Autograft or Allograft for ACL Reconstruction?

Careful graft selection plays key role in ACL reconstruction outcomes

Jennie McKee

Whether to use an autograft or an allograft in anterior cruciate ligament (ACL) reconstruction is

still controversial. Although patella tendon autograft has long been considered the gold
standard, allograft safety has improved significantly in the last 15 years, making it a viable
option in some patients, according to Mark D. Miller, MD, who reported on the latest
information on autograft and allograft tissue and offered tips on selecting an allograft tissue
bank during the 2012 Arthroscopy Association of North America Specialty Day Program.

Commonly used allografts include (top to bottom): Achilles tendon, tibialis anterior,
and semitendinosus (after preparation).
Courtesy of Mark D. Miller, MD

Autograft tissue
Autograft options include central one-third patellar tendon, quadrupled hamstring tendons, and
quadriceps tendon (with or without bone block).

“In some studies, patella tendon autograft has been found to be slightly more stable than
hamstring grafts,” said Dr. Miller. “It has strong initial fixation, but some studies have found an
increased incidence of kneeling pain in patients, and some morbidity risks are associated with
harvesting the patella tendon.”
harvesting the patella tendon.”

According to Dr. Miller, a quadrupled hamstring autograft may represent a new gold standard,
or join the patella tendon autograft as a “co–gold standard.”

“Quadrupled hamstring grafts have less harvest site morbidity than other types of autograft,
but the saphenous nerve branches can be injured during harvest, and there is some
postoperative weakness with deep knee flexion,” he said. “Quadrupled hamstring grafts also
have slightly less stability than patella tendon grafts in some studies.”

He added that recent data suggest that quadrupled hamstring grafts smaller than 8 mm have
increased failure rates.

“Concern about smaller grafts has led some surgeons to use an extra semitendinosus allograft,
creating a six-strand hybrid autograft-allograft, or to triple the semitendinosus autograft, if it is
long enough, to create a five-strand autograft,” he said.

Intraoperative photograph of posterior mini-incision hamstring harvest technique.

Reproduced from Prodromos CC, Fu FH, Howell SM, Johnson DH, Lawhorn K:
Controversies in Soft-tissue Anterior Cruciate Ligament Reconstruction: Grafts,
Bundles, Tunnels, Fixation, and Harvest. J Am Acad Orthop Surg 2008; 16:376-384.

Another option is the quadriceps tendon graft, which can be used with or without a bone block.
This is a strong graft, noted Dr. Miller, with “surprisingly little morbidity.”

“Quadriceps tendon grafts can be dissected in layers, but cosmesis may be an issue,” he said.

Allograft tissue
Allograft options include the patellar tendon and the Achilles tendon, which are available with
bone blocks. Soft tissue–only allografts include the semitendinosus, tibialis anterior, tibialis
posterior, peroneus longus, and iliotibial band allografts.

“Using an allograft avoids the issue of harvest site morbidity,” he said. “Allograft use also
results in slightly less loss of motion and requires less surgical time. In my experience, allografts
results in slightly less loss of motion and requires less surgical time. In my experience, allografts
are useful for complex cases, such as those involving multiple ligament injuries and revisions.”

But allografts have some disadvantages, including cost, availability, immune response, bacterial
infection risk, and delayed graft incorporation/failure.

“Immune response and bacterial infection risk may be diminished by modern allograft
processing techniques and shorter surgical times,” he said, adding that the smaller incision
required with allograft tissue may also reduce the risk of bacterial infection.

“Viral infection risk may be offset by better donor screening and allograft disinfection
techniques,” he added.

“Perhaps the most concerning disadvantage is an alarmingly high failure rate in young, active
patients,” said Dr. Miller. “Recent studies have raised serious concerns about using allografts in
this patient population. In one study, the risk of failure with bone-patella tendon-bone allograft
was 2.6 times to 4.2 times higher than bone-patella tendon-bone autograft.”

Allograft processing
Another factor to consider, said Dr. Miller, is that modern allograft processing techniques have
improved allograft safety.

“Not everyone who signs the back of a driver’s license is an acceptable donor, so it is good that
nucleic acid testing for HIV-1 has reduced the time required to receive test results from 22 to
12 days,” he said.

Aseptic tissue recovery—meaning tissue recovery that does not involve contact with
microorganisms—is important; however, sterility, or freedom from living microorganisms,
cannot usually be achieved, said Dr. Miller.

“Sterile acquisition is just not possible in most settings, but the goal is to ensure that no further
bioburden is introduced,” he said, noting that disinfection is required to lower the sterility
assurance level (SAL), with a goal of reaching 10¯6 SAL.

Tissue processing, asserted Dr. Miller, is a “delicate balance between preserving the biologic
function of the tissue and removing potentially infectious agents.”

Processing may include chemical disinfectants or terminal sterilization (irradiation).

“Processing methods must be validated to reduce the risk of terminal contamination and
cross-contamination,” said Dr. Miller.

Secondary sterilization is used to address potential pathogens that may have survived the
harvest and initial processing.
“All sterilization processes have the potential to affect the biomechanic and biologic properties,
which is a major concern,” he said. “These techniques vary with every tissue bank.”

Dr. Miller explained that although low-dose irradiation is sufficient for bacteria and spores,
higher doses are required to kill viruses, such as HIV.

“The more irradiation, however, the greater the potential for problems, because the
biomechanic properties of the graft are adversely affected,” he said, noting that doses higher
than 2.5 megarads (Mrads)—and, possibly even doses lower than that—can adversely affect
mechanical properties.

Recent clinical studies have compared irradiated and nonirradiated grafts. “One study found a
failure rate of 2.4 percent in nonirradiated Achilles allograft compared to a failure rate of 33
percent in Achilles allograft irradiated with 2.5 Mrads,” he said.

Dr. Miller recommends using only tissue banks that are accredited by the American Association
of Tissue Banks (AATB), registered with the U.S. Food and Drug Administration and the state,
and certified by the International Organization for Standardization.

“Do your research,” he said. “Make sure the tissue bank has a good safety track record and
good clinical results. Understand the processing and packaging procedures they use. Ensure
that the sterility level reached is 10¯6 SAL. Also, be aware of processing fees and the level of
customer service provided.

“Although allograft safety has improved significantly over the last 15 years, some allograft
tissue may not be sterile,” emphasized Dr. Miller. “Remember that not all tissue banks use the
same methods for donor screening or for tissue harvesting, tissue processing, safety
purification, and secondary sterilization. Implantation has risks: It can cause infection with
significant morbidity and mortality.

“Ultimately, graft choice is up to the patient,” he concluded. The orthopaedist’s job is to help
educate the patient.”

Disclosure: Dr. Miller—Saunders/Mosby-Elsevier, Wolters Kluwer Health/Lippincott Williams &

Wilkins, and The Journal of Bone and Joint Surgery.

Jennie McKee is a staff writer for AAOS Now. She can be reached at mckee@aaos.org

AAOS information statement on the use of musculoskeletal allograft tissue

Bottom Line

Although patella tendon autograft has long been considered the gold standard for ACL
reconstruction, quadrupled hamstring autograft is another option. In addition, allograft safety
has improved significantly in the last 15 years, making allograft a viable option in some
 patients.
Tissue banks may use different processes for the following: donor screening, tissue
harvesting and processing, safety purification, and secondary sterilization.
Studies have found a high failure rate in young, active patients who undergo ACL
reconstruction using allograft.

References

1. Barrett GR, Luber K, Replogle WH et al: Allograft anterior cruciate ligament reconstruction in
the young, active patient: Tegner activity level and failure rate. Arthroscopy 2010
26(12):1593-1601. Epub 2010 Oct 16.
2. Rappé M, Horodyski M, Meister K, et al: Nonirradiated versus irradiated Achilles allograft: in
vivo failure comparison. Am J Sports Med 2007 Oct; 35(10):1653-8. Epub 2007 May 21.

AAOS Now
April 2012 Issue
http://www.aaos.org/news/aaosnow/apr12/cover1.asp

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