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J Knee Surg 2023; 36(05): 475-482
DOI: 10.1055/s-0041-1736195
Original Article

Aseptically Processed Allograft Implantation: A Safe Strategy for Knee Ligament Reconstructions

Chilan B.G. Leite 
1   Instituto de Ortopedia e Traumatologia, Hospital das Clinicas, HCFMUSP – Hospital das Clinicas, Faculdade de Medicina, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Sao Paulo, Brazil
,
João M.N. Montechi
1   Instituto de Ortopedia e Traumatologia, Hospital das Clinicas, HCFMUSP – Hospital das Clinicas, Faculdade de Medicina, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Sao Paulo, Brazil
,
Gilberto L. Camanho
1   Instituto de Ortopedia e Traumatologia, Hospital das Clinicas, HCFMUSP – Hospital das Clinicas, Faculdade de Medicina, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Sao Paulo, Brazil
,
Riccardo G. Gobbi
1   Instituto de Ortopedia e Traumatologia, Hospital das Clinicas, HCFMUSP – Hospital das Clinicas, Faculdade de Medicina, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Sao Paulo, Brazil
,
Fabio J. Angelini
1   Instituto de Ortopedia e Traumatologia, Hospital das Clinicas, HCFMUSP – Hospital das Clinicas, Faculdade de Medicina, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Sao Paulo, Brazil
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Abstract

Postoperative infections after allograft implantation is a major concern in knee ligament reconstructions considering the theoretical risk of disease transmission and its potential severity. Here, we aimed to evaluate the postoperative infection rate after knee ligament reconstructions using aseptically processed allografts, and provide an overview of the allografts use in an academic tertiary hospital. A retrospective study was performed evaluating patients who underwent knee ligament reconstructions using aseptically processed allografts, including primary and revision surgeries, from 2005 to 2018. Demographic data, including the type of knee injury and trauma energy, and postoperative data were collected focusing on postoperative infections. Regarding these infected cases, further analyses were performed considering the presenting signs and symptoms, the isolated microorganism identified in culture, the time between graft implantation and diagnosis of infection (defined as acute, subacute, and late), and the need for graft removal. A total of 180 cases of ligament reconstructions were included. The mean follow-up was 8.2 (range: 2.1–15.6) years and the mean age at surgery was 34.1 (± 11.1) years. A total of 262 allografts were implanted in those 180 cases, 93 (35.5%) as bone plug allografts and 169 (64.5%) as soft tissue allografts. Common surgical indications included multiligament reconstruction (57.2%) and primary anterior cruciate ligament (ACL) reconstruction (15%). Seven cases (3.9%) presented postoperative infections. Knee pain (100%) and swelling (100%) were the most prevalent symptoms. Two cases (28.6%) presented sinus tract. Allografts were removed in two cases, the same cases that presented draining sinus (p = 0.04). High-energy trauma was the only statistically associated factor for infection (p = 0.04). No significant association between infection and the type of allograft (p > 0.99) or sex (p = 0.35) were observed. Four cases (57.1%) had monomicrobial staphylococcal infections. Based on that, the allograft-related infection rate was 1.7% (the remaining three infected cases). Nonirradiated, aseptically processed allografts have a low postoperative infection rate in knee ligament reconstructions, being a safe alternative for surgeries that require additional source, increased variety, and quantity of grafts.

Keywords

allograft - knee - infection - ligament reconstruction


Publication History

Received: 29 September 2020

Accepted: 18 August 2021

Article published online:
05 October 2021

© 2021. Thieme. All rights reserved.

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  • References

  • 1 Barrera Oro F, Sikka RS, Wolters B. et al. Autograft versus allograft: an economic cost comparison of anterior cruciate ligament reconstruction. Arthroscopy 2011; 27 (09) 1219-1225
    CrossrefPubMedGoogle Scholar
  • 2 Hulet C, Sonnery-Cottet B, Stevenson C. et al. The use of allograft tendons in primary ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2019; 27 (06) 1754-1770
    PubMedGoogle Scholar
  • 3 Razi M, Moradi A, Safarcherati A. et al. Allograft or autograft in skeletally immature anterior cruciate ligament reconstruction: a prospective evaluation using both partial and complete transphyseal techniques. J Orthop Surg Res 2019; 14 (01) 85
    CrossrefPubMedGoogle Scholar
  • 4 Eagan MJ, McAllister DR. Biology of allograft incorporation. Clin Sports Med 2009; 28 (02) 203-214 , vii
    CrossrefPubMedGoogle Scholar
  • 5 Miller BS, Wojtys EM. Basic science aspects of the use of allografts in revision anterior cruciate ligament surgery. Sports Med Arthrosc Rev 2005; 13 (01) 3
    CrossrefPubMedGoogle Scholar
  • 6 Robertson A, Nutton RW, Keating JF. Current trends in the use of tendon allografts in orthopaedic surgery. J Bone Joint Surg 2006; 88-B (08) 988-992
    CrossrefPubMedGoogle Scholar
  • 7 Tisherman R, Wilson K, Horvath A, Byrne K, De Groot J, Musahl V. Allograft for knee ligament surgery: an American perspective. Knee Surg Sports Traumatol Arthrosc 2019; 27 (06) 1882-1890
    CrossrefPubMedGoogle Scholar
  • 8 Mistry H, Metcalfe A, Colquitt J. et al. Autograft or allograft for reconstruction of anterior cruciate ligament: a health economics perspective. Knee Surg Sports Traumatol Arthrosc 2019; 27 (06) 1782-1790
    CrossrefPubMedGoogle Scholar
  • 9 Brown MJ, Carter T. ACL allograft: advantages and when to use. Sports Med Arthrosc Rev 2018; 26 (02) 75-78
    CrossrefPubMedGoogle Scholar
  • 10 Suarez LS, Richmond JC. Overview of procurement, processing, and sterilization of soft tissue allografts for sports medicine. Sports Med Arthrosc Rev 2007; 15 (03) 106-113
    CrossrefPubMedGoogle Scholar
  • 11 Condello V, Zdanowicz U, Di Matteo B. et al. Allograft tendons are a safe and effective option for revision ACL reconstruction: a clinical review. Knee Surg Sports Traumatol Arthrosc 2019; 27 (06) 1771-1781
    CrossrefPubMedGoogle Scholar
  • 12 DiBartola AC, Everhart JS, Kaeding CC, Magnussen RA, Flanigan DC. Maximum load to failure of high dose versus low dose gamma irradiation of anterior cruciate ligament allografts: a meta-analysis. Knee 2016; 23 (05) 755-762
    CrossrefPubMedGoogle Scholar
  • 13 Crawford C, Kainer M, Jernigan D. et al. Investigation of postoperative allograft-associated infections in patients who underwent musculoskeletal allograft implantation. Clin Infect Dis 2005; 41 (02) 195-200
    CrossrefPubMedGoogle Scholar
  • 14 Lavernia CJ, Malinin TI, Temple HT, Moreyra CE. Bone and tissue allograft use by orthopaedic surgeons. J Arthroplasty 2004; 19 (04) 430-435
    CrossrefPubMedGoogle Scholar
  • 15 Schmidt-Hebbel A, Gomez C, Aviles C. et al. No association between positive intraoperative allograft cultures and infection rates after reconstructive knee ligament surgery. Knee 2018; 25 (06) 1129-1133
    CrossrefPubMedGoogle Scholar
  • 16 Tomford WW, Thongphasuk J, Mankin HJ, Ferraro MJ. Frozen musculoskeletal allografts. A study of the clinical incidence and causes of infection associated with their use. J Bone Joint Surg Am 1990; 72 (08) 1137-1143
    CrossrefPubMedGoogle Scholar
  • 17 Amatuzzi MM, Croci AT, Giovani AMM, Santos LAU. Banco de tecidos: estruturação e normatização. Rev Bras Ortop 2000; 35 (05) 165-172
    PubMedGoogle Scholar
  • 18 Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection, 1999. Am J Infect Control 1999; 27 (02) 97-132 , quiz 133–134, discussion 96
    CrossrefPubMedGoogle Scholar
  • 19 Williams III RJ, Laurencin CT, Warren RF, Speciale AC, Brause BD, O'Brien S. Septic arthritis after arthroscopic anterior cruciate ligament reconstruction. Diagnosis and management. Am J Sports Med 1997; 25 (02) 261-267
    CrossrefPubMedGoogle Scholar
  • 20 Centers for Disease Control and Prevention (CDC). Update: allograft-associated bacterial infections–United States, 2002. MMWR Morb Mortal Wkly Rep 2002; 51 (10) 207-210
    PubMedGoogle Scholar
  • 21 Granjeiro RC, Souza BGS, Antebi U. et al. Aspectos da distribuição de tecidos músculo-esqueléticos de um banco de tecidos. Acta Ortop Bras 2009; 17 (06) 336-339
    CrossrefPubMedGoogle Scholar
  • 22 Baldini T, Caperton K, Hawkins M, McCarty E. Effect of a novel sterilization method on biomechanical properties of soft tissue allografts. Knee Surg Sports Traumatol Arthrosc 2016; 24 (12) 3971-3975
    CrossrefPubMedGoogle Scholar
  • 23 Indelicato PA, Ciccotti MG, Boyd J, Higgins LD, Shaffer BS, Vangsness Jr CT. Aseptically processed and chemically sterilized BTB allografts for anterior cruciate ligament reconstruction: a prospective randomized study. Knee Surg Sports Traumatol Arthrosc 2013; 21 (09) 2107-2112
    CrossrefPubMedGoogle Scholar
  • 24 Rappé M, Horodyski M, Meister K, Indelicato PA. Nonirradiated versus irradiated Achilles allograft: in vivo failure comparison. Am J Sports Med 2007; 35 (10) 1653-1658
    CrossrefPubMedGoogle Scholar
  • 25 Sun K, Zhang J, Wang Y. et al. A prospective randomized comparison of irradiated and non-irradiated hamstring tendon allograft for ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2012; 20 (01) 187-194
    CrossrefPubMedGoogle Scholar
  • 26 Yu A, Prentice HA, Burfeind WE, Funahashi T, Maletis GB. Risk of infection after allograft anterior cruciate ligament reconstruction: are nonprocessed allografts more likely to get infected? A cohort study of over 10,000 allografts. Am J Sports Med 2018; 46 (04) 846-851
    CrossrefPubMedGoogle Scholar
  • 27 Nakata K, Shino K, Horibe S. et al. Arthroscopic anterior cruciate ligament reconstruction using fresh-frozen bone plug-free allogeneic tendons: 10-year follow-up. Arthroscopy 2008; 24 (03) 285-291
    CrossrefPubMedGoogle Scholar
  • 28 McGilvray KC, Santoni BG, Turner AS, Bogdansky S, Wheeler DL, Puttlitz CM. Effects of (60)Co gamma radiation dose on initial structural biomechanical properties of ovine bone–patellar tendon–bone allografts. Cell Tissue Bank 2011; 12 (02) 89-98
    CrossrefPubMedGoogle Scholar
  • 29 Yanke AB, Bell R, Lee A. et al. The biomechanical effects of 1.0 to 1.2 Mrad of γ irradiation on human bone-patellar tendon-bone allografts. Am J Sports Med 2013; 41 (04) 835-840
    CrossrefPubMedGoogle Scholar
  • 30 Maletis GB, Chen J, Inacio MCS, Love RM, Funahashi TT. Increased risk of revision after anterior cruciate ligament reconstruction with soft tissue allografts compared with autografts: graft processing and time make a difference. Am J Sports Med 2017; 45 (08) 1837-1844
    CrossrefPubMedGoogle Scholar
  • 31 Zeng C, Gao S-G, Li H. et al. Autograft versus allograft in anterior cruciate ligament reconstruction: a meta-analysis of randomized controlled trials and systematic review of overlapping systematic reviews. Arthroscopy 2016; 32 (01) 153-63.e18
    CrossrefPubMedGoogle Scholar
  • 32 Kainer MA, Linden JV, Whaley DN. et al. Clostridium infections associated with musculoskeletal-tissue allografts. N Engl J Med 2004; 350 (25) 2564-2571
    CrossrefPubMedGoogle Scholar
  • 33 Mouzopoulos G, Fotopoulos VC, Tzurbakis M. Septic knee arthritis following ACL reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc 2009; 17 (09) 1033-1042
    CrossrefPubMedGoogle Scholar
  • 34 Ibrahim T, Stafford H, Esler CNA, Power RA. Cadaveric allograft microbiology. Int Orthop 2004; 28 (05) 315-318
    CrossrefPubMedGoogle Scholar
  • 35 Maletis GB, Inacio MCS, Reynolds S, Desmond JL, Maletis MM, Funahashi TT. Incidence of postoperative anterior cruciate ligament reconstruction infections: graft choice makes a difference. Am J Sports Med 2013; 41 (08) 1780-1785
    CrossrefPubMedGoogle Scholar
  • 36 Katz LM, Battaglia TC, Patino P, Reichmann W, Hunter DJ, Richmond JC. A retrospective comparison of the incidence of bacterial infection following anterior cruciate ligament reconstruction with autograft versus allograft. Arthroscopy 2008; 24 (12) 1330-1335
    CrossrefPubMedGoogle Scholar
  • 37 Centeno JM, Woolf S, Reid III JB, Lubowitz JH. Do anterior cruciate ligament allograft culture results correlate with clinical infections?. Arthroscopy 2007; 23 (10) 1100-1103
    CrossrefPubMedGoogle Scholar
  • 38 Barker JU, Drakos MC, Maak TG, Warren RF, Williams III RJ, Allen AA. Effect of graft selection on the incidence of postoperative infection in anterior cruciate ligament reconstruction. Am J Sports Med 2010; 38 (02) 281-286
    CrossrefPubMedGoogle Scholar
  • 39 Burks RT, Friederichs MG, Fink B, Luker MG, West HS, Greis PE. Treatment of postoperative anterior cruciate ligament infections with graft removal and early reimplantation. Am J Sports Med 2003; 31 (03) 414-418
    CrossrefPubMedGoogle Scholar
  • 40 Indelli PF, Dillingham M, Fanton G, Schurman DJ. Septic arthritis in postoperative anterior cruciate ligament reconstruction. Clin Orthop Relat Res 2002; (398) 182-188
    CrossrefPubMedGoogle Scholar
  • 41 Judd D, Bottoni C, Kim D, Burke M, Hooker S. Infections following arthroscopic anterior cruciate ligament reconstruction. Arthroscopy 2006; 22 (04) 375-384
    CrossrefPubMedGoogle Scholar