The decision on whether to have ACL surgery is a decision that every person should discuss carefully with their surgeon.
In this article we discuss 6 key ACL graft options available to you when considering an ACL operation.
However, the question becomes which graft should a person with an ACL injury choose?
However, there are predominantly three main types of ACL graft procedures that surgeons use:
- Patellar Tendon Graft: In this procedure, surgeons use a portion of the patient’s tendon that connects the kneecap and shin.
- Hamstring Graft: Surgeons use a hamstring tendon from the back of the patient’s thigh.
- Allograft: Surgeons harvest a tendon from an external source, like a cadaver
Each of these 3 graft options have there pros and cons but often it will come down to the preference of your surgeon for one type of graft over another.
According to the Boston Children’s Hospital
there are approximately 400,000 Anterior Cruciate Ligament injuries every year in the United States. Statistics indicate that the re-tear rate for ACL reconstructions can be as high as 20% for teens and up to 80% will develop arthritis 15 to 20 years after surgery
Once the decision is made to have ACL reconstruction surgery
traditionally most people opt for either a patella or hamstring graft to replace the severed ACL graft.
Surgeons can disagree on the ACL graft choice
It is also important to note that not all surgeons agree on the type of ACL graft that should be used for a person undergoing a reconstruction. In fact it it fair to say that surgeons can disagree on which graft types are the most effective and successful.
Choosing the right ACL graft is even more important if you intend to return to playing a high level of sport which requires a lot of pivoting and twisting movements of the knee. Some studies have suggested that the re-tear rates and ACL recovery timelines
can vary between graft types.
In that respect it is advisable to talk to multiple surgeons and physicians to understand what is the right option for you. Even talking to your local doctor or physio who can provide guidance or refer you to a preferred specialist.
6 Key ACL Graft Options
1. Patella tendon graft
In this procedure, surgeons use a portion of the patient’s tendon that connects the kneecap and shin.
Many surgeons prefer to use a patella tendon graft as it closely resembles the torn ACL and is approximately the same length as the ACL and the bone ends of the graft can be placed into the bone where the ACL attaches.
The disadvantages of using a patella tendon graft is that there is potential for risk of experiencing pain at the front of the knee. In particularly where the patella tendon graft was taken.
2. Hamstring tendon graft
Surgeons use a hamstring tendon from the back of the patient’s thigh. The hamstring tendon is where two of the tendons of the hamstring muscle are effectively removed and bundled together to create a new ACL graft.
One of the key advantages of using a hamstring tendon graft is it avoids the common problem associated with using a patella tendon graft where pain is known to occur at the front of the knee. This is not a problem with hamstring tendon grafts as the incision to obtain the graft is smaller and overall the pain is thought to be less.
One of the key disadvantages with hamstring tendon grafts is it takes a longer period of time for the graft to become rigid and therefore people often need longer to be protected whilst the graft heals into place. Further, hamstring grafts have in some studies shown to result in less strength of the hamstrings after surgery.
Patella Tendon v Hamstring Tendon graft
Whilst patella tendon revision rates are thought to be lower than hamstring tendon grafts, it is clear that both graft options have low revision rates and are excellent choices for ACL grafts.
In other words the revision rates ‘after and during’ ACL surgery recovery
are low for both the hamstring and patella tendon graft types.
The ACL Reconstruction Surgery Procedure
The procedure is typically performed through an arthroscopy. The benefits of arthroscopic procedures include ease of viewing and manipulating the knee, smaller incisions, ability to complete surgery at the time of diagnosis, and fewer risks compared to open procedures. Arthroscopic procedures can be done under regional or general anaesthetic.
3. Allograft (Donor Tissue)
An allograft is not to be confused with an autograft.
An Allograft is tissue (also referred to by some surgeons as Cadaver tissue) such as a ligament, bone or tendon that is surgically implanted from one person to another. Whereas an autograft takes tissue from one part of your own body for transplant to another part of your body.
Allografts can be used in a number of different medical procedures such as shoulder or ankle repairs, plus also used as an ACL graft option for knee reconstructions.
The allograft tissue can come from death where a person has consented (or consent is provided through family) to donate his or her tissue to another individual to enhance their quality of life.
According to some sources there are approximately 1 million allograft medical procedures in the United States every year and have been used for approximately 150 years.
Some studies have shown that an allograft may not be as strong as a patient’s own tissue leading to an increased risk of re-tear. For many patients however the strength of an allograft may be sufficient to meet their demands.
4. LARS as an ACL surgery option
LARS which stands for Ligament Augmentation and Reconstruction System is effectively the use of an artificial polyester material to replace an injured ACL graft.
When it comes to ACL reconstructions for professional sports athletes, one of the most hotly debated topics in media circles is whether or not an athlete is using LARS or the traditional patella tendon or hamstring tendon graft options.
The key advantages of using LARS are the significantly reduced ACL recovery times which allow athletes to return to sport in a quicker time frame.
However, there are some concerns around the failure rates of LARS which has promoted many surgeons to continue using the traditional autograft options rather than LARS for their patients.
5. Bridge Enhanced ACL Repair
Bridge Enhanced ACL Repair is a new technique which uses stitches and injection of the patients own blood to stimulate the healing of a torn ACL. It stimulates a torn ACL to heal itself and eliminates the need for a tendon graft.
It is hoped that this method which aims to repair the existing torn ACL rather than replace the graft, will reduce the time it takes to recover from ACL surgery and possibly reduce the long term risk of arthritis in the injured knee.
Currently Bridge Enhanced ACL repair is still a relatively new procedure and has been trialled on a limited number of patients and animal models.
The goal of current and future studies is to determine whether or not this new technique is as reliable as a reconstruction for patients and to the determine the levels of revision rates compared to the traditional ACL autograft option.
6. Do not have surgery nor replace the severed ACL graft
Not everyone who injures their ACL needs to have ACL reconstruction surgery. There is no urgency about the decision to have an operation which it can be made at any time. Therefore not having ACL surgery is a very realistic option that people do choose if the circumstances are right for them.
There are instances where your surgeon will recommend not having a knee reconstruction. For example, for older and non-active people, surgeons may choose not to repair the ACL at all, but rather just recommend a rehabilitation program that includes strengthening and mobility exercises.