Document Title: West-JAAOS-May05.shtml
Article Title: Graft Selection in Anterior Cruciate Ligament Reconstruction
Authors: Robin V. West, MD, and Christopher D. Harner, MD
Publication: Journal of the American Academy of Orthopedic Surgeons
Date: May/June 2005
Volume 13, Number 3, pages 197-207
Keywords: ACL reconstruction, graft selection, autografting, allografting, patellar-tendon, quadriceps tendon, hamstring, DLSTG.

(Reference-denoting numbers appear in the same font and point size as the document text. As with all Knee Library documents, this article is provided in full-text form, complete with all figures and tables.)

Comments: This article provides a plethora of excellent comments on graft selection, albeit given its publication date of May 2005, it might seem surprising that it overlooks a number of the most recent research studies in this realm. (One plausible explanation for this is that this paper was in preparation for many months; this would have resulted in some studies being published during the period of time between when the authors did their gathering of background research and the actual release of this article.) The section entitled "The Biology of Healing" is a must-read for anyone who is undergoing any type of ACL reconstruction, because it describes in good detail the various phases that all ACL grafts go through. For example, it notes that a graft first dies off (via avascular necrosis), reaching a strength of only 11% of a normal ACL. The longer revascularization of soft-tissue (e.g. hamstring/DLSTG) grafts is noted (as compared to patellar-tendon autografting), as is the very protracted ligamentization of allografts (cadaver grafts). The authors also note that patellar-tendon autografting is still the best choice of athletes and highly active people; it is also a good choice even for people who are not tremendously active. Hamstring autografting is considered to be not quite as good a choice if the person is very athletic; hamstring autografting brings the pronounced drawback of permanently hampered terminal knee flexion and permanent weakening of the hamstring group (remember that the hamstring group itself is important in protecting the ACL; this illustrates the very serious irony of harvesting hamstring tendons for ACL reconstruction). Also a must-read is the "Anterior Knee Pain" section, especially if you are concerned about pain while kneeling with the patellar-tendon autograft. Patellar-tendon autografting is renowned for its advantages of rapid and secure healing, characteristics which result from its having bone plugs at both ends. Allografting, as noted by subsequent authors (see, for example, Gorschewsky-AJSM-Aug05.shtml and Beynnon-AJSM-Oct05.shtml, both here in the Knee Library) is generally not considered to be the best choice (particularly for active people), given the higher risk of complications and graft failures (for which one cause is damage done or chemical residues left by allograft-disinfection procedures such as irradiation, chemical treatment, or cryogenic treatment), and also given the very protracted ligamentization period.

Abstract

The ideal graft for use in anterior cruciate ligament reconstruction should have structural and biomechanical properties similar to those of the native ligament, permit secure fixation and rapid biologic incorporation, and limit donor site morbidity. Many options have been clinically successful, but the ideal graft remains controversial. Graft choice depends on surgeon experience and preference, tissue availability, patient activity level, comorbidities, prior surgery, and patient preference. Patellar tendon autograft, the most widely used graft source, appears to be associated with an increased incidence of anterior knee pain compared with hamstring autograft. Use of hamstring autograft is increasing. Quadriceps tendon autograft is less popular but has shown excellent clinical results with low morbidity. Improved sterilization techniques have led to increased safety and availability of allograft, although allografts have a slower rate of incorporation than do most types of autograft. No graft has clearly been shown to provide a faster return to play. However, in general, patellar tendon autografts are preferable for high-performance athletes, and hamstring autografts and allografts have some relative advantages for lower-demand individuals. No current indications exist for synthetic ligaments.

To access the full text of this article, please click here.
There is no charge for viewing articles. However, a password is required.
If you do not already have a password, please e-mail Michael Frind at frind@execulink.com for one.
Prior to requesting a password, please make certain you have read the Site Terms of Use pertaining to this site.

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Copyright Journal of the American Academy of Orthopedic Surgeons, May 2005. For details regarding copyright as it applies to this page, please visit the page entitled Site Terms of Use and Aspects of Copyright on this site.

This website was created for the benefit of the world's largest knee-injury community, Bob's ACL WWWBoard (also known as the Kneeboard), accessible to everyone at http://factotem.org.

Documents posted on this site serve merely as a virtual library, and are intended solely for purposes of making access to high-quality peer-reviewed medical-journal articles convenient for all users of the Kneeboard. Knee-injury patients are hereby encouraged to discuss this material with their respective medical teams.

Site Terms of Use and Aspects of Copyright

Printing Hints and Tips