Donor-Site Morbidity and Anterior Knee Problems After ACL Reconstruction Using Autografts
Abstract & Commentary
Synopsis: Donor site morbidity continues to be a concern when harvesting autografts for ACL reconstruction.
Source: Kartus J, et al. Donor site morbidity and anterior knee problems after anterior cruciate ligament reconstruction using autografts. Arthroscopy. 2001;17(9):971-980.
This current concepts article reviews the literature on donor-site morbidity and anterior knee pain following harvesting of the 4 commonly used ACL autografts: patella tendon, hamstring tendons, iliotibial band, and quadriceps tendon. According to Kartus and colleagues, 40-60% of patients undergoing ACL reconstruction using autografts report symptoms of donor-site morbidity-tenderness, anterior knee pain, altered knee sensitivity, and inability to kneel. Yet, autografts remain the graft of choice for ACL reconstruction.
The greatest number of donor-site morbidity symptoms are reported for patella tendon autografts, even when great care is taken during the procedure. Kartus et al divide donor-site morbidity into 3 categories: 1) general pain and discomfort secondary to decreased function (loss of range of motion and strength); 2) specific discomfort-tenderness, numbness within the incisional area; and 3) late tissue reactions at or close to the donor site.
There is some dispute about whether anterior knee symptoms are related to loss of full flexion, but as noted in this article, lack of full extension and decreased quadriceps or hamstrings strength does appear to correlate with postoperative anterior knee pain. Kartus et al also stress that great care must be exerted when making incisions about the patella to protect the infrapatellar branch of the saphenous nerve, as alteration of sensation in its distribution results in significant discomfort, especially with kneeling. The pattern of altered sensitivity of the knee produced by injuring a branch of this nerve when making incisions for hamstring grafts does not appear to result in as many complaints, as the area of altered sensation is located more distally. Kartus et al diagrammatically illustrate the course of this nerve and potential sites of injury.
Harvesting fascia lata can result in a fascia hernia in the lateral thigh. There is not much information in the literature on complications following quadriceps tendon harvesting.
Radiographic assessment of donor sites has revealed that the thickness of the patella tendon increases for at least 2 years following graft harvest, and reports on the time needed for radiographic healing of the tendon defect created by harvesting patella tendon varies from 6 months to 2 years. Some report the defect persists even after 2 years; hence, reharvesting patella should be discouraged for at least 2 years following the index operation. Even though the defect within the tendon seems to persist for quite some time, symptoms rarely correlate with imaging evidence of persistence of the defect. Histological examination of biopsies from patella tendon harvest sites in humans where the graft site was closed and from harvest sites where it was left open do not appear normal even after several years.
Imaging studies support regrowth of semitendinous and gracilis tendons following harvesting, and in one study of 5 open biopsies following harvesting, the biopsy specimens of the hamstring graft sites revealed tissue resembling normal tendon. Kartus et al found no radiographic or histological data for iliotibial band or quadriceps tendon harvest sites.
Comment by Letha Y. Griffin, MD, PhD
Kartus et al do an excellent job in reviewing the current literature on graft site morbidity following ACL reconstruction. A decade or so ago, allografts were favored by some as they eliminated the problem of donor site morbidity. However, concern continues over the degree to which allografts are replaced by autologous tissue, forcing orthopedists to discover ways to decrease autograft harvest site morbidity.
For example, Kartus et al stress the need to be cognizant of the course of the infrapatella nerve to try to avoid injuring it with incisions about the anterior knee. They also stress the need for developing full range of motion and strength postoperatively since failing to do so is correlated with an increase in postoperative anterior knee pain. Moreover, since graft site symptoms are greater following patella tendon than hamstring graft harvests, Kartus et al suggest that ". . .if, in prospective randomized studies, the use of hamstring tendon autografts for ACL reconstruction is shown to produce long-term laxity measurements equal to those of patella tendon autografts. . ." surgeons should preferentially consider hamstring tendon autografts.
Dr. Griffin, Adjunct and Clinical Faculty, Department of Kinesiology and Health, Georgia State University, Atlanta, GA, is Associate Editor of Sports Medicine Reports.
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