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What Factors Influence the Biomechanical Properties of Allograft Tissue for ACL Reconstruction? A Systematic Review

Lansdown, D. A., Riff, A. J., Meadows, M., Yanke, A. B., & Bach, B. R. (2017). What Factors Influence the Biomechanical Properties of Allograft Tissue for ACL Reconstruction? A Systematic Review. Clinical Orthopaedics and Related Research, 1–15.

Background

Allograft tissue is used in 22% to 42% of anterior cruciate ligament (ACL) reconstructions. Clinical outcomes have been inconsistent with allograft tissue, with some series reporting no differences in outcomes and others reporting increased risk of failure. There are numerous variations in processing and preparation that may influence the eventual performance of allograft tissue in ACL reconstruction. We sought to perform a systematic review to summarize the factors that affect the biomechanical properties of allograft tissue for use in ACL reconstruction. Many factors might impact the biomechanical properties of allograft tissue, and these should be understood when considering using allograft tissue or when reporting outcomes from allograft reconstruction.

Questions/purposes

What factors affect the biomechanical properties of allograft tissue used for ACL reconstruction?

Methods

We performed a systematic review to identify studies on factors that influence the biomechanical properties of allograft tissue through PubMed and SCOPUS databases. We included cadaveric and animal studies that reported on results of biomechanical testing, whereas studies on fixation, histologic evaluation, and clinical outcomes were excluded. There were 319 unique publications identified through the search with 48 identified as relevant to answering the study question. For each study, we recorded the type of tissue tested, parameters investigated, and the effects on biomechanical behavior, including load to failure and stiffness. Primary factors identified to influence allograft tissue properties were graft tissue type, sterilization methods (irradiation and chemical processing), graft preparation, donor parameters, and biologic adjuncts.

Results

Load to failure and graft stiffness varied across different tissue types, with nonlooped tibialis grafts exhibiting the lowest values. Studies on low-dose irradiation showed variable effects, whereas high-dose irradiation consistently produced decreased load to failure and stiffness values. Various chemical sterilization measures were also associated with negative effects on biomechanical properties. Prolonged freezing decreased load to failure, ultimate stress, and ultimate strain. Up to eight freeze-thaw cycles did not lead to differences in biomechanical properties of cadaveric grafts. Regional differences were noted in patellar tendon grafts, with the central third showing the highest load to failure and stiffness. Graft diameter strongly contributed to load-to-failure measurements. Age older than 40 years, and especially older than 65 years, negatively impacted biomechanical properties, whereas gender had minimal effect on the properties of allograft tissue. Biologic adjuncts show potential for improving in vivo properties of allograft tissue.

Conclusions

Future clinical studies on allograft ACL reconstruction should investigate in vivo graft performance with standardized allograft processing and preparation methods that limit the negative effects on the biomechanical properties of tissue. Additionally, biologic adjuncts may improve the biomechanical properties of allograft tissue, although future preclinical and clinical studies are necessary to clarify the role of these treatments.

Cartilage Restoration and Meniscus Transplantation

Lansdown, D. A., Riff, A. J., Meadows, M., Yanke, A. B., & Bach, B. R. (2017). What Factors Influence the Biomechanical Properties of Allograft Tissue for ACL Reconstruction? A Systematic Review. Clinical Orthopaedics and Related Research, 1–15.

Meyer, M. A., Leroux, T. S., Levy, D. M., Tilton, A. K., Lewis, P. B., Yanke, A. B., & Cole, B. J. (2017). Flexion Posteroanterior Radiographs Affect Both Enrollment for and Outcomes After Injection Therapy for Knee Osteoarthritis. Orthopaedic Journal of Sports Medicine, 5(5), 2325967117706692.

Meyer MA, McCarthy MA, Gitelis ME, Poland SG, Urita A, Chubinskaya S, Yanke AB, Cole BJ. (2016). Effectiveness of Lavage Techniques in Removing Immunogenic Elements from Osteochondral Allografts. Cartilage.

Saltzman BM, Meyer MA, Weber AE, Poland SG, Yanke AB, & Cole BJ. (2017). Prospective Clinical and Radiographic Outcomes After Concomitant Anterior Cruciate Ligament Reconstruction and Meniscal Allograft Transplantation at a Mean 5-Year Follow-up. The American Journal of Sports Medicine, 45(3), 550–562.

Saltzman BM, Griffin JW, Wetters N, Meyer MA, Cole BJ, Yanke AB. (2016) Concomitant Arthroscopic Meniscal Allograft Transplantation and Anterior Cruciate Ligament Reconstruction. Arthroscopy Techniques, 5(5), e1161–e1171.

Hamamoto JT, Leroux T, Chahla J, Bhatia S, Higgins JD, Romeo AA, Yanke AB, Verma NN. Assessment and Evaluation of Glenoid Bone Loss. Arthroscopy Techniques, 5(4), e947–e951.

Riboh JC, Cvetanovich GL, Cole BJ, Yanke AB. Comparative efficacy of cartilage repair procedures in the knee: a network meta-analysis. Knee Surgery, Sports Traumatology, Arthroscopy, 1–14.

Riboh, J. C., Saltzman, B. M., Yanke, A. B., & Cole, B. J. (2015). Human Amniotic Membrane-Derived Products in Sports Medicine: Basic Science, Early Results, and Potential Clinical Applications. The American Journal of Sports Medicine.

Saltzman BM, Kuhns BD, Weber AE, Yanke AB, Nho SJ. (2016). Stem Cells in Orthopedics: A Comprehensive Guide for the General Orthopedist. American Journal of Orthopedics (Belle Mead, N.J.), 45(5), 280–326.

Fillingham, Y. A., Riboh, J. C., Erickson, B. J., Bach, B. R., & Yanke, A. B. (2016). Inside-Out Versus All-Inside Repair of Isolated Meniscal Tears: An Updated Systematic Review. The American Journal of Sports Medicine.

Riboh JC, Saltzman BM, Yanke AB, Cole BJ. Human Amniotic Membrane-Derived Products in Sports Medicine: Basic Science, Early Results, and Potential Clinical Applications. The American Journal of Sports Medicine.

Rabinowitz, J., Yanke, A. B., & Cole, B. J. (2015). Evaluating Healing of Allograft Tissues in the Shoulder – Cartilage and Bone. Operative Techniques in Sports Medicine, 23(1), 18–23.

Riboh JC, Saltzman BM, Yanke AB, Fortier L, Cole BJ. Effect of Leukocyte Concentration on the Efficacy of Platelet-Rich Plasma in the Treatment of Knee Osteoarthritis. The American Journal of Sports Medicine, 0363546515580787.

Yanke, A. B., & Chubinskaya, S. (2015). The state of cartilage regeneration: current and future technologies. Current Reviews in Musculoskeletal Medicine. doi:10.1007/s12178-014-9254-7

Shin, J. J., Haro, M., Yanke, A. B., Mascarenhas, R., Romeo, A. A., Cole, B. J., et al. (2015). Topographic Analysis of the Capitellum and Distal Femoral Condyle: Finding the Best Match for Treating Osteochondral Defects of the Humeral Capitellum. Arthroscopy : the Journal of Arthroscopic & Related Surgery : Official Publication of the Arthroscopy Association of North America and the International Arthroscopy Association. doi:10.1016/j.arthro.2014.11.039

Cvetanovich, G. L., Yanke, A. B., McCormick, F., Bach, B. R., & Cole, B. J. (2015). Trends in Meniscal Allograft Transplantation in the United States, 2007 to 2011. Arthroscopy : the Journal of Arthroscopic & Related Surgery : Official Publication of the Arthroscopy Association of North America and the International Arthroscopy Association. doi:10.1016/j.arthro.2014.12.020

Yanke, A. B., & Chubinskaya, S. (2015). The state of cartilage regeneration: current and future technologies. Current Reviews in Musculoskeletal Medicine. doi:10.1007/s12178-014-9254-7

Yanke AB, Cole BJ. (2014). Microfracture: dead or the future? Orthopedics, 37(12), 798–800. doi:10.3928/01477447-20141124-02

Yanke AB, Chalmers PN, Frank RM, Friel NA, Karas V, Cole BJ. (2014). Clinical Outcome of Revision Meniscal Allograft Transplantation: Minimum 2-Year Follow-up. Arthroscopy : the Journal of Arthroscopic & Related Surgery : Official Publication of the Arthroscopy Association of North America and the International Arthroscopy Association. doi:10.1016/j.arthro.2014.06.027

Click here to download the article: Clinical Outcome of Revision Meniscal Allograft Transplantation: Minimum 2-Year Follow-up

Yanke AB, Wuerz T, Saltzman BM, Butty D, Cole BJ. (2014). Management of Patellofemoral Chondral Injuries. Clinics in Sports Medicine, 33(3), 477–500. doi:10.1016/j.csm.2014.03.004

Mascarenhas R, Yanke AB, Frank RM, Butty DC, Cole BJ. (2014). Meniscal Allograft Transplantation: Preoperative Assessment, Surgical Considerations, and Clinical Outcomes. The Journal of Knee Surgery. doi:10.1055/s-0034-1382080

McCormick F, Yanke AB, Provencher MT, Cole BJ: Minced articular cartilage-Basic science, surgical technique, and clinical application. Sports Med and Arthroscopy Review, 16(4): 217-220, 2008.

Cvetanovich GL, Chalmers PN, Yanke AB, Gupta AK, Klosterman EL, Verma NN, Romeo AA. Feasibility of an osteochondral allograft for biologic glenoid resurfacing. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons … [et al.]. doi:10.1016/j.jse.2013.07.038

Erickson BJ, Chalmers PN, Yanke AB, Cole BJ. Surgical management of osteochondritis dissecans of the knee. Curr Rev Musculoskelet Med. 2013 Feb 3.

Chalmers PN, Yanke AB, Karas V, Sherman SL, Cole BJ. Combined cartilage restoration and distal realignment for patellar and trochlear chondral lesions. American Academy of Orthopaedic Surgeons

McNickle AG, L’Heureux DR, Yanke AB, Cole BJ. Outcomes of autologous chondrocyte implantation in a diverse patient population. Am J Sports Med. 2009 Jul.;37(7):1344–1350. PMID: 19286911

Van Thiel GS, Verma N, Yanke AB, Basu S, Farr J, Cole BJ. Meniscal Allograft Size Can Be Predicted by Height, Weight, and Gender. Arthroscopy, 2009 July; 25(7):722-727. PMID: 19560635

Gomoll AH, Yanke AB, Kang RW, Chubinskaya S, Williams JM, Bach BR, et al. Long-term effects of bupivacaine on cartilage in a rabbit shoulder model. Am J Sports Med. 2009 Jan.;37(1):72–77. PMID: 18832481

McCormick F, Yanke A, Provencher MT, Cole BJ. Minced articular cartilage-basic science, surgical technique, and clinical application. Sports Med Arthrosc, 2008 Dec; 16(4):217-20.PMID: 19011553

Rue J-PH, Yanke AB, Busam ML, McNickle AG, Cole BJ. Prospective evaluation of concurrent meniscus transplantation and articular cartilage repair: minimum 2-year follow-up. Am J Sports Med. 2008 Sep.;36(9):1770–1778. PMID: 18483199

Chubinskaya S, Hakimiyan A, Rappoport L, Yanke A, Rueger DC, Cole BJ. Response of Human Chondrocytes Prepared for Autologous Implantation to Growth Factors. Journal of Knee Surgery, 2008 Jul;21(3):192-9. PMID: 18686480

Lewis PB, Williams JM, Hallab N, Virdi A, Yanke AB, Cole BJ. Multiple freeze-thaw cycled meniscal allograft tissue: A biomechanical, biochemical, and histologic analysis. J Orthop Res. 2008 Jan.;26(1):49–55. PMID: 17676620

Cole BJ, Yanke A, Provencher MT: Nonarthroplasty Alternatives for the Treatments of Glenohumeral Arthritis. J Shoulder and Elbow Surg. Jul 20 2007. PMID: 17644005

Chubinskaya S, Hakimiyan A, Pacione C, Yanke A, Rappoport L, Aigner T, Rueger D, Loeser RF. Synergistic Effect of IGF-1 and OP-1 on Matrix Formation by Normal and OA Chondrocytes Cultured in Alginate Beads. Osteoarthritis and Cartilage, Apr; 15(4):421-30, 2007. PMID: 1894688

Landis WJ, Jacquet R, Hillyer J, Lowder E, Yanke A, Siperko L, Asamura S, Kusuhara H, Enjo M, Chubinskaya S, Potter K, and Isogai N: Design and assessment of a tissue-engineered model of human phalanges and a small joint. Orthod Craniofac Res, Nov; 8(4): 303-12, 2005. PMID: 16238611

Patellofemoral Disorders – Yanke AB, Wuerz T, Saltzman BM, Butty D, Cole BJ. (2014). Management of Patellofemoral Chondral Injuries. Clinics in Sports Medicine, 33(3), 477–500. doi:10.1016/j.csm.2014.03.004

Chalmers PN, Yanke AB, Karas V, Sherman SL, Cole BJ. Combined cartilage restoration and distal realignment for patellar and trochlear chondral lesions. American Academy of Orthopaedic Surgeons

ACL Surgery

Other Knee

Rotator Cuff Repair

Other Shoulder

Yanke AB, Shin J, Pearson I, Bach BR Jr, Romeo A, Cole BJ, , Verma N. Glenoid Bone Loss: Three Dimensional MRI versus CT Reconstructions. Arthroscopy : the Journal of Arthroscopic & Related Surgery : Official Publication of the Arthroscopy Association of North America and the International Arthroscopy Association.

Shin JJ, Mascarenhas R, Patel AV, Yanke AB, Nicholson GP, Cole BJ, Romeo AA, Verma NN. (2015). Clinical outcomes following revision anterior shoulder arthroscopic capsulolabral stabilization. Archives of Orthopaedic and Trauma Surgery, 1–7.

Mellano CR, Shin JJ, Yanke AB, Verma NN. Disorders of the Long Head of the Biceps Tendon. Instr Course Lect 2015; 64: Journal of Bone and Joint Surgery

Chalmers PN, Yanke AB, Cvetanovich GL, Verma NN, Romeo AA: Arthroscopic and open biceps tenodesis distal to the intertubercular groove. Orthopaedic Knowledge Online Journal 2013;11(7): Accessed July 1, 2013.

Ellman MB, Yanke AB, Juhan T, Verma NN, Nicholson GP, Bush-Joseph C, Romeo AA. Open repair of retracted latissimus dorsi tendon avulsion. Am J Orthopedics. June 2013, 42(6), 280–285.

Ellman MB, Yanke AB, Juhan T, Verma NN, Nicholson GP, Bush-Joseph C, Bach BR, Romeo AA. Open repair of an acute latissimus tendon avulsion in a Major League Baseball pitcher. Journal of Shoulder and Elbow Surgery: 22(7), e19–23. doi:10.1016/j.jse.2013.03.013

Bhatia S, Chalmers PN, Yanke AB, Romeo AA, Verma NN. (2012). Arthroscopic suprascapular nerve decompression: transarticular and subacromial approach. Arthroscopy Techniques, 1(2), e187–92. doi:10.1016/j.eats.2012.07.004

Yanke AB, Ghodadra N, Sherman SL, Romeo A, Verma MV. Arthroscopic Suprascapular Nerve Decompression: Etiology, Diagnosis, and Surgical Technique. American Academy of Orthopaedic Surgeons Web site: Orthopaedic Knowledge Online 2012 10(2): Accessed February 1, 2012

Yanke AB, Van Thiel GS, LeClere LE, Solomon DJ, Bach BR Jr, Provencher MT: Diagnosis and arthroscopic management of posterior shoulder instability. American Academy of Orthopaedic

Singaraju VM, Kang RW, Yanke AB, McNickle AG, Lewis PB, Wang VM, Williams JM, Chubinskaya S, Romeo AA, Cole BJ. Biceps Tendinitis in Chronic Rotator Cuff Tears: A Histological Perspective. Journal of Shoulder and Elbow Surgery, 2008 Nov-Dec;17(6):898-904. PMID: 18786837

Alpert JM, Verma NN, Wysocki R, Yanke AB, Romeo AA. Arthroscopic Treatment of Multidirectional Shoulder Instability with Minimum 270° Labral Repair: Minimum 2 year follow-up. Arthroscopy, 2008 Jun;24(6):704-11. PMID: 18514115

Hip Impingement and Other