ACL graft selection
PRESENTER- DR. AKRAM
MODERATOR- DR. K. DEBNATH SIR
INTRODUCTION
• Injury to the anterior cruciate ligament (ACL) is one of the most common
sports-related injuries, and its incidence has been increasing at all levels of
competition.
Incidence;
• 150,000-400,000 ACL tears annually
• Chronic ACL deficient knees associated with
chondral injuries
complex unrepairable meniscal tears
relation with arthritis is controversial
• Recent prospective cohort studies have identified risk factors for ACL
reconstruction graft failure*:
such as younger patient age,
increased activity level,
nonanatomic tunnel placement,
and, the use of allograft.
Anatomy & Biomechanics of ACL
ACL attachments:
Arises from posteromedial corner of the
lateral femoral condyle in the intercondylar
notch
Broad insertion at anterior intercondylar
portion of the tibia
length of 38 mm (range 25 to 41 mm)
width of 10 mm (range 7 to 17 mm)
ACL is intra-articular and extra-synovial
Blood supply is the middle genicular artery.
Primary function is to prevent anterior translation
of the tibia
Secondary role in preventing internal rotation of
tibia
ACL composed of Two Bundles
Anteromedial Posterolateral
• Tight in Flexion 45-60 • Tight in Extension
• Controls anterior Translation • Rotatory stability and anterior
motion
highly organized collagen matrix with 20-mm-thick
bundles of collagen fibers .
maximum tensile strength reported as high as 2160 N
(mean tensile strength approximately 1725 N), with a
stiffness of 242 N/mm (mean stiffness 182 N/mm) and a
strain rate of approximately 20% before failure.
Mechanism of Injury
• typically, the ACL is torn in a
noncontact deceleration situation
that produces a valgus twisting
injury, this usually occurs when
the athlete lands on the leg and
quickly pivots in the opposite
direction
• Other Mechanisms
- hyperextension
- marked internal rotation of tibia
on femur
- pure deceleration
Operative (ACL reconstruction)
Indications
• in younger, more active patients
(reduces incidence of mensical or
chondral injury)
• older active patients (Age >40 is
not contraindication if high
demand athlete)
• ACL reconstruction failure
• Attempted ligament "repair" has
high failure rate
IDEAL GRAFT
The ideal graft for use in ACLR should have:
• similar properties to those of the native
ligament
• limit donor site morbidity, and
• allow for secure fixation and rapid
incorporation
Graft Options in ACL Reconstruction
Autograft Allograft
Bone-patella tendon-bone
Bone-patella
Hamstring
tendon-bone Quadriceps
Hamstring Tibialis anterior
Tibialis posterior
Quadriceps Achilles tendon
Fascia lata
Peroneus longus
Synthetic- Dacron , GORE-TEX , Kennedy Ligament
Augmentation Device and Leeds-Keio. , Newer
generation - Ligament Augmentation and
Reconstruction System (LARS).
ACL Autografts
Advantages: Disadvantages
No issue regarding cost More wound pain
and availability of graft More prominent
No risk of disease scar
transmission Longer surgical time
Good potential of Donor site morbidity
bone-graft interface
No tissue rejection
1 N = 1 kg⋅m/s2
Bone-patella tendon-bone
For past few decades,
Gold Standard for ACL
Reconstruction
Clinical Studies have
not shown significant
differences between
grafts
Ease of harvest
Bone-to-bone healing
with secure fixation
Bone-patella tendon-bone
Disadvantages
Potential negative effect on
the knee extensor
mechanism
Anterior knee pain /
kneeling pain
Risk for patella fracture
Anterior knee numbness
Numbness of the anterior knee is caused by injury to
the infrapatellar branch of the saphenous nerve during
graft harvest.
Injury to the nerve may occur with arthroscopic portal
placement or the incision made to harvest BPTB grafts
Hamstring tendon
Combined
semitendinosus and
gracilis hamstring
tendons
Less anterior knee
pain, no disruption of
knee extensor
mechanism, and less
risk for patella
fracture
Quadrupled
Hamstring strongest
Graft 4090N nearly
double native ACL
Hamstring tendon
Potential Limitations:
• Slower soft-tissue graft-tunnel healing
• Potential for tunnel widening and graft laxity (windshield wiper effect from the suspensory fixation.)
• Functional hamstring weakness from graft harvesting
• Some studies show lower return to pre-injury activity levels
• contraindication for athletes who heavily rely on their HSs for their athletic performance (ie,
sprinters).
Quadriceps tendon
Noted to be more
difficult to harvest
Potential for anterior
knee pain
Persistent quadriceps
weakness?
Thicker than patellar
tendon
META-ANALYSIS-QT also showed
improved functional outcomes
compared with HS autograft and
significantly less harvest site pain
compared with BPTB autograft.
Historically less used, more research
needed.
Graft Selection in Anterior Cruciate Ligament Reconstruction Walter R. Shelton, MD Bryan C.
Fagan, MD JAAOS 2011;19: 259-264
Allografts
Wide range of graft sources and availability
Availability of larger grafts
Quicker surgical time
No donor site morbidity
Lower incidence of post-operative arthrofibrosis
Faster immediate post-operative recovery and less
post-operative pain
Easier rehabilitation
Useful in revision ACL reconstruction procedures.
ACL Allografts
Disadvantages
Expensive
Risk (minimal) of tissue rejection
Risk (minimal) of disease transmission
Relatively longer healing time of the graft
Variability in mechanical properties of ACL allografts
Allografts can be stored as fresh frozen, freeze dried, or cryopreserved
and typically remain frozen for approximately 2 to 4 weeks until
serologic studies are complete to confirm that the grafts are disease
free.
In some studies higher failure rates
When irradiated and chemically processed grafts were excluded, then failure
rates were no longer statistically significant
Gamma Irradiation of ACL Allografts
One of the most widely utilized forms of secondary graft
sterilization is gamma irradiation
Known pathogens Susceptibilities:
Non-spore-forming bacteria: 0.5 Mrad
Bacterial spores: 2.1 Mrad
Yeast/Mold: 0.8 Mrad
HIV: 1.5 – 4 Mrad
Irradiation doses > 2 Mrad have demonstrated decreases in
biomechanical properties of the allograft
Studies have shown that lower irradiation levels (1.0 – 2.0
Mrad) do not compromise graft biomechanical properties
These doses will not eliminate HIV, hepatitis, and spore-forming
bacteria.
Newer sterilization techniques including supercritical carbon dioxide and the use of
gamma irradiation in conjunction with antioxidants have been developed.
H
Grafts undergo a process of incorporation after implantation ,
which includes graft necrosis, cellular repopulation,
revascularization, and remodeling. E
However allografts demonstrate a slower time to healing and
A
graft incorporation L
I
N
G
C) T1-weighted sagittal image. At the distal part of the tibial bone tunnel the
interference screw is visible. The arrow proximal to the interference screw
highlights the fibrous interface in the anterior part of the bone tunnel.
Graft Fixation Methods
• In general, fixation methods include interference screws (aperture fixation),
suspensory fixation with( fixed or adjustable loops, buttons, )or a combination
of both fixation types.
• A recent prospective, randomized controlled trial evaluated long-term
outcomes of ACLR using either HA coated PLLA screws versus titanium screws
and found equivalent clinical results lasting up to 13 years postoperatively.
• A recent prospective study demonstrated that both fixed loop and adjustable
loop suspensory devices are equally effective fixation methods for ACLR.
ACL Tears in Children
• Treatment in Children (< 14 yrs with open physis)
– strongly consider operative
• activity limitation impractical
• transphyseal soft tissue grafts rarely lead to growth
disturbances
• avoid transphyseal metallic fixation
• Fixation outside the physis (over the top techniques)
Summary
• The ideal graft choice for ACLR depends on many patient factors and should be
individualized to best match the patient’s anatomy, age, needs, and
expectations..
• The treating surgeon should thus be familiar with all the ACLR reconstruction
options available to individualize and optimize each patient’s treatment and
outcomes.
d...
Grafts
• TABLE 2
THANK YOU
