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What ACL graft is best for older active patients who are uncomfortable with receiving allograft tissue?
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Advantages with quadrupled semitendinosus autograft
There is no question in my mind that the ideal ACL graft for an active older patient who is uncomfortable with an allograft is a quadrupled semitendinosus autograft. By quadrupling the tendon, sufficient size and strength of the graft can be achieved. The fact that the quadrupled graft may be shorter can easily be accommodated by using an all-inside technique with bony sockets. With the harvesting of only a single hamstring, the risk of harvest morbidity is low and there is little early postoperative pain. This allows early weight-bearing and shorter time on crutches, which should decrease the risk of deep vein thrombosis or falls. The harvesting is relatively straightforward and can be performed quickly without a tourniquet. Any resulting minor hamstring weakness is unlikely to be noticed in these patients. With respect to concerns about graft retear, because the risk of ACL graft retear declines with age, as much as 50% for each decade of life, retear rates should be low. There is a reason hamstring grafts are the most commonly used grafts for ACL reconstruction worldwide and the benefits of this graft choice are amplified in the older population. In addition, any potential downsides of hamstring graft use are minimized in this age group.
Christopher C. Kaeding, MD, is executive director of sports medicine at The Ohio State University Wexner Medical Center in Columbus, Ohio.
Disclosure: Kaeding reports no relevant financial disclosures.
Choose hamstring or bone-tendon-bone autograft
Based on Multicenter Orthopaedic Outcomes Network or MOON prospective longitudinal cohort data, which has followed outcomes for 2, 6 and 10 years after ACL reconstruction, there are no differences in patient-reported outcomes for autograft hamstring vs. bone-tendon-bone. These patient-reported outcome measures include KOOS, IKDC, Marx Activity Rating Scale and SF-36 for all these time points. We do not have any quadriceps tendon ACL reconstruction; therefore, we cannot evaluate that vs. use of the two aforementioned autografts. For this reason, hamstring or bone-tendon-bone would be my autograft of choice.
I am applying this to patients who are 30 years old or older. The rate of failure is low at these ages, and no significant differences have been observed between these two autografts.
Kurt P. Spindler, MD, is vice chair of research for the Orthopedics & Rheumatologic Institute at Cleveland Clinic in Cleveland.
Disclosure: Spindler reports he receives grants from the NIH/National Institute of Arthritis and Musculoskeletal and Skin Diseases and receives other funding or support from DonJoy Orthopaedics, National Football League, Cytori, Mitek and nPhase.