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BPTB allograft for ACL reconstruction linked with greater revision risk vs autograft
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Researchers found a 4.5-times adjusted greater overall revision risk when bone-patellar tendon-bone allograft was used for primary ACL reconstruction compared with the use of bone-patellar tendon-bone autograft.
“[One] should expect a 4.5-times higher risk of revision after ACL reconstruction if a [bone-patellar tendon-bone] BPTB allograft is used rather than a BPTB autograft,” Gregory B. Maletis, MD, study author and orthopedic surgeon from Kaiser Permanente Baldwin Park Medical Center, told Healio.com/Orthopedics. “Interestingly, whether the BPTB allograft tissue was chemically processed and/or irradiated, or not processed at all, made little difference in the overall risk of revision.”
Researchers performed a retrospective cohort study using prospectively collected data from the Kaiser Permanente ACL Reconstruction Registry to identify 5,586 patients who underwent primary unilateral ACL reconstruction. Of these patients, 4,557 patients underwent reconstruction with BPTB and 1,029 patients underwent reconstruction with BPTB allograft. The primary endpoint was aseptic revision. The Kaplan-Meier curves were used to compared cumulative failure distributions. To compare the risk of autograft vs. allograft, investigators used Cox proportional hazards models.
Results showed that for patients who underwent ACL reconstruction with allograft, the estimated cumulative revision at 2 years was 4.1%; whereas for patients in which autograft was used, the revision rate was 1.7%. Investigators noted the adjusted risk of revision was significantly higher in patients who underwent reconstruction with allograft compared with those who underwent reconstruction with autograft.
“This higher risk of revision was consistent with all allograft processing methods when compared with autografts and also consistently higher in patients with allografts regardless of age,” the researchers wrote. – by Monica Jaramillo
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Benedict U. Nwachukwu, MD, MBA
Graft type for ACLR remains controversial. The BPTB autograft and hamstring autograft have their relative advantages and indications can vary based on patient and surgeon considerations. Allograft ACLR has also become increasingly popular for ACLR and the literature is inconclusive with regard to comparative outcome differences for auto vs. allograft.
Maletis and colleagues used the Kaiser Permanente ACLR Registry to compare the risk of revision between BPTB autograft and allograft. The authors noted a 2-year 4.1% cumulative revision rate for allografts and 1.7% for autografts. In adjusted analyses, allograft BPTB was associated with an overall 4.54-times increased risk. The increased risk of revision for allograft BPTB was persistent regardless of age grouping or allograft processing method.
The study findings should be interpreted in light of the obvious study weaknesses which include a lack of clinical and functional patient data, heterogeneous patient population, multiple contributing surgeons with varying surgical techniques/rehabilitative protocols and potential loss to follow-up bias.
Despite these limitations, the study provides important findings and surgeons should certainly be aware of the strong association between risk of revision and use of allograft ACLR. It is not readily apparent however, from the present study, which patients would benefit from allograft vs autograft ACLR. Future studies may help us better understand whether activity level and sport have an influence on the risk of revision. Such an investigation will help us continually refine our indications for ACLR graft type.
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