Current trends in graft choice for anterior cruciate ligament reconstruction – part I: anatomy, biomechanics, graft incorporation and fixation

Abstract

Graft selection in anterior cruciate ligament (ACL) reconstruction is critical, as it remains one of the most easily adjustable factors affecting graft rupture and reoperation rates. Commonly used autografts, including hamstring tendon, quadriceps tendon and bone-patellar-tendon-bone, are reported to be biomechanically equivalent or superior compared to the native ACL. Despite this, such grafts are unable to perfectly replicate the complex anatomical and histological characteristics of the native ACL. While there remains inconclusive evidence as to the superiority of one autograft in terms of graft incorporation and maturity, allografts appear to demonstrate slower incorporation and maturity compared to autografts. Graft fixation also affects graft properties and subsequent outcomes, with each technique having unique advantages and disadvantages that should be carefully considered during graft selection.

No difference in revision risk between autologous hamstring graft less than 8 mm versus hybrid graft 8 mm or larger in anterior cruciate ligament reconstruction

“…The addition of an allograft, while it increases overall graft diameter, may have detrimental efects as studies have shown that processed grafts could negatively impact biomechanical properties and patient outcomes [4,23,24]. The association between processing techniques for allografts used in HY grafts and outcomes following primary ACLR was outside the scope of the present study comparing < 8 mm HA to ≥ 8 mm HY.…”

Mini-Invasive Harvesting of Quadriceps Tendon Graft With Patellar Bone Block for ACL Reconstruction Using a Dedicated Harvester

“…2 Other options include allografts, tensor fascia Lata grafts, and artificial bands or augmentations, but these are usually reserved for rare cases or in the event of multiligament reconstructions requiring multiple transplants. 2,8,9 The BPTB historically has been considered the gold standard and has been the most commonly used graft for many years. 10 However, it has been gradually overtaken by the use of hamstrings that have become the most popular choice for primary ACL reconstruction both in the United States and in Europe.…”

“…The QT is a stiff and robust graft, it has shown comparable biomechanical properties to quadrupled hamstrings and BPTB, with ultimate failure loads comparable to those of the native ACL. 8,9 The QT offers the possibility of harvesting a graft with bone block. Bone-to-bone healing has shown to be faster and more physiologic than tendon-to-bone interface.…”

“…The possibility of harvesting a QT with bone block enhances its biological healing potential, placing it as a valid alternative to the classic BPTB. 8,9 The QT has also shown lower morbidity rates compared with both hamstrings and BPTB, reducing anterior knee pain, donor site morbidity, and difficulty in kneeling. 4 Regarding re-rupture rates recent meta-analyses showed similar re-rupture rates to both BPTB and hamstrings.…”

“…4 Regarding re-rupture rates recent meta-analyses showed similar re-rupture rates to both BPTB and hamstrings. 4,8,9 In conclusion, the QT should be considered as a viable option for all patients, but it proves especially adapted for young and active patients who practice activities or professions that require kneeling, or athletes in which hamstrings preservation is advisable like sprinters or martial arts athletes. 2,8,9 The main advantages of using the QT are a predictable tissue mass, and adjustable length.…”