Bone-Patellar
Tendon-Bone Autograft Versus Allograft in Outcomes of Anterior Cruciate
Ligament Reconstruction: A Meta-Analysis of 5182 Patients
Tendon-Bone Autograft Versus Allograft in Outcomes of Anterior Cruciate
Ligament Reconstruction: A Meta-Analysis of 5182 Patients
Kraeutler
MJ, Bravman JT, & McCarty EC. American Journal of Sports Medicine. 2013, E-pub ahead of print. DOI:
10.1177/0363546513484127
MJ, Bravman JT, & McCarty EC. American Journal of Sports Medicine. 2013, E-pub ahead of print. DOI:
10.1177/0363546513484127
Take
Home Message: There is still no clear answer as to whether to use an autograft
or allograft bone-patellar tendon-bone ACL reconstruction.
Home Message: There is still no clear answer as to whether to use an autograft
or allograft bone-patellar tendon-bone ACL reconstruction.
Patients and clinicians often need to
consider what surgical options they prefer when undergoing anterior cruciate
ligament (ACL) reconstruction. Many
physicians and researchers have investigated the benefits of either an auto- or
allo- bone-patellar tendon-bone graft, however, conclusive evidence as to which
is the best option has yet to be determined.
The purpose of this meta-analysis was to compare outcomes between these
two specific surgical options in efforts to better answer this debate. A literature search yielded 76 studies
published between 1998 and 2012 that included 5182 patients (young and
physically active) who had ACL reconstruction utilizing either an auto- or
allo-graft reconstruction. The studies
did not have to directly compare the two types of grafts. Outcomes of interest
were passive knee stability (pivot-shift), anterior knee laxity (KT-1000),
single-legged hop, anterior knee pain, return to preinjury activity level, and
overall International Knee Documentation Committee (IKDC) scores.
The authors found that patients with allografts had better return to
preinjury level, passive knee stability, overall IKDC scores, and anterior knee
pain. However, patients with autografts had
better graft rupture rate, subjective IKDC scores, Lysholm scores, anterior
knee laxity, and single-legged hop test performance.
consider what surgical options they prefer when undergoing anterior cruciate
ligament (ACL) reconstruction. Many
physicians and researchers have investigated the benefits of either an auto- or
allo- bone-patellar tendon-bone graft, however, conclusive evidence as to which
is the best option has yet to be determined.
The purpose of this meta-analysis was to compare outcomes between these
two specific surgical options in efforts to better answer this debate. A literature search yielded 76 studies
published between 1998 and 2012 that included 5182 patients (young and
physically active) who had ACL reconstruction utilizing either an auto- or
allo-graft reconstruction. The studies
did not have to directly compare the two types of grafts. Outcomes of interest
were passive knee stability (pivot-shift), anterior knee laxity (KT-1000),
single-legged hop, anterior knee pain, return to preinjury activity level, and
overall International Knee Documentation Committee (IKDC) scores.
The authors found that patients with allografts had better return to
preinjury level, passive knee stability, overall IKDC scores, and anterior knee
pain. However, patients with autografts had
better graft rupture rate, subjective IKDC scores, Lysholm scores, anterior
knee laxity, and single-legged hop test performance.
The debate continues as to whether or
not an allograft or an autograft may be better when utilizing a bone-patellar
tendon-bone ACL reconstruction. The results
of this study, as well as a previous meta-analysis, appear to be
marginally in favor of the autograft.
However, readers should interpret these results with caution. In efforts to gather a higher number of
scientific studies for this analysis, this study merely looked at outcomes
based studies, and did not exclusively include studies that directly compared
the two techniques. This results in a
possibility for variability in between study methodology results, ultimately
potentially affecting the outcomes. For example, there may be patient
characteristics that influenced the decision of whether to have an allograft or
autograft (e.g., history of anterior knee pain, age). What is interesting is that this study, along
with an earlier 2008 meta-analysis, found higher graft rupture rates in
allograft patients. There are different
theories as to why this may be occurring, but there is consistent evidence that
autografts have a lower risk of graft rupture.
The authors highlight patient satisfaction as the most important factor
in deciding outcomes post ACL reconstruction and indicate that indirect
assessments of patient satisfaction (i.e., Lysholm, subjective IKDC) favor
autograft as the best selection. Anterior
knee pain was significantly less in an allograft patient (as expected), but it
is interesting that this is not considered to be a measure of patient
satisfaction based on the authors’ interpretation. It would be interesting to
see a meta-analysis conducted on randomized comparative studies of these two
grafts that followed patients out to various time points and included imaging to
assess joint degeneration as well as the traditional patient-reported and
functional outcomes.
not an allograft or an autograft may be better when utilizing a bone-patellar
tendon-bone ACL reconstruction. The results
of this study, as well as a previous meta-analysis, appear to be
marginally in favor of the autograft.
However, readers should interpret these results with caution. In efforts to gather a higher number of
scientific studies for this analysis, this study merely looked at outcomes
based studies, and did not exclusively include studies that directly compared
the two techniques. This results in a
possibility for variability in between study methodology results, ultimately
potentially affecting the outcomes. For example, there may be patient
characteristics that influenced the decision of whether to have an allograft or
autograft (e.g., history of anterior knee pain, age). What is interesting is that this study, along
with an earlier 2008 meta-analysis, found higher graft rupture rates in
allograft patients. There are different
theories as to why this may be occurring, but there is consistent evidence that
autografts have a lower risk of graft rupture.
The authors highlight patient satisfaction as the most important factor
in deciding outcomes post ACL reconstruction and indicate that indirect
assessments of patient satisfaction (i.e., Lysholm, subjective IKDC) favor
autograft as the best selection. Anterior
knee pain was significantly less in an allograft patient (as expected), but it
is interesting that this is not considered to be a measure of patient
satisfaction based on the authors’ interpretation. It would be interesting to
see a meta-analysis conducted on randomized comparative studies of these two
grafts that followed patients out to various time points and included imaging to
assess joint degeneration as well as the traditional patient-reported and
functional outcomes.
Questions
for Discussion: What are your thoughts on what measures constitute a successful
ACL reconstruction? What recommendations
are you currently making to patients regarding graft type?
for Discussion: What are your thoughts on what measures constitute a successful
ACL reconstruction? What recommendations
are you currently making to patients regarding graft type?
Written
by: Nicole Cattano
by: Nicole Cattano
Reviewed
by: Jeffrey Driban
by: Jeffrey Driban
Related Post:
Kraeutler, M., Bravman, J., & McCarty, E. (2013). Bone-Patellar Tendon-Bone Autograft Versus Allograft in Outcomes of Anterior Cruciate Ligament Reconstruction: A Meta-analysis of 5182 Patients The American Journal of Sports Medicine DOI: 10.1177/0363546513484127
This article still eludes the question of whether non irradiated grafts are as effective as autografts. When all the meta analysis literatur is considered, non irradiated allografts compare equally to autografts. The presence of small amounts of gamma irradiation (terminal sterilization) immediately renders allograft tissue mechanically inferior to autograft.
John, you are absolutely right. These articles didn't address whether or not the grafts were irradiated or not. But that being said, it still seems that the option is up to the patient and the surgeon as both result in relatively similar outcomes. Are you personally in favor of one over the other? Any thoughts as to when you would pick either?