When you are considering ACL Surgery, choosing which ACL replacement graft to use is not always an easy decision.
This will be the second post in our “Straightforward Diagnosis, 5 Professional Opinion Series”. Our first post focused on our approach to an 18 year old athlete and how we determined who needed to consider ACL surgery and who didn’t.
Once the decision has been made to proceed with ACL surgery, the surgeon, and you need to determine which graft would best suit your needs. Our choices include your own tissue (autograft) or cadaveric tissue (allograft). Within the autograft category we have the choice of using your:
- Patella Tendon
- Quadriceps Tendon
- and Hamstring Tendon(s).
Choosing which graft is more appropriate for your needs is not always straightforward. Let’s see what our panel of experts says.
Which ACL graft Would You Choose to Reconstruct the ACL of an 18 year old Athlete?
S.S : My preference in young patients is to use autograft. Many recent studies, including the recent MOON studies, have demonstrated that autograft is superior to allograft, with significantly decreased risk of re-rupture, in a young athletic population. The risk of re-rupture approaches equal at about age 35. My graft of choice for this patient would be a semitendinosis autograft. Harvest of this graft has lower risk and morbidity than bone-patellar tendon graft. There is a lower risk of persistent anterior knee pain and patella fracture with hamstring graft. Most studies have shown equivalent functional results, re-rupture rates and return to sport when comparing hamstring to patellar tendon grafts.
D.G. : I am a strong proponent of using autografts for young, active patients. Generally I tend to like patellar tendon grafts, but I would be fine with either a patellar tendon autograft or hamstring autograft. I do tend to worry a little bit about hamstring grafts in females due to the possibility of worsening the quadriceps:hamstring imbalance. I try to avoid allografts in young active patients due to a higher rate of reinjury that many studies in recent years have shown.
D.O. : I would typically use HAMSTRING AUTOGRAFT as my graft of choice. While bone-patellar tendon-bone autograft is another good choice, the disruption of the patellofemoral mechanism can increase chances of later patellofemoral pain and arthritis, down the line. I have some experience with quadriceps tendon allograft, and this would be another good choice as well.
J.B. : No Allografts for primary isolated ACL reconstruction in any active (usually all) pts under 45 yo. Too much data showing higher rates of failure for me. I find autografts are easy to harvest. Offer BPB and quadrupled HS autografts with preference for HS. My interpretation of the data is both provide very similar outcomes. BPB higher rate of anterior knee pain, kneeling pain, earlier PF OA and risk of patellar Fx. I’ve seen all of them except fractures in my patient (seen fractures in others). I see very little, if any, complications with HS and prefer that. No experience with Quad tendon.
S.M : Most of my experience is with bone patella tendon bone AUTOGRAFT. I recommend this graft for most of my patients. Other than the slight loss of sensation around the incision I have not had patients complain of significnant anterior knee pain. I believe this is due to the details of post op therapy which focuses on patella mobility, quad tendon stretching and maximizing knee extension. I do use bone patella tendon bone ALLOGRAFT for less active older patients (older than 40) especially if the patient cannot afford to be off work.
When discussing your ACL surgery with you, your surgeon should discuss the graft choices available, and which graft they feel is best to suit your needs.
Our panel is in agreement:
- Allografts (cadaver) grafts are probably a poor choice in an athletic population.
- Hamstring grafts are a good choice, but might cause weakness – if both of them are used.
- Patella tendon grafts are also a strong choice, but might raise the risk of residual pain in the front of the knee.
Which ACL graft is best for you? That’s a good question to ask your surgeon, and hopefully these experts have given you some key points to review with your experienced ACL surgeon.
The participants :
D.G.: Dr David Geier : Twitter: @DrDavidGeier ; Website
J. B.: Dr Jeff Berg: Twitter: @DrJeffBerg ; Website
D.O.: Dr Derek Ochiai: Twitter: @DrDerekOchiai ; Website
S.M.: Dr. Steve Mora: Twitter: @myorthodoc ; Website
S.S: Dr Scott Slattery: Twitter: @sportscaduceus ; Website:
Bob Smith
Hi Dr. Luks – Thanks for the great article & your responses above. I tore my ACL this summer & am facing surgery in a few weeks. I am an athletic 15 year old boy hoping to play high school sports again in a year or so. Which option do you think is best for me? We’re also talking with two potential surgeons, both highly recommended with excellent reputations, one has about 10 years experience & the other about 45. Any thoughts on that?
Howard J. Luks, MD
Good Luck Bob … your options might be limited if your growth plates are open. Then the hamstring is likely your best option. When growth plates are closed then you can discuss the options of a patella tendon or hamstring graft with your surgeons. Avoid allograft.
Good luck to you.
Luke
Hi Dr L
I tore my left ACL in March while playing rugby. I’m 14 years old and play sports at a competitive level.
In July my Dr said that surgery is know needed. If I am to be operated on BEFORE my growth plates close which is the best option and which one is the best choice AFTER my growth plates close. After 9 months recovery, I want to return to playing contact and non-contact sports and a highl level so which type do you suggest when.
Thanks for your time
Howard J. Luks, MD
A patella tendon graft is likely the best graft for active contact athletes… but you would need to wait until your growth plates are closed. Timing is an issue. Most of us favor early reconstructions in children because you are at high risk for developing secondary injuries such as a meniscus tear.
Andrew Hall
Hi Doctor – I had a partial tear in my ACL which the surgeon decided to shave rather than perform a full replacement. 8 weeks after the operation the same has occurred, the decision this time round is for a full ACL reconstruction. I have been advised by the surgeon that the best option for myself would be for a synthetic graft reconstruction. I am a very active 24yo who played football 4/5 times per week. After reading the above I am skeptical of the decision that has been made. Could you give me your opinion?
Howard J. Luks, MD
I think the post is pretty clear. allograft or synthetics would not be the best choice.
Good Luck
CB
My daughter tore her ACL playing soccer and is preparing for surgery. Her age is uncertain (international adoptee) but likely 13-15. She is two years post onset of menses. Her growth plates are very slightly open, Thoughts on best material for reconstruction?
Howard J. Luks, MD
If the growth plates are open then a soft tissue reconstruction — commonly a quadrupled hamstring is indicated. If the growth plates are closed, anything but allograft is ok. A wrist xray can give you a “bone age” .
Lisa
First, thank you for this series. It is so helpful to be able to read opinions and link to studies when getting ready to make these decisions. My brother-in-law had ACL reconstruction using his hamstring a number of years ago, and has since had problems with his hamstring cramping and loss of range of motion. Because of this, my husband was going to ask for allograft for our son (almost 17 y.o. athlete) until I read this–again, thank you! I have a feeling our surgeon knows all this and would tell us what we’re reading here in our upcoming MRI discussion, but I wonder if you’ve heard of many patients with hamstring problems following autograft? Was there something my BIL’s surgeon could have done to prevent the problems he’s having?