Allografts in PCL Reconstructions

  • Luís Duarte SilvaEmail author
  • Hélder Pereira
  • Alberto Monteiro
  • Artur Pereira de Castro
  • Sérgio R. Piedade
  • Pedro Luís Ripoll
  • Joaquim M. Oliveira
  • Rui L. Reis
  • João Espregueira-Mendes
Living reference work entry

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Posterior cruciate ligament (PCL) injuries are often associated with other ligament lesions. Multiligament reconstructions require an important quantity of grafts and often determine the need for cadaver allografts during the surgical repair procedures. Herein, the fundamentals of allografts that have been currently used for PCL reconstructions are overviewed. The main issues to be considered when surgeons choose this therapeutic option are also discussed.


Posterior Cruciate Ligament Posterior Cruciate Ligament Reconstruction Posterior Cruciate Ligament Injury Tendon Allograft Tibial Inlay 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Adler GG (2013) All-inside posterior cruciate ligament reconstruction with a GraftLink. Arthrosc Tech 2:e111–e115PubMedCentralPubMedCrossRefGoogle Scholar
  2. Ahn JH, Yoo JC, Wang JH (2005) Posterior cruciate ligament reconstruction: double-loop hamstring tendon autograft versus Achilles tendon allograft–clinical results of a minimum 2-year follow-up. Arthroscopy 21:965–969PubMedCrossRefGoogle Scholar
  3. Barbour SA, King W (2003) The safe and effective use of allograft tissue–an update. Am J Sports Med 31:791–797PubMedGoogle Scholar
  4. Bosch U, Kasperczyk WJ (1992) Healing of the patellar tendon autograft after posterior cruciate ligament reconstruction–a process of ligamentization? An experimental study in a sheep model. Am J Sports Med 20:558–566PubMedCrossRefGoogle Scholar
  5. Brunet P, Charrois O, Degeorges R, Boisrenoult P, Beaufils P (2005) Reconstruction of acute posterior cruciate ligament tears using a synthetic ligament. Rev Chir Orthop Reparatrice Appar Mot 91:34–43PubMedCrossRefGoogle Scholar
  6. Bullis DW, Paulos LE (1994) Reconstruction of the posterior cruciate ligament with allograft. Clin Sports Med 13:581–597PubMedGoogle Scholar
  7. Chhabra A, Kline AJ, Harner CD (2006) Single-bundle versus double-bundle posterior cruciate ligament reconstruction: scientific rationale and surgical technique. Instr Course Lect 55:497–507PubMedGoogle Scholar
  8. Collins JE, Katz JN, Donnell-Fink LA, Martin SD, Losina E (2013) Cumulative incidence of ACL reconstruction after ACL injury in adults: role of age, sex, and race. Am J Sports Med 41:544–549PubMedCentralPubMedCrossRefGoogle Scholar
  9. Cooper DE, Stewart D (2004) Posterior cruciate ligament reconstruction using single-bundle patella tendon graft with tibial inlay fixation: 2- to 10-year follow-up. Am J Sports Med 32:346–360PubMedCrossRefGoogle Scholar
  10. Curran AR, Adams DJ, Gill JL, Steiner ME, Scheller AD (2004) The biomechanical effects of low-dose irradiation on bone-patellar tendon-bone allografts. Am J Sports Med 32:1131–1135PubMedCrossRefGoogle Scholar
  11. Daniel Slullitel HG, Ojeda V, Seri M (2012) Double-bundle “all-inside” posterior cruciate ligament reconstruction. Arthrosc Tech 1:141–148CrossRefGoogle Scholar
  12. Dennis MG, Fox JA, Alford JW, Hayden JK, Bach BR Jr (2004) Posterior cruciate ligament reconstruction: current trends. J Knee Surg 17:133–139PubMedGoogle Scholar
  13. Espregueira-Mendes J, Pereira H, Sevivas N, Passos C, Vasconcelos JC, Monteiro A et al (2012) Assessment of rotatory laxity in anterior cruciate ligament-deficient knees using magnetic resonance imaging with Porto-knee testing device. Knee Surg Sports Traumatol Arthrosc 20:671–678PubMedCrossRefGoogle Scholar
  14. Fanelli GC, Edson CJ (2002) Arthroscopically assisted combined anterior and posterior cruciate ligament reconstruction in the multiple ligament injured knee: 2- to 10-year follow-up. Arthroscopy 18:703–714PubMedCrossRefGoogle Scholar
  15. Fanelli GC, Beck JD, Edson CJ (2010) Current concepts review: the posterior cruciate ligament. J Knee Surg 23:61–72PubMedCrossRefGoogle Scholar
  16. Fanelli GC, Beck JD, Edson CJ (2012) Single compared to double-bundle PCL reconstruction using allograft tissue. J Knee Surg 25:59–64PubMedCrossRefGoogle Scholar
  17. Farrow LD, Bergfeld JA (2009) Posterior Cruciate Ligament reconstruction: Single Bundle Tibial Inlay Technique. In: Gill TJ (ed) Arthroscopic techniques of the knee: a visual guide. SLACK incorporated, Thorofare, pp 171–188Google Scholar
  18. Fideler BMVCJ, Moore T et al (1994) Effects of gamma irradiation on the human immunodeficiency virus. A study in frozen human bone-patellar ligament-bone grafts obtained from infected cadavera. J Bone Joint Surg Am 76(7):1032–1035PubMedGoogle Scholar
  19. Fideler BM, Vangsness CT Jr, Lu B, Orlando C, Moore T (1995) Gamma irradiation: effects on biomechanical properties of human bone-patellar tendon-bone allografts. Am J Sports Med 23:643–646PubMedCrossRefGoogle Scholar
  20. Garavaglia G, Lubbeke A, Dubois-Ferriere V, Suva D, Fritschy D, Menetrey J (2007) Accuracy of stress radiography techniques in grading isolated and combined posterior knee injuries: a cadaveric study. Am J Sports Med 35:2051–2056PubMedCrossRefGoogle Scholar
  21. Gelber PE, Gonzalez G, Lloreta JL, Reina F, Caceres E, Monllau JC (2008) Freezing causes changes in the meniscus collagen net: a new ultrastructural meniscus disarray scale. Knee Surg Sports Traumatol Arthrosc 16:353–359PubMedCrossRefGoogle Scholar
  22. Guo L, Yang L, Duan XJ, He R, Chen GX, Wang FY et al (2012) Anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft: comparison of autograft, fresh-frozen allograft, and gamma-irradiated allograft. Arthroscopy 28:211–217PubMedCrossRefGoogle Scholar
  23. Hansen JM, Shaffer HL (2001) Sterilization and Preservation by Radiation Sterilization, In: Block SS (ed) Disinfection, sterilization, and preservation, 5th edn. Lippincott, Williams & Wilkins, Philadelphia, pp 729–746Google Scholar
  24. Hoburg A, Keshlaf S, Schmidt T, Smith M, Gohs U, Perka C et al (2011) Fractionation of high-dose electron beam irradiation of BPTB grafts provides significantly improved viscoelastic and structural properties compared to standard gamma irradiation. Knee Surg Sports Traumatol Arthrosc 19:1955–1961PubMedCrossRefGoogle Scholar
  25. Hudgens JL, Gillette BP, Krych AJ, Stuart MJ, May JH, Levy BA (2013) Allograft versus autograft in posterior cruciate ligament reconstruction: an evidence-based systematic review. J Knee Surg 26:109–115PubMedCrossRefGoogle Scholar
  26. Irrgang JJ, West R, Sahasrabudhe A, Harner C (2006) Rehabilitation after Posterior Cruciate Ligament Reconstruction. In : Manske RC (ed) Postsurgical Orthopedic Sports Rehabilitation: Knee & Shoulder. Elsevier Health Sciences, Missouri, pp 245–256Google Scholar
  27. Jackson DW WG, Simon TM (1990) Intraarticular reaction associated with the use of freeze-dried, ethylene oxide-sterilized bone-patella tendon-bone allografts in the reconstruction of the anterior cruciate ligament. Am J Sports 18:1–11CrossRefGoogle Scholar
  28. James JI (1953) Tuberculosis transmitted by banked bone. J Bone Joint Surg Br 35-B:578PubMedGoogle Scholar
  29. Joyce MJ (2005) Safety and FDA regulations for musculoskeletal allografts: perspective of an orthopaedic surgeon. Clin Orthop Relat Res 22–30Google Scholar
  30. Jung TM, Lubowicki A, Wienand A, Wagner M, Weiler A (2011) Knee stability after posterior cruciate ligament reconstruction in female versus male patients: a prospective matched-group analysis. Arthroscopy 27:399–403PubMedCrossRefGoogle Scholar
  31. Kainer MA, Linden JV, Whaley DN, Holmes HT, Jarvis WR, Jernigan DB et al (2004) Clostridium infections associated with musculoskeletal-tissue allografts. N Engl J Med 350:2564–2571PubMedCrossRefGoogle Scholar
  32. Kasperczyk WJ, Bosch U, Oestern HJ, Tscherne H (1993) Staging of patellar tendon autograft healing after posterior cruciate ligament reconstruction. A biomechanical and histological study in a sheep model. Clin Orthop Relat Res 286:271–282Google Scholar
  33. Kim SJ, Park IS (2005) Arthroscopic reconstruction of the posterior cruciate ligament using tibial-inlay and double-bundle technique. Arthroscopy 21:1271PubMedGoogle Scholar
  34. Kim SJ, Choi CH, Kim HS (2004a) Arthroscopic posterior cruciate ligament tibial inlay reconstruction. Arthroscopy 20(Suppl 2):149–154PubMedCrossRefGoogle Scholar
  35. Kim SJ, Park IS, Cheon YM, Ryu SW (2004b) Double-bundle technique: endoscopic posterior cruciate ligament reconstruction using tibialis posterior allograft. Arthroscopy 20:1090–1094PubMedCrossRefGoogle Scholar
  36. Kim SJ, Bae JH, Lim HC (2012) Comparison of Achilles and tibialis anterior tendon allografts after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 22:135–41PubMedCrossRefGoogle Scholar
  37. Kohen RB, Sekiya JK (2009) Single-bundle versus double-bundle posterior cruciate ligament reconstruction. Arthroscopy 25:1470–1477PubMedCrossRefGoogle Scholar
  38. Kraft J, Alexander LA, Rowlands DT Jr (1992) Tissue transplantation. Quality assurance in the banking and utilization of musculoskeletal allografts. Physician Assist 16(49–50):3–6Google Scholar
  39. Lawhorn KW, Howell SM, Traina SM, Gottlieb JE, Meade TD, Freedberg HI (2012) The effect of graft tissue on anterior cruciate ligament outcomes: a multicenter, prospective, randomized controlled trial comparing autograft hamstrings with fresh-frozen anterior tibialis allograft. Arthroscopy 28:1079–1086PubMedCrossRefGoogle Scholar
  40. Levy BA, Stuart MJ (2012) Treatment of PCL, ACL, and lateral-side knee injuries: acute and chronic. J Knee Surg 25:295–305PubMedCrossRefGoogle Scholar
  41. Lord CF, Gebhardt MC, Tomford WW, Mankin HJ (1988) Infection in bone allografts. Incidence, nature, and treatment. J Bone Joint Surg Am 70:369–376PubMedGoogle Scholar
  42. Makino A, Aponte Tinao L, Ayerza MA, Pascual Garrido C, Costa Paz M, Muscolo DL (2006) Anatomic double-bundle posterior cruciate ligament reconstruction using double-double tunnel with tibial anterior and posterior fresh-frozen allograft. Arthroscopy 22(684):e1–e5PubMedGoogle Scholar
  43. Malinin T (1993) Allografts for the reconstruction of the cruciate ligaments of the knee: procurement, preservation, and storage. Sports Med Arthrosc Rev 1:31–41CrossRefGoogle Scholar
  44. Margheritini F, Rihn J, Musahl V, Mariani PP, Harner C (2002) Posterior cruciate ligament injuries in the athlete: an anatomical, biomechanical and clinical review. Sports Med 32:393–408PubMedCrossRefGoogle Scholar
  45. Mariscalco MW, Magnussen RA, Mehta D, Hewett TE, Flanigan DC, Kaeding CC (2013) Autograft versus nonirradiated allograft tissue for anterior cruciate ligament reconstruction: a systematic review. Am J Sports Med 42:492–499PubMedCrossRefGoogle Scholar
  46. Menetrey J, Garavaglia G, Fritschy D (2007) Definition, classification, rationale and treatment for PCl deficient knee. Rev Chir Orthop Reparatrice Appar Mot 93:5S70–5S73PubMedCrossRefGoogle Scholar
  47. Miller MD, Johnson DL, Harner CD, Fu FH (1993) Posterior cruciate ligament injuries. Orthop Rev 22:1201–1210PubMedGoogle Scholar
  48. Min BH, Lee YS, Lee YS, Jin CZ, Son KH (2011) Evaluation of transtibial double-bundle posterior cruciate ligament reconstruction using a single-sling method with a tibialis anterior allograft. Am J Sports Med 39:374–379PubMedCrossRefGoogle Scholar
  49. Monllau JC, González-Lucena G, Gelber PE, Pelfort X (2010) Allograft meniscus transplantation: a current review. Tech Knee Surg 9:107–113CrossRefGoogle Scholar
  50. Montgomery SR, Johnson JS, McAllister DR, Petrigliano FA (2013) Surgical management of PCL injuries: indications, techniques, and outcomes. Curr Rev Musculoskelet Med 6:115–123PubMedCentralPubMedCrossRefGoogle Scholar
  51. MTF (2005) Allograft safety and ethical considerations. Proceedings of the fourth symposium sponsored by the Musculoskeletal Transplant Foundation. September 2003. Edinburgh, Scotland, United Kingdom. Clin Orthop Relat Res 435:2–117Google Scholar
  52. Noh JH, Roh YH, Lee K, Lee JS (2012) Achilles tendon allograft with its bony attachment to repair rupture and extensive degeneration of the heel cord. Acta Orthop Belg 78:678–680PubMedGoogle Scholar
  53. Noyes FR, Barber-Westin S (2011) Decision Making and Surgical Treatment of Posterior Cruciate Ligament Ruptures. In: Scott WN, Insall JN, Scuderi GR (eds) Insall and Scott Surgery of the Knee, 5th edn. Elsevier/Churchill LivingstoneGoogle Scholar
  54. Peter MacDonald DW (2009) Technical considerations in posterior cruciate ligament reconstruction. A Canadian perspective. Oper Tech Sports Med 17:156–161CrossRefGoogle Scholar
  55. Piedade SR, Munhoz RR, Cavenaghi G, Miranda JB, Mischan MM (2006) Knee P.C.L. reconstruction: a tibial bed fixation (“INLAY”) technique. Objective and subjective evaluation of a 30-cases series. Acta Ortop Bras 14:92–96CrossRefGoogle Scholar
  56. Prolo DJ, Pedrotti PW, White DH (1980) Ethylene oxide sterilization of bone, dura mater, and fascia lata for human transplantation. Neurosurgery 6:529–539PubMedCrossRefGoogle Scholar
  57. Rasmussen TJ, Feder SM, Butler DL, Noyes FR (1994) The effects of 4 Mrad of gamma irradiation on the initial mechanical properties of bone-patellar tendon-bone grafts. Arthroscopy 10:188–197PubMedCrossRefGoogle Scholar
  58. Roberts TS, Drez D Jr, McCarthy W, Paine R (1991) Anterior cruciate ligament reconstruction using freeze-dried, ethylene oxide-sterilized, bone-patellar tendon-bone allografts. Two year results in thirty-six patients. Am J Sports Med 19:35–41PubMedCrossRefGoogle Scholar
  59. Robertson A, Nutton RW, Keating JF (2006) Current trends in the use of tendon allografts in orthopaedic surgery. J Bone Joint Surg Br 88:988–992PubMedCrossRefGoogle Scholar
  60. Rosenthal MD, Rainey CE, Tognoni A, Worms R (2012) Evaluation and management of posterior cruciate ligament injuries. Phys Ther Sport 13:196–208PubMedCrossRefGoogle Scholar
  61. Sekiya JK, West RV, Ong BC, Irrgang JJ, Fu FH, Harner CD (2005) Clinical outcomes after isolated arthroscopic single-bundle posterior cruciate ligament reconstruction. Arthroscopy 21:1042–1050PubMedCrossRefGoogle Scholar
  62. Service SNBTSST (2004) Standard Operating Procedure TSD 290 03 Tendon donor referral and retrieval from multi-organ donors. p. NationGoogle Scholar
  63. Shelbourne KD, Davis TJ, Patel DV (1999) The natural history of acute, isolated, nonoperatively treated posterior cruciate ligament injuries. A prospective study. Am J Sports Med 27:276–283PubMedGoogle Scholar
  64. Simonds RJ, Holmberg SD, Hurwitz RL, Coleman TR, Bottenfield S, Conley LJ et al (1992) Transmission of human immunodeficiency virus type 1 from a seronegative organ and tissue donor. N Engl J Med 326:726–732PubMedCrossRefGoogle Scholar
  65. Singh R, Singh D (2012) Sterilization of bone allografts by microwave and gamma radiation. Int J Radiat Biol 88:661–666PubMedCrossRefGoogle Scholar
  66. Slullitel D, Galan H, Ojeda V, Seri M (2012) Double-bundle “all-inside” posterior cruciate ligament reconstruction. Arthrosc Tech 1:e141–e148PubMedCentralPubMedCrossRefGoogle Scholar
  67. Suhodolcan L, Brojan M, Kosel F, Drobnic M, Alibegovic A, Brecelj J (2013) Cryopreservation with glycerol improves the in vitro biomechanical characteristics of human patellar tendon allografts. Knee Surg Sports Traumatol Arthrosc 21:1218–1225PubMedCrossRefGoogle Scholar
  68. Sun K, Zhang J, Wang Y, Xia C, Zhang C, Yu T et al (2011) Arthroscopic reconstruction of the anterior cruciate ligament with hamstring tendon autograft and fresh-frozen allograft: a prospective, randomized controlled study. Am J Sports Med 39:1430–1438PubMedCrossRefGoogle Scholar
  69. U.S. Department of Health and Human Services FaDA, Center for Biologics Evaluation and Research (2007) Guidance for industry: eligibility determination for donors of human cells, tissues, and cellular and tissue-based productsGoogle Scholar
  70. Vangsness CT Jr, Garcia IA, Mills CR, Kainer MA, Roberts MR, Moore TM (2003) Allograft transplantation in the knee: tissue regulation, procurement, processing, and sterilization. Am J Sports Med 31:474–481PubMedGoogle Scholar
  71. Voos JE, Mauro CS, Wente T, Warren RF, Wickiewicz TL (2012) Posterior cruciate ligament: anatomy, biomechanics, and outcomes. Am J Sports Med 40:222–231PubMedCrossRefGoogle Scholar
  72. Wang CJ, Chan YS, Weng LH, Yuan LJ, Chen HS (2004) Comparison of autogenous and allogenous posterior cruciate ligament reconstructions of the knee. Injury 35:1279–1285PubMedCrossRefGoogle Scholar
  73. Whiddon DR, Sekiya JK (2005) Double-bundle posterior cruciate ligament reconstruction with a bifid bone- patellar tendon-bone allograft. Oper Tech Sports Med 13(4):233–240Google Scholar
  74. Yang JH, Yoon JR, Jeong HI, Hwang DH, Woo SJ, Kwon JH et al (2012) Second-look arthroscopic assessment of arthroscopic single-bundle posterior cruciate ligament reconstruction: comparison of mixed graft versus achilles tendon allograft. Am J Sports Med 40:2052–2060PubMedCrossRefGoogle Scholar
  75. Yoon KH, Bae DK, Song SJ, Lim CT (2005) Arthroscopic double-bundle augmentation of posterior cruciate ligament using split Achilles allograft. Arthroscopy 21:1436–1442PubMedCrossRefGoogle Scholar
  76. Yoon KH, Bae DK, Song SJ, Cho HJ, Lee JH (2011) A prospective randomized study comparing arthroscopic single-bundle and double-bundle posterior cruciate ligament reconstructions preserving remnant fibers. Am J Sports Med 39:474–480PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • Luís Duarte Silva
    • 3
    • 8
    Email author
  • Hélder Pereira
    • 1
    • 2
    • 3
    • 4
  • Alberto Monteiro
    • 3
  • Artur Pereira de Castro
    • 5
  • Sérgio R. Piedade
    • 6
  • Pedro Luís Ripoll
    • 7
  • Joaquim M. Oliveira
    • 1
    • 2
    • 3
  • Rui L. Reis
    • 1
    • 2
    • 3
    • 9
  • João Espregueira-Mendes
    • 1
    • 2
    • 3
    • 4
  1. 1.3B’s Research Group – Biomaterials, Biodegradables and BiomimeticsUniv. Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative MedicineTaipasPortugal
  2. 2.ICVS/3B’s – PT Government Associated LaboratoryGuimarãesPortugal
  3. 3.Clínica Espregueira-Mendes F.C. Porto StadiumFIFA Medical Centre of ExcellencePortoPortugal
  4. 4.Orthopedic DepartmentCentro Hospitalar Póvoa de Varzim – Vila do CondeVila do CondePortugal
  5. 5.DESPORSANO Sports ClinicLisboaPortugal
  6. 6.Orthopaedic and Traumatology Department of FCM/UNICAMPUniverisdade Estadual de CampinasCampinasBrazil
  7. 7.Ripoll y De Prado Sport Clinic -FIFA Medical Centre of ExcellenceMurciaSpain
  8. 8.Orthopedic Department ULS-GuardaGuardaPortugal
  9. 9.Orthopaedic DepartmentHospital de S. SebastiãoFeiraPortugal

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