Yet, most orthopedic surgeons prefer hamstring grafts for younger athletes and cadaver grafts for older patients.
PTGs allow for unrestricted rehabilitation and earlier return to sports than hamstring grafts. With the ACL reconstruction and rehabilitation process used at Shelbourne Knee Center, athletes return to sport in an average of about 4—6 months after surgery 1 , compared to 12 months or more for hamstring grafts. With hamstring and cadaver grafts, orthopedic surgeons want the knee to be stiff for stability.
When rehab is done properly, however, the results are far superior. With hamstring and cadaver grafts, patients rarely achieve full range of motion or full strength, says Dr. Seven physical therapists and one athletic trainer are part of the team at Shelbourne Knee Center, which has an on-site gym.
All too often, the graft choice for that person may not be the best option for their age, goals and for their lifestyle, amongst many other things. Consideration for the current research should play a big role in this decision-making process on which graft to use for ACL reconstruction.
What are the options and why choose one over the other? Allograft means using tissue from a cadaver. It is believed that the bone-patella tendon-bone graft has a stronger fixation because of the bone plugs that can incorporate into the femoral and tibial tunnels by weeks after surgery. Better graft fixation may prevent stretching or excessive laxity that is often seen with hamstring autografts and allografts.
A strong and stable graft is key when considering the long term stability of the knee joint, as seen in this video showing the harvesting of the graft and the reconstruction.
Numerous studies have shown that re-tear rates are also significantly lower in patients undergoing a reconstruction with a patella tendon versus a hamstring tendon autograft. A Scandinavian study looking at nearly 46, reconstructions showed this as well as a Norwegian study looking at greater than 12, reconstructions.
Furthermore a Danish study of nearly 14, reconstructions showed similar results. Here in the US, a similar trend has been identified when looking at revision rates amongst the different graft choices.
In this study out of over 21, reconstructions in California, patients under 21 years old with hamstring autografts had a 1. In patients less than 40 years old, those with allografts had a higher risk of revision than those with patellar tendon autografts.
A couple of disadvantages that are often reported after the surgery are an increase in general knee pain because of the soft tissue and bony dissection and anterior knee pain. This anterior knee pain may be more of a long term issue for some, especially while trying to kneel, because of the graft harvesting and scar that remains. To me, this is a small inconvenience but I always let my clients know of the potential long term kneeling limits.
Usually not a big deal for most but you never know. They often feel that residual medial knee pain where the tendon was harvested and are reluctant to allow me to stretch them out into hyperextension. Regardless, while anterior knee pain and range of motion restrictions are often cited as concerns, in my experience I feel these can be overcome with good postoperative rehabilitation.
The hamstring tendon autograft is another graft option for someone about to undergo an ACL reconstruction, as you can see in this video by Dr. I think it is too widely used currently and we need to further assess the outcomes and high risk of re-tear rate studies that I just presented. Yeah, it may hurt less, and I stress MAY, but in my experience it is a graft that often presents a pretty big pain challenge.
Think about a tendon shaver being poked under your skin high enough to clip the tendon from the muscle belly. This is usually due to poor rehab, and consequently, can be avoided in most cases with appropriate physical therapy and strenghtening of the muscles around the knee.
For patients who would like to avoid the possibility of anterior front knee pain, or already have a history of anterior knee pain, I would advise the use of a hamstring tendon graft or quadriceps tendon graft.
Both of these are excellent alternatives to the patella tendon graft. Hamstrings also have a long track record but do have a small increased risk of stretching out over time, particularly in young females. Quadriceps tendon graft is a relatively new option but the short-term results are promising.
It is a large, strong graft, and is well suited for young patients, and it is also very useful in cases of revision redo ACL surgery where a hamstring or patellar tendon graft may have already been harvested. I reserve allograft for patients who are low-demand or those who simply do not want to use their own tissue. In choosing the appropriate graft, orthopedic surgeons and patients have the options of using either an autograft or an allograft.
Lyle Cain Jr. Among autograft choices, the most commonly used include patellar tendon and hamstring tendon, as well as the quadriceps tendon, according to Brett D. Although there are several allograft and autograft options available for ACL reconstruction, Owens noted a higher failure rate when allografts are used in young athletes. In a systematic review of eight overlapping meta-analyses, Randy Mascarenhas, MD, FRCSC, and his colleagues found lower re-rupture rates in autografts among multiple studies compared with allografts, but no significant differences in clinical outcomes between the two grafts.
More specifically, Cain noted patella tendon graft is chosen by many orthopedic surgeons because it has tissue quality similar to the ACL. He added, when the patellar tendon is matched with the bone tunnel on the femur and tibia, the bone heals within the bone faster compared with the healing rate of soft tissue. This bone-to-bone healing with the patellar graft is advantageous for athletes who are interested in returning to activity as quickly as possible, according to Owens. According to McCulloch, there have been reports that patients experienced anterior knee pain when a patellar tendon graft was used in ACL reconstruction.
However, Brian J. Patients with patellar tendon graft also have reported a little bit more difficulty early on in rehabilitation compared with cadaver grafts, according to Cain. Compared with patellar tendon grafts, hamstring grafts have donor site morbidity, but Owens noted less knee pain. The biggest concerns of the hamstring graft are about the fixation strength and the healing.
Mark E. Steiner, MD, section chief of sports medicine at New England Baptist Hospital, noted allografts in general have less pain and are easier for rehabilitation compared with autografts, but also have an increased risk of re-injury, particularly in college and high school athletes, and pose a theoretical risk of infection transmitted by the graft.
According to McCulloch, patients may view the various advantages and disadvantages of graft options differently, and should have a say in the choice of graft. Steiner noted successful implantation of the graft may be more important than the type of graft used. Several studies have shown the preference for use of patellar tendon autograft among team physicians. In a study published in Arthroscopy , Brandon J.
Erickson, MD, Cole and their colleagues found
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