Autograft Versus Allograft Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized Clinical Trial with a Minimum 10-year follow up
Bottoni CR, Smith EL, Shaha J, Shaha SS, Raybin SG, Tokish JM, & Rowles DJ. Am J Sports Med. Published Online First: August 26, 2015; doi: 10.1177/0363546515596406.
Take Home Message: Overall, revision rates for ACL reconstruction were relatively small 10 years post surgery. However, ACLs that were reconstructed with allografts had three times higher failure rates than autograft reconstruction.
Anterior cruciate ligament (ACL) reconstructions are relatively common in the athletic and physically active populations. Sports Med Res has a few posts on articles addressing the graft selection dispute, yet the debate continues as to which graft may be the ideal selection for optimal short- and long-term outcomes. The authors of this randomized clinical trial conducted a long-term follow-up to assess patients who had either an ACL reconstruction with a hamstring autograft or an allograft (tibialis posterior). The participants were on active military duty and over 18 years of age at the start of the study. Participants completed the same rehabilitation protocol. At 10 to 11 years post-surgery, the authors assessed graft integrity, functional status, as well as subjective knee stability, function, and symptoms. The 78 patients with 79 ACL reconstructions reported favorable outcomes with no differences between groups. However, the overall mean scores are lower than previously reported normative data (from healthy individuals). The authors found only 17 failures during the first 10 years after surgery; however, the number of allograft failures (27%) was 3 times higher than autograft failures (8%). There were no differences in patient-reported outcomes or activity levels between graft types among knees that remained stable.
Clinically, the autograft reconstruction technique had a lower number of failures in comparison to the allograft reconstruction. While the overall number of failures requiring revisions were relatively low, it is alarming that retears for allografts were 3 times higher than autograft rates. ACL injury, and subsequent reconstruction, are risk factors for osteoarthritis. In fact, about half of patients that have had an ACL reconstruction have evidence of osteoarthritis by 10 years post surgery. It would be interesting if the authors of this study assessed the participants for osteoarthritis or degenerative evidence. Participants had comparable outcomes for symptoms, stability, function, as well as activity levels. While these outcomes were deemed favorable by the authors, it is concerning that the outcomes reported in this research study were overall lower than normative data in previous comparable age groups. Ultimately this highlights the need for more research regarding long term radiographic outcomes, and the question as to whether allografts have clinically significantly higher revision rates. Graft selection is often based on surgeon expertise, however, if a patient has an option, they should consider the higher incidence of allograft failures. As clinicians, we may need to educate our patients regarding graft choices. While patient perceived outcomes are similar between grafts, there appears to be a greater risk of retear with allograft selection.
Questions for Discussion: Are there any clinical findings that you consistently see with patients who have chosen either allograft or autograft? How many patients do you know that have had a choice regarding graft and what factors have you counseled them on?
Written by: Nicole Cattano
Reviewed by: Jeffrey Driban
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