankle instability.
A literature search was performed in PubMed MEDLINE, Cochrane Library, EMBASE and Google Scholar databases, over the years 1994–2017, to identify the studies presenting clinical results of anatomic lateral ankle ligaments reconstruction using various combinations of the keywords “lateral ankle ligaments reconstruction”, “anatomic reconstruction”, “chronic ankle instability”, “allograft”, “autograft”. The surgical procedure was considered anatomic if consistent with the description of lateral ankle ligaments made by Burks and Morgan in 1994.
Among the 89 papers matching the search terms, only 12 could be included in which 357 anatomic lateral ankle ligaments reconstructions were performed. One was a comparative case series (level of evidence III — LOE III) while other papers were retrospective case series (LOE IV), the mean Modified Coleman Methodology Score (MCMS) was fair: 56.7 (SD ± 5.2). Due to the low level of evidence of the available literature only a qualitative analysis was performed. The limited evidence from the studies analysed suggests that there is no difference in graft survivorship, graft-dependent variables, patient’s satisfaction, clinical outcome measures and radiographic results between allograft and autograft.
Given the low number of studies, their poor methodology score and their low level of evidence it is not possible to determine if allograft is better or safer than autograft.
Level of evidence: Level IV, review paper of level III and level IV studies.

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Note: To access the supplementary materials accompanying this article, visit the July 2005 issue of Arthroscopy at www.arthroscopyjournal.org.

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Original articleAnalysis of Outcomes of Anterior Cruciate Ligament Repair With 5-Year Follow-up: Allograft Versus Autograft

Section snippets

Methods

Results

Discussion

Conclusions

Acknowledgment

Orthop Clin North Am

Arthroscopy

Pain

Arthroscopy

Arthroscopy

Arthroscopy

Arthroscopy

Isolated tear of the anterior cruciate ligament5-year follow-up study

Am J Sports Med

The treatment of injuries of the anterior cruciate ligament

J Bone Joint Surg Am

The torn ACLNatural history of untreated lesions and rationale for selective treatment

Accelerated rehabilitation after anterior cruciate ligament reconstruction

Am J Sports Med

Does the patellar tendon normalize after harvesting its central thirdA prospective long-term MRI study

Am J Sports Med

Reconstruction of anterior cruciate ligaments with bone-patellar tendon-bone and Achilles tendon allografts

Clin Orthop

Reconstruction of the anterior cruciate ligament with human allograft

J Bone Joint Surg Am

Bone-patellar ligament–bone and fascia lata allografts for reconstruction of the anterior cruciate ligament

J Bone Joint Surg Am

Allograft versus autograft anterior cruciate ligament reconstruction

Clin Orthop

Use of soft tissue allografts in sports medicine

Adv Oper Orthop

Measures of need and outcome for primary health care

The RAND 36-Item Health Survey 1.0

Health Econ

Original article
Analysis of Outcomes of Anterior Cruciate Ligament Repair With 5-Year Follow-up: Allograft Versus Autograft