Graft Selection in Contemporary Anterior Cruciate Ligament Reconstruction

Abstract

In the last decade, there have been significant advances in our understanding of anterior cruciate ligament (ACL) reconstruction. Recent prospective cohort studies have identified risk factors for ACL reconstruction graft failure such as younger patient age, increased activity level, nonanatomic tunnel placement, and the use of allograft. Among these, the most easily modifiable risk factor is graft choice. Given that the surgeon's recommendation has been shown to be one of the most important factors behind patients' graft choice, it is critical that the operating surgeon have a thorough understanding of all the ACL graft options available to choose the graft that would be most suitable for the patient's personalized reconstruction (i.e., patient's anatomy, sport, level of competition, age, risk factors for failure, and graft used in previous ACL surgery). The purpose of this review is to provide an up-to-date understanding of the current ACL graft reconstruction options. The indications, advantages, and disadvantages of the different ACL reconstruction graft options available will be discussed.

Optimal Graft Choice in Athletic Patients with Anterior Cruciate Ligament Injuries: Review and Clinical Insights

“…The ideal graft should have similar properties to the native ligament, limit donor site morbidity, and allow for secure fixation and rapid incorporation. 8 …”

“… 13 , 14 Particular consideration should be taken in skeletally immature individuals as graft harvest and fixation methods could compromise physes and increase the risk of growth arrest. 8 , 12…”

“…Literature supports greater biomechanical strength with larger grafts, but a downside of potential impingement during knee range of motion. 8 In contrast to the standardized interference fixation for BPTB, a variety of different fixation methods are used with the HT graft with no consensus on the optimal method between surgeons. The most common methods are interference screw, suspensory, or cross-pin fixation.…”

“…The quadriceps tendon (QT) autograft has recently increased in usage and popularity, with studies reporting comparable outcomes to HT autograft. 8 , 19 Different harvesting techniques have been described to obtain partial- to full-thickness grafts with or without a bone block. 20 The range of graft subtypes allow for different sizes and thicknesses and, therefore, varying biomechanical graft properties.…”

“…All allografts have slower rates of incorporation compared to autograft, alongside a much higher failure rate of up to 25% in the active population. 8 , 29 Additionally, allograft is reported to have a lower return-to-sport rate compared to autograft (43% vs 75%). 30 Current evidence supports its use in specific circumstances such as multi-ligament knee reconstruction, inadequate autograft tissue, or in older, less active populations.…”