State of the Art

ACL graft selection: state of the art

Hideyuki Koga,1 Stefano Zaffagnini,2 Alan M Getgood,3 Takeshi Muneta4
1
Department of Joint Surgery Abstract have to consider several factors to facilitate an
and Sports Medicine, Graduate Despite recent developments in anterior cruciate informed choice. These include rate of graft failure/
School, Tokyo Medical and
Dental University, Tokyo, Japan ligament (ACL) reconstruction techniques, there are revision, rate of return to preinjury activity level,
2
II Orthopaedic Clinic, Sports still several intraoperative factors affecting clinical donor site morbidity, risk of future OA, surgical
Traumatology, Istituto outcomes that remain widely debated. Among such time, cost effectiveness, associated complications
Ortopedico Rizzoli, Universita factors, graft selection might be the most critical yet and also surgeons’ familiarity with the graft in order
degli Studi di Bologna, Bologna, to make this critical decision. Currently available
controversial question for surgeons. As the primary
Italy
3
Fowler Kennedy Sport Medicine factor influencing a patient’s choice for the ACL graft is grafts can be categorised into autograft, allograft
Clinic, University of Western surgeon recommendation, surgeons have to consider or synthetics. In terms of autograft, there are three
Ontario, London, Canada several factors to select the best graft for each patient. main options: hamstring tendon, bone-patellar
4
Department of Orthopaedic Graft options currently include autograft, allograft or tendon-bone (BPTB) and quadriceps tendon, with
Surgery, National Hospital
Organization Disaster Medical synthetic grafts. In terms of autograft, there are three the two most commonly used being hamstring and
Center, Tokyo, Japan main options: hamstring tendon, bone-patellar tendon- BPTB. There are many studies comparing these
bone (BPTB) and quadriceps tendon, the two most two autografts, with more recent meta-analyses
Correspondence to commonly used being hamstring tendon and BPTB. and systematic reviews having summarised high-
Dr Takeshi Muneta, National Limited evidence is available to select the one best quality randomised controlled trials, prospective
Hospital Organization Disaster graft for every individual patient. Graft selection should comparative cohorts and large national registries.2–6
Medical Center, Tachikawa,
Tokyo 190-0014, Japan; be based on the reported rate of graft failure/revision However, conclusions from these studies are still
​munetaorj3255@​gmail.​com and be individualised according to multiple factors controversial. Allografts are also commonly used in
such as gender, age, activity level and type of activity, some parts of the world with theoretical advantages
Received 4 October 2017 complications and other patient needs and demands. in elimination of donor site morbidity and shorter
Revised 4 December 2017 surgical time. Several studies have compared auto-
Accepted 6 December 2017
Furthermore, surgeons should be familiar with a variety
Published Online First of grafts, their specific associated surgical procedures grafts and allografts as well as the source and prepa-
10 January 2018 and the advantages and disadvantages of each, with the ration of allografts. Synthetic grafts had been less
aim of offering the best graft selection for each individual commonly used because of the high risk of compli-
patient. cations such as mechanical failure, infection, tunnel
osteolysis and massive effusions. But even this
option is making a comeback with the introduction
of newer generation devices. The purpose of this
Introduction article is to summarise the current literature and
Anterior cruciate ligament (ACL) injury is one of discuss the current state of the art of graft selection
the most commonly seen injuries in orthopaedics, in the treatment of ACL injury.
especially among young athletes. If athletes suffer
from recurrent knee instability, it is difficult for Current state of the art: graft selection
them to return to preinjury activity level. There- Graft selection should be individualised as it can
fore, ACL reconstruction has been developed to be affected by factors such as gender, age, patient’s
restore knee stability as well as to restore prein- activity level and other needs and demands such as
jury activity levels. Recent short-term knee stability employment. The following is a thorough review of
and patient-reported functional outcomes of ACL current popular graft options.
reconstruction have been good to excellent in most
cases. However, failure rates can be up to 30% in Hamstring tendon autograft
young athletes, return to sport can take as long The use of hamstring tendons was first reported in
as 18 months and the development of post-trau- 1982.7 After criticism of poor strength and stiff-
matic osteoarthritis (OA) following reconstruction ness in 2-strand hamstring tendon grafts, 4-strand
continues to be an unsolved issue. hamstring tendon constructs were introduced
While many of these issues surround the biolog- showing comparable strength to BPTB grafts.8
ical impact of the injury and the ongoing deficits in Subsequently, there has been an increased popu-
neuromuscular conditioning, there are still several larity of hamstring tendons in recent years.
intraoperative factors affecting clinical outcomes The semitendinosus tendon with or without
that remain widely debated. These include graft gracilis tendon is harvested and can be fashioned
selection, tunnel position, graft fixation angle, into multistrand graft(s) to be used to reconstruct
initial graft tension, native tissue remnant preserva- the ACL either with single-bundle (SB) or double-
tion and concomitant ligament/meniscus/ cartilage bundle (DB) technique (figure 1). The native ACL
injuries. Among them, graft selection might be the does not function as a SB and can be anatomically
most critical but controversial question for surgeons divided into two bundles: the anteromedial bundle
To cite: Koga H, Zaffagnini S, that can be addressed at the time of surgery. As the (AMB) and posterolateral bundle (PLB). Anatom-
Getgood AM, et al. JISAKOS primary factor influencing a patient’s choice for the ically, DB technique, which replicates both the
2018;3:177–184. ACL graft is surgeon recommendation,1 surgeons AMB and the PLB of the native ligament, better
Koga H, et al. JISAKOS 2018;3:177–184. doi:10.1136/jisakos-2017-000136. Copyright © 2018 ISAKOS 177
 State of the Art

Box 1 Key articles on anterior cruciate ligament graft Box 2 Validated outcome measures
selection
Primary outcomes:
1. Poehling-Monaghan KL, Salem H, Ross KE, et al. Long-term ►► Graft failure/revision rate.
outcomes in anterior cruciate ligament reconstruction: ►► Instrumented laxity measurement.
A systematic review of patellar tendon versus hamstring ►► Lachman test.
autografts. Orthop J Sports Med 2017;5:2325967117709735. ►► Pivot shift test.
2. Samuelsen BT, Webster KE, Johnson NR, et al. Hamstring Secondary outcomes:
autograft versus patellar tendon autograft for ACL ►► Muscle strength.
reconstruction: Is there a difference in graft failure rate? ►► Rate of return to preinjury activity level.
A meta-analysis of 47,613 patients. Clin Orthop Relat Res ►► Tegner activity scale.
2017. ►► International Knee Documentation Committee Score.
3. Gabler CM, Jacobs CA, Howard JS, et al. Comparison of graft ►► Lysholm Score.
failure rate between autografts placed via an anatomic ►► Knee injury and Osteoarthritis Outcome Score .
anterior cruciate ligament reconstruction technique: A ►► Rate of anterior knee pain.
systematic review, meta-analysis, and meta-regression. Am J ►► Rate of kneeling pain.
Sports Med 2016;44:1069–79. ►► Infection rate.
4. Gifstad T, Foss OA, Engebretsen L, et al. Lower risk of
revision with patellar tendon autografts compared with
hamstring autografts: a registry study based on 45 998 usually used for the femoral side, whereas various devices are
primary ACL reconstructions in Scandinavia. Am J Sports used for the tibial side. It has been reported that use of cortical
Med 2014;42:2319–28. suspensory fixation causes tunnel widening mainly because of
5. Xie X, Liu X, Chen Z, et al. A meta-analysis of bone-patellar an increased distance between the location of fixation and ACL
tendon-bone autograft versus four-strand hamstring tendon natural insertion. Therefore, other femoral fixation devices such
autograft for anterior cruciate ligament reconstruction. Knee as cross-pin fixation have been developed to shorten the fixa-
2015;22:100–10. tion distance. However, a recent meta-analysis showed that there
6. Xie X, Xiao Z, Li Q, et al. Increased incidence of osteoarthritis were no differences in clinical and functional outcomes between
of knee joint after ACL reconstruction with bone-patellar cortical button fixation and cross-pin fixation.14 However, it is
tendon-bone autografts than hamstring autografts: a meta- expected that longer graft incorporation will be observed with
analysis of 1443 patients at a minimum of 5 years. European the use of hamstring tendon grafts compared with BPTB grafts,
journal of orthopaedic surgery & traumatology: orthopedie as the former is based on tendon-to-bone healing inside the
traumatologie 2015;25:149–59. tunnels. Furthermore, without bone, the normal bone-ligament
7. Slone HS, Romine SE, Premkumar A, et al. Quadriceps tendon junction can never be restored.
autograft for anterior cruciate ligament reconstruction: a Hamstrings tendon grafts gained popularity mainly because of
comprehensive review of current literature and systematic lower donor site morbidity, such as kneeling pain and anterior
review of clinical results. Arthroscopy 2015;31:541–54. knee pain that is reported with BPTB graft.2 6 On the other hand,
8. Maletis GB, Inacio MC, Reynolds S, et al. Incidence of knee flexor strength deficits after hamstring tendon harvest is a
postoperative anterior cruciate ligament reconstruction common complaint.15 16 In this regard, this morbidity could be
infections: graft choice makes a difference. Am J Sports Med greater if additional gracilis tendon is harvested in addition to
2013;41:1780–5. semitendinosus tendon. As such, some surgeons recommended
9. Tejwani SG, Chen J, Funahashi TT, et al. Revision risk that gracilis tendon should be preserved if possible.17–19 Even DB
after allograft anterior cruciate ligament reconstruction: ACL reconstruction can be performed using only semitendinosus
Association with graft processing techniques, patient tendon in most cases, although in some cases with thin and/or
characteristics, and graft type. Am J Sports Med
2015;43:2696–705.
10. Batty LM, Norsworthy CJ, Lash NJ, et al. Synthetic devices for
reconstructive surgery of the cruciate ligaments: a systematic Box 3 Key issues for graft selection
review. Arthroscopy 2015;31:957–68.
Graft failure/revision.
Knee laxity:
►► Anterior laxity.
reproduces native ACL anatomy. Recent biomechanical studies
►► Anterolateral rotational laxity.
have revealed that DB ACL reconstruction restores more normal
Muscle strength:
knee biomechanics than traditional SB reconstructions, espe-
►► Knee extensor muscle strength.
cially in response to rotatory loading.9 10 A recent meta-analysis
►► Knee flexor muscle strength.
has revealed that DB reconstruction has some clinical advan-
Return to preinjury activity level.
tages in objective measurements of knee stability and protec-
Patient-reported clinical outcomes.
tion against repeat ACL rupture or a new meniscal injury.11
Osteoarthritis.
In addition, more recent studies comparing only anatomic SB
Pain:
versus DB reconstructions further have revealed that DB recon-
►► Anterior knee pain.
struction is better in terms of restoration of knee kinematics as
►► Kneeling pain.
well as reduced risk of revision surgery.12 13 In terms of graft
Infection.
fixation, extracortical suspensory fixation such as EndoButton
Tunnel enlargement.
(Smith & Nephew Endoscopy, Andover, Massachusetts, USA) is
178 Koga H, et al. JISAKOS 2018;3:177–184. doi:10.1136/jisakos-2017-000136
 State of the Art

Box 4 Considerations for graft selection

Graft selection should be individualised according to multiple

factors as below and other patient needs and demands.
1. Reported rate of graft failure/revision: Lower revision rate
with autografts has been reported compared with allograft
and synthetic graft, although revision rate among allografts
seems to depend on processing and preparation methods.
Among autografts, hamstring tendon graft seems to show
higher revision rate than bone-patellar tendon-bone (BPTB),
although results are still controversial.
2. Age: In young active patients, use of allograft should be
avoided as it has been reported to have higher revision rate
than autografts. Use of BPTB might also have to be avoided
in elderly patients with poor muscle strength.
3. Patient’ s activity level and type of activity: In active patients,
use of allograft should be avoided as it has been reported to
have higher revision rate than autografts. In patients with
contact sports, use of BPTB could be recommended because
of high strength and stiffness and faster graft incorporation
with solid fixation.
4. Complications: In patients with strict requirements for
kneeling and females with low activity level, use of BPTB
should be avoided to reduce the risk of anterior knee pain Figure 1 Anatomic double-bundle ACL reconstruction using hamstring
and kneeling pain. In patients with osteoarthritis (OA), use of tendon graft. (A) Femoral tunnels for AMB (blue suture) and PLB (white
BPTB might also have to be avoided, as it has higher risk of suture). (B) Reconstructed ACL. The grafts are covered with preserved
OA. In patients with high risk of infection, use of hamstring remnant tissues. (C,D) Postoperative 3D-CT of the femur (C) and
tendon might be avoided, as the significantly higher rate tibia (D). ACL, anterior cruciate ligament; AMB, anteromedial bundle;
of infection after hamstring tendon graft reconstruction is PLB, posterolateral bundle.
reported.
Recently, the concept of anatomic reconstruction has also
been applied to BPTB grafts, with the anatomic rectangular
short semitendinosus tendon, additional gracilis tendon harvest tunnel reconstruction to mimic natural ACL fibre arrangement
is necessary. (figure 2).27 This technique has some theoretical advantages such
as to mimic fibre orientation of the native ACL, to maximise
Bone-patellar tendon-bone (BPTB) autograft
BPTB graft had been the gold standard until the 1980s because
of high strength and stiffness, consistency of the size of the graft
and faster graft incorporation with solid fixation using inter-
ference screws.20 21 However, there are several complications
associated with the use of BPTB grafts mainly due to donor site
morbidity, such as anterior knee pain, kneeling pain, extensor
strength deficit, patellar fracture, patellar tendon rupture and
postoperative OA.5 6 22 23 Therefore, hamstring tendon grafts
became more popular in the 1990s. However, a more recent
swing back to BPTB grafts seems to be occurring after more
recent large national registry studies showed that BPTB grafts
had lower risk of revision compared with hamstring tendon
grafts.24–26

Box 5 Future perspectives

1. Graft selection should be individualised, and surgeons should

be familiar with every kind of graft available to offer best
graft selection for each patient.
2. Graft failure rate should be just one part of a larger
conversation with each individual patient regarding optimal
graft selection; every factor such as gender, age, activity level
and type of activity, complications and other patient needs
Figure 2 Anatomic rectangular tunnel reconstruction using BPTB graft.
and demands should be considered.
(A) Femoral rectangular tunnel. (B) Reconstructed ACL. (C, D) Postoperative
3. Accumulating more evidence is necessary in order to select
3D-CT of the femur (C) and tibia (D). ACL, anterior cruciate ligament;
best graft for each patient.
BPTB, bone-patellar tendon-bone.
Koga H, et al. JISAKOS 2018;3:177–184. doi:10.1136/jisakos-2017-000136 179
 State of the Art
the graft-tunnel contact area, to keep tunnel apertures inside grafts,2 4 whereas one meta-analysis showed that BPTB had
the ACL attachment areas and to preserve the notch anatomy. lower rate of positive pivot shift after excluding one hetero-
A recent biomechanical study also showed that using BPTB geneous study.6 Actually this excluded study compared the
graft, the ACL-reconstructed knee with a rectangular femoral outcomes of DB hamstring tendon reconstruction versus SB
tunnel more closely resembled the normal knee in biomechanical BPTB reconstruction, favouring hamstring tendon.41 It has been
behaviour than that with a round femoral tunnel.28 shown that DB reconstruction has some clinical advantages in
knee stability and graft failure. Therefore, further comparative
Hamstring versus BPTB: comparative studies studies should focus on comparison of anatomic DB hamstring
There are numerous studies comparing hamstring tendon and tendon reconstruction and anatomic BPTB reconstruction. The
BPTB grafts for ACL reconstruction. Several past meta-analyses recent randomised controlled trial comparing BPTB, SB and DB
comparing hamstring tendon and BPTB included multiple (2–5) hamstring tendon grafts showed that BPTB was better than both
strand grafts and the results of 4-strand graft were not analysed SB and DB hamstring tendon in static anterior laxity, although
separately.23 29 30 Recent meta-analyses compared BPTB graft there were no differences in other outcomes.42 On the other
with 4-strand hamstring tendon graft, although they still did not hand, a most recent study comparing anatomic DB hamstring
separately analyse SB and DB.3 4 23 In this regard, a most recent tendon reconstruction and anatomic rectangular tunnel BPTB
randomised controlled trial with large population compared reconstruction showed that there were no difference in any of
BPTB, SB and DB hamstring tendon grafts.31 objective and subjective outcome measures at 2 year follow-up.43

Graft failure/revision Muscle strength

There is still no consensus regarding risk of graft failure/revi- Many studies have evaluated muscle strength after ACL recon-
sion between Hamstring tendon and BPTB, whereas recent large struction with either hamstring tendon or BPTB grafts. The loca-
registry studies from both Scandinavian registries24–26 and Kaiser tion of the donor site has an influence on the muscle deficit.
Permanente registry32 showed that hamstring tendon grafts had Recent meta-analysis and systematic review studies showed that
higher revision rates than BPTB grafts. In addition, a recent patients with BPTB grafts showed a greater deficit in extensor
randomised controlled trial with large population comparing muscle strength and lower deficit in flexor muscle strength
BPTB, SB and DB hamstring tendon grafts showed that more compared with hamstring tendon graft, and these deficits appear
traumatic reinjuries occurred with SB and DB hamstring grafts to be unresolved up to 2–5 years after ACL reconstruction.44
compared with BPTB. However, no recent systematic reviews Therefore, rehabilitation protocols after ACL reconstruction
or meta-analyses of randomised or prospective studies showed should focus on the specific graft used, especially in terms of
any difference in the revision rate between hamstrings and BPTB muscle strength training. With regard to hamstring tendon graft,
grafts,2 3 6 except one most recent meta-analysis showing that the residual hamstrings deficits were related to the number of
hamstring tendon graft failed at a higher rate than BPTB graft.4 tendons harvested, and this flexor muscle strength deficit is
One large limitation of this study is, however, that most of the more emphasised in deep flexion angle.17–19 Therefore, it is
patients included in this study came from the Scandinavian suggested that the gracilis tendon could be preserved if possible
registry study with the lowest Modified Coleman Methodology in hamstring tendon graft reconstruction, and in some specific
Score and those results factor heavily into the results (79.1%). In sports needing deep flexion (eg, ballet, judo and so on), use of
any case, failure rates in both grafts were quite low and almost hamstring tendon graft should be avoided.
equivalent, and the small difference in failure rate should be just
one part of a larger conversation with each individual patient Return to preinjury activity level
regarding optimal graft selection. ACL injuries occur mostly in young athletes, and for those
athletes, one of the most important clinical outcomes after ACL
Stability reconstruction is return to preinjury activity level or even higher
Laxity in ACL-injured knees can be described in two ways: ante- level. There are plenty of factors affecting ability to return
rior and rotatory laxity. Anterior laxity is manually assessed by to preinjury activity level; however, it still remains unclear
Lachman test, which has been shown to be a non-invasive test how graft selection affects return to preinjury level. A recent
with high specificity and high sensitivity.33 In addition, anterior meta-analysis showed a statistical difference in favour of BPTB
laxity can be semiquantitatively evaluated by an instrument such grafts compared with hamstring tendon grafts.6 On the other
as the KT-1000 arthrometer (MEDmetric, San Diego, California, hand, other systematic review and meta-analyses have shown
USA), again with high inter-rater reliability.34 35 On the other that there are no differences in return to preinjury activity level
hand, rotatory laxity in ACL-injured knees is commonly repre- or Tegner activity scale.2 23
sented by the pivot shift test. It has been shown to be superior
to anterior laxity tests such as Lachman and KT-1000 measure- Other clinical evaluation scores
ment when it comes to predicting patient-reported instability. International Knee Documentation Committee (IKDC) score
It has shown to be correlated with poor subjective and objec- and patient-reported Lysholm score have been widely used to
tive outcome scores34 as well as osteoarthritis after ACL recon- evaluate postoperative ACL reconstruction outcomes. Several
struction;36 however, the pivot shift test is subjective with low meta-analysis and systematic review papers have shown that
interobserver reliability.37 38 It has also been reported that there there are no differences in IKDC score and Lysholm score
are no correlations between anterior and rotatory laxities.39 40 between hamstring tendon and BPTB grafts.2 6 15 Recently, the
Recent meta-analyses and systematic reviews have shown that importance of a patient-reported outcome score such as the Knee
there are no differences in regards to anterior laxity, as repre- injury and Osteoarthritis Outcome Score (KOOS) has gained
sented by the Lachman test and instrumented laxity measure- attention. Inadequate knee function detected by the KOOS has
ments, between the two grafts.2 4 6 In terms of the pivot shift also been reported to be associated with future ACL-reconstruc-
test, some studies have shown no difference between the two tion graft failure.45 Several comparative studies have shown that
180 Koga H, et al. JISAKOS 2018;3:177–184. doi:10.1136/jisakos-2017-000136
 State of the Art
there are no differences in the KOOS between hamstring tendon Quadriceps tendon autograft
graft and BPTB;16 43 however, there has been no meta-analysis Although the quadriceps tendon is the least studied and least
study comparing the KOOS between the two grafts. used autograft for ACL reconstruction, interest in and use of
the quadriceps tendon seem to be increasing. Quadriceps tendon
Osteoarthritis grafts have been reported to have comparable strength and stiff-
Prevention of OA after ACL injuries is also one the most ness to BPTB grafts58 and have several theoretical advantages
important goals after ACL reconstruction, as the ACL-injured such as smaller incision, less morbidity in regards to anterior
knee is at significant risk of developing post-traumatic OA.46 knee pain and kneeling pain, less knee flexor muscle strength
However, OA has been reported in up to 40% of patients at deficit than hamstring tendon grafts and still its bone block on
long-term follow-up after ACL reconstruction.47 Reported one end would allow for bone-to-bone healing.59 60 Recently,
factors associated with the risk of OA include meniscus status, several papers comparing the clinical results after ACL recon-
meniscus treatment, cartilage injury, age and obesity.48 49 Graft struction using quadriceps tendon graft and either hamstring
selection has also been shown to be another associated factor for tendon60 61 or BPTB grafts59 62 63 have been published.
OA. Recent meta-analysis and systematic review papers revealed When quadriceps tendon and hamstring tendon were
that BPTB graft resulted in an increased incidence of OA in compared, a cadaveric study showed that there were no biome-
both the patellofemoral joint and tibiofemoral joint compared chanical differences between SB ACL reconstruction with quad-
with hamstring tendon graft.2 5 50 On the other hand, in a large riceps-bone graft and that with 4-strand hamstring tendon
cohort study, graft selection itself was not a significant predictor graft.64 Clinical studies have also shown that ACL reconstruction
for OA.48 There are many confounding variables on this topic; using a quadriceps tendon graft leads to equal or better knee
therefore, more evidence is needed with future studies aiming to laxity measurements and patient-reported outcomes and less
determine the effects of graft selection on risk of OA in anatomic flexor muscle strength deficit than that using hamstring tendon
ACL reconstruction. grafts.60 61
A recent systematic review comparing quadriceps tendon and
Pain BPTB grafts showed that knee stability, functional outcomes,
Anterior knee pain and kneeling pain are common complications overall patient satisfaction, range of motion and complica-
after ACL reconstruction, especially using BPTB grafts. Several tions were similar between the two grafts, with less donor-site
meta-analyses and systematic reviews have shown that the occur- morbidity such as anterior knee pain and kneeling pain.59 These
rence of anterior knee pain and kneeling pain were significantly morbidities can be further decreased if the quadriceps tendon is
higher in BPTB graft than hamstring tendon grafts after ACL harvested without a bone block.65
reconstruction.2 6 15 30 51 This donor site morbidity after ACL These data suggest that quadriceps tendon grafts may be the
reconstruction with BPTB grafts, as well as extensor muscle least morbid of the currently used ACL autograft reconstruc-
strength deficits, is a significant concern for both patients and tion alternatives; however, complications after quadriceps graft
surgeons, particularly for those who have strict requirements for harvest such as quadriceps muscle strength deficits and retrac-
kneeling, such as for employment and sporting purposes or for tion of the rectus femoris muscle should be noted, especially
praying as is the case in many countries. In these circumstances, for many surgeons who are unfamiliar with quadriceps tendon
BPTB grafts should be avoided. harvest technique.

Infection Allograft
Infections after ACL reconstruction can be a devastating Donor site morbidity, particularly in regard to BPTB grafts have
complication requiring further surgeries, antibiotics and some- led to the demand for the use of allograft, and classic animal
times graft removal depending on the extension of the infec- studies,66–68 followed by human clinical studies,69–71 have justi-
tion, causal bacteria and type of graft (biological vs synthetic). fied use of allograft for ACL reconstruction.
Several meta-analyses and large nationwide registry studies were Lack of donor site morbidity, smaller incisions, availability of
conducted and revealed that there is an increased risk of infec- predictable graft sizes, shorter operative time and ease of use
tions with hamstring tendon compared with BPTB grafts.52–54 in multiple ligament and revision reconstructions are obvious
Although the overall infection rate is low with both graft types, advantages of allograft reconstruction. However, the use of
the significantly higher rate of infection after hamstring tendon allografts have been shown to have a higher risk of revision
graft reconstruction should be a consideration when discussing compared with autografts, especially in younger patients.72 73
graft selection for ACL reconstruction. Allografts have a longer and less complete course of incorpo-
ration and remodelling than autografts and are biomechanically
Tunnel enlargement inferior to autografts.74 Furthermore, the potential risk of immu-
The majority of studies that have assessed radiographic tunnel nogenic reaction and disease transmission along with increased
enlargement have shown that hamstring tendon grafts cause cost for storage and preparation when compared with autograft
greater tunnel enlargement than BPTB grafts in both femoral are also matters of concern. However, the use of allograft does
and tibial tunnels.55 56 However, it seems that the tunnel enlarge- not seem to increase the risk of infection.52 75 Factors associated
ment does not correlate with clinical outcomes including knee with a higher risk of allograft failure include graft irradiation
laxity and functional knee scores.56 However, these results greater than 1.8 Mrad, BioCleanse graft processing and the use
suggest that femoral tunnels should be created at a somewhat of BPTB allograft.76 On the other hand, clinical results with
more posterior position to the native ACL attachment site, espe- non-irradiated and/or unprocessed allograft have been reported
cially when using a hamstring tendon graft, as the femoral tunnel to be comparable to those with autograft.76–83 However, a recent
enlargement occurs anteriorly.57 By doing so, the risk of decrease randomised controlled trial did demonstrate a higher failure rate
in knee joint stability caused by anterior deviation of the graft of non-irradiated allograft ACL reconstructions compared with
could be reduced. autograft in a young active military population.84 Indications for
Koga H, et al. JISAKOS 2018;3:177–184. doi:10.1136/jisakos-2017-000136 181
 State of the Art
allograft should therefore be limited to patients with shortage Geographical differences
of autograft, low-demand elderly patients or patients who are In an epidemiologic study, 261 orthopaedic surgeons of 10
reluctant to have autograft harvest. subspecialties from 57 countries (53% European, 23% North
American, 7% Asian, 7% South American, 7% Middle East and
2% African) took part in a survey.93 The study documented
Synthetic grafts that hamstring autograft was the most popular choice (63%),
To overcome the concerns of both autograft (donor site followed by BPTB (26%) and allograft (11%). Rate of allograft
morbidity) and allograft (higher failure rates and disease trans- selection was 19%, 9% and 7% in North America, Europe and
mission), several kinds of synthetic grafts have been developed. other countries, respectively. Another survey of 34 orthopaedic
They had gained in popularity because of easy availability, surgeons who attended an ACL conference in 2011 documented
convenience, lack of disease transmission and donor site the preferred graft choice was hamstring tendon autograft
morbidity and the potential for dramatically accelerated reha- (53.1%) followed by BPTB (22.8%) and allograft (13.5%).94
bilitation with return to sport significantly earlier than autograft The rate of allograft selection seems to be higher in USA, as the
and allograft. community-based Kaiser Permanente Anterior Cruciate Liga-
However, earlier generations such as Dacron (Stryker, Kalam- ment Reconstruction Registry of 15 101 primary ACLR patients
azoo, Michigan, USA), GORE-TEX (W.L. Gore and Associates, by 244 surgeons in 48 medical centres within USA documented
Flagstaff, Arizona, USA), Kennedy Ligament Augmentation that allograft was used in 42.4%.95 On the other hand, in Scan-
Device (3M, St Paul, Minnesota, USA) and Leeds-Keio (Xiros, dinavian countries, their national registries between 2004 and
Leeds, England) have demonstrated high risk of complications 2011 documented that majority of surgeons preferred hamstring
including recurrent pain, mechanical failure, infection, tunnel tendon autograft (84.1%), followed by BPTB (14.6%) and less
osteolysis, massive effusions and OA.85–87 Patients with failed than 1.0% used allograft.24 In addition, in some countries such
synthetic grafts often present with recurrent instability, pain, as Japan the use of allografts is very limited. In these countries,
swelling and/or effusions, and these devices are not available for only autografts are available. Graft selection is especially diffi-
ACL reconstruction anymore. cult in cases with multiple ligament injuries and multiple revi-
On the other hand, newer generation devices such as Liga- sion surgeries and all possible autografts should be considered.
ment Augmentation and Reconstruction System (LARS; Surgical However, in very rare cases, use of synthetic graft can also be
Implants and Devices, Arc-sur-Tille, France) have been reported considered.
with lower rates of failure, revision and sterile effusion/syno-
vitis compared with other devices.88 While the results comparing
Conclusion
LARS and autograft are controversial,89–91 more large cohort
Graft selection should be individualised as it is affected by
studies or high quality randomised control trials are necessary to
factors such as reported rate of graft failure/revision, gender,
justify the use of synthetic grafts.
age, activity level and type of activity, complications and other
patient needs and demands. However, one of the most influ-
Graft selection in revision surgeries encing factors seems to be surgeons’ familiarity with the graft.
Graft selection in revision surgeries should also be individual- Therefore, surgeons should be familiar with every kind of grafts
ised, as it could be affected by factors such as the graft used available to offer the best graft selection for each patient. It
in the primary surgery, gender, age, patient’s activity level and is clear that more high level evidence is necessary, especially
other patient needs and demands. The most likely factor is graft in terms of long-term clinical outcomes, graft failure rate and
availability, which will clearly depend on what graft was used for future risk of OA, before the true superiority of one graft over
the primary procedure. BPTB or quad autografts can be useful to another can be ascertained.
fill larger bone tunnels or defects. If the tunnels are satisfactory,
Contributors HK drafted the manuscript. SZ, AMG and TM completed the final
then a hamstring graft may be harvested from the ipsilateral or
manuscript. Final version of the manuscript was approved by all authors.
contralateral side. Similar to the primary ACL reconstruction,
Competing interests None declared.
allograft may also be used. The major advantage in the revision
scenario is the ability to fill larger bone defects in a single stage, Provenance and peer review Commissioned; externally peer reviewed.
as opposed to performing a two stage revision with initial tunnel © International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports
bone grafting and subsequent second stage revision reconstruc- Medicine (unless otherwise stated in the text of the article) 2018. All rights reserved.
No commercial use is permitted unless otherwise expressly granted.
tion. A DB technique with hamstring tendon graft can be used
in patients after primary BPTB reconstruction, patients with
failure of the primary hamstrings tendon reconstruction due to References
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