Revision ACL reconstruction, or re-doing the ACL surgery, is a technically complex procedure. There are many reasons for ACL surgery to fail, including technical problems from the initial surgery, biologic failure of the graft and traumatic re-injury. In some cases there is more than one reason for the re-injury. In view of the challenges involved in revision ACL reconstruction, Dr. Marx assembled a group of international experts in revision surgery to contribute to his textbook that was recently published. Click here to view the textbook.
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There are several options to choose from when selecting a graft for ACL reconstruction. Dr. Marx performs ACL reconstruction using autografts including patellar tendon, hamstring tendon, and quadriceps tendon, and he also uses allografts (also known as donor tissue or cadaver tissue). Each graft option has pros and cons.
Patellar tendon autografts have the lowest re-tear rate but can be a little more uncomfortable in the first few weeks post operatively. Dr. Marx tends to use this graft in younger patients returning to more aggressive sports such as soccer, American football, and basketball.
Hamstring tendon autografts have higher re-tear rates than patellar tendons, but the early postoperative recovery is a little easier for patients, particularly those who are not participating in aggressive, cutting sports such as the ones mentioned above.
Allograft tissue has a higher re-tear rate than either the patient’s own patellar tendon or hamstring tendon. In general, patients over 40-years-old have a relatively low re-tear rate, so allograft is often an acceptable option for those patients. Dr. Marx also uses allograft for revision surgery and multi-ligament reconstructions, where several grafts are required for the same knee at once. Allograft has an unacceptably high re-tear rate in younger patients (particularly under 20 years of age) and it is generally to be avoided in such individuals.
Quadriceps tendon autografts are also a viable option that Dr. Marx will use in revision surgery if the patellar tendon has been used previously and when it is preferred to use the patient’s own tissue to decrease re-tear rate or because the patient would prefer to avoid allograft. The main advantage of allograft tissue is that it requires less surgery on the patient (because the graft does not need to be harvested from the patient), and therefore the recovery is easier and slightly less painful.
In summary, there is no perfect graft, but there are several options, each with their own pros and cons. Dr. Marx believes that an individual decision should be made for each patient after considering the risks and benefits involved for each graft type.