Graft Choice in ACL reconstructions - The Place of Allografts

[jamiec123]

Well good luck with the op Tony and make sure u post as soon as u can to let us know how it went!!

Jay

[tony1233]

Thanks Jay,

getting excited and nervous now, o nly one more night of sleep, if you can even call it that at this point. I know I havenèt really slept well in the last few nights so Im sure I wont sleep tomorrow night at all

I plan on trying to post wednesday evening, not 100% sure how well that will go though LOL please forgive if nothing makes sense.

Tony

[ACLDad]

I am new hear.  My 18yr old college freshman tore her acl a month ago.  Her doctor did a anterior tibial allograft.  I am not sure of the attachment method he used.  Everything happened so fast we had about 10 days from the tear to the surgery.  Now we hear all of these horror stories about allograft failures happening all the time.  Am just looking for some reassurance here.  I want to thank Steve for his excellent advice.  It would seem that there is no need to try to return as quickly as possible but rather resign yourself to 8 to 12 months to let the graft (regardless of allo or auto) fully vascularize, and at her age the chances of that occuring fully are good right.

Tony - ACLDad

[drmark]

I don't think the "allograft is where its at"
Finally, a multicenter study, with a minimum of 6 years followup, and Level 2 evidence.  (Level 1 evidence may not be possible to procure considering it would be unethical to not inform patients what was implanted in them)

Sorry to bust the bubble.........

http://ajs.sagepub.com/content/39/2/348.abstract

[sherwooa]

So that MOON study is definitely interesting, and I can't see the full text, but I have read elsewhere (http://www.orthosupersite.com/view.aspx?rid=32440) that this study only compares tibialis allografts with hamstring autografts.  Given that, it doesn't seem scientifically valid to say that all autografts are superior to all allografts, especially since many allografts now are done with B-P-B instead of free tissue.  Thoughts?

[drmark]

If you are interested, you can email me at [email protected] and I will forward to you the entire PDf.  Many different autografts and allograft types were used in the study.  For purposes of analysis the autografts were grouped together and the allografts were grouped together. 

In my not so humble opinion, the hopes, prayers, and desires of the immediate world will never be answered that dead tissues taken from a dead person, soaked in caustic stuff to kill the  "cooties", or worse irradiated, can ever work as good as living tissue taken from the person who is receiving that same tissue.  Even as we continually grasp at straws in order to show it.  When will nutrasweet and skim milk be shown to make a dessert as tasty as the one made with real sugar and real cream?
Mark Sanders MD FACS

[nathanappasamy]

Hello everybody,



I am looking for people who have had Anterior Cruciate Ligament Reconstruction on at least one of their knees to take part in a study focusing on the effects and impact of ACL Reconstruction surgery on someone's Athletic Identity.



As someone who has had multiple knee surgeries, I am very interested in the psychological effects of such mobility impairing surgery and do not believe there has been enough research undertaken in the field. The hope for this study (which is part of an MSc in Psychology) is to provide a greater insight into the short term and longterm effects of ACL reconstruction on a person's sense of Self and Identity. If you have had ACL reconstruction surgery and would like your experiences to count towards our understanding within the field, your contribution is of value.



If you would like to take part in the study (which should take no longer than 15 minutes to complete), please click on the below link for further information. Alternatively, copy and paste the link directly into the address bar of your browser. If you know of anyone who may also be interested, then I would be grateful if you would notify them of this opportunity to participate:



https://www.surveymonkey.com/s/NNAquestionnaire



If you have any questions (which are not answered by the information sheet, after clicking on the link), please contact me by email at [email protected], and I'll be happy to help.



Nathan Appasamy

[sherwooa]

Thought I'd post some of the recent research on auto vs. allo, though it adds to the confusion a bit.  Though not as big as the MOON study, here is a recent prospective, multicenter cohort study with Level II evidence that shows no statistically significant differences between the two types of grafts:

http://www.ncbi.nlm.nih.gov/pubmed/21694588

"Abstract

OBJECTIVE:
To compare the clinical outcomes after anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone autograft (BPTBAu), BPTB allograft (BPTBAll), or hamstring (semitendinosus-gracilis) tendon autograft (HTAu), performing bone drilling with same methods in terms of transtibial drilling, orientation, positioning, and width of femoral and tibial tunnels.
DESIGN:
Multicenter prospective cohort study (level of evidence II).
SETTING:
Departments of Orthopedic Surgery of Centro Médico Teknon (Barcelona, Spain) Clínica Universitaria de Navarra (Navarra, Spain), and Clínica FREMAP (Gijón, Spain).
PATIENTS:
All patients with ACL tears attending 3 different institutions between January 2004 and June 2006 were approached for eligibility and those meeting inclusion criteria finally participated in this study.
INTERVENTION:
Each institution was assigned to perform a specific surgical technique. Patients were prospectively followed after undergoing ACL reconstruction with BPTBAu, BPTBAll, or HTAu, with a minimum follow-up of 24 months.
MAIN OUTCOME MEASURES:
Included knee laxity and International Knee Documentation Committee (IKDC) score. Knee laxity was assessed with the KT-1000 arthrometer (evaluated with neutral and external rotation positions) and both Lachman and pivot shift tests. Additional outcomes included main symptoms (anterior knee pain, swelling, crepitation, and instability), disturbance in knee sensation, visual analogue scale (VAS) for satisfaction with surgery, range of motion (ROM), and isokinetic knee strength.
RESULTS:
There were no significant differences among the 3 groups for any of the clinical outcomes, except for a slightly greater KT-1000-measured knee laxity in external rotation in the BPTBAu compared with the other groups. All patients demonstrated grade A or B of the IKDC. The mean VAS for satisfaction with surgery in all patients was 8.5.
CONCLUSIONS:
The selection of the surgical technique for ACL reconstruction may be based on the surgeon's preferences."

[filamentary]

Allografts are where it's at.  Robbing Peter to pay Paul (autografts) is not a particularly good idea since God didn't make us with any spare parts. 

i don't agree that allografts are where it's at, at all.  they're great for older patients, or patients who don't do a lot of vigorous/challenging physical activities.  basically people who only use their legs for walking, and maybe do a little family-friendly hiking with the kids or grandkids.  but they have a crazy high failure rate in young and athletic people.  i just keep seeing disheartening story after disheartening story of people who've had multiple ACL reconstructions.  most people will never tear an ACL once in their lifetime.  it's not exactly a high-frequency injury.  it's already unfortunate that we only have one ACL and it can't regenerate.  but the whole idea behind reconstruction is that you should be as prepared for the world and sports activity as you were with your original, not some weaker, less-prepared version of yourself, where it's just a matter of time before this sad, inadequate little thing snaps.

with autografts, you often end up with an ACL that's stronger than it originally was.  and the loss of strength to the hamstrings is pretty minimal, and able to be compensated by training the muscles.  perhaps if you are a competitive lifter whose major competitive lift is the romanian deadlift, you might be put out by this, but the loss of strength isn't enough to make you incapable of having a strong, muscularly balanced and well-protected knee.  you can't compensate or train away laxity or weakness in a ligament.  frankly i'm surprised there are so many doctors willing to do allografts as often as they seem to be getting done.  sure, it's scary, and it's a longer recovery, having tissue harvested from your own body.

but if you're going to have ONE little broken thing in your knee, why not just be missing two measly little tendons from your hamstrings, which operate quite well without them (the three they don't harvest are way more massive and important to the hamstrings' function), rather than be missing the very important ligament inside your knee?  doing a hamstring autograft is basically just shifting the injury from inside the knee joint capsule to the back of the knee, to the hamstrings, but also while diminishing the severity of the injury.  you can't change that you permanently injured your knee, and that it will never be the same knee you had before the injury.  but with a hamstring autograft, you can shift the damage to the big, strong hamstring, which easily absorbs the damage b/c of all the redundant working-together fibers (unlike the lonely ACL).  and also the literature shows that one of the two harvested tendons is actually starting to be recognized as having regenerated (even though it is often repeated that lost tendons are just lost forever)!  so you're really only short one tendon, and have one (perhaps slightly less good than original due to surrounding scar tissue) regenerated one.  that seems like a really excellent compromise.

having multiple subsequent re-tears of the ACL and additional reconstruction surgeries (each time, taking a full year out of your normal life, and enduring some of the most awful pain and immobilization it's possible to have, plus adding more and more scar tissue which is increasingly understood to be the main source of all pain and mobility issues over the long term), this seems like a terrible alternative.  and this is exactly what a huge percentage of allograft patients have in their future.  why not skip the whole mess?  if the replacement ACL is as strong as the original, then it's just as unlikely that it'll break the second time as that it broke in the first place.  it's just as likely that they'll tear the OTHER leg's ACL as that they'll re-tear the graft.  well, i guess i'd be amiss not to acknowledge that having a dominant foot might make one leg more likely to be injured in a given sport than the other due to certain ways of holding the body in situations where collisions or falls tend to occur.

i mean, assuming they follow medical advice and heed the one-full-year-to-full-recovery guideline (some people really push it trying to get back to sports too soon, and while i understand the desire to do this, if it re-breaks, they shouldn't be surprised) they should fix their ACL and put a tremendous amount of effort, over the following year, into recovery (including strength training), then that should be it, they should never have this problem again unless they're supremely unlucky a second time.  but with allografts, they're way more likely to tear it again (more likely than they were before the ACL reconstruction, and more likely than their never-ACL-deficient teammates).  it just seems like too small a payoff (a slightly shorter/less painful initial recovery, but still followed by a full year of waiting for the graft to "take" fully) to trade out a permanent, once-and-done fix versus one you have to repeat, time and again, thus actually adding up to far more cost, recovery time, and total time spent immobilized and suffering.

i have researched the HECK out of this thing before my own surgery, and all the best doctors and institutions seem to be leaning this way.  especially in the knees that are most in need of being returned as close as possible to original condition and capability, like professional athletes.  and if it's the best for them, it's also the best for the rest of us (except, as i mentioned, people who basically only use their legs for walking).  i'm really surprised to find someone here prominently advocating allografts, when they have such a high failure rate.  especially b/c it's easy to be swayed toward thinking you want an allograft out of fear of the harvest site pain, but really people need to be reassured that it's better to get back a functional ACL and have a teeny bit of injured hamstring tissue, and NEVER revisit the problem again.  this seems way more responsible than the alternative, which so often ends in multiple surgeries.

[healingup]

With Lars u can return to sports much sooner than with allograft/autograft. HOWEVER, syntetic grafts are not living tissues so it can only break down. Living tissues have the ability to remodel, repair to a certain extent etc. So it is still not know whether lars hold for your entire life. 10 year follow up is fine but it is the 40 year that u are interested in. If u can offord to take it easy for one to two years I would go for the allograft.