ACL Surgery: Use Your Own Tissue or Donor Graft

Is Donor ACL Reconstruction Still a Reasonable Alternative?

knee acl surgery
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Injury to the anterior cruciate ligament is a devastating injury for athletes of all ages. Treatment usually involves surgery. If you undergo surgical reconstruction, you may have to choose between using your own tissue or using a donor graft.

Understanding ACL Tears

The anterior cruciate ligament (ACL) is one of four major ligaments in the knee joint.

These ligaments work collectively to allow the knee to bend normally, but also to be stable throughout this motion.

When the anterior cruciate ligament is torn, sensations of instability—experienced as a buckling or giving out of the knee—can occur. ACL tears often lead to an inability to participate in sports that require a stable knee joint. These sports include activities that involve side to side, cutting, and pivoting movements. Sports that place a high demand on the ACL include soccer, basketball, and tennis.

Typically when an athlete sustains an injury to the ACL, the treatment involves a surgical procedure. The standard surgical procedure is to reconstruct the ligament with new tissue.

Repair of the ACL has not worked well historically, and newer procedures attempting to repair the ACL have not shown consistently good results over the long-term. While this may be the future of treatment, the current standard is to reconstruct the ligament using tissue from elsewhere in the body.

Options for Reconstruction

The first question when deciding what to reconstruct the ACL with, is to decide if you want to use your own tissue, or tissue from a donor.

Using Your Own Tissue

Using your own tissue means that your surgeon will have to harvest ligament or tendon from elsewhere in your body, typically the same leg as your injury, and use this to reconstruct a new ligament.

The most common tissues used to reconstruct the ACL are the patellar tendon and the hamstring tendon. There is great debate among orthopedic surgeons as to which of these is better, and there is no conclusive evidence to say that one is substantially better than the other. The bottom line is, they both work very well.

Using Tissue From a Donor

The other option for surgery is to have tissue from a donor used to reconstruct the ACL. Donor grafts are obtained from people who have died, and donated tissues within their body. The tissues are harvested shortly after the person has died, they are sterilized and processed, and frozen until they are used in surgery. The options for donor tissue are similar, and typically surgeons will use patellar tendon or hamstring tendons from a cadaveric donor.

Once the tissue type is selected, your surgeon will remove the remanent of your torn ACL, create tunnels in the bone, and pass the new tissue through those tunnels to create a new anterior cruciate ligament in the proper position in the center of the knee. The surgically implanted ACL is held in position with screws or some other fixation device, and over time your body will heal the graft solidly into position.

The surgical procedure to reconstruct the ACL takes about 60-90 minutes, but tends to be faster when using donor tissue. Following surgery, people will return home, typically using crutches.

Why Use Donor Tissue

Donor tissue gained significant interest a few decades ago because it made the early stages of recovery following ACL surgery much easier. The surgical procedure when using donor tissue is much faster (there is no need to obtain tissue graft), and the pain following surgery is much less (no surgery to harvest the graft).

By offering a faster surgery with less discomfort, many surgeons started to favor the use of donor tissue.

Among the advantages, were that athletes could begin their rehab a little quicker, and had better motion in the early phases of her rehab with much less discomfort.

Because of these advantages, many surgeons began performing ACL surgery with the use of donor grafts. However, as the number of donor graft ACL surgeries increased, surgeons began to notice an increase in the number of failures that resulted in the need for additional surgery.

It is well-known that not every ACL surgery works perfectly. Even with standard ACL surgery using someone's own tissue, there is about a 5-10 percent chance of reinjury of the ACL leading to the need for revision ACL surgery.

Donor Tissue Failures

Surgeons have become much more cautious in the past decade with the use of donor tissues. Compared to a 5-10 percent chance of graft failure when using an individual's own tissue, donor grafts have shown rates of failure of 25-33 percent. 

That is certainly not a guarantee of failure, and many high-level athletes have had successful ACL reconstruction with normal return to activity following donor tissue surgery. However, the likelihood of reinjury seems to be dramatically increased when donor tissue is used.

The exact reason for this higher failure rate is not entirely clear. There had been several theories that can be used to explain this higher failure rate. One of the more concerning reasons why these grafts may not be as durable is the fact that the processing of the donated tissue may lead to a weakening of that tissue. During this sterilization process, living cells are removed from the donated tissue. The process of sterilization, followed by a preservation of the tissue may weaken the overall structure of the tissue causing it to be more susceptible to failure.

Another possible explanation is that because your own tissue is already populated with living cells, the graft tissue incorporates into your body faster when using your own tissue. When using donor tissue, this process may take longer, leading to a higher susceptibility of reinjury.

For this reason, most surgeons delay the recovery timeline for people having donor tissue grafts. However, it is not clear what the optimal time frame for graft incorporation might be, and perhaps many surgeons are still too aggressive with recovery following donor tissue ACL reconstruction.

In the early days of ACL reconstruction using donor tissue, the primary concern was that of disease transmission. Many people were concerned about the possibility of transmission of viruses such as HIV or hepatitis. With improvements in testing and sterilization, the likelihood of disease transmission is close to zero.

There is a much higher theoretical chance of contamination of the graft, rather than disease transmission. However, even that is exceedingly unlikely. Today, the much bigger concern is whether or not these donor tissue grafts are strong enough. As stated previously, the failure rate of donor tissue grafts seems to be higher than when using your own tissue, but it is still a successful operation for many people.

Eligibility

Who should have a donor graft? This is a question that is open to great debate. There are surgeons who feel the donor grafts should not be used for ACL reconstruction, and there are other surgeons who are still using donor grafts in high-performance athletes.

Most surgeons agree that for participants in organized athletics, such as high school, collegiate, or professional sports, the best graft is to use their own tissue. For people who are in their 30s, 40s, or older, and do not participate in high intensity sports that place significant strain on the ACL, donor grafts may be just as effective, and the surgery much easier to tolerate. These people should understand that the rehabilitation may take longer, even if the pain level and mobility is better in those early phases following surgery. The overall incorporation of the graft into their body probably takes at least several months longer than when using your own tissue.

Typical ACL rehabilitation protocols following surgical reconstruction take approximately seven months for recovery and return to sports. There are some surgeons that accelerate this protocol, and others that may delay this, as well as variations in injury patterns which may alter this protocol.

When donor grafts are used, most surgeons will extend the rehabilitation protocol from seven months up to 9-12 months. Again, there is significant variability, and no clear consensus, on the optimal length of time from surgery to return to sports activities, but in general donor rehabilitation protocols take several months longer.

A Word From Verywell

Donor ACL graft surgery was quite popular, but has become less common in the last decade because of concerns about reinjury to the knee joint. Donor grafts have clearly shown in numerous studies a higher rate of failure that is possibly the result of weakening of the tissue during processing and sterilization. Because of this, most surgeons recommend that younger athletes, and those people participating in a regular organized sports activities consider having their own tissue used for ACL reconstruction.

Donor grafts probably have a place, which should be used most often with athletes who participate in lower intensity sports and can devote a longer time to recovery to allow the donor graft to incorporate into their body.