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Author Topic: hamstring autograft failed at 7 mos -now what??? Allograft??  (Read 2387 times)

Offline Augsbut

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hamstring autograft failed at 7 mos -now what??? Allograft??
« on: January 14, 2007, 02:16:39 PM »
A month ago I posted a note on this site about my 16 yr old daughter trying to return to football at 6 mos and the concern we had about her instability.  Now two MRI's indicate her graft has failed and she is scheduled for a scope to confirm later this week. 

As you can imagine, she is devastated.  We are now struggling with the decision wheter to use the Patella- tendon autograft or an allograft for the revision.  After the hamstring technique the first time, the allograft seems more attractive but we are afraid of the disease transmission risk and the worry that the allograft won't be strong enough.  ANY advice would be greatly appreciated! 

Offline pauldfc

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Re: hamstring autograft failed at 7 mos -now what??? Allograft??
« Reply #1 on: January 14, 2007, 02:35:21 PM »
Im gutted for your daughter, i am about to go back to footie training next week, its the risk we take!
Mniscus removed form right knee
Miniscus removed from left knee
ACL ruptured left knee
ACL recon left knee

Back playing football, 5 times a week and arguably as fit as i was!!

Offline jb-knee-geek

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Re: hamstring autograft failed at 7 mos -now what??? Allograft??
« Reply #2 on: January 14, 2007, 04:48:47 PM »
the allograft seems more attractive but we are afraid of the disease transmission risk and the worry that the allograft won't be strong enough.

Disease transmission is rare due to graft cleansing techniques and donor verification (in the U.S. at least).

Assuming proper rehab, graft function over time is as good as autografts for most uses.

You might be intereted in these studies,

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16130349&query_hl=1&itool=pubmed_DocSum

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16012489&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 UK Girl !

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Re: hamstring autograft failed at 7 mos -now what??? Allograft??
« Reply #3 on: January 14, 2007, 05:13:55 PM »
Did the graft fail or did it become damaged due to returning to football too soon? just interested as my son was told he could not return to rugby/football  until 9 months post op. I can't remember how long the timescale was but I know he was not allowed to actually kick a ball for a long time even though he could run - the difference being that when running his foot came back in contact with something solid and when he kicked a ball it was left loose.

Good Luck with her next op.

anja
1978 - ruptured acl and all cartalidge removed.
several debridements over years
TKR 10TH JULY 2006 http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=28257.0  Aug 07 patellar maltracking - more physio! Still pain - but so much better !
BIOMET AGC  TKR  (with 10 yr warranty !)

Offline zengirl

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Re: hamstring autograft failed at 7 mos -now what??? Allograft??
« Reply #4 on: January 14, 2007, 10:16:21 PM »
I think the disease risk is very very minimal. I think the allograft method is a good one (although I had a hamstring autograft - but if I had the choice I'd go for a donor graft - one less wound for the body to heal).
Feb '03 Ladies badminton, bad fall, detached ACL
May '06 - ACL reconstruction & meniscus repair
Complications - swelling, pain, lack of flexion/extension, 50% graft failure
Jan '07 Arthoscopy, debride, removal of adhesions & 50% of graft
Attempting to rebuild muscles so can continue sport & life

Offline Kai

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Re: hamstring autograft failed at 7 mos -now what??? Allograft??
« Reply #5 on: January 15, 2007, 12:33:25 AM »
I personally would question the use of cadaver graft in so young a patient...  More importantly, why did the hamstring graft fail ?  The number one reason is improper tunnel placement... something the original OS would be loath to admit...    an autograft failure demands a second opinion...    as far as graft choice goes.. if it was my child it would be contralateral patella....    but that would certainly depend on the OS..  I am very sorry for your child's experience..   I hope things go better in the future.
ACLR - (patellar BTB autograft) left knee - May 31, 2006
Partial Lateral Meniscectomy right knee Feb 20, 2008
Partial Lateral Meniscectomy right knee Aug 11, 2008

Offline loz8

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Re: hamstring autograft failed at 7 mos -now what??? Allograft??
« Reply #6 on: January 15, 2007, 12:59:09 PM »
I would question the PT and the return to soccer at 6 months when there was still some instability. Someone at that age waiting an extra few months to ensure that the knee is fully prepared is certainly of key importance.
Loz
ACL Tear 2001
ACL Recon Oct 2005

Offline bumknee5

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Re: hamstring autograft failed at 7 mos -now what??? Allograft??
« Reply #7 on: January 15, 2007, 03:58:31 PM »
I am a 16 year old female, and I had ACL surgery 6 months ago.  I use allograft and my recovery has been great.  I have been playing soccer since 20 weeks and have no problems.  My vote is for the allograft.  Good luck!

Offline Kai

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Re: hamstring autograft failed at 7 mos -now what??? Allograft??
« Reply #8 on: January 15, 2007, 04:05:16 PM »
bumknee I am very glad that you are doing well.  Im sure that will continue.  The studies I have read are long term..  2 to 4 years out after the surgery and in them, allografts show a 4 to 8 times higher failure rate in young athletic people than the autografts. Its hard to normalize these studies cause there are more than one way to skin a cat, especially with aclr where there are so many different protocols, etc..  but it was enough to convince me.  Many would disagree. 
ACLR - (patellar BTB autograft) left knee - May 31, 2006
Partial Lateral Meniscectomy right knee Feb 20, 2008
Partial Lateral Meniscectomy right knee Aug 11, 2008

Offline jb-knee-geek

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Re: hamstring autograft failed at 7 mos -now what??? Allograft??
« Reply #9 on: January 15, 2007, 07:11:02 PM »
Hi Kai, can you provide a reference for this statement? That is a significant failure rate among athletes.

thanks,

The studies I have read are long term..  2 to 4 years out after the surgery and in them, allografts show a 4 to 8 times higher failure rate in young athletic people than the autografts.
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 Kai

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Re: hamstring autograft failed at 7 mos -now what??? Allograft??
« Reply #10 on: January 16, 2007, 01:54:47 AM »
Hey there JB.  The following information is what I base my opinion on.  It is provided by Sue Barber-Westin, and I am one of her fans.  I hope this helps answer your question.

Sue says -
In response to this issue, it is important that several points and qualifiers
be made up front:

1) My educated guess is that probably 95% follow-up rates, a minimum of 2
years postop. In our studies, we provide an overall rate of failure for all
patients entered, regardless of when or how it occurred. In general, the
allografts failed in 30% of knees with chronic ACL ruptures, whereas
autografts failed in 7%. These are the data we go by and tell our patients
because, in our hands, this is reality. I have read articles of allografts in
which a 0% failure rate is reported and I'm going to refrain on commenting on
these in this forum.

The other important issues with allografts include:

The chance, however remote, of disease transmission. This is true even with
the most careful approach, in which grafts are purchased from tissue banks
certified by the AATB and FDA-inspected, and secondarily sterilized with low
dose irradiation.

Increased cost to the patient/insurance company.

Delayed healing and graft maturation that necessitate a prolonged course of
rehabilitation. Many patients do not follow this advice and wind up with a
failed graft.

Now, we do use allografts in knees with multiple ligament ruptures
(dislocations), and in posterolateral reconstructions. We sometimes use 2
allografts, or 1 allograft and 1 autograft, in knees that undergo two-strand
posterior cruciate ligament reconstruction. We work with only a few tissue
banks, certified by the AATB and inspected by the FDA, and all grafts undergo
low-dose irradiation. So it's important to realize that allografts do have a
role in knee reconstruction, even in a Center such as ours that is more biased
toward autografts. We also use allografts for meniscus replacement.

Certainly, there are many success stories of allografts and that is obviously
a good thing.I remember when we first began using allografts in 1983 in an
effort to decrease the morbidity of ACL reconstruction. Back then, the knee
was completely opened (foot long incision) and the minimum 12-month recovery
was incredibly difficult. The difference in installing an allograft using 2
small incisions and not having to harvest autogenous tissue was wonderful for
many patients. However, with the tremendous advances in graft harvest,
endoscopic (single incision) procedures, and rehabilitation, we simply believe
PT autograft offer the greatest chance of success.

The major studies we have published on allografts are:

Noyes FR, Barber SD, Mangine RE: Bone-patellar ligament-bone and fascia lata
allografts for anterior cruciate ligament reconstruction. J. Bone Joint Surg.
72-A: 1125-1136, 1990.

Noyes FR, Barber SD: The effect of an extra-articular procedure on allograft
reconstructions for chronic ruptures of the anterior cruciate ligament. J.
Bone Joint Surg. 73-A: 882-892, 1991.

Noyes FR, Barber SD: The effect of a ligament augmentation device on allograft
reconstructions for chronic ruptures of the anterior cruciate ligament. J.
Bone Joint Surg. 74-A: 960-973, 1992.

Barber-Westin SD, Noyes FR: The effect of rehabilitation on anterior/posterior
knee displacements following anterior cruciate ligament reconstruction. Am. J.
Sports Med. 21: 264-270, 1993.

Noyes FR, Barber-Westin SD, Roberts C: Use of allografts after failed
treatment of rupture of the anterior cruciate ligament. J. Bone Joint Surg.
76-A: 1019-1031, 1994.
Noyes FR, Barber-Westin SD: Reconstruction of the anterior cruciate ligament
with human allograft. Comparison of early and later results. J. Bone Joint
Surg. 78-A: 524-537, 1996.

Noyes FR, Barber-Westin SD: Arthroscopic-assisted allograft anterior cruciate
ligament reconstruction in patients with symptomatic arthrosis. Arthroscopy
13: 24-32, 1997

In our hands, patellar tendon autograft reconstruction has reliably high (95%)
success rates in terms of restoration of stability, and exceedingly low (1%)
complication rates in terms of knee motion problems. So our decision is based
on years of studies and data from hundreds of patients.

ACLR - (patellar BTB autograft) left knee - May 31, 2006
Partial Lateral Meniscectomy right knee Feb 20, 2008
Partial Lateral Meniscectomy right knee Aug 11, 2008

Offline jb-knee-geek

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Re: hamstring autograft failed at 7 mos -now what??? Allograft??
« Reply #11 on: January 16, 2007, 02:47:52 AM »
Thanks Kai, I remember another poster stating similar numbers (30%) of graft failures for college athletes using allografts in the past.

Not sure the reasons for this, it would be nice to read an article on it though. Perhaps Sue can point us to one?

High level athletes who play demanding sports usually opt for autografts, probably for the reasons Sue states.

For other athletes and non-athletes allografts are a good choice. Recent studies confirm this.

In this case, a revision ACLr on a 16 year old, at least she has the option.

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 ATsoccergirl

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Re: hamstring autograft failed at 7 mos -now what??? Allograft??
« Reply #12 on: January 16, 2007, 03:46:16 AM »
Tough luck for your daughter. 

I think it will be very important to determine why the graft failed before thinking about a revision.  A second opinion wouldn't be a bad idea.  It would also be important to determine if your daughter's knee could handle another reconstruction at this point.  The bone around the tunnels have to be significantly healed in order to drill again. 

In terms of grafts, I would think long and hard before using patellar autograft in a female athlete.  Graft site morbidity and patellar femoral dysfunction is far more likely to occur in female athletes after surgery than males.  Both complications can last for quite a while, and can be quite painful.  This why many OSs prefer to use the hamstring autografts in females.  I believe that allografts are a very viable option for your daughter.  They offer a quicker and often easier recovery.  I think we are just now starting to fully understand everything about allografts.  They do have a slightly higher failure rate.

Today, the allograft failure rate in high level athletes is very similar to the general population.  Today there are far better fixation techniques, better graft selection, and better grafts.  The increasing use of the extremely strong achilles tendon and ant. tibialis has helped this.  It's important to realize that all those articles are at least 10 years old. 

Other autografts may be an option also.  A Contralateral patellar autograft was mentioned.  This involves taking the graft from the opposite knee.  The theory is that the trauma of surgery is spread between the two knees so that both recover faster.  With a contralateral graft, patients can accelerate rehab fairly early on.  It also greatly reduces the chances of graft site morbidity to about 1-2%, an ispilateral graft generaly has a chance of graft site morbidity around 10-15%.  However, surgeons generally want patients who choose this option to be older.  Another option would be using the quad tendon.  This graft only has one bone plug, but the harvested graft can be larger.  There is also a low chance of harvest site issues. 
1999 LR, 2002 ACL/PLC recon, reversal of LR, 2004 ACL revision, 2006 Car accident torn PCL and small fractures resulting in bone chips in my knee.  Torn MCL 3 times.  Wicked screws under IT band and Pes Anserine.  June 2008-Hip Arthroscopy.

Offline loz8

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Re: hamstring autograft failed at 7 mos -now what??? Allograft??
« Reply #13 on: January 16, 2007, 09:55:16 AM »
Is there an argument that no matter what graft is used there comes a time when you have to just accept that the patient has returned to competitive sport too quickly?
Loz
ACL Tear 2001
ACL Recon Oct 2005

Offline ATsoccergirl

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Re: hamstring autograft failed at 7 mos -now what??? Allograft??
« Reply #14 on: January 16, 2007, 12:39:45 PM »
According to her mother's previous posts, she was released by her OS and had already been training.  The instability started when she started doing more dynamic moves, ie cutting.  Based on this, It sounds like the graft may have failed earlier in the process rather than at that moment. 

Just another thought, before the scope ask that they take a look at her posterolateral complex.  Early ACL failure can be caused by damage to these structures.  I've seen stats as high as 60% of early ACL failures (between 4-8 months) can be caused by the PLC.  Damage to these structures can put a great deal of strain on a new graft since there is no restraint to external tibial rotation.  This is something that may have not shown up on the MRI.  I had a combined injury, and luckily I was referred to a surgeon who knew how to diagnosis the PLC injury, so I had a combined surgery. 
1999 LR, 2002 ACL/PLC recon, reversal of LR, 2004 ACL revision, 2006 Car accident torn PCL and small fractures resulting in bone chips in my knee.  Torn MCL 3 times.  Wicked screws under IT band and Pes Anserine.  June 2008-Hip Arthroscopy.

 















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