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Running head: INTEGRATIVE REVIEW

Integrative Review

Yi Foster

Bon Secours Memorial College of Nursing

Arlene Holowaychuk, EdD, MSN RN, CNE

NUR 4122

November 12, 2019

Honor Code: “I pledge”

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Abstract

The purpose of this integrated review is to analyze research literatures that evaluates and

compares the clinical outcome of anterior cruciate ligament (ACL) reconstruction surgery using

allograft and autograft techniques across various patient demographics. Previous research

indicates that ACL reconstruction surgery with allograft and autograft can prevent further

ligament, cartilage and meniscus damage. The PICO questions under consideration is, “In

Patients with ACL reconstructions, what is the effect of using autograft compared with using

allograft?” The research design is an integrative review. The research articles were collected

from online databases such as EBSCO Discovery, under two content providers, CINAHL

Complete and MEDLINE Complete. The results yielded 409 articles and five met the inclusion

criteria. All five articles indicate that ACL reconstruction with either allograft or autograft can

lead to knee restoration, regarding both knee function and stability. However post-operative

complications may occur in both types of graft. Limitations to the review include the possibility

that the researcher had a biased assumption prior to integrative review. A few of the articles had

small sample sizes and weak methodologies by using non-randomized design in the studied

groups. Implications of this review conclude both grafts can produce equal outcomes and

complications ranging from graft failure all the way to infection. Surgeons can use this

information and better assist patients in selecting grafts that would be appropriate for their

unique situations. Recommendations for possible future research about this topic should range

from patients’ characteristics, demographics, and comorbidities, as well as expanding on the

correlations regarding infection risk and graft revision.

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Integrative Review

The purpose of this integrated review is to analyze research literatures that evaluates and

compares the clinical outcome of anterior cruciate ligament (ACL) reconstruction surgery using

allograft and autograft techniques in various patient demographics. ACL reconstruction surgery

is a very common surgery performed to regain knee stability and function. Previous research

indicates patients with ACL reconstruction will prevent further damage to the structure of the

knee, including ligaments, cartilage and meniscus. Both allograft and autograft can lead to a

good result in post-operative objective and subjective variables (Mardani-Kivi et al., 2016).

However, there are benefits and risk factors among using both autograft and allograft. The main

issue is that the graft choices between allograft and autograft still remains a debatable topic

within the profession. Surgeons and other medical professionals are still unsure which graft will

have a higher success rate as well as fewer complications, including deep infection and graft

failure (Legnani, Zini, Borgo & Ventura, 2016). The aim of this review is to examine and discuss

the previous published literatures as it relates to the researcher’s PICO question, “In Patients

with ACL reconstructions, what is the effect of using autograft compared with using allograft?”

Design and Search Methods

The research design is an integrative review. The search for research articles was

conducted with one computer-based search engine, EBSCO Discovery, under two content

providers, CINAHL Complete and MEDLINE Complete. The search terms included ‘autograft,’

‘allograft,’ ‘ACL reconstruction,’ ‘autograft vs allograft.’ The search results yielded 153 articles

in MEDLINE Complete and 99 in CINAHL Complete in EBSCO Discovery. In order to remain

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true to the issue, the search was filtered to peer-reviewed, full text, quantitative research journal

articles, published in English, and published between 2016 to 2019. The articles were further

assessed for relevance and appropriateness to the researcher’s PICO question, “In patients with

ACL reconstruction, what is the effect of using autograft compare with using allograft?” The

researcher further screened the articles base on the inclusion criteria: quantitative research

design, objective and subjective outcome variables. The articles that did not meet the inclusion

criteria were excluded from the review. The screening resulted in 5 chosen quantitative articles

for this integrative review.

Findings and Results

The findings and results of the five reviewed studies indicate complications may occur

with both allograft and autograft in ACL reconstruction and both types of graft can produce good

postoperative outcome for patients (Legnani et al., 2016; Mardani-Kivi et al., 2016; Murphy et

al., 2016; Nissen, Eysturoy, Nielsen & Lind, 2018; Razi et al., 2019). A detailed summary of

each research article is attached via Appendix 1. The researcher structured the review based on

the following themes found among outcome of ACL reconstruction with allograft and autograft:

patient satisfactory, surgical complication and graft complications.

Patient Satisfaction

Four of the five research articles utilized quantitative studies in order to demonstrate

patient satisfactory with post-operative outcome prior to ACL reconstruction (Legnani et al.,

2016; Mardani-Kivi et al., 2016; Nissen et al., 2018; Razi et al., 2019). The study by Legnani et

al. (2016) the authors compared the clinical outcome among athletes with ACL revision surgery

between contralateral hamstring tendon autografts and allograft. This is a quantitative non-

experimental with retrospective, longitudinal, cohort study. The study had a total of 44
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participants; 23 participants used contralateral autogenous hamstring tendon graft and 21

participants used allograft for ACL revision surgery. All participants met the inclusion criteria of

failed primary ACL reconstruction and exclusion criteria were severe cartilage damage and other

significant knee disease. Legnani et al. (2016) used Knee Osteoarthritis Outcome Score (KOOS),

International Knee Documentation Committee (IKDC), Subject Knee Form and Tegner activity

level to collect subject evaluations. Objective evaluations used laxity test with a KT 1000

arthrometer. The authors used the Wilcoxon test to analyze and compare the pre-operative and

post-operative evaluations, which is an appropriate statistical test for this study. The statistically

significant data were set with P< 0.05. The result of the Legnani et al. (2016) study revealed

there’s a significant improvement in overall scores from post-operative assessment compared to

pre-operative assessment in both the subjective and objective evaluations when using

contralateral hamstring tendon autograft and allograft. There was no significant difference in

subjective and objective scores between the two surgical grafts.

In the second study, Mardani-Kivi et al. (2016) used a quantitative non-experimental

longitudinal retrospective study to compare knee function and clinical outcome between

hamstring tendon (HT) autograft and fresh-frozen tibialis posterior (TP) allograft in primary

ACL reconstruction surgery. The inclusion criteria set by Mardani-Kivi et al. (2016) was the

same surgical technique for both grafts and post-operative protocols; the exclusion criteria were

participants with history of ligament and meniscus injuries, as well as leads to meniscectomy and

meniscus graft. The sample of this study include TP allograft group of 104 patients (88 males

and 16 females), HT autograft group consist of 108 patients (99 males and 19 females). The

authors collected subjective evaluations with Lysholm score/knee symptoms and IKDC

participant questionnaires; objective evaluations were measured with Lax side to side difference
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(SSD), range of motion (ROM) with KT-1000 device. The data was collected at pre-operative

and post-operative appointments, as well as at weekly and monthly follow-ups for six months

and re-evaluations after one-year follow-up. The quantitative variable used a chi-square test and

t-test, which is appropriate for the design. Mardani-Kivi et al. (2016) considered P < 0.05 to be

statistically significant for all of the analysis. The result indicates ROM in both groups improve

significantly post operatively (P<0.001) however, there is no significant difference between the

two grafts. At the final follow-up there was significant difference in the subjective evaluations

between pre-operative and postoperative scores. The participants in both groups report

significant improvement in Lyscholm knee scores and IKDC.

Due to limited literature on outcomes of ACL surgery revisions, Nissen et al. (2018)

conducted a study to further investigate the clinical outcome of revision ACL reconstructions

performed between allograft and autograft. The study was a quantitative non-experimental

observational cohort study. Nissen et al. (2018) identified a total of 1619 participants (1315

autograft and 221 allograft) with revision ACL reconstructions by utilizing data from the Danish

Knee Ligament Reconstruction Registry. The authors set inclusion criteria of participants with

first-time revision ACL reconstructions with allograft or autograft; exclusion criteria were set

with participants with unknown graft type or with prior multi-ligament reconstruction. Nissen et

al. (2018) collect and evaluated subjective and objective data on both allograft and autografts.

The subjective evaluations used KOOS and Tegner activity score for participants quality in life.

The objective evaluations measured knee stability using Rolimeter or KT-1000 arthrometer. The

authors used a t-test to compare a 1 year follow-up of objective and subjective data between

allograft and autograft. The rates of allograft and autograft reconstruction re-revision was

compared using the chi-square test. Hazard ratio was modified by using a log-linear Cox
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regression analysis and P < 0.05 was recognized as statistically significant. The selected test to

compare quantitative variables was appropriate for this study. Significant improvements were

found from participants of both allograft and autograft group in subjective outcome based on

KOOS and Tegner scores comparing preoperative to postoperative at year assessments.

There is significant improvement in subjective outcome from pre-operative to postoperative

assessment at 1 year from participants from both allograft and autograft group base on KOOS

and Tegner scores.

Lastly Razi et al. (2019) conducted a study to compare pediatric patients with ACL

reconstruction surgery with allograft and autograft using both partial and complete transphyseal

techniques. The study was a quantitative non-experimental design with a prospective, cohort

study. The sampling size was a total of 31 patients diagnosed with ACL tear for ACL

reconstruction at Hazrat Rasoul Hospital. The patients were evaluated by according to the Tanner

stage and MRI results to determine the appropriate surgical technique (partial or full transphyseal

ACL reconstruction). Razi et al. (2019) grouped the patients based on the graft that was used for

ACL reconstruction surgery (13 patients used TP allograft and 18 patients used HT autograft).

The objective evaluations were collected from ROM, Lachman and Pivot shift test and the

Brighton scale for knee stability and laxity. The subjective evaluations were collected from

KOOS and IKDC.

Razi et al. (2019) used the t-test to compare the quantitative variables with normal distribution

and chose the Mann-Whitney test for data without normal distribution within the groups. Chi-

square and Fischer exact test were also used to collect the necessary data. All tests were

appropriate for this study. The finding indicates that there was no statistical difference in
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subjective outcome between allograft and autograft groups. Patients from both groups reported

no instability or locking of the knee.

Surgical Complications

ACL reconstruction is a common surgery performed in United States to restore knee

stability and functions. However, with any surgery complications may occur that result in a poor

clinical outcome. One of the five articles analyzed the potential risk of deep infection following

the ACL reconstruction (Murphy et al., 2016). The quantitative non-experimental design with

retrospective cohort study was conducted by Murphy et al. (2016) to examine and determine the

effect of graft choice (allograft, bone-patellar tendon-bone autograft, or hamstring autograft) on

deep tissue infection after ACL reconstruction. The study involved a sample size of 11,772

patient records (4,610 allografts, 4,491 bone-patellar tendon bone autografts and 2,671 hamstring

autograft). Murphy et al. (2016) used an insurance claim database from a total of 6 US health

plans to identify patients who underwent ACL reconstruction. Further inclusion criteria were set

by searching specific code within the insurance database to identify patients with potential

postoperative infection within the insurance data base. Murphy et al. (2016) used a hierarchical

stratified sampling strategy to identify patients with higher risk of infection. The selected patient

records were put into sub-categories. The authors generated confidence intervals (CIs) using

Monte Carlo simulations and logistic regression to analyze the correlations between infections

and patient demographics, choice of graft and comorbidities. Both tests were appropriate for this

study. The significant statistical data indicate hamstring autografts had a higher probability of

infection than bone-patellar tendon-bone autograft and allograft. There was no significant risk of

infection between bone-patellar tendon-bone autografts and allografts. However, authors did find
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certain criteria of demographic characteristics. The comorbidities can increase the risk of

infection after ACL reconstruction.

Graft Complications

Two out of the five articles discussed graft complications such as graft failure or revision

ACL reconstruction among allograft and autograft (Mardarni-Kivi et al., 2016; Nissen et al.,

2018). The longitudinal retrospective study conducted by Mardarni-Kivi et al. (2016) found

participants experienced graft failure in both HT autograft (3.4%) and TP allograft (1.9%).

However, there was no statistically significant difference found between the two groups (P =

0.133). The cohort study conducted by Nissen et al. (2018) explored the clinical outcome and

failure rates of revision ACL reconstruction by using either allograft or autograft. The authors

found after 1year postoperative, participants with allograft revision rate had a significantly

higher failure compared to autograft (5.4%) (P < 0.001).

Discussion and Implications

Based on the articles selected for the integrative review, there is it a strong evidence that

successful ACL reconstruction with either allograft and autograft can restore knee functionality

and the complications may occur among both grafts. The PICO questions, in patients with ACL

reconstructions, what is the effect of using autograft compare with using allograft. Quantitative

research conducted by Legnani et al. (2016), Mardani-Kivi et al. (2016), Nissen et al. (2018),

Razi et al. (2019) concludes that all the participants from both grafts subjective scores have

improved in post-operative assessment when compared to the pre-surgery assessments. The

implications of the articles suggest both allograft and autograft have risk of complications such

as infection and failure rate. Mardani-Kivi et al. (2016) and Nissen et al. (2018) indicate graft
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failure in ACL reconstruction can occur using either allograft or autograft. In Murphy et al.

(2016) the findings support that the risk of infection can occur in both allograft and autograft

recipients. However, certain types of autografts had a higher risk of infection compare to other

selection of grafts. The recommendation for future research is to include further study and

compare clinical outcomes of sub-categories in both allograft (irradiated vs. non-irradiated) and

autograft (Mardani-Kivi et al., 2016). Murphy et al. (2016) suggest further study on patientts’

characteristics, demographics, comorbidities, and of the correlations to risk of infection and graft

revision.

Limitations

The limitations are that the researcher is inexperienced in conducting an integrative

review. Prior to conducting the Integrative Review, the researcher had biased assumptions that

ACL reconstruction with autograft will have a higher success rate for restoring knee function and

stability for athletes. In addition, only five articles published within five years are used for this

assignment, resulting in the inability to complete an exhaustive review. In Nissen et al. (2016)

the graft information was not precise; the patients’ data did specify graft subtypes among

allograft and autograft. Both Legnani et al. (2016) and Razi et al. (2019) had inadequate sample

sizes, and the limited study population may affect data between groups. Mardani-Kivi et al.

(2016) grouped patients with similar findings in preoperative findings instead of randomized

patterns, which could have affected the results obtained. Murphy et al. (2016) stated a limitation

of the study is using retrospective design and narrowing duration of risk window for deep

infection at 6 months rather than 1 year.

Conclusion
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The evidence in this integrative review concludes both allograft and autografts in

arthroscopic ACL reconstruction can successfully restore knee stability and function. The

review highlights participants personal experiences and objective data of their function and

stability both prior and following the ACL surgery with both allograft and autograft. This

integrative review supports the PICOT question, “In patients with ACL reconstruction, what is

the effect of using autograft compare with using allograft?” The findings in this integrative

review implicate that while both grafts can produce equal outcomes, complications such as graft

failure and infection can also occur. Surgeons can use this information to better assist their

patients in selecting grafts that would be appropriate for their unique situations.
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References

Legnani, C., Zini, S., Borgo, E., & Ventura, A. (2016). Can graft choice affect return to sport

following revision anterior cruciate ligament reconstruction surgery? Archives of

Orthopaedic & Trauma Surgery, 136(4), 527-531. Retrieved from doi: 10.1007/s00402-

015-2387-3

Mardani-Kivi, M., Karimi-Mobarakeh, M., Keyhani, S., Saheb-Ekhtiari, K., Hashemi-Motlagh,

K., & Sarvi, A. (2016). Hamstring tendon autograft versus fresh-frozen tibialis posterior

allograft in primary arthroscopic anterior cruciate ligament reconstruction: A

retrospective cohort study with three to six years follow-up. International

Orthopaedics, 40(9), 1905–1911. Retrieved from doi: 10.1007/s00264-016-3164-9

Murphy, M. V., Du, D. (Tony), Hua, W., Cortez, K. J., Butler, M. G., Davis, R. L., … Klompas,

M. (2016) Risk factor for surgical site infection following anterior cruciate ligament

reconstruction. Infection Control & Hospital Epidemiology, 37(7), 827-833. Retrieved

from doi: 10.1017/ice.2016.65

Nissen, K. A., Eysturoy, N. H., Nielson, T. G., & Lind, M. (2018). Allograft use results in higher

re-revision rate for revision anterior cruciate ligament reconstruction. Orthopaedic

Journal of Sports Medicine, 6(6), 1-5. Retrieved from doi: 10.1177/2325967118775381

Razi, M., Moradi, A., Safarchertati, A., Askari, A., Arasteh, P., Ziabari, E. Z., & Dadgostar. H.

(2019). Allograft or autograft in skeletally immature anterior cruciate ligament

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reconstruction: A prospective evaluation using both partial and complete transphyseal

techniques. Journal of Orthopaedic Surgery and Research, 6(1), 1-8. Retrieved from doi:

10.1186/s13018-019-1128-7

Appendix I: Summary of Literature Tables

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Article Reference Legnani, C., Zini, S., Borgo, E., & Ventura, A. (2016). Can graft
choice affect return to sport following revision anterior cruciate
ligament reconstruction surgery? Archives of Orthopaedic &
Trauma Surgery, 136(4), 527-531. Retrieved from doi:
10.1007/s00402-015-2387-3
Background/Problem Increase in revision ACL surgery over the years and the choice of
Statement graft in revision still remain debatable issue. Aim is to compare
the clinical outcome between contralateral hamstring tendon
autografts vs. allografts for ACL revision in categories of patient
satisfactory, return to sports, preinjury activity level, postoperative
outcome. (p 528)
Conceptual/theoretical Did not discuss
Framework
Design/ Quantitative non-experimental retrospective longitudinal cohort
Method/Philosophical study.
Underpinnings 5.2 years follow-up

Sample/ Setting/Ethical Sample: 44 total participants. 23 revision ACL reconstruction

Considerations with contralateral autogenous hamstring tendon graft vs 21
allograft revision
surgery. (p 527)
inclusion and exclusion discussed (p.528)
Ethical: written consent, study followed guidelines by Ethical
Committee of the Institute
Major Variables Contralateral autogenous Hamstring tendon graft vs. allograft
Studied (and their group compare objective and subjective scores relating to patient
definition), if satisfactory, postoperative outcome (ROM, laxity test) (p.529)
appropriate

Measurement Tool/Data Measurement tool: Knee Osteoarthritis Outcome Score (KOOS),

Collection Method International Knee Documentation Committee (IKDC) Subjective
Knee Form, Tegner Activity level,
Objective examination instrument: Laxity test (KT-1000
arthrometer (p 529)
Data Analysis Data analyzed using program SPSS Version 19.0
Wilcoxon test used to compare pre-op vs follow-up status.
P<0.05 considered statistically significant
Article Reference Mardani-Kivi, M., Karimi-Mobarakeh, M., Keyhani, S., Saheb-
Findings/Discussion Both surgical grafts provide good results with improvement of
Ekhtiari, K., Hashemi-Motlagh, K., & Sarvi, A. (2016).
knee stability and knee score values. (p 529)
Hamstring Tendon autograft versus fresh-frozen tibialis posterior
There’s no significant difference in subjective or objective scores
allograft in primary arthroscopic anterior cruciate ligament
vs the different surgical grafts used.
reconstruction: A retrospective cohort study with three to six years
-significant difference in increase overall mean of KOOS score in
follow-up. International Orthopaedics, 40(9), 1905-1911.
preoperative and follow-up outcome. (p 529)
Retrieved from doi: 10.1007/s00264-016-3164-9
Limitations: sample is small, limited study population may affect
data between groups.
Greater number of participants in each group could have increase
statistical significance of the results collected.
Appraisal/Worth to Yes support the pico Q and result of the study demonstrated both
practice graft are appropriate to use and produce similar subjective and
objective outcomes.
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Background/Problem there is various autograft and allograft options for acl

Statement reconstruction, however scarce study on the long-term follow on
its functional and clinical outcome.
Aim: to compare and evaluate between two source of graft (TP
allograft & HT autograft) in outcomes of stability and function of
the knee. (p 1906)
Conceptual/theoretical Did not discuss in the article
Framework
Design/ Quantitative non-experimental longitudinal retrospective study
Method/Philosophical
Underpinnings

Sample/ Setting/Ethical TP allograft group: 104 patients (88 males and 16 females)
Considerations HT autograft group: 108 patients (99 males and 19 females)
pg.1907
Ethics: approved by the Local Ethical Committee of Guilan
University of Medical Sciences. Followed ethical principle from
Declaration of Helsinki both disadvantages and advantages of
both methods were discussed with patients.
Informed consent was obtained

Major Variables Independent variables: Tibialis posterior (TP) allograft vs.

Studied (and their Hamstring tendon (HT) autograft
definition), if Dependent variable: “conceptual” variable”: stability and function
appropriate of the knee after ACL reconstruction
“operational v: what test did they use to measure the stability and
function

Measurement Tool/Data Subjective evaluation: Lysholm score/knee symptoms and

Collection Method International Knee Document Committee (IKDC) participant
questionaires.
Objective evaluation: measuring lax side to side difference (SSD),
range of motion (ROM) by using KT-1000 device.
Data Analysis Quantitative variables were used chi-square test and t-test.
P<0.5 was considered to be statistical significant for all analyses.
Quantitative variables described and compared using the mean
scores 95% CI.
Objective eva: SSD was insignificant lower in the HT group in
comparison to the TP group(P= 0.0301)
Both TP group and HT group experience graft failure. However,
there was no significants among the 2 group (p=0.133)
Significant difference between pre-op and post of SSD score in
both group (p<0.001)
ROM significantly improved for both group between pre-op and
post-op, however no significant difference between the two
groups.
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Subjective eva: (p 1907)

IKDC and Lysholm scores improved by both graft comparison to
pre-op scores. (P< 0.001)

Findings/Discussion -the objective and subjective evaluations of this study

demonstrated that both type of grafts for ACL reconstruction will
be acceptable and give similar results in ROM, knee function and
similar post-operative complications.
-literature review supports autograft longer intra-operative and
recovery time. (p 1908)
-literature review compared ten-year follow up of pediatric
patients with allografts and result in adequate stability and knee
function.
-irradiated allografts have poor result in function and stability than
autografts
-no significant difference in end result between autograft and non-
irradiated allografts.

Limitations: non-randomized pattern in both groups

-Socioeconomical factor may influence patient rehabilitation
progress
-VAS score of patient’s satisfactions in early follow-up was not
evaluated.

Appraisal/Worth to Support PICO questions and the result of the study provide
practice evidence that HT autograft and TP allograft both are equally
effective in restoring functions and stability of the knee.

Article Reference Murphy, M. V., Du, D. (Tony), Hua, W., Cortez, K. J., Butler, M.
G., Davis, R. L., … Klompas, M. (2016) Risk factor for surgical
site infection following anterior cruciate ligament reconstruction.
Infection Control & Hospital Epidemiology, 37(7), 827-833.
Retrieved from doi: 10.1017/ice.2016.65
Background/Problem Background: Anterior cruciate ligament (ACL) reconstruction is
Statement very common surgeries performed annually in U.S. Risk for deep
infection is low, however have detrimental impact recovery time
and additional procedures.
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Problem statement: The researcher purpose is to determine effect

of graft choice (allograft, bone-patellar tendon-bone autograft,
hamstring autograft) on deep tissue infection following the (ACL)
reconstruction. Pg 827
Conceptual/theoretical none
Framework
Design/ Design: Non-experimental, retrospective cohort study
Method/Philosophical “descriptive”
Underpinnings Method: used past patient’s data
Hierarchical stratified sampling strategy to identify patients with
ACL reconstruction and determine graft type, clinical
characteristics, infection status.
Logistic regression to examine association between infection and
patient’s demographic characteristics, comorbidities and choice of
graft.

Sample/ Setting/Ethical -study population of 11,772 patients. searched through insurance

Considerations claims from each site by using specific code to identify patients
with ACL reconstruction from 1/1/2000-12/31/2008. (p. 828)
-setting: Conduct at 6 US health plans: Harvard Pilgrim Health
Care, Health Partners Institute for Education and Research, Henry
Ford Health System, LCF Research, Kaiser Permanente Georgia,
Kaiser Permanente Hawaii. All provided board of approval.
-did not discuss ethical consideration

Major Variables Allograft tissue: 4,610

Studied (and their Bone-patellar tendon bone autograft tissue: 4,491
definition), if Hamstring autograft: 2671
appropriate

Measurement Tool/Data Researchers went detail explaining how the patients were picked,
Collection Method used hierarchical stratified sampling strategy to determine patients
with higher risk of infection.
-nurses review the selected patient record and abstract data into
sub categories: demographic characteristics, medical history,
comorbidities, medications, surgical procedures, evidence of
infection within 6 months
- trained abstractors look for outliers/unorthodox (p.828)
Data Analysis - This total population risk of infection was calculated by
sampling medical records from each stratum.
-confidence intervals (CI) created using Monte Carlo simulations.
95% Cis from the resulting 2.5 and 97.5 %
-logistic regression to analyze the association between infections
and patient’s demographic characteristics, comorbidities, and
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choice of graft.
Analyses were performed using SAS, version 9.3
Findings/Discussion -The result was presented clearly and organized base on the
specific aim;
hamstring autograft had higher risk of infection than BPTB
autograft. There’s no significant risk between BPTB autograft and
allograft (p 831)
-higher risk in certain criteria such as male, age of 20 years or
greater, connective tissue disorder, immune suppressive
medications.
-BPTB allograft less infection rate than BPTB autograft; decrease
surgical time, less extensive tissue dissection, less graft
preparation. (p 831)
-proposed potential cause: increase prepping time for hamstring
autografts, use multifilament sutures that harbor bacterial, the
location of graft promote more bacterial growth

-limitation: retrospective design, did not have all operative details

concurrent procedures.
-limit the postoperative risk window for deep infection to 6
months instead of longer. Deep infection occurs within 3 months

Appraisal/Worth to Supports PICO questions and result of the study shows that
practice allograft is a safe alternative to autografts. Other risk factor for
infection can be due to patients prior conditions and
demographics.

Article Reference Nissen, K. A., Eysturoy, N. H., Nielson, T. G., & Lind, M. (2018).
Allograft use results in higher re-revision rate for revision anterior
cruciate ligament reconstruction. Orthopaedic Journal of Sports
Medicine, 6(6), 1-5. Retrieved from doi:
10.1177/2325967118775381
Background/Problem Limited literature on outcomes of revision ACL reconstruction,
Statement more data needed regarding to failure rates of revision ACLRs
performed with allograft and autograft.
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Conceptual/theoretical No did not discuss

Framework
Design/ Quantitative non-experimental “observational population-based
Method/Philosophical study” cohort study
Underpinnings

Sample/ Setting/Ethical Data collected from Danish Knee Ligament Reconstruction

Considerations Registry total of 1619 identified for revision ACLRs. (1315
autograft vs 221 allograft)
before surgery and 1 year after surgery.
-total population of 1619 used for
-include all first-time revision ACLRs performed with allograft or
autograft.
Exclusion: patient with multi-ligament reconstruction and patient
with unknown graft type
Ethics: The Danish Board of Health and the Danish Data
Protection agency approved this study.

Major Variables Autograft cohort group and allograft cohort group.

Studied (and their
definition), if
appropriate

Measurement Tool/Data 1year of follow up

Collection Method Subjective outcome/knee function: Knee injury and osteoarthritis
outcome score (KOOS) and Tegner activity score
Objective Knee stability using Rolimeter or KT-1000 arthrometer
measurement.

Data Analysis Statistical analysis was performed using Stata software version 14
Chi-square test compared rats of allograft and autograft
Statistical significant P<0.5 (p 3)
Log-linear Cox regression analysis use to modify hazard ratio for
following factors

Findings/Discussion Finding:
Statistically Re-revision rate was significantly higher for allograft
(12.7%) compared with autograft (5.4%) (P<.001)
-higher percentage of success with autografts
- Hazard ratio for re-revision was 2.2 (95% CI) for allografts vs
autografts when corrected for age.
- improve subjective outcome from both grafts base on using
KOOS and Tegner scores between pre-operative to 1-year post-
operative.
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Allograft technique is 2.2 times higher risk of re-revision

compared to autograft when correct for age.
-no significant difference between autograft and allograft within
objective knee instability. (p 3)
-significant difference (P=.01) for objective knee instability score
between autograft and allograft at 1 year postoperative.

Discussion:
Authors relate back to other literature supports that autograft
result in better outcome as in patients subjective scores, lower
tearing rates and improve sports function.
Limitations:
-Cohorts different in size, affect the comparisons made
-No information about postoperative rehabilitation programs or if
patient is compliant to post-operative protocols
-in the study the grafts were not divided into graft subtype within
autograft and allograft. Data may be less precise

Appraisal/Worth to Yes, relate to PICO questions and both grafts improve subjective
practice clinical outcome. Allograft higher re-tear rate and laxity than
autograft at 1 year.

Article Reference Razi, M., Moradi, A., Safarchertati, A., Askari, A., Arasteh, P.,
Ziabari, E. Z., & Dadgostar. H. (2019). Allograft or autograft in
skeletally immature anterior cruciate ligament reconstruction: A
prospective evaluation using both partial and complete
transphyseal techniques. Journal of Orthopaedic Surgery and
Research, 6(1), 1-8. Retrieved from doi: 10.1186/s13018-019-
1128-7
Background/Problem It’s recommended pediatric patients for ACL reconstruction once
Statement the complete tear of ACL in confirmed. However, prolonged
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instability leads to further damages in meniscus and octahedral

resulting in early degenerative changes. (p 1)
-adolescents with ACL tear with failure of ACL reconstructive
can be caused by weakness of collagen fibers and their
connection.
-allograft in the adolescent athlete may lead to failure rate and
difficulty selecting size ad tensile resistance of autografts in those
who are considered to be skeletally immature. (p 2)

Conceptual/theoretical No did not discuss

Framework
Design/ Quantitative prospective cross-sectional study.
Method/Philosophical
Underpinnings

Sample/ Setting/Ethical 31 total participants (Male younger than 18 years old and female
Considerations younger than 16 years old) diagnosed of ACL tear and have ACL
reconstruction
Setting: Hazrat Rasoul Hospital
Ethical: did not discuss
Major Variables -13 patients used tibialis posterior tendon allograft
Studied (and their -18 patients used semitendinosus/hamstring autograft
definition), if Surgery techniques: Partial or complete transphyseal ACL
appropriate reconstruction

Measurement Tool/Data Objective outcome/assessment:

Collection Method Evaluated post op 3, 6, 12, 24 months.
Tanner stage system used to determine patient’s degree of
maturation/used to determine procedures between partial or full
transphyseal ACL reconstruction
-length and alignment of lower extremities
-ROM
-knee stability/ Lachman and Pivot shift test
-laxity/Beighton scale
Subjective outcome/assessment
-Knee Injury and Osteoarthritis Outcome Score (KOOS)
-2000 International Knee Documentation Committee (IKDC)
subjective knee evaluation form

Data Analysis SPSS software for windows version 16.

Compare quantitative data with normal distribution used t test and
without normal distribution within groups with Mann-Whitney
test.
The Chi-square and Fischer exact test were used for qualitative
data.
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P<0.5 is considered statically significant

Findings/Discussion -There’s no statistical significant among Subjective outcome:
IKDC score and KOOS between allograft and autograft (p 5)
-lachman test/knee instability positive (46% allograft group) and
(39% in autograft group)
Discussion:
-skeletal maturity is the most important determining factor to
which ACL technique should be used for pediatrics due to their
anatomy.
(partial or complete transphyseal acl reconstruction)
-literature review: other cohort study the odds of re-tear is 4 times
higher in allograft than autograft in young active patients.
-in engleman et al. study found no significant different with
subjective and objective outcome among the two types graft,
however the hazard ratio of graft failure was x4.4 greater in
allograft group vs autograft. (p 6)
-In this study research only used non-irradiated allograft
excluding irradiated allograft.
-disadvantage of allograft and autograft: transmissible disease,
increase cost, donor site morbidity.
Limitation:
-longer follow-up may provide more accurate results.
-small sample size (not appropriate) low power of study after
power of study
- first type of study on using allograft in acl reconstruction for
pediatric patient with laxity.
-beighton score (laxity) is all or non-scale, does not provide
degrees of laxity,

Appraisal/Worth to It does support the PICO questions; however, sample size is too
practice small to produce accurate results. Only one type of allograft was
used in this study which cannot accurately predict success rate in
pediatric. The selection of the type of graft should be considered
base on patient’s demographics and other factors both grafts have
their own advantages and disadvantages.