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WHAT TYPE OF GRAFT (AUTOGRAFT AND/OR ALLOGRAFT) SHOULD I CHOOSE FOR MY ANTERIOR CRUCIATE LIGAMENT (ACL) RECONSTRUCTION SURGERY?

There are multiple graft options for arthroscopic anterior cruciate ligament (ACL) reconstruction surgery. Each graft option has some specific pros and cons, and the best graft for you depends on numerous individual factors. What makes sense for one patient may be different from person to person. Some surgeons prefer to use one type of graft for every ACL surgery. I prefer to discuss the options with my patient and help them choose what type of graft is the best for their specific needs. Some options and implications are listed below.

 

Autograft means tissue taken from your own body. Typical autografts used for ACL reconstruction include:

  • Patellar Tendon (bone-patellar tendon-bone/PTG/BTB)
  • Hamstring Tendons (gracilis/semitendinosus, quadrupled hamstrings)
  • Quadriceps Tendon
  • Contralateral (un-injured) knee patellar, hamstring, or quadriceps tendon graft

 

The primary benefits of using autograft tissue are :

  • This type of tissue will incorporate and “heal” the fastest, potentially allowing slightly earlier return to full activity and sports than allograft tissue. Though I typically will still recommend a 6-9 month period before return to pivoting sports, sometimes accelerated returns at 4-6 months are possible with autograft tissue in specific situations.
  • Using your own tissue carries no risk of disease transmission (bacteria or viruses)
  • The overall re-rupture rate, especially for young athletes, seems to be slightly lower with autograft tissue when compared to allograft tissue, though the reasons for this are still unclear and more investigation is needed to determine if this is a true advantage (see disadvantage of allograft tissue section below).

 

The primary disadvantages of using autograft tissue are:

  • Because  we are taking additional tissue from your knee, there may be some additional discomfort and pain in the initial post-operative period (2-6 weeks)
  • Depending on which location the tissue comes from, you may experience quadriceps or hamstring weakness during the rehabilitation process. This usually normalizes after 6-12 months. Still, hurdlers and track athletes may prefer to not use hamstring grafts, while jumpers may prefer not to use patellar tendon grafts.
  • Patellar tendon grafts may be associated with higher incidence of post-operative patellar tendinitis and anterior knee pain. This graft should not be used if you already have patellar tendinitis or anterior knee pain or if you are a wrestler or have to do activities which require a great deal of jumping, kneeling or squatting.
  • Autografts require longer incisions and thus longer scars to acquire the tissue.
  • Because autografts need to first be harvested (acquired) from your knee to be used in surgery, the duration/length of surgery is increased over allograft tissue
  • If you have injured multiple ligaments and multiple grafts are required, the availability of autograft tissue is limited.

 

Allograft means tissue taken from someone else’s body (a donated cadaver tissue)

  • Patellar Tendon (bone-patellar tendon-bone/PTG/BTB)
  • Hamstring Tendons (gracilis/semitendinosus, quadrupled hamstrings)
  • Quadriceps Tendon
  • Achilles Tendon
  • Anterior or Posterior Tibialis Tendon

 

The primary advantages of using allograft tissues are:

  • Early post-operative discomfort and pain is minimized so the initial recovery and rehabilitation may progress faster.
  • Surgical incisions and thus scars can be minimized.
  • If multiple ligaments are being reconstructed, availability of graft tissue is not an issue.
  • Duration/length of surgery is decreased.

 

The primary disadvantages of using allograft tissue are:

  • Because the donated tissue comes from another person, there is a theoretical risk of bacterial or viral disease transmission. However, we only use tissues from highly accredited tissue banks that use stringent donor criteria, tissue handling and sterilizing processes. Grafts are safer today than they have ever been and risk of actual disease transmission is very low.  I would feel comfortable using cadaver tissue in my own body if I needed it.
  • Because the tissue has been stored sterilely and is not living tissue, it may take slightly longer to incorporate (“heal”) in the knee than autograft. Though return to full activity is still highly reliable, I wouldn’t recommend hastened or accelerated return to sport after allograft reconstruction. General return to sport time periods are 6-9 months for allograft reconstruction.
  • Some studies have shown a slightly higher re-rupture rate for allograft reconstructions when compared to autograft reconstructions. This was especially true in younger athletes. The problem with these studies is that many different types of allograft tissue have been studied and many different types of surgical techniques are included in these studies. This includes grafts which were irradiated, not age-matched, and often reconstructions which included older surgical techniques. There is yet to be a well-designed study comparing the newest anatomic surgical reconstruction techniques and non-irradiated age-matched cadaver grafts to the same techniques with autograft tissue. These are the grafts and techniques that I use when I do use allograft tissue, and I believe when these data become available the re-rupture rate will be nearly equal. Until we have more information, however, I lean towards autograft tissue in young athletes and cadaver (allograft) tissue once patients are in their late 20′s or 30′s or are less active. This is still a controversial and very closely evaluated topic in the world of sports medicine and orthopedic surgery.

Written by Vishal Michael Shah, M.D.