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GRAFT CHOICE AND RESULTS: WHAT DOES THE LITERATURE SAY?
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CONSIDERATIONS FOR
SPECIFIC GRAFT TYPES
Allograft
Advantages of allograft include faster surgery
and less harvest site morbidity. Increased
failure risk has been noted in young active
patients, particularly if irradiated tissue is
used [13]. Although exceeding rare, patients
should be counseled about possible disease
transmission via allograft. Bacterial infection
risk with allograft is comparable to that noted
after autograft ACL reconstruction.
Patellar Tendon Autograft
Patellar tendon grafts have long been
considered the gold standard for ACL
reconstruction. They consistently have similar
or lower failure risk compared to all other graft
types. The risk of anterior knee pain at mini
mum 5 years following ACL reconstruction is
between 25 and 38%, while the risk of kneeling
pain at this time point has been reported from
19 to 72% [6]. The risk of osteoarthritis at
minimum of 5 years following ACL
reconstruction varies greatly (9 to 72%) and
may be slightly higher than that noted with
other graft types, particularly in the
patellofemoral joint [6, 18]. Patellar tendon
harvest is typically associated with larger scars
than hamstring tendon autograft, although
techniques exist to harvest that graft through
smaller transverse incisions with improved
cosmesis.
Hamstring Autograft
Hamstring autograft has been shown in
numerous studies to yield similar patient-
reported outcomes to patellar tendon grafts, but
may be associated with slightly increased
failure risk, particularly in younger, more
active patients. Amajor concern with hamstring
autografts is the influence of graft size on
outcome. Grafts smaller than 8 to 8.5mm in
diameter have been associated with increased
failure risk relative to larger hamstring
autografts in young active patients [8, 10, 14].
The intra-operative problem of a small
hamstring graft can be solved in multiple ways,
including folding the graft differently to
increase diameter, switching to a different
autograft source, or adding allograft tendon to
the small graft to increase its diameter [7].
Early data suggest that allograft augmentation
may be associated with failure risks comparable
to those encountered with the use of small
grafts [1].
Quadriceps Autograft
Quadriceps autograft has excellent potential as
a graft choice for ACL reconstruction as it can
minimize harvest morbidity and provide
outcomes similar to those of other autografts
[16]. Harvest site cosmesis is a concern with
this graft, particularly if a long, vertical
incision is used for harvest. Minimally invasive
harvest techniques that utilize specialized
instrumentation allow harvest through a
smaller transverse incision with improved
cosmesis [2].
CONCLUSION
Numerous graft choices are available for ACL
reconstruction and there is no one graft type
that is ideal for all patients. Surgeons and
patients should discuss the relative risks and
benefits of each graft type and select the most
appropriate graft for each patient based on all
these considerations.