Allografts for Ligament Reconstruction: Where Are We Now?

The use of musculoskeletal allografts by orthopedic surgeons continues to rise. The process of procuring and sterilizing allografts is evolving with much consideration to limiting the spread of infectious diseases and preserving tissue integrity. Research involving the application of allografts, particularly for ligament repair, is quite active, necessitating an update for the practicing orthopedist. Avoiding donor site morbidities is one of the most commonly cited advantages of allografts over autografts. There is controversy amongst studies for allografts in terms of their biological incorporation and clinical outcomes compared to autografts. This article focuses on reviewing the most current literature and usage of allograft tissue for ligamentous reconstruction amongst orthopedic surgeons today. It includes an in-depth analysis of the current processing, handling, and safety standards employed today, in addition to the advantages and disadvantages of allograft use.

Empirical correction of multifilter rotating shadowband radiometer (MFRSR) aerosol optical depths for the aerosol forward scattering and development of a long-term integrated MFRSR-Cimel dataset at Lampedusa.

Aerosol optical properties have been measured on the island of Lampedusa (35.5°N, 12.6°E) with seven-band multifilter rotating shadowband radiometers (MFRSRs) and a CE 318 Cimel sunphotometer (part of the AERONET network) since 1999. Four different MFRSRs have operated since 1999. The Cimel sunphotometer has been operational for a short period in 2000 and in 2003-2006 and 2010-present. Simultaneous determinations of the aerosol optical depth (AOD) from the two instruments were compared over a period of almost 4 years at several wavelengths between 415 and 870 nm. This is the first long-term comparison at a site strongly influenced by desert dust and marine aerosols and characterized by frequent cases of elevated AOD. The datasets show a good agreement, with MFRSR underestimating the Cimel AOD in cases with low Ångström exponent; the underestimate decreases for increasing wavelength and increases with AOD. This underestimate is attributed to the effect of aerosol forward scattering on the relatively wide field of view of the MFRSR. An empirical correction of the MFRSR data was implemented. After correction, the mean bias (MB) between MFRSR and Cimel simultaneous AOD determinations is always smaller than 0.004, and the root mean square difference is ≤0.031 at all wavelengths. The MB between MFRSR and Cimel monthly averages (for months with at least 20 days with AOD determinations) is 0.0052. Thus, by combining the MFRSR and Cimel observations, an integrated long-term series is obtained, covering the period 1999-present, with almost continuous measurements since early 2002. The long-term data show a small (nonstatistically significant) decreasing trend over the period 2002-2013, in agreement with independent observations in the Mediterranean. The integrated Lampedusa dataset will be used for aerosol climatological studies and for verification of satellite observations and model analyses.

Myth busters: an AOA symposium: AOA critical issues.

One of the goals of the annual American Orthopaedic Association (AOA) meeting is to address controversy, both in leadership and clinical practice. A panel of experts in their respective fields presented the background and literature behind three "myths" in orthopaedic management and made conclusions as to their validity. First, Dr. Kocher took on the myth of prophylactic pinning on the contralateral "normal" side for a patient with a slipped capital femoral epiphysis. Second, Dr. Probe evaluated the myth that all intertrochanteric fractures are best treated with intramedullary devices. Last, Dr. Foster and Dr. Silvestri tackled the myth that autograft is always the best choice for anterior cruciate ligament (ACL) reconstruction. All three of these topics are subjects of current debate. The panel's careful examination of the available data along with their expertise in the management of these problems is presented in this thought-provoking JBJS Critical Issues article.

Does double-row rotator cuff repair improve functional outcome of patients compared with single-row technique? A systematic review.

BACKGROUND: The advantage of single-row versus double-row arthroscopic rotator cuff repair techniques has been a controversial issue in sports medicine and shoulder surgery. There is biomechanical evidence that double-row techniques are superior to single-row techniques; however, there is no clinical evidence that the double-row technique provides an improved functional outcome. HYPOTHESIS: When compared with single-row rotator cuff repair, double-row fixation, although biomechanically superior, has no clinical benefit with respect to retear rate or improved functional outcome. STUDY DESIGN: Systematic review. METHODS: The authors reviewed prospective studies of level I or II clinical evidence that compared the efficacy of single- and double-row rotator cuff repairs. Functional outcome scores included the American Shoulder and Elbow Surgeons (ASES) shoulder scale, the Constant shoulder score, and the University of California, Los Angeles (UCLA) shoulder rating scale. Radiographic failures and complications were also analyzed. A test of heterogeneity for patient demographics was also performed to determine if there were differences in the patient profiles across the included studies. RESULTS: Seven studies fulfilled our inclusion criteria. The test of heterogeneity across these studies showed no differences. The functional ASES, Constant, and UCLA outcome scores revealed no difference between single- and double-row rotator cuff repairs. The total retear rate, which included both complete and partial retears, was 43.1% for the single-row repair and 27.2% for the double-row repair (P = .057), representing a trend toward higher failures in the single-row group. CONCLUSION: Through a comprehensive literature search and meta-analysis of current arthroscopic rotator cuff repairs, we found that the single-row repairs did not differ from the double-row repairs in functional outcome scores. The double-row repairs revealed a trend toward a lower radiographic proven retear rate, although the data did not reach statistical significance. There may be a concerning trend toward higher retear rates in patients undergoing a single-row repair, but further studies are required.

Does the graft source really matter in the outcome of patients undergoing anterior cruciate ligament reconstruction? An evaluation of autograft versus allograft reconstruction results: a systematic review.

BACKGROUND: Despite the large number of anterior cruciate ligament reconstructions performed each year, there remains a significant controversy regarding the effect of the graft source on the functional outcome of patients. HYPOTHESIS: There is no difference in outcomes of autograft versus allograft anterior cruciate ligament reconstructions. STUDY DESIGN: Systematic review. METHODS: The authors systematically identified prospective studies (Oxford level of evidence I or II only) that included autograft patients, allograft patients, or both. Objective outcomes that were reported were meta-analyzed; this included pivot-shift results, KT-1000 arthrometer results, International Knee Documentation Committee (IKDC) scores, Lysholm Scores, graft failures, and postoperative complications. Two statistical analyses were performed. First a primary statistical analysis was performed comparing pooled autograft data (bone-patellar-tendon bone and hamstrings combined) and pooled allograft data (bone-patellar-tendon bone and hamstrings combined). To have a more comprehensive understanding of the differences between each specific graft source, a secondary analysis was performed without pooling the data; this directly compared the 4 types of graft sources that were studied. RESULTS: Over 400 scientific manuscripts were initially reviewed; 31 manuscripts fulfilled all of the search criteria. There were very few statistically significant differences between autograft and allograft tissue. The KT-1000 arthrometer laxity testing revealed a mean of 1.4 +/- 0.2 mm (weighted mean +/- standard error of the mean) for the allograft group compared with 1.8 +/- 0.1 mm for the autograft group (t = 2.40; P <.02). However, this difference was only for the mean score; there was no statistical significance when considering KT-1000 arthrometer measurements of greater than 3 or 5 mm. The percentage of patients receiving a final IKDC score of "A" (normal knee) was statistically significant for allograft tissue (43.9% +/- 5.5%) versus autograft tissue (28.2% +/- 1.0%) reconstructions. There was no statistically significant difference between the percentages of IKDC scores of A or B for patients receiving pooled allograft (82.9% +/- 4.2%) versus pooled autograft (87.2% +/- 0.9%) anterior cruciate ligament reconstruction (t = 1.01; P > .1). The graft failure rate was 4.7 +/- 0.5 per 100 for autograft reconstructions and 8.2 +/- 2.1 per 100 allograft reconstructions; although this may represent a trend, it is not statistically significant (t = 1.49; P > .1). The complication rate was slightly higher for autograft reconstructions at 3.5 +/- 0.4 complications per 100 autograft reconstructions compared with 2.4 +/- 1.1 complications per 100 allograft reconstructions, but not significant (t = 1.41; P > .1). CONCLUSION: After a comprehensive examination and statistical analysis of the modern literature, the authors could not identify an individual graft source that was clearly superior to the other graft sources. This led them to believe that, with currently available data, the graft source has a minimal effect on the outcome of patients undergoing anterior cruciate ligament reconstruction.