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Evidence-Based Orthopaedics   |    
A Systematic Review of Anterior Cruciate Ligament Reconstruction with Autograft Compared with Allograft
James L. Carey, MD, MPH1; Warren R. Dunn, MD, MPH1; Diane L. Dahm, MD2; Scott L. Zeger, PhD3; Kurt P. Spindler, MD1
1 Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Medical Center East, South Tower, Suite 3200, Nashville, TN 37232. E-mail address for J.L. Carey: james.carey@vanderbilt.edu
2 Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
3 Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205
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Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from NIH/NIAMS (R01 AR053684-01A1) and NIAMS (5 K23 AR052392-04). In addition, one or more of the authors received a research grant in excess of $10,000 from Smith and Nephew and an unrestricted research grant in excess of $10,000 from DonJoy, neither of which contributed to the development of this manuscript. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2009 Sep 01;91(9):2242-2250. doi: 10.2106/JBJS.I.00610
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Abstract

Background: Anterior cruciate ligament reconstruction can be performed with use of either autograft or allograft tissue. It is currently unclear if the outcomes of these two methods differ significantly. This systematic review and meta-analysis investigated whether the short-term clinical outcomes of anterior cruciate reconstruction with allograft were significantly different from those with autograft.

Methods: A computerized search of the electronic databases MEDLINE and EMBASE was conducted. Only therapeutic studies with a prospective or retrospective comparative design were considered for inclusion in the present investigation. Two reviewers independently assessed the methodological quality and extracted relevant data from each included study. If a study failed the qualitative assessment and statistical tests of homogeneity, it was excluded from the meta-analysis. Furthermore, a study was withdrawn from the meta-analysis of a particular outcome if that outcome was not studied or was not reported adequately. A Mantel-Haenszel analysis utilizing a random-effects model allowed for pooling of results according to graft source while accounting for the number of subjects in individual studies.

Results: Nine studies were determined to be appropriate for the systematic review. Eight studies compared bone-patellar tendon-bone grafts, and one study compared quadruple-stranded hamstring grafts. Five studies were prospective comparative studies, and four were retrospective comparative studies. One study, which investigated allografts that underwent a unique sterilization process, demonstrated an allograft failure rate of 45% (thirty-eight of eighty-five). That study failed the qualitative assessment and statistical tests of homogeneity and consequently was excluded from the meta-analysis. When the outcomes from the remaining studies were pooled according to graft source, the meta-analyses of the Lysholm score, instrumented laxity measurements, and the clinical failure rate estimated mean differences and odds ratios that were not significant. These findings were robust during the sensitivity analysis, which varied the included studies or variables on the basis of graft type, instrumented laxity cut-off value, secondary sterilization technique, duration of follow-up, mean patient age, and study methodology.

Conclusions: In general, the short-term clinical outcomes of anterior cruciate reconstruction with allograft were not significantly different from those with autograft. However, it is important to note that none of these nonrandomized studies stratified outcomes according to age or utilized multivariable modeling to mathematically control for age (or any other possible confounder, such as activity level, that is not equally distributed in the two treatment groups). Understanding these limitations of the best available evidence, the surgeon may incorporate the results of the present systematic review into the informed-consent and shared-decision-making process in order to individualize optimum patient care.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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