ACL Graft Comparison between Patellar Autograft,Hamstring Autograft, and Allografts

Athletes playing sports that involve running, cutting, pivoting, or contact have an unavoidable

risk of tearing the anterior cruciate ligament (ACL) in the tibiofemoral joint. The ACL restricts anterior

translation of the tibia, and a secondary resistor to rotation and varus/valgus stress (1). Many factors,

including age, knee joint laxity, activity level, biomechanics, and preexisting comorbidities can affect

the risk of stretching or tearing the ACL (1,8,). When a tear occurs in an athlete, most often the athlete

undergoes an ACL reconstruction, which involves attaching a new “ligament” that could either be from

the patient’s own body (autograft) or from a cadaver (allograft) (13). This is the most frequently re-

paired ligament in the knee joint (1). It has about a 90% success rate in restoring knee stability and pa-

tient satisfaction (8). Different types of tissue that is used to fashion a new “ligament” could come from

the patellar tendon, a hamstring tendon, or one of these two tendons from a cadaver (and other sources

we aren’t looking into) (1,8,13). The appropriate graft usage depends on the surgeon’s philosophy and

experience, patient activity level, and tissue availability. The rehabilitation of a typical ACL recon-

struction can take from 6-8 months to get a patient back to sports specific training, which means going

through this surgery is not a small task. Many studies look into which graft, if any, has a lower failure

rate in the short and long term.

Patellar tendon autografts are the most widely used graft source and have the most positive re-

ported outcomes and is considered the gold standard (3). This graft comes from the tibial tuberosity

and a section of the tendon leading up to the musculotendinous unit of the quadriceps musclulature

(2,4,5,9). Individuals that demand cutting, pivoting, and jumping in their respective sports, as well of

those who desire a more rapid return to play, most often use the patellar graft (1,2,5,14). The recon-

struction involves drilling into the anteriomedial tibial shaft, aiming superiorly, up into the joint capsule

following the same trajectory the old ACL used (1). The drilling continues up into the lateral femoral

condyle, where the new ACL graft will be pulled through and attached with the tibial tuberosity piece

(1). The BPTB (bone patellar tendon bone) graft has an increased maximal tensile strength over an in-

tact ACL, more stiffness, and slightly smaller cross sectional area (1). Historically because of these

characteristics, BPTB grafts are the most popular choice due to the strength, ease of harvest, rigid fixa-

tion to the tibia and femur, how quickly the bone-on-bone healing occurs at the drilling sites, and pa-

tient outcomes (1,2,4,5,9,12,14,18). There are negatives, however. Cutting some of the patellar tendon

out can cause some tightness and significant permanent weakness in the quadriceps (6,7). Donor site

morbidity of the BPTB grafts has caused enough problems to look into other methods for reconstruc-

tion (6,7,14,24). Some of these problems include patella infera, patellar fractures, patellar tendon rup-

tures, tendonitis, and numbness. Also patients are more acceptable to anterior knee pain and synovitis.

Hamstring autografts most often come from the semitendinosus muscle. This graft is most often

chosen for those who are recreational athletes, low demand patients, or youth with open growth plates

(1,10,11). Hamstring grafts have shown to have a better continuation of knee extension and has less ev-

idence of radiographic osteoarthritis (3,10,11). Hamstring grafts should not be used in competitive

sprinters (due to terminal flexion weakness), those with generalized ligamentous laxity, or those with

previous hamstring injury (1). Recommendations say to opt out of the hamstring graft for any high-de-

mand athletes (1,10,11). The surgery requires the tendon to be doubled over itself several times before

being able to conform to the size of the previously intact ACL (1,10,11). A quadruple hamstring graft

(tendon has been folded over to quadruple the cross sectional area) has almost twice the maximal ten-

sile load, an incredible increase in stiffness, and a slightly higher cross sectional area from the intact

ACL (1). Less anterior knee pain occurs in those with hamstring grafts (12%) than those with patellar

grafts (17.4%) (1). There are several negatives to the hamstring graft, not including knee pain. Patellar

grafts have less laxity, measured by the KT-1000 machine, after a reconstruction (1,6,7). In some stud-

ies, knee flexion strength is sometimes slow to return to bilateral equality, taking up to 12 months

(12,14). This strength weakness shows up easily during isokinetic testing (13). Deep flexion angles also

show more prominent weakness (13). Harvesting a hamstring graft requires ample knowledge of the

semitendinosus or and gracilis insertion points, making it more difficult than patellar grafts. (1,10,11)

Fears of disease transmission from allograft transplants have diminished in modern times. This

is mostly due to the extensive history taking and testing that is done before such a procedure is under-

gone (1). There was a study done that incorporated 238 reconstructive ACL repairs and that compared

the use of autographs and allographs (25). The study concluded that there was no significant laxity and

no difference in the clinical evaluation (25). The arthrometric measurements between the two have

shown no significant differences (25). The use of this type of graft eliminates the donor morbidity and

no weakening of the extensor or flexor muscles (18). Also there is a shorter operating time, less pain,

smaller incisions, and better cosmetic result (18). The allograph has negative effects as well that in-

clude host immune response against donor tissue and an increase in cost (18). Overall the allograph has

the same clinical outcome as the autograph and can produce the same results. There is a lack of re-

search for the cadaver/allograft useage compared to our other two options, which is something impor-

tant to note since it seems that using an allograft, when possible, is typically a successful choice.

Purpose

            Our literature review shows many benefits and hindrances with each type of ACL graft we are

examining with this study. There are certain situations where a specific graft is required for usage, such

as a lack of compatible allografts, in which the pros and cons of the non-usable graft are irrelevant. In

situations where the type of graft has no effect on the surgery success, physicians should be able to

clearly outline what is potentially positive and negative about the choices and make a recommendation

based on each patient’s individual circumstances. What we plan to do with this study is to analyze what

previous literature and data collection says about each graft choice, including the patellar autograft,

hamstring autograft, and allograft, and to send out our own questionnaire to recent ACL reconstruction

patients to collect our on data to add to the already present knowledge. Many studies include a vast

range of ages and backgrounds, but we are interested in a much more specific group. Our questionnaire

will focus on college-aged athletes who underwent the reconstruction within the past 3 years. This will

allow us to focus in on a specific population, as well as allow us to collect information pertaining to

post-reconstruction athletic participation.

Hypothesis

Our research says that for high level athletes, which would include our sample of college-level

athletes, bone-patellar-tendon-bone grafts are the most successful reconstructions. Based solely on the

research, we believe that our questionnaire will have results that say BPTB grafts have the highest suc-

cess rate, lowest rupture rate, fastest healing rates, and highest patient outcomes compared to hamstring

and cadaver grafts for college-level athletes.

Study overview

This study will be executed through a non -experimental, descriptive questionnaire designed to

compare the effectiveness of patellar autografts, allografts, and hamstring autografts on repairing an

anterior cruciate ligament tear. College aged athletes will be focused on for this study. We will include

athletes who have undergone one of these forms of reconstruction within the past three years.

Inclusion criteria

College-aged athletes who have undergone either a patellar autograft, allograft, or hamstring

autograft in order to repair an ACL injury within the past three years. Regardless of procedural success

all college-aged athletes that have undergone one of the three forms of reconstruction will be eligible to

participate.

Exclusion Criteria

College aged individuals that are not athletes that have had one of the reconstructions will not

be included. Subjects that have had one of the reconstructions prior to three years from the start of the

study date will excluded. Any athlete that has any other prior orthopedic surgery will be excluded.

Data Collection

After the subjects have been chosen based off of their eligibility they will be asked over email

to complete the informed consent document and will be informed of what is expected from the

subjects. Questions regarding the study and the expectations may be asked over email/phone during

this time before the study begins. If the subjects wish to further participate in this study, they will be

asked to give information regarding their medical history. After determining which individuals will

participate and ensuring the subject is informed the questionnaire will be administered.

ACL Graft Comparison between Patellar Autograft, Hamstring Autograft, and Allografts

I, _______________________, agree to be a participant in the ACL Graft Comparison between Patellar Autograft, Hamstring Autograft, and Allografts which is being conducted by ____________who can be reached at (478)957-2535. I understand this participation is entirely voluntary; I can withdraw my consent at any time and have the results of the participation returned to me, removed from the experimental records, or destroyed.

The following points have been explained to me:1. Patellar tendon autographs are the most widely used graph source and is considered the gold standard. The purpose of this study is to identify whether this “gold standard” graph is supported through research for our population the most beneficial Anterior Cruciate Ligament reconstruction graft by comparing data from past studies with information received from questionnaires administered to college aged athletes that have undergone one of the procedures. The study is looking at which graft has the most beneficial clinical outcome with the least amount of negative side effects.2. The procedures are as follows: You will be asked to disclose information on any previous medical procedure that may conflict with an ACL repair and you will be asked to answer questions regarding your ACL reconstructions. You will not list your name on the questionnaire or on any documents that may disclose medical history. Therefore; the information gathered will be completely anonymous. You will be asked to sign two of these consent forms. One form will be returned to the investigator and the other consent form will be kept for your records. 3. Your participation in this questionnaire is entirely voluntary. You may find that many questions are invasive or personal. It is your choice whether you want to participate or not. If you become uncomfortable answering any questions, you may cease participation at that time. No discomforts or

distresses will be faced during this research.4. No physical, psychological, social or legal risks exist in this study. 5. The results of this participation will be anonymous and will not be released in any individually identifiable form without my prior consent unless required by law.6. If you should have any further questions before or after participation the investigator will answer any questions about the research (see above phone numbers).7. In addition to the above, further information, including a full explanation of the purpose of this research, will be provided at the completion of the research project, if you request.

_______________________________________________________________________Signature of Investigator Date

_______________________________________________________________________Signature of Participant Date

_______________________________________________________________________Signature of Parent or Guardian Date(If participant is less than 18 years of age)

***************************************

Research at Georgia College & State University involving human participants is carried out under the oversight of the Institutional Review Board. Questions or problems regarding these activities should be addressed to Mr. Marc Cardinalli, Director of Legal Affairs, CBX 041, GCSU, (478) 445-2037.

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