Allografts for ACL Reconstruction Survey Report

Transcription

Allografts for ACL Reconstruction Survey
Report
Prepared by: American Academy of Orthopaedic Surgeons (AAOS)
Department of Research and Scientific Affairs
July 1, 2013
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Table of Contents
Executive Summary ........................................................................................................................ 3
Background ..................................................................................................................................... 4
Methodology ................................................................................................................................... 4
Demographics ................................................................................................................................. 4
Results ............................................................................................................................................. 6
Appendix A: Results with Confidence Intervals .......................................................................... 16
Appendix B: Survey Instrument ................................................................................................... 66
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Executive Summary
1) 4,000 orthopaedic surgeons with a sports medicine specialty were invited to
participate in a survey regarding allografts for ACL reconstruction. 833 surgeons
completed the survey which represents a response rate of 20.8%.
2) Many surgeons reported that they are more hesitant to use allografts with young
athletic patients who intend to return to ACL-dependent activities. Many cited
research reports that appeared recently that have indicated higher graft failure rates in
this population.
3) On the other hand, a significant percent of respondents indicated that they are using
allografts more in active patients over 35-40 years of age.
4) Most respondents do not have different rehabilitation protocols for allograft patients
although half do delay return to sports compared with autograft patients.
5) The effects of irradiation on graft biological and biomechanical properties is a
concern for many surgeon although close to one-half use irradiated grafts.
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Background
The 2013 Allografts for ACL Reconstruction Survey was developed by the American
Orthopaedic Society for Sports Medicine (AOSSM) in conjunction with the American Academy
of Orthopaedic Surgeons (AAOS) Department of Research and Scientific Affairs to assess the
practices, beliefs and knowledge of orthopaedic surgeons with a sports medicine focus regarding
the use of allografts in ACL reconstruction. The results of this survey will serve as benchmark
information for future research.
Methodology
The web-based 2013 Allografts for ACL Reconstruction Survey was distributed to 4,000
orthopaedic surgeons (2,500 AOSSM members; 1,500 AAOS members) who indicated a sports
medicine subspecialty. Eight hundred thirty-three replied giving a response rate of 20.8%.
Email survey invitations were sent on May 15, 2013. Data collection closed on May 31, 2013.
Non-respondents were sent an email reminder on May 21, 2013 to answer to survey.
Online data were retrieved and tabulated by the AAOS Department of Research and Scientific
Affairs. All responses are depicted in counts and percentages. Confidence Interval (CI) values
at 95% were provided for each survey item in Appendix A.
Demographics
Age
The average age of respondents was 47 years old (SD = 9.2) with a range of 32 to 72 years old.
Years in Practice
Years in practice
21+ years,
29%
16 - 20
years,
16%
0 - 5 years,
24%
6 - 10 years,
15%
11 - 15
years,
16%
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Organizational Membership
Are you a member of AOSSM, AAOS, or both?
AOSSM only
1%
AAOS only
23%
I am a
member of
both AOSSM
and AAOS
76%
Sports Medicine Practice
Survey invitees were asked what percentage of their practice was sports medicine. Answers
ranged from 10% to 100%. The mean percent of sports medicine practice was 67.2% (SD =
23.3).
Under 50%,
16.9%
Over 75%,
38.2%
50% - 75%,
44.9%
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Results
Allograft Use in Primary ACL Reconstructions
Survey invitees were asked how many primary ACL reconstruction they performed in 2012, the
percentage of these procedures in which an allograft was used, and the percentage of patients
who requested an allograft. Mean responses were 43.1 procedures, 26.6% allograft, and 18.1%
patients requesting allografts, respectively. Responses ranged from 0 to 275 for number of
procedures, 0% to 100% for the percentage of procedures in which an allograft was used, and 0%
to 100% for the percentage of patients who requested an allograft. Approximately one-fifth
(19.6%) of respondents indicated that they did not use allografts at all for primary ACLR in 2012
whereas 23.9% reported using allografts in the majority of primary ACLRs.
Primary ACL Reconstruction
Approximately how many did you
perform in 2012 (excluding multiligament procedures)?
What percentage of these
procedures did you use an
allograft?
What percentage of your patients
requested an allograft?
N
Mean
Std.
Deviation
95%CI
Min
Max
824
43.1
34.6
±2.4
0
275
776
26.6%
30.4
±2.2
0
100
787
18.1%
25.3
±1.8
0
100
Allograft Use in Revision ACL Reconstruction
Survey invitees were asked how many revision ACL reconstructions they performed in 2012, the
percentage of these procedures in which an allograft was used, and the percentage of patients
who requested in allograft. Mean responses were 6.3 procedures, 62.3% allografts, and 29.8%
patients requesting allografts, respectively. Responses ranged from 0 to 60 for the number of
ACL revisions, 0% to 100% for the percentage of procedures in which an allograft was used, and
0% to 100% for the percentage of patients who requested an allograft.
Table 3. Revision ACL Reconstruction
N
Mean
Std.
Deviation
95%CI
Min
Max
Approximately how many did you
perform in 2012 (excluding multiligament procedures)?
796
6.3
7.3
±0.5
0
60
What percentage of these
procedures did you use an
allograft?
734
62.3%
40.7
±2.9
0
100
What percentage of your patients
requested an allograft?
712
29.8%
39.3
±2.9
0
100
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Change in the Use of Allografts for ACL Reconstruction
Has your use of allografts in ACL reconstruction changed over
the last few years?
Yes,
44%
No,
56%
For those who indicated their use has changed over the last few years, they were asked to
describe how their use has changed and the reasons for the change(s). Most responses reflected a
decrease in the use of allografts, especially in younger, active patients. However, many
respondents noted an increased use of allografts in patients 40 years of age and older. Verbatim
answers are in Appendix A, p. 16.
Graft Preferences by Age and Revision Situation for Athletes
Survey invitees were given six patient situations and asked to indicate their preferred graft choice
for ACL reconstruction.
For a high school or college athlete with primary ACL reconstruction, respondents prefer patellar
tendon BTB allograft (54.8%) or hamstring tendon autograft (38.0%). Only 6.0% of respondents
indicated a preference for any type of allograft in this situation.
For an adult recreational athlete with primary ACL reconstruction, 44.0% of respondents prefer
hamstring tendon autograft and an additional 19.2% would use patellar tendon BTB autograft.
Over a third (35.1%) of respondents indicated a preference for an allograft in this situation.
For a high school or college athlete with primary autograft failure who is having revision ACL
reconstruction, 27.4% of surgeons prefer patellar tendon BTB autograft and 21.2% prefer
patellar tendon BTB allograft. Over half (52.3%) of respondents prefer allografts for this clinical
presentation.
For a high school or college athlete with primary allograft failure who is having revision ACL
reconstruction, 46.8% of respondents prefer patellar tendon BTB autograft and 22.7% would use
a hamstring autograft. 26.8% prefer an allograft in this situation.
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For an adult recreational athlete with primary autograft failure who is having revision ACL
reconstruction, 24.8% of the surgeons prefer patellar tendon BTB allograft and 20.5% would use
a tibialis anterior allograft. Overall, 71.8% of surgeons would prefer an allograft for this
presentation.
For an adult recreational athlete with primary allograft failure who is going through revision
ACL reconstruction, 22.9% of respondents prefer hamstring tendon autograft and 22.9% would
use patellar tendon BTB autograft. Approximate a half (50.4%) of respondents reported a
preference for an allograft in this situation.
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Primary High School
or College
Athlete
Primary Adult
Recreational
Athlete
Revision HS/CA
Primary
Autograft
Failure
Revision HS/CA
Primary
Allograft
Failure
Revision ARA Primary
Autograft
Failure
Revision ARA Primary
Allograft
Failure
Other
1.0%
1.4%
3.7%
2.3%
3.2%
2.8%
Tibialis posterior Allograft
1.2%
5.1%
5.9%
3.4%
8.6%
5.8%
Tibialis anterior Allograft
2.3%
12.3%
12.6%
6.1%
20.5%
12.7%
Achilles tendon Allograft
1.0%
4.8%
8.7%
5.3%
10.9%
10.4%
Quadriceps tendon Allograft
0.0%
0.0%
0.0%
0.0%
.1%
.1%
Quadriceps tendon Autograft
.4%
.4%
1.9%
1.5%
1.0%
.9%
Hamstring tendon Allograft
.4%
2.9%
3.9%
2.7%
6.9%
4.4%
Hamstring tendon Autograft
38.0%
44.0%
14.6%
22.7%
11.4%
22.9%
Patellar tendon BTB Allograft
1.1%
10.0%
21.2%
9.3%
24.8%
17.0%
Patellar tendon BTB Autograft
54.8%
19.2%
27.4%
46.8%
12.6%
22.9%
For a breakdown of verbatim responses when “Other” was selected, please see Appendix A, pp.
29-33.
Factors Influencing Decision to Use an Allograft
Respondents were asked to indicate the impact of different variables on their decision to use an
allograft for ACL reconstructions. The response choices were “Less Likely to Use an
Allograft,” “No Impact,” and “More Likely to Use an Allograft.”
Respondents were LESS LIKELY to use an allograft for ACL reconstruction if the patient is
young (90.1%), the patient’s intent to return to high ACL demanding activity (81.9%), graft
failure rates reported in literature (84.6%), considerations about graft incorporation rate/time to
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return to full activities (68.8%), and graft failures experienced in their own practice (47.4%).
Respondents were MORE LIKELY to use an allograft for ACL reconstruction for concerns
about donor site morbidity (63.3%), postoperative pain (49%), and recovery time (45.8%).
A majority of respondents indicated that the following factors would not affect their use of an
allograft in ACLR: surgical time (66.3%), if the patient was female (65.3%), cosmesis (59.2%),
cost (54.6%), and disease transmission concerns (51.7%).
How would the following influence whether you use an allograft for an ACL
reconstruction (excluding multi-ligament procedures) for a given patient:
Disease transmission concerns
47.8%
Graft incorporation rate/time to return to
full activities
Graft failures I have experiences in my
practice
51.7%
68.8%
46.8%
Graft failure rates reported in literature
84.6%
3.9%
Recovery time in immediate
postoperative pain
8.8%
Cosmesis
4.1%
Donor site morbidity
Surgical time
49.0%
45.4%
45.8%
59.2%
More likely to use
28.9%
43.8%
54.6%
24.3%
1.6%
65.3%
81.9%
Younger patient
20.0%
40.0%
10.3%
16.7% 1.4%
90.1%
0.0%
Wouldnt affect
63.3%
66.3%
Patient intent to return to high ACL
demanding activity
Less likely to Use Allograft
36.7%
4.6% 32.1%
4.7%
5.8%
13.8% 1.6%
47.1%
Cost
Female
29.0% 2.2%
47.4%
Postoperative pain
.5%
7.9% 1.9%
60.0%
80.0% 100.0%
Graft availability for double-bundle
5.9%
procedures
0.0%
41.2%
17.9%
Wouldnt affect
35.0%
More likely to use
20.0%
40.0%
60.0%
80.0%
100.0%
N/A
Almost all (98%) surgeons with 0-5 years of practice reported that they would be less likely to
use an allograft in a younger patient compared with respondents with 21 or more years of
experience (82%). Similarly, 92% of respondents with 0-5 years of experience indicated they
would be less likely to use an allograft with a patient who intended to return to a high ACL9|P a g e
demand activity compared with 76% of those with 21 or more years in practice. There was also
a trend for those with more years in practice to use gender in decision making regarding allograft
use. Surgeons with 0-5 years in practice were also more likely to be dissuaded from using
allografts in ACLR by failure rates reported in the literature compared to surgeons with the most
experience.
Factors Affecting Success of Allografts for ACLR
Survey invitees were given seven factors that might affect overall success of an allograft used in
ACL reconstruction. They were asked to indicate if each factor had no impact, small impact,
moderate impact or a strong impact. Respondents indicated that the following factors would
have a STRONG or MODERATE IMPACT on the overall success of an allograft used in ACL
reconstruction: age of patient (58.9%), level of irradiation used in sterilization (51.9%), and
ACL demands of patient after clearance to return to activities (48.9%).
Factors that were thought to have the least impact on success were time on the shelf (47.1%
indicated no or small impact), rehabilitation strategies (40.3%), and the use of chemical
disinfectants (38.6%).
To what extent do you beleive the following factors affect overall success
of an allograft used in ACL reconstruction?
Rehabilitation strategy (accelerated
associated with worse outcomes for 10.4% 29.9%
allografts)
ACL demands of patient after clearance
to return to sport/activity/work (worse 4.8%15.5% 30.8%
outcomes for higher demands)
48.9%
Age of patient (worse outcomes for
2.9%11.6% 26.5%
younger patients)
Time on the shelf 7.7%
21.4%
38.3%
58.9%
No Impact
12.1%
40.8%
39.4%
Small Impact
Moderate Impact
Age of donor 3.5% 22.5%
47.3%
Use of chemical disinfectants 4.8% 33.8%
Level of irradiation used in sterilization 1.7% 14.3% 32.2%
0.0%
26.7%
Strong Impact
21.2%
40.2%
51.9%
20.0% 40.0% 60.0% 80.0% 100.0%
Rehabilitation and Return to Play
More than half of respondents (61.7%) indicated that they DO NOT have different rehabilitation
instruction for patients who receive an allograft for ACL reconstruction from those who had an
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autograft. The majority of respondents (74.9%) indicated their allograft ACLR patients do as
well as their autograft ACLR patients with proper rehabilitation and compliance by patients.
Approximately half (49.5%) of respondents indicated that they generally delay return to sports
for patients who receive an allograft compared with those who have an autograft. For those who
do delay return to sports for allograft patients, the average return to sports was 6 months for
autograft patients and 9 months for allograft patients although many surgeons delay return until
12 months.
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Irradiation
Respondents were asked, “Do you feel knowledgeable about the true amount of irradiation
required to completely sterilize (i.e., eradicate everything including spores and viruses) allografts
used for ACL reconstruction?” Almost two-thirds of respondents (65.8%) indicated that they
were not sure. Of those who did report feeling knowledgeable, the modal response was
2.5mRAD was required to completely sterilize grafts with a median of 3.0mRAD. Over 40%
believed that 4.0mRAD were required and 11% believed that 5.0mRAD and above were
necessary for complete sterility.
When asked about the level of irradiation that is harmful to the biomechanical/physiological
properties of the graft, almost a third (32.0%) of respondents believed that any degree of
irradiation is harmful, 41.5% of respondents indicated that low dose irradiation (1.0 – 1.2
mRAD) is not harmful but higher levels are; 24% reported that medium dose irradiation (up to
2.5 mRAD) is not harmful, and 2.6% indicated that high dose irradiation (up to 5 mRAD) is not
harmful.
What level irradiation do you believe is harmful to the
biomechanical/physiological properties of the graft?
Higher dose
irradiation (up to
5.0 mRAD) is not
harmful, 3%
Medium dose
irradiation (up to
2.5 mRAD) is not
harmful but higher
levels are, 24%
Any degree of
irradiation is
harmful, 32%
Low dose
irradiation (1.0 1.2 mRAD) is not
harmful but higher
levels are, 41%
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Do you believe that some level of irradiation is essential for allografts
used in ACL reconstruction to eliminate pathogens?
Yes,
34%
Not sure,
29%
No, the donor
screening
processes and
nucleic acid
amplification
testing (NAT)
currently used by
processors is
sufficient to all but
eliminate the risk
of disease
transmission, 16%
No, nonirradiation
sterilization
processes are able
to achieve
acceptable levels
of sterility, 21%
A third of respondents (34%) indicated that they do believe some level of irradiation is essential
for allografts used in ACL reconstruction to eliminate pathogens, followed by 29% indicating
they are not sure. Twenty percent indicated no, non-irradiation sterilization processes are able to
achieve acceptable levels of sterility and 16% percent of respondents believe that the donor
screening processes and NAT currently used is sufficient to all but eliminate the risk of disease
transmission.
Do You Use Allografts for ACL Reconstruction
That Have Been Irradiated?
50%
43.5%
40%
35.6%
30%
20.9%
20%
10%
0%
Yes
No
Not Sure
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Forty-three percent of respondents use allografts that have been irradiated for ACL
reconstruction, 35.6% indicated that they do not use irradiated grafts, and 20.9% indicated that
they were not sure if the grafts they used had been irradiated.
Allograft Source
Who provides most of the allografts that you use for ACL
reconstruction? (check all that apply)
Not sure,
19%
RTI, 18%
Other,
9% Allosource
, 15%
LifeNet, 18%
MTF/ConMed,
41%
MTF/ConMed (41.2%) provides most of the allografts respondents use for ACL reconstruction.
Note that respondents were able to check all answers that applied.
Do the allografts you use for ACL reconstruction come from a tissue
bank that is approved by the American Association of Tissue Banks
(AATB)?
No, 1%
Not
sure,
12%
Yes, 87%
The majority of respondents (87%) indicated that the allografts they use for ACL reconstruction
come from an AATB-approved tissue bank although over 1 in 10 was not sure.
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Have you personally researched the safety track record and clinical
results of the tissue bank from which you get allografts?
No, 57%
Yes, 43%
More than half of respondents (57%) have not personally researched the safety track record and
clinical results of the tissue bank from which they get allografts.
Survey invitees were asked to provide comments about allografts for ACL reconstruction. The
responses varied, but commonly referred to usage, disease transmission, and associated research.
Please refer to Appendix A, p.53 for verbatim responses.
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Appendix A: Results with Confidence Intervals
Has your use of allografts in ACL reconstruction changed over the last few years?
N
CI
Lower
Upper
Yes
364
3.368
40.33
47.07
No
469
3.368
52.93
59.67
Total
833
You indicated that your use of allografts in ACL reconstruction changed over the last few years. How has your
use changed and what have been the primary reasons for the change?
DECREASED USE COMMENTS
• Use less allograft-- clinical experience and particularly research outcomes
• Less use b/c higher failure rate
• Using less; potential for having higher failure rate
• Use of allograft for primary and revision ACL has decreased. Primary reasons are the results of
the MOON and MARS studies, and the fact that allograft tissue is no longer covered by insurance
companies.
• I do it less often in younger people due to recent reports of higher failure
• About 16 years ago, I used primarily patellar tendon autografts, and then started using more
hamstring autografts with allografts use only at 10% of the time. About 10 ten years ago, the
tissue bank industry came under greater scrutiny and the safety of allograft usage significantly
improved. At that time, I made a significant change in my practice and began using a very high
percentage of allografts (90%). Anyways I discussed the pros and cons of allograft versus
autograft. Ultimately, the patients requested allograft based on the information that I provided.
Overall, my results have been very good. However, the literature is supporting autograft usage
as an advantage for higher level athletes and now I am shifting back toward the autograft
direction.
• Fewer allografts because patients are typically HS or college athletes
• Now only using allograft as an augment if needed due to small autograft size. Reason for this is
stretching of allografts and concern of re rupture.
• Decrease use. Have used many more quad autografts for revisions
• I use them less frequently in younger or collision/contact athletes. I have also changed the grafts
that I use. Formerly mostly Achilles, more recently hamstrings, but considering changing back or
going to BPTB for certain uses.
• Less use of allografts in young athletic patients. I seek autograft sources when possible.
• I use less allograft in patients <20 years old
• Decreased use due to reports suggesting better outcomes with autograft, costs
• No longer use in any young patients
• I no longer use them for primary ACLR, and use them for revision surgery only when ipsilateral
autograft is not available.
• I use them less frequently based on published data of higher rerupture rates in younger patients
• I have used less allograft. Most of my ACL population are young patients where allografts have
shown to carry a higher rate of failure.
• I use fewer allografts in younger athletic pts than I did in previous years. For example, I use more
patellar tendon autografts for young female athletes with hyper laxity. I do not trust the
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allografts in female athletes due to reports of higher failure rate, and these pts have a higher
failure rate in the best of scenarios.
I use much less. I don't like the expense. Failure rate is higher in younger people, and I don't
trust the allograft industry as a whole.
I use more autograft recently because of recent research on lower retear rates with autografts
Recommend against in active patients age 25 years or younger.
Decreased. No longer recommend to younger athletes.
I use less allografts and have switched from tibialis anterior to double semi-tendinosis
I stopped using them on primary ACL reconstruction due to unacceptable failure rate.
I no longer do allograft in patients under 30 years old. there is an unacceptable rerupture rate
with allograft in this group
Having revised other surgeons allografts and having taken out perfectly good allografts and
done autografts on patents for "rejection" complaints I refuse to use them or recommend them
Decreased usage secondary to worse results
Recent studies indicating higher rerupture rate in younger athletes with allograft. However, I
don't think these were great studies.
I never used allografts before this year. I am less likely to use them in the future
Using many fewer allografts in young people (10-30 years due to some report evidence of higher
failure rate
Using less due to inferior results and high re-rupture rates
Decreased due to increased risk of retear
Using fewer. Higher failure rates in high demand patients.
Recent MOON study has made me recommend more autografts.
Decreased
Have used less allograft secondary to stretch and re-tear rate
I use them less secondary to observed increased rate of retear in patients I use allografts
compared to autograft.
Use less, concerns for rupture in young patients and concerns of safety in many
Using more auto grafts. Geographic change and change in age group of my patients. Lived in
California where more patients requested allografts. Moved to Idaho more patients request
autografts.
Decrease due to higher rerupture rate in young athletes compared to autograft
Minimize allograft in younger than 25 yrs old.
Less allografts
Less allograft, new technique.
Never used a lot of allograft, but only consider allograft in low demand patients or revisions
now.
Increased rate of failure, loosening of the graft over time
Concern over failure rate
I'm now not using allograft in patients under 20-25 due to recent studies showing higher failure
rates
I use allografts LESS frequently now, primarily due to data from MOON group suggesting higher
failure rates.
Less use. Increased age to 40 and above
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I use them far less in primary ACLs now (most of my patients are under 20YO), only usually as a
supplement if the hamstring tendons aren't big or long enough to make a quadruple graft (more
of a backup plan than primary choice).
I use even less allografts especially in patients under the age of 40. I believe there is a higher
failure rate with allografts in younger patients.
Reported failure rates and personal observation have decreased my enthusiasm for allograft,
especially in young patients.
Less use of allograft due to concern of increased failure rate
Less use in patients under 40...but now, some feeling that non-irradiated allografts in patients
under 40 may be OK.
Decreased with reports of higher failure rates
Failure in young age groups and the compelling evidence from MOON
I use less allograft ACL reconstruction because of a concern for higher rupture rates in the
younger patient
Less
Several years ago I had a significantly increased infection rate (bacterial septic arthritis) with use
of allografts for ACL reconstructions, causing me to temporarily halt use of allografts for all but
revision cases. I have gradually resumed use of some allografts, but still generally prefer
autograft.
I have used them less and less in the younger populations and continued use in the older
population. This is mostly due to a perceived and reported increase in failures of the allograft
ACL's, even though the recovery is quicker and easier.
Decreased use under age 25 due to studies showing high failure rates, although I did not see this
in my practice
Decreased use of allografts in patients younger than 35
I will not use an allograft in a young patient anymore
MOON knee group study regarding failure rate. Tend to offer it in older less active patients or in
a multi-ligament setting.
I rarely will use an allograft in patients under the age of 35 even if they ask for it for 2 reasons.
One- the recent literature showing a higher risk of graft retear in younger patients with use of
an allograft. Two- I routinely harvest just the semi-T for a quadrupled graft with a minimally
invasive posterior approach which is just as benign as using an allograft.
Decreased. Insurance won't pay for it. Higher failure rate
Decreased use because of increase rerupture rates n young patients
I have decreased the frequency of allograft use due to further evidence of allograft failure in the
literature in as well as increased use of the Graft-link procedure using hamstrings tendon
I avoid allografts in young high-demand patients because of the increased risk of failure.
Fewer because of failure rates with allograft
I have virtually eliminated the use of allografts except in multi-ligament reconstruction. I have
personally seen a higher failure rate with the use of all types of allografts in my practice which
has also mirrored the results in the literature. Furthermore, my revision practice is at least 10 to
1 allografts failure versus autograph failure.
Rarely use allografts for primary or revision surgery due to high incidence of failure in the
literature and the quality of the tissue
Fewer primary Acl recons in young patients with allograft due to higher failure rates.
Decreased use of allografts due to data suggesting higher rerupture rate.
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The increased failure rate of allografts in those under 25 has changed my recommendation to
that age group. I used to let them choose allo or auto now I insist on auto.
Decreased use in HS and college-age pts after results of study showing definitive increase risk of
failure
Decreased. concerns regarding incorporation and overall sense of higher failure and laxity
Doing less. Poor results in studies.
I am using less and less due to my impressions of failure rates and tunnel osteolysis
I had three patients last summer that seemed to reject their grafts. They had an unusual amount
of pain and swelling at about 2 weeks post-op. They all showed no indication of infection. All
required a second arthroscopy to washout the knee. In each the graft looked bad. They all
improved after the second procedure, but their progress was very slow afterward. Before these
three cases allograft ACL was my preferred method. Since these cases I have switched to
hamstring tendons as my preferred graft.
Decreased use, evidence of higher rerupture and lower outcome scores
Decreased b/c of increasing evidence of risk of failure
Using less due to fear of failure and graft osteolysis within the tunnels. I currently only use
allografts in patients older than 45 or in select revision cases.
Less usage due to failure rates in younger PT population
I use it less. I believe there is a higher re-rupture rate and this is being shown in a number of
studies
Use them slightly less
Stopped using for younger patients (<25) receiving primary reconstructions due to MOON/MARS
info
Use less. Prefer autografts more and especially in young patients below 40.
Use them less than previously, especially in younger patients
Do not place them in younger patients < 35 years
Previously used almost exclusively allograft...now use almost exclusively autograft. Recent
literature showing the higher failure rate and delayed healing or incorporation with allograft has
caused that change.
Less likely to use in younger patients, more confident to use in older patients
Minimize use in younger populations. Based on literature
Would not use in young patient unless there was no other choice intraoperatively. Would use
for most/all revisions, would consider for patients > 40-50 yrs old that need ACL recon. Don't
believe patients/therapists wait long enough for it to consolidate, feel great so much sooner
that that just don’t' wait. would consider BTB allograft only choice I would use in younger
patients, for reasons of earlier bone healing primarily
Rarely do allografts in patients below the age of 35 y.o.
We quit using one company and try to use autograft for younger especially male patients
Less in young athletes. Higher reported rerupture rate
Decreased due to increasing evidence of higher failure rate, especially in younger and more
active patients
I have decreased due to literature suggesting that allograft has a very large failure rate.
Use less commonly, especially for primary ACL reconstruction. Poorer results, both in my own
clinical experience and as reported in the literature
Poor results with allograft in my practice, suspected increase in infection, long term studies
Decreased because of unacceptable failure rates.
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Higher retear rate in younger patients than autograft.
Less because results not as good
I noticed a higher failure rate with allograft which has been supported with recent publications.
Decreased due to increasing documentation and experiences regarding failures.
Less willing to use an allograft in a primary setting regardless of age or activity level due the
published higher rate of failure compared to autograft tissue
Diminished significantly
I have decreased the use of allografts. Reasons include graft durability issues, cost, availability,
concern over the risk of disease transmission, etc.
Decreased. Too many failures
Less in patients under 30 due to high failure rate reported in literature
Results of higher failure rates
Decreased. Data and own experience suggest higher risk of failure in patients <40
Decreased following the MOON Study data.
Stopped using in patients under 25 years of age
Using less allografts due to more evidence of graft failure.
Decreased. Studies show higher failure rate.
Using less allografts, because data shows higher failure rate
Using much less in younger athletes
I no longer offer allograft acl reconstruction in high level athletes, I may offer allograft
reconstruction to recreational athletes but strongly recommend against allograft.
less use of Achilles allograft
I am using it less even in my older, low activity patients. I just hate the possibility of revision and
would like to reduce this as much as possible.
Decreased, concerned about outcomes relative to autografts with some of the new data that is
coming out
Lowered use secondary to higher re-rupture rate
Data to support the potential higher failure rate with allograft in younger, active and female
patients - MOON
Use fewer allografts in patient less than 30 due to increased failure rate in young athletes
Using fewer. Have not been happy with Lachman test in office. Feel that allografts loosen over
first 1-2 years.
Used less for primary ACLR
Using less allograft tissue. Except in revision cases and patient request/choice.
Decreased usage due to published results of increased failure rate in younger active patients
Decreased number of allografts. Results of allografts decreased versus autografts. Also cost of
allografts high.
I use them much less due to increased incidence of tunnel osteolysis in our patients and due to
recent suggesting higher failure rates.
Less use of allograft. Clinical studies, such as MOON group report, that show increased failure of
allografts in high-level athlete.
Decreased due to data on young athletes increased failure rate
Use less allografts in athletes due to data regarding increased failure rates. Have avoided
allografts in revisions also because of failure concerns in this population.
Using allografts at all. Now using allografts for older patients. With better fixation available
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I am using less allograft and more autograft as I have had higher failure rates and increased post
op laxity with my allograft reconstructions compared with autograft.
No longer use them due to a high failure rate
Use them less. Had some failures due to poor graft strength
Stopped primary use of allograft due to ease and success of HS autografts
None under 25y/o, due to moon data
Much less likely to use in patients under 30 due to studies showing higher failure rate in younger
athletes
Due to recent studies on increase failure rates for allograft, I have predominately used autograft
this year.
I have decreased use of allografts based on results and literature.
Using fewer allografts due to recent literature suggesting poorer results
Used less allograft due to increased failure rate I have observed.
No allografts under 40 yo
Less use. Training.
No longer use in athletes under age 25-30. Autograft is now graft of choice. reason is literature
supports autograft in this patient population
I used to rarely use. Started to use more. Approached 100%. Had some failures. Now using in
revisions and older patients only
I have used less allograft
Doing less allograft ACL due to journal publication information
Much less allograft due to research on rerupture rates
I have used less soft tissue allograft for primary ACL reconstruction particularly in patients under
Age 40.
Data has shown an increased risk of rerupture of an allograft ACL, so I won't do them in young
patients at all, and will give patients older than 40 years old the option of an allograft.
Less allografts. More concerns with rerupture given practice mix of young patients.
I have decreased the use of allograft for PRIMARY reconstructions in younger patients ( under
25)
Decreased use concerned about failures without any clear history of trauma and on F/U exam
appear to loosen
Decrease usage due to worse outcome for younger age group
Using them less due to concerns over inferior clinical outcomes compared to autograft
I use less because they do not seem to hold up over the long term
I do not use allograft for ACL reconstruction. The reported failure rate is too high to justify its
use.
Use less than used to never on young people think they fail more
Probably do a little less use of allograft. Avoid in young primary reconstructions
Decreased use 2/2 new literature on increased failure rates in the young/active population
Slight trend toward more autografts. I have generally favored autografts over the years but
recent data suggesting higher failure rate of allografts, especially in adolescents has
strengthened this approach. This is balanced by anecdotal experience of several patients having
had successful auto graft but requesting allograft for their contralateral acl tear and being
happier with the allograft side.
Not using allografts in young patients secondary to higher rupture rate versus autograft
Less use in primaries. MOON and MARS prospective studies
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Less use allograft due to higher failure rate in elite athletes
I have used it less in young people because of the apparent higher instance of rupture over
autograft. Also, I think I can return them to activities faster with an autograft
Small decrease due in part to new studies showing a possible increased risk of retear in younger
patients.
Less allograft in younger patients given EBM.
Do not utilize on young active pts, unless revision
Less use in younger female patients because of literature
I'm changing to autograft again. Cost, MOON study
Higher failure rate in young patients. Graft failure without adequate mechanism.
Decreased
Decrease; concern over healing rates
Limited use due to high failure rate with athletes
I use them less often 2 reasons. One, my patient population has changed dramatically since
changing practices. (I now see many more "young" patients - without a return to work
consideration and who are more concerned with long term results Second - Paper published by
Aros et al. Meta analysis of Moon group regarding the differential higher failure of allografts in
younger patients With a younger patient population in my practice, that study has a
proportionally higher effect on my recommendations
Less likely to use allograft due to better data on increased failure rate and having alternative of
4 strand ST graft autograft working so well
Literature showing higher failure rate in young patients has led me to strongly recommend auto
in patients younger than 30
Less likely to use in a young pt (<35) due to recent research
I no longer use them.
Will only use allograft for Primary ACL in patients over 35, in revision situations still try and use
autograft if possible, if not will use allograft
Use less frequently
Almost never under the age of forty. Compelling studies regarding rerupture rate
I don't use allografts in active patients less than 25 years old based on evidence that rehear
rates are higher in this population
Decreased use in younger, active patients... Failures
I use fewer allografts overall and only in my lower demand ACL patients 40 yo and up. I don’t
use them in HS or college or professional athletes.
Use less often - not offered for primaries unless requested by patient
I have used fewer, due to reports of higher failure rates in younger patients and those who are
more active.
Almost never use them for a primary reconstruction in people under 30
Less allografts during the last 2 years; based upon personally-observed and literature
documented higher rates of failure when allografts used as compared to autograft tissue.
When I do use allografts, I have modified the post-operative rehab and criteria for return to full
athletic participation.
WILL not use in athlete under any circumstance and allow to return to play in less than 9 months
I have decreased the number of allografts because I felt there was more laxity in the grafts
One bad experience with allograft in patella tendon reconstruction for chronic patella tendon
rupture - fungal infection. Have been using primarily autograft since.
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Using less because they take longer to heal and may stretch out more and have a higher failure
rate
Slight decrease in use especially in the young (less than 22). I have concerns about the higher
failure rate in this age group and the chance of long term loosening
Use them less because of data showing high failure rate
Decreased use due to increased cost and concern for high failure in the young population
Trying to use less. Doing more BTB. More two stage
Decreased/almost eliminated
Decreased use, increased failure rate, cost persistent effusions
In patients younger than 30 at a high level of sporting activities, I will discourage the use of
allograft until we truly know the risks with current fixation techniques of revision.
Decrease allograft use secondary to increase in failures in the literature among younger
patients.
Published MOON data on failure rate increase for allograft vs. autograft by younger age Kaeding Sport Health 2011
Use them much less frequently. Too many retears.
Decrease their use due to data suggesting they stretch out.
Use them less often. Higher failure rates noted in younger patients
I have stopped using them unless it's a multi ligament injury. Failure rates seem to be higher in
literature
Decrease in number for primary reconstruction
Using less allografts, studies showing higher failure rates in allografts, now have PA in or for
help w surgery times
Good articles stating increased failure rate, leaving residency and fellowship
Research documenting failure rate in patients under 20 years of ago
Using it less, based on research that allograft performs poorly in younger patients
Using less and less. Concerned about atraumatic failure. Mainly younger athletic population so
using much more BTB autograft.
I believe outcomes are more reliable with autograft tissue.
Hígher failure rate
I have used less of them....concerned about failure rates in younger patients.
I have chosen to limit my allograft usage to people 40 or older unless a revision is needed and
the patient does not want a contralateral harvest. I also have started using an allograft to
augment my hamstring autografts if the folded diameter is less than 8mm for the ST and gracilis.
If I have enough length, I will cut my ST in half; otherwise I add an allograft to increase the
diameter of the graft.
I use them much less now. Used them much more in residency and fellowship. I use the
patients' own tissue if at all possible now
I used to perform most of my ACL reconstructions with allograft I now try to refrain from
allograft use in females aged 14-22
Decreased use in young patients and competitive athletes secondary to concern for increased
re-tear rate compared to autograft
I am using less allograft for primary ACL recon, especially in younger more active patients
No use of primary allograft for any active patients 35 and younger. Worse outcomes in the
literature and in my practice with allograft usage.
Don't use any more
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Doing more autografts in younger pts. Studies showing higher failure rates in younger pts with
allograft.
less use in younger patients use only non-irradiated grafts
I no longer even consider them in the young athlete
I'm using less allografts due to patient preferences
Failure in young adults
Fewer used. Worse failure rates.
Recent literature with mixed results using allografts, particularly in younger pts
Decreased use in younger, more aggressive patients < 35 years of age.
Not using them for young patients
Using less allografts especially in younger patients.
Only using allografts as backups in the setting of a failed autograft in younger patients, using
them primarily over age 35, and for revisions. Not using them as much for younger patient's
primary ACL now.
Decreased until results (rerupture) in younger athletes are clarified in the literature.
I use less allografts primarily because of studies showing increased failure rates in younger
patients.
Failures
I am using autograft more frequently particularly in patients under 35
I rarely use allografts for primary reconstruction due to higher failure rates in younger patients ,
and higher costs
A high failure rate with allografts and some rejections
OUTCOMES STUDIES SHOWING HIGHER RISK OF FAILURE AND LAXITY
Less frequent in younger patients. Have had late (greater 5 years) ruptures and on revision it did
not appear that the graft had fully incorporated.
More likely to use autograft in young athletes
Lectures and outcomes. Only failures with allograft. Concerned about the gamma radiation.
Allograft failure
Allograft failures. Cost.
Increased failure rate
Less cases now than before
INCREASED USE COMMENTS
• Increased use. People wanting to get back to work faster fear of losing job.
• Safety in preparation. Increase in uniform strength, ease of use, less post-op morbidity----more
use of allografts
• Better success rates that were previously thought and more patients requests
• More patients are asking for an allograft, and not wanting autograft
• We are using more allografts in ACL revision
• More allografts, easier initial rehab
• I use an increased number of soft tissue allografts for reconstruction given the improvement in
fixation options. I mainly use allograft in the >30yo patients.
• Increased. Safer testing/preparation of allografts, less traumatic procedure for patients...
• Increased. Decreased morbidity. Good results
• I have increased my usage of allograft in non-adolescent patients.
• I use them more often. The latest literature is more supportive of their use.
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I have increased the use of allografts due to results equal to autograft, less morbidity, ease of
use.
More common usage in the patients over age 30 that want to get back to work quicker.
I let my patients choose their graft source, typically between btb auto, st/g auto, or btb allo.
Patients request allografts more frequently now.
Trained on East coast now work on west coast- allografts are much more prevalent here.
Increasing usage of BTB allografts over entire career. 5 year increments revealed 1,3,13,34,50,
>50%. Age and activity impacts recommendations. !00% >40, 60-65% >30-40, $0% 25-29. <10%
in patients under 20. Use one tissue bank since 1986. Do not use tibialias ant for ACL R. Use
infrequent HS allo in prepubescent children who are petite and have significant growth
remaining. KT 1000 reviewed 6 wks to one year show no differences in first year between auto
and allo allograft with no "creep” in KT values. Last year reviewed prospectively maintained
database. Personal revision rate overall was 1.5% for auto BTB, 2.0% for allo BTB Combined in
1809 aclr 1.7% (1200 auto 600 allo). In this study reconstruction of contralateral ACL was 10%
(n=110)
I am using them more on employed people for faster return to work since the change in
sterilization techniques. I offer both allo- and auto-graft options to all patients, but they seem
to split along younger athlete vs. older employed populations. I make the allografts wait 9 mos
for sports
The percentage of allografts has increased steadily over time. This is because the out of pocket
costs for the patient are actually less for the allograft than the autograft. With the autograft
every therapy visit requires a copay of up to $50. Autografts require generally 25 therapy visits
at least. If the out of pocket cost is $50 a visit x 25 visits that means the patient must pay $1250
in addition to the surgery costs. Allografts require much less therapy and consequently cost the
patients less.
Increased use due to patient request, improved data.
More allografts. Easier recovery for older patients and patient request.
Better quality grafts and results in active patients over 25 equivalent
Increased use, good outcomes noted in most patients, better fixation
Increased
Increased to exclusively allograft. Patient demand and decreased pain post operatively.
Use allografts almost exclusively for revisions. More patient's requesting allografts
More patients are comfortable with their use.
I have been using more allografts. I previously used allografts rarely for primaries. My patients
are getting older and the results of allografts are good, in the literature and in my patients.
Increased. Patients request allograft.
More confidence in tissue processing. Increased patient demand
Increased usage in patients over 35
Increased use in older patients for faster return to work, less pain, quicker mobility after surgery
Only using non-treated, non-irradiated grafts. also using more autografts
More allografts because this community is 100% allograft and I became an outlier by using
autograft.
Increased use. Improved preservation techniques and less trauma to patient.
Used primarily allografts, then decreased due to negative study reports. Looked at my own
outcomes and couldn't confirm increased failure rates, so allograft use has been increasing, but
only in patients older than 30
Graft availability. Surgery speed. Improved long term results.
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Increased usage due to older patient population.
Use more often. Better quality with less risk.
I use them more often because my clinical outcomes have been as good or better than autograft
Using more allografts in >40 group based on literature showing good outcomes.
The technology and the positive effect on tissue sterility and allograft mechanical properties
Using for all females
I am using more allografts. I like the decreased morbidity.
Using more allografts because patients’ success is very good and they are requesting it more....
I've been using more for primary procedures due to less morbidity, excellent results and safety
I use it in individuals over the age of 30 and sometimes in younger individuals if they request it.
Although allograft is a little expensive than autograft, you still save time with allograft, avoid
harvesting complications and you are assured to use a desired thickness of graft. It is helpful for
individuals like me who do not do thousands of ACL reconstructions like Freddie Fu or Stephen
Howell to have allograft as an alternative source.
Ease of use, faster recovery
More allografts for older individuals none for younger pts
Increased
I am trying to use allograft on most adult pts who are not actively competing in cutting/contact
sports. Decreased donor site morbidity with makes pt's happier in the long run. Also stress the
need to strictly follow PT protocol even though pain is less.
More use of allografts. Reason is graft site morbidity and similar functional results with
allografts
Increase use especially in patients over 30. I use only fresh frozen non-irradiated, non-treated
soft tissue grafts
Increased. Now use tibialis posterior allograft.
Increased. Patient preference.
Increased use, patients' requests, improved clinical data, better graft sterilization
Availability, ease, efficacy, safety
Increase us of autografts
Increased use of allografts to meet competition offerings. Patients locally feel that allografts are
less painful and heal more quickly.
More usage and more requests from patients
Larger source, ease of use
Pt wishes, quicker rehab
Increased use due to pt. request
More likely to use BTB Allograft for revision ACL as well as for primary ACL in patients over age
of 40 (than Tibialis Anterior Allograft)
Increased use
Increased use. Equal results
More patients are asking for it primarily
An increase in use for the athlete over the age of 40
More primary procedures, using for younger patients than I used to. Better procedures for graft
prep and fixation.
More patients request them. Clinical outcomes good. No increased morbidity.
More allografts because of older patient population in new practice
Mild increase based on patient education and review of current literature
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More usage - more revisions and some older patients
My use has increased for two reasons. To decrease patient morbidity and to get reliable and
robust graft sizes.
Increased use. Mainly due to improved faith in the processing methods and age of donors we
are able to obtain.
Increased. Studies confirmed older pts do well. Like the graftlink technique.
Patient demand, improved fixation
Nearly all revisions, also is primary consideration for adult reconstructions.
Lack of help in the OR for ACL prep has prompted more allografts.
Increased, surgeon and patient preference
Reconstructing older patients who can’t miss much work
I use them more for revisions than I used to. Primarily because there are options for sizes, bone
grafting, etc. which are helpful in revision surgery.
More common acceptance for relatively older and less active patients.
NOW USING ALMOST EXCLUSIVELY. ALLOGRAFTS SEEM TO BE WORKING WELL AND PATIENTS
RECOVER MUCH QUICKER
OTHER COMMENTS
• Age limitation recommendations for allograft usage in primary reconstructions
• Autograft for patients under 25 yrs. both personal experience and literature supports this.
• The age of the donor vs. the age of the patient. If under 30 yrs -- autograft for primary
• Autografts for collision athletes, allografts for my older, employed patients
• I have considered using autograft more often in younger patients and athletes, however I still do
discuss and at times use allograft in those patients. I'm very particular about the allografts I use,
however.
• Have increased the age at which I recommend allograft. I try not to use allograft in patients
under 40 and I keep allograft patients out of sports for longer than auto grafts.
• More conservative w return to play decisions in "older” athlete allowing a change in graft
selection
• Better outcome with non-irradiated grafts, shift to older patient population
• Use them for non-athletic patient, low demand with instability.
• Only for revision setting. I do not like to go to multi source harvesting in a single knee. Only use
one source for graft then move to allograft.
• Fellowship experience
• To Achilles tendon, stronger
• Gone from Achilles to BTB
• From BTB allograft to PTT allograft secondary to poor bone quality in allograft tissue and better
fixation with tendon allograft.
• In the past I would perform most ACL reconstructions using autogenous hamstring tendons.
• The regulation in Germany does allow the use of allograft only in very very specific indications.
• I no longer use irradiated grafts
• Non-irritated. Use PRP
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Changed from freeze dried patella tendon to fresh frozen tibialis that is more readily available
and suitable to use with endobutton fixation mode.
Used to use BTB now use Ant Tib
Hamstring rather than BTB
Changed from semitendinosus to Achilles tendon
Was never taught to use at all
Use more types of grafts
Frequently supplement primary hamstring autograft reconstructions with allograft if the 4stranded autograft has less than 8mm diameter.
Changed from Achilles Tendon to Anterior Tibialis Folded in half. Stopped using the X trans-tibial
system and changed to the Y Tight Rope System.
Occasional augmentation of auto hamstring grafts if autograft is of insufficient size.
Q5) What is your preferred graft choice for ACL reconstruction in the varying patient situations indicated in the
grid below? (Check one response per line.)
Primary High
School or
College
Athlete
Primary Adult
Recreation
al Athlete
Revision HS/CA
Primary
Autograft
Failure
Revision HS/CA
Primary
Allograft
Failure
Revision ARA
Primary
Autograft
Failure
Revision ARA
Primary
Allograft
Failure
Patellar
tendon
BTB
Autograft
Patellar
tendon
BTB
Allograft
Hamstring
tendon
Autograft
Hamstring
tendon
Allograft
Quadriceps
tendon
Autograft
Quadriceps
tendon
Allograft
Achilles
tendon
Allograft
Tibialis
anterior
Allograft
Tibialis
posterior
Allograft
Other
Total
N
455
9
316
3
3
0
8
19
10
8
831
%
54.8%
1.1%
38.0%
.4%
.4%
0.0%
1.0%
2.3%
1.2%
1.0%
100.0
%
CI
3.384
0.704
3.301
0.408
0.408
0.000
0.664
1.016
0.741
0.664
N
159
83
365
24
3
0
40
102
42
12
830
100.0
%
%
19.2%
10.0%
44.0%
2.9%
.4%
0.0%
4.8%
12.3%
5.1%
1.4%
CI
2.677
2.041
3.377
1.140
0.408
0.000
1.457
2.234
1.491
0.812
N
227
175
121
32
16
0
72
104
49
31
827
%
27.4%
21.2%
14.6%
3.9%
1.9%
0.0%
8.7%
12.6%
5.9%
3.7%
100.0
%
CI
3.041
2.784
2.409
1.314
0.939
0.000
1.921
2.260
1.609
1.295
N
386
77
187
22
12
0
44
50
28
19
825
%
46.8%
9.3%
22.7%
2.7%
1.5%
0.0%
5.3%
6.1%
3.4%
2.3%
100.0
%
CI
3.405
1.985
2.857
1.099
0.817
0.000
1.533
1.628
1.236
1.024
N
104
205
94
57
8
1
90
169
71
26
825
%
12.6%
24.8%
11.4%
6.9%
1.0%
.1%
10.9%
20.5%
8.6%
3.2%
100.0
%
CI
2.265
2.949
2.168
1.731
0.669
0.237
2.127
2.754
1.914
1.192
N
187
139
187
36
7
1
85
104
47
23
816
%
22.9%
17.0%
22.9%
4.4%
.9%
.1%
10.4%
12.7%
5.8%
2.8%
100.0
%
CI
2.884
2.579
2.884
1.409
0.633
0.240
2.096
2.288
1.599
1.136
28 | P a g e
Q5 Other - verbatim) If you have selected "Other" for any Primary or Revision response, please specify:
PRIMARY - High school or college athlete
1
For athletes over 220 lbs or for hypermobile and small female athletes I perform autograft patellar tendon
preferentially, for the rest of the HS and college athletes I prefer hamstring autograft for primary ACL reconstruction.
3
For primary ACLs I will perform autograft only for anyone under the age of approximately 40 years. The patient and I
will choose between BPTB and hamstrings based on their concern about possible side effects of the respective
harvests. If patients older than forty ask for an allograft I will use BPTB allograft. In a revision situation, if another
surgeon had used allograft I will try to use autologous BPTB. We may also consider revision of a failed autograft with
another available autograft if the morbidity isn't considered to be high.
Freeze-dried fascia lata allograft
4
I reserve BTB autograft for heavier contact sport HS or college athletes.
5
I use both BTB and HS for colegiate and HS athletes depending on anatomy, sport, size of HS
2
7
I use BTB autografts for collision/contact athletes who are or will be collegiate/elite athletes, but hamstring autografts
for non-collision athletes, and high school athletes who do not intend to play in college or at advanced levels.
Use Allograft, but consider Hamstring Autograft as well
8
young athletes, in my care, choose BPTB auto or ham auto after discussion
6
PRIMARY - Adult recreational athlete
9
all inside graftlink usually peroneus longus folded over 4 times
10
depends on primary sport or activity
11
12
14
I am a pediatric orthopedist and all my patients are under 21 - many high level athletes. I offer everyone the choice of
BPB autograft versus Posterior Tibialis allograft. Long discussion about recent literature concerning increased failure
rates in young patients with allograft is made, weighed against significantly shorter operative/anesthesia time,
improved cosmesis, improved rehabilitation in the early period, and lack of damaging another portion of the knee. In
11 years of practice, I've had less than 2-3 failures in either types of reconstruction and have found no differences in
clinical or functional outcomes.
I am a pediatric specialist and do not operate on adults
15
If there are Patellofemoral symptoms I will proceed with a hamstring autograft, otherwise a B-PT-B autograft
13
17
In situations B) and F)the status of the patient, past medical hx, past surgical hx, and underlying chondral/meniscal
status will determine my graft choice preference.
Other = Peroneus Longus
18
other graft is peroneus longs allograft, goes through tunnels more smoothly than AT
19
Peroneus longus allograft
16
REVISION - High school or college athlete/ PRIMARY: Autograft failure
22
"other" is dependent on what autograft they had orgiginally. If they had a BTB, I use hamstrings. If hamstrings first,
BTB for revision.
1. Autograft-allograft hybrid of hamstrings + tibialis posterior allograft in an attempt to create a graft diameter of at
least 11mm. 2. If hamstrings previously used, then PT BTB autograft
Autograft tissue not used in the index procedure.
23
Biocleanse adjustable length allograft
24
Contra lateral autograft
25
Contra-lateral hamstrings or fresh frozen tibialis
20
21
29 | P a g e
26
27
28
29
30
31
32
Depends on the tunnels- if I'm happy with the tunnels I may use autograft hamstring. Otherwise I will use either donor
or auto patella tendon I there is significant tunnel widening I might also use an Achilles. But. More likely to use hemipatella allograft.
Depends on which primary autograft is used. If BTB, will use hamstring. If hamstring, then will do allograft Same for
recreational athletes
don't do revision acl
Each revision situation is unique, and different grafts are optimal for differing circumstances. This is a poor question,
particularly since the primary graft that failed (HS vs. BTB) is not identified.
For primary autograft failure for high school/college would tend to use that autograft which had not failed (BTB or
hamstring). I tend to use allograft as a first choice and revisions in patients over 40.
For the primary autograft failure in high school if hamstrings would do BTB and if BTB would do hamstrings or
contralateral BTB; in adult autograft failures if BTB would do hamstrings, if hamstrings failed would give pt choice
autograft hamstring other knee or allograft
33
34
35
graft choice for revisions depends on nature of tunnels, ie tunnel size,location,lysis so can't answer C-F in this format
Graft selection for revision depends a great deal on what graft was used as primary
36
Hamstring of contralateral leg if available
37
I do very few revision ACL's
38
I don't do revision ACL surgery
39
40
41
42
43
44
I prefer a hamstring autograft in all pts unless >2 Beighton signs positive. In those cases I will either use auto patellar
tendon in younger athletes (< 30 yo) and posterior tib allograft in those >30. In revision scenarios, I will use same
criteria and prefer to use autograft if available. In young athletes, I will even consider autograft from contralateral side
to stay with autograft. In pts > 30 or non athletic population I will use allograft post tib.
I would try to use hamstring or patellar tendon autograft if it hasnt been used previously and if the tunnel size allows it.
Otherwise i would use a tibialis anterior allograft.
I would use autograft HSTG or BTB, whichever one was used in the primary procedure.
If the primary autograft was NOT the Patellar tendon BTB, then I will use it. If it was used, then I use a Patellar tendon
BTB allograft.
In revision situations it depends what was used in the primary case and the age---I always try to use Autograft for
revisions (either BTB or HS---whatever was not used the first time
46
Less than 35 y.o., use ipsilateral BPB or hamstring if hasn't been used, or contralateral autograft
My preference is highly influenced by the individual patient's circumstances; as a result, I don't have a specific graft
preference that I can offer a generalized response. Also note, that I completed fellowship in July 2012, so I only worked
from Aug to Dec during 2012.
Other - Depends on bone loss or tunnel enlargement. I prefer allograft posterior tib, but if there is bone loss or tunnel
enlargement, I will use achilles allograft
47
48
49
regarding revision cases-depends on the primary graft used and the amount of tunnel widening
45
REVISION - High school or college athlete/ PRIMARY: Allograft failure
50
51
52
Consideration for contralateral BTB autograft.
30 | P a g e
53
54
55
57
58
I do not do allografts in high school and college aged athletes
59
I do very few revision ACL's
60
56
62
I prefer a hamstring autograft in all pts unless >2 Beighton signs positive. In those cases I will either use auto patellar
tendon in younger athletes (< 30 yo) and posterior tib allograft in those >30. In revision scenarios, I will use same
criteria and prefer to use autograft if available. In young athletes, I will even consider autograft from contralateral side
to stay with autograft. In pts > 30 or non athletic population I will use allograft post tib.
63
64
65
66
Use Allograft, but consider Hamstring Autograft as well
61
REVISION - Adult Recreational Athlete/ PRIMARY: Autograft failure
68
"other" is dependent on what autograft they had orgiginally. If they had a BTB, I use hamstrings. If hamstrings first,
BTB for revision.
1. Autograft-allograft hybrid of hamstrings + tibialis posterior allograft in an attempt to create a graft diameter of at
least 11mm. 2. If hamstrings previously used, then PT BTB autograft
69
70
Biocleanse adjustable length allograft
67
71
72
73
Depends on which primary autograft is used. If BTB, will use hamstring. If hamstring, then will do allograft Same for
recreational athletes
75
fan-folded fascia lata allograft
76
Fan-folded tensor fascia lata allograft
77
78
79
80
Hamstring of contralateral leg if available
74
31 | P a g e
82
83
84
I would try to use hamstring or patellar tendon autograft if it hasnt been used previously and if the tunnel size allows it.
Otherwise i would use a tibialis anterior allograft.
81
86
In revision situations it depends what was used in the primary case and the age---I always try to use Autograft for
revisions (either BTB or HS---whatever was not used the first time
87
88
89
90
91
85
REVISION - Adult Recreational Athlete/ PRIMARY: Allograft failure
92
93
Consideration for contralateral BTB autograft.
94
95
96
97
fan-folded fascia lata allograft
98
Fan-folded tensor fascia lata allograft
99
100
101
103
104
105
In situations B) and F)the status of the patient, past medical hx, past surgical hx, and underlying chondral/meniscal
status will determine my graft choice preference.
102
106
107
108
109
No preference: I explain the pros and cons of each and let patient decide.
32 | P a g e
110
111
112
Q6) How would the following influence whether you use an allograft for an ACL reconstruction (excluding multiligament procedures) for a given patient:
Younger patient
Patient intent to return
to high ACL demanding
activity
Female
Cost
Surgical time
Donor site morbidity
Cosmesis
Recovery time in
immediate
postoperative pain
Postoperative pain
Graft failure rates
reported in literature
Graft failures I have
experiences in my
practice
Graft incorporation
rate/time to return to
full activities
Disease transmission
concerns
Wouldn't affect
More likely to Use Allograft
Total
N
%
CI
740
90.1%
2.040
65
7.9%
1.847
16
1.9%
0.946
821
100.0%
N
678
138
12
828
%
81.9%
16.7%
1.4%
100.0%
CI
2.623
2.538
0.814
N
200
537
85
822
%
24.3%
65.3%
10.3%
100.0%
CI
2.933
3.254
2.082
N
361
450
13
824
%
43.8%
54.6%
1.6%
100.0%
CI
3.388
3.399
0.851
N
39
548
239
826
%
4.7%
66.3%
28.9%
100.0%
CI
1.446
3.223
3.092
N
38
265
522
825
%
4.6%
32.1%
63.3%
100.0%
CI
1.430
3.186
3.290
N
34
488
303
825
%
4.1%
59.2%
36.7%
100.0%
CI
1.356
3.354
3.290
N
73
375
378
826
%
8.8%
45.4%
45.8%
100.0%
CI
1.936
3.395
3.398
N
32
385
400
817
%
3.9%
47.1%
49.0%
100.0%
CI
1.330
3.423
3.428
N
698
114
13
825
%
84.6%
13.8%
1.6%
100.0%
CI
2.463
2.355
0.850
N
391
386
48
825
%
47.4%
46.8%
5.8%
100.0%
CI
3.407
3.405
1.597
N
568
239
18
825
68.8%
29.0%
2.2%
100.0%
3.160
3.095
0.997
%
CI
N
389
420
4
813
%
47.8%
51.7%
.5%
100.0%
CI
3.434
3.435
0.481
33 | P a g e
Graft availability for
double-bundle
procedures
Wouldn't affect
More likely to Use Allograft
N/A
Total
N
47
326
142
277
792
%
5.9%
41.2%
17.9%
35.0%
100.0%
CI
1.646
3.428
2.670
3.322
Q7) To what extent do you believe the following factors affect overall success of an allograft used in ACL
reconstruction?
No Impact
Level of irradiation used in sterilization
Use of chemical disinfectants
Age of donor
Time on the shelf
Age of patient (worse outcomes for younger patients)
ACL demands of patient after clearance to return to
sport/activity/work (worse outcomes for higher
demands)
Rehabilitation strategy (accelerated associated with
worse outcomes for allografts)
Small
Impact
Moderate
Impact
Strong
Impact
Total
N
14
118
266
429
827
%
1.7%
14.3%
32.2%
51.9%
100.0%
CI
0.879
2.384
3.184
3.405
N
40
279
332
175
826
%
4.8%
33.8%
40.2%
21.2%
100.0%
CI
1.464
3.225
3.344
2.787
N
29
185
389
220
823
%
3.5%
22.5%
47.3%
26.7%
100.0%
CI
1.260
2.852
3.411
3.024
N
63
322
333
99
817
%
7.7%
39.4%
40.8%
12.1%
100.0%
CI
1.829
3.351
3.370
2.238
N
24
96
219
486
825
%
2.9%
11.6%
26.5%
58.9%
100.0%
CI
1.147
2.188
3.013
3.357
N
40
128
255
404
827
%
4.8%
15.5%
30.8%
48.9%
100.0%
CI
1.462
2.465
3.148
3.407
N
86
247
317
177
827
%
10.4%
29.9%
38.3%
21.4%
100.0%
34 | P a g e
Q8) Please indicate your agreement with the following statements:
Yes
No
Total
N
%
CI
319
38.3%
3.301
514
61.7%
3.301
833
100.0%
Lower
34.99
58.40
Upper
41.60
65.01
N
%
CI
624
74.9%
2.944
209
25.1%
2.944
A) Do you have different rehabilitation instructions for patients who receive an
allograft for ACL reconstruction from those who had an autograft?
B) With proper rehabilitation and compliance by patients, do your allograft ACLR
patients do as well as your autograft ACLR patients?
833
100.0%
Lower
71.97
22.15
Upper
77.85
28.03
N
412
421
833
100.0%
C) Do you delay return to play timing for your ACLR allograft patients compared
with autograft?
%
49.5%
50.5%
CI
3.395
3.395
Lower
46.06
47.14
Upper
52.86
53.94
N
285
548
833
100.0%
D) Do you feel knowledgeable concerning the true amount of irradiation required
to completely sterilize (i.e., eradicate everything including spores and viruses)
allografts used for ACL reconstruction?
%
34.2%
65.8%
CI
3.222
3.222
Lower
30.99
62.56
Upper
37.44
69.01
Q8 Follow up A1 – verbatim) You indicated that you have different rehabilitation instructions for patients who
receive an allograft for ACL reconstruction from those who had an autograft.
How are your instructions different for the allograft patient?
1
150% longer to resume ACL straining exercises
2
2 months longer to return to running & jumping
3
2months longer for return to running or sports
4
6 month for allograft vs 3 month auto
5
6 month return for autograft, 9 month for allograft
6
6 month to return to sport with allograft, 4 months with autograft.
7
9 month RTP for allo, not 6 month
8
9-12 months for allo. 6-7 months for auto
9
ABOUT 50% LONGER TO RETURN TO ACTIVITIES
10
accelerated with allograft
11
Added time to full unrestricted activity
12
Advancement is approximately three months delayed in allograft ACLR
13
allograft 6 weeks protected weight bearing and no active flexion, extension
14
allograft and hamsitrngs autograft same postop, whereas bptb auto has accelerated. based more on bone-bone versus
soft tissue-bone healing rather than allo versus auto.
15
Allograft and hamstring autografts in my practice receive a delayed ACL rehab protocol with slower return to running,
cutting, and jumping activities. Also a delayed return to sport timeframe.
16
Allograft patient can stop using crutches as soon as comfortable, compared to mandatory 6 weeks for autograft PT.
Otherwise rehab is the same for my practice.
17
allograft patients advanced slower
35 | P a g e
18
Allograft patients are slower and not cleared for 9-12 months
19
avoid full arc open chain quad pre's for 20 weeks
20
basically just about 6-8 weeks slower
21
basically pivot/duckwalk squatting/impact/sports/accel-decel activities or even uphill running/stair running delayed
until 9-12 mos. with allograft, esp soft tissue allograft.
22
Brace for 6 weeks. Autograft d/c brace prn
23
brace for six weeks vs four
24
Brace postoperatively, slower progression
25
Bracing for sports for 18 months postop until graft incorporation occurs.
26
crutches for 4-6 weeks with allograft
27
Crutches partial weight longer ( 4-6 weeks), same rehab program but at about half the speed with same emphasis on
weight bearing closed chain exercises.
28
decreased time to functional rehab part of protocol.
29
Delay impact ex and return to sports.
30
delay in cutting and full contact unless patient states they are willing to accept risks of reinjury , otherwise all rehab is
the same
31
Delay jogging for an additional month and longer to return to full sports activities
32
delay open chain exercises by one month
33
Delay open chain exercises, delay ultimate return to high demand sports
34
Delay pounding (I.e. running) activities until at least 12 weeks, no jumping until 20 weeks
35
Delay progression with regard to sport specific and jump cutting activity
36
Delay return to full sports to 8 or 9 months vs 6 to 7 in ALC BTB autograft
37
Delay return to play
38
delay return to play and delay sport-specific activity--cut and pivot.
39
delay return to sport
40
Delay return to sport
41
Delay return to sport additional two months
42
delay return to sport by about 2-3 months
43
Delay return to sports to 9 months
44
delay running and cutting activities by at least 4 weeks compared to BTB autograft
45
delay stressing the graft about a month longer.
46
Delay weightbearing in the early post-op period for allograft and delay running/cutting in the later period.
47
Delayed progression for return to running, cutting and sports
48
Delayed progression to aggressive pivoting activity.
49
Delayed quadriceps strengthening.
50
Delayed return to high impact activity
51
Delayed return to impact activities.
52
Delayed return to play until 9 months
53
Delayed return to running , more restricted wgt bearing initially.
54
Delayed return to running and ultimately, return to competitive sports.
55
Delayed return to sport for allograft 9 months vs. 6 months
56
Delayed running and cutting
57
Delayed running until 4 months. Delayed return to sports 9-12 months.
36 | P a g e
58
Delayed weight bearing in the allograft and prlonged bracing
59
Delays in advanced muscle training, return to athletics
60
Depends on what it is being compared to. I use different protocols for autograft hamstring and BPTB as well.
61
Diffent PT protocol. Slower return (approx by 4 weeks) in all activities. More akin to ACLR/MMR protocol.
62
do not allow return to running until 6 months.
63
dont use allograft anymore
64
Duration of bracing 8 weeks for allograft patients vs 4 weeks
65
E very thing is just slowed down
66
Earliest rtp8 mth
67
Early post op is the same. My allograft patients are older, less active. The big difference is return to more aggressive
sport,or full duty for a fire fighter/police. Autograft in younger pts- full activity (if appropriate) 6 months. Allograft 9
months. However, many of these pt's are not that active and can modify their activity to return by 6 months.
68
elongated protocol to tailor 12 month return to everything vs. 9 months for autograft
69
everything delayed by about 1 month and return to sport 1-2 months
70
everything same just delayed by 6 weeks
71
Expectations and time to return vary. Times and rates of progression are slower
72
faster
73
faster return to rom exercises for allograft due to less donor morbidity site healing with autograft
74
75
For allograft patients: I brace postoperatively, I delay plometrics / jump training / agility until 9 months postop, I dely
return to sports until 1 yr postop (assuming all rehab goals met) and then recommend bracing for sports until 18
months postop.
From the start they understand that the the time to full activities, and rehabilitation in general will be slower
76
full activity at 8 months postop with allo vs 6 months with auto
77
Generally similar program but delay most phases or advancements by 4-6 wks. I.e. jogging at 4 months instead of 3
78
Generally slower to return to run and sport. Initial rehab is identical.
79
Globally delayed with open chain, running, cutting, return to sport
80
go slower
81
Go slower and less initial flexion.
82
Go slower for allografts.
83
Go slower in all phases
84
Go slower in the 2 to 6 month range with allograft pts
85
go slower, though pts feel better
86
I am less likely to allow allografts to increase to higher level of rehab due to stretch and rehab
87
I delay aggressive protocol until after six weeks
88
i delay return to high demand torsional activities for the minimum of 9 months
89
I delay when they start running about 1-2 months. I also do not let them back to full activities, cutting and pivoting
until 9-10 months.
90
I don't allow my allograft patients to start running quite as soon as autograft patients
91
I don't perform allograft reconstructions because the results have been shown to be inferior. IF I did them I would
progress them much more slowly.
92
93
94
I don't use allografts anymore, so difficult to answer. But My impression is they incorporate more slowly.
I emphasize on Range of motion and quad strength in the initial postoperative period with aggressive ACL rehab 3 mths
after surgery. Not every athlete can become like Michael Jordan and similarly all surgeons can't be like John Charnley.
I generally advance more slowly through the rehab protocol, but I typically will allow them to fully participate at 6
months if they meet all rehab criteria- same as I would with an autograft
37 | P a g e
95
I go slower.Return to sports a little later
96
I have less concern for patellar tendonitis and usually have to slow them down due to less pain and swelling.
97
I hold allograft ACL patients back from functional drills and agility exercises longer than autograft ACL patients.
98
I instruct the allograft patients to advance through strengthening and plyometrics later than the autograft patients.
99
I just go slower and less aggressively, but again, my selection criteria is such that those that get allografts are more
sedentary.
100
I progress them more slowly to general activity. They are released to run later than autografts
101
102
I recommend a slower return to full activity following allograft surgery. However, this is skewed somewhat by the fact
that I use allografts in revision cases, where I recommend a slower return to full activity anyway.
I rehab allograft patients slower and allow full activity after 8 months versus autograft get aggressive rehab and return
after 6 months.
103
I require allograft patients to wear a post op hinged brace for 6 weeks. i delay running for 4 months and return to sport
for 8-12 months.
104
I take more time and go more slowly
105
I use my revision protocol which goes slower and and return to full activity i slcoser to 9-12 months
106
I will be a little slower with the initial 4-6 weeks of rehab
107
108
109
I would delay mailestones significantly. I would not allow full activity until 1-year as opposed to 6-months with
autograft
I would recommend slower return to sports. With a healthy BTB autograft, my patient return to full sport at 3 months,
with less than 1 percent failure rate. With allograft I would wait closer to 6 months.
If hamstring autograft, avoid hamstring strengthening in immediate post-op period.
110
Immmediate post operative weight bearing restrictions are maintained for a longer period of time due to delayed
incorporation rates of allograft tissue.
111
In general, slower
112
In the immediate post-op period, for up to 3 months, rehab progresses at a slower rate.
113
Increased time before return to sports
114
Initial rehab identical. Return to run/sport delayed for allograft patients.
115
Is been many years since I used an allograft. I would keep them off sports for at least one year.
116
It is different because of the donor site pain/morbidity.
117
Jog at 4 months and twist activity at 6 months, with full return to sport at 12 months, I feel I am slowing the allo
patients down and reminding them not to speed their recovery.
118
Less accelerated rehab
119
Less aggressive early motion. Delayed return to sports or physical activities
120
Less aggressive rehab, delay return to sports
121
122
Less aggressive with initial rehabilitation. I do not delay their return to activity since I use allograft for those with low
activity demands, and allograft incorporation/maturity can take over 2 years.
Less formal PT in the first 4-6 weeks as I find that motion comes back easily and I don't want them to progress too
rapidly.
123
less time in brace for allograft
124
Limit flex ion to 90 degrees for 6 weeks
125
Limit motion early, NWB x 6 wks
126
Limited weight bearing in the early post-operative period; use of rehab brace for 6 weeks; delay in-line jogging program
by one month
127
Longer before return to play
128
Longer delay in full return to activity
129
Longer delay to sports-specific activities after allograft.
38 | P a g e
130
Longer for an allograft
131
Longer incorporation times buy less postoperative pain has unique rehab challenges.
132
Longer neuromuscular feedback program with delay in side to side movements
133
longer on crutches and brace. slower progression. need to hold allograft back more since they feel better more quickly,
which I think is main reason for increased failures in younger (aka less wise) patients
134
Longer protected time - 3-8 Months time, less aggressive rehab
135
longer protected weight bearing
136
longer protective period
137
longer recommended time to return to full sporting activity
138
longer rehab 12 months
139
longer rehab cautions, lower demand level goals I have had allografts fail at 5 years so early rehab is onew thing, graft
acceptance is another.
140
Longer rehab for allo
141
longer return to activity at every stage. I let autograft pt. full return to sport at 6 months. I like to wait until 9 months
for allograft
142
Longer return to jumping, cutting, pivoting sports
143
longer return to run, jump, sports
144
Longer return to sports.
145
Longer time before cutting/pivot exercises
146
Longer time before RTP.
147
longer time in post-op brace therapists progress them slower
148
Longer time to rtp
149
longer time to sports participation
150
longer time to weight bear
151
longer tome w/ brace and crutches
152
longer wait unti return
153
longer weight-bearing precautions
154
more conservative approach such as delayed return to open chain exercises, and sports and longer brace times.
155
More likely to protect WB longer with allograft
156
more time for intitial immobilization and to functional activites and athletic activities
157
most strength and ALL activity recommendations and delayed at least 50%
158
Much less aggressive rehab if I were to use an allograft, but I don't use allograft
159
Much longer rehab. Much longer time to pivoting exercises, and full return to sports at 10-11months postop.
160
Much slower progression for allografts especially in the first 4 months.
161
Much slower rehab
162
Much slower rehabilitation protocol for allograft. Will delay return to cutting and pivoting by 3 months compared to
autograft. Return to play with allograft is at the earliest one year compared to 9 months with autograft.
163
Must wait one year (compared to 6-9 months for autograft) to return to sports
164
No accelerated rehab
165
no active hamstring strengthening for 8 weeks after surgery w/ dlsg autograft
166
No cyclical loading for 8 weeks after surgery. Limit open chain as long as possible.
167
no jumping, leg presses or cutting activity for 3 to 6 months
168
No resistive quad exercise
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169
No restriction on hamstring use in rehab.
170
No running til 4 mos post-op No return to high level sports til >1year post-op
171
no running until 4 months as opposed to 3 months
172
No use of CPM
173
not really am holding patients longer before return to play, making them pass functional testing before RTP
174
on crutches PWB for one month
175
one month longer to move to next level of activity
176
One year prior to return to sports at risk.
177
Partial weightbearing for 6 weeks as opposed to weightbearing as tolerated Potential to increase the brace wearing
time (usually not though)
178
Proceed slower with return to sport/full activities.
179
Progression significantly slowed; progression of weight bearing slowed in 1st 6 weeks; long times for return to running
and return to sport/cutting activities
180
Progression through rehabilitation is slower to allow for greater incorporation time
181
Prolong stage III and IV of rehab for 3 months
182
Protected weight bearing for 4 weeks in brace and slow flexion.
183
Rehab goes slower
184
Rehab is a little slower in all aspects
185
Rehab is the same for allograft and autograft hamstrings but different from auto btw
186
Rehabilitation slowed, longer time unti RTP
187
Return to athletics at 6 months for autograft and 9 months for allograft patients. Start treadmill jogging at 3 months
for autograft and 4.5 months for allograft.
188
Return to contact sports is delayed for 12 months.
189
Return to full athletics is delayed for one full year. Do not allow any lateral cutting for 6 months.
190
return to paly 9-12 months vs 4-6 mos for autograft
191
return to play is generally 8-9 mo after allograft and generally 6-8 mo after the autograft hamstring or patellar tendon.
All soft tissue grafts require ACL knee brace to return to pivot sports
192
Return to play later / protected
193
return to sport delayed with slower transition to open chain activities
194
Return to sport slightly slowly , must complete our ACL rehab testing either way.
195
Return to sports about 9 months post-op.
196
rtn to play at 1 year vs 6 mo auto
197
RTP earliest 9 months not 6 months and have them demonstrate greater strength to progress thru the protoocol
198
Run at 4.5 mos
199
Running starts at 12 weeks instead of 6 weeks. Pivotinng starts at 5 months instead of 3 months. Full return to sports is
at 6 months (with a derotational brace) instead of 4 months. Brace wear continues for 24 months instead of 12 months.
200
significantly slower with allografts in all phases of rehab
201
Slight delay until full return to activities
202
Slightly less aggressive in return to play. More time in aquatic treadmill early on.
203
slightly more aggressive protocol
204
slow down rehab in the 6-10 week period where I believe allograft at its weakest
205
Slow them Down
206
Slower (Indicated 6x)
207
Slower (Indicated 4x)
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208
Slower advance to cutting and pivoting activities
209
Slower advancement of rehab.
210
Slower advancement of strengthening program and terminal extension work.
211
Slower e less aggressive return to play
212
slower first six weeks and slower RTP
213
slower for allo
214
Slower in later phases
215
Slower intitial post-operative advancement.
216
Slower introduction of full activity.
217
Slower mobilization, slower loading, longer to return to cutting/loading
218
slower progress
219
Slower progress
220
Slower progress no return to sport for 1year
221
Slower progress to activity levels on protocol
222
slower progression (Indicated 3x)
223
Slower progression (Indicated 3x)
224
slower progression and longer return to sport
225
Slower progression in PT; longer interval before jogging, cutting, plyis, etc
226
Slower progression of strengthening and return to sports after 3 months
227
slower progression the first 3-4 months
228
slower progression through rehab
229
Slower progression through the phases of recovery and return to sports.
230
Slower progression to functional activities with allograft
231
Slower progression to graft stressing activities. Delayed squating in weight bearing positions.
232
slower progression to return to cutting and twisting sports
233
Slower progression, longer time to return to play
234
Slower progression.
235
Slower progression. Longer time to release to full play
236
slower rehab (Indicated 3x)
237
Slower rehab
238
slower rehab and longer return to activities
239
Slower rehab and return to play
240
slower rehab for allograft
241
Slower rehab for allografts
242
Slower rehab in all phases. Minimum 9 months before fully cleared for sports.
243
slower rehab overall with delay in open chain exercises
244
slower rehab process, longer time to return to functional rehab and sports
245
Slower rehab program
246
Slower rehab rate. Longer time to release to sports. 6 mos vs 9 mos
247
slower rehab slower return to pivoting sports
248
Slower rehab time frame.
41 | P a g e
249
Slower rehab, later return to running
250
Slower rehab, return to sport delayed to 1 year
251
Slower return
252
slower return for allograft patients.
253
slower return to activities
254
slower return to activities ie running and sport specific drills
255
slower return to activity
256
Slower return to contact and cutting activities
257
Slower return to cutting sports
258
Slower return to cutting, twisting, sports
259
Slower return to cutting/pivoting activities
260
Slower return to full activities
261
Slower return to full unrestricted sports participation
262
Slower return to full weightbearing. Slower progression to impact activity (running)
263
Slower return to impact/balistic/twisting activities.
264
Slower return to open chain activities. Delay jogging until 4 months.
265
slower return to play
266
Slower return to running
267
Slower return to running activities
268
slower return to sport
269
Slower return to sport
270
Slower return to sport specific rehab.
271
slower return to sports
272
Slower return to sports and stress of the graft
273
slower return to sports/pivoting activities with allograft
274
Slower returns
275
Slower rom,block terminal 10 degrees, slower with isotonics
276
Slower sports return
277
Slower time frame to return to activity
278
Slower time to return to full activities
279
Slower to progress to milestones of running, plyometric and open chain activites, and return to sport
280
Slower to return to full sports
281
Slower to return to stage 3 -- agility training and plyometrics
282
slower with allograft
283
slower. No return to sports for 10-12 months
284
tdwb on operative leg for 6 weeks
285
The allograft patients do not need addition rehab for donor site
286
the graft takes longer to incorporate, therefore there rehabe has to be more controlled.
287
The recovery time is longer
288
These patients usually have less pain. They can move more quickly.
289
They rehab faster Get their motion back faster
42 | P a g e
290
They start jogging 6 weeks later than BTB autograft and return to sports 3 months later
291
too long for this survey
292
TTWB x4 weeks, prolonged return to running, sports
293
Use a delayed rehab protocol (Noyes delayed vs aggressive)
294
Usually will wait a full year before allow return to play
295
Wait 1year to return to play after allograft
296
We follow the same protocol up to starting agility drills at ~ 6mo. I allow autograft patients to return to sport specific
conditioning after clearing agility, and return to play when they feel ready. However, my allograft patients are not
allowed to compete in collision/contact sports for 1 yr.
297
We slow down the aggressive strengthening.
298
Weight bearing is partial during first 6 weeks. I use a hinged post up brace for the first 3 months I allow patient to
return full sports at the end of 6 months.
299
weightbearing status initially.
Q8 Follow up C1 – verbatim) You indicated that you delay return to play timing for your ACLR allograft patients
compared with autograft.
When do you typically allow return to play for autograft patients and when for allograft patients?
1
~6 months auto; 8-9 months allo
2
1 year (Indicated 3x)
3
1 year allograft 6 months autograft
4
1 year allograft, 9 months autograft
5
1 year if strong enough
6
1 yr
7
1-2 years
8
10-11 months post surgery.
9
10-12 months
10
10-12 months versus 9-10 months.
11
12 month return to everything vs. 9 months for autograft
12
12 months (Indicated 3x)
13
12 months autograft 12 months allograft
14
12 months avg for allografts; 8 months avg autografts. Lots of assumptions here though
15
12 months for both
16
12 mos vs 6 mos
17
12 onths and full quad strength
18
12-16 months for allo, 9-12 for auto
19
3 months later
20
3-4 mos autograft 6 0r more allograft
21
3.5-4 mos auto, 4-6 mos all
22
4 - 6 months for autografts; 8 - 12 months for allografts. I tell both groups that I do not expect they will "fully recover
until at least one year, however.
23
4 months auto. 6 months allograft. On average the real time is a function of strength.
24
4 months before running
25
4 months for autograft depending on sport, ie college linemen 9 months for allografts who knows we negotiate
43 | P a g e
26
4 months for autograft if they do a perfect job on rehab and can pass a functional test. 1 year for allograft if they can
pass a functional test.
27
4 mos 6 mos
28
4 to 6 months for autograft. 8 to 12 months for allograft
29
4-6 months autograft. 9-12 allograft
30
4-6 months vs 6-9 months
31
4-6 mos auto 8-12 mos allo
32
4-6 or 9 months vs 6-9 or 12 months.
33
4-6mo for auto graft 6-8 months for allograft
34
4-6mos autograft 6-9mos allograft
35
4-8 auto ,6-10 allo
36
5 month autograft 6 month allograft
37
5 months for autograft, 8 months for allograft
38
5 months in auto, 8-9 in allo.
39
5-6 months Autograft, 9-10 months allograft
40
5-6 months for auto, 12 for allo
41
5-6 months for autograft and 9-10 months for allograft.
42
5-6 months with autograft if have fullROM and strength with single leg hop test equal, 6-9 months with allograft
43
6 - 8 MOS auto, 9-12 mos allo
44
6 for auto, 6-9 for allo
45
6 mnths auto 9 allo
46
6 mo ACLR autograft and 9 months ACLR allograft
47
6 mo auto 6-9 mo allo. Would only use allo on lower demand/older pts
48
6 mo auto, 9 mo allo
49
6 mo, 9 mo
50
6 month auto 9 month allo
51
6 month auto 9 months allo
52
6 month for auto vs 6-9 months for allo
53
6 month return for autograft, 9 month for allograft
54
6 months
55
6 months auto, 12 months allo
56
6 months - 9 months
57
6 MONTHS -7 MONTHS ALLOGRAFT: 9 MONTHS
58
6 months (dependent on strength test) for auto and 6-8 for allograft
59
6 months / 9 months
60
6 months 9 months
61
6 months and 8 months
62
6 months and 9 months
63
6 months auto 12 months allo
64
6 months auto 7-8 months allo
65
6 months auto and 9 months to 1 year allo
66
6 months auto btw, 9 months for all others
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67
6 months auto- and 9 months allo-
68
69
70
6 months auto.
71
6 months auto. 9 months allo.
8 months allograft
72
6 months autograft, 12 months allograft but allografts are not high demand patients
73
6 months autograft, 8-9 months allograft
74
6 months autograft; 8-9 months allograft
75
6 months earliest for autograft, 9 months for allograft
76
6 months for auto 9 months for allo
77
6 months for auto-, 12 months for allo-
78
6 months for auto. 8 for allo
79
6 months for autograft Rarely use allograft
80
6 months for autograft 8-9 months for allograft
81
6 months for autograft and 12 months for allograft
82
6 months for autograft and 7-9 for allograft
83
6 months for autograft and 8 months for allograft
84
6 months for autograft and 9 for allo
85
6 months for autograft and 9 months for allograft.
86
6 months for autograft and 9-12 for allografts
87
6 months for autograft if they have their strength back and 1 year for allografts
88
89
6 months for autograft patients depending on functional testing versus 8-9 months for allograft patients depending on
the functional testing of the patient.
6 months for autograft provided they pass functional testing by our therapists/trainers. 8 months or longer for
allograft and they have to pass functional testing.
90
6 months for autograft pts. Usually 9 months for allograft pts.
91
6 months for autograft versus 7-9 months for allograft
92
6 months for autograft, 1 year for allografts
93
6 months for autograft, 12 months for allograft
94
6 months for autograft, 8-9 months for allograft
95
6 months for autograft, 9 months for allograft (Indicated 2x)
96
6 months for autograft. would not do allograft if intent was to perform sports. would delay as much as possible for
allograft up to one year
97
6 months for autografts and 9 months for allografts.
98
6 months for RTP in autograft 8 months for RTP in allograft
99
6 months minimum for autograft if strength is sufficient. Minimum 9 months for allograft if strength is sufficient.
100
6 months versus 8 months
101
6 months versus 9
102
6 months versus 9 months to 1 year
103
6 months vs 12 months minimum(9vs18moths to 18vs 36 months for graft maturity)
104
6 months vs 9 months (Indicated 2x)
105
6 months, 9months
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106
6 months,12 months
107
6 months/12 months
108
6 mos auto 1 yr allo
109
6 mos for auto, 12 mos for allo
110
6 mos for auto, 6-9 for allo.
111
6 mos vs 10mos
112
6 mos vs 9 mos
113
6 mos, 7-8 months
114
6 to 9 mos auto 9 to 12 mos allo
115
6 vs 9 months, but the allografts are mostly revisions
116
6-12 months auto, 2 years allo
117
6-7 months autograft, 9 months allograft
118
6-7 mos for auto
119
6-8 months
120
6-8 months 10-12 months
121
6-8 months for auto. 9-12 months for allo.
122
6-8 months for autograft. 10-12 months for allograft.
123
6-8 mos autograt 9-12 mos allograft
124
6-8 mos for an allograft, 4-6 mos for autograft
125
6-8 mos for autographs and one year for allographs
126
6-8 mth versus8-12
127
6-9 month rtp for autografts and 9-12 month rtp for allografts.
128
6-9 months
129
6-9 months 9-12 months
130
6-9 months auto 9-12 months allo
131
6-9 months auto vs 9-12 months allo
132
6-9 months autograft. 9-12 months allograft.
133
6-9 months autograft. Prefer 9-12 for allograft.
134
6-9 months for Auto, 7-10 for allo
135
6-9 months for auto, 9-12 for allo
136
6-9 months for auto. 9-12 months for allo
137
6-9 months for autograft and 8-10 months for allograft
138
6-9 months for autograft; 9 months for allograft revisions.
139
6-9 months for autograft; 9-12 months for allo
140
6-9 months for autograft; 9-12 months for allograft
141
6-9 months for autograft. 12months or greater for allograft
142
6-9 months for autograft. 1+ yr for allograft
143
6-9 months for cutting sports for autograft. Greater than 1 year for allograft.
144
6-9 months sutograft 12-18 monthss allograft
145
6-9 months versus 9-12 months
146
6-9 months verus 9-12 months
7-8 mos for allo
46 | P a g e
147
6-9 months vs 12 months
148
6-9 months vs 9-12 months (Indicated 2x)
149
6-9 months- auto 9-12 months- allo
150
6-9 mos
151
6-9 mos auto , 12 for allo
152
6-9 mos vs 9-12 mos
153
6-9 mos. vs. 5-6 mos.
154
6-9 vs 9-12 months
155
6-9months for autograft patient 12months for allograft patient
156
6mo auto vs 1 yr allo
157
6mo auto, 9-12 allo
158
6mo autograft 8mo allo
159
6mo vs 8mo
160
6months auto:8-10 allo
161
6months auto. 1 year allo
162
6months,8months
163
6mos v 8 moso
164
7 months
165
7 months for autograft, 9 months for allograft but allograft older and usually no set time frame for return to sport
166
7 months to 8 months
167
7 vs 8 month
168
7-8 months allo. 6 months auto
169
7-8 months auto, 9-12 months allo
170
7-9 months autograft 9-12 months allograft
171
7-9 months for auto, 9-12 months for allo
172
7-9 months for autograft, 9-12 months for allograft. Depends on patient factors, strength, etc
173
8 months for autografts and 10 months for allografts.
174
8 months vs 10-12
175
8 months vs 12
176
8 monyhs
177
8 mos allografts 6 mos auto
178
8 to 9 months for auto longer for allograft
179
8 to 9 months if patient passes sports test
180
8-9 months autograft 9-12 months allograft
181
8months auto 12 months allo
182
8mos to 1 year depending on sport
183
9 - 12 months
184
9 mo auto 12 mo allo
185
9 mo for allo, 6 mo for auto. Both need to have FROM and symmetric quad girth prior to pivot sports. Thinking about
moving to functional testing as indication to play.
186
9 month RTP for allo, not 6 month
187
9 months (Indicated 3x)
47 | P a g e
188
9 months allograft; 6-7 months autograft
189
9 months at the earliest
190
9 months autograft, 12 months allograft
191
9 months autograft. 12 months allograft
192
9 months for allograft; 6 months for autograft
193
9 months for auto and 12 months for allo
194
9 months for autograft 12 months for allograft
195
9 months for autograft, 12 for allograft
196
9 months for autografts, 12-14 months for allografts
197
9 months for both
198
9 MONTHS FOR BOTH
199
9 months post op
200
9 months.
201
9 months. Patients are revision ACLs only
202
9 to 12 months
203
9 to 12 months depending on specific activity
204
9-12 for auto and more than 12 for allo.
205
9-12 months (Indicated 3x)
206
9-12 months 12 -14 months
207
9-12 months allograft, 6 months auto
208
9-12 months for allo. 6-7 months for auto
209
9-12 months for autograft. minimum of 12 months for allograft
210
9-12 months for RTP for allograft
211
9-12 months instead of 6-8 months for autograft
212
9m+ Auto, 12m+ allo
213
9months and 1 year
214
9months autograft if muscle recovery allows....12 months for allograft
215
9mths for autograft and 15mths for allograft.
216
above
217
add 2 months
218
After 9 months with good strength and functional test results
219
Again, because I do so few allo this is hard to say. Do not have specific time- table for auto- let the knee make th
decision. With allo try to slow it up but no specific times.
220
allograft - 8 to 9 months autograft - 6 months
221
allograft-- at least 9 months. autograft-- at least 7-8 months
222
approx 9 mos for auto 9-12 mos for allo
223
as above (Indicated 3x)
224
As above 6 months autograft. 9 months allograft. For my younger pt's with an allograft revision ACL reconstruction, I
would wait 12 months.
225
As I stated before, I do not use allografts anymore. My impression is that they incorporate more slowly, and therefore
should have demands placed on them more slowly.
226
Assuming able to do a single limb squat- RTP for allograft 8 months RTP for BTB auto 5 months
227
At least 1 yr for allograft, 6-12 mo for autograft.
48 | P a g e
228
At least one year, maybe longer. Can be upto 18 months.
229
At the USNA we almost never use allograft in our contact collision athletes, and we follow functional criteria for all
return to play considerations following ACLR regardless of graft choice. In addition, they have to pass a very rigorous/
formal physical readiness test prior to returning to their sport. Most athletes aren't ready to compete at this level until
about 6-7 month mark. If we use an allograft, then it's probably on a revision, in which case we would lilkley hold out
until approximately 9-12 months.
230
auto 8 months allo 12 months
231
Auto - 6 months. Allo - 8-9 months.
232
auto - 9 months, allo - 1 year
233
Auto 4-5 months, 5-6 allo
234
auto 4-6 months allo 6-12 months
235
Auto 5 months Allo 6 months
236
auto 5-7 months allo 9-12 mos
237
auto 6 months allo 8
238
Auto 6 months Allo 8-9 months
239
Auto 6 months Allo 9 months
240
auto 6 months allograft 9 months
241
auto 6-8 mo allo 8-12 mo
242
auto 6-8 mo, allo 7-9 mo depending on clinical exam, quad girth and function
243
Auto 6-8 months. Allo 8-12 months
244
Auto 6-9 months. Allo 9-12 months
245
Auto 6-9 months. Allo 9+ months
246
Auto 6m, allo 8m
247
Auto 9-12 m, Allo 12-16 m
248
Auto about 6 mo and allo 9-12 mo
249
auto approx. 6 months but sometimes sooner. allo. not for 8 months and often later.
250
auto graft 6 months allograft 9 months
251
Auto grafts: 8-12 months Allografts: 10-14 months
252
Auto is 6 months while allo is 9 months
253
auto- 7-9 months allo-9-12 months
254
Auto: 5-6 months Allo: 6 1/2 - 7 months
255
Auto: 5-6 months. Allo: 8-9 months
256
auto: 6-8 monts, allo: 9-12 months
257
Auto...9-12 months
258
autograft 6 mos; allograft 8 mos
259
Autograft - 6 months. Allograft - 8 months
260
Autograft - 6-9 months Allograft - 9-12 months
261
Autograft - 9 months, allograft - 12 months.
262
Autograft - full unlimited activity at 6 months. with Allograft, full activity at 12 months
263
autograft = 6 months provided that they have passed functional rehab testing emphasising neuromuscular re-education
and core stability. allograft = 9 months provided that... ".
264
Autograft = 9-10 months Allograft = 12 months
265
autograft 4-6 months allograft 9-12 months
Allo...min 12 months
49 | P a g e
266
autograft 4-6 months Allograft min 6 months
267
Autograft 4-6 months, allograft 9-12
268
Autograft 5-6 months if neuromuscularly competent. Allograft 6-12 months if so.
269
Autograft 5-6 months, Allograft 7-8 months
270
autograft 6 mo, allogrft 1 yr
271
Autograft 6 months Allograft 1year but I don't do these.
272
Autograft 6 months Allograft 8 mos
273
Autograft 6 months with brace, 12 months without brace. Allograft 9 months with brace, 18 months without brace.
274
Autograft 6 months, allograft 9 months
275
Autograft 6 months, Allograft 9 months (though I do not use allograft for athletes).
276
Autograft 6 months, allograft 9-12 months
277
autograft 6 to 8 months allograft 8 to 10 months
278
Autograft 6- 8 months Allograft 1 year
279
Autograft 6-12 months depending on leg symmetry. Allograft 9-15 months depending on leg symmetry
280
Autograft 6-8 months Allograft 9-12 months
281
autograft 6-8 months depending on sport and strength I very rarely do allograft because I feel there is higher failure
rate but return would be 8-12 months
282
Autograft 6-8 months. Allograft 8-12 months.
283
284
autograft 6-9 months allograft 1 year
285
autograft 6-9 months allograft 12 months
286
autograft 8 months, allograft 10 months
287
288
Autograft 9 mo. Allograft 12 mo
289
Autograft 9 months Allograft 12 months (Indicated 2x)
290
Autograft 9 mos Allograft 12 mos
291
Autograft about 6 months and allograft 9 months
292
autograft about 6- 8 months (also based on functional criteria) allograft about 9-12 months (also based on functional
criteria)
293
autograft aclr return to play 6-8 monhths, allograft rtp 9-12 months
294
autograft are cleared typically in 6-8 months allograft are cleared typically in 9-12 months
295
Autograft at 6-8 months depending upon muscle strength/patient ability. Allograft at 8-9 months depending upon
above.
296
Autograft at 85% quad strength to cl side ~4.5-8 months post op. allograft no cutting sports < 1 year post op.
297
Autograft BTB at 6 months; Autograft HSTG at 7-8 months; Allograft at 9 months; All patients must have at least 90%
quad strength, pass single leg hop test, have good return of core strength and stable knee w/ full ROM and no
pain/swelling
298
autograft minimum 6 months allograft probably closer to 9 months
299
Autograft patients allowed when they have demonstrated appropriate neuromuscular recovery and successful
completion of sport-specific exercise regimen. Allograft: the above, after 10 months, whichever is longer.
300
Autograft patients are allowed to return to play after completing our rehab program, and then completing sportspecific conditioning to their satisfaction. Allograft patients who are returning to collision/contact sports are delayed
for a year.
301
autograft patients may return in 4-6months. allograft patients after 6 months.
50 | P a g e
302
Autograft patients: 6 months; allograft: 9-12 months.
303
Autograft pts generally RTP at 8 months, while Allografts RTP at 12 months.
304
autograft ranges from 6-8 months whereas allograft 9-12 months
305
306
Autograft return occurs when patient had successfully completed their accelerated program - usually 4-6months, but
some are ready at 3 months. Allograft - I typically wait for six months.
Autograft return to sports at 7-8 months postop. Allograft return to sports 12 months postop (in brace until 18 months
postop).
307
Autograft usually 6-9 months. Allograft 9-12 months
308
Autograft when passing functional test at 6 months; Allograft when passing functional test at 9-12 months
309
Autograft when ready....typically 9-12 mos Allograft typically > 1year
310
Autograft when strength has returned, allograft no sooner than 6 months, but I don't use allograft
311
Autograft when they demonstrate appropriate strength, function and progressive sport specific function. Allograft
when they have had significant time for healing.
312
Autograft- 4-6 months Allogaft - 6-9 months
313
autograft- minimum 6 months, avg 9-12 months. allograft- minimum 9 months return to sport
314
autograft- usually 6-9 months. Allograft 9-12 months.
315
Autograft-- 4-6 mos Allograft -- 8 mos
316
Autograft-6 months. Allograft-9 months.
317
Autograft: return to run @ approx 4 mos, return to sport @ approx 6 mos Allograft: return to run @ approx 6 mos,
return to sport @ 9-12 mos
318
Autograft: 4 months. Allograft: 6 months
319
autograft: 4-5 months; allograft 5-6 months
320
autograft: 6-9 mo allograft: 12 mo
321
Autograft: run without cutting @ 4 mos, sport @ approx 6 mos Allograft: run without cutting @ 6 mos, sport @ 9-12
mos
322
Autograft:6-10 months Allograft: 10-12 months
323
Autografts 9 months, allografts 12 months
324
autografts 9 months, allografts 9-12 months...however, both groups need to demonstarte through cybex testing and/or
single-leg hop confidence/strength in the knee before return, otherwise they are extended till they demonstrate they
can retrun safely
325
Autografts between 6 and 8 months, allografts at least one year
326
autografts: 6-8 months Allografts: 8-12 months
327
Autos - 6-9 months Allos - 8-12 months
328
Based on achievement of multiple criteria, not time from surgery
329
Because I use allograft in older its return to play in 9-12 months vs 6-9 for autografts who are younger
330
Begin training unrestricted training at 8 months.
331
BTB auto approx 5 months; hamstring auto approx 6 months; allograft approx 6+ months.
332
BTB auto pts return to play 9-12 months. Hamstring auto and allograft return to play no sooner than 12 months.
333
BTB auto- 6 months, Hamstring auto- 7-8 months, Allograft- 8-10 months
334
BTB auto: 6 months minimum, HS auto and allografts 7-9 months minimum
335
criteria, not time based
336
Delay return to sports to 9 months
337
Delayed to 9 months
Depends on how do in PT--follow delayed protocol as above--ultimately probably marginal difference in return to
sports--do mostly autograft in all comers (mainly slower rehab more so than slower return to sports)
338
51 | P a g e
339
Depends on patient age. Typically 8 months for auto. 2-4 weeks longer for allograft.
340
Depends on quad strength. Usually 6 months for autograft and 9 months for allograft.
341
depends on return of quad strength for autograft, any where from 4 m on if strength is normal for quad and full rom for
allograft it is at least 6m
342
343
depends on sport for contact or high-demand sports in general autograft 8 months but only when meets other criteria
allograft 10 months
Different for everyone but earliest for auto is 6 months, earliest for allo is 9 but I will stretch it out to one year unless
they need to get back
344
Earliest at 6 months for autograft, earliest 9 months for allografts.
345
error i allow both back at 6 months
346
For allograft patients typically by 6 months but dependent on meeting milestones of rehab program. I do not use
allografts for my primary cases, but in my revision cases I will allow them to return to full play by 6 months provided
the patient has meet milestones of rehab program.
347
Full return to sports is at 6 months (with a derotational brace)for allografts instead of 4 months. Brace wear continues
for 24 months instead of 12 months.
348
Generally it is 6 months before contact sports with all ACL reconstructions assuming that they are doing well with core
stability, strength, and full range of motion and no swelling or pain. Occasionally, if someone is doing extremely well
with a patellar tendon autograft, I will let him participate in some sports like baseball is early as 4 months realizing that
they have a higher risk of reinjury according to some studies. This is discussed with the patient and family.
349
generally the same for both, when rehab-is optimized, fully confident, somewhere between 6-9 months , but generally
delay the allografts towards the 9 month mark
350
Have strength and functional test performed at 5 months for auto and 6 months for allograft. Can return when
functional 90%of opposite side.
351
Historically 4-6 months for autografts. I have slowed it down to 9 months, over the last year, secondary to data and
expert opinions at the AOSSM meetings last year. I have historically held allografts to 9 months or later, due to slowere
remodelling concerns.
352
Hop test earliest at 6 m autograft, 9 m allograft
353
I haven't done an autograft in more than 15 years, so I don't know
354
I suggest to them that we take more time
355
If quads rehabbed adequately - autograft at 8 months allograft at 10-12
356
In general 8-10 months vs 4-6 for autograft (both pending functional rehabilitation measurements)
358
In higher level athletes I'm far more likely to recommend autograft and let them return at minimum 6 months with
appropriate clinical improvement. If I chose allograft for those patients I would probably recommend delaying RTP by a
couple of months.
light sports (no contact) at 6 months and full sports (contact) at one year
359
longer
360
Longer
361
Longer for an allograft
362
Min 6 months for autograft, typically min 8 months for allograft
363
min 9 months
364
minimum 9 months
365
more around 6 months if they are young, FROM, no effusion, neg pivot, no guarding, able to squat and side-to-side
hop.
366
Must wait one year (compared to 6-9 months for autograft) to return to sports
367
My autograft ACLRs are release at 6 months. IF I used an allograft i would delay return to 9-12 months postop
368
Not before 6 months for auto, not before 8-9 months for allograft
369
Not until a yesr
357
52 | P a g e
370
one year
371
Return to athletics at 6 months for autograft and 9 months for allograft (if quad strength and hop test are adequate).
372
return to play is based on functional testing for both patients but I typically am more conservative with the allograft
patient
373
Return to play is suggested no earlier than 10 months, but usually around 1 year.
374
return to unrestricted sports at: 10-12 months after surgery for allograft 7-9 months after surgery for autograft
375
running: 3 mths auto, 4 mnths allo. cutting: 6 mths auto, 8 mths allo
376
See above
377
Six months for autograft patients, eight to nine for allograft.
378
Slow them down
379
380
Slower
slower for allo
381
Slower return to impact, jumps, sports (9 months for allograft, 6 months for auto)
382
Sport specific gradual increase to prepare for RTP at 6 months with auto, a month usually behind for allograft but pt
specific. Warnings of decreased chance of full incorporation has been discussed.
383
These are generally my older patients and thus they are not rushing back for a season. I typically recommend 9-12
months to return.
384
This is typically delayed by 3 months or so
385
Timing of return is dictated by appropriate progression through rehabilitation program: typically 6+ months for
autograft vs 9+ months for allograft for return to high-demand/unrestricted sports
386
Ultimately it's determined by the results of patient's functional testing, but generically 6 months for autograft and 9
months for allograft.
387
Usually I use allografts for revision surgery, and typically I recommend longer time for return to full play in this
circumstance (usually 9-12 months postop).
388
Variable depending on function
389
When quad and hamstring strength is within 15% of other leg and I will observe game situation practice.
390
When there is equal quad girth measurement and 80% strength measurement on Biodex machine. Usually not sooner
than 6 months with autograft and not sooner than 10 months with allograft.
391
392
When they are strong enough, usually: Auto-9 mos Allo-11 mos
Yes by 3 months
Q8 Follow up D1 – verbatim) You indicated that you feel knowledgeable concerning the true amount of
irradiation required to completely sterilize (i.e., eradicate everything including spores and viruses) allografts
used for ACL reconstruction.
What level is required: _____ mRAD
1
?
2
?? not sure
3
.5
4
>1
5
>2.0
6
>3
7
>3 is required which is above safe level assumed to be 2.5. But I personally think that it takes a lot more than 3 mrad
and then you throw in the word "completely" and I don't think that it can be done at a level that doesn't damage the
graft tissue. This is one of the reasons that I don't use allografts unless I lack other tissue or have s strong request from
the patient who is informed of the risks.
8
>3 rads but decreasing structural integrity
53 | P a g e
9
>3.0 to kill viruses but this can weaken gradt when >2.5
10
>3.5
11
>3.5 mRAD
12
>5
13
>7-9 mRAD (>5 is too high--leads to loss of biomechanical properties of the graft--I won't accept graft irradiated at 5 or
greater)
14
0
15
0 I do not use iterated grafts.
16
0- ie not required
17
1 (Indicated 3x)
18
1-2.5 mRad for low dose, 3-5 for everything
19
1.2 (Indicated 2x)
20
1.5 (Indicated 6x)
21
1.5 mRads-2.5mRads
22
1.5 to 2
23
1.5 to 2.5 mRads
24
1.5-2.5---Depends on the study
25
1.8
26
10 (Indicated 3x)
27
100
28
1000 (Indicated 2x)
29
15
30
2 (Indicated 8x)
31
2 mRAD is the max before significant damage to the graft occurs. However, even at this level the graft is not sterile. I
believe the dose for 100% sterility is 4 mRAD.
32
2-2.5
33
2-3 (Indicated 2x)
34
2-3 mrads
35
2-5
36
2.0
37
2.5 (Indicated 39x)
38
2.5 MRAD
39
2.5mRAD
40
20 (Indicated 3x)
41
20 -30 kGy
42
2000
43
25
44
250
45
25kGy
46
3 meg
47
3-4
48
3-4 mRads
54 | P a g e
49
3-4.5
50
3 (Indicated 29x)
51
3.5 (Indicated 2x)
52
30
53
300
54
3000
55
35 kg gray
56
3500
57
35kGy
58
3mRads to get everything
59
4 (Indicated 24x)
60
4 mRAD (Indicated 2x)
61
4 mRad for HIV
62
4 Mrad to eradicate everything
63
4 or more
64
4-5 (Indicated 2x)
65
4-5. I do not recommend using irradiated allografts. The literature is difficult to interpret due to many Level 4 evidence
retrospective studies. However, there is a growing body of literature demonstrating superior outcomes with fresh
frozen grafts compared to irradiated grafts. This is further supported by a growing body of literature using less and less
irradiation where the recent published studies out of Rush using 1.2Mrad has little effect on biomechanical properties
and biologic incorporation in a rabbit model. I believe we will come to find sterile aseptic processing eliminating
radiation will provide the best results with allograft tissue
66
4.0 (Indicated 2x)
67
4.0 However this destroys structural integrity of the graft and thus I request un-irradiated allografts only
68
4.0 mRAD
69
4.1
70
4+
71
40
72
4mRAD for everything which makes the graft very weak
73
4mRads
74
5 (Indicated 14x)
75
5 mrad.
76
5 to eradicate ALL
77
5-10
78
5-6 mRad
79
5-8
80
50 (Indicated 2x)
81
500 (Indicated 4x)
82
5000
83
6 (Indicated 4x)
84
60
85
7
86
70
55 | P a g e
87
80
88
Above 3.5
89
above 4 mRad
90
Allograft can never be completely "sterilized," but it can be aceullar. I prefer low-dose irradiated grafts of 2.5 mRAD or
less when using allograft in order to prevent decreasing the tensile strenght of the tissue
91
approx .2 mRad
92
Appx 3.5
93
at least 2.5 for bacteria i believe greater than 3 for viruses I USE ONLY FRESH FROZEN ALLOGRAFTS FROM DONORS
AGE LESS THAN 40YRS AND AT LEAST 9 MM IN CROSS SECTIONAL DIAMETER GRAFT MATTERS REASON FOR
URBAN MYTH OF ALLOGRAFTS IS POOR QUALITY OF TISSUE AND SMALL SIZE WITH LESS THAN OPTIMAL FIXATION
94
at least 4
95
busted
96
can't say without looking up again.
97
Cant recall, bu it is quite high for complete sterilization.
98
dependant on whether you are also using additional chemical sterilization 6- high level irradiation with mechanical
effects on graft 3- mod irrad low level irrad usually about 1mRAD but with additional chemical sterilization
99
Depends on load, at least 1-2.5 mRAD
100
don't know that, but feel any irradiation is deleterious to graft; use mtf non-irrad grafts only
101
Don't know.
102
dont know
103
Enough
104
greater than 4. In otherwords, the graft would have to be fried to the point of uselessness to truly make it sterile.
Therefore, I request non-irradiated allografts whenever they are available.
105
Greater Than 5 megarads
106
I can't tell you this AM. However, our graft source (Allosource) which is a division of UNYTS uses the NTB standards
which are essentially the same as MTF.
107
I know what the literature says; are those studies accurate; I don't know that for sure.
108
I only use non-irradiated allografts (Achilles Tendon) age matched to the patient.
109
I thought that I answered the opposite
110
I would have to look it up but I think 2
111
I would prefer less than 1.8 mRADs based off of FA Barber studies.
112
less than 2.5 mRad
113
less than 2mrads
114
less then 2 MRADS...even that is too much...no irradiation...think e Beam?
115
More the better
116
N/a
117
Needs low dose irratiation.
118
None
119
over 1.25 x 10 to the 6th rads
120
over 2
121
radiation is not required
122
Sterilization is a probability function and chance of complete sterilization is dependent on amount of contamination.
Higher dose, less chance. 2.5 mRAD is commonly used dose to decrease chance to less that 1 in 1000000 (standard
acceptable reduction for medical products ), which assumes a low level of contamination,
56 | P a g e
123
The level is unknown, but too large to be considered
124
The level required to 'sterilize' a graft of spores will destroy the effectiveness of the graft. Any irradiation above
2.5mRADs creates a graft that should not be used. There is no truely sterile allograft that has the structural sufficient to
provide good outcomes. Conseqeuntly the recovery of the graft material should be within 12 hours and done in a
sterile environment. AATB standards are a bare minimum and caustic chemical or irradiation are contraindications for
my use of a graft. I use MTF grafts exclusively.
125
This is dose dependant
126
three
127
use RTI which doesnt use radiation
128
x
129
zero i only use non irradiated grafts
Q9) What level irradiation do you believe is harmful to the biomechanical/physiological properties of the graft?
N
Valid
Percent
CI
Lower
Upper
Any degree of irradiation is harmful
260
31.8
3.194
28.63
35.02
Low dose irradiation (1.0 - 1.2 mRAD) is not
harmful but higher levels are
339
41.5
3.379
38.11
44.87
Medium dose irradiation (up to 2.5 mRAD) is not
harmful but higher levels are
197
24.1
2.933
21.18
27.05
21
2.6
1.085
1.49
3.66
817
100.0
Higher dose irradiation (up to 5.0 mRAD) is not
harmful
Total
Q10) Do you believe that some level of irradiation is essential for allografts used in ACL reconstruction to
eliminate pathogens?
CI
Lower
Upper
281
Valid
Percent
34.1
3.237
30.87
37.34
135
16.4
2.527
13.86
18.91
No, non-irradiation sterilization processes are able to achieve
acceptable levels of sterility
172
20.9
2.775
18.10
23.65
Not sure
236
28.6
3.087
25.55
31.73
Total
824
100.0
N
Yes
No, the donor screening processes and nucleic acid amplification
testing (NAT) currently used by processors is sufficient to all but
eliminate the risk of disease transmission
Q11) Do you use allografts for ACL reconstruction that have been irradiated?
N
Yes
No
360
295
Valid
Percent
43.5
35.6
CI
Lower
Upper
3.377
3.262
40.10
32.37
46.85
38.89
57 | P a g e
Not sure
173
20.9
Total
828
100.0
2.769
18.12
23.66
Q12) Who provides most of the allografts that you use for ACL reconstruction? (Check all that apply.)
Frequency
Valid Percent
122
146
335
147
154
15.0
17.9
41.2
18.1
18.9
73
9.0
Allosource
LifeNet
MTF/ConMed
RTI
Not sure
Other
Q12 Other – verbatim)
1
100% Allosource since 1986
2
AATB source
3
Alamo (indicated 2x)
4
Arthrex
5
Arthrex (perhaps through one of those sources)
6
Arthrex vendor
7
Arthrex/ATSI?
8
Bacterin
9
can't remember
10
Community
11
Community tissue
12
Community Tissue
13
community tissue bank
14
community tissue services
15
Community Tissue Services
16
Community Tissue Services of Dayton, Ohio
17
cts
18
dci
19
DCI
20
DCI - by med center contract, not doctor decision
21
DCI Donor Services (indicated 2x)
22
DCI from Tn
23
DCI Tissue Services
24
Depends on hospital vendor agreements
25
Do not use
26
don't use
27
dont use
28
Eurotransplant Leyden
29
Hema quebec, Halifax
30
Hospital das Clínicas (São Paulo/Brazil)
58 | P a g e
31
hospital recently switched
32
I do not use allografts, so do not weight any statement about use of allografts in my answers
33
I don't use allografts
34
I don't use allografts for ACLR
35
I don't use any
36
I have checked this, think it is Allosource, but don't recall with certainty
37
I haven't used one in years
38
Life link
39
lifelink
40
Lifelink (indicated 3x)
41
42
LifeLink (indicated 3x)
local Community Tissue Bank
43
local distributorship
44
miami
45
Miami Soft tissue Bank
46
Miami tissue bank
47
Miami Tissue Bank (indicated 2x)
48
mt sinai toronto
49
MTF
50
N
51
n/a
52
none
53
NW Tissue Bank
54
NW tissue center
55
Ohio Bank
56
Our own regional tissue bank
57
58
Queensalnd Tissue Bank, Australia
R and M distributing
59
60
Red Cross
Smith & Nephew
61
62
63
Source dictated by hospital
tissue net (indicated 2x)
TissueNet
Univ of Miami (indicated 3x)
64
66
University of Miami Tissue Bank (indicated 2x)
Victorian Tissue Bank (Australia)
67
68
Was Northwest Tissue Center, bought by Lifenet.
Whatever the hospital arranges
65
Q13) Do the allografts you use for ACL reconstruction come from a tissue bank that is approved by the
American Association of Tissue Banks (AATB)?
N
Yes
No
715
7
Valid
Percent
87.4
.9
CI
Lower
Upper
2.274
0.631
85.13
0.22
89.68
1.49
59 | P a g e
Not sure
96
11.7
Total
818
100.0
2.206
9.53
13.94
Q14) Have you personally researched the safety track record and clinical results of the tissue bank from which
you get allografts?
N
Valid
Percent
42.5
CI
Lower
Upper
3.374
39.17
45.92
3.374
54.08
60.83
Yes
No
351
474
57.5
Total
825
100.0
Q15 - verbatim) Please use the box below to provide any additional information, thoughts, questions, and
concerns you have about allografts for ACL reconstruction.
1
1. Industry leader 2. Low-dose irradiation 3. Long trouble-free track record
2
After recently reviewing our 10 year data of primary allograft acls using only MTF grafts, I will no longer offer allografts
to patients under 30-35 for primary reconstructions. Under our ideal circumstances, failure rate is around 30 percent
for young folks!
3
Allgrafts are safe to use as long as you are not using soft tissue only grafts. BTB allografts have great outcomes.
4
Allograft sources frequently change based on institutional prices. I do my best to keep up with what is currently being
used but must confess that sometimes I use them without knowing the details of the graft and its preparation. Unless
the patient is a relatively low activity level and more advanced age, I make every effort to use autograft. My mean
primary ACL reconstruction age is between 20 and 22 years old. Most revisions I do had primary ACLs with allograft.
5
allografts in primary ACLR when >40 y/o. Mutliple graft sources, confuses the issue.
6
Allografts are good as long as not irradiated. PRP "not proven" adds benefit to healing.
7
Allografts are overused. Increased costs, increased failure rates justify their use in limited situations
8
Allografts have been shown in meta-analyses to provide poorer results while at the same time being expensive. The
tissue bank reps however are very aggressive in pushing allografts for their own profit, and provide skewed date to
surgeons. They should only be used in special circumstances. The only rationale for using them is that the surgeon is
not comfortable with the use of autografts: which is not a good reaosn. Numerous studies have also shown delayed
allograft incorporation (e.g. Sheffler from Berlin in a large animal model)
9
Allografts should not be used
10
Almost never use allograft
11
As a resident we collectively researched MTF As an Attending I did a less thorough research process on RTI based on
their own reported data
12
Avoid if possible. Respect pts choices though if they insist. Give info
13
14
Because we are now reconstructing ACLs more anatomically, the graft experiences more strain early on in the rehab
process, as opposed to ones placed nonanatomically. For this reason, I feel more allograft ACLRs fail early.
Being part of Mayo Clinic Health Systems - we are required to use AATB approved tissue banks. This is vital to assuring
the sterility and safety of the allografts.
15
Best option for women over 40,low-demand patients and revisions
16
can be difficult to assimilate the important data on allograft usage and apply to everyday practice. a regular update on
latest data and recommendations for safest and most effective allograft usage would be helpful
17
Currently only using for augment when hamstring autografts are used and are smaller than 8mm
18
Do not use allografts; HIV was transmitted pre 1984 from blood transfusions when the HIV virus was not yet known. I
am afraid that there are potential pathogens (prions, etc.) that are not testable that are potentially present in allografts
that we do not yet even know exist.
19
don't use allografts
60 | P a g e
20
Failure rates among allograft , I believe, is NOT due to nature of graft but due to premature return to activity with
inadequate restoration of quads and hamstring proprioceptive strength that results in re injury with subsequent re
tear. Reason for premature return to high level activity is secondary to false belief that they are already healed because
patients post allograft have very little pain and are able to achieve excellent motion much earlier than autograft. I have
had no failure in all comers since I do not allow return to high level activity until at least 9 months when there is
excellent muscular strength and control and brace for first year with sports.
21
For years I was in a major medical center and the allografts came from either MTF or Biocleanse. Now I practice in a
small community hospital and have not used allograft yet and am not sure of the supplier.
22
Glad to participate in this survey
23
graft cost, sterility, and disease transmission, are the primary reasons I dont use allografts regularly
24
graft properties is only one possible reason for failure. I think the failure mode is always speculative.
25
have no concerns regarding the safe use of allografts for primary and revision ACL reconstruction in patients older than
30 yo age. My biggest concerns relate to the indication for the use of an allograft in elite athletes, or primary ACLR in
pts younger than 30 yo age or revision procedures where a failed allograft was used during the primary reconstruction.
I have been using allografts in more than 90% of my patients for the last five years with only one serious adverse event
which not related to the use of the allograft. Literature review seems to suggest similar outcome in the general
population. However, the orthopedic sports medicine community seems to be unable to find a common background on
this topic, yet. Cost-related issues of an allograft need to be taken in consideration, too. The latter seems not to be a
discriminative factor in Academic practices but it is definetely a burden in the private sector. I would like to see clear
cutting-edge information in th e literature from metanalysis of RCT studies regarding outcome and complications of
allo- and autografts and, more important, specific recommendations from the AOSSM applicable to different scenario
(primary, revision, occasional athletes, collegiate or professional athletes, age, sex etc) based on the general consensus
from panel of experts.
26
HIV transmission has always been a concern, but with CRYOLIFE failure in 90's- other disease transmissions a concern.
Improved cleansing techniques very beneficial and have alleviated my concerns. Even though studies have not shown
it, I believe age of graft is important also.
27
I accept the limitations of the cleaning and irridation and attempt to limit the usgae when I can. However, there are
situations where an allograft is a good option so choosing grafts with limited irradition is the best I can hope. However,
the disease risk is still there as high dose radition--the amount required to eliminate HIV/Hep C--grafts have too high a
failure rate in my opinion.
28
I am a poor one to ask since I never bought into Allografts because of skepticism that they were not as good as Dr. Fu
said. I just never felt the benefits outweighed patella tendon autograft. Of course recent literature has almost proven I
was right!
29
I am interested in using them more often and hope we can improve the stregnth
30
I am very skeptical of an unregulated industry dealing with human body parts
31
I believe Irradiation and many of the sterilization processes used for Graft sterility are detrimental to the mechanical
and structural properties of the grafts. However I believe the primary reason for allograft failure In some studies has to
do with graft choice, surgical technique and poor fixation device choice. I have not had major issues with graft failures
in patients undergoing acl reconstruction even in younger higher level athletes. However I am continuing to stay up-todate on the literature, following studies, and give consideration for practice changes if the data clearly supports
switching back to autograft.
32
I believe most of the failures in younger people are due to too aggressive of a rehab. minimum 9 months of rehab.
really stress squats in the younger population. Dramatic increases in quad and buttock muscles are to key to good
rehab.
33
I believe much of my success with allograft has been due to the way the tissue has been processed. Avoiding radiation
is important to me.
34
35
36
I can not justify the cost and risks of routine use of allograft for questionable/soft benefits (cosmetics, early postop
pain).
I chose several years ago not to use allografts unless my patients tell me otherwise, but i review with my pts the pros
and cons of allograft use and always agree to use their own tissue. If it is a revision and they hve no options on the
ipsilateral side i will harvest from the other leg with no cases of morbidity.
I discuss allograft with my patients but most don't want them
61 | P a g e
37
I do not use allografts for primary ACLs in competitive athletes.
38
I do not use them for primary at all and would be very reluctant even in revision
39
i do this so rarely but when I do I do check on the sterilization process but not the tissue banks track record. I rely on
the orthopaedic coordinator to give met he information
40
I don't believe they have broad indications in my practice. More selected indications. I am 48 yo and if I had an ACL
recon I would think I am the perfect demographic for the allograft, but if I wanted to get back to sports earlier, I would
still have a hamstring autograft.
41
42
I feel the primary cause for allograft failure is the early return to activity and increased stress on the graft due to less
pain and trauma to the joint. Those that follow protocol do well. Younger age patients are not compliant.
I generally use autograft for all patients under 30. For all patients I discuss the risks and benefits of both depending on
their age and activity level and allow them to decide what they think is best for them.
43
I have a detailed discussion of options risks and benefits with each patient.
44
I have a general algorithm for choosing which graft I use. In a young patient less than 25 years old I use Bone patella
Bone Autograft unless the patient has Knee pain, then I use Hamstring Autograft. If the patient is older than 35, then I
use Hamstring Allograft. For kids with open physis within a year of Closure I use Hamstring Autograft as well. For
patients between 25 and 35 I present the options and let the patient decide. If any of my patients feel strongly about
the graft type they have the ultimate choice but I do review the pros and cons with them.
45
I have a partner who does more allo than I and has done the research regarding the bank we use , etc.
46
I have always been a B-PT-B autograft surgeon
I have been in practice for over 30 yrs .Fellowship trained in sports medicine. I have used primary repairs, extra
articular reconstructions,gortex grafts, Dacron grafts, xenografts, LAD grafts,auto grafts bone patella bone
,hamstring,iliotibial band,quadriceps tendon. Allograft fresh frozen freeze dried irradiated, no irradiated & chemically
sterilized Achilles ,bone patella bone, hamstring ,anterior & posterior tibialis tendons. My best results have been with
chemically sterilized posterior tibialis tendon double looped.
I have found them safe. Tissue quantity usually is excellent. Quality is another issue and I will not implant a graft from
donor over 40 years old, this is anecdotal with my practice but I have seen some very poor appearing tissue in older
donors
47
48
49
I have gotten away from allografts secondary to high failure rates and several rejections
50
I have had no allograft failures in my practice, and very rare autograft failure. I do think that it is important to give the
grafts time to mature, and I suspect that the presence of host cells and lack of storage in the graft allow faster
incorporation of autografts. I suspect that market forces lead surgeons to allow return to sport too early, but most of
the revisions I do are due to inappropriate graft placement, not tissue type.
51
I have had poor results with soft tissue allografts compared to my autografts in my clinical practice for patients younger
than 25
52
I have moved toward using allografts significantly less in my practice. I implanted BTB Allografts as a primary graft in
"all comers" during 2011. Since then, I have noted a 25-30% re-rupture rate during that short term follow up.
53
I have never trusted allografts because of the risk of disease transmission and the fact that the early animal studies
show delayed healing of allografts relative to autografts.
54
I have not noted any significant donor site issues even in older patients when using hamstring autografts.
55
I like the Achilles tendon for the ACLR. I have used it for at least 15 years with no failures. The youngest patient was a
16 year old girl, competitive soccer player that went on to resume her career and went to college with a scholarship. I
have not used a double bundle graft, I feel it's not necesary, the donor site is painful, not cosmetically pleasing,
recuperation is slower. Before I went into the Achilles tendon I did use the patient's own patellar tendon. There is much
more pain and in women the cosmesis is important.
56
I never use allografts. Hamstring tendon autograft has worked well for me since the early 1990's.
57
I now have concerns about allograft ACLR in younger patients, whereas previously I did not.
58
I personally visited the MTF facility in Edison NJ and was briefed on the process. It required a trip from Dallas to do this
but I felt that was needed since there is such confusion among clincians and many conflictinng claims are being
published. Some of these misconceptions are reflected in how the questions of this survey were composed.
59
I prefer to use MTF non-irradiated grafts. Sometimes, surgical centers or hopsital have other vendors.
60
I really don't use allografts
62 | P a g e
61
I reserve the use of allografts for patients over the age of 45 and only if they insist on the use of an allograft. I typically
insist on the use of autograft; routinely BTB autograft. when performing double bundle reconstructions, I use an 8mm
BTB autograft for the AM bundle and a single hamstring for the PL bundle
62
I talk young patients out of allografts all of the time, citing available literature (especially MOON study). Many other
surgeons in my area use allografts more often. I revise several of them, but most of those failures also have tunnel
issues.
63
I tend to use them for lower demand athletes and revision cases
64
I think that graft variability (all of the variables that you have brought up) is a big reason that we have had such
variability in allograft outcomes studies
65
I think the grafts and outcomes should be compared by type, sterilization process, rehab protocols, fixation methods,
notchplasty, gender, and age of patient.
66
I think they are overused by many
67
I trained using many allografts in my fellowship, so I did many when I started my practice. Way too many re-tore with
minimal trauma. So I published my results and presented at the academy meeting. I my results were published too
soon before everyone else figured this out. I was soundly criticized. Allografts are a complete scam and they often fail.
They should not be used often. Now I just use hamstrings for my patients that want an easier recovery or smaller scar.
An all inside single strand quadrupled hamstring is much better than an allograft for an adult non-athlete. The athletes
need BTB!!
68
I use age 40 as a cut off. Under age 40 I always recommend autograft PAT. Over age 40 I recommend allograft. Under
age 40, I will do allograft if significant other damage to the joint/post traumatic arthritis. Over age 40 I will do autograft
if patient desires it. I am appalled that any of our colleagues are doing allograft primary ACLs in young athletes. I
believe that they do it for marketing purposes (less pain and quicker rehabilitation). 20% fail in young athletes.
Perhaps that allows them (the ortho docs) to do 20% more cases.
69
I use allograft so infrequently I no longer recall the tissue bank that we use. My total in 16 plus years is 4 allografts, last
used more than 5 years ago. I reseasrched the safety profile when I began practice in mid 90s.
70
I use allograft tissue that is non-irradiated only, age-matched to the age of the patient (+/- 5-7 years), no harsh
cleansing, and no female donors for male patients. I have found that these restrictions provide comparable results to
autograft hamstring, which is my autograft of choice. Lifenet irradiates, and RTI uses a detrimental cleansing process.
71
I use almost no allografts - only for revisions or if requested
72
I use grafts that are sterilized using supercritical CO2
73
I use only not for profit tissue banks.
74
I use RRi grafts. They have a proprietary cleansing process. Howver, they have had some unfavorable media attention
recently. After doing some investigation, I have continued using their grafts. I have impanted >100 without an
infection. Regardless, the process of choosing a vendor is difficult and I do not feel that I have satisfactory or guidance
from AAOS, AOSSM or AANA to make an educated decision
75
I use very few allografts.
76
I was trained to use allografts in fellowship - prior to that, in residency, I had never used them. In my practice, I give the
patients the choice every single time. And most times, they select allograft. My use has not changed over the years,
but I see that my peers use them more and more. In my practice, I am unable to tell the difference in stability or
outcomes between my allo- and autograft reconstructions. I think it would be useful for you to focus on overall
infection rates - the risk of infection from allograft graft vs. host disease is much smaller than the reported infection
from local skin bacteria that seeds an autograft. This is much more clinically significant because it is perhaps a factor of
100x greater.
77
I will only use one if I have to
78
I would like to see more series of non-irradiated allografts reported in the literature.
79
i'd love more education on this stuff!
80
I'm having good to excellent results with a very low failure rate using nearly 100% allografts for ACL reconstruction!
81
In Australia access to non-irradiated soft tissue allograft is very limited. As such use of allograft is much lower than what
I experienced when doing my fellowship training in the US (Duke University)
63 | P a g e
82
In general, I try to avoid the use of allografts for ACL reconstructions. I will use allografts for revision and multiligament
cases as needed.
83
In my humble opinion non-irradiated Achilles tendon Allografts, aged matched to the patient undergoing the
reconstruction have worked well in my practice with zero failures thus far since 2005 (although we never know for sure
if the patient goes elsewhere). My fellowship attendings have used the same grafts since the 1980's and 1990's with
excellent results. I use grafts from the University of Miami bone bank. I brace my patients for sports for 18 months to
allow the graft to incorporate. In 2009 I switched to anatomical tunnel placement from transtibial (single bundle still)
and results have not changed. I use metal interference screw (S&N Softsilk) in femoral tunnel (bone plug from
calcaneus) and washer lock system (Biomet Sports) in tibial tunnel. My patients ages range from 14-15yo to mid 40's.
Football, Soccer, LaCrosse, Basketball, weekend warrior). Hope this helps. No graft vs. host nor host vs. graft reactions,
no infections, thus far. BP
84
interested to hear the findings; please keep me posted!
85
Irradiated allografts have been successful in my practice with over 30 year old recreational athletes with 9 months of
protection from rtp. There are legal concerns about an infection occurring in a pt with a non sterile graft, even though
they may be unfounded
86
Its not clear what pocessing is performed on allografts. We get fairly limited info from companies including from
brochures and reps... I steer toward auto on all comers including rec athletes.. and lean towards allo on almost all
revisions.. more options w/allo esp. w/defects on revision.. more of my pts are younger resulting in more getting auto
particularly BPTB
87
know your tissue bank...
88
LIke ilicit drugs, I just say no to ACL allografts. Sorry I can be of more help
89
Looking at switching suppliers currently. Leaning toward using non-irradiated grafts when allograft use is chosen.
90
Many of the late failures that I have had were large tubularized achilles grafts.The center of the grafts seen at the time
of revison appeared completely avascular. Have switched to Tib ant grafts. I wonder if the multiple strands and
increased surface area lead to better incorporation.
91
Morbidity of donor site for a single hamstring (4 strand semitendinosis) that my use of allografts has dropped. Hard to
justify a documented higher failure rate with allograft
92
most of the questions are too simplistic. for example, I do use different allograft tissue for revisions depending on
whether there is tunnel widening or not
93
MTF does a good job of working with us and tissue quality is high.
94
My confidence in allograft reconstruction continues to decline. I use them primarily for revisions but am considering
more use of autograft for revision as well.
95
My lack of control over the allograft is one reason I do not use it
96
97
98
My major concern with allografts is their ridiculous price. I get pretty good results with not much pain and quick rehab
using auto, even in older folks.
My opinion is that allografts should not be used in primary ACL reconstruction in young athletes. If the failure rate is
even only 1% greater,, it is unacceptable for a young athlete. We know that autograph reconstruction works at a high
percentage. Any young athlete should be able to overcome Any graft site morbidity.
My practice is to use autograft bone patellar tendon bone tissue if at all possible, including harvesting from the
contralateral knee encases of autograft failure.
99
My review of published literature regarding increased failure rates with allografts indicates that with appropriately
modified rehab protocols and delayed return to sports, allografts can have excellent outcomes -- if and only if the
biology is respected. Patients have to know this and agree to abide by these rules before I will utilize an allograft. In
choosing patient's appropriately, I have been very pleased with my allograft outcomes as have my patients.
100
my surgical center takes care
101
my true answers don't fit neatly in your multiple choice questions
102
NEED LARGE GRAFTS FROM YOUNG DONORS WITH NO STERILIZATION {CHEMICAL OR RADIATION}
103
Need to pre stretch after prep to remove creep prior to placing by using tension board
104
none
105
None
64 | P a g e
106
not done many ACL in 2012 usually do up to 10 per year, only use allograft for multiligament and if patient desires
after lengthy conversation and for revisions.
107
one of the only times I use allografts is to augment hamstring autografts of a diameter of less than 8 mm in an average
sized patient.
108
our hospital estbalished an annual review of our tissue bank acreditation and adverse outcome data. Although I dont
know it by memory it is monitored.
109
Our hospital tissue bank monitors and selects the source of allografts.
110
overall concerned higher failure rate with tibialis tendon allografts have moved towards Bone tendon bone for
allografts as they are stiffer and I think stretch out less
111
patients and their families are given the choice between allograft versus autograft after full risks/benefits/alternatives
reviewed by me. Most skeletally or near skeletally patients opt for the posterior tibial allograft due to significantly
shorter operative/anesthesia time, decreased collateral damage to other parts of the knee due to harvesting, better
cosmesis, improved pain profiles, less painful post operative courses, and in my practice no differences in outcomes.
All patients (auto and allograft ACLRs) are rehabilitated with bracing/CPM for one month, and PT for a strict 6 months.
An ACL brace is used to return to sports and is used at 6 months to 1 year postop. AFter one year, the patient has the
option to use the brace or not, and has no restrictions. I am in a group of 3 FT Peds Orthopedist with 100/cases per
year and have had no problems with allograft. We are worried that this trend to insist on autograft in younger patients
is misleading and has not proved clinically relevant in our practice. I am also concerned about harvesting autografts in
young patients (hamstrings and BPB, etc) and not knowing if there are any longterm effects yet to be realized.
112
patients have less post-op morbidity and return to work quicker with allograft
113
Personal experience has shown inferior results with allograft and much higher retear rate.
114
please let me know the results
115
probably should check more about the company sterilziation techniques
116
Recently joined group. Allografts kept in house, not sure of prep.
117
Recently switched from RTI after co tamination in plant
118
Results are inferior with higher failure rate compared to autograft
119
RTI fails frequently and have stopped using them. Possible to insert larger patella tendon width with allograft compared
to auto graft 10-12mm harvest maximum.
120
See Lawhorn et al. Arthroscopy Aug 2012
121
Studies Re. allografts vs autograft have tended to speak generically about allografts without specifying size(eg 1/2
patellar tendon maybe used instead of 1/3 tendon),type of tissue used,or how its prepared. I have had success rate
approaching, if not comparable to autografts in collegiate athletes without the donor site morbidity and with quicker
return to competition without the high injury rate that national literature and theory Re. delayed graft incorporation
would seem to indicate. Since I have been using allograft 50% 0f the time since 1987 I tend to be skeptical about
national literature's high allograft failure rate and need to delay return to sport in view of my own clinical experience;
although, I always advise my patients that literature points toward autograft as the superior graft if one discounts graft
donor site morbidity.
122
Tend to use autograft. With allograft as back up. I have a graft available that does not cost unless used, other
companies charge for delivery even if it is not used
123
Thank you for doing this! I will be very interested in your results.
124
The aaos and the aossm need to condemn the use of allograft for high school/college and high demand athletes. It is
an inferior graft with too high a failure rate and our patients are being harmed. Too many surgeons use allografts
because its faster and they can "advertise" lower morbidity and quicker rehab.
125
The clinical use of allograft vs autograft assuming no radiation >2.5mRad and no proprietary chemical or other
processing should be determined by the data which means high school and college level should not use allograft on
primary ACLR. The data from MOON (LOEI) and military academies, and Barret db and peds show very significant higher
failure that is clinically relevant in young patients and high demand! Revision MARS will determine auto vs allo in next
year
126
The hospital contracts with DCI. I do not agree with these and infact have sent back a few grafts because I thought they
were of inferior quality. If a young athletic patient insists on allograft, I will usually use a BTB allograft from RTI (non
irradiated). otherwise, for the weekend warrior 30-40 something, the DCI allografts are usually fine.
65 | P a g e
127
The literature that depicts allografts having a poor success rate is mostly flawed due to variables such as lack of
documentation relative to graft processing as well as usage of irradiation...
128
The most common cause for graft failure is return to activity too soon (doing too much too soon).
129
The number one reason for any ACL failure is surgical technique Regardless of the graft, if it isn't done properly, it will
have an increased incidence of failure.
130
There are doctors in my community using allografts for high school athletes and showing unreasonably high failure
rates. I am frustrated with having to manage their poor results and hope this study can help protect these young
athletes.
131
There is no way that an allograft will ever match the biologic healing of an autograft. The question always has to be the
safety of the patient. I let my patient know that allografts are inferior, but there are advantages as well. The patient
should be as informed as possible. In my practice, all of the failures I see, from other doctors, is from hamstings. It
makes no sense to me that 4 strands are going to be perfectly matched with tension, and induce adequate
revascularization. I have seen my own auto graft BTB grafts, they look like native ACLs after 6 months, including full
synovial coverage.
132
There is no way to assess the graft prior being obliged to implant it.
133
These parameters are poorly documented in most studies including the MOON
134
they add significant cost to the procedure in the surgery center setting that cannot be absorbed by the institution. My
observation, over the years is that many surgeons that push allograft usage just plane don't like taking the time to
harvest an autograft; in other words it saves 30 minutes in the OR; is that good or bad?
135
They are used far too frequently in the wrong patients by surgeons who are too lazy or don't know how to harvest an
autograft. Anybody with even a casual knowledge of data knows they should not be used in most patients. Especially
the high school athlete. The failure rate of this operation even with autograft by the general orthopedist I bet is three
times what the literature shows. I would fear to know what it was when the average Joe Slams in an allograft.
136
they mostly benefit surgeon more than patient.
137
To lump allografts is problemmatic. Factors include bone bank, processing, age of donor and surgical technique. The
allograft may have a higher failure rate when the graft is not properly positioned. I believe that many allograft failures
represent suboptimal technique. All allografts are not created equal. Inour practice we see many tib ant grafts done in
the community as failures. Most BTB allograft failures seen in my office I can identify a technical component: vertical
femoral tunnel, posteriorized tibial tunnel. Of note with my revision experience I have 31/1806 primary acl R
personally revised through 3 /1012. Revision expereince includes 31 of my own and 150+ referred to my practice.
Thanks Important survey. BRBach
138
Too many allograft are being used.
139
Unfortunately we are at mercy of our hospitals and surgery centers to obtaining allograft tissue. I hope the evidence
does not come out that some vendors are unscrupulous.
140
use as absolute last resort, results are unpredictable
141
Use Tibialis Anterior Fresh Frozen Allograft (irradiated to <2.5-2.7 mRAD's) to augment Hamstring Autograft that size to
< or equal 8 mm; Will use BTB Allograft for revision ACL with BTB Autograft already harvested and pt declines
contralateral knee and will use BTB Allograft in patients >40 with lower demand life-styles.
142
Very important to discuss pros and cons of graft choice with patients preoperatively. I believe pros are easier early
rehab, normalization of gait, driving safely, and avoiding morbidity of autografts, with the trade-off for higher failure
rates in young/active patients (I avoid allografts in this group) and longer time frame for rehab/return to full sports
participation.
143
very rarely use allografts
144
We need a position white paper from the AOSSM regarding allograft use so that the insurances are not allowed to call
them experimental and deny their use.
145
We need a strong recommendation from AOSSM on this issue - what type of allogeneic tissue and with what
sterilization process is best?
146
X
147
you did not inquire as to the use of super-critical CO2 processing.
66 | P a g e
148
Your questions about "what source we would use for revision, when primary failed...it doesn't state what the primary
source was. If primary was allograft or hamstring, I would use Patellar tendon autograft. I answered assuming primary
was BTB autograft.
Q16) Are you a member of AOSSM, AAOS, or both?
N
Valid
Percent
1.3
22.4
CI
Lower
Upper
0.775
2.834
0.55
19.62
2.10
25.28
2.891
73.34
79.12
AOSSM only
AAOS only
I am a member of both AOSSM and AAOS
11
187
635
76.2
Total
833
100.0
Q18) How many years have you been in practice (if applicable)?
Completing Fellowship
0-5
6 - 10
11 - 15
16 - 20
21+
0
197
126
130
133
Valid
Percent
0.0
23.8
15.2
15.7
16.1
241
29.1
Total
827
100.0
N
CI
Lower
Upper
0.000
2.903
2.449
2.481
2.504
0.00
20.92
12.79
13.24
13.58
0.00
26.72
17.69
18.20
18.59
3.097
26.04
32.24
67 | P a g e
Appendix B: Survey Instrument
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Allografts for ACL Reconstruction Survey Report

Transcription

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