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Author Topic: Patella Tendon Autograft versus Allograft  (Read 3131 times)

Offline TR

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Patella Tendon Autograft versus Allograft
« on: June 22, 2006, 04:56:51 PM »
Dear Geeks,

Firstly I have to share my delight in the knowledge of your existence…somehow the fact that others out there are suffering too and can share in my frustration makes things better – no that’s not what I meant…hope you get the meaning.

Anyhow I have this dilemma: I have had a hamstring tendon autograft in December  that has recently been diagnosed to have been a failure. One surgeon – Fares Haddad has suggested an allograft and another – the person who did the original autograft has suggested a patella autograft.

Now it’s 1 -1 in the auto – allo finals. I have a final appointment with Andrew Williams on the 4th July to obtain another opinion and hopefully decided which to undertake. I have also read these message boards and am none the wiser.

These are my thoughts but would like to hear from others who know better, have experience:

•   The allograft requires less surgery time and involves less weakening of the leg, quicker recovery period and less time off work  but there’s a small risk that the tendons can become infected. In the long-run it is also slightly weaker – also more expensive!
•   The patellar tendon autograft involved further weakening of my right leg – on which I already have had the hamstring autograft – meaning further weakening of the leg that was operated upon as recently as December last year. In the long-run its stronger but requires a longer recovery period – also cheaper

What do you think?

Offline kevc

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Re: Patella Tendon Autograft versus Allograft
« Reply #1 on: June 22, 2006, 05:18:19 PM »
I'd go with the patella autograft because:

1) Its stronger

2) I dont think recovery period is longer - patalla ACLR recovery is about 2 months faster than hamstring ACLR

3) You want this to be your last ACLR right?  Allografts have a higher risk of requiring revision from what I have read.

What kind of activity level do you want to return to and how soon?  Allografts are preferred for revision patients who are not desiring returning to a high activity level fast.

The only side effect of patella graft is that the graft site is very sore after the op and the area will always be sensitive meaning you find it painful/uncomfortable to kneel.  For me personally I'd use allograft as a last resort.  After I had no more tissue left.  I had an autograft revision.
07/01 ACL rupture, left knee
08/02 ACL reconstruction (patellar tendon graft)
10/05 Re-tore ACL graft
01/06 Scheduled for ACL revision using hamstring graft

Offline smokyter

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Re: Patella Tendon Autograft versus Allograft
« Reply #2 on: June 22, 2006, 05:22:53 PM »
TR,
Sorry to hear that you have to go through it all over again.  I had a patella autograft a month ago.  I chose to go with the auto because of the chance of infection.  That was before I knew how small the risk was though.  If I had it to do over, I’d go for the allograft.  For me, it seems like one of my biggest inhibiters from healing quickly has been the graft harvest site.  Even now, a month later, the remaining 2/3’s of my patella tendon is very tight.  There is also the real possibility of having lifelong patella pain with the auto-patella graft.  I don’t have to worry about cost though because of my insurance.  If I had to foot the bill on my own, I might go for the cheapest.  You have a hard decision.  Good luck. 
 ;D
04/22/06- Complete ACL tear and bucket handle tear of the meniscus.
05/26/06- Patella autograph and meniscus repair scheduled.

Offline TR

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Re: Patella Tendon Autograft versus Allograft
« Reply #3 on: June 22, 2006, 05:29:19 PM »
Thanks for the swift reply geeks....

But Noooooo not the mixed signals that makes it 2-2 in the allo-auto sudden death...sudden death? that has to be a yellow-card offense. Apologies for my idle banter just have this world cup fever that threatens my sanity.

Seriously though my pain threshold is not very high so is the trade-off between lifelong patellar-region aches and pains(plus not being able to kneel properly versus a slightly more lax ACL?

Offline jb-knee-geek

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Re: Patella Tendon Autograft versus Allograft
« Reply #4 on: June 22, 2006, 07:30:00 PM »
there were several kneeguru threads in the past which deal with this subject.

In the US allografts are safe with excellent results. Outside of the US, not sure how available they are...

Allografts take longer to revascularize, not an issue if you are careful for the first year(s). After 2 years, not sure there is a difference. My 2 cents.

here's a recent study from pubmed.com, do a search on allograft, lots of good stuff.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=16533430&query_hl=1&itool=pubmed_docsum
torn RK ACL March 2001, surgery Aug. 14 2006, after 4 knee sprains since Oct. '05.  Allograft, ~40% medial meniscus removed, some wear in the trochlear groove. Everything else looks good.

Post-op diary: http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=29749.

Offline jb-knee-geek

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torn RK ACL March 2001, surgery Aug. 14 2006, after 4 knee sprains since Oct. '05.  Allograft, ~40% medial meniscus removed, some wear in the trochlear groove. Everything else looks good.

Post-op diary: http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=29749.

Offline jennifer_in_clyde

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Re: Patella Tendon Autograft versus Allograft
« Reply #6 on: June 22, 2006, 07:40:35 PM »
I'm having an ACLR in 3 weeks and just had to make this decision.

I have a good surgeon who I trust very much. He wanted me to make my own decision - and provided research for me to look at as well. But his advice - since I am 34 (not 15) was the allograft.

He suggested this because the more of your own supportive tissue you remove - the more pain you rehab through (and I'm also having a meniscus repair - which will have a longer slightly tougher rehab already)- and the tougher it can be as you age and degenerate (ie as you get older your patela tendon would weaken on it's own - and would weaken more if you remove portions of it for an autograph).

In his experience his allographs have equal long term strength to autographs (at 2 years and longer) at one year he finds the allograph to be at 75-80% strength vs 80-85% for an autograph.

He said he would do an allograph on his own knee for all of these reasons.

Some doctors however do NOT have the same sucess rates (ie no need for revisions in the next xx years) and do better with autographs - and may not be as confident in their tissue sources (and may have higher infection rates). All of these things should be looked at with your own OS before you decide.

Tough to have to think about all of this stuff in addition to the trauma of needing the surgery in the first place!!
May 2006 ruptured right ACL and tore medial meniscus
July 14 2006 allograft ACLR and meniscus repair
July 2011..reinjury - is my ACL okay??
December 2011- surgery - turned out to be a articular cartilage tear - MFX and lateral menisectomy

Offline keather

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Re: Patella Tendon Autograft versus Allograft
« Reply #7 on: June 22, 2006, 08:23:25 PM »
Another thing to discuss or consider is the potential for a mismatch in length.  This is something that I did not find in my pre-surgical research and not something mentioned by the surgeon when discussing risks and potential complications.  Of course, the chance of a length mismatch in an autograph is likely to be less.

But if anyone has any information/experience with this issue, I would love to hear. 

My surgery took much longer and the technique of fixation modified because of a mismatch between my knee and the allograft.  Had I known that this could happen, I may have chosen either a different surgeon or a different graft type.  I ended up with a longer surgery (more cost) another tunnel chiseled into my tibia and a reconstruct with a higher probablity of failure, not due to revascularization issue.

TR - if you talk to your surgeon about this, please let me know what you learn.
Complete ACL tear and tibial plateau fracture/contusion Feb 28 2006 2 hours into ski vacation

ACL reconstruction w/ patellar tendon allograft May 17 2006

Offline jb-knee-geek

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Re: Patella Tendon Autograft versus Allograft
« Reply #8 on: June 22, 2006, 09:20:44 PM »
keather - have you had a 2nd opinion of the technique used? I've never heard of the graft length being an issue in allograft ACL surgery. I read that the graft is measured and cut to meet the need.

JIC - HIV and HepC infections are almost nil, thanks to graft preparation by companies who provide the grafts. Infection rates from surgery are probably the same for any surgery.

more on the subject:

http://www.medscape.com/viewarticle/408512
torn RK ACL March 2001, surgery Aug. 14 2006, after 4 knee sprains since Oct. '05.  Allograft, ~40% medial meniscus removed, some wear in the trochlear groove. Everything else looks good.

Post-op diary: http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=29749.

Offline keather

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Re: Patella Tendon Autograft versus Allograft
« Reply #9 on: June 22, 2006, 10:46:12 PM »
I have not gotten a second opinion yet but intend to.

As I understand it, this can be planned for but maybe wasn't in my case :'( :-\ :o >:( :(  Also, as I understand it, the graft was so extra long and likely already fixed on the femur end that the bony part on the tibia end was entirely outside the hole drilled thru my tibia that the only thing to do was to fix it in a tunnel along the front of my tibia - or to cut off the bony end.  My main concern is the increased potential for it to fai

I am hoping to hear from more folks thru this forum that have encountered the mismatch issue either pre-surgery (planning) or after surgery.  So far I have heard from 2 that it was planned for and have read about 2 individuals that have had the staple fixation.

Complete ACL tear and tibial plateau fracture/contusion Feb 28 2006 2 hours into ski vacation

ACL reconstruction w/ patellar tendon allograft May 17 2006

Offline jb-knee-geek

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Re: Patella Tendon Autograft versus Allograft
« Reply #10 on: June 22, 2006, 11:25:04 PM »
It sounds like youv'e had a BTB patellar tendon allograft inserted.

Perhaps they drilled a piece of your tibia to "fit" that bone graft into your tibia.

You've got bone (end of the patallar graft) growing into bone (extra hole in tibia). Other than the extra drill site, is that a bad thing? BTB patella allografts are strong once revascularized. What level of sports or activites do you play?

What does your OS think? Has he done any more of these?


torn RK ACL March 2001, surgery Aug. 14 2006, after 4 knee sprains since Oct. '05.  Allograft, ~40% medial meniscus removed, some wear in the trochlear groove. Everything else looks good.

Post-op diary: http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=29749.

Offline keather

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Re: Patella Tendon Autograft versus Allograft
« Reply #11 on: June 22, 2006, 11:38:20 PM »
Sounds like you got the picture. 

The concern I have is primarily the increased chance of failure because of the tendon now has two places to rub against bone and potentially fail - the corner formed by the two tunnels drilled into my tibia and also the sharp angle of the tendon coming out of the tibia into the joint tunnel.   Had the graft been fixed inside the normally used tibia tunnel, the point of fixation would have been closer to the anatomical location of a normal ligament to bone which I have read is less desirable.

I have also read about problems with the staple pulling out or the graft slipping under it.  Increased potential for laxity was also mentioned.

My physical therapist (Ph.D. and hundreds of ACL clients) has never heard of this.  When I asked my surgeon, he said that it happens 10-15 percent of the time with allografts.  What also really irks me is that if this is true, which I remain skeptical about, why was it not mentioned to me in addition to things that were alot less likely to happen.

As for sports, skating (rollerblading, ice, skate skiing) and telemark skiing have been my passions but may need to rething doing these for quite sometime in order to safeguard.  I also jog, hike in the AK mountains.  Would be playing ultimate frisbee and going tandem paragliding this summer..........  Bike alot too which I think will be my new mainstay along with jogging.........

« Last Edit: June 22, 2006, 11:42:13 PM by keather »
Complete ACL tear and tibial plateau fracture/contusion Feb 28 2006 2 hours into ski vacation

ACL reconstruction w/ patellar tendon allograft May 17 2006

Offline jb-knee-geek

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Re: Patella Tendon Autograft versus Allograft
« Reply #12 on: June 23, 2006, 12:12:43 AM »
10-15% of the time? That's hard to believe, and your PhD. physical therpist hasn't heard of it all?

I've never read about it, nor has anyone on these boards asked about it in the 2 years I've been hanging around this site.

I'd get a 2nd opinion, even 3rd from the top OS in your area, ask around at a university athletic dept. or ski resort, bound to be some ACL experience there.



torn RK ACL March 2001, surgery Aug. 14 2006, after 4 knee sprains since Oct. '05.  Allograft, ~40% medial meniscus removed, some wear in the trochlear groove. Everything else looks good.

Post-op diary: http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=29749.

Offline feeny

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Re: Patella Tendon Autograft versus Allograft
« Reply #13 on: June 23, 2006, 05:29:32 AM »
If it were my leg and I had already had the hamstring autograft I would probably opt for the allograft.
I wouldnt want to make my leg any weaker again than necessary.
I believe the chance of infection and rejection is very very low.

I would however seek out an allograft specialist - someone who only does allografts and knows all the ins and outs of measurement and handling of allografts.

To clarify -- if it were my first injury I would opt for hamstring autograft - single strand unless there was a reason not to.
Sep-05 ACL rupture, Medial mensical tear, MCL rupture
Oct-05 Had it all repaired (hamstring graft, meniscal rivet)
-and then-
4.5 Months post-op Snowboarding like a demon
7 Months post-op Successful return to indoor soccer (YEH!)

Offline patpalloon

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Re: Patella Tendon Autograft versus Allograft
« Reply #14 on: June 23, 2006, 08:47:08 AM »
My PT has been on a course by a leading ACL surgeon (I forget his name) and his method of choice is patella tendon autograft, but harvested from the good leg. This could be an option if you're having a revision and didn't want to weaken the injured leg any more.
LEFT KNEE: ACL and medial meniscal tear Sept 05.
Arthroscopy Jan 06.
Hamstring ACLR Apr 06.

RIGHT KNEE: meniscal tear 2008. Partial meniscectomy 2008 and again 2009.

 















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