What is the ideal graft for ACL surgery in female athletes?
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Case-by-case basis
Female athletes, especially those who participate in pivoting sports, are known to have a higher risk for ACL tears, along with contralateral ACL tears and subsequent revision ACL reconstructions.
This higher risk of ACL tears has been associated with different biomechanical and hormonal factors compared to their male counterparts. Thus, these biomechanical and hormonal differences have been demonstrated to lead to a greater rotatory knee laxity, while also increasing the overall ligamentous laxity. Therefore, promoting the prevention of ACL tears through specific strengthening and agility exercises is of utmost importance among female athletes. However, ACL reconstruction is the recommended treatment when injuries do occur. To this day, there is a lack of consensus as to which graft should be used for ACL reconstruction in this specific athletic female population.
It is widely accepted that, compared with autografts, the use of allografts, especially in younger athletes, yields worse outcomes and higher rates of graft failures. Similarly, the use of hamstring tendon autografts has been associated with higher graft failure rates, although a significant improvement in outcomes with the addition of a lateral extra-articular tenodesis (LET) has been demonstrated in a previous randomized controlled trial called the STABILITY I Trial. On the other hand, both quadriceps tendon and bone-patellar tendon-bone (BPTB) autografts have been shown to exhibit comparable outcomes, each with its advantages and disadvantages. While the BPTB autograft provides the benefit of bone-to-bone healing, it has also been associated with an increased risk of donor-site morbidities, such as higher rates of postoperative anterior knee pain. Quadriceps tendon autografts have regained popularity in the past decade, offering diverse biomechanical advantages with a more robust graft diameter and decreased risk of donor-site morbidities. However, difficulties in regaining terminal knee extension and quadriceps strength may occur in certain patients after ACL reconstruction is performed with a quadriceps tendon autograft, particularly among older female athletes.
Nevertheless, the choice of graft for ACL reconstruction cannot be entirely generalized based solely on a specific population, as there are many factors that should be considered in each individualized case. Above all, the graft choice should come as a discussion between the patient and the doctor and should not be solely based on the patient’s biological sex. In the near future, a randomized controlled trial on graft types and LETs, called the STABILITY II Trial, is expected to shed more light on the ideal graft choice for ACL reconstruction for each specific group of athletes. However, the current evidence supports the use of hamstring autograft plus LET or quadriceps tendon and BPTB autografts over isolated hamstring autografts in young active patients participating in high-risk sports.
- References:
- Getgood AMJ, et al. Am J Sports Med. 2020;doi:10.1177/0363546519896333.
- Greiner JJ, et al. Orthop J Sports Med. 2024;doi:10.1177/23259671241239692.
- Hughes JD, et al. Orthop J Sports Med. 2019;doi:10.1177/2325967119847630.
- Sheean AJ, et al. Br J Sprts Med. 2018;doi:10.1136/bjsports-2017-098769.
Volker Musahl, MD, is of the department of orthopedic surgery and UPMC Freddie Fu Sports Medicine Center at the University of Pittsburgh in Pittsburgh.
Skeletal maturity matters
Patellar tendon autograft is the ideal graft choice for skeletally mature female athletes and quadriceps tendon autograft is the ideal graft choice for skeletally immature female athletes.
ACL tears in female patients are up to eight times higher than in male patients. This increased risk has been attributed to various anatomical, developmental, neuromuscular and hormonal factors. Anatomical and hormonal factors include osseous anatomy, ligamentous laxity and hamstring muscular recruitment. Postural stability and impact absorption can also be altered in female patients and can raise the risk of noncontact ACL injuries.
When considering which ACL graft is best to use in female athletes, there are several things to consider: history of prior injuries, the status of the growth plates, associated injuries and return to sport goals. The keys to a successful outcome include appropriate graft selection, good surgical technique and the quality of rehabilitation. Therapy should address the specific neuromuscular effects that are associated with each graft type.
Results from the long-term study by the MOON Research Knee Group of more than 3,500 ACL reconstructions has shown that younger patients have higher recurrent ACL injuries, patellar tendon autografts have the lowest retear risk, hamstring tendon grafts have a higher reinjury risk and allografts have a three times higher rate of retears than autografts in patients younger than 22 years. The MOON Group also showed that the incidence of ACL graft revision in female athletes, aged 14 to 22 years, at 6 years after index surgery was 2.1 times higher with a hamstring tendon autograft compared with a patellar tendon autograft. The addition of an extra-articular tenodesis can reduce the risk of ACL failures with hamstring tendon grafts.
The patient-reported outcomes are similar among patellar tendon, quadriceps tendon and hamstring tendon autografts. Limb symmetry index is negatively affected by all autograft choices and normalizes over the first 12 to 24 months after surgery. However, patellar tendon and quadriceps tendon grafts have decreased isokinetic quadriceps strength testing when compared with hamstring tendon grafts during the first year after surgery. At 7 months after ACL reconstruction, patients with quadriceps tendon grafts show significantly worse isokinetic quadriceps strength than patients with hamstring tendon and patellar tendon grafts. However, hamstring strength has been shown to be significantly decreased for more than a year following a hamstring tendon graft.
As most of our ACL reconstructions in female athletes are done in middle school, high school and collegiate level athletes, the specific risks of reinjury need to be mitigated. I prefer a patellar tendon graft in skeletally mature and a quadriceps tendon graft in skeletally immature female athletes compared with a hamstring tendon graft for several key reasons, including neuromuscular and developmental risk factors, associated higher risk of recurrent ACL tears and the link with lower hamstring:quad ratios and higher rates of ACL tears.
- References:
- Firth AD, et al. Am J Sports Med. 2022;doi:10.1177/03635465211061150.
- Hewett TE, et al. Am J Sports Med. 2017;doi:10.1177/0363546517700128.
- Inclan PM, et al. Bone Joint J. 2023;doi:10.1302/0301-620X.105B5.BJJ-2022-1064.R1.
- Maletis GB, et al. Am J Sports Med. 2015;doi:10.1177/0363546514561745.
- Mouarbes D, et al. Am J Sports Med. 2019;doi:10.1177/0363546518825340.
- Runer A, et al. Am J Sports Med. 2020;doi:10.1177/0363546520931829.
- Salem HS, et al. Am J Sports Med. 2019;doi:10.1177/0363546519854762.
- Spindler KP, et al. Am J Sports Med. 2020;doi:10.1177/0363546519892991.
- Tiplady A, et al. Am J Sports Med. 2023;doi:10.1177/03635465221146299.
Robin West, MD, is the president of the Inova musculoskeletal service line, associate professor at Georgetown University Medical Center and the Uniformed Services University of the Health Sciences, professor of medical education at the University of Virginia School of Medicine, Inova Campus and team physician for the Washington Nationals in Washington DC.
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