Graft Selection in ACL Reconstructive Surgery

Past, Present, and Future

Ahmad Oryan; Ali Moshiri; Abdolhamid Meimandi-Parizi


Curr Orthop Pract. 2013;24(3):321-333. 

In This Article

Other Options

Processed xenografts can be considered as another option, but their effectiveness is still under debate.[10] Tissue-engineered artificial ligaments have been shown to have some distinct advantages; these include the ability to control manufacturing, condition, quality, sterility, and size of the graft before implantation.[10] Mechanically tested and controlled grafts could be made available off the shelf and eliminate the need to create a second defect site through the harvesting of healthy tissue.[31]

Use of a prosthetic device for complete replacement of the ACL has met with various degrees of acceptance around the world.[13] A theoretical advantage of ligament augmentation devices is that they supply immediate strength to autogenous or allograft material so that during the revascularization and remodeling stages of healing, more vigorous rehabilitation can be attempted without endangering the graft. Prosthetic devices can be securely fixed to bone so that the graft can immediately withstand functional loads.[13] Another advantage is related to reduction of the morbidity from harvesting a tendon or fascia from the patient and, thus, minimizing the amount of dissection that is needed for the reconstructive procedure.[13]

Guo et al.[25] investigated the surgical technique and short-term effectiveness of ACL reconstruction with Ligament Augmentation and Reconstruction System (LARS; JK Orthomedic, Quebec, Canada) artificial ligament. Eighty patients, 51 men and 29 women, between 17–43 years of age, with ACL injury were arthroscopically treated using a LARS artificial ligament. They failed to comprehensively analyze the efficacy of this device, and they suggested that a proper clinical result only could be achieved if the technique is well applied.

These structures have no cellular elements; there are no well-approved scientific studies that have tested the inflammatory response due to host defense mechanisms after surgical implantation of these products.[26] Ligament-augmentation devices have been studied on a limited basis, and although early results have been encouraging, no investigation has demonstrated these devices to be clearly superior to the present autogenous graft techniques.[10,13] Many studies have demonstrated their early success, but, as far as we know, no long-term investigations have shown convincingly that these constructs remain intact or that they fulfill the functional ability of the ACL effectively.[13]

Unfortunately, most artificial ACLs have suffered from low mechanical strength and in some cases biological insufficiencies and have been removed from the market. In the early postoperative stages, most failures occurred in the bone tunnels.[27] Fatigue, fretting, and wear have resulted in an unacceptably high rate of failure. Thus, it seems replacement with a prosthesis in the ACL has limited value in ACL reconstruction, and tougher regulatory measurements should be applied to ensure the safety and efficacy of these commercial scaffolds.[13]