With an estimated 80,000 anterior cruciate ligament (ACL) tears each year in the United States, including the recent injury to golfer Tiger Woods, choosing the best replacement ligament for an ACL surgery is vital.
A new study just released at the 2008 Annual Meeting of the American Orthopaedic Society for Sports Medicine found that using a cadaver ligament may not be the best choice.

The ACL is one of the major stabilizing ligaments of the knee. Located in the center of the knee joint, it runs from the thigh bone to the shin bone, through the center of the knee. Typically, the ACL tear occurs after a sudden direction change. To repair a torn ACL, an orthopedic surgeon replaces the damaged ligament with a new one, either from a cadaver or from the patient’s own body (usually the patellar-tendon bone or the hamstring tendon).

But according to a study done at the Mississippi Sports Medicine and Orthopaedic Center, cadaver ligaments fail about a fourth of the time.  In this study, 64 patients aged 40 years and younger with high activity levels who had ACL reconstruction with a cadaver replacement ligament were followed for at least 2 years. ACL reconstruction failure was defined as the need for a second reconstruction because of injury, graft failure, or poor scores on a combination of orthopedic outcome-measure tests. The study found that ACL reconstructions failed, as defined by the study, in 15 of 64 patients( or 23.4%).

“Choosing a replacement ligament, whether it comes from a cadaver or the patient’s own tissue, is a decision that must be made by the surgeon and patient,” coauthor Kurre Luber, MD, orthopedic surgery fellow at Mississippi Sports Medicine and Orthopedic Center, in Jackson, said during his presentation.

The study, he said, found a significantly high failure rate in patients aged 40 years and younger with high activity levels in ACL-dependent sports, such as tennis, basketball, soccer, and downhill skiing.

“Certainly, it would be naïve to think that only the graft selection led to these failures, we also need to look at surgical technique (single versus double bundle),” Luber said. “Better outcome measures also need to be developed. However, this study definitely raises questions about the validity of using cadaver tissue in this patient subgroup.”

“The failure rate in this young active population is exceedingly high when compared with a previous study that looked at failure rates of cadaver replacement ligament in patients older than 40,” said corresponding author Gene Barrett, MD, also from the Mississippi Sports Medicine and Orthopedic Center. “The older group’s failure rate was 2.4%. So although there are obvious benefits to using the cadaver ligament, such as avoiding a second surgical site on the patient, a quicker return to work, and less postoperative pain, for a young patient who is very active, it may not be the right choice.”

Joseph Bosco, MD, vice chair of orthopaedics at New York University Medical Center, in New York, who was not involved in the study, agreed. “It seems a viable option for the older sedentary patient, but for the younger patient, most of us would choose to use their own tissue,” said Bosco. “It just makes more intuitive sense.

**quotes were taken from Doctor interviews with Medscape Medical News