➢ Graft selection is one of the main topics of discussion between surgeons and their patients requiring anterior cruciate ligament (ACL) reconstruction.
➢ Understanding the importance of a patient’s age, occupation, activity level, surgical history, and future goals is vital to determining the ideal choice of graft.
➢ Reviewing the risks and benefits of each graft option with a patient is crucial for a successful preoperative consultation.
➢ Both allograft and autograft options can be successful if used in the appropriate clinical setting.
In the United States, the incidence of anterior cruciate ligament (ACL) reconstruction is approximately 125,000 cases annually1. ACL reconstruction is indicated to prevent knee laxity and functional instability during physical activities, particularly those that require cutting or pivoting motions. Reconstruction also aims to protect the knee by lowering the risk of subsequent meniscal injury and perhaps the development of degenerative joint disease in the meniscus-deficient knee2.
Once the decision has been made to proceed with an ACL reconstruction, a substantial amount of time is invested into preoperative counseling of the patient, particularly with regard to graft selection. Because of the plethora of information available on the web regarding ACL surgery, patients often present with preconceived perceptions regarding particular graft choices. A surgeon must be knowledgeable about the benefits and disadvantages of each graft choice to effectively counsel the patient prior to surgery.
Although no graft can restore the normal structure or biomechanical properties of the ACL, the graft that is selected for ACL reconstruction must possess minimal structural and mechanical properties to aptly substitute for the native ACL. These properties include the ability to rapidly integrate into host tissues, to minimize harvest-site morbidity, and to approximate the biomechanical properties of the native ACL3. Numerous factors, including patient age, occupation, activity level, graft availability, surgical history, existing tendinopathy, and the experience and preference of the surgeon, should be considered prior to determining which type of graft will be used for reconstruction. Currently, most grafts are divided into two groups: autografts and allografts. Bone-patellar tendon-bone, four-strand hamstring tendon, and quadriceps tendon-bone grafts are the most common autograft choices, whereas bone-patellar tendon-bone, hamstring tendon, tibialis anterior, tibialis posterior, and Achilles tendon grafts are the most common allograft choices.
For graft selection to be optimal, the surgeon must understand the risks and benefits of each graft choice. Factors such as clinical outcome and return to sport may be at the forefront of the graft-choice discussion, but it is essential for the surgeon to thoroughly explain the differences in structural properties, biology of healing, fixation strength, and donor-site morbidity in order for a patient to make an informed decision that is based on his or her future aspirations.
Autografts, particularly bone-patellar tendon-bone and four-strand hamstring tendon grafts, have been the standard for ACL reconstruction4. Autografts are favorable because they lack the risk of disease transmission and have more rapid biological integration compared with allografts. However, these benefits must be balanced against the accompanying donor-site morbidity.
Bone-Patellar Tendon-Bone Autograft
Bone-patellar tendon-bone autograft is harvested from the central third of the patellar tendon and includes bone plugs from the inferior aspect of the patella and the tibial tubercle. The presence of bone plugs allows for the integration of bone in the surgically created tunnels and is an advantage of using bone-patellar tendon-bone graft (Fig. 1). The bone plugs heal into the tunnels via creeping substitution, which is both stronger and more reliable than the spot welds of soft-tissue-to-bone healing3. Graft integration has been shown to be quicker at the bone-bone interface (eight weeks) compared with the tendon-bone interface (twelve weeks)3,5.
Bone-patellar tendon-bone autograft also has biomechanical properties similar to those of native ACL. Bone-patellar tendon-bone autograft has a greater ultimate tensile load and stiffness than the native ACL but has a slightly smaller cross-sectional area3 (Table I). The reduced cross-sectional area of the bone-patellar tendon-bone graft has been cited as one reason to preferentially select quadriceps tendon autograft, particularly in the setting of tunnel widening and revision surgery.
Bone-patellar tendon-bone autograft has clear advantages, but its disadvantages must also be considered. One such disadvantage is the potential for patellar fracture or patellar tendon rupture at the harvest site, with reported rates of 0% to 2%6,7 and 0.24%8, respectively. Removal of the inferior portion of the patella during a bone-patellar tendon-bone harvest may result in patellar fractures secondary to the resultant stress riser (Fig. 2)6. Direct impact on the anterior aspect of the knee or indirect impact via an eccentric contraction of the quadriceps may be responsible for patellar fractures after bone-patellar tendon-bone harvest. Unless treated with bone graft, the patellar defect is replaced by fibrous tissue, which has inferior mechanical properties compared with the cortical bone and has less resistance to tensile forces, resulting in a higher risk of both patellar fracture and patellar tendon rupture9. The risk of fracture can be minimized by avoiding cross-hatching at the corners of the harvested bone plugs and also by avoiding an overaggressive plug harvest10. Ferrari and Bach7 treated the patellar defect with autologous bone produced from tunnel reamings and reported less donor-site pain and no cases of patellar fractures in a study of 693 bone-patellar tendon-bone ACL reconstructions.
A second disadvantage of bone-patellar tendon-bone autograft, and one that should be emphasized during preoperative counseling, is the risk of anterior knee pain and/or patellar tendinitis following surgery. A randomized controlled trial with a mean eight-year follow-up demonstrated significantly greater pain with kneeling (p < 0.001) in patients who underwent ACL reconstruction with bone-patellar tendon-bone autograft as compared with hamstring tendon autograft11. Feller and Webster demonstrated a significant difference (p < 0.05) in the incidence of anterior knee pain two years after ACL reconstruction in the bone-patellar tendon-bone autograft group (52%) as compared with the hamstring tendon autograft group (17%)12. However, this difference was no longer significant at three years after reconstruction. Other studies have demonstrated no significant difference in knee pain between groups treated with these two types of grafts13-15. Nevertheless, it is important for a surgeon to discuss this postoperative complication with patients whose sport, profession, or religion requires a substantial amount of time kneeling.
Another potential drawback of bone-patellar tendon-bone autograft is postoperative quadriceps weakness. Mohammadi et al.16 demonstrated that athletes who underwent reconstruction with bone-patellar tendon-bone autograft had significantly (p < 0.01) less isokinetic peak quadriceps torque at the time of the eight-month follow-up than those who underwent reconstruction with hamstring tendon autograft. In addition, Keays et al. demonstrated greater functional quadriceps weakness at six years in athletes who had undergone reconstruction with bone-patellar tendon-bone autograft as compared with hamstring tendon autograft17. Studies have suggested that ACL reconstruction, independent of graft selection, is associated with a persistent strength deficit compared with the contralateral knee even by one year postoperatively18.
Using a bone-patellar tendon-bone autograft can present technical challenges for the surgeon, such as the risk of graft-tunnel mismatch. Unlike soft-tissue autografts, bone-patellar tendon-bone autograft has a static length between the bone plugs. The length of the bone-patellar tendon-bone graft should equal the sum of the length of the drilled tunnels and the intra-articular distance. However, variable length of the drilled tunnels or anatomic variations in tendon length (i.e., patella alta or baja) may result in graft-tunnel mismatch. Similarly, patients who are unusually short or tall may not have ideal bone-patellar tendon-bone grafts available for use in reconstruction. Thus, when utilizing bone-patellar tendon-bone autograft, the surgeon should be well versed in techniques to resolve graft-tunnel mismatch.
Finally, there is a concern about osteoarthritis after ACL reconstruction with bone-patellar tendon-bone autograft. Multiple intermediate and long-term studies have demonstrated an increase in the prevalence of tibiofemoral and patellofemoral osteoarthritis in patients who have undergone ACL reconstruction with use of bone-patellar tendon-bone autograft compared with hamstring tendon autograft2,17,19,20. Holm et al.14 demonstrated no difference in the rate of arthritis between hamstring tendon and bone-patellar tendon-bone autograft groups ten years after ACL reconstruction; however, both groups had an increased rate of arthritis in the involved knee compared with the contralateral knee. Thus, the traumatic effect of the inciting injury is clearly a cause of earlier-onset arthritic changes in the knee despite the graft choice.
Hamstring Tendon Autograft
Quadrupled-strand hamstring tendon is harvested from the anteromedial side of the knee, most frequently at the pes anserinus insertion, and is most commonly composed of the semitendinosus and gracilis tendons. Hamstring tendon autograft is the preferred choice of some surgeons secondary to the increased risk of graft-site morbidities such as anterior knee pain and patellar fracture that have been associated with bone-patellar tendon-bone autografts21.
The biomechanical properties of hamstring tendon make it an appropriate substitute for the native ACL. The hamstring tendon autograft has a greater ultimate tensile load, stiffness, and cross-sectional area than both the native ACL and bone-patellar tendon-bone autograft (Table I). In addition, graft-tunnel mismatch is less likely, as fixation can be placed along the length of the graft, and a variety of soft-tissue fixation options are available to the surgeon. This benefit, however, is accompanied by the risk of slippage and reduced strength of interference fixation at the tendon-bone interface as compared with that at a bone-bone interface.
Although hamstring tendon autograft is associated with minimal concern about graft-tunnel mismatch, hamstring tendon grafts cannot be customized to size and smaller-diameter tendons can increase the risk of failure. A systematic review demonstrated a 6.8 times greater relative risk of failure after ACL reconstruction if the hamstring tendon graft diameter was ≤8 mm22. Similarly, Mariscalco et al.23 reported failure in fourteen (7%) of 199 patients in whom ACL reconstruction had been performed with hamstring tendon autografts that were ≤8 mm in diameter, compared with zero of sixty-four patients who had received autografts that were >8 mm in diameter. Of note, thirteen of the fourteen failures were in patients under the age of eighteen years. Thus, grafts with a quadrupled diameter of ≤8 mm should be augmented with allograft or additionally folded to increase cross-sectional area.
Hamstring weakness is another concern associated with the use of hamstring tendon autograft. Mohammadi et al.16 demonstrated no difference in hamstring isokinetic peak torque between bone-patellar tendon-bone and hamstring tendon autografts at eight months postoperatively. However, a separate study demonstrated that hamstring isokinetic peak torque was less in the hamstring tendon group than in the bone-patellar tendon-bone group at five years after ACL reconstruction24. Hamstring strength impairments have led some surgeons to avoid utilizing hamstring tendon autografts in high-level athletes because of the risk of functional limitations during high-speed directional change movements and sprinting25.
Tunnel widening is another concern when using hamstring tendon grafts because of the possibility that radiographic tunnel widening is associated with increased graft laxity. A systematic review demonstrated greater evidence of radiographic tunnel widening after the use of hamstring tendon autograft as compared with bone-patellar tendon-bone autograft26. In addition, both early and intermediate-term follow-up studies have demonstrated that radiographic femoral tunnel widening3,12 and tibial tunnel widening26 were more common in patients who had ACL reconstruction with hamstring tendon autograft than in those who had reconstruction with bone-patellar tendon-bone autograft. However, it is unclear if the differences in tunnel widening reflect the graft selection or the associated difference in suspensory fixation and aperture fixation utilized for hamstring tendon and bone-patellar tendon-bone, respectively. Suspensory fixation has been associated with increased micromotion between fixation points and a so-called “bungee cord effect” with soft-tissue grafts27.
Increased knee laxity is another concern associated with ACL reconstruction with use of hamstring tendon autograft. A randomized controlled trial involving KT-1000 arthrometer measurements showed side-to-side differences of >3 mm in 15% of patients in the hamstring tendon autograft group compared with 5% of those in the bone-patellar tendon-bone autograft group at three years postoperatively12. The authors also demonstrated a trace-positive pivot-shift test in five patients in the hamstring tendon group, compared with zero patients in the bone-patellar tendon-bone group12. Anderson et al.28 also showed greater laxity in the hamstring tendon autograft group than in the bone-patellar tendon-bone autograft group after a minimum duration of follow-up of two years. However, other studies have demonstrated no difference in laxity between the two types of grafts29-31.
Finally, although there is a low rate of infection after ACL reconstruction (~0.48%)32, evidence indicates a higher likelihood in patients managed with hamstring autograft. Judd et al.33, in a study of 1615 patients who underwent ACL reconstruction (with nearly equal numbers of patients receiving hamstring tendon and bone-patellar tendon-bone autografts), reported that all eleven infections occurred in the hamstring tendon autograft group. Similarly, Maletis et al.32 demonstrated an 8.2 times higher risk of surgical site infection in association with hamstring tendon autograft as compared with bone-patellar tendon-bone autograft but reported no difference between bone-patellar tendon-bone autograft and allograft. Although the cause of these findings was unclear, they may have been due to a relatively high suture burden in the graft as these foreign bodies may present as a nidus for infection. In addition, the use of a post-and-washer construct may place the graft substance more superficially and theoretically allow for communication of subcutaneous tissues with the joint33.
Quadriceps Tendon Autograft
Quadriceps tendon-bone autograft has emerged as a third option for ACL reconstruction. This graft is fashioned by removing the central third of the quadriceps tendon, and the surgeon can either incorporate the superior patellar bone plug or simply detach soft tissue alone. Benefits of the quadriceps tendon graft include an increased graft cross-sectional area and a potentially reduced prevalence of knee pain and patellar fracture34. Multiple studies have demonstrated less donor-site morbidity in association with quadriceps tendon-bone graft as compared with bone-patellar tendon-bone graft34-37. Moreover, the clinical and functional outcomes of the quadriceps tendon-bone graft have been similar to those of hamstring tendon graft and bone-patellar tendon-bone graft38.
Because the quadriceps tendon graft may have only one bone plug for tunnel incorporation, biological healing may not be as efficacious as with bone-patellar tendon-bone grafts. Furthermore, harvesting of the graft does pose technical challenges due to the tendon depth, the curvature of the superior patellar surface, and accompanying proximity to the suprapatellar bursa. Outcomes from ongoing clinical studies focusing on this graft will help bear out any other potential advantages and disadvantages associated with the use of this graft for ACL reconstruction.
Clinical Outcomes of Bone-Patellar Tendon-Bone Autograft and Hamstring Tendon Autograft
ACL reconstruction has been successful with both bone-patellar tendon-bone and hamstring tendon autografts. Short and intermediate-term outcome studies have shown no significant differences between the two types of grafts with respect to functional assessment, patient-reported outcomes, stability, and return to activity12,14,24,29,30,39,40. However, bone-patellar tendon-bone autograft has been shown, on the basis of clinical testing, to result in a more objectively stable knee compared with hamstring tendon reconstruction39.
Long-term studies have also shown that both types of grafts have been associated with similarly successful results with respect to function, subjective outcomes, stability, and return to sports11,14,26. However, a recent fifteen-year follow-up study showed that hamstring tendon autografts were superior to bone-patellar tendon-bone autografts in terms of patient satisfaction, function, stability, and activity level41.
Although both types of grafts have been associated with successful functional outcomes and subjective outcome scores, multiple studies have shown that hamstring tendon autograft may have a higher rate of graft failure42-44. A systematic review comparing bone-patellar tendon-bone and hamstring tendon autografts demonstrated a higher rate of overall graft failure in the hamstring tendon group (10.9%) compared with the bone-patellar tendon-bone group (4.2%)45. Persson et al.43 compared revision rates at one, two, and five years in a study involving 12,643 patients who were included in a Norwegian knee registry. A higher revision rate was recorded for hamstring tendon autografts at all follow-up times. When adjusted for sex, age, and type of graft, hamstring tendon autografts were 2.3 times more likely to be revised. The most important finding was the increased five-year revision rate in younger patients (fifteen to nineteen years of age) when hamstring tendon autograft was compared with bone-patellar tendon-bone autograft (9.5% versus 3.5%)43.
Finally, in Denmark, Rahr-Wagner and colleagues44 performed a population-based study of 13,647 patients and found that the hamstring tendon autograft group had a greater than four times increased risk of revision compared with the bone-patellar tendon-bone group at the time of the one-year follow-up but that there was no significant difference at five years. The authors associated the earlier risk of re-rupture in the hamstring tendon group with a premature return to sport and called for longer rehabilitation times for patients managed with hamstring tendon autograft44. Similarly, Maletis et al.42 demonstrated a 1.8 times greater risk of earlier revision when hamstring tendon autografts were compared with bone-patellar tendon-bone autografts after a mean duration of follow-up of 1.5 years (Table II).
Allografts have been long utilized for ACL reconstruction and remain an excellent option for many patients. Allograft options include the autograft options discussed previously as well as Achilles tendon and tibialis anterior and tibialis posterior tendons. Traditionally, allografts have been reserved for older, less-active patients. One study demonstrated that, at the age of forty years, the risk of failure is nearly equivalent between autografts and allografts46. Recently, another study involving young patients in their late twenties demonstrated no difference in graft failure rates when autografts were compared with non-irradiated allografts4. Furthermore, patients with substantial tissue laxity or connective-tissue disorders (i.e., Ehlers-Danlos or Marfan syndrome) are good candidates for allograft reconstruction. Additional benefits of allograft use include a lack of donor-site morbidity and reduced postoperative pain and surgical times. However, allografts also have disadvantages, such as delayed biological healing, cost, higher failure rates in younger populations, and the possible risk of disease transmission46. When utilizing allografts, it is crucial to review the origin of the allograft, the age of the donor, and the graft-sterilization process and shelf time.
While allografts may undergo a similar process of integration as autografts, the process of biologic incorporation is typically slower. In sheep, fresh-frozen allograft tissue showed a delay in remodeling and healing compared with soft-tissue autografts at both six and twelve weeks postoperatively47. A delay in graft incorporation may lead to inferior biomechanical properties. In goats, the bone-patellar tendon-bone autograft group had a greater ultimate failure load and more evidence of mature remodeling compared with the bone-patellar tendon-bone allograft group at six months postoperatively48. These findings have not been validated in patients.
Patients commonly fear the risk of disease transmission associated with the use of allografts. Disease transmission is rare because of improvements in screening and testing of donor grafts at tissue banks, but the risk of transmission still exists. Tissue banks screen for hepatitis B, hepatitis C, HIV (human immunodeficiency virus), and many other viral risks3. The rate of transmission of hepatitis B or C is unknown, but the risk remains realistic. One study showed that, for appropriately screened patients, the risk of HIV transmission is one in 1,667,00049.
Surgeons must familiarize themselves with their local tissue bank because of the variability in methods of graft acquisition, preparation, sterilization, and storage. The graft-sterilization process can alter mechanical properties and is difficult to determine in proprietary protocols. Of note, some tissue banks do not irradiate grafts, thus not altering the mechanical properties. Allograft tissue can be sterilized with gamma irradiation and ethylene oxide. Gamma irradiation effectively kills virus cells within allograft tissue; however, high doses (>3 Mrad) may have deleterious effects on the graft’s mechanical properties3. Additionally, studies have shown that gamma irradiation doses of between 2 and 2.5 Mrad result in high failure rates with poorer clinical outcomes50,51. Ethylene oxide does not have detrimental effects on the mechanical properties of the graft, but it may cause a persistent synovitis resulting in graft failure52.
Synovitis also may be the result of immunological rejection of the allograft tissue. Fresh-frozen allografts can incite a cytokine-mediated inflammation, resulting in an acute synovitis and possibly a latent immunological rejection53. Patients may present with fever, erythema, swelling, and pain. Cases of spontaneous dissolution and resorption of allografts used for ACL reconstruction have been reported54.
Finally, surgeons should also consider the age of the allograft donor. Currently, there is a paucity of clinical data on the effect, if any, of donor age on the outcomes of allograft ACL reconstruction. A laboratory study demonstrated that donor age resulted in 6% of the variation in structural and mechanical properties of posterior tibialis tendon allografts55. The authors concluded that the magnitude of the differences in these properties was small and not clinically relevant. At this time, the effect of donor age on outcomes remains unknown.
Clinical Outcomes of Allografts
Individual allografts such as bone-patellar tendon-bone, Achilles tendon, and tibialis anterior grafts are often categorized into a single allograft group, despite having different outcomes. It is important to review the outcomes of each type of allograft. Achilles tendon allograft has advantageous mechanical properties, a large cross-sectional area, a bone plug, and a minimal risk of graft-tunnel length mismatch56. Achilles tendon allograft is more cylindrical than bone-patellar tendon-bone graft and has a greater cross-sectional area for a given diameter, which correlates with greater strength57. Chehab et al.56 utilized Achilles tendon allograft for ACL reconstruction in patients thirty years of age and older and successfully restored 90% of the knees to normal or near normal according to the International Knee Documentation Committee (IKDC) score at two years. However, another study demonstrated an unacceptable failure rate of 21% (five of twenty-four) when ACL reconstruction was performed with Achilles tendon allograft in a similar cohort of patients thirty years of age and older58.
Single-loop (double-strand) tibialis anterior allografts have been shown to have strength similar to that of hamstring tendon autografts59,60. Kim et al., in a retrospective review of 131 patients who underwent ACL reconstruction with either Achilles tendon allograft or tibialis anterior allograft, reported no difference between the two groups on evaluation of laxity; IKDC, Lysholm, or Tegner activity scores; or second-look arthroscopy61. However, Achilles tendon bone plugs reduced femoral tunnel enlargement compared with tibialis anterior allograft without inducing instability. Singhal et al.62 reported that, after ACL reconstruction with tibialis anterior allograft, 38% of patients required revision surgery; patients under the age of twenty-five years had the greatest risk for failure.
The use of allografts has the advantage of decreasing operative time by avoiding graft harvest, but allografts are expensive and the shorter operative time does not necessarily result in decreased costs. One center demonstrated that although bone-patellar tendon-bone allograft was an average of twelve minutes faster, the center saved nearly $1100 every time autograft was used instead of allograft during bone-patellar tendon-bone ACL reconstruction because of the increased supply costs of the allograft group63. This difference may be amplified in the long term with the additional morbidity of increased failure rates and the need for revision surgery.
Autograft Compared with Allograft
Much of the literature shows better clinical outcomes following ACL reconstruction with autograft as compared with allograft46,64-66, but, when used correctly, allograft has been shown to have successful clinical outcomes as well4,13. The major deterrent of using allograft is the higher failure rates compared with autograft, and thus, failure is the outcome that is most scrutinized.
Krych et al.67 demonstrated a five times greater risk of rupture in the bone-patellar tendon-bone allograft group compared with the bone-patellar tendon-bone autograft group. Their results showed no significant difference between graft types when irradiated and chemically processed grafts were excluded, but only six studies met the inclusion criteria.
Kaeding et al.46, in the Multicenter Orthopaedic Outcomes Network (MOON) trials, demonstrated that patients who had an allograft ACL reconstruction were four times more likely to have a graft tear than those who underwent autograft ACL reconstruction. They also demonstrated that the risk of ACL graft tear in their youngest group (ten to nineteen years) was 2.33 times higher than that in the group of peers who were ten years older after controlling for graft type. However, the risk of failure nearly equalized between the two groups by the age of forty years. The data used in the model to generate this increased risk of failure included tibialis anterior, tibialis posterior, Achilles tendon, and bone-patellar tendon-bone allografts. Although the majority of the allografts in the study were either fresh-frozen or irradiated <2.5 Mrad, the effect of allograft processing was not investigated in the study. An ad hoc analysis failed to identify tissue bank, allograft type, or processing as important variables in relation to allograft retear.
More recently, Kraeutler and colleagues64 found that patients undergoing ACL reconstruction with bone-patellar tendon-bone autografts had lower rates of graft rupture (4.3% compared with 12.7%), lower levels of knee laxity, improved single-leg hop test results, and generally greater subjective satisfaction postoperatively than patients undergoing ACL reconstruction with bone-patellar tendon-bone allograft (Table III). However, in that study, both fresh-frozen and irradiated grafts were used and were not differentiated. In addition, patients in the allograft group demonstrated less knee pain when compared with patients in the autograft group at the time of the five-year follow-up.
It is important to note that, perhaps because of the lack of donor-site morbidity, patients who have undergone allograft ACL reconstruction tend to feel ready to return to activity sooner than their counterparts who have undergone autograft ACL reconstruction. This factor could also contribute to the higher failure rates associated with allografts because of the discrepancy between subjective and objective return of strength and proprioception prior to return to play. Perhaps it would be prudent to slow the rehabilitation of patients on the basis of graft type.
Irradiated Compared with Non-Irradiated Allograft
As previously discussed, sterilization techniques can alter the mechanical properties of a graft. With higher failure rates of irradiated allografts in ACL reconstruction compared with autografts, some surgeons believe that non-irradiated allografts would have equivalent outcomes to autografts.
A systematic review showed that irradiated (<2.5 Mrad) allografts (n = 415) were associated with a higher rate of revision surgery than non-irradiated allografts (n = 1038) at a mean of 49.8 months after ACL reconstruction68. However, because of insufficient power, the effects of graft type and surgical technique could not be determined.
Yao et al.13 demonstrated no significant difference in the rate of graft failure between bone-patellar tendon-bone autograft and fresh-frozen bone-patellar tendon-bone allograft. However, the results were skewed by a selection bias as no randomized controlled clinical trials were reviewed in the study.
Mariscalco et al.4 demonstrated no significant difference in the graft failure rate, postoperative laxity, or patient-reported outcome scores between autografts and non-irradiated allografts. They recommended caution when applying these findings to younger patients as the results were limited to patients in their late twenties and early thirties.
The ideal graft choice for ACL reconstruction is individualized and must account for patient and surgeon preferences based on risks and expectations. A number of viable autograft and allograft options exist that can all achieve favorable clinical outcomes in the right setting. Graft selection cannot supplant the importance of appropriate indications, surgical technique, and postoperative rehabilitation in ACL reconstruction.
Source of Funding: No external funding of any kind was received for this manuscript.
Investigation performed at Henry Ford Hospital, Detroit, and University of Michigan, Ann Arbor, Michigan
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
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