Sunday, January 4, 2009

ACL Reconstruction of the Knee: Autograft better than Allograft









ACL Reconstruction restores knee stability and allows athletes to return to their desired sports activities. Two recent studies, one published in 2007 and one in 2008 questions the use of allografts in patients planning to return to sports prior to 1 year after surgery (one study defined younger as under 25 and the other under 40).

My clinical experience in the last 3 years supports the observation that allograft ACL reconstructions fail at a higher rate than autograft ACL reconstructions in younger patients returning to "aggressive" sports. I have noted that younger knees treated with allografts (tibialis tendons) combined with aggressive rehab with return to sport at 6 months have a higher re injury rate than similar patients treated with either patellar tendon (cartoon upper left) or composite hamstring autografts (photo upper right) and similar return to sport programs.

The reason for this observation is unclear but may be due to younger patients having a more active cellullar immune response which leads to allograft resorption or allograft healing times are simply longer than autograft healing times.

More clinical observation and study needs to occur to validate or disprove these findings. At this time these are only preliminary observations. However, because of my observation of autograft successes and allograft failures in 20 + years of practice I will recommend autograft reconstruction for most patients. Both the surgeon and the ACL patient want to have a ONE successful knee reconstruction and agree that graft failure and revision surgery is to be avoided if at all possible. Here is a link for more detailed information on ACL reconstruction.

6 comments:

Eddie said...

Hi doctor Tarlow my name is Eddie Mc Mahon from Ireland,dublin.Iv been doing some research on the internet about a ACL recosruction and i came across your link which i found very helpfull on deciding on the best recon.I am due to get mine done this january but in doubt of having it done im hearing too many bad stories of re injuries i no time is the trick. I ruptured my acl playing a gaelic football match in 2008 and in may 2009 had a knee anthroscope.I recoverd well but im on two minds of getting the big op as im only 27 id like to return to sport within the next year.Is it worth getting the op just to return to sport? iv a phsyical job aswell doing painting and decorating so im thinking that will take its toll on my knee if dont get it done as i need proper stability.Id like your opinion if possible and if i was going for the op id pick Autograft.Looking forward to hearing from you.Thanks Eddie.

Stefan D. Tarlow MD said...

Eddie,

Get your knee reconstructed and use an autograft.

Mike said...

Dr Tarlow,

Thank you for this valuable information -- I wish I had received it years earlier, as I assumed the strongest joint would be from an allograft since I did not have to sacrifice other tendons. Could you give any advice on my situation?

I had arthroscopic ACL reconstruction using an allograft in 1998, at the age of 17. I returned to football and wrestling approximately 4.5 months after surgery. I wore the prescribed brace during all physical activity, but at least once per football game my knee would painfully *pop* and become immobile. I'd have to hop to the sidelines, remove the brace, and wiggle the joint until it *popped* again, at which point I'd replace the brace and get back in the game. Other than during these extreme activities, the knee seemed stable.

Five years ago, I felt that painful *pop* again while pushing a heavy object. Now it happens while doing more mundane activities like hastily push-mowing the lawn. I'm fairly certain that I'm in need of another reconstruction -- (I can easily pull my tibia about 1 cm forward from my bent knee), but I'm not sure which way to go. From what I've read, much has improved with Allografts (stronger due to lower radiation dose, better fastening techniques), and I feel my return to sports was likely premature and is probably what caused the new ACL to fail later in life. I've been considering enlisting in the military, so I'd need something that could hold up to the rigors of boot camp, and possibly combat -- but on that note I wonder what are the dangers of weakening the patellar tendon or hamstring tendon as with an autograft?

One last question -- my original graft was fixed to the tibia with a staple, leaving a palpable bump. If any pressure is placed on that bump (like when kneeling) it is pretty painful -- is that normal?

Thanks --- Mike

Marc said...

What do you suggest for a 15 year old athlete (lacrosse) who is having a second reconstruction because the first reconstruction resulted in an acceptably loose ACL which was not able to support the knee? Can you harvest hamstring tendons twice from the same leg? Does it make sense to invade the healthy knee for tissue? Or do you take your chances with an allograft? Thanks.

scott said...

Is it even at least a possibility that your results are skewed because you compared results using an allograft Tibialis Anterior with an autograft BTB? These types of comments without empirical evidence to back them up do a disservice to patients who are looking for accurate answers. Also, you ignored the increased donor site morbidity, longer recovery/rehab time, and weakening an already weak knee.

Stefan D. Tarlow MD said...

Scott,
Thank you for your feedback. Donor morbidity is nearly none for hamstring autograft. Recovery time is identical for autograft (better if you factor in having to go through revision surgery with allograft), and graft harvest does not substantially weaken the injured knee. There are multiple scientific studies backing up this line of thought - I disagree this is "empirical" evidence. Finally, my experience leads me to conclude that allograft of any type fail at a much higher rate than autograft acl reconstructions. Doc Tlow