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Allograft and autograft for ACL reconstruction lead to similar clinical outcomes
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April 2013
Allograft and autograft for ACL reconstruction lead to similar clinical outcomes
Study Type:Meta analysis
OE Level Evidence:2
Journal Level of Evidence:N/A
Allograft versus autograft for anterior cruciate ligament reconstruction: an up-to-date meta-analysis of prospective studies
Int Orthop. 2013 Feb;37(2):311-20. doi: 10.1007/s00264-012-1720-5. Epub 2012 Dec 4Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
Synopsis
Nine studies (818 patients) were identified to compare the clinical outcomes of allograft versus autograft for anterior cruciate ligament (ACL) reconstruction. No significant differences in clinical outcomes were identified between the two treatments to determine which was more optimal for ACL reconstruction. However, subgroup analysis revealed that reconstruction with bone-patellar tendon-bone (BPTB) autograft may allow patients to return to higher levels of activity when compared to BPTB allograft.
Publication Funding Details
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Funding:
Non-Industry funded
Sponsor:
The National Natural Science Foundation of China
Conflicts:
None disclosed
Were the search methods used to find evidence (original research) on the primary question or questions stated?
Was the search for evidence reasonably comprehensive?
Were the criteria used for deciding which studies to include in the overview reported?
Was the bias in the selection of studies avoided?
Were the criteria used for assessing the validity of the included studies reported?
Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)?
Were the methods used to combine the findings of the relevant studies (to reach a conclusion) reported?
Were the findings of the relevant studies combined appropriately relative to the primary question that the overview addresses?
Were the conclusions made by the author or authors supported by the data and or analysis reported in the overview?
How would you rate the scientific quality of this evidence?
Yes = 1
Uncertain = 0.5
Not Relevant = 0
No = 0
The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.
4/4
Introduction
4/4
Accessing Data
4/4
Analysing Data
3/4
Results
3/4
Discussion
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.
Why was this study needed now?
ACL reconstruction is the primary treatment option for ACL ruptures to prevent knee instability. However, it is still uncertain whether allografts provide similar results as autografts for ACL reconstruction. The majority of the past systematic reviews reporting these treatments have been based on low-quality studies. With the publication of new randomized trials since the latest systematic review, this meta-analysis aimed to evaluate the clinical outcomes of allografts versus autografts for ACL reconstruction.
What was the principal research question?
Which treatment - allografts or autografts - for ACL reconstruction led to better clinical outcomes?
Study Characteristics
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Data Source:
The following electronic databases (from 1980 to October 2012) were searched: PubMed, Embase, Scopus, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews.
Index Terms:
("anterior cruciate ligament" or "ACL") AND ("autograft" and "allograft").
Study Selection:
The selection criteria were as follows: 1) a prospective comparative study; 2) patients with a unilateral ACL rupture in need of primary ACL reconstruction; 3) bone-patellar tendon-bone (BPTB) autograft compared to BPTB allograft, or soft-tissue autograft compared to soft-tissue allograft; 4) minimum 2 year follow-up; and 5) included any clinically relevant subjective and objective outcomes (stability, functional, and patient-oriented outcomes as well as morbidity). Studies were excluded if: 1) the study was a case-control study, retrospective cohort study, or case series; 2) the study used gamma irradiation in allografts; 3) the study compared BPTB grafts to soft-tissue grafts.
Data Extraction:
Using a pre-developed data extraction table, data were extracted independently from each eligible study by two reviewers. Any discrepancies between the extracted data were resolved through consensus.
Data Synthesis:
Data analysis was performed through RevMan 5.1. In order to pool results, a random-effects model was used. Risk ratio (RR) was used as a summary statistic to perform statistical analysis of dichotomous variables, while the mean difference (MD) was used to analyze continuous variables. The chi-square and I-square tests were used to evaluate statistical heterogeneity between trials, with significance set at P < 0.10. Lastly, a subgroup analysis was performed to identify the potential differences in graft type (BPTB grafts or soft-tissue grafts).
What were the important findings?
- 9 studies (410 patients in the autograft and 408 patients in the allograft group) were included in this meta-analysis; 4 studies were randomized controlled studies (RCTs) and 5 were prospective cohort studies.
- Analysis from 6 studies revealed the risk ratio for KT-1000/2000 side-to-side difference >5 mm was 1.19 in favour of allograft (95% CI, 0.63 to 2.24); however, the results were not significant (P = 0.59).
- According to 6 studies, the risk ratio for abnormal Lachman test (grade >0) was 0.88 in favour of autograft (95% CI, 0.64 to 1.2); the results were not deemed significant (P = 0.41).
- 7 studies indicated that the risk ratio for abnormal Pivot Shift test (grade >0) was 0.97 in favour of autograft (95% CI, 0.64 to 1.46); however, the results were not significant (P = 0.88).
- In regards to objective IKDC scores, analysis from 7 studies revealed that the risk ratio for being considered abnormal or severely abnormal was 0.96 favouring autograft (95% CI, 0.6 to 1.54); the results were not statistically significant (P = 0.87).
- 3 studies revealed a mean difference of 0.3 on Lysholm scores in favour of autograft (95% CI, -1.97 to 2.57), where the results were not significant (P = 0.79); the same 3 studies indicated a mean difference of 0.25 on Tegner scores in favour of autograft (95% CI, -0.01 to 0.52), where the results were not significant (P = 0.06).
- The subgroup analysis of Tegner scores by only pooling 4 studies involving BPTB grafts estimated a mean difference of 0.5 in favour autograft (95% CI, 0.15 to 0.85; P = 0.005).
What should I remember most?
This meta-analysis revealed that ACL reconstruction with allografts or autografts led to similar clinical outcomes. However, subgroup analysis indicated that reconstruction with BPTB autograft may allow patients to return to higher levels of activity in comparison with BPTB allograft.
How will this affect the care of my patients?
There was insufficient evidence to determine which graft technique was superior for ACL reconstruction. These results suggest equivocal clinical results for allograft and autograft overall, although bone patellar tendon bone autografts may be superior to allograft for return to high-level activity. Future research involving high-quality RCTs with specified age and activity are required to further evaluate the outcomes of these two treatments.
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