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Anterior Cruciate Ligament Reconstruction With Autografts Compared With Non-irradiated, Non-chemically Treated Allografts

      Purpose

      Allograft anterior cruciate ligament (ACL) reconstruction obviates donor site morbidity and may accelerate postoperative recovery. However, allograft use can lead to increased rates of surgical failure, particularly when chemical processing or irradiation is used. Few studies have rigorously evaluated the comparative outcomes of autografts and fresh-frozen allograft tissue for ACL reconstruction.

      Methods

      We performed a PubMed search to identify and systematically evaluate outcomes of autograft and non–chemically treated non-irradiated allograft tissue in ACL reconstruction between 1980 and 2012. We included studies with Level of evidence of I to III, determinate graft treatment, a minimum of 25 patients per treatment arm, a minimum 2-year follow-up, and selected subjective and objective outcome measures.

      Results

      After the exclusion of 585 citations, we isolated 11 studies for further review. All patients showed improvement in clinical outcome measures and knee stability end points from injury to definitive surgical management. No statistically significant differences were detected between autografts and non-chemically processed non-irradiated allografts in Lysholm scores, International Knee Documentation Committee (IKDC) scores, Lachman examinations, pivot-shift testing, KT-1000 measurements, or failure rates.

      Conclusions

      Further large-scale, well-designed studies are required to better evaluate the comparative outcomes after fresh-frozen allograft ACL reconstruction. The current study suggests that the results after autograft ACL reconstruction are comparable to those using non-chemically processed nonirradiated allograft tissue.

      Level of Evidence

      Systematic review of Level I to III studies.
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      References

        • Garrett W.E.
        • Swiontkowski M.F.
        • Weinstein J.N.
        • et al.
        American Board of Orthopaedic Surgery Practice of the Orthopaedic Surgeon: Part-II, certification examination case mix.
        J Bone Joint Surg Am. 2006; 88: 660-667
        • Daniel D.M.
        • Stone M.L.
        • Dobson B.E.
        • et al.
        Fate of the ACL injured patient: A prospective outcome study.
        Am J Sports Med. 1994; 22: 632-644
        • Wilk K.E.
        • Andrews J.R.
        Current concepts in the treatment of anterior cruciate ligament disruption.
        J Orthop Sports Phys Ther. 1992; 15: 279-293
        • Taylor D.C.
        • Posner M.
        • Curl W.W.
        • Feagin J.A.
        Isolated tears of the anterior cruciate ligament: Over 30-year follow-up of patients treated with arthrotomy and primary repair.
        Am J Sports Med. 2009; 37: 65-71
        • Mascarenhas R.
        • Macdonald P.B.
        Anterior cruciate ligament reconstructions: A look at prosthetics, past, present and possible future.
        Mcgill J Med. 2008; 11: 29-37
        • Fu F.H.
        • Bennett C.H.
        • Ma C.B.
        • et al.
        Current trends in anterior cruciate ligament reconstruction. Part II: Operative procedures and clinical correlations.
        Am J Sports Med. 2000; 28: 124
        • Shelton W.R.
        • Treacy S.H.
        • Dukes A.D.
        • Bomboy A.L.
        Use of allografts in knee reconstruction: II. Surgical considerations.
        J Am Acad Orthop Surg. 1998; 6: 169-175
        • Gorschewsky O.
        • Klakow A.
        • Riechert K.
        • Pitzl M.
        • Becker R.
        Clinical comparison of the Tutoplast allograft and autologous patellar tendon (bone-patellar tendon-bone) for the reconstruction of the anterior cruciate ligament: 2- and 6-year results.
        Am J Sports Med. 2005; 33: 1202-1209
        • Schmidt T.
        • Hoburg A.
        • Broziat C.
        • et al.
        Sterilization with electron beam irradiation influences the biomechanical properties and the early remodeling of tendon allografts for reconstruction of the anterior cruciate ligament (ACL).
        Cell Tissue Bank. 2012; 13: 387-400
        • Leal-Blanquet J.
        • Maestro A.
        Anterior cruciate ligament reconstruction: A multicenter prospective cohort study evaluating 3 different grafts using same bone drilling method.
        Clin J Sport Med. 2011; 21: 294-300
        • Krych A.J.
        • Jackson J.D.
        • Hoskin T.L.
        • Dahm D.L.
        A meta-analysis of patellar tendon autograft versus patellar tendon allograft in anterior cruciate ligament reconstruction.
        Arthroscopy. 2008; 24: 292-298
        • Rihn J.A.
        • Irrgang J.J.
        • Chhabra A.
        • Fu F.H.
        • Harner C.D.
        Does irradiation affect the clinical outcome of patellar tendon allograft ACL reconstruction?.
        Knee Surg Sports Traumatol Arthrosc. 2006; 14: 885-896
        • Sun K.
        • Tian S.
        • Zhang J.
        • Xia C.
        • Zhang C.
        • Yu T.
        Anterior cruciate ligament reconstruction with BPTB autograft, irradiated versus non-irradiated allograft: A prospective randomized clinical study.
        Knee Surg Sports Traumatol Arthrosc. 2009; 17: 464-474
        • Harner C.D.
        • Olson E.
        • Irrgang J.J.
        • Silverstein S.
        • Fu F.H.
        • Silbey M.
        Allograft versus autograft anterior cruciate ligament reconstruction: 3- to 5-year outcome.
        Clin Orthop Relat Res. 1996; 324: 134-144
        • Shelton W.R.
        • Papendick L.
        • Dukes A.D.
        Autograft versus allograft anterior cruciate ligament reconstruction.
        Arthroscopy. 1997; 13: 446-449
        • Kleipool A.E.
        • Zijl J.A.
        • Willems W.J.
        Arthroscopic anterior cruciate ligament reconstruction with bone-patellar tendon-bone allograft or autograft: A prospective study with an average follow up of 4 years.
        Knee Surg Sports Traumatol Arthrosc. 1998; 6: 224-230
        • Peterson R.K.
        • Shelton W.R.
        • Bomboy A.L.
        Allograft versus autograft patellar tendon anterior cruciate ligament reconstruction: A 5-year follow-up.
        Arthroscopy. 2001; 7: 9-13
        • Barrett G.
        • Stokes D.
        • White M.
        Anterior cruciate ligament reconstruction in patients older than 40 years: Allograft versus autograft patellar tendon.
        Am J Sports Med. 2005; 33: 1505-1512
        • Edgar C.M.
        • Zimmer S.
        • Kakar S.
        • Jones H.
        • Schepsis A.A.
        Prospective comparison of auto and allograft hamstring tendon constructs for ACL reconstruction.
        Clin Orthop Relat Res. 2008; 466: 2238-2246
        • Sun K.
        • Tian S.Q.
        • Zhang J.H.
        • Xia C.S.
        • Zhang C.L.
        • Yu T.B.
        Anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft versus allograft.
        Arthroscopy. 2009; 25: 750-759
        • Noh J.H.
        • Yi S.R.
        • Song S.J.
        • Kim S.W.
        • Kim W.
        Comparison between hamstring autograft and free tendon Achilles allograft: Minimum 2-year follow-up after anterior cruciate ligament reconstruction using EndoButton and Intrafix.
        Knee Surg Sports Traumatol Arthrosc. 2011; 19: 816-822
        • Sun K.
        • Zhang J.
        • Wang Y.
        • et al.
        Arthroscopic reconstruction of the anterior cruciate ligament with hamstring tendon autograft and fresh-frozen allograft: A prospective, randomized controlled study.
        Am J Sports Med. 2011; 39: 1430-1438
        • Lawhorn K.W.
        • Howell S.M.
        • Traina S.M.
        • Gottlieb J.E.
        • Meade T.D.
        • Freedberg H.I.
        The effect of graft tissue on anterior cruciate ligament outcomes: A multicenter, prospective, randomized controlled trial comparing autograft hamstrings with fresh-frozen anterior tibialis allograft.
        Arthroscopy. 2012; 28: 1079-1086
        • Guo L.
        • Yang L.
        • Duan X.J.
        • et al.
        Anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft: Comparison of autograft, fresh-frozen allograft, and gamma-irradiated allograft.
        Arthroscopy. 2012; 28: 211-217
        • Shaieb M.D.
        • Kan D.M.
        • Chang S.K.
        • Marumoto J.M.
        • Richardson A.B.
        A prospective randomized comparison of patellar tendon versus semitendinosus and gracilis tendon autografts for anterior cruciate ligament reconstruction.
        Am J Sports Med. 2002; 30: 214-220
        • Spindler K.P.
        • Kuhn J.E.
        • Freedman K.B.
        • Matthews C.E.
        • Dittus R.S.
        • Harrell Jr., F.E.
        Anterior cruciate ligament reconstruction autograft choice: Bone-tendon-bone versus hamstring: Does it really matter? A systematic review.
        Am J Sports Med. 2004; 32: 1986-1995
        • Samuelsson K.
        • Andersson D.
        • Karlsson J.
        Treatment of anterior cruciate ligament injuries with special reference to graft type and surgical technique: An assessment of randomized controlled trials.
        Arthroscopy. 2009; 25: 1139-1174
        • Poehling G.G.
        • Smith B.P.
        Analysis of outcomes of anterior cruciate ligament repair with 5 year follow-up: Allograft versus autograft.
        Arthroscopy. 2005; 21: 774-785
        • Sherman O.H.
        • Banffy M.B.
        Anterior cruciate ligament reconstruction: Which graft is best?.
        Arthroscopy. 2004; 2: 974-980
        • Rosenburg T.D.
        • Franklin J.L.
        • Baldwin G.N.
        • Nelson K.A.
        Extensor mechanism function after patellar tendon graft harvest for anterior cruciate ligament reconstruction.
        Am J Sports Med. 1992; 20: 519-525
      1. Janson KA, Linko E, Sandelin J, Harilainen A. A prospective randomized study of patellar versus hamstring tendon autografts for anterior cruciate ligament reconstruction. Am J Sports Med 200;31:12-18.

        • Yasuda K.
        • Tsujino J.
        • Ohkoshi Y.
        • Tanabe Y.
        • Kaneda K.
        Graft site morbidity with autogenous semitendinosus and gracilis tendons.
        Am J Sports Med. 1995; 23: 706-714
        • Jin G.K.
        • Sang J.Y.
        The effects of hamstring harvesting on outcomes in anterior cruciate ligament–reconstructed patients: A comparative study between hamstring-harvested and -unharvested patients.
        Arthroscopy. 2011; 27: 1226-1234
        • McGuire D.A.
        • Hendricks S.D.
        Allograft tissue in ACL reconstruction.
        Sports Med Arthrosc. 2009; 17: 224-233
        • Rihn J.A.
        • Harner C.D.
        The use of musculoskeletal allograft tissue in knee surgery.
        Arthroscopy. 2003; 19: 51-56
        • Curran A.R.
        • Adams D.J.
        • Gill J.L.
        • Steiner M.E.
        • Scheller A.D.
        The biomechanical effects of low-dose irradiation on bone-patellar tendon-bone allografts.
        Am J Sports Med. 2004; 32: 1131-1135
        • Fideler B.M.
        • Vangsness T.
        • Lu B.
        • Orlando C.
        • Moore T.
        Gamma irradiation: Effects on biomechanical properties of human bone-patellar tendon-bone allografts.
        Am J Sports Med. 1995; 23: 643-646
        • Prodromos C.
        • Joyce B.
        • Shi K.
        A meta-analysis of stability of autografts compared to allografts after anterior cruciate ligament reconstruction.
        Knee Surg Sports Traumatol Arthrosc. 2007; 15: 851-856
        • Jackson D.W.
        • Windler G.E.
        • Simon T.M.
        Intraarticular reaction associated with the use of freeze-dried, ethylene oxide-sterilized bone-patellar tendon-bone allografts in the reconstruction of the anterior cruciate ligament.
        Am J Sports Med. 1990; 18: 1-10
        • Roberts T.S.
        • Drez Jr., D.
        • McCarthy W.
        • Paine R.
        Anterior cruciate ligament reconstruction using freeze-dried, ethylene oxide-sterilized, bone-patellar tendon-bone allografts. Two year results in thirty-six patients.
        Am J Sports Med. 1991; 19: 35-41
        • Sheffler S.U.
        • Gonnermann J.
        • Kamp J.
        • Przybilla D.
        • Pruss A.
        Remodeling of ACL allografts is inhibited by peracetic acid sterilization.
        Clin Orthop Relat Res. 2008; 466: 1810-1818
        • Mroz T.E.
        • Wang J.W.
        Musculoskeletal allograft risks and recalls in the United States.
        J Am Acad Orthop Surg. 2008; 16: 559-565
        • Sun K.
        • Zhang J.
        • Wang Y.
        • et al.
        A prospective randomized comparison of irradiated and non-irradiated hamstring tendon allograft for ACL reconstruction.
        Knee Surg Sports Traumatol Arthrosc. 2012; 20: 187-194
        • Jackson D.W.
        • Corsetti J.
        • Simon T.M.
        Biologic incorporation of allograft anterior cruciate ligament replacements.
        Clin Orthop Relat Res. 1996; 324: 126-133
        • Malinin T.I.
        • Levitt R.L.
        • Bashore C.
        • Temple H.T.
        • Mnaymneh W.
        A study of retrieved allografts used to replace anterior cruciate ligaments.
        Arthroscopy. 2002; 18: 163-170
        • Scheffler S.U.
        • Schmidt T.
        • Gangey I.
        • et al.
        Fresh-frozen free-tendon allografts versus autografts in anterior cruciate ligament reconstruction: Delayed remodeling and inferior mechanical function during long-term healing in sheep.
        Arthroscopy. 2008; 24: 448-458
        • Pallis M.
        • Svoboda S.J.
        • Cameron K.L.
        • Owens B.D.
        Survival comparison of allograft and autograft anterior cruciate ligament reconstruction at the United States Military Academy.
        Am J Sports Med. 2012; 40: 1242-1246
        • Spindler K.P.
        • Huston L.J.
        • Wright R.W.
        • et al.
        The prognosis and predictors of sports function and activity at minimum 6 years after anterior cruciate ligament reconstruction: A population cohort study.
        Am J Sports Med. 2011; 39: 348-359
        • Kaeding C.C.
        • Aros B.
        • Pedroza A.
        • et al.
        Allograft versus autograft anterior cruciate ligament reconstruction: Predictors of failure from a MOON prospective longitudinal cohort.
        Sports Health. 2011; 3: 73-81
        • Van Eck C.F.
        • Schkrohowsky J.B.
        • Working Z.M.
        • Irrgang J.J.
        • Fu F.H.
        Prospective analysis of failure rate and predictors of failure after anatomic anterior cruciate ligament reconstruction with allograft.
        Am J Sports Med. 2012; 40: 800-807

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