The use of allograft tendons in primary ACL reconstruction

Abstract

Purpose Graft choice in primary anterior cruciate ligament (ACL) reconstruction remains controversial. The use of allograft has risen exponentially in recent years with the attraction of absent donor site morbidity, reduced surgical time and reliable graft size. However, the published evidence examining their clinical effectiveness over autograft tendons has been unclear. The aim of this paper is to provide a current review of the clinical evidence available to help guide surgeons through the decision-making process for the use of allografts in primary ACL reconstruction. Methods The literature in relation to allograft healing, storage, sterilisation, differences in surgical technique and rehabilitation have been reviewed in addition to recent comparative studies and all clinical systematic reviews and meta-analyses. Results Early reviews have indicated a higher risk of failure with allografts due to association with irradiation for sterilisation and where rehabilitation programs and post-operative loading may ignore the slower incorporation of allografts. More recent analysis indicates a similar low failure rate for allograft and autograft methods of reconstruction when using non-irradiated allografts that have not undergone chemically processing and where rehabilitation has been slower. However, inferior outcomes with allografts have been reported in young (< 25 years) highly active patients, and also when irradiated or chemically processed grafts are used. Conclusion When considering use of allografts in primary ACL reconstruction, use of irradiation, chemical processing and rehabilitation programs suited to autograft are important negative factors. Allografts, when used for primary ACL reconstruction, should be fresh frozen and non-irradiated. Quantification of the risk of use of allograft in the young requires further evaluation. Levels of evidence III. Keywords Anterior cruciate ligament reconstruction • Allografts • ACL • Graft choice • Decision making • AutograftsThis work performed as part of the ESSKA Arthroscopy Committee.

Use of Allografts in Orthopaedic Surgery: Safety, Procurement, Storage, and Outcomes

“…The graft undergoes long-term storage in liquid nitrogen at –196° C. It is worth noting that the cryoprotective solutions are associated with a diminished intravascular immune response by the host and heightened angiogenesis. 32 Of additional importance is the distinction that cryopreservation may allow for cell viability, while fresh-frozen and freeze-dried grafts do not. 58 Suhodolčan et al 58 compared the biomechanical properties of cryopreserved BTB allografts using glycerol as a cryoprotective agent with fresh-frozen allografts.…”

Graft considerations for successful anterior cruciate ligament reconstruction

“…However, there were no reports that suggest that allograft may have a better longterm outcome than autograft. Allografts have inherent disadvantages, including a longer and less complete course of incorporation, remodeling, biomechanical inferiority to autograft, and the potential risk of immunogenic reaction and disease transmission [13,14]. Allograft remodeling is delayed in ACL reconstruction and results in reduced long-term stability and mechanical function compared with autograft ACL reconstruction [13,14].…”

“…Allografts have inherent disadvantages, including a longer and less complete course of incorporation, remodeling, biomechanical inferiority to autograft, and the potential risk of immunogenic reaction and disease transmission [13,14]. Allograft remodeling is delayed in ACL reconstruction and results in reduced long-term stability and mechanical function compared with autograft ACL reconstruction [13,14]. Higher longterm failure rates and poorer graft maturation score for allograft were reported compared with those for autograft [15,16].…”

Allografts

“…So erfolgten in den USA. beispielsweise bereits im Jahr 2013 etwa 40 % der primären vorderen Kreuzbandrekonstruktionen und 80 % der Bandrevisionen mittels Allografts [1].…”