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Year : 2016  |  Volume : 16  |  Issue : 1  |  Page : 7-14

Choices of graft for anterior cruciate ligament reconstruction

Department of Orthopaedic Surgery, J.N. Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Date of Web Publication7-Jan-2016

Correspondence Address:
Rahul Ranjan
Department of Orthopaedic Surgery, J.N. Medical College, Aligarh Muslim University, Aligarh - 202 002, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-6308.173471

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An injury to the anterior cruciate ligament (ACL) results in significant functional disability. One-third of the patients require reconstruction. The graft choice for ACL reconstruction is a controversial issue. The graft choices include autograft, allograft, and synthetic/prosthetic ligaments. Autografts include the middle third of the patella tendon, the quadriceps tendon, semitendinosus tendon, gracilis tendon, iliotibial band, tensor fascia lata, and the Achilles tendon. In last few decades, there have been several meta-analyses, comparative trials, which have fail to an answer with regards to the best graft available. The purpose of this review article is to provide concepts in graft choices for ACL reconstruction. This article will emphasize the pros and cons of the graft choices available and also regarding the donor site morbidity.

  Abstract in Arabic 

خيارات الطعم ( الرقعة ) لإعادة الإعمار في الرباط الصليبي الأمامي
إصابة في الرباط الصليبي الأمامي (ACL) تنتج عنها إعاقة وظيفية كبيرة. خيث إن ثلث المرضى يتطلب إعادة الإعمار. و قد أصبح خيار الطعم لإعادة إعمار الرباط الصليبي الأماميACL مسألة مثيرة للجدل. وتشمل خيارات الطعم:
الطعم الذاتي، المزروع، والاصطناعية / الأربطة الاصطناعية. تشمل طعم ذاتي الثلث المتوسط من وتر الرضفة، والعضلة رباعية الرؤوس، العضلة الوترية، الناحلة وتر الشريط الحرقفي الظنبوبي، ووتر العرقوب.
في العقود القليلة الماضية، كانت هناك عدة تحليلات: الفوقية، والتجارب المقارنة، التي تفشل في إجابة فيما يتعلق بأفضل أنواع الطعم المتاحة.
والغرض من هذه المقالة تقديم المفاهيم في الخيارات المتاحة من الطعم لإعادة إعمار الرباط الصليبي الأمامي ACL.
هذه المقالة تؤكد إيجابيات وسلبيات الخيارات المتاحة من أنواع الطعم ، وكذلك فيما يتعلق بالجهات المانحة للمرضى.

Keywords: Allograft, anterior cruciate ligament, autograft, synthetic graft

How to cite this article:
Ranjan R, Asif N. Choices of graft for anterior cruciate ligament reconstruction. Saudi J Sports Med 2016;16:7-14

How to cite this URL:
Ranjan R, Asif N. Choices of graft for anterior cruciate ligament reconstruction. Saudi J Sports Med [serial online] 2016 [cited 2023 Mar 21];16:7-14. Available from: https://www.sjosm.org/text.asp?2016/16/1/7/173471

  Introduction Top

The anterior cruciate ligament (ACL) reconstruction is the sixth most common procedure in orthopedic surgery, with more than 100,000 surgeries performed in the United States per year.[1] Once the decision to reconstruct is made, the next critical decision is with regards to the graft choice. The ideal graft for ACL reconstruction should reproduce the histological and biomechanical characteristics of the native ligament, incorporate fully and quickly within bone tunnels, have no risk of rejection or disease transmission, minimal donor site morbidity, be of sufficient length and diameter, and be cost-effective, as well as readily available.[2] The ultimate physical and mechanical properties of implanted graft should approximate or exceed the native ACL. It is summarized in [Table 1].
Table 1: The biomechanical properties of different grafts

Click here to view

There are many graft sources available to the surgeon, and these can be broadly categorized into autografts and allografts. Autologous grafts can be harvested from the ipsilateral or contralateral patellar tendon, the semitendinosus, and gracilis tendons, or from the quadriceps tendon with or without a bone plug. Allografts typically used for ACL reconstruction include cadaveric forms of these same types of autologous grafts, as well as tibialis anterior and Achilles tendon grafts. Every patients should be individualized about the graft choices according to patient's need.[12] While planning the amount of instability (isolated/multiligament injury), the age, the activity level, occupation and recreational activities of the patient should be taken into account.

Two most commonly used autografts are bone-patellar tendon-bone (BPTB) and hamstrings tendon. A recent review of Cochrane have shown an insignificant difference between the outcome of BPTB and hamstring tendon.[13] There have been several studies comparing the outcome of allograft and autografts.[14],[15],[16],[17],[18],[19],[20] The use of allograft have be less popular due to associate complications.[21],[22],[23] The aim of this article is to review the literature on ACL graft sources and allow the surgeon to make a correct decision with their patients as to the appropriate graft for each individual patient.

  Autograft Top

The two most commonly used autografts are BPTB and hamstring tendon.[24] Other autografts are an iliotibial band, quadriceps tendon, and Achilles tendon.

  Bone-Patellar Tendon-Bone Grafts Top

BTB or BPTB grafts allow for bone-to-bone healing within the tunnels, seen to have favorable time-zero biomechanical strength and have good-to-excellent clinical outcomes on long-term follow-up.[25],[26],[27] Histologic studies have shown that osteonecrosis occurs at the graft tunnel interface, followed by creeping substitution and rapid incorporation into surrounding host bone. Dense fibrous tissue surrounds the bone block at 3 weeks with complete incorporation of the grafted bone to the host bone by 6 weeks.[26]

The ultimate tensile load, stiffness and cross-sectional area of the BPTB are comparable with the intact ACL [Table 1]. Thus, the BTB autograft has the intrinsic properties that allow immediate active rehabilitation, and these favorable biomechanical properties combined with bone to bone healing and rigid, aperture fixation with interference screws account for the graft's excellent initial and continued long-term performance.

Another advantage is the length and width of BTB autografts can be adjusted to match patient size and footprint anatomy. Depending on the size of the patient's patellar tendon, in some cases a 12 mm graft can be obtained while still safely retaining sufficient tendon on either side of the graft.

Literature has described many disadvantages of patellar tendon autograft. First, the length of the BPTB graft is fixed and is vulnerable to graft tunnel mismatch when tunnel length is not adjusted accordingly. However, it can be overcome by certain intraoperative maneuvers such as recessing the femoral bone plug, drilling a longer tibial tunnel, graft rotation.[28],[29],[30] The surgeon should be particularly aware of this problem with an alternate fixation options in the case of patella alta or baja.

Another well-known disadvantage of BTB autografts is a higher incidence of anterior knee pain. Dis-satisfaction and potential inability to return to work have been reported in patients that perform kneeling as part of their occupation or religion (like in Muslims). Other conditions that may disqualify the use of a BPTB autograft include Osgood–Schlatter or patellar tendinosis or tendonitis; however, there is no good data to advocate against BPTB use in this population. A Cochrane review renowned more anterior knee discomfort, especially with kneeling after BPTB autografts. BPTB grafts had a clinically insignificant loss of extension, whereas hamstring reconstructions had a trend toward a loss of knee flexion. BPTB grafts demonstrated a trend towards reduced extension strength while hamstrings grafts had a statistically significant reduction in knee flexion strength.[13]

Patella fracture is another disadvantage that is associated, following ACL reconstruction using BPTB autograft. Stein et al. have reported an incidence of patella fracture following graft harvest of 1.3%; however, these all occurred at least 3 weeks postoperatively.[31] Another study have reported only 2 of 1725 ACL reconstruction (one intra-operative and one postoperative).[32] Although the incidence of patellar fracture is low, the complication should be discussed with the patient preoperatively. This risk can be minimized by taking a bone plug no more than half the length of the patella, making cuts angled and no more than 10 mm deep, avoiding cross-hatching at the corners, and creating a trapezoidal cut rather than triangular or square.

Another limitation of BPTB is the use in the pediatric population. In the pediatric population, with open physes it can result in angular deformity or apophyseal closure. However, several recent studies have demonstrated that this may not be the case. In a recent study, using BTB autografts that traversed the open physis in patients Tanner Stage 3 or greater found no growth disturbance; however fixation was placed extraphyseal.[33] This complication can be minimized by placing the graft centrally in the physis. The more vertical the tunnel, the more circular theaperture, reducing the cross-sectional area of physeal injury. Furthermore, a centrally positioned physeal injury or bar resulting from graft placement may restrict growth but will minimize the risk of angular deformity. However, when the femoral tunnel is placed anatomic, the tunnel is oblique and affects more total volume of the physis.[34] This complication is associated more with double bundle reconstruction. A single bundle anatomic reconstruction affect <7% of the physis [35] which has been shown to be the critical amount for increased risk of partial physeal closure in an animal model.[36]

  Hamstring Graft Top

The gracilis and semitendinosus are typically harvested separately and then combined and doubled over themselves to create a 4-strand graft. Some authors describe creating 5- or 6-strand grafts to improve diameter and strength. Hamstring grafts are typically stretched in order to remove some of the creep in the tendons prior to inserting and tensioning the graft. It can be fixed with numerous fixation devices such as a cortical suspensory fixation, aperture interference fixation, and a combination of these methods.

It produces small scar which hardly leads to a cosmetically ugly scar. The location of the semitendinosus and gracilis tendons' insertion conveniently is in the same location as the starting point for the tibial tunnel, and thus the same incision can be used for both graft harvest and tunnel drilling.

Another advantage of hamstrings grafts is that it avoids the disadvantages reported for bone-patellar bone autograft. In a long-term follow-up study, hamstrings autografts were found to have better IKDC, kneeling, knee walking, and single leg hop compared to BTB autografts; however, hamstrings grafts did have inferior knee flexion strength. This study found no difference in the range of motion, KT-1000 anthropometric data, or pivot shift examination.[37] At an average of 86 months follow-up, another study found no difference in osteoarthritis, Lachman, and anthropometric testing, kneeling, IKDC, Tegner, and single leg hop testing between patellar tendon and hamstrings grafts.[38]

Another long-term follow-up study [39] have noted superior results in the hamstring tendon group in terms of osteoarthritis, motion loss, single leg hop, and kneeling pain, but no difference in IKDC scores. Thus, it can be a better option in patients at the risk of anterior knee pain.

Soft tissue grafts are also favored for a transphyseal approach in skeletally immature patients to minimize the risk of bar formation and a secondary growth deformity.[40]

Another notable advantage is the less postoperative pain. In a study of the early postoperative morbidity associated with ACL reconstruction have demonstrated significantly better pain scores in hamstrings compared to patellar tendon group up to 8 weeks postoperatively; however, the differences were relatively small and the clinical significance was questioned and was not clearly defined.[41]

One of the disadvantage of hamstrings tendon graft is increase laxity over time.[42] Another disadvantage to using hamstrings tendon grafts is that soft tissue to bone healing takes longer than bone-to-bone healing and is less reliable. The intact ACL inserts into the bone through direct insertion, which has 4 zones: Tendon, unmineralized fibrocartilage, mineralized fibrocartilage, and bone.[25] The fibrocartilage has a mixture of collagen II, IX, X, and XI, with type X being the most significant. ACL tendon-bone healing occurs with a layer of fibrovascular scar between tendon and bone at graft-tunnel interface. This eventually organizes into perpendicular fibers that resemble Sharpey's fibers. Presence and number of these fibers are directly correlated with pull-out strength.[43],[44],[45] This process takes approximately 12 weeks, until which time hamstrings autografts demonstrated reduced ultimate failure load when compared to BPTB autografts.[27]

It is also associated with more chances with the tunnel widening.[46],[47] However, this is unknown to be a function of the soft tissue graft or the suspensory fixation [48] often used with soft tissue grafts.[49] There are other causes of tunnel expansion are graft micromotion, stress shielding, drill-related necrosis, accelerated rehabilitation, bone resorption and remodeling, graft swelling, synovial fluid propagation, and increased synovial cytokine production.[11],[50],[51],[52],[53] This tunnel widening hardly affect clinical outcome. A major concern of the tunnel widening is at the time of revision when vastly expanded tunnels may compromise graft fixation necessitating a two-stage revision approach.

Few studies while evaluating the morbidity of hamstring tendon harvest have demonstrated reduced knee flexion strength compared with the contralateral extremity, but similar to the loss of extension strength seen in some studies after BPTB autografts. It is unknown if this difference in clinically significant.[54]

  Bone-Patellar Tendon-Bone or Hamstring Graft Top

There have been several controlled trials comparing the clinical outcome of BPTB and HT graft. It is a notable that in these studies various fixation methods, outcome measurement and different period of follow-up, which is necessary to taken into account while assessing the quality of the studies. The summary of different studies comparing hamstring and BPTB graft has been enlisted in [Table 2].
Table 2: List of the studies that has compared the BPTB and the Hamstring graft for ACL reconstruction

Click here to view

  Quadriceps Graft Top

The quadriceps tendon graft is used mainly in the revision ACL reconstruction.[63] The large cross-sectional area leads to a favorable time-zero biomechanical strength and is particularly useful to fill expanded tunnels at the time of a single-stage revision ACL reconstruction. While both quadriceps tendon and patellar tendon grafts are stronger than the native ACL, several studies have demonstrated weaker mechanical characteristics for the quadriceps tendon graft when compared to a 10 mm patellar tendon autograft.[6],[7]

The major disadvantage to the patellar tendon graft is the possible complication of anterior knee pain, which is mainly due to scar sensitivity, fat pad herniation and neuroma of the infrapatellar branch of the saphenous nerve.

Another disadvantage of the quadriceps graft is the lack of level I clinical studies with long-term follow-up that can demonstrate no functional loss of extensor mechanism strength, similar graft incorporation and longevity as the patellar tendon graft, and minimal donor site morbidity or complications related to the graft harvest. Future studies are necessary to define these outcomes and the role of quadriceps graft in primary ACL reconstruction.

  Allograft Top

The allografts able to eliminate the donor site morbidity completely. That is the reason, why there has been steadily increasing demand of the allograft. Before 1990's, it was popular, but in the nineties it became unpopular due to increased risk of viral disease transmission. Sterilization techniques was known to damage the collagen mechanical properties.[64]

Allograft causes an immunogenic response of the host to the graft and thus delay graft incorporation when compared to the autograft. In a histological study have shown poor vascularization in the center portion of the graft at an autopsy 2 years after reconstruction.[65]

In 2010, Foster et al. conducted a systematic review and analyzed the graft sources affecting the functional outcomes in ACL reconstruction.[66] Out of 31 studies, there were only 4 studies on the functional outcome after allograft used in ACL reconstruction. There was no difference in the outcome for allografts compared to autografts in patients with up to 6 years of follow-up.

There are few studies that have compared allograft with the autograft. This has been summarized in [Table 3].
Table 3: List of the studies comparing the allograft with the autogrft for ACL reconstruction

Click here to view

In spite of having above review, reduction in the morbidity when using an allograft has not been supported. There is also a risk of disease transmission in the allograft. Still its use is increasing.

  Synthetic Top

To surmount the disadvantages associated with allografts while maintaining the benefits such as lack of donor site morbidity and easier surgical technique, there was an inclination toward synthetic grafts in the early nineties. In 1981, Dandy et al. first introduced a carbon fiber reinforced substitute for ACL through an arthroscopic method. However, it became unpopular due to early rupture and carbon deposition in the liver and inflammatory synovitis in the knee.[70] Polytetrafluoroethylene (PTFE) (Gore-Tex) was introduced in 1986 and was approved in the US for use in revision reconstruction autologous grafts. These synthetic ligaments had a very high ultimate tensile strength and also stiffness. They had very encouraging results initially, but later studies showed complications in 76% of the cases [71] with up to 29% graft failure rate,[72] tunnel osteolysis [73] and deposits of PTFE particles in lymph nodes distant to the knee.[74] They were eventually withdrawn from the market in 1993.

The Dacron ligament was then introduced. Despite initial encouraging results [75] a very high rupture rate ranging from 29% to 60% were reported in the literature.[76],[77] While presenting the long-term outcomes authors also noted that 83% of the patients had degenerative changes in the knee joint with only 14% of patients having an acceptable stability and functional outcome.[76] This product was later withdrawn from the market in 1994.

The Leeds-Keio (LK) ligament was developed in 1982. The LK ligament is a “scaffold” type of prosthesis, as it acts as an inducer for tissue ingrowth; porous coating allows the induction of biological tissue and promotes the formation of a neo-ligament on the intra-articular portion. In a study of 152 patients with a follow-up of more than 4 years: 90.1% had a negative Lachman test and 82.2% a negative anterior drawer sign; no major complications were noticed.[78] Engström et al. in a prospective randomized controlled trial comparing LK ligament versus autologous BPTB grafts noticed increased anterior laxity and positive pivot shift test after an average follow-up of 27 months.[79]

Ligament Advanced Reinforcement System (LARS ligament) made of polyethylene terephthalate have an encouraging result. It allows tissue in growth in the intra-articular part. Lavoie et al. presented their study of 47 patients with a follow-up of 8–45 months with good results in subjective parameters and satisfying Tegner activity level. The results with LARS ligament are promising however long-term results are awaited.

  Conclusions Top

The decision making for the surgeon with regard to the choices of graft depends upon the age, activity level; the nature of the injury, patient's occupation and the familiarity with the surgical technique. There still lack of sound evidence regarding the “gold standard” graft concept. Every graft has advantages, as well as disadvantages. The author algorithm for graft choice is described in [Figure 1].
Figure 1: Algorithm for graft choice in ACL reconstruction

Click here to view

Further studies are necessary to standardize the processes involved in ACL reconstruction including the graft choice, graft fixation methods, and rehabilitation protocol.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]


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