Anterior cruciate ligament reconstruction- allograft versus autograft

Anterior cruciate ligament reconstruction- allograft versus autograft

1. Anterior Cruciate Ligament Reconstruction - Allograft versus Autograft Andris Levis MF VI versus Kristaps Blūms MF VI Mentor : Dr . Modris Ciems

2. Anterior Cruciate Ligament (ACL) Functions: Limits the forward motion of the tibia 1 ; P revents hyperextension of the knee 1 ; P rovides roughly 90% of stability in the knee joint 1

3. Incidence of Injury A nnual incidence of more than 200,000 cases with ~100,000 of these knees reconstructed 2 ; M ost prevalent (1 in 1,750 persons) in patients 15-45 years of age 1 ; An estimated 70% of ACL injuries are sustained through non-contact mechanisms, while the remaining 30% result from direct contact. 1

4. Indications for surgery Knee instability 5 ; C ombined injuries ( 30-50% ) 3 ; ACL reconstruction could prevent further damage 4 ; High-demand patients 5

5. Patient related factors Allograft N o donor site morbidity 6 ; No weakening of the flexor / extensor apparatuses 8 ; F aste r return to a ctivities of d aily l iving 8 ; L east painful post-operatively 8 ; Higher IKDC scores 10 ; Patients older than 45 years 8 ; Lower demand patients 8 ; Multiligamentous knee injury reconstructions 8 ; Revision ACL surgery . 8 Autograft Young patients 11 Athletes 12 No difference in Lysholm II and KT 1000 scores 13 More pain – immidiate r ehabilitation and activities possible - paradox

6. Surgery related factors Allograft S maller incisio n 8 ; Reduced operative time 6 ; Smaller risk of complications under anesthesia 5 ; No risk of patellar fracture 9 ; No need for an assistant . Autograft Operative time can be evened with asisstant Lower cost $4,587 92 min vs $3,849 125 min 14

7. Transplant related factors Allograft G reater availability 8 ; Larger cross sectional size 8 ; Potential graft tissue source for backup 9 ; Autograft Greater avalailabilty in Latvia Lower tear rate 8,9% vs 3,5% 11 More than 10% difference in patients less than 18yo 11 At 6 months better AP restraint to AP force , more cross sectional area , twice load to failure strentgh 15 Loses less time zero strenght 17

8. Biological factors Allograft Low dose irradiation - eliminate bacteria 7 ; High dose irradiation - eliminate both bacterial and viral pathogens 7 ; The estimated risk of HIV transmission is 1 : 8,000,000. 7 Autograft Histocompatibility No infection transmission risk Faster incorporation 17

9. Bottom line The surgeon has many choices when it comes to graft selection for ACL reconstruction ; There are certain situations in which one graft may be favored over another ; No graft is perfect ; Individual approach is the most important

10. Future ?

11. Literature Griffin LY. Noncontact Anterior Cruciate Ligament Injuries: Risk Factors and Prevention Strategies. Journal of the American Academy of Orthopaedic Surgeons. 2000;8:141-150 Miyasaka KC, Daniel DM, Stone ML. The incidence of knee ligament injuries in the general population. Am J Knee Surg 1991;4:43-48. Hefzy MS, Grood ES. Ligament restraints in anterior cruciate ligament-deficient knees . In : Jackson DW, Arnoczky SP, Woo SL-Y, Frank CB, Simon TM, eds . The Anterior Cruciate Ligament . Current and Future Concepts . New York : Raven Press , 1993;141-151. Cannon W, Jr , Vittori J. The incidence of healing in arthroscopic meniscal repairs in anterior cruciate ligament-reconstructed knees versus stable knees. Am J Sports Med 1992;20(2):176-181. Johnson RJ, Beynnon BD, Nichols CE, et al. Current concepts review. The treatment of injuries of the anterior cruciate ligament. J Bone Joint Surg Am 1992;74A:140-151. Fu FH, Jackson DW, Jamison J, et al . Allograft reconstruction of the anterior cruciate ligament . In : Jackson DW, Arnoczky SP, Woo SL-Y, Frank CB, Simon TM, eds . The Anterior Cruciate Ligament . Current and Future Concepts . New York : Raven Press , 1993;325-338. Pruss A, Kao M, Gohs U, Koscielny J, von Versen R, Pauli G. Effect of gamma irradiation on human cortical bone transplants contaminated with enveloped and non-enveloped viruses . Biologicals 2002;30:125-133. Shelton WR, Papendick L, Dukes AD. Autograft versus allograft anterior cruciate ligament reconstruction . Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association . Aug 1997;13(4):446-449. Miller SL, Gladstone JN. Graft selection in anterior cruciate ligament reconstruction. The Orthopedic clinics of North America. Oct 2002;33(4):675-683. Robert H. Miller and Frederick M. Azar . Campbell's Operative Orthopaedics , Chapter 45, 2121-2297.e16

12. Kaeding CC, Aros BC, 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 Pallis M, Svoboda SJ, Cameron KL, Owens BD. Survival Comparison of Allograft and Autograft Anterior Cruciate Ligament Reconstruction at the United States Military Academy. Am J Sports Med 2012;40:1242–6. doi:10.1177/0363546512443945. Chang SKY, Egami DK, Shaieb MD, Kan DM, Richardson AB. Anterior cruciate ligament reconstruction: allograft versus autograft. Arthroscopy 2003;19:453–62. doi:10.1053/jars.2003.50103. Greis PE, Koch BS, Adams B. Tibialis anterior or posterior allograft anterior cruciate ligament reconstruction versus hamstring autograft reconstruction: an economic analysis in a hospital-based outpatient setting. Arthroscopy 2012;28:1695–701. doi:10.1016/j.arthro.2012.04.144. Gulotta LV, Rodeo SA. Biology of autograft and allograft healing in anterior cruciate ligament reconstruction. Clin Sports Med 2007;26:509-524. Jackson DW, Grood ES, Goldstein JD, et al . A comparison of patellar tendon autograft and allograft used for anterior cruciate ligament reconstruction in the goat model . Am J Sports Med 1993;21:176-185. Jackson DW, Corsetti J, Simon TM. Biologic incorporation of allograft anterior cruciate ligament replacements . Clin Orthop Relat Res 1996:126-133.