Failure Rates of Autograft and Allograft ACL Reconstruction in Patients 19 Years of Age and Younger

Abstract

Background: Graft choice for pediatric anterior cruciate ligament reconstruction (ACLR) is determined by several factors. There is limited information on the use and outcomes of allograft ACLR in pediatric patients. The purpose of this systematic review and meta-analysis was to quantify reported failure rates of allograft versus autograft ACLR in patients ≤19 years of age with ≥2 years of follow-up. We hypothesized that there would be higher rates of failure for allograft compared with autograft ACLR in this population. Methods: PubMed/MEDLINE and Embase databases were systematically searched for literature regarding allograft and autograft ACLR in pediatric/adolescent patients. Articles were included if they described a cohort of patients with average age of ≤19 years, had a minimum of 2 years of follow-up, described graft failure as an outcome, and had a Level of Evidence grade of I to III. Qualitative review and quantitative meta-analysis were performed to compare graft failure rates. A random-effects model was created to compare failure events in patients receiving allograft versus autograft in a pairwise fashion. Data analysis was completed using RevMan 5.3 software (The Cochrane Collaboration). Results: The database search identified 1,604 studies; 203 full-text articles were assessed for eligibility. Fourteen studies met the inclusion criteria for qualitative review; 5 studies were included for quantitative meta-analysis. Bone-patellar tendon-bone (BTB) represented 58.2% (n = 1,012) of the autografts, and hamstring grafts represented 41.8% (n = 727). Hybrid allografts (autograft + supplemental allograft) represented 12.8% (n = 18) of all allograft ACLRs (n = 141). The unweighted, pooled failure rate for each graft type was 8.5% for BTB, 16.6% for hamstring, and 25.5% for allograft. Allografts were significantly more likely than autografts to result in graft failure (odds ratio, 3.87; 95% confidence interval, 2.24 to 6.69). Conclusions: Allograft ACLR in pediatric and adolescent patients should be used judiciously, as existing studies revealed a significantly higher failure rate for allograft compared with autograft ACLR in this patient population. Additional studies are needed to improve the understanding of variables associated with the high ACLR failure rate among pediatric and adolescent patients. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Combined Anterior Cruciate Ligament Reconstruction and Modified Lemaire Lateral Extra-articular Tenodesis Better Restores Knee Stability and Reduces Failure Rates Than Isolated Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients

“…3,26,38 One of the great concerns raised when facing an ACL reconstruction in this population is the high risk of graft failure, which is estimated to occur in 8.3% to 25.5% of the cases regardless of the technique and graft used. 8,26,49 This failure rate has been described as 2 to 3 times higher when compared with that in adult patients. 2,17,44…”

Outcomes, Including Graft Tears, Contralateral Anterior Cruciate Ligament Tears, and All-Cause Ipsilateral Knee Operations, are Similar for Adult-type, Transphyseal, and Partial Transphyseal Anterior Cruciate Ligament Reconstruction Using Hamstring Autograft in Pediatric and Adolescent Patients

“… 17 Allograft has frequently demonstrated higher failure rates in the adolescent population relative to autograft. 19 , 20 , 21 , 22 …”

“…17 Allograft has frequently demonstrated higher failure rates in the adolescent population relative to autograft. [19][20][21][22] In addition to graft selection, numerous other surgical factors may govern outcomes after ACLR in the pediatric and adolescent patient, of which reconstruction technique with respect to the physis is a critical consideration. 17,23 Reconstruction techniques vary based on drilling and fixation across the physis on the proximal tibia and distal femur and whether the reconstruction incorporates intra-or extra-articular techniques.…”

Autograft and Nonirradiated Allograft for Anterior Cruciate Ligament Reconstruction Demonstrate Similar Clinical Outcomes and Graft Failure Rates: An Updated Systematic Review

“… 3 , 4 , 5 There are several autograft and allograft options for ACLR, with multiple studies demonstrating increased graft rupture rates with allograft compared with autograft, particularly in younger patients. 6 , 7 , 8 , 9 …”

“…[3][4][5] There are several autograft and allograft options for ACLR, with multiple studies demonstrating increased graft rupture rates with allograft compared with autograft, particularly in younger patients. [6][7][8][9] One of the factors thought to be involved in the greater failure rate of allografts is the graft-processing method, namely the use of radiation sterilization due to its detrimental biomechanical effects on allograft…”