Anterior cruciate ligament reconstruction

 

 

Graft options for ACL reconstruction

There are two common options for the graft material:

• Autograft - using the patient's own tissues for the reconstruction
• Allograft - using donor tissues rather than the patient's own tissue

Artificial ligaments and xenograft (animal material) remain options but are seldom considered.

 

• Quote from peer-reviewed paper:

  ....In ACL reconstruction, clinical results with autografts are as good as or slightly better than with allografts. Allografts cost more, indicating that autografts are more cost-effective and should usually be first choice....."

  Citation: Mistry H, Metcalfe A, Colquitt J, Loveman E, Smith NA, Royle P, Waugh N. Autograft or allograft for reconstruction of anterior cruciate ligament: a health economics perspective. Knee Surg Sports Traumatol Arthrosc. 2019 Jun;27(6):1782-1790. doi: 10.1007/s00167-019-05436-z. Epub 2019 Mar 14. PMID: 30874836; PMCID: PMC6541574.

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Graft harvest and preparation for cruciate surgery

The native anterior cruciate ligament provides stability between the femur and the tibia of the knee both in a backwards/forwards direction and also in rotation.

To achieve this, the native ACL has two ligament bundles and they work synergistically to distribute the loads. This is very challenging to reproduce in an ACL reconstruction, and has given rise to the concepts of single-bundle and double-bundle reconstruction techniques.

 

• Quote from peer-reviewed paper:

  ....The autograft choices most commonly used include hamstring (HS), bone–patellar tendon–bone (BPTB), and quadriceps tendon (QT) with or without a bone block......"

  Citation: Buerba RA, Boden SA, Lesniak B. Graft Selection in Contemporary Anterior Cruciate Ligament Reconstruction. J Am Acad Orthop Surg Glob Res Rev. 2021 Oct 25;5(10):e21.00230. doi: 10.5435/JAAOSGlobal-D-21-00230. PMCID: PMC8547917.

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Are there long term issues at the donor site?

Patients will be concerned about those sites where there own tissues have been harvested for the ACL graft.

For example, calf pain is common after a hamstrings graft for ACL reconstruction, and patellar-tendon graft patients are likely to have problems kneeling and walking on their knees.

 

• Quote from peer-reviewed paper:

  ....proper [hamstrings] harvest can be challenging, and several complications can be encountered, including, iatrogenic neurovascular damage, premature amputation of the tendons, graft contamination, and postoperative hematoma......"

  Citation: Familiari F, Palco M, Russo R, LaPrade RF, Simonetta R. How to Avoid Common Complications in Hamstrings Harvest for Anterior Cruciate Ligament Reconstruction: A Practical Guide. Arch Bone Jt Surg. 2023;11(7):458-464. doi: 10.22038/ABJS.2023.70676.3310. PMID: 37538129; PMCID: PMC10394750.

• Quote from peer-reviewed paper:

  ....Postoperative donor-site morbidity and anterior knee pain following ACL surgery may result in substantial impairment for patients....hamstring tendon autografts appears to cause less postoperative donor-site morbidity and anterior knee problems than the use of patellar tendon autografts......."

  Citation: Kartus J, Movin T, Karlsson J. Donor-site morbidity and anterior knee problems after anterior cruciate ligament reconstruction using autografts. Arthroscopy. 2001 Nov-Dec;17(9):971-80. doi: 10.1053/jars.2001.28979. PMID: 11694930.

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Long term considerations after cruciate injury

Patients with cruciate ligament problems are often sportspeople, anxious to return to their game.

However it is important for them to realise that the knee is now fundamentally different, and long term outcomes will depend on carefully protecting that knee over the long term.

 

• Quote from peer-reviewed paper:

  "It is of paramount importance to understand the long-term consequences that develop as a result of an ACL tear....more than 50% of patients that sustain an ACL injury will develop symptomatic OA in the following 10 to 20 years. When combined with a meniscectomy, an ACL tear can further increase the prevalence of OA."

  Citation: Paschos NK, Howell SM. Anterior cruciate ligament reconstruction: principles of treatment. EFORT Open Rev. 2017 Mar 13;1(11):398-408. doi: 10.1302/2058-5241.1.160032. PMID: 28461919; PMCID: PMC5367541.

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Forum discussions

• Quadriceps tendon graft

  Discussion about quadriceps (quads) tendon graft, and also other graft options.

• recovery of gracilis after hamstring aclr?!

  Discussion about struggles after hamstrings harvest.

• ACL Repair at 62?

  Interesting chat about the need to consider ACL reconstruction after coping well with instability for many years..

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