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Other possibilities, though used less often, are the quadriceps tendon and iliotibial band. The quadriceps tendon autograft for ACL reconstruction is getting supported by current orthopaedic literature as a safe, reproducible, and versatile graft that should be considered in future studies of ACL reconstruction.
When it comes to decide in between auto or allografts Among the advantages of the autograft are faster integration to bone and no risks of disease transmission or immune reactions. Nonetheless, the morbidity at the site of extraction as well as the potential limitations of the size of the graft are worth discussing. Additionally, the use of autografts imposes a limitation in the advent that revision surgery is required. In these cases, ipsilateral BTB grafts are often the choice if it has not been previously used in the primary surgery; if it has, the contralateral BTB can be used. The repeated use of the BTB or of the quadruple ST-G have also succeeded, although there are doubts about the mechanical properties of the re-extracted autograft. For this reason, reuse is not advised in general.
Allografts are being used increasingly, in revision surgeries as well as primary surgeries. They offer advantages such as less morbidity, avoiding complications at the graft extraction site, a shorter surgery time and more options for choosing the right size and shape of the graft. Among the worries are the biologic integration, the risk of transmitting diseases, the availability and cost. Allografts tend to incorporate more slowly than autografts, which can prolong the rehabilitation process. Several studies have failed to identify significant differences between autografts and allografts at a one-year follow-up although, the recent literature has suggested that allografts may have a greater rate of failure in young athletic and active patients, with failure rates as high as 15 times more likely in the allograft group compared with the autograft cohort.
Of note, the recent literature has suggested that allografts may have a greater rate of failure in young athletic and active patients, with failure rates as high as 15 times more likely in the allograft group compared with the autograft cohort.
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PEARLS & PITFALLS – SURGICAL TECHNIQUE
When to Stage the Procedure
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We favor a non-staged revision ACL procedure whenever proper tunnel placement and stable graft fixation can be achieved. Two-stage revision surgery is often necessary in cases of tunnel widening, synovial fluid fistules through the tunnel or artificial grafts with severe synovitis. In such cases, a first surgery may be performed to remove remnants of the previously reconstructed ACL and place bone graft into the old tunnel. Tunnel widening occurs more commonly when using soft tissue or synthetic graft. This situation usually arises when the graft does not exactly match the tunnel width; it may have been diminished by using press- fit techniques or interferential screws that locked the graft as close as possible to its entrance into the joint in both femur and tibia; this prevents a windshield-wiper effect and the synovial fluid to ingress into the tunnel, enhancing graft incorporation.
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ISAKOS NEWSLETTER 2015: Volume I 15