Arthroscopic posterior cruciate ligament reconstruction with allograft versus autograft

Allografts as alternative to autografts in primary posterior cruciate ligament reconstruction: a systematic review and meta-analysis

PURPOSE

Following posterior cruciate ligament (PCL) rupture, autografts and allografts are routinely used for its reconstruction. This study investigated the efficacy and safety of allografts for primary PCL reconstruction, comparing them to autografts in terms of patient-reported outcome measures (PROMs), functional tests, and complications.

METHODS

This study followed the PRISMA guidelines. PubMed, Web of Science, Google Scholar, Embase, and Scopus were accessed in October 2022. All the clinical studies investigating the outcomes of primary PCL reconstruction using allografts, or comparing the outcomes of allografts versus autografts, were accessed. The outcomes of interests were: instrumental laxity, range of motion (ROM), Telos stress radiography, drawer test, International Knee Documentation Committee (IKDC), Tegner Activity Scale, and the Lysholm Knee Scoring Scale. Data on complications were also recorded.

RESULTS

A total of 445 patients were included. The mean follow-up was 45.2 ± 23.8 months. The mean age of the patients was 30.6 ± 2.2 years. The time span between the injury and surgical intervention was 12.9 ± 10 months. Overall, 28% (125 of 445 patients) were women. Good baseline comparability was found between the two cohorts. No difference was found in terms of Lysholm Score, ROM, Tegner Scale, IKDC, arthrometer laxity, drawer test, and Telos stress radiography. No difference was found in the rates of anterior knee pain and revision.

CONCLUSION

Allografts can be considered a suitable alternative to autografts for PCL reconstruction.

LEVEL OF EVIDENCE

III.

Global variation in isolated posterior cruciate ligament reconstruction

Purpose

In the setting of persistent instability or failed non-operative management, surgical reconstruction is commonly recommended for isolated posterior cruciate ligament (PCL) tears. The purpose of this study was to systematically review published studies to evaluate regional variation in the epidemiology of and surgical approaches to primary, isolated PCL reconstruction.

Methods

A systematic review was performed in June 2022 to identify studies examining operative techniques during primary, isolated PCL reconstruction. Collected variables consisted of reconstruction technique, graft type, graft source, tibial reconstruction technique, femoral and tibial drilling and fixation methods, and whether the remnant PCL was preserved or debrided. Studies were classified into four global regions: Asia, Europe, North America, and South America.

Results

Forty-five studies, consisting of 1461 total patients, were identified. Most of the included studies were from Asia (69%, n = 31/45). Single bundle reconstruction was more commonly reported in studies out of Asia, Europe, and North America. Hamstring autografts were utilized in 51.7% (n = 611/1181) of patients from Asia and 60.8% (n = 124/204) of patients from Europe. Trans-tibial drilling and outside-in femoral drilling were commonly reported in all global regions. The PCL remnant was generally debrided, while remnant preservation was commonly reported in studies from Asia.

Conclusion

Surgical treatment of isolated PCL injuries varies by region, with the majority of published studies coming from Asia. Single-bundle reconstruction with hamstring autograft through a trans-tibial approach is the most commonly reported technique in the literature, with males reported to undergo isolated reconstruction more often than females.

Level of Evidence

Systematic review, Level IV.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40634-022-00541-4.

Ligament Advanced Reinforcement System (LARS) synthetic graft for PCL reconstruction: systematic review and meta-analysis

INTRODUCTION

Several strategies are available for posterior cruciate ligament (PCL) reconstruction.

SOURCE OF DATA

Recently published literature in PubMed, Google Scholar and Embase databases.

AREAS OF AGREEMENT

The Ligament Advanced Reinforcement System (LARS) is a scaffold type artificial ligament, which has been widely used for ligament reconstruction of the knee.

AREAS OF CONTROVERSY

Current evidence on the reliability and feasibility of LARS for primary isolated PCL reconstruction is limited.

GROWING POINTS

The primary outcome of interest of the present work was to investigate the outcomes of PCL reconstruction using the LARS. The secondary outcome of interest was to compare the LARS versus four-strand hamstring tendon (4SHT) autograft for PCL reconstruction.

AREAS TIMELY FOR DEVELOPING RESEARCH

LARS for primary isolated PCL reconstruction seems to be effective and safe, with results comparable to the 4SHT autograft.

Hamstring, bone-patellar tendon-bone, quadriceps and peroneus longus tendon autografts for primary isolated posterior cruciate ligament reconstruction: a systematic review

INTRODUCTION

Several autografts are available to reconstruct the posterior cruciate ligament (PCL).

SOURCE OF DATA

Current scientific literature published in PubMed, Google scholar, Embase and Scopus.

AREAS OF AGREEMENT

Hamstring, bone-patellar tendon-bone (BPTB), quadriceps and peroneus longus (PLT) are the most common tendon autografts used for primary isolated PCL reconstruction.

AREAS OF CONTROVERSY

The optimal tendon source for PCL reconstruction remains nevertheless debated. Identifying the most suitable tendon autograft could assist the surgeon during primary PCL reconstruction.

GROWING POINTS

The present study compared the outcome of PCL reconstruction using hamstring, BPTB, quadriceps and PLT autografts. The focus was on patient-reported outcome measures (PROMs), joint laxity, range of motion and complications.

AREAS TIMELY FOR DEVELOPING RESEARCH

All autografts are viable options for PCL reconstruction, with BTB and hamstring autografts demonstrating superior PROMs. However, further clinical investigations are required to determine the ideal autograft construct.

Single versus double bundle in posterior cruciate ligament (PCL) reconstruction: a meta-analysis

Posterior cruciate ligament (PCL) reconstruction can be performed using single bundle (SB) and double bundle (DB) techniques. The present study investigated whether DB PCL reconstruction is superior to SB reconstruction in terms of patient reported outcome measures (PROMs) and joint stability. In December 2021 Embase, Google Scholar, Pubmed, Scopus databases were accessed. All clinical trials comparing SB versus DB reconstruction to address PCL insufficiency in skeletally mature patients were considered. Data from 483 procedures were retrieved. The mean follow-up was 31.0 (28.0 to 107.6) months, and the mean timespan between injury and surgery was 11.3 (6 to 37) months. The mean age of the patients was 29.3 ± 3.8 years. 85 of 483 patients (18%) were women. At a mean of 31.0 months post reconstruction, ROM (P = 0.03) was slightly greater in the SB group, while the Tegner score (P = 0.03) and the Telos stress (P = 0.04) were more favorable in the DB cohort. Similarity was found in instrumental laxity (P = 0.4) and Lysholm score (P = 0.3). The current evidence does not support the use of DB techniques for PCL reconstruction. Both methods could restore knee stability and motion with satisfactory short term patient reported outcome measures. Further high quality clinical trials are required to validate these results on a larger scale.

Evolving evidence in the treatment of primary and recurrent posterior cruciate ligament injuries, part 2: surgical techniques, outcomes and rehabilitation

Isolated and combined posterior cruciate ligament (PCL) injuries are associated with severe limitations in daily, professional, and sports activities as well as with devastating long-term effects for the knee joint. As the number of primary and recurrent PCL injuries increases, so does the body of literature, with high-quality evidence evolving in recent years. However, the debate about the ideal treatment approach such as; operative vs. non-operative; single-bundle vs. double-bundle reconstruction; transtibial vs. tibial inlay technique, continues. Ultimately, the goal in the treatment of PCL injuries is restoring native knee kinematics and preventing residual posterior and combined rotatory knee laxity through an individualized approach. Certain demographic, anatomical, and surgical risk factors for failures in operative treatment have been identified. Failures after PCL reconstruction are increasing, confronting the treating surgeon with challenges including the need for revision PCL reconstruction. Part 2 of the evidence-based update on the management of primary and recurrent PCL injuries will summarize the outcomes of operative and non-operative treatment including indications, surgical techniques, complications, and risk factors for recurrent PCL deficiency. This paper aims to support surgeons in decision-making for the treatment of PCL injuries by systematically evaluating underlying risk factors, thus preventing postoperative complications and recurrent knee laxity. LEVEL OF EVIDENCE: V.

The lower trapezius transfer: a systematic review of biomechanical data, techniques, and clinical outcomes

BACKGROUND

Lower trapezius (LT) transfers were originally described to restore external rotation (ER) in the management of brachial plexus palsy; however, there is recent interest in the role of this transfer to restore shoulder function, specifically ER, in patients with a massive irreparable rotator cuff tear (RCT). The purpose of this systematic review is to summarize the current literature pertaining to LT transfers, including biomechanics, techniques, and clinical outcomes for patients with brachial plexus palsy and massive RCTs.

METHODS

MEDLINE, EMBASE, and PubMed were searched for biomechanical and clinical studies, as well as technique articles. Four biomechanical studies reported on moment arms, range of motion (ROM), and force vectors. Seven clinical studies reported postoperative ROM and functional outcomes, and weighted mean improvements in ROM were calculated.

RESULTS

Overall, 18 studies were included, and then subdivided into 3 themes: biomechanical, technique, and clinical. Biomechanical studies comparing LT and latissimus dorsi (LD) transfers observed an overall larger moment arm in abduction and ER in adduction for the LT transfer, with similar results in forward elevation. Clinical studies noted significant improvement in shoulder function following the LT transfer, including ROM and functional outcome scores. There were several described techniques for performing the LT transfer, including arthroscopically assisted and open approaches, and the use of both allograft and autograft augmentation.

CONCLUSION

This study suggests that the LT transfer is generally safe, and the clinical and biomechanical data to date support the use of the LT transfer for restoration of function in these challenging patient populations.

The use of allograft tissue in posterior cruciate, collateral and multi-ligament knee reconstruction

PURPOSE

Currently both autograft and allograft tissues are available for reconstruction of posterior cruciate, collateral and multi-ligament knee injuries. Decision-making is based on a complex interplay between anatomical structures, functional bundles and varying biomechanical requirements. Despite theoretically better biological healing and reduced risk of disease transmission autografts are associated with donor site morbidity as well as being limited by size and quantity. The use of allografts eliminates donor-site morbidity but raises cost and issues of clinical effectiveness. The purpose of this paper is to review current concepts and evidence for the use of allografts in primary posterior cruciate, collateral and multi-ligament reconstructions.

METHODS

A narrative review of the relevant literature was conducted for PCL, collateral ligament and multi-ligament knee reconstruction. Studies were identified using a targeted and systematic search with focus on recent comparative studies and all clinical systematic reviews and meta-analyses. The rationale and principles of management underpinning the role of allograft tissue were identified and the clinical and functional outcomes were analysed. Finally, the position of postoperative physiotherapy and rehabilitation was identified.

RESULTS

The review demonstrated paucity in high quality and up-to-date results addressing the issue especially on collaterals and multi-ligament reconstructions. There was no significant evidence of superiority of a graft type over another for PCL reconstruction. Contemporary principles in the management of posterolateral corner, MCL and multi-ligament injuries support the use of allograft tissue.

CONCLUSION

The present review demonstrates equivalent clinical results with the use of autografts or allografts. It remains, however, difficult to generate a conclusive evidence-based approach due to the paucity of high-level research. When confronted by the need for combined reconstructions with multiple grafts, preservation of synergistic muscles, and adapted postoperative rehabilitation; the current evidence does offer support for the use of allograft tissue.

LEVEL OF EVIDENCE

IV.

Influence of Graft Source on Postoperative Activity and Joint Laxity in Posterior Cruciate Ligament Reconstruction: A Systematic Review

PURPOSE

To compare the clinical and functional outcomes of allograft and autograft reconstruction in patients with posterior cruciate ligament (PCL) deficiency.

METHODS

The MEDLINE, Embase, and Cochrane Library databases were used to identify all relevant articles. Clinical outcomes including International Knee Documentation Committee, Tegner, and Lysholm scores; joint laxity; and posterior tibial displacement were evaluated.

RESULTS

Among the 145 unique articles identified during the title screening, 25 studies published between 2002 and 2016 with a combined population of 900 patients were deemed eligible for inclusion in the review. Of the 900 patients, 603 were treated with autograft and 297 were treated with allograft PCL reconstruction. Five of the included studies directly compared autograft and allograft PCL reconstruction. Most studies found postoperative functional outcomes and joint laxity to improve postoperatively regardless of graft source. With only 1 exception, the included comparative studies found no significant postoperative difference in any of the functional outcome scores between patients treated with allograft and those treated with autograft. Two comparative studies found autograft reconstruction to result in significantly less posterior laxity than in the allograft group, whereas 2 comparative studies found no significant difference in posterior laxity between the 2 groups.

CONCLUSIONS

PCL reconstruction results in improved functional outcome scores and joint laxity regardless of graft source. Current studies suggest there is no significant difference in postoperative functional outcomes between patients treated with autograft and those treated with allograft. Patients treated with autograft have donor-site morbidity that is not associated with allograft reconstruction. Some evidence suggests that autograft reconstruction may result in reduced posterior laxity relative to allograft reconstruction. The magnitude of this finding, however, may not be clinically significant. Our review found that decision making based on the current literature is at high risk of potential bias. LEVEL OF EVIDENCE: Level IV, systematic review of Level I to IV studies.

Allografts in reconstruction of the posterior cruciate ligament: a health economics perspective

PURPOSE

To review the relative cost-effectiveness of allografts and autografts in reconstruction of the posterior cruciate ligament.

METHODS

Systematic review and cost-effectiveness analysis.

RESULTS

The available evidence does not show any significant difference in clinical effectiveness between autografts and allografts. Given that, only a cost analysis is provided, which shows that allografts are more costly.

CONCLUSION

Given the lack of any benefit of allografts over autografts, autografts should be preferred on cost grounds, if available. However, there may be situations where an allograft is indicated, for example, in multiple ligament reconstructions.

LEVEL OF EVIDENCE

IV.

Graft sources do not affect to the outcome of transtibial posterior cruciate ligament reconstruction: a systematic review

INTRODUCTION

Despite numerous published reports on posterior cruciate ligament (PCL) reconstruction in the past 30 years, the ideal graft source remains unclear, and few objective scientific data have been published that thoroughly evaluate the long-term outcomes according to the graft source. We, therefore, conducted a systematic review of available high-quality comparative studies that evaluated clinical and objective stability testing to compare the different graft sources for PCL reconstruction.

MATERIALS AND METHODS

Eight articles were included in the final analysis. There were two level II and six level III studies. Autograft included 4-strand hamstring grafts (SHGs), 7-SHGs, quadriceps tendon, and patellar tendon. Allografts included Achilles tendon and tibialis anterior tendon. Hybrid graft and a ligament advanced reinforcement system (LARS) were used in one study each. Comparison was performed between autografts and allografts in three studies, between different autografts in two studies, between autograft and LARS in one study, among three different grafts in one study, and between 4 and 7-SHGs in one study.

RESULTS

Most studies reported no statistically significant differences in the clinical results, except for one study that compared 4- and 7-SHG. Stability was similar or superior in a comparison between autografts and allografts, and was not statistically different between different autografts or between 4-SHG and LARS. However, more-stranded HG showed better stability than that of the less-stranded HG. Complications were more frequent with autografts.

CONCLUSION

Using a comprehensive analysis of the current literature, the authors could not identify an individual graft source with clearly superior clinical results, compared with other graft sources. However, autografts, especially 4-SHGs, showed similar or superior stability to irradiated allografts. Therefore, the graft source has a minimal effect on the clinical outcome, but it could have some effects on stability in single bundle transtibial PCL reconstruction.

Autograft Versus Allograft for Posterior Cruciate Ligament Reconstruction: An Updated Systematic Review and Meta-analysis

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.

Comparison of autograft and allograft tendons in posterior cruciate ligament reconstruction: A meta-analysis

BACKGROUND

The purpose of this meta-analysis of randomized controlled trials (RCTs) and non-RCTs was to compare the clinical outcomes of autograft versus allograft tendons in patients who underwent posterior cruciate ligament (PCL) reconstruction.

METHODS

We conducted a search of PubMed, EMBASE, The Cochrane Library, and Web of Science databases for RCTs and non-RCTs comparing autograft and allograft tendons in PCL reconstruction up to August 2016. The outcomes were Lysholm knee function score, postoperative objective and subjective International Knee Documentation Committee Score (IKDCS), Tegner activity scale, and knee posterior stability. Data analysis was performed using RevMan 5.3 software.

RESULTS

One RCT and 4 non-RCTs met the inclusion criteria. The current meta-analysis indicated that there were no significant differences in the Lysholm knee function score (mean difference [MD] = -0.99, 95% confidence interval [CI]: -5.51 to 3.54, P = .67), Tegner activity scale (MD = 0.46, 95% CI: 0.03 to 0.90, P = .04), postoperative objective IKDCS (odds ratio [OR] = 1.66, 95% CI: 0.77 to 3.58, P = .20), postoperative subjective IKDCS (MD = 3.00, 95% CI: -0.29 to 6.29, P = .07), or knee posterior stability (MD = -0.45, 95% CI: -1.28 to 0.38, P = .29) between patients who received autograft tendons and those who received allograft tendons. The patients with autograft tendons had a higher Tegner activity scale (MD = 0.46, 95% CI: 0.03 to 0.90, P = .04) than those with allograft tendons.

CONCLUSIONS

The present meta-analysis shows that there was insufficient evidence to indicate that allograft tendons were significantly better than autograft tendons for PCL reconstruction. Due to the limited quality and data in the studies currently available, in the future, more high-quality RCTs are required to answer this question more definitively.

Double-Bundle, All-Inside Posterior Cruciate Ligament Reconstruction: A Technique Using 2 Separate Autologous Grafts

In a double-bundle posterior cruciate ligament reconstruction, several surgical techniques are available. Compared with other techniques, the advantages of the all-inside technique and cortical suspension devices with variable loop length are that shorter grafts can be used, tendons can be quadrupled, and a double-bundle posterior cruciate ligament reconstruction can be performed with autologous grafts. Furthermore, the all-inside technique provides independent outside-in socket reaming and is soft tissue, cortex, and bone sparing because no full diameter tunnels but sockets are created with a small diameter guide pin, which can transform into a retrograde drill. Sockets could however lead to bottoming out of the grafts at the femoral side and subsequent residual laxity. This can be avoided by using 2 separate grafts that are fixed in 2 femoral sockets before they are independently fixed and tensioned in 1 tibial socket in their corresponding flexion angle. In this technical note, we present a double-bundle, all-inside posterior cruciate ligament reconstruction using 2 separate autologous grafts.