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Malige A, Baghdadi S, Hast MW, Schmidt EC, Shea KG, Ganley TJ. Biomechanical properties of common graft choices for anterior cruciate ligament reconstruction: A systematic review. Clin Biomech (Bristol, Avon) 2022; 95:105636. [PMID: 35428007 DOI: 10.1016/j.clinbiomech.2022.105636] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 03/21/2022] [Accepted: 03/25/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND This systematic review explores the differences in the intrinsic biomechanical properties of different graft sources used in anterior cruciate ligament (ACL) reconstruction as tested in a laboratory setting. METHODS Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, two authors conducted a systematic review exploring the biomechanical properties of ACL graft sources (querying PubMed, Cochrane, and Embase databases). Using the keywords "anterior cruciate ligament graft," "biomechanics," and "biomechanical testing," relevant articles of any level of evidence were identified as eligible and included if they reported on the biomechanical properties of skeletally immature or mature ACL grafts solely and if the grafts were studied in vitro, in isolation, and under similar testing conditions. Studies were excluded if performed on both skeletally immature and mature or non-human grafts, or if the grafts were tested after fixation in a cadaveric knee. For each graft, failure load, stiffness, Young's modulus, maximum stress, and maximum strain were recorded. FINDINGS Twenty-six articles were included. Most studies reported equal or increased biomechanical failure load and stiffness of their tested bone-patellar tendon-bone, hamstring, quadriceps, peroneus longus, tibialis anterior and posterior, Achilles, tensor fascia lata, and iliotibial band grafts compared to the native ACL. All recorded biomechanical properties had similar values between graft types. INTERPRETATION Most grafts used for ACL reconstruction are biomechanically superior to the native ACL. Utilizing a proper graft, combined with a standard surgical technique and a rigorous rehabilitation before and after surgery, will improve outcomes of ACL reconstruction.
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Affiliation(s)
- Ajith Malige
- St. Luke's University Health Network, Department of Orthopaedic Surgery, 801 Ostrum Street, Bethlehem, PA 18015, USA.
| | - Soroush Baghdadi
- Children's Hospital of Philadelphia Department of Orthopaedic Surgery 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Michael W Hast
- Biedermann Laboratory for Orthopaedic Research, University of Pennsylvania Department of Orthopaedic Surgery, 3737 Market Street 10th Floor, Suite 1050, Philadelphia, PA 19104, USA
| | - Elaine C Schmidt
- Biedermann Laboratory for Orthopaedic Research, University of Pennsylvania Department of Orthopaedic Surgery, 3737 Market Street 10th Floor, Suite 1050, Philadelphia, PA 19104, USA
| | - Kevin G Shea
- Stanford University Department of Orthopaedic Surgery 450 Broadway, Redwood City, CA 94063, USA
| | - Theodore J Ganley
- Children's Hospital of Philadelphia Department of Orthopaedic Surgery 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
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Goetz G, de Villiers C, Sadoghi P, Geiger-Gritsch S. Allograft for Anterior Cruciate Ligament Reconstruction (ACLR): A Systematic Review and Meta-Analysis of Long-Term Comparative Effectiveness and Safety. Results of a Health Technology Assessment. Arthrosc Sports Med Rehabil 2020; 2:e873-e891. [PMID: 33376999 PMCID: PMC7754611 DOI: 10.1016/j.asmr.2020.07.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 07/06/2020] [Indexed: 11/19/2022] Open
Abstract
Purpose To evaluate whether allograft anterior cruciate ligament reconstruction (ACLR) is superior or inferior to autograft ACLR or conservative management in terms of effectiveness and safety. Methods A systematic review of the evidence for allograft ACLR was conducted. Randomized controlled trials with a minimum mean follow-up time of 5 years were included. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the EUnetHTA-Core-Model were used as reporting standards. A meta-analysis was conducted for selected crucial outcomes using a random-effects model. The strength of the available evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. Results Six randomized trials were included comparing allograft with autograft. Patients were on average between 28 and 32.8 years of age (allograft group) and 28.9 and 31.7 years of age (autograft group). Based on the crucial outcomes, the meta-analyses showed no statistically significant differences in Lysholm score, Tegner score, and Cincinnati Knee Score between groups. A small statistical difference favoring autografts was found across studies in the subjective International Knee Documentation Committee score (–2.25; 95% confidence interval –3.02 to –1.47; I2 = 0%; range of all scores: 73.7-90). Two of six studies reported on graft failure, with a statistically significant difference to the detriment of using allografts (13/49 [26.5%] vs 4/48 [8.3%] in one study, 13/43 [30.2%] vs 3/40 [7.5%] in the other study). Conclusions Although no substantial difference in patient-reported function, activity level, and symptoms was demonstrated, evidence from the included studies showed a greater risk for graft failure or revision that may make allograft a less safe treatment modality in ACLR. The strength of available evidence is low based on the crucial outcomes due to the lack of high-quality research and the present increased risk of bias in primary studies. Priority should be shifted toward reflecting on whether there is a subpopulation for whom allograft ACLR may still be advantageous in theory (e.g., less-active older patients) and further conduct RCTs in this population. Level of Evidence Level II, systematic review of Level II evidence studies.
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Affiliation(s)
- Gregor Goetz
- HTA Austria - Austrian Institute for Health Technology Assessment GmbH (Former: Ludwig Boltzmann Institute for HTA), Vienna, Austria
- Address correspondence to Gregor Goetz, M.S.Sc., M.P.H., Garnisongasse 7/20, 1090 Vienna, Austria.
| | - Cecilia de Villiers
- HTA Austria - Austrian Institute for Health Technology Assessment GmbH (Former: Ludwig Boltzmann Institute for HTA), Vienna, Austria
| | - Patrick Sadoghi
- Department of Orthopaedics and Trauma, Medizinische Universität Graz, Graz, Austria
| | - Sabine Geiger-Gritsch
- HTA Austria - Austrian Institute for Health Technology Assessment GmbH (Former: Ludwig Boltzmann Institute for HTA), Vienna, Austria
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Sun Y, Lovric V, Wang T, Oliver RA, Walsh WR. Effects of SCCO 2, Gamma Irradiation, and Sodium Dodecyl Sulfate Treatments on the Initial Properties of Tendon Allografts. Int J Mol Sci 2020; 21:ijms21051565. [PMID: 32106592 PMCID: PMC7084268 DOI: 10.3390/ijms21051565] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/07/2020] [Accepted: 02/15/2020] [Indexed: 01/05/2023] Open
Abstract
Sterile and decellularized allograft tendons are viable biomaterials used in reconstructive surgeries for dense connective tissue injuries. Established allograft processing techniques including gamma irradiation and sodium dodecyl sulfate (SDS) can affect tissue integrity. Supercritical carbon dioxide (SCCO2) represents a novel alternative that has the potential to decellularize and sterilize tendons with minimized exposure to denaturants, shortened treatment time, lack of toxic residues, and superior tissue penetration, and thus efficacy. This study attempted to develop a single-step hybrid decellularization and sterilization protocol for tendons that involved SCCO2 treatment with various chemical additives. The processed tendons were evaluated with mechanical testing, histology, scanning electron microscopy (SEM), and Fourier-transform infrared (FTIR) spectroscopy. Uniaxial mechanical testing showed that tendons treated with SCCO2 and additive NovaKillTM Gen2 and 0.1% SDS had significantly higher (p < 0.05) ultimate tensile stress (UTS) and Young's modulus compared to gamma-irradiated and standard-SDS-treated tendons. This was corroborated by the ultrastructural intactness of SCCO2-treated tendons as examined by SEM and FTIR spectroscopy, which was not preserved in gamma-irradiated and standard SDS-treated tendons. However, complete decellularization was not achieved by the experimented SCCO2-SDS protocols used in this study. The present study therefore serves as a concrete starting point for development of an SCCO2-based combined sterilization and decellularization protocol for allograft tendons, where additive choice is to be optimized.
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Ishibashi Y, Adachi N, Koga H, Kondo E, Kuroda R, Mae T, Uchio Y. Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of anterior cruciate ligament injury - Secondary publication. J Orthop Sci 2020; 25:6-45. [PMID: 31843222 DOI: 10.1016/j.jos.2019.10.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 10/12/2019] [Accepted: 10/16/2019] [Indexed: 02/09/2023]
Abstract
BACKGROUND This clinical guideline presents recommendations for the management of patients with anterior cruciate ligament (ACL) injury, endorsed by the Japanese Orthopaedic Association (JOA) and Japanese Orthopaedic Society of Knee, Arthroscopy and Sports Medicine (JOSKAS). METHODS The JOA ACL guideline committee revised the previous guideline based on "Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014", which proposed a desirable method for preparing clinical guidelines in Japan. Furthermore, the importance of "the balance of benefit and harm" was also emphasized. This guideline consists of 21 clinical questions (CQ) and 23 background questions (BQ). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design. RESULTS We evaluated the objectives and results of each study in order to make a decision on the level of evidence so as to integrate the results with our recommendations for each CQ. For BQ, the guideline committee proposed recommendations based on the literature. CONCLUSIONS This guideline is intended to be used by physicians, orthopedic surgeons, physical therapists, and athletic trainers managing ACL injuries. We hope that this guideline is useful for appropriate decision-making and improved management of ACL injuries.
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Affiliation(s)
- Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Japan.
| | - Nobuo Adachi
- Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Japan
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Eiji Kondo
- Centre for Sports Medicine, Hokkaido University Hospital, Japan
| | - Ryosuke Kuroda
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Japan
| | - Tatsuo Mae
- Department of Sports Medical Biomechanics, Osaka University Graduate School of Medicine, Japan
| | - Yuji Uchio
- Department of Orthopaedic Surgery, Shimane University School of Medicine, Japan
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Ligamentäre Allografts in der Gelenkchirurgie. ARTHROSKOPIE 2019. [DOI: 10.1007/s00142-019-00316-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Hulet C, Sonnery-Cottet B, Stevenson C, Samuelsson K, Laver L, Zdanowicz U, Stufkens S, Curado J, Verdonk P, Spalding T. The use of allograft tendons in primary ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2019; 27:1754-1770. [PMID: 30830297 DOI: 10.1007/s00167-019-05440-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 02/22/2019] [Indexed: 12/16/2022]
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.
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Affiliation(s)
- Christophe Hulet
- Department of Orthopedics and Traumatology, Caen University Hospital, Avenue Cote de Nacre, 14000, Caen, France
| | - Bertrand Sonnery-Cottet
- Centre Orthopédique Santy, FIFA Medical Centre of Excellence, Groupe Ramsay-Générale de Santé, Hôpital Privé Jean Mermoz, Lyon, France
| | - Ciara Stevenson
- University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, UK
| | - Kristian Samuelsson
- Sahlgrenska University Hospital, Mölndal, Sweden
- Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lior Laver
- University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, UK
| | - Urszula Zdanowicz
- Carolina Medical Center, Pory 78, 02-757, Warsaw, Poland
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, 450 Technology Drive, Suite 300, Pittsburgh, PA, 15219-3110, USA
| | - Sjoerd Stufkens
- Academic Medical Center Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Jonathan Curado
- Department of Orthopedics and Traumatology, Caen University Hospital, Avenue Cote de Nacre, 14000, Caen, France
| | - Peter Verdonk
- Antwerp Orthopedic Center, Monica Hospitals, Antwerp, Belgium
| | - Tim Spalding
- University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, UK.
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Mistry H, Metcalfe A, Colquitt J, Loveman E, Smith NA, Royle P, Waugh N. Autograft or allograft for reconstruction of anterior cruciate ligament: a health economics perspective. Knee Surg Sports Traumatol Arthrosc 2019; 27:1782-1790. [PMID: 30874836 PMCID: PMC6541574 DOI: 10.1007/s00167-019-05436-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 02/20/2019] [Indexed: 01/15/2023]
Abstract
PURPOSE To assess the clinical and cost-effectiveness of allografts versus autografts in the reconstruction of anterior cruciate ligaments. METHODS Systematic review of comparative clinical effectiveness and cost-effectiveness analysis. RESULTS Both autograft and allograft reconstruction are highly effective. Recent studies show little difference in failure rates between autografts and allografts (about 6% and 7%, respectively). In cost-effectiveness analysis, the price differential is the main factor, making autografts the first choice. However, there will be situations, particularly in revision ACL reconstruction, where an allograft may be preferred, or may be the only reasonable option available. CONCLUSION In ACL reconstruction, clinical results with autografts are as good as or slightly better than with allografts. Allografts cost more, indicating that autografts are more cost-effective and should usually be first choice. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Hema Mistry
- Division of Health Sciences, Warwick Medical School, Gibbet Hill Campus, University of Warwick, Coventry, CV4 7AL, UK.
| | - Andrew Metcalfe
- Warwick Clinical Trials Unit, University of Warwick Medical School, Coventry, CV4 7AL, UK
| | - Jill Colquitt
- Effective Evidence, Waterlooville, Hampshire, PO8 9SE, UK
| | - Emma Loveman
- Effective Evidence, Waterlooville, Hampshire, PO8 9SE, UK
| | - Nick A Smith
- Department of Orthopaedics, University Hospitals Coventry and Warwickshire, Coventry, CV2 2DX, UK
| | - Pamela Royle
- Division of Health Sciences, Warwick Medical School, Gibbet Hill Campus, University of Warwick, Coventry, CV4 7AL, UK
| | - Norman Waugh
- Division of Health Sciences, Warwick Medical School, Gibbet Hill Campus, University of Warwick, Coventry, CV4 7AL, UK
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Issın A, Öner A, Sofu H, Yurten H. Comparison of freeze-dried tibialis anterior allograft and four-strand hamstring autograft in anterior cruciate ligament reconstruction. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2019; 53:45-49. [PMID: 30243835 PMCID: PMC6424693 DOI: 10.1016/j.aott.2018.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 08/12/2018] [Accepted: 08/29/2018] [Indexed: 01/15/2023]
Abstract
PURPOSE The aim of this retrospective study was to evaluate the clinical outcomes of the patients who underwent primary anterior cruciate ligament (ACL) reconstruction surgery with either hamstring autograft or freeze-dried tibialis anterior allograft, which performed by the same surgeon using the same fixation technique. METHODS In this retrospective study, patients who had primary ACL reconstruction using either four-strand hamstring autograft (FSH) or freeze-dried irradiated tibialis anterior allograft (FDT) between 2012 and 2015 were evaluated. Patients who were skeletally mature with a minimum follow-up of 24 months and who had no previous surgery from the affected knee were included; patients who had multiple ligament injuries or chondral lesions over Outerbridge grade 2 were excluded from the study. Patients were grouped according to the graft type used in ACL reconstruction. Tegner activity scale and Lysholm knee scoring scale were used to assess patients' activity levels and functional status preoperatively and at the final follow-up. KT-2000 arthrometer measurements were done at the final follow-up to evaluate anterior laxity. RESULTS There were 27 patients (mean age 27 ± 8.9 years) in the FSH group and 36 patients (mean age 27.1 ± 6.7 years) in the FDT group. The mean follow-up time was 38.2 ± 3.5 months for the FSH group and 41 ± 6.1 months for the FDT group. There were no statistically significant differences between the groups when preoperative and postoperative Tegner-Lysholm scores were compared (Tegner P = 0.583, 0.742; Lysholm P = 0.592, 0.249). The mean anteroposterior laxity and side-to-side differences measured by KT-2000 were 4.1 mm and 2.1 mm for the FSH group, respectively; 4.2 mm and 2.2 mm for the FDT group, respectively. There was not a statistically significant difference (P = 0.745, 0.562 respectively). CONCLUSIONS Primary ACL reconstruction with a single loop freeze-dried irradiated tibialis anterior allograft revealed comparable results with four-strand hamstring autograft in non-athlete patients. LEVEL OF EVIDENCE Level III, Therapeutic study.
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Wang S, Zhang C, Cai Y, Lin X. Autograft or Allograft? Irradiated or Not? A Contrast Between Autograft and Allograft in Anterior Cruciate Ligament Reconstruction: A Meta-analysis. Arthroscopy 2018; 34:3258-3265. [PMID: 30396800 DOI: 10.1016/j.arthro.2018.06.053] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 06/21/2018] [Accepted: 06/25/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the clinical outcomes and adverse events associated with irradiated and nonirradiated allografts in anterior cruciate ligament (ACL) reconstruction. METHODS PubMed, Web of Science, and EMBASE were searched for randomized controlled trials from January 1990 to March 2018 to compare autograft with allograft in ACL reconstruction. Both objective and subjective outcomes of the function and adverse events were meta-analyzed. Two comparisons were summarized: (1) autograft and nonirradiated allograft and (2) autograft and irradiated allograft. The bias risk was based on the Cochrane Handbook for Systematic Reviews of Interventions. The overall risk ratio or weighted mean difference was calculated using a fixed- or random-effects model. Heterogeneity between studies was evaluated by the Q and the I2 statistics. RESULTS Eleven trials were included in this review for meta-analysis. A total of 1,172 patients were involved (465 autograft and 461 nonirradiated allograft; 141 autograft and 138 irradiated allograft patients). The average follow-up varied from 2 to >10 years. The mean patient age varied from 22 to 32.8 years. The total failure rate was 2.5%. Our analyses demonstrated better clinical outcomes in autograft than irradiated allograft, which could be observed clearly through the International Knee Documentation Committee score (3.84; 95% confidence interval [CI], 1.93-5.76; P < .0001; I2 = 0%), Lysholm score (2.94; 95% CI, 0.66-5.22; P = .01; I2 = 0%), and Tegner score (0.14; 95% CI, -0.08 to 0.36; P = .22; I2 = 0%) with fewer adverse events 0.20 (95% CI, 0.11-0.39; P < .00001; I2 = 0%). There were no significant differences in autograft and nonirradiated allograft groups (P = .47, P = .27, P = .24, and P = .24, respectively). CONCLUSIONS Autograft offered greater advantages in functional outcomes and adverse events than irradiated allograft in ACL reconstruction; however, there were no significant differences between autograft and nonirradiated allograft in ACL reconstruction. LEVEL OF EVIDENCE Level II, meta-analysis of Level I and Level II studies.
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Affiliation(s)
- ShuaiYi Wang
- Center for Sport Medicine, First Affiliated Hospital, College of Medicine Zhejiang University, Hangzhou, China
| | - Chi Zhang
- Center for Sport Medicine, First Affiliated Hospital, College of Medicine Zhejiang University, Hangzhou, China
| | - YouZhi Cai
- Center for Sport Medicine, First Affiliated Hospital, College of Medicine Zhejiang University, Hangzhou, China
| | - XiangJin Lin
- Center for Sport Medicine, First Affiliated Hospital, College of Medicine Zhejiang University, Hangzhou, China.
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Belk JW, Kraeutler MJ, Purcell JM, McCarty EC. Autograft Versus Allograft for Posterior Cruciate Ligament Reconstruction: An Updated Systematic Review and Meta-analysis. Am J Sports Med 2018. [PMID: 28636429 DOI: 10.1177/0363546517713164] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Multiple studies have demonstrated a higher risk of graft failure after anterior cruciate ligament reconstruction with allograft, but limited data are available comparing outcomes of posterior cruciate ligament reconstruction (PCLR) with autograft versus allograft. PURPOSE To compare the clinical outcomes of autograft versus allograft for primary PCLR. STUDY DESIGN Systematic review. METHODS A systematic review was performed by searching PubMed, the Cochrane Library, and EMBASE to locate studies (level of evidence I-III) comparing clinical outcomes of autograft versus allograft in patients undergoing primary PCLR with the conventional transtibial technique. Search terms used were "posterior cruciate ligament," "autograft," and "allograft." Patients were evaluated based on graft failure rate, examination of knee laxity, and patient-reported outcome scores (Lysholm, Tegner, subjective International Knee Documentation Committee [IKDC], and objective IKDC scores). RESULTS Five studies (2 level II, 3 level III) were identified that met inclusion criteria, including a total of 132 patients undergoing PCLR with autograft (semitendinosus-gracilis or bone-patellar tendon-bone) and 110 patients with allograft (tibialis anterior, Achilles tendon, or bone-patellar tendon-bone). No patients experienced graft failure. Average anteroposterior (AP) knee laxity was significantly higher in allograft patients (3.8 mm) compared with autograft patients (3.1 mm) ( P < .01). Subjective IKDC, Lysholm, and Tegner scores improved for both groups across studies, without a significant difference in improvement between groups except in one study, in which Lysholm scores improved to a significantly greater extent in the autograft group ( P < .01). CONCLUSION Patients undergoing primary PCLR with either autograft or allograft can be expected to experience improvement in clinical outcomes. Autograft patients experienced less AP knee laxity postoperatively, although the clinical significance of this is unclear and subjective outcomes improved substantially and to a similar degree in both groups.
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Affiliation(s)
- John W Belk
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Matthew J Kraeutler
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Justin M Purcell
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Eric C McCarty
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, USA
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Houck DA, Kraeutler MJ, Vidal AF, McCarty EC, Bravman JT, Wolcott ML. Variance in Anterior Cruciate Ligament Reconstruction Graft Selection based on Patient Demographics and Location within the Multicenter Orthopaedic Outcomes Network Cohort. J Knee Surg 2018; 31:472-478. [PMID: 28701007 PMCID: PMC5780252 DOI: 10.1055/s-0037-1604147] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The purpose of this study is to determine whether any regional or age-related patterns exist in graft choice for patients undergoing primary anterior cruciate ligament reconstruction (ACLR) within a large multicenter consortium. A retrospective cohort study was performed using data collected from the Multicenter Orthopaedic Outcomes Network (MOON) on patients having undergone primary ACLR. Patients were stratified by age group (younger than 20, 20-29, 30-39, 40-49, and 50+ years) and four demographic regions (Midwest, Southeast, Northeast, and West). A total of 2,149 patients (1,288 males, 861 females) were included. At least 70% of the patients were treated by a single surgeon in three of the four demographic regions. There were no clinically significant differences in body mass index (BMI), and no statistically significant differences in Marx activity rating scale (p > 0.05) between regions within any particular age group. There were significant differences in the proportion of autografts versus allografts used for primary ACLR between regions in every age group (p < 0.01). There were also significant differences in autograft (p < 0.001) and allograft (p < 0.001) harvest location based on demographic region. The Southeast and Northeast were more likely to use bone-patellar-tendon-bone autograft while the West and Midwest were likely to use hamstring autograft. Within our consortium, regional patterns exist both in autograft versus allograft use in patients undergoing primary ACLR, as well as harvest location of autografts and allografts. Given the similarities in average patient BMI and activity level between regions, as well as the single surgeon influence in three of the four regions, the regional patterns in graft use are likely due to surgeon preference.
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Affiliation(s)
- Darby A Houck
- CU Sports Medicine and Performance Center, Boulder, CO 80309
| | | | - Armando F Vidal
- CU Sports Medicine and Performance Center, Boulder, CO 80309,MOON Knee Group, Vanderbilt University Medical Center, 1215 21st Avenue South, MCE, South Tower, Suite 4200, Nashville, TN 37232
| | - Eric C McCarty
- CU Sports Medicine and Performance Center, Boulder, CO 80309,MOON Knee Group, Vanderbilt University Medical Center, 1215 21st Avenue South, MCE, South Tower, Suite 4200, Nashville, TN 37232
| | | | - MOON Knee Group
- MOON Knee Group, Vanderbilt University Medical Center, 1215 21st Avenue South, MCE, South Tower, Suite 4200, Nashville, TN 37232
| | - Michelle L Wolcott
- CU Sports Medicine and Performance Center, Boulder, CO 80309,MOON Knee Group, Vanderbilt University Medical Center, 1215 21st Avenue South, MCE, South Tower, Suite 4200, Nashville, TN 37232
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14
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Wang HD, Zhu YB, Wang TR, Zhang WF, Zhang YZ. Irradiated allograft versus autograft for anterior cruciate ligament reconstruction: A meta-analysis and systematic review of prospective studies. Int J Surg 2018; 49:45-55. [DOI: 10.1016/j.ijsu.2017.12.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 11/18/2017] [Accepted: 12/08/2017] [Indexed: 01/15/2023]
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Grassi A, Nitri M, Moulton SG, Marcheggiani Muccioli GM, Bondi A, Romagnoli M, Zaffagnini S. Does the type of graft affect the outcome of revision anterior cruciate ligament reconstruction? a meta-analysis of 32 studies. Bone Joint J 2017; 99-B:714-723. [PMID: 28566389 DOI: 10.1302/0301-620x.99b6.bjj-2016-0929.r2] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 02/16/2017] [Indexed: 01/02/2023]
Abstract
AIMS Our aim was to perform a meta-analysis of the outcomes of revision anterior cruciate ligament (ACL) reconstruction, comparing the use of different types of graft. MATERIALS AND METHODS A search was performed of Medline and Pubmed using the terms "Anterior Cruciate Ligament" and "ACL" combined with "revision", "re-operation" and "failure". Only studies that reported the outcome at a minimum follow-up of two years were included. Two authors reviewed the papers, and outcomes were subdivided into autograft and allograft. Autograft was subdivided into hamstring (HS) and bone-patellar tendon-bone (BPTB). Subjective and objective outcome measures were analysed and odds ratios with confidence intervals were calculated. RESULTS A total of 32 studies met the inclusion criteria. Five studies used HS autografts, eight reported using BPTB autografts, two used quadriceps tendon autografts and eight used various types. Seven studies reported using allografts, while the two remaining used both BPTB autografts and allografts. Overall, 1192 patients with a mean age of 28.7 years (22.5 to 39) and a mean follow-up of 5.4 years (2.0 to 9.6) were treated with autografts, while 269 patients with a mean age of 28.4 years (25 to 34.6) and a mean follow-up of 4.0 years (2.3 to 6.0) were treated with allografts. Regarding allografts, irradiation with 2.5 mrad was used in two studies while the graft was not irradiated in the seven remaining studies. Reconstructions following the use of autografts had better outcomes than those using allograft with respect to laxity, measured by KT-1000/2000 (MEDmetric Corporation) and the rates of complications and re-operations. Those following the use of allografts had better mean Lysholm and Tegner activity scores compared with autografts. If irradiated allografts were excluded from the analysis, outcomes no longer differed between the use of autografts and allografts. Comparing the types of autograft, all outcomes were similar except for HS grafts which had better International Knee Documentation Committee scores compared with BPTB grafts. CONCLUSION Autografts had better outcomes than allografts in revision ACL reconstruction, with lower post-operative laxity and rates of complications and re-operations. However, after excluding irradiated allografts, outcomes were similar between autografts and allografts. Overall, the choice of graft at revision ACL reconstruction should be on an individual basis considering, for instance, the preferred technique of the surgeon, whether a combined reconstruction is required, the type of graft that was previously used, whether the tunnels are enlarged and the availability of allograft. Cite this article: Bone Joint J 2017;99-B:714-23.
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Affiliation(s)
- A Grassi
- Orthopedic Institute Rizzoli, 90011 Bologna, Italy
| | - M Nitri
- Orthopedic Institute Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy
| | - S G Moulton
- Oregon Health & Science University, 3181 SW, Sam Jackson Park Rd, Portland, Oregon, USA
| | | | - A Bondi
- Orthopedic Institute Rizzoli, 90011 Bologna, Italy
| | - M Romagnoli
- Orthopedic Institute Rizzoli, 90011 Bologna, Italy
| | - S Zaffagnini
- Orthopedic Institute Rizzoli, 90011 Bologna, Italy
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van der List JP, DiFelice GS. Range of motion and complications following primary repair versus reconstruction of the anterior cruciate ligament. Knee 2017; 24:798-807. [PMID: 28549818 DOI: 10.1016/j.knee.2017.04.007] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 03/20/2017] [Accepted: 04/05/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Recently, there has been a resurgence of interest in primary anterior cruciate ligament (ACL) repair. The procedure is less invasive than ACL reconstruction, yet studies assessing early postoperative course are lacking. Goal therefore was to assess postoperative range of motion (ROM), complications and operative times following primary repair and compare this to the gold standard of reconstruction. METHODS A retrospective study was performed for which 52 repair and 90 reconstruction patients could be included. Patients were examined at one week and one, three and six months. Rehabilitation protocol consisted of early ROM and was equal for both groups. Outcomes were compared using independent t-tests and chi-square tests, and reported in mean±standard deviation. RESULTS Repair had more ROM than reconstruction patients at one week (89°±18 vs. 61°±21, p<0.01) and one month (125°±14 vs. 116°±18, p < 0.01) postoperatively. Fewer repair patients had 90° ROM at one week (23% vs. 84%, p<0.01), and more repair patients had full ROM at one month (57% vs. 30%, p<0.01). Treatment of meniscal lesions, but not chondral lesions, influenced ROM. Trends towards fewer complications (2% vs. 9%, p=0.19) and infections (0% vs. 6%, p=0.20) were noted following primary repair, and the procedure was significantly shorter. CONCLUSIONS Following primary repair, patients had better ROM, and trends towards fewer complications than reconstruction. Primary repair is a safe, brief procedure with early ROM and low complication rates.
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Affiliation(s)
- Jelle P van der List
- Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, NewYork-Presbyterian, Weill Medical College of Cornell University, New York, NY, United States.
| | - Gregory S DiFelice
- Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, NewYork-Presbyterian, Weill Medical College of Cornell University, New York, NY, United States
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Palmer JE, Russell JP, Grieshober J, Iacangelo A, Ellison BA, Lease TD, Kim H, Henn RF, Hsieh AH. A Biomechanical Comparison of Allograft Tendons for Ligament Reconstruction. Am J Sports Med 2017; 45:701-707. [PMID: 28272925 DOI: 10.1177/0363546516671944] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Allograft tendons are frequently used for ligament reconstruction about the knee, but they entail availability and cost challenges. The identification of other tissues that demonstrate equivalent performance to preferred tendons would improve limitations. Hypothesis/Purpose: We compared the biomechanical properties of 4 soft tissue allograft tendons: tibialis anterior (TA), tibialis posterior (TP), peroneus longus (PL), and semitendinosus (ST). We hypothesized that allograft properties would be similar when standardized by the looped diameter. STUDY DESIGN Controlled laboratory study. METHODS This study consisted of 2 arms evaluating large and small looped-diameter grafts: experiment A consisted of TA, TP, and PL tendons (n = 47 each) with larger looped diameters of 9.0 to 9.5 mm, and experiment B consisted of TA, TP, PL, and ST tendons (n = 53 each) with smaller looped diameters of 7.0 to 7.5 mm. Each specimen underwent mechanical testing to measure the modulus of elasticity (E), ultimate tensile force (UTF), maximal elongation at failure, ultimate tensile stress (UTS), and ultimate tensile strain (UTε). RESULTS Experiment A: No significant differences were noted among tendons for UTF, maximal elongation at failure, and UTϵ. UTS was significantly higher for the PL (54 MPa) compared with the TA (44 MPa) and TP (43 MPa) tendons. E was significantly higher for the PL (501 MPa) compared with the TP (416 MPa) tendons. Equivalence testing showed that the TP and PL tendon properties were equivalent or superior to those of the TA tendons for all outcomes. Experiment B: All groups exhibited a similar E. UTF was again highest in the PL tendons (2294 N) but was significantly different from only the ST tendons (1915 N). UTϵ was significantly higher for the ST (0.22) compared with the TA (0.19) and TP (0.19) tendons. Equivalence testing showed that the TA, TP, and PL tendon properties were equivalent or superior to those of the ST tendons. CONCLUSION Compared with TA tendons, TP and PL tendons of a given looped diameter exhibited noninferior initial biomechanical strength and stiffness characteristics. ST tendons were mostly similar to TA tendons but exhibited a significantly higher elongation/UTϵ and smaller cross-sectional area. For smaller looped-diameter grafts, all tissues were noninferior to ST tendons. In contrast to previous findings, PL tendons proved to be equally strong. CLINICAL RELEVANCE The results of this study should encourage surgeons to use these soft tissue allografts interchangeably, which is important as the number of ligament reconstructions performed with allografts continues to rise.
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Affiliation(s)
- Jeremiah E Palmer
- Department of Orthopaedics, University of Maryland, Baltimore, Baltimore, Maryland, USA
| | - Joseph P Russell
- Fischell Department of Bioengineering, University of Maryland, College Park, College Park, Maryland, USA
| | - Jason Grieshober
- Department of Orthopaedics, University of Maryland, Baltimore, Baltimore, Maryland, USA
| | - Abigail Iacangelo
- Fischell Department of Bioengineering, University of Maryland, College Park, College Park, Maryland, USA
| | - Benjamin A Ellison
- Fischell Department of Bioengineering, University of Maryland, College Park, College Park, Maryland, USA
| | - T Dylan Lease
- Fischell Department of Bioengineering, University of Maryland, College Park, College Park, Maryland, USA
| | - Hyunchul Kim
- Fischell Department of Bioengineering, University of Maryland, College Park, College Park, Maryland, USA
| | - R Frank Henn
- Department of Orthopaedics, University of Maryland, Baltimore, Baltimore, Maryland, USA
| | - Adam H Hsieh
- Department of Orthopaedics, University of Maryland, Baltimore, Baltimore, Maryland, USA.,Fischell Department of Bioengineering, University of Maryland, College Park, College Park, Maryland, USA
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