The document discusses graft choices for anterior cruciate ligament (ACL) reconstruction. It finds that bone-patellar tendon-bone (BPTB) autografts have the lowest risk of revision compared to allografts and hamstring tendon autografts. Specifically, allografts have over 3 times the risk of revision compared to BPTB autografts, while hamstring autografts have an 82% higher risk. BPTB autografts remain the gold standard due to their excellent clinical results and strength, though they can cause donor site complications. No ideal graft currently exists and research continues to improve options.

1. Graft choices for Anterior
Cruciate Ligament
Reconstruction
American Journal Of Sports Medicine
| March 2016 |
PRESENTER: Dr CHINTAN N PATEL
CHAIR PERSON : Dr KIRAN S PATIL
Dept of Orthopaedics J.N. Medical College and
Dr. Prabhakar Kore Hospital and MRC, Belgaum

2. INTRODUCTION
• The anterior cruciate ligament (ACL) is the most
commonly injured ligament in sports persons.
• Available data shows that approximately 3,00,000
ACL reconstructions are performed every year in
USA alone.

3. ABSTRACT
• Using soft tissue allografts (cadaver tissue) in
ACL reconstructions may increase the risks for a
revision reconstruction postoperatively,
according to research presented at the American
Orthopaedic Society for Sports Medicine's
(AOSSM) Specialty Day.
• The study adds to research demonstrating that the
bone-patellar tendon bone (BPTB) autograft
(graft harvested from the surgical patient)
remains a strong choice for these surgeries.

4. • After adjusting for age, gender, ethnicity, and body
mass index, allografts had a 3.02 times (95%
confidence interval (CI) 1.93 to 4.72) higher risk of
aseptic revision than bone–patellar tendon–bone
autografts (p < 0.001).
• Hamstring tendon autografts had a 1.82 times (95% CI
1.10 to 3.00) higher risk of revision compared with
bone–patellar tendon–bone autografts (p = 0.019).
• For each year increase in age, the risk of revision
decreased by 7% (95% CI 5 to 9). In gender-specific
analyses a 2.26 times (95% CI 1.15 to 4.44) increased
risk of hamstring tendon autograft revision in females
was observed compared with bone–patellar tendon–
bone autograft.
ANALYSIS

6. Various grafts are available for
reconstruction of ACL
Autografts –
 Bone Patellar Tendon Bone (BPTB),
 Hamstring (HS)
Bone Quadriceps Tendon (BQT) graft
Allografts
Synthetic grafts

7. The ideal graft for reconstruction of ACL
• biomechanically similar to native ligament
• easily harvested
• least harvest site morbidity
• get well incorporated with bone
Till date there is no ideal graft

9. POST OP
X-RAY

12. BPTB Graft
• BPTB considered “gold standard” for ACL
reconstruction
• BPTB autograft has excellent clinical results and high
level of patient satisfaction
• Franke K used BPTB graft consisting middle 1/3rd of
patellar tendon with attached patellar and tibial bone
block for first time
• Allows fast bone to bone healing within the tibial and
femoral tunnels

14. BPTB GRAFT HARVEST

17. • Long term results (17–20 years) showed
83% of patients having stable, normal or near
normal functions
• 1.6% of patients needed revision ACL
reconstruction
 BPTB
• has high strength and stiffness
• maintains consistency
• easy to harvest
• can be secured very well in the canal by
interference screws
Results

18. Complications
• patellar tendon rupture
• patellar/ tibial fracture
• quadriceps weakness
• loss of full extension
• anterior knee pain
• difficulty in kneeling
• numbness due to injury to the infrapatellar
branch of saphenous nerve

19. Hamstring tendon grafts
• The Semitendinosus tendon with or without Gracilis
tendon is harvested from ipsilateral leg.
• Used as Quadruple Stranded grafts and are comparable
to native ACL.
 Advantages :
• No fear of Fracture of Patella/Tibial tuberosity Avulsion
• No kneeling pain
• Minimizing donor site morbidity.

21. GRAFT PREPARATION

22. • Reduced knee flexion strength
• Sciatic/ Saphenous nerve palsy
• Less fixation strength
 The long term follow-up results showed 75%
patients scored normal or near normal results.
 Re-rupture rate was 17%.
Disadvantages:

24. Need for Allograft?
• Failure rates high with use of HS grafts.
• Donor site complications more with BPTB.
• Surveys showed use of BPTB graft has declined
and use of HS and allograft is increasing,
probably because BPTB graft cannot be used for
a double bundle ACL reconstruction.

25. Allografts
The commonly used allografts for ACL
reconstruction are
 BPTB grafts
 HS grafts
 Tibialis Posterior/Anterior
 Tendo Achilles grafts.

27. Advantages of allografts :
• No harvest site morbidity
• Predictable graft sizes
• Shorter operative time
• Easily of used in multiligament and Revision
situations
• Easier recovery in postoperative period

28. Disadvantages
• Risk for disease transmission
• Possible immunogenicity
• Slower incorporation
Sterilization with Irradiation or Ethylene Glycol
are recommended to reduce immunogenic
reaction and disease transmission.
Irradiated allografts are more likely to fail
because of decreased mechanical properties due
to sterilization and possibility of triggering an
inflammatory response.

29. Synthetic Ligaments
• Carbon fibers
• Gore-Tex
• Dacron
• Kennedy-LAD
• Trevira
• Leeds-Keio
• 1st
generation ligaments were knitted woven or braided which was
subject to early breakage and tended to elongate.
 2 ligaments commonly used were
• (i) proplast made of Teflon plus carbon
• (ii) polyflex made of polypropylene

30. Complications
• Early rupture
• Deposition of carbon
• Inflammatory synovitis of knee
 2nd
generation ligaments had additional braided woven
longitudinal and transverse fibers in which Dacron and Polytetra
Fluoro Ethylene (PTFE) were used.
 These ligaments allowed fibroblasts in growth, but suffered with
wear, fraying and low abrasion resistance.

31. PTFE was used for vascular surgery
• This graft has 5300N tensile strength which is
higher than any other commercially available
ligament. (natural ACL in young population has
strength of 1730 to 2200N)
 Drawbacks :
• Mechanical fatigue
• Lack of tissue in growth
• Presence of wear debris
• Rupture rate was 29%

32. Dacron ligament
has tensile strength of 3631N.
• failed due to elongation property
• high rupture rate
• high revision rate

33. 3rd
generation synthetic grafts have knitted
extra-articular portion with free longitudinal
fibers which resist elongation but without any
braids, to reduce wear debris.
 Currently used synthetics are
• Ligament Augmentation Reconstruction System
• Leeds-Keio

34. RESULTS
Data for the study was collected from the
Kaiser Permanente ACLR Registry. Of the
cases analyzed,
• 4,557 (32.5%) BPTB autografts,
• 3,751 (26.8%) Soft tissue allograft, and
• 5,707 (40.7%) Hamstring allograft.
After a 3-year follow-up, the overall revision
rates were 2.5% for BPTP, 3.5% for hamstring
autografts, and 3.7% for soft tissue allografts.

35. Conclusion
• Ideal graft is yet to be available.
• The BPTB graft still remains gold standard.
• HS graft has minimal donor site morbidity but
has problems with bone tendon junction healing
and elongation.
• Allograft has poor results in terms of re-rupture
rates and immunity but can be used in
multiligamentous injuries or in revision.
• Synthetic grafts are still under evolution.