A 17-year-old male presents after sustaining a right knee injury during a lacrosse game. He felt a “pop” in the knee as he pivoted to avoid an opponent. His primary care physician ordered magnetic resonance imaging after the injury, which showed a complete anterior cruciate ligament (ACL) rupture. You discuss recommendations for ACL reconstruction with the patient, including which graft types are available.
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The anterior cruciate ligament (ACL) is an essential stabilizing structure in the knee that primarily provides restraint to anterior translation and rotation of the tibia. A deficient ACL causes the knee to give out or become unstable with activities that require running and cutting, such as athletics. A deficient ACL may also cause buckling of the knee with day-to-day activities, such as walking down stairs or changing direction quickly.
In most active patients, an ACL-deficient knee must be treated immediately, as damage to the menisci and articular cartilage can occur with instability episodes. This involves an arthroscopic procedure that takes out the torn tissue and reconstructs the ligament with a graft, either from the patient’s own tissue (autograft) or from donated cadaver tissue (allograft).
There are several factors to be considered by patients and orthopedic surgeons when choosing which graft to use. The differences in success rates among graft choices are small, so the benefits and disadvantages of each should be discussed and considered. Autografts have the advantage of using the patient’s own tissue, which tends to heal a little faster than donated tissue. The most commonly used graft type in the United States is a bone patella bone autograft, and the second most commonly used graft is hamstring autograft. Professional athletes most commonly choose bone patella bone autograft followed by hamstring autograft. The downside of autografts is the additional pain postoperatively that is associated with harvesting the graft. Allografts have a higher failure rate in young athletes but result in less pain after surgery and tend to rehabilitate a little quicker. This is why recreational athletes aged more than 35 to 40 years generally choose an allograft for a quicker return to work. Surgeon preference also plays a major role when patients select graft choice. Graft choice can come with its own unique surgical approach/technique and often, surgeons choose the graft and technique with which they are most familiar.
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).