From the Guidelines
The best reason to use an autograft for Anterior Cruciate Ligament (ACL) reconstruction in a young athlete is to improve patient outcomes and decrease ACL graft failure rate, particularly in young and/or active patients, based on strong evidence. This is supported by the American Academy of Orthopaedic Surgeons clinical practice guideline summary, which recommends that surgeons should consider autograft over allograft for ACL reconstruction in young and/or active patients 1. The use of autografts has potential benefits for graft ruptures/revision and functional scores, as demonstrated by 2 high, 2 moderate, and 11 low-level studies 1.
Key Considerations
- Autografts demonstrate superior biological integration with the surrounding tissues, leading to better long-term stability and function of the reconstructed ACL.
- Young athletes particularly benefit from this enhanced biological integration, as it provides a durable, long-lasting ACL reconstruction that can withstand the rigors of athletic activity for many years.
- While autografts do have some disadvantages, including donor site morbidity and potentially longer initial recovery time, the superior graft incorporation provides the strongest biological foundation for high-demand athletes.
Guideline Recommendations
- The current CPG recommends ACL reconstruction as soon as possible when indicated, as the risk of additional cartilage and meniscal injury starts to increase within 3 months, citing strong evidence 2.
- Surgeons may favor bone-tendon-bone (BTB) to reduce the risk of graft failure or infection or hamstring to reduce the risk of anterior or kneeling pain when using autograft to perform ACL reconstruction in skeletally mature patients, citing moderate evidence 1.
- Functional evaluation, such as the hop test, may be considered as one factor to determine return to sport after ACL reconstruction, based on limited evidence 3.
From the Research
Autograft vs Allograft for ACL Reconstruction
The decision to use an autograft or allograft for Anterior Cruciate Ligament (ACL) reconstruction in a young athlete is crucial for the success of the surgery.
- Autografts are considered a better option for young athletes due to their higher success rate and lower failure rate compared to allografts 4, 5, 6.
- A study published in The American Journal of Sports Medicine found that at a minimum of 10 years after ACL reconstruction, the failure rate for allografts was over 3 times higher than for autografts 4.
- Another study published in the same journal found that individuals who underwent allograft ACL reconstruction were 7.7 times more likely to experience clinical failure requiring revision reconstruction compared to those who underwent autologous graft reconstruction 5.
- A systematic review of meta-analyses comparing autografts and allografts for ACL reconstruction found that the current best available evidence suggests no differences in rupture rates and clinical outcomes, but lower quality meta-analyses indicate that autografts may provide a lower rerupture rate and better objective knee stability than allografts 7.
- The use of autografts is recommended for young, active patients due to their improved outcomes in primary ACL reconstruction and revision ACL reconstruction surgery 8.
- A case-control study found that graft type and postoperative knee laxity were significant predictors of graft survival, and the hazard of graft failure was 4.4 times greater in the allograft group compared to the autograft group 6.
Key Findings
- Autografts have a lower failure rate compared to allografts in young athletes 4, 5, 6.
- Allografts have a higher failure rate in young athletes, with a hazard of graft failure 4.4 times greater than autografts 6.
- Autografts are recommended for young, active patients due to their improved outcomes in primary and revision ACL reconstruction surgery 8.
- Graft type and postoperative knee laxity are significant predictors of graft survival 6.