Anterior Cruciate Ligament Reconstruction Using Achilles Tendon Allograft: an Assessment of Outcome for Patients Age 30 Years and Older

Abstract

Achilles allografts have become popular for anterior cruciate ligament (ACL) reconstructions in older patients. Primary ACL reconstructions using Achilles tendon allografts in patients age 30 years and older are successful in restoring the knee to “normal” or “near normal.” During a three-year period, the two senior authors performed 65 primary ACL reconstructions using Achilles tendon allografts in patients aged 30 years and older. Our exclusion criteria were periarticular fracture, ipsilateral/contralateral knee ligament injury, and previous or concomitant osteotomy or cartilage restoration procedure. Each patient was evaluated via physical examination, functional and arthrometric testing, and radiographic and subjective outcome. Knees were considered normal, near normal, or abnormal based on the International Knee Documentation Committee (IKDC) system. Forty-three patients were examined at an average of 33 months (minimum, 24 months) postoperatively. At the time of ACL reconstruction, 35% had normal articular cartilage in all three compartments and 70% had meniscal tears. No re-ruptures occurred. While 24% had mean maximal translation differences less than or equal to 3 mm, none had side-to-side differences greater than 5 mm. Postoperative IKDC, Activities of Daily Living, and Activity Rating Scale scores averaged 88, 94, and 7.7, respectively. Despite the overall favorable outcomes, 29% had worsened radiographic grades at follow-up. Using an Achilles allograft for ACL reconstruction in patients older than 30 years, we restored over 90% of knees to normal or near normal while limiting postoperative complications. Poor subjective results may be related less to instability and more to pain, which may result from progressive arthritis.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2

References

  1. 1.

    Aït Si, Selmi T, Fithian D, Neyret P. The evolution of osteoarthritis in 103 patients with ACL reconstruction at 17 years follow-up. Knee 2006;13(5):353–8.

    Article  Google Scholar 

  2. 2.

    Anderson AF, Irrgang JJ, Kocher MS, Mann BJ, Harrast JJ. The International Knee Documentation Committee Subjective Knee Evaluation Form. Normative Data. Am J Sports Med 2006;34:128–135.

    Article  PubMed  Google Scholar 

  3. 3.

    Bach BR Jr, Aadalen KJ, Dennis MG, Carreira DS, Bojchuk J, Hayden JK, Bush-Joseph CA. Primary anterior cruciate ligament reconstruction using fresh-frozen, nonirradiated patellar tendon allograft: minimum 2-year follow-up. Am J Sports Med 2005;33(2):284–92.

    Article  PubMed  Google Scholar 

  4. 4.

    Barber FA, Elrod BF, McGuire DA, Paulos LE. Is an anterior cruciate ligament reconstruction outcome age dependent? Arthroscopy 1996;12(6):720–5.

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    Barbour SA, King W. The safe and effective use of allograft tissue—an update. Am J Sports Med 2003;31(5):791–7.

    PubMed  Google Scholar 

  6. 6.

    Barrett G, Stokes D, White M. Anterior cruciate ligament reconstruction in patients older than 40 years: allograft versus autograft patellar tendon. Am J Sports Med 2005;33:1505–1512.

    Article  PubMed  Google Scholar 

  7. 7.

    Beynnon BD, Johnson RJ, Fleming BC, Kannus P, Kaplan M, Samani J, Renström P. Anterior cruciate ligament replacement: comparison of bone-patellar tendon-bone grafts with two-strand hamstring grafts. A prospective, randomized study. J Bone Joint Surg Am 2002;84-A(9):1503–13.

    PubMed  Google Scholar 

  8. 8.

    Bonamo JJ, Krinick RM, Sporn AA. Rupture of the patellar ligament after use of its central third for anterior cruciate reconstruction. J Bone Joint Surg Am 1984;66:1294–1297.

    CAS  PubMed  Google Scholar 

  9. 9.

    Breitfuss H, Frohlich R, Povacz P, Resch H, Wicker A. The tendon defect after anterior cruciate ligament reconstruction using the midthird patellar tendon—a problem for the patellofemoral joint? Knee Surg Sports Traumatol Arthrosc 1996;4:194–198.

    Article  Google Scholar 

  10. 10.

    Buck BE, Malinin TI, Brown MD. Bone transplantation and human immunodeficiency virus. An estimate of risk of acquired immunodeficiency syndrome (AIDS). Clin Orthop Relat Res 1989;(240):129–36.

  11. 11.

    Buss DD, Warren RF, Wickiewicz TL, Galinat BJ, Panariello R. Arthroscopically assisted reconstruction of the anterior cruciate ligament with use of autogenous patellar-ligament grafts. Results after twenty-four to forty-two months. J Bone Joint Surg Am 1993;75(9):1346–55.

    CAS  PubMed  Google Scholar 

  12. 12.

    Cohen M, Amaro JT, Ejnisman B, Carvalho RT, Nakano KK, Peccin MS, Teixeira R, Laurino CF, Abdalla RJ. Anterior cruciate ligament reconstruction after 10 to 15 years: association between meniscectomy and osteoarthrosis. Arthroscopy 2007;23(6):629–34.

    Article  PubMed  Google Scholar 

  13. 13.

    Daniel DM, Stone ML, Dobson BE, Fithian DC, Rossman DJ, Kaufman KR. Fate of the ACL-injured patient. A prospective outcome study. Am J Sports Med 1994;22(5):632–44.

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Daniel DM, Malcom LL, Losse G, Stone ML, Sachs R, Burks R. Instrumented measurement of anterior laxity of the knee. J Bone Joint Surg Am 1985;67(5):720–6.

    CAS  PubMed  Google Scholar 

  15. 15.

    Daniel DM, Stone ML, Sachs R, Malcom L. Instrumented measurement of anterior knee laxity in patients with acute anterior cruciate ligament disruption. Am J Sports Med 1985;13(6):401–7.

    CAS  Article  PubMed  Google Scholar 

  16. 16.

    Dunn WR, Lyman S, Lincoln AE, Amoroso PJ, Wickiewicz T, Marx RG. The effect of anterior cruciate ligament reconstruction on the risk of knee reinjury. Am J Sports Med 2004;32(8):1906–14.

    Article  PubMed  Google Scholar 

  17. 17.

    Fahey M, Indelicato PA. Bone tunnel enlargement after anterior cruciate ligament replacement. Am J Sports Med 1994;22(3):410–4.

    CAS  Article  PubMed  Google Scholar 

  18. 18.

    Ferretti A, Conteduca F, De Carli A, Fontana M, Mariani PP. Osteoarthritis of the knee after ACL reconstruction. Int Orthop 1991;15(4):367–71.

    CAS  Article  PubMed  Google Scholar 

  19. 19.

    Fideler BM, Vangsness CT Jr, Lu B, Orlando C, Moore T. Gamma irradiation: effects on biomechanical properties of human bone-patellar tendon-bone allografts. Am J Sports Med 1995;23(5):643–6.

    CAS  Article  PubMed  Google Scholar 

  20. 20.

    Freedman KB, D’Amato MJ, Nedeff DD, Kaz A, Bach BR Jr. Arthroscopic anterior cruciate ligament reconstruction: a metaanalysis comparing patellar tendon and hamstring tendon autografts. Am J Sports Med 2003;31(1):2–11.

    PubMed  Google Scholar 

  21. 21.

    Garratt AM, Brealey S, Gillespie WJ, and in collaboration with the DAMASK Trial Team. Patient-assessed health instruments for the knee: a structured review. Rheumatology 2004;43(11):1414–1423.

    CAS  Article  PubMed  Google Scholar 

  22. 22.

    Gibbons MJ, Butler DL, Grood ES, Bylski-Austrow DI, Levy MS, Noyes FR. Effects of gamma irradiation on the initial mechanical and material properties of goat bone-patellar tendon-bone allografts. J Orthop Res 1991;9(2):209–18.

    CAS  Article  PubMed  Google Scholar 

  23. 23.

    Gobbi A, Francisco R. Factors affecting return to sports after anterior cruciate ligament reconstruction with patellar tendon and hamstring graft: a prospective clinical investigation. Knee Surg Sports Traumatol Arthrosc 2006;14(10):1021–1028.

    Article  PubMed  Google Scholar 

  24. 24.

    Grafe MW, Kurzweil PR. Anterior cruciate ligament reconstruction with Achilles tendon allografts in revisions and in patients older than 30. Am J Orthop 2008;37(6):302–308.

    PubMed  Google Scholar 

  25. 25.

    Harner CD, Olson E, Irrgang JJ, Silverstein S, Fu FH, Silbey M. Allograft versus autograft anterior cruciate ligament reconstruction: 3- to 5-year outcome. Clin Orthop Relat Res 1996 Mar;(324):134–44.

  26. 26.

    Indelli PF, Dillingham MF, Fanton GS, Schurman DJ. Anterior cruciate ligament reconstruction using cryopreserved allografts. Clin Orthop Relat Res 2004 Mar;(420):268–75.

  27. 27.

    Jackson DW, Grood ES, Goldstein JD, Rosen MA, Kurzweil PR, Cummings JF, Simon TM. A comparison of patellar tendon autograft and allograft used for anterior cruciate ligament reconstruction in the goat model. Am J Sports Med 1993;21:176–185.

    CAS  Article  PubMed  Google Scholar 

  28. 28.

    Järvelä T, Paakkala T, Kannus P, Järvinen M. The incidence of patellofemoral osteoarthritis and associated findings 7 years after anterior cruciate ligament reconstruction with a bone-patellar tendon-bone autograft. Am J Sports Med. 2001;29(1):18–24.

    PubMed  Google Scholar 

  29. 29.

    Levy IM, Torzilli PA, Warren RF. The effect of medial meniscectomy on anterior-posterior motion of the knee. J Bone Joint Surg Am 1982;64(6):883–8.

    CAS  PubMed  Google Scholar 

  30. 30.

    Linn RM, Fischer DA, Smith JP, Burstein DB, Quick DC. Achilles tendon allograft reconstruction of the anterior cruciate ligament-deficient knee. Am J Sports Med 1993;21(6):825–31.

    CAS  Article  PubMed  Google Scholar 

  31. 31.

    Marx RG, Stump TJ, Jones EC, Wickiewicz TL, Warren RF. Development and evaluation of an activity rating scale for disorders of the knee. Am J Sports Med 2001;29(2):213–8.

    CAS  PubMed  Google Scholar 

  32. 32.

    Mastrokalos DS, Springer J, Siebold R, Paessler HH.Donor site morbidity and return to the preinjury activity level after anterior cruciate ligament reconstruction using ipsilateral and contralateral patellar tendon autograft: a retrospective, nonrandomized study.Am J Sports Med. 2005;33(1):85–93.

    Article  PubMed  Google Scholar 

  33. 33.

    McCarroll JR. Fracture of the patella during a golf swing following reconstruction of the anterior cruciate ligament. Am J Sports Med 1983;11:26–27.

    CAS  Article  PubMed  Google Scholar 

  34. 34.

    Miller SL, Gladstone JN. Graft selection in anterior cruciate ligament reconstruction. Orthop Clin North Am 2002;33(4):675–83.

    Article  PubMed  Google Scholar 

  35. 35.

    Noyes FR, Barber-Westin SD. Anterior cruciate ligament revision reconstruction: results using a quadriceps tendon-patellar bone autograft. Am J Sports Med 2006 Apr;34(4):553–64.

    Article  PubMed  Google Scholar 

  36. 36.

    Noyes FR, Barber-Westin SD. Reconstruction of the anterior cruciate ligament with human allograft. Comparison of early and later results. J Bone Joint Surg Am 1996 Apr;78(4):524–37.

    CAS  PubMed  Google Scholar 

  37. 37.

    Noyes FR, Mooar PA, Matthews DS, Butler DL. The symptomatic anterior cruciate-deficient knee. Part I: the long-term functional disability in athletically active individuals. J Bone Joint Surg Am 1983;65(2):154–62.

    CAS  PubMed  Google Scholar 

  38. 38.

    Plancher KD, Steadman JR, Briggs KK, Hutton KS. Reconstruction of the anterior cruciate ligament in patients who are at least forty years old. A long-term follow-up and outcome study. J Bone Joint Surg Am 1998;80(2):184–97.

    CAS  PubMed  Google Scholar 

  39. 39.

    Poehling GG, Curl WW, Lee CA, Ginn TA, Rushing JT, Naughton MJ, Holden MB, Martin DF, Smith BP. Analysis of outcomes of anterior cruciate ligament repair with 5-year follow-up: allograft versus autograft. Arthroscopy 2005;21(7):774–85.

    Article  PubMed  Google Scholar 

  40. 40.

    Prodromos CC, Fu FH, Howell SM, Johnson DH, Lawhorn K. Controversies in soft-tissue anterior cruciate ligament reconstruction: grafts, bundles, tunnels, fixation, and harvest. J Am Acad Orthop Surg 2008;16(7):376–384.

    PubMed  Google Scholar 

  41. 41.

    Prodromos CC, Han Y, Rogowski J, Joyce B, Shi K. A meta-analysis of the incidence of anterior cruciate ligament tears as a function of gender, sport, and a knee injury-reduction regimen. Arthroscopy 2007;23(12):1320–1325.e6.

    Article  PubMed  Google Scholar 

  42. 42.

    Roe J, Pinczewski LA, Russell VJ, Salmon LJ, Kawamata T, Chew M. A 7-year follow-up of patellar tendon and hamstring tendon grafts for arthroscopic anterior cruciate ligament reconstruction: differences and similarities. Am J Sports Med 2005;33(9):1337–45.

    Article  PubMed  Google Scholar 

  43. 43.

    Scheffler SU, Schmidt T, Gangéy I, Dustmann M, Unterhauser F, Weiler A. Fresh-frozen free-tendon allografts versus autografts in anterior cruciate ligament reconstruction: delayed remodeling and inferior mechanical function during long-term healing in sheep. Arthroscopy. 2008 Apr;24(4):448–58.

    Article  PubMed  Google Scholar 

  44. 44.

    Seon JK, Song EK, Park SJ. Osteoarthritis after anterior cruciate ligament reconstruction using a patellar tendon autograft. Int Orthop 2006 Apr;30(2):94–8.

    Article  PubMed  Google Scholar 

  45. 45.

    Shelbourne KD, Benner RW. Isolated anterior cruciate ligament reconstruction in the chronic ACL-deficient knee with degenerative medial arthrosis. J Knee Surg 2007;20(3):216–22.

    PubMed  Google Scholar 

  46. 46.

    Shelbourne KD, Stube KC. Anterior cruciate ligament (ACL)-deficient knee with degenerative arthrosis: treatment with an isolated autogenous patellar tendon ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 1997;5(3):150–6.

    CAS  Article  PubMed  Google Scholar 

  47. 47.

    Shino K, Nakata K, Horibe S, Inoue M, Nakagawa S. Quantitative evaluation after arthroscopic anterior cruciate ligament reconstruction. Allograft versus autograft. Am J Sports Med 1993;21(4):609–16.

    CAS  Article  PubMed  Google Scholar 

  48. 48.

    Siebold R, Buelow JU, Bos L, Ellermann A. Primary ACL reconstruction with fresh-frozen patellar versus Achilles tendon allografts. Arch Orthop Trauma Surg 2003;123(4):180–5.

    CAS  PubMed  Google Scholar 

  49. 49.

    Spindler KP, Kuhn JE, Freedman KB, Matthews CE, Dittus RS, Harrell FE Jr. Anterior cruciate ligament reconstruction autograft choice: bone-tendon-bone versus hamstring: does it really matter? A systematic review. Am J Sports Med. 2004;32(8):1986–95.

    Article  PubMed  Google Scholar 

  50. 50.

    Tanner SM, Dainty KN, Marx RG, Kirkley A. Knee-specific quality-of-life instruments: which ones measure symptoms and disabilities most important to patients? Am J Sports Med 2007;35(9):1450–1458.

    Article  PubMed  Google Scholar 

  51. 51.

    Tashiro T, Kurosawa H, Kawakami A, Hikita A, Fukui N. Influence of medial hamstring tendon harvest on knee flexor strength after anterior cruciate ligament reconstruction. A detailed evaluation with comparison of single- and double-tendon harvest. Am J Sports Med. 2003;31(4):522–9.

    Article  PubMed  Google Scholar 

  52. 52.

    West RV, Harner CD. Graft selection in anterior cruciate ligament reconstruction. J Am Acad Orthop Surg 2005;13(3):197–207.

    PubMed  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Robert A. Gallo MD.

Additional information

This study was supported by outside funding or grant(s) from the Institute for Sports Medicine Research, New York, NY.

None of the researchers or an affiliated institute has received (or agreed to receive) from a commercial entity something of value (exceeding the equivalent of US $500) related in any way to this manuscript or research.

Each author certifies that his or her institution has approved the reporting of these cases, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participating in the study was obtained.

Research was performed at the Hospital for Special Surgery, New York, NY.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Chehab, E.L., Flik, K.R., Vidal, A.F. et al. Anterior Cruciate Ligament Reconstruction Using Achilles Tendon Allograft: an Assessment of Outcome for Patients Age 30 Years and Older. HSS Jrnl 7, 44–51 (2011). https://doi.org/10.1007/s11420-010-9183-y

Download citation

Keywords

  • anterior cruciate ligament reconstruction
  • allograft