Allograft vs. autograft ACL revision rates study

[Dexter Rutecki]

This should be of interest around here, and sheds some light on various claims that have been made. In general I would say it supports what Dr. Mark has always contended--that autografts are preferable, although these authors note that there may be instances in which an allograft should be considered.

Also worth noting, I think, that in non-irradiated allografts there was no difference in revision rates. Personally my knees have experienced a 50% failure rate in autografts, and 0% failure rate in allografts. I hope those particular numbers stay the same...

http://www.orthosupersite.com/view.asp?rID=59368


Comparison of Revision Rates in Bone-Patella Tendon-Bone Autograft and Allograft Anterior Cruciate Ligament Reconstruction
By Vishal M. Mehta, MD; Cassie Mandala, PA-C; Danielle Foster, BS; Timothy S. Petsche, MD
ORTHOPEDICS 2010; 33:12
Abstract

This study compared the revision rates after autograft and allograft bone-patella tendon-bone anterior cruciate ligament (ACL) reconstruction. All bone-patella tendon-bone ACL reconstructions performed by a single surgeon between January 2000 and December 2006 were identified by retrospective chart review. Two hundred twenty-three patients met the inclusion criteria and 173 patients were available for follow-up. One hundred forty-two patients underwent bone-patella tendon-bone autograft reconstruction, and 31 patients underwent bone-patella tendon-bone allograft reconstruction.

At a mean follow-up of 49 months (range, 11-91 months), revision rates were 0.7% (1/142) in the bone-patella tendon-bone autograft group versus 9.7% (3/31) in the bone-patella tendon-bone allograft group (P=.02). Subjective International Knee Documentation Committee (IKDC) scores of nonrevised (surviving) grafts in the bone-patella tendon-bone autograft group were 98.3 versus 95.2 in the bone-patella tendon-bone-allograft group (P=.0006). Tegner scores of nonrevised grafts in the bone-patella tendon-bone-autograft group were 6.2 vs 6.5 in the bone-patella tendon-bone-allograft group (P=.03). Fourteen of the 31 (45%) allografts were irradiated and all failures occurred in irradiated grafts. When irradiated grafts were excluded, no difference in revision rates was found. Anterior cruciate ligament reconstruction with the use of bone-patella tendon-bone allografts is associated with a higher revision rate when compared to bone-patella tendon autograft reconstruction. In addition, when comparing surviving grafts, the subjective IKDC scores are higher in the autograft group. When irradiated grafts are excluded, no difference in revision rates was found. Surgeons should be aware of the higher revision rate associated with allograft ACL reconstruction when counseling patients on graft options. Level of Evidence: III; retrospective comparative study.

[hwiser09]

This should be of interest around here, and sheds some light on various claims that have been made. In general I would say it supports what Dr. Mark has always contended--that autografts are preferable, although these authors note that there may be instances in which an allograft should be considered.

Also worth noting, I think, that in non-irradiated allografts there was no difference in revision rates. Personally my knees have experienced a 50% failure rate in autografts, and 0% failure rate in allografts. I hope those particular numbers stay the same...

http://www.orthosupersite.com/view.asp?rID=59368


Comparison of Revision Rates in Bone-Patella Tendon-Bone Autograft and Allograft Anterior Cruciate Ligament Reconstruction
By Vishal M. Mehta, MD; Cassie Mandala, PA-C; Danielle Foster, BS; Timothy S. Petsche, MD
ORTHOPEDICS 2010; 33:12
Abstract

This study compared the revision rates after autograft and allograft bone-patella tendon-bone anterior cruciate ligament (ACL) reconstruction. All bone-patella tendon-bone ACL reconstructions performed by a single surgeon between January 2000 and December 2006 were identified by retrospective chart review. Two hundred twenty-three patients met the inclusion criteria and 173 patients were available for follow-up. One hundred forty-two patients underwent bone-patella tendon-bone autograft reconstruction, and 31 patients underwent bone-patella tendon-bone allograft reconstruction.

At a mean follow-up of 49 months (range, 11-91 months), revision rates were 0.7% (1/142) in the bone-patella tendon-bone autograft group versus 9.7% (3/31) in the bone-patella tendon-bone allograft group (P=.02). Subjective International Knee Documentation Committee (IKDC) scores of nonrevised (surviving) grafts in the bone-patella tendon-bone autograft group were 98.3 versus 95.2 in the bone-patella tendon-bone-allograft group (P=.0006). Tegner scores of nonrevised grafts in the bone-patella tendon-bone-autograft group were 6.2 vs 6.5 in the bone-patella tendon-bone-allograft group (P=.03). Fourteen of the 31 (45%) allografts were irradiated and all failures occurred in irradiated grafts. When irradiated grafts were excluded, no difference in revision rates was found. Anterior cruciate ligament reconstruction with the use of bone-patella tendon-bone allografts is associated with a higher revision rate when compared to bone-patella tendon autograft reconstruction. In addition, when comparing surviving grafts, the subjective IKDC scores are higher in the autograft group. When irradiated grafts are excluded, no difference in revision rates was found. Surgeons should be aware of the higher revision rate associated with allograft ACL reconstruction when counseling patients on graft options. Level of Evidence: III; retrospective comparative study.

would you say that autograft will also depend on the age of a person?That autograft is best for younger individuals?

[drmark]

There aren't enough young people who ride their motorcycles in heavy trafffic who's families consent to having them carved up.

Most allografts come don't come from 17 year old cadavers, so you never quite know what you are getting.

Many older people can live just fine without an ACL. Those that are very active are physiologically young and do better with autografts if they can't or dont' want to sit out for one year.

If someone is willing to restrict their activities to the health club for a year to a year and one half, an allograft is fine. And remember most people that sit out for that long never get back in. They become couch potatoes.

[StuntCok]

Dr Mark, i asked in another thread that is long since buried but since I see you back around these parts have you heard of the LARS method and what do you think. I read that in Aus, they have Aussie rules players back in action 3 mos after full tears and ops.

[drmark]

Any nonliving device, given enough cycles will deteriorate and fail.
Your tires and break shoes only last 15,000 miles at best.
Are still driving the same car your folks bought for you on yur 16th birthday?

[gibbssco]

Dexter,

Do you recall whether your's was irradiated or not? Just shredded mine a few weeks ago and am bulking up on my edjumacation in the ACL arena!

[Dexter Rutecki]

Not sure how I posted this thread and managed to forget about it for a few years...just found it searching for something, and it seems worthwhile for gimp central.

If someone is willing to restrict their activities to the health club for a year to a year and one half, an allograft is fine. And remember most people that sit out for that long never get back in. They become couch potatoes.

I have to say, drmark posted a lot of questionable things about allografts, but this one really sticks out. A little over four months out following my allograft I started playing hockey again, and was skiing at almost 100% a little more than six months out. I have no idea where he got the idea that allograft patients can't do much for a year and a half (maybe it's because he has no experience with allograft recipients).

Dexter,

Do you recall whether your's was irradiated or not? Just shredded mine a few weeks ago and am bulking up on my edjumacation in the ACL arena!

I actually don't know--I could find out, but I guess it's whatever my surgeon/hospital generally uses. All I know is I'm a few years out and skiing just as I was before (no problem doing anything--gates, heavy pow, air, etc.). I was pretty worried about the allograft based on some of what was presented as fact around here, but so far so good (think it's also obvious that if you can do patella autograft it's preferable).

[drmark]

I have no intention of doing the library research for you and I don't have a copy of the paper in the My Documents file, but if you want to do it yourself you will find that the time it takes for an allograft to be replaced by living tissue is 12-18 months in lesser animal studies. And typically incorporation of a dead tissue is slower in humans than animals. From this data, the reccommendation to avoid stressful sports comes.

This data doesn't have police powers. There is free will in the universe. People can do whatever they want to do. Some will return to sports in a few weeks, when the knee feels good, and will prosper, other will see their graft implode. Those that do are reduced to the ACL deficient and ACL deficient folks participate in sports all the time. Unless one has had instrumented knee laxity measurements, one may really have no clue as to the intregity of the graft-living or dead.

[Dexter Rutecki]

Again, what you're saying doesn't match current protocols. The idea that one waits 18 months (which I did read is the time it can take for allograft tissue to be fully incorporated) with a successful allograft before a return to sports is at odds with the three recovery protocols I just looked at (online, from reputable orthopedic sites), and at odds with what my PT and ortho had me do.

I also ran across this study, which seems to contradict what you have presented here (many times) as fact:

http://www.arthroscopyjournal.org/ar...122-5/abstract

Autograft versus allograft anterior cruciate ligament reconstruction

* Walter R. Shelton, M.D.
Affiliations
o Corresponding Author InformationAddress correspondence and reprint requests to Walter R. Shelton, M.D., 1325 East Fortification St, Jackson, MS 39202.
o Mississippi Sports Medicine and Orthopaedic Center, Jackson, Mississippi, U.S.A.
* , Lew Papendick, M.D.
Affiliations
o Rapid City, South Dakota, U.S.A.
* , Andrea D. Dukes, M.S.
Affiliations
o Mississippi Sports Medicine and Orthopaedic Center, Jackson, Mississippi, U.S.A.

* Abstract
* Abstract + References
* PDF
* References

Abstract

To compare the efficacy of allograft versus autograft central one third patella bone-tendon-bone reconstruction of anterior cruciate ligaments (ACL), subjective and objective criteria were compared between two groups of 30 patients with 2-year follow-up. Over a 15-month period, 60 patients underwent ACL reconstruction with 30 allografts and 30 autografts. One surgeon performed all reconstructions, and interference fit screw fixation was used. An early rehabilitation protocol was instituted. At 3, 6, 12, and 24 months, allograft and autograft groups were compared based on side-to-side arthrometer difference, swelling, pain, range of motion, patellofermoral pain and crepitation, Lachman's test, pivot shift test, and side-to-side thigh circumference difference. Average age in the autograft group was 25 years (range, 15 to 43; standard deviation, 8.1), and in the allograft group was 27 years (range, 15 to 55; standard deviation, 10.9). Thirteen meniscectomies and 12 meniscal repairs were performed at the time of ACL autograft. Fifteen patients in the allograft group had menscectomies, and 10 had meniscal repairs. There were 15 acute and 15 chronic injuries in the allograft group and 24 acute and 6 chronic in the autograft group. Results were analyzed using a χ-square test, and no statistical differences between groups were shown at 3, 6, 12, or 24 months for swelling, pain, side-to-side arthrometer difference, pivot shift test, range of motion, patellofermoral pain and crepitation, or Lachman's test comparisons. There was a trend for more of the allografts (20%) to have a glide on pivot shift at 24 months than autografts (7%). At 12 and 24 months, there was no difference in patellofermoral crepitus or thigh circumference. Complications included two patients with superficial infections.


I don't feel like spending $32 to see the whole thing, especially since it only seems to confirm what I've been told.

One more:

Allograft versus autograft patellar tendon anterior cruciate ligament reconstruction:☆
A 5-year follow-up

* Robert K. Peterson, M.D.
* , Walter R. Shelton, M.D.
* , Anna Laura Bomboy, B.S.

* Abstract
* Full Text
* PDF
* References

Abstract

Purpose: To compare the long-term results of allograft versus autograft central one-third bone–patellar tendon–bone reconstruction of the anterior cruciate ligament (ACL), 2 groups of 30 patients were evaluated subjectively and objectively at an average follow-up of 63 months (range, 55 to 78 months). Type of Study: A prospective nonrandomized study. Methods: All surgeries were performed endoscopically by a single surgeon using metal interference screw fixation between May 1991 and November 1992. Early aggressive rehabilitation was employed and follow-up visits at 3, 6, 12, 24, and 60 months noted swelling, pain, range of motion, and patellofemoral crepitus, and Lachman test, pivot shift test, and side-to-side arthrometer differences. Results: Results were analyzed using 2-sample t test and χ-square analysis. Average age at surgery for autografts was 25 years (range, 14 to 49) and for allografts was 28 years (range, 14 to 53). The presence of meniscal tears were similar (allografts, 23 tears; autografts, 19 tears). At follow-up, no statistically significant difference was found for the presence of pain, giving way, effusion, Lachman and pivot shift results, or arthrometer measurements. Two patients, 1 allograft and 1 autograft had complete rupture of their grafts. There was no late stretching out of either graft and patients stable at 2 years were stable at 5 years, with the exception of the 1 ruptured graft in each group. Conclusions: A trend toward a greater incidence of glide on pivot testing was seen in the allografts (4 allografts v 2 autografts) but was present at 2 years and did not change at 5 years. A trend toward greater loss of extension in autografts (2.47°) than allografts (1.07°) was seen at 5-year follow-up, not seen at 2 years.

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 1 (January), 2001: pp 9–13


I personally haven't had the kt-1000 on this knee, but based on what I'm able to do now (that was impossible before surgery) and what my ortho felt at my last exam (one year after surgery) I can't imagine there's any laxity worth worrying about. Feels just as good as my autograft right knee. I know you have your own personal bias, based on the type of surgery you do, but your views don't seem to be shared by other orthopedists (none that I've found, anyway).

I don't have a dog in this fight anymore, as my knee was done awhile back, but I am still curious as to the substance of your argument, particularly for those who can't have the patellar autograft.

[drmark]

Last I checked a doc doesnt need a special license to install ACL allografts, so I really don't have a dog in the race either.

The articles you quoted are actually only one study published to two different journals. (Read the abstracts, and look at the authors, its all nearly the same) They seem at odds with many dozens of others that you can easily find in the AJSM. But really they are not. Both articles found a "trend to an increased "pivot glide" amongst the allograft cases. A "pivot glide" is a benign way to say "pivot shift" which is a hallmark of treatment failure.


"Conclusions: A trend toward a greater incidence of glide on pivot testing was seen in the allografts (4 allografts v 2 autografts) but was present at 2 years and did not change at 5 years."

More simply put, people seemed to be satisfied with their allografts, but the knees werent' as tight.

A statistical difference at a P value of less than 0.05 couldn't be proven as far as the pivot was concerned, but common sense may cause you to agree that with a sample size of ony 30 patients per study, a larger sample is necessary when we are talking about a condition in which over 100,000 persons per year come to surgery in this country alone.

Not all published articles have the same power (number of cases studied)

Since I am getting too old to argue anymore, and there is fresh powder outside, I will agree with you that allografts and autograft ACLR do work. Besides, a good patient, surgeon, and rehab person, everyone needs luck. With cadaver grafts, you just need a bit more luck.

[jon gaper]

"Since I am getting too old to argue anymore, and there is fresh powder outside, I will agree with you that allografts and autograft ACLR do work. Besides, a good patient, surgeon, and rehab person, everyone needs luck. With cadaver grafts, you just need a bit more luck"

congrats on powder in houston!
dr mark is right. there is no better substitute in the human body than your own tissue,whatever the material or location.

that has been proven in every part of the body 100's of times

i am impressed ,however, that dex can read an abstract, even if he cant understand it

[Dexter Rutecki]

dr mark is right. there is no better substitute in the human body than your own tissue,whatever the material or location.

that has been proven in every part of the body 100's of times

That was never the issue, but keep at it and maybe you'll catch up. Probably not, but give it a shot.

[BadGalSkiier]

Not that anyone really cares but may doc has always told me no sports for at least 1 year (preferably longer) after my allografts. I am free to do as I wish but he told me that he wouldn't feel bad for me if the allograft ruptured due to early return to sports. It's stated in the literature so I don't understand where this argument is coming from. I too felt good at 6 months post op but was instructed over and over again by my doc not to engage in any sports because the risk was too high due to slower graft incorporation times. Dr. Mark is 100% correct on this one. All I can say is Dexter, I hope you are not giving other people advice.

[Dexter Rutecki]

I too felt good at 6 months post op but was instructed over and over again by my doc not to engage in any sports because the risk was too high due to slower graft incorporation times. Dr. Mark is 100% correct on this one. All I can say is Dexter, I hope you are not giving other people advice.

Not giving anyone advice, just stating the facts. Your doctor telling you to sit out longer doesn't represent the consensus, and if you look at the current protocol from HSS (and other top places--you can find some protocols online) they don't match what you were told to do. They all state, barring complications, return to sports at 6-7 months. If your doctor has some evidence that waiting six or twelve more months results in lower failure rates he should let everyone else in on it.

[drmark]

No powder in Houston. I am in Vail. Back home tonight :-(

[drmark]

This is a must read for the intelligent person facing ACLR. It is Level 2 evidence, which is the best quality of evidence available in a clinical study on ACLR

I am sorry to report that it will take at least a generation or two for the local docs to get on the wagon.

http://ajs.sagepub.com/content/39/2/348.abstract

(For those folks without Master's Degrees, just read the conclusion)

[montanaskier]

No powder in Houston. I am in Vail. Back home tonight :-(

I feel dirty knowing this douche was in town. I bet you were really ripping it up. How did the snowblades work out?

[drmark]

I have a house in Vail. Don't worrry you can't afford my neighboorhood.

[montanaskier]

You'd probably be surprised who your neighbors are big Texas. You continue to prove the point of those that don't like you with every post....congrats. Shoot me a PM the next time you are in town, it is a ski forum afterall, lets ski.

[nieveparasiempre]

Fourteen of the 31 (45%) allografts were irradiated and all failures occurred in irradiated grafts. When irradiated grafts were excluded, no difference in revision rates was found.

This is important to note.

Also see here and you'll find that only 2.4% of allograft ACL's fail when not irradiated.

So maybe with the proper pre-processing of the tissue, allograft is the way to go. Never had an ACL done myself....just adding more info here.

[drmark]

The beauty of the study that I referenced earlier is that is contains hundreds and hundreds of cases. Many of the other studies quoted in this thread contain a very limited number of cases, and as such the conclusions drawn are subject to the errors that occur in small samples.

[CUnger77]

I had my left knee done with a hamstring about 3 years ago, and I go in Thursday for my right knee. I am thinking of going with a allograft this time as per the recommendation of my doctor, and because my hamstring still doesn't feel right. So we will see how it goes.

[nieveparasiempre]

The beauty of the study that I referenced earlier is that is contains hundreds and hundreds of cases. Many of the other studies quoted in this thread contain a very limited number of cases, and as such the conclusions drawn are subject to the errors that occur in small samples.

I agree that the study you mentioned had significantly more cases involved. But it also mentioned that only 16% were allograft, 1/2 of which were irradiated. It would be interesting to see how the numbers would come out with the irradiated allografts excluded.