Allografts for ACL Reconstruction Survey Report...3 | Page Executive Summary 1) 4,000 orthopaedic...

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Allografts for ACL Reconstruction Survey Report

Prepared by: American Academy of Orthopaedic Surgeons (AAOS) Department of Research and Scientific Affairs

July 1, 2013

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Table of Contents Executive Summary ........................................................................................................................ 3

Background ..................................................................................................................................... 4

Methodology ................................................................................................................................... 4

Demographics ................................................................................................................................. 4

Results ............................................................................................................................................. 6

Appendix A: Results with Confidence Intervals .......................................................................... 16

Appendix B: Survey Instrument ................................................................................................... 66

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Executive Summary 1) 4,000 orthopaedic surgeons with a sports medicine specialty were invited to

participate in a survey regarding allografts for ACL reconstruction. 833 surgeons completed the survey which represents a response rate of 20.8%.

2) Many surgeons reported that they are more hesitant to use allografts with young athletic patients who intend to return to ACL-dependent activities. Many cited research reports that appeared recently that have indicated higher graft failure rates in this population.

3) On the other hand, a significant percent of respondents indicated that they are using allografts more in active patients over 35-40 years of age.

4) Most respondents do not have different rehabilitation protocols for allograft patients although half do delay return to sports compared with autograft patients.

5) The effects of irradiation on graft biological and biomechanical properties is a concern for many surgeon although close to one-half use irradiated grafts.

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Background The 2013 Allografts for ACL Reconstruction Survey was developed by the American Orthopaedic Society for Sports Medicine (AOSSM) in conjunction with the American Academy of Orthopaedic Surgeons (AAOS) Department of Research and Scientific Affairs to assess the practices, beliefs and knowledge of orthopaedic surgeons with a sports medicine focus regarding the use of allografts in ACL reconstruction. The results of this survey will serve as benchmark information for future research.

Methodology The web-based 2013 Allografts for ACL Reconstruction Survey was distributed to 4,000 orthopaedic surgeons (2,500 AOSSM members; 1,500 AAOS members) who indicated a sports medicine subspecialty. Eight hundred thirty-three replied giving a response rate of 20.8%. Email survey invitations were sent on May 15, 2013. Data collection closed on May 31, 2013. Non-respondents were sent an email reminder on May 21, 2013 to answer to survey. Online data were retrieved and tabulated by the AAOS Department of Research and Scientific Affairs. All responses are depicted in counts and percentages. Confidence Interval (CI) values at 95% were provided for each survey item in Appendix A.

Demographics Age

The average age of respondents was 47 years old (SD = 9.2) with a range of 32 to 72 years old.

Years in Practice

0 - 5 years, 24%

6 - 10 years, 15%

11 - 15 years, 16%

16 - 20 years, 16%

21+ years, 29%

Years in practice

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Organizational Membership

Sports Medicine Practice

Survey invitees were asked what percentage of their practice was sports medicine. Answers ranged from 10% to 100%. The mean percent of sports medicine practice was 67.2% (SD = 23.3).

AOSSM only 1%

AAOS only 23%

I am a member of

both AOSSM and AAOS

76%

Are you a member of AOSSM, AAOS, or both?

Under 50%, 16.9%

50% - 75%, 44.9%

Over 75%, 38.2%

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Results Allograft Use in Primary ACL Reconstructions

Survey invitees were asked how many primary ACL reconstruction they performed in 2012, the percentage of these procedures in which an allograft was used, and the percentage of patients who requested an allograft. Mean responses were 43.1 procedures, 26.6% allograft, and 18.1% patients requesting allografts, respectively. Responses ranged from 0 to 275 for number of procedures, 0% to 100% for the percentage of procedures in which an allograft was used, and 0% to 100% for the percentage of patients who requested an allograft. Approximately one-fifth (19.6%) of respondents indicated that they did not use allografts at all for primary ACLR in 2012 whereas 23.9% reported using allografts in the majority of primary ACLRs.

Primary ACL Reconstruction

N Mean Std. Deviation 95%CI Min Max

Approximately how many did you perform in 2012 (excluding multi-ligament procedures)?

824 43.1 34.6 ±2.4 0 275

What percentage of these procedures did you use an allograft?

776 26.6% 30.4 ±2.2 0 100

What percentage of your patients requested an allograft? 787 18.1% 25.3 ±1.8 0 100

Allograft Use in Revision ACL Reconstruction

Survey invitees were asked how many revision ACL reconstructions they performed in 2012, the percentage of these procedures in which an allograft was used, and the percentage of patients who requested in allograft. Mean responses were 6.3 procedures, 62.3% allografts, and 29.8% patients requesting allografts, respectively. Responses ranged from 0 to 60 for the number of ACL revisions, 0% to 100% for the percentage of procedures in which an allograft was used, and 0% to 100% for the percentage of patients who requested an allograft.

Table 3. Revision ACL Reconstruction

N Mean Std. Deviation 95%CI Min Max

Approximately how many did you perform in 2012 (excluding multi-ligament procedures)?

796 6.3 7.3 ±0.5 0 60

What percentage of these procedures did you use an allograft?

734 62.3% 40.7 ±2.9 0 100

What percentage of your patients requested an allograft? 712 29.8% 39.3 ±2.9 0 100

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Change in the Use of Allografts for ACL Reconstruction

For those who indicated their use has changed over the last few years, they were asked to describe how their use has changed and the reasons for the change(s). Most responses reflected a decrease in the use of allografts, especially in younger, active patients. However, many respondents noted an increased use of allografts in patients 40 years of age and older. Verbatim answers are in Appendix A, p. 16.

Graft Preferences by Age and Revision Situation for Athletes

Survey invitees were given six patient situations and asked to indicate their preferred graft choice for ACL reconstruction. For a high school or college athlete with primary ACL reconstruction, respondents prefer patellar tendon BTB allograft (54.8%) or hamstring tendon autograft (38.0%). Only 6.0% of respondents indicated a preference for any type of allograft in this situation.

For an adult recreational athlete with primary ACL reconstruction, 44.0% of respondents prefer hamstring tendon autograft and an additional 19.2% would use patellar tendon BTB autograft. Over a third (35.1%) of respondents indicated a preference for an allograft in this situation.

For a high school or college athlete with primary autograft failure who is having revision ACL reconstruction, 27.4% of surgeons prefer patellar tendon BTB autograft and 21.2% prefer patellar tendon BTB allograft. Over half (52.3%) of respondents prefer allografts for this clinical presentation.

For a high school or college athlete with primary allograft failure who is having revision ACL reconstruction, 46.8% of respondents prefer patellar tendon BTB autograft and 22.7% would use a hamstring autograft. 26.8% prefer an allograft in this situation.

Yes, 44%

No, 56%

Has your use of allografts in ACL reconstruction changed over the last few years?

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For an adult recreational athlete with primary autograft failure who is having revision ACL reconstruction, 24.8% of the surgeons prefer patellar tendon BTB allograft and 20.5% would use a tibialis anterior allograft. Overall, 71.8% of surgeons would prefer an allograft for this presentation.

For an adult recreational athlete with primary allograft failure who is going through revision ACL reconstruction, 22.9% of respondents prefer hamstring tendon autograft and 22.9% would use patellar tendon BTB autograft. Approximate a half (50.4%) of respondents reported a preference for an allograft in this situation.

For a breakdown of verbatim responses when “Other” was selected, please see Appendix A, pp. 29-33.

Factors Influencing Decision to Use an Allograft

Respondents were asked to indicate the impact of different variables on their decision to use an allograft for ACL reconstructions. The response choices were “Less Likely to Use an Allograft,” “No Impact,” and “More Likely to Use an Allograft.”

Respondents were LESS LIKELY to use an allograft for ACL reconstruction if the patient is young (90.1%), the patient’s intent to return to high ACL demanding activity (81.9%), graft failure rates reported in literature (84.6%), considerations about graft incorporation rate/time to

Primary -High Schoolor College

Athlete

Primary -Adult

RecreationalAthlete

Revision -HS/CA

PrimaryAutograft

Failure

Revision -HS/CA

PrimaryAllograftFailure

Revision -ARA Primary

AutograftFailure

Revision -ARA Primary

AllograftFailure

Other 1.0% 1.4% 3.7% 2.3% 3.2% 2.8%

Tibialis posterior Allograft 1.2% 5.1% 5.9% 3.4% 8.6% 5.8%

Tibialis anterior Allograft 2.3% 12.3% 12.6% 6.1% 20.5% 12.7%

Achilles tendon Allograft 1.0% 4.8% 8.7% 5.3% 10.9% 10.4%

Quadriceps tendon Allograft 0.0% 0.0% 0.0% 0.0% .1% .1%

Quadriceps tendon Autograft .4% .4% 1.9% 1.5% 1.0% .9%

Hamstring tendon Allograft .4% 2.9% 3.9% 2.7% 6.9% 4.4%

Hamstring tendon Autograft 38.0% 44.0% 14.6% 22.7% 11.4% 22.9%

Patellar tendon BTB Allograft 1.1% 10.0% 21.2% 9.3% 24.8% 17.0%

Patellar tendon BTB Autograft 54.8% 19.2% 27.4% 46.8% 12.6% 22.9%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

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return to full activities (68.8%), and graft failures experienced in their own practice (47.4%). Respondents were MORE LIKELY to use an allograft for ACL reconstruction for concerns about donor site morbidity (63.3%), postoperative pain (49%), and recovery time (45.8%). A majority of respondents indicated that the following factors would not affect their use of an allograft in ACLR: surgical time (66.3%), if the patient was female (65.3%), cosmesis (59.2%), cost (54.6%), and disease transmission concerns (51.7%).

Almost all (98%) surgeons with 0-5 years of practice reported that they would be less likely to use an allograft in a younger patient compared with respondents with 21 or more years of experience (82%). Similarly, 92% of respondents with 0-5 years of experience indicated they would be less likely to use an allograft with a patient who intended to return to a high ACL-

90.1%

81.9%

24.3%

43.8%

4.7%

4.6%

4.1%

8.8%

3.9%

84.6%

47.4%

68.8%

47.8%

7.9%

16.7%

65.3%

54.6%

66.3%

32.1%

59.2%

45.4%

47.1%

13.8%

46.8%

29.0%

51.7%

1.9%

1.4%

10.3%

1.6%

28.9%

63.3%

36.7%

45.8%

49.0%

1.6%

5.8%

2.2%

.5%

0.0% 20.0% 40.0% 60.0% 80.0% 100.0%

Younger patient

Patient intent to return to high ACLdemanding activity

Female

Cost

Surgical time

Donor site morbidity

Cosmesis

Recovery time in immediatepostoperative pain

Postoperative pain

Graft failure rates reported in literature

Graft failures I have experiences in mypractice

Graft incorporation rate/time to return tofull activities

Disease transmission concerns

How would the following influence whether you use an allograft for an ACL reconstruction (excluding multi-ligament procedures) for a given patient:

Less likely to Use Allograft

Wouldnt affect

More likely to use

5.9% 41.2% 17.9% 35.0%

0.0% 20.0% 40.0% 60.0% 80.0% 100.0%

Graft availability for double-bundleprocedures

Less likely to Use Allograft

Wouldnt affect

More likely to use

N/A

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demand activity compared with 76% of those with 21 or more years in practice. There was also a trend for those with more years in practice to use gender in decision making regarding allograft use. Surgeons with 0-5 years in practice were also more likely to be dissuaded from using allografts in ACLR by failure rates reported in the literature compared to surgeons with the most experience. Factors Affecting Success of Allografts for ACLR

Survey invitees were given seven factors that might affect overall success of an allograft used in ACL reconstruction. They were asked to indicate if each factor had no impact, small impact, moderate impact or a strong impact. Respondents indicated that the following factors would have a STRONG or MODERATE IMPACT on the overall success of an allograft used in ACL reconstruction: age of patient (58.9%), level of irradiation used in sterilization (51.9%), and ACL demands of patient after clearance to return to activities (48.9%). Factors that were thought to have the least impact on success were time on the shelf (47.1% indicated no or small impact), rehabilitation strategies (40.3%), and the use of chemical disinfectants (38.6%).

Rehabilitation and Return to Play

More than half of respondents (61.7%) indicated that they DO NOT have different rehabilitation instruction for patients who receive an allograft for ACL reconstruction from those who had an

1.7%

4.8%

3.5%

7.7%

2.9%

4.8%

10.4%

14.3%

33.8%

22.5%

39.4%

11.6%

15.5%

29.9%

32.2%

40.2%

47.3%

40.8%

26.5%

30.8%

38.3%

51.9%

21.2%

26.7%

12.1%

58.9%

48.9%

21.4%

0.0% 20.0% 40.0% 60.0% 80.0% 100.0%

Level of irradiation used in sterilization

Use of chemical disinfectants

Age of donor

Time on the shelf

Age of patient (worse outcomes foryounger patients)

ACL demands of patient after clearanceto return to sport/activity/work (worse

outcomes for higher demands)

Rehabilitation strategy (acceleratedassociated with worse outcomes for

allografts)

To what extent do you beleive the following factors affect overall success of an allograft used in ACL reconstruction?

No Impact

Small Impact

Moderate Impact

Strong Impact

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autograft. The majority of respondents (74.9%) indicated their allograft ACLR patients do as well as their autograft ACLR patients with proper rehabilitation and compliance by patients. Approximately half (49.5%) of respondents indicated that they generally delay return to sports for patients who receive an allograft compared with those who have an autograft. For those who do delay return to sports for allograft patients, the average return to sports was 6 months for autograft patients and 9 months for allograft patients although many surgeons delay return until 12 months.

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Irradiation

Respondents were asked, “Do you feel knowledgeable about the true amount of irradiation required to completely sterilize (i.e., eradicate everything including spores and viruses) allografts used for ACL reconstruction?” Almost two-thirds of respondents (65.8%) indicated that they were not sure. Of those who did report feeling knowledgeable, the modal response was 2.5mRAD was required to completely sterilize grafts with a median of 3.0mRAD. Over 40% believed that 4.0mRAD were required and 11% believed that 5.0mRAD and above were necessary for complete sterility. When asked about the level of irradiation that is harmful to the biomechanical/physiological properties of the graft, almost a third (32.0%) of respondents believed that any degree of irradiation is harmful, 41.5% of respondents indicated that low dose irradiation (1.0 – 1.2 mRAD) is not harmful but higher levels are; 24% reported that medium dose irradiation (up to 2.5 mRAD) is not harmful, and 2.6% indicated that high dose irradiation (up to 5 mRAD) is not harmful.

Any degree of irradiation is harmful, 32%

Low dose irradiation (1.0 - 1.2 mRAD) is not

harmful but higher levels are, 41%

Medium dose irradiation (up to 2.5 mRAD) is not

harmful but higher levels are, 24%

Higher dose irradiation (up to 5.0 mRAD) is not

harmful, 3%

What level irradiation do you believe is harmful to the biomechanical/physiological properties of the graft?

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A third of respondents (34%) indicated that they do believe some level of irradiation is essential for allografts used in ACL reconstruction to eliminate pathogens, followed by 29% indicating they are not sure. Twenty percent indicated no, non-irradiation sterilization processes are able to achieve acceptable levels of sterility and 16% percent of respondents believe that the donor screening processes and NAT currently used is sufficient to all but eliminate the risk of disease transmission.

Yes, 34%

No, the donor screening

processes and nucleic acid

amplification testing (NAT)

currently used by processors is

sufficient to all but eliminate the risk

of disease transmission, 16%

No, non-irradiation

sterilization processes are able

to achieve acceptable levels of sterility, 21%

Not sure, 29%

Do you believe that some level of irradiation is essential for allografts used in ACL reconstruction to eliminate pathogens?

43.5%

35.6%

20.9%

0%

10%

20%

30%

40%

50%

Yes No Not Sure

Do You Use Allografts for ACL Reconstruction That Have Been Irradiated?

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Forty-three percent of respondents use allografts that have been irradiated for ACL reconstruction, 35.6% indicated that they do not use irradiated grafts, and 20.9% indicated that they were not sure if the grafts they used had been irradiated.

Allograft Source

MTF/ConMed (41.2%) provides most of the allografts respondents use for ACL reconstruction. Note that respondents were able to check all answers that applied.

The majority of respondents (87%) indicated that the allografts they use for ACL reconstruction come from an AATB-approved tissue bank although over 1 in 10 was not sure.

Allosource, 15%

LifeNet, 18%

MTF/ConMed, 41%

RTI, 18%

Not sure, 19%

Other, 9%

Who provides most of the allografts that you use for ACL reconstruction? (check all that apply)

Yes, 87%

No, 1% Not sure, 12%

Do the allografts you use for ACL reconstruction come from a tissue bank that is approved by the American Association of Tissue Banks

(AATB)?

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More than half of respondents (57%) have not personally researched the safety track record and clinical results of the tissue bank from which they get allografts.

Survey invitees were asked to provide comments about allografts for ACL reconstruction. The responses varied, but commonly referred to usage, disease transmission, and associated research. Please refer to Appendix A, p.53 for verbatim responses.

Yes, 43% No, 57%

Have you personally researched the safety track record and clinical results of the tissue bank from which you get allografts?

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Appendix A: Results with Confidence Intervals Has your use of allografts in ACL reconstruction changed over the last few years?

N CI Lower Upper Yes 364 3.368 40.33 47.07 No 469 3.368 52.93 59.67

Total 833

You indicated that your use of allografts in ACL reconstruction changed over the last few years. How has your use changed and what have been the primary reasons for the change?

DECREASED USE COMMENTS • Use less allograft-- clinical experience and particularly research outcomes • Less use b/c higher failure rate • Using less; potential for having higher failure rate • Use of allograft for primary and revision ACL has decreased. Primary reasons are the results of

the MOON and MARS studies, and the fact that allograft tissue is no longer covered by insurance companies.

• I do it less often in younger people due to recent reports of higher failure • About 16 years ago, I used primarily patellar tendon autografts, and then started using more

hamstring autografts with allografts use only at 10% of the time. About 10 ten years ago, the tissue bank industry came under greater scrutiny and the safety of allograft usage significantly improved. At that time, I made a significant change in my practice and began using a very high percentage of allografts (90%). Anyways I discussed the pros and cons of allograft versus autograft. Ultimately, the patients requested allograft based on the information that I provided. Overall, my results have been very good. However, the literature is supporting autograft usage as an advantage for higher level athletes and now I am shifting back toward the autograft direction.

• Fewer allografts because patients are typically HS or college athletes • Now only using allograft as an augment if needed due to small autograft size. Reason for this is

stretching of allografts and concern of re rupture. • Decrease use. Have used many more quad autografts for revisions • I use them less frequently in younger or collision/contact athletes. I have also changed the grafts

that I use. Formerly mostly Achilles, more recently hamstrings, but considering changing back or going to BPTB for certain uses.

• Less use of allografts in young athletic patients. I seek autograft sources when possible. • I use less allograft in patients <20 years old • Decreased use due to reports suggesting better outcomes with autograft, costs • No longer use in any young patients • I no longer use them for primary ACLR, and use them for revision surgery only when ipsilateral

autograft is not available. • I use them less frequently based on published data of higher rerupture rates in younger patients • I have used less allograft. Most of my ACL population are young patients where allografts have

shown to carry a higher rate of failure. • I use fewer allografts in younger athletic pts than I did in previous years. For example, I use more

patellar tendon autografts for young female athletes with hyper laxity. I do not trust the

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allografts in female athletes due to reports of higher failure rate, and these pts have a higher failure rate in the best of scenarios.

• I use much less. I don't like the expense. Failure rate is higher in younger people, and I don't trust the allograft industry as a whole.

• I use more autograft recently because of recent research on lower retear rates with autografts • Recommend against in active patients age 25 years or younger. • Decreased. No longer recommend to younger athletes. • I use less allografts and have switched from tibialis anterior to double semi-tendinosis • I stopped using them on primary ACL reconstruction due to unacceptable failure rate. • I no longer do allograft in patients under 30 years old. there is an unacceptable rerupture rate

with allograft in this group • Having revised other surgeons allografts and having taken out perfectly good allografts and

done autografts on patents for "rejection" complaints I refuse to use them or recommend them • Decreased usage secondary to worse results • Recent studies indicating higher rerupture rate in younger athletes with allograft. However, I

don't think these were great studies. • I never used allografts before this year. I am less likely to use them in the future • Using many fewer allografts in young people (10-30 years due to some report evidence of higher

failure rate • Using less due to inferior results and high re-rupture rates • Decreased due to increased risk of retear • Using fewer. Higher failure rates in high demand patients. • Recent MOON study has made me recommend more autografts. • Decreased • Have used less allograft secondary to stretch and re-tear rate • I use them less secondary to observed increased rate of retear in patients I use allografts

compared to autograft. • Use less, concerns for rupture in young patients and concerns of safety in many • Using more auto grafts. Geographic change and change in age group of my patients. Lived in

California where more patients requested allografts. Moved to Idaho more patients request autografts.

• Decrease due to higher rerupture rate in young athletes compared to autograft • Minimize allograft in younger than 25 yrs old. • Less allografts • Less allograft, new technique. • Never used a lot of allograft, but only consider allograft in low demand patients or revisions

now. • Increased rate of failure, loosening of the graft over time • Concern over failure rate • I'm now not using allograft in patients under 20-25 due to recent studies showing higher failure

rates • I use allografts LESS frequently now, primarily due to data from MOON group suggesting higher

failure rates. • Less use. Increased age to 40 and above

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• I use them far less in primary ACLs now (most of my patients are under 20YO), only usually as a supplement if the hamstring tendons aren't big or long enough to make a quadruple graft (more of a backup plan than primary choice).

• I use even less allografts especially in patients under the age of 40. I believe there is a higher failure rate with allografts in younger patients.

• Reported failure rates and personal observation have decreased my enthusiasm for allograft, especially in young patients.

• Less use of allograft due to concern of increased failure rate • Less use in patients under 40...but now, some feeling that non-irradiated allografts in patients

under 40 may be OK. • Decreased with reports of higher failure rates • Failure in young age groups and the compelling evidence from MOON • I use less allograft ACL reconstruction because of a concern for higher rupture rates in the

younger patient • Less • Several years ago I had a significantly increased infection rate (bacterial septic arthritis) with use

of allografts for ACL reconstructions, causing me to temporarily halt use of allografts for all but revision cases. I have gradually resumed use of some allografts, but still generally prefer autograft.

• I have used them less and less in the younger populations and continued use in the older population. This is mostly due to a perceived and reported increase in failures of the allograft ACL's, even though the recovery is quicker and easier.

• Decreased use under age 25 due to studies showing high failure rates, although I did not see this in my practice

• Decreased use of allografts in patients younger than 35 • I will not use an allograft in a young patient anymore • MOON knee group study regarding failure rate. Tend to offer it in older less active patients or in

a multi-ligament setting. • I rarely will use an allograft in patients under the age of 35 even if they ask for it for 2 reasons.

One- the recent literature showing a higher risk of graft retear in younger patients with use of an allograft. Two- I routinely harvest just the semi-T for a quadrupled graft with a minimally invasive posterior approach which is just as benign as using an allograft.

• Decreased. Insurance won't pay for it. Higher failure rate • Decreased use because of increase rerupture rates n young patients • I have decreased the frequency of allograft use due to further evidence of allograft failure in the

literature in as well as increased use of the Graft-link procedure using hamstrings tendon • I avoid allografts in young high-demand patients because of the increased risk of failure. • Fewer because of failure rates with allograft • I have virtually eliminated the use of allografts except in multi-ligament reconstruction. I have

personally seen a higher failure rate with the use of all types of allografts in my practice which has also mirrored the results in the literature. Furthermore, my revision practice is at least 10 to 1 allografts failure versus autograph failure.

• Rarely use allografts for primary or revision surgery due to high incidence of failure in the literature and the quality of the tissue

• Fewer primary Acl recons in young patients with allograft due to higher failure rates. • Decreased use of allografts due to data suggesting higher rerupture rate.

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• The increased failure rate of allografts in those under 25 has changed my recommendation to that age group. I used to let them choose allo or auto now I insist on auto.

• Decreased use in HS and college-age pts after results of study showing definitive increase risk of failure

• Decreased. concerns regarding incorporation and overall sense of higher failure and laxity • Doing less. Poor results in studies. • I am using less and less due to my impressions of failure rates and tunnel osteolysis • I had three patients last summer that seemed to reject their grafts. They had an unusual amount

of pain and swelling at about 2 weeks post-op. They all showed no indication of infection. All required a second arthroscopy to washout the knee. In each the graft looked bad. They all improved after the second procedure, but their progress was very slow afterward. Before these three cases allograft ACL was my preferred method. Since these cases I have switched to hamstring tendons as my preferred graft.

• Decreased use, evidence of higher rerupture and lower outcome scores • Decreased b/c of increasing evidence of risk of failure • Using less due to fear of failure and graft osteolysis within the tunnels. I currently only use

allografts in patients older than 45 or in select revision cases. • Less usage due to failure rates in younger PT population • I use it less. I believe there is a higher re-rupture rate and this is being shown in a number of

studies • Use them slightly less • Stopped using for younger patients (<25) receiving primary reconstructions due to MOON/MARS

info • Use less. Prefer autografts more and especially in young patients below 40. • Use them less than previously, especially in younger patients • Do not place them in younger patients < 35 years • Previously used almost exclusively allograft...now use almost exclusively autograft. Recent

literature showing the higher failure rate and delayed healing or incorporation with allograft has caused that change.

• Less likely to use in younger patients, more confident to use in older patients • Minimize use in younger populations. Based on literature • Would not use in young patient unless there was no other choice intraoperatively. Would use

for most/all revisions, would consider for patients > 40-50 yrs old that need ACL recon. Don't believe patients/therapists wait long enough for it to consolidate, feel great so much sooner that that just don’t' wait. would consider BTB allograft only choice I would use in younger patients, for reasons of earlier bone healing primarily

• Rarely do allografts in patients below the age of 35 y.o. • We quit using one company and try to use autograft for younger especially male patients • Less in young athletes. Higher reported rerupture rate • Decreased due to increasing evidence of higher failure rate, especially in younger and more

active patients • I have decreased due to literature suggesting that allograft has a very large failure rate. • Use less commonly, especially for primary ACL reconstruction. Poorer results, both in my own

clinical experience and as reported in the literature • Poor results with allograft in my practice, suspected increase in infection, long term studies • Decreased because of unacceptable failure rates.

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• Higher retear rate in younger patients than autograft. • Less because results not as good • I noticed a higher failure rate with allograft which has been supported with recent publications. • Decreased due to increasing documentation and experiences regarding failures. • Less willing to use an allograft in a primary setting regardless of age or activity level due the

published higher rate of failure compared to autograft tissue • Diminished significantly • I have decreased the use of allografts. Reasons include graft durability issues, cost, availability,

concern over the risk of disease transmission, etc. • Decreased. Too many failures • Less in patients under 30 due to high failure rate reported in literature • Results of higher failure rates • Decreased. Data and own experience suggest higher risk of failure in patients <40 • Decreased following the MOON Study data. • Stopped using in patients under 25 years of age • Using less allografts due to more evidence of graft failure. • Decreased. Studies show higher failure rate. • Using less allografts, because data shows higher failure rate • Using much less in younger athletes • I no longer offer allograft acl reconstruction in high level athletes, I may offer allograft

reconstruction to recreational athletes but strongly recommend against allograft. • less use of Achilles allograft • I am using it less even in my older, low activity patients. I just hate the possibility of revision and

would like to reduce this as much as possible. • Decreased, concerned about outcomes relative to autografts with some of the new data that is

coming out • Lowered use secondary to higher re-rupture rate • Data to support the potential higher failure rate with allograft in younger, active and female

patients - MOON • Use fewer allografts in patient less than 30 due to increased failure rate in young athletes • Using fewer. Have not been happy with Lachman test in office. Feel that allografts loosen over

first 1-2 years. • Used less for primary ACLR • Using less allograft tissue. Except in revision cases and patient request/choice. • Decreased usage due to published results of increased failure rate in younger active patients • Decreased number of allografts. Results of allografts decreased versus autografts. Also cost of

allografts high. • I use them much less due to increased incidence of tunnel osteolysis in our patients and due to

recent suggesting higher failure rates. • Less use of allograft. Clinical studies, such as MOON group report, that show increased failure of

allografts in high-level athlete. • Decreased due to data on young athletes increased failure rate • Use less allografts in athletes due to data regarding increased failure rates. Have avoided

allografts in revisions also because of failure concerns in this population. • Using allografts at all. Now using allografts for older patients. With better fixation available

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• I am using less allograft and more autograft as I have had higher failure rates and increased post op laxity with my allograft reconstructions compared with autograft.

• No longer use them due to a high failure rate • Use them less. Had some failures due to poor graft strength • Stopped primary use of allograft due to ease and success of HS autografts • None under 25y/o, due to moon data • Much less likely to use in patients under 30 due to studies showing higher failure rate in younger

athletes • Due to recent studies on increase failure rates for allograft, I have predominately used autograft

this year. • I have decreased use of allografts based on results and literature. • Using fewer allografts due to recent literature suggesting poorer results • Used less allograft due to increased failure rate I have observed. • No allografts under 40 yo • Less use. Training. • No longer use in athletes under age 25-30. Autograft is now graft of choice. reason is literature

supports autograft in this patient population • I used to rarely use. Started to use more. Approached 100%. Had some failures. Now using in

revisions and older patients only • I have used less allograft • Doing less allograft ACL due to journal publication information • Much less allograft due to research on rerupture rates • I have used less soft tissue allograft for primary ACL reconstruction particularly in patients under • Age 40. • Data has shown an increased risk of rerupture of an allograft ACL, so I won't do them in young

patients at all, and will give patients older than 40 years old the option of an allograft. • Less allografts. More concerns with rerupture given practice mix of young patients. • I have decreased the use of allograft for PRIMARY reconstructions in younger patients ( under

25) • Decreased use concerned about failures without any clear history of trauma and on F/U exam

appear to loosen • Decrease usage due to worse outcome for younger age group • Using them less due to concerns over inferior clinical outcomes compared to autograft • I use less because they do not seem to hold up over the long term • I do not use allograft for ACL reconstruction. The reported failure rate is too high to justify its

use. • Use less than used to never on young people think they fail more • Probably do a little less use of allograft. Avoid in young primary reconstructions • Decreased use 2/2 new literature on increased failure rates in the young/active population • Slight trend toward more autografts. I have generally favored autografts over the years but

recent data suggesting higher failure rate of allografts, especially in adolescents has strengthened this approach. This is balanced by anecdotal experience of several patients having had successful auto graft but requesting allograft for their contralateral acl tear and being happier with the allograft side.

• Not using allografts in young patients secondary to higher rupture rate versus autograft • Less use in primaries. MOON and MARS prospective studies

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• Less use allograft due to higher failure rate in elite athletes • I have used it less in young people because of the apparent higher instance of rupture over

autograft. Also, I think I can return them to activities faster with an autograft • Small decrease due in part to new studies showing a possible increased risk of retear in younger

patients. • Less allograft in younger patients given EBM. • Do not utilize on young active pts, unless revision • Less use in younger female patients because of literature • I'm changing to autograft again. Cost, MOON study • Higher failure rate in young patients. Graft failure without adequate mechanism. • Decreased • Decrease; concern over healing rates • Limited use due to high failure rate with athletes • I use them less often 2 reasons. One, my patient population has changed dramatically since

changing practices. (I now see many more "young" patients - without a return to work consideration and who are more concerned with long term results Second - Paper published by Aros et al. Meta analysis of Moon group regarding the differential higher failure of allografts in younger patients With a younger patient population in my practice, that study has a proportionally higher effect on my recommendations

• Less likely to use allograft due to better data on increased failure rate and having alternative of 4 strand ST graft autograft working so well

• Literature showing higher failure rate in young patients has led me to strongly recommend auto in patients younger than 30

• Less likely to use in a young pt (<35) due to recent research • I no longer use them. • Will only use allograft for Primary ACL in patients over 35, in revision situations still try and use

autograft if possible, if not will use allograft • Use less frequently • Almost never under the age of forty. Compelling studies regarding rerupture rate • I don't use allografts in active patients less than 25 years old based on evidence that rehear

rates are higher in this population • Decreased use in younger, active patients... Failures • I use fewer allografts overall and only in my lower demand ACL patients 40 yo and up. I don’t

use them in HS or college or professional athletes. • Use less often - not offered for primaries unless requested by patient • I have used fewer, due to reports of higher failure rates in younger patients and those who are

more active. • Almost never use them for a primary reconstruction in people under 30 • Less allografts during the last 2 years; based upon personally-observed and literature

documented higher rates of failure when allografts used as compared to autograft tissue. When I do use allografts, I have modified the post-operative rehab and criteria for return to full athletic participation.

• WILL not use in athlete under any circumstance and allow to return to play in less than 9 months • I have decreased the number of allografts because I felt there was more laxity in the grafts • One bad experience with allograft in patella tendon reconstruction for chronic patella tendon

rupture - fungal infection. Have been using primarily autograft since.

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• Using less because they take longer to heal and may stretch out more and have a higher failure rate

• Slight decrease in use especially in the young (less than 22). I have concerns about the higher failure rate in this age group and the chance of long term loosening

• Use them less because of data showing high failure rate • Decreased use due to increased cost and concern for high failure in the young population • Trying to use less. Doing more BTB. More two stage • Decreased/almost eliminated • Decreased use, increased failure rate, cost persistent effusions • In patients younger than 30 at a high level of sporting activities, I will discourage the use of

allograft until we truly know the risks with current fixation techniques of revision. • Decrease allograft use secondary to increase in failures in the literature among younger

patients. • Published MOON data on failure rate increase for allograft vs. autograft by younger age -

Kaeding Sport Health 2011 • Use them much less frequently. Too many retears. • Decrease their use due to data suggesting they stretch out. • Use them less often. Higher failure rates noted in younger patients • I have stopped using them unless it's a multi ligament injury. Failure rates seem to be higher in

literature • Decrease in number for primary reconstruction • Using less allografts, studies showing higher failure rates in allografts, now have PA in or for

help w surgery times • Good articles stating increased failure rate, leaving residency and fellowship • Research documenting failure rate in patients under 20 years of ago • Using it less, based on research that allograft performs poorly in younger patients • Using less and less. Concerned about atraumatic failure. Mainly younger athletic population so

using much more BTB autograft. • I believe outcomes are more reliable with autograft tissue. • Hígher failure rate • I have used less of them....concerned about failure rates in younger patients. • I have chosen to limit my allograft usage to people 40 or older unless a revision is needed and

the patient does not want a contralateral harvest. I also have started using an allograft to augment my hamstring autografts if the folded diameter is less than 8mm for the ST and gracilis. If I have enough length, I will cut my ST in half; otherwise I add an allograft to increase the diameter of the graft.

• I use them much less now. Used them much more in residency and fellowship. I use the patients' own tissue if at all possible now

• I used to perform most of my ACL reconstructions with allograft I now try to refrain from allograft use in females aged 14-22

• Decreased use in young patients and competitive athletes secondary to concern for increased re-tear rate compared to autograft

• I am using less allograft for primary ACL recon, especially in younger more active patients • No use of primary allograft for any active patients 35 and younger. Worse outcomes in the

literature and in my practice with allograft usage. • Don't use any more

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• Doing more autografts in younger pts. Studies showing higher failure rates in younger pts with allograft.

• less use in younger patients use only non-irradiated grafts • I no longer even consider them in the young athlete • I'm using less allografts due to patient preferences • Failure in young adults • Fewer used. Worse failure rates. • Recent literature with mixed results using allografts, particularly in younger pts • Decreased use in younger, more aggressive patients < 35 years of age. • Not using them for young patients • Using less allografts especially in younger patients. • Only using allografts as backups in the setting of a failed autograft in younger patients, using

them primarily over age 35, and for revisions. Not using them as much for younger patient's primary ACL now.

• Decreased until results (rerupture) in younger athletes are clarified in the literature. • I use less allografts primarily because of studies showing increased failure rates in younger

patients. • Failures • I am using autograft more frequently particularly in patients under 35 • I rarely use allografts for primary reconstruction due to higher failure rates in younger patients ,

and higher costs • A high failure rate with allografts and some rejections • OUTCOMES STUDIES SHOWING HIGHER RISK OF FAILURE AND LAXITY • Less frequent in younger patients. Have had late (greater 5 years) ruptures and on revision it did

not appear that the graft had fully incorporated. • More likely to use autograft in young athletes • Lectures and outcomes. Only failures with allograft. Concerned about the gamma radiation. • Allograft failure • Allograft failures. Cost. • Increased failure rate • Less cases now than before

INCREASED USE COMMENTS

• Increased use. People wanting to get back to work faster fear of losing job. • Safety in preparation. Increase in uniform strength, ease of use, less post-op morbidity----more

use of allografts • Better success rates that were previously thought and more patients requests • More patients are asking for an allograft, and not wanting autograft • We are using more allografts in ACL revision • More allografts, easier initial rehab • I use an increased number of soft tissue allografts for reconstruction given the improvement in

fixation options. I mainly use allograft in the >30yo patients. • Increased. Safer testing/preparation of allografts, less traumatic procedure for patients... • Increased. Decreased morbidity. Good results • I have increased my usage of allograft in non-adolescent patients. • I use them more often. The latest literature is more supportive of their use.

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• I have increased the use of allografts due to results equal to autograft, less morbidity, ease of use.

• More common usage in the patients over age 30 that want to get back to work quicker. • I let my patients choose their graft source, typically between btb auto, st/g auto, or btb allo.

Patients request allografts more frequently now. • Trained on East coast now work on west coast- allografts are much more prevalent here. • Increasing usage of BTB allografts over entire career. 5 year increments revealed 1,3,13,34,50,

>50%. Age and activity impacts recommendations. !00% >40, 60-65% >30-40, $0% 25-29. <10% in patients under 20. Use one tissue bank since 1986. Do not use tibialias ant for ACL R. Use infrequent HS allo in prepubescent children who are petite and have significant growth remaining. KT 1000 reviewed 6 wks to one year show no differences in first year between auto and allo allograft with no "creep” in KT values. Last year reviewed prospectively maintained database. Personal revision rate overall was 1.5% for auto BTB, 2.0% for allo BTB Combined in 1809 aclr 1.7% (1200 auto 600 allo). In this study reconstruction of contralateral ACL was 10% (n=110)

• I am using them more on employed people for faster return to work since the change in sterilization techniques. I offer both allo- and auto-graft options to all patients, but they seem to split along younger athlete vs. older employed populations. I make the allografts wait 9 mos for sports

• The percentage of allografts has increased steadily over time. This is because the out of pocket costs for the patient are actually less for the allograft than the autograft. With the autograft every therapy visit requires a copay of up to $50. Autografts require generally 25 therapy visits at least. If the out of pocket cost is $50 a visit x 25 visits that means the patient must pay $1250 in addition to the surgery costs. Allografts require much less therapy and consequently cost the patients less.

• Increased use due to patient request, improved data. • More allografts. Easier recovery for older patients and patient request. • Better quality grafts and results in active patients over 25 equivalent • Increased use, good outcomes noted in most patients, better fixation • Increased • Increased to exclusively allograft. Patient demand and decreased pain post operatively. • Use allografts almost exclusively for revisions. More patient's requesting allografts • More patients are comfortable with their use. • I have been using more allografts. I previously used allografts rarely for primaries. My patients

are getting older and the results of allografts are good, in the literature and in my patients. • Increased. Patients request allograft. • More confidence in tissue processing. Increased patient demand • Increased usage in patients over 35 • Increased use in older patients for faster return to work, less pain, quicker mobility after surgery • Only using non-treated, non-irradiated grafts. also using more autografts • More allografts because this community is 100% allograft and I became an outlier by using

autograft. • Increased use. Improved preservation techniques and less trauma to patient. • Used primarily allografts, then decreased due to negative study reports. Looked at my own

outcomes and couldn't confirm increased failure rates, so allograft use has been increasing, but only in patients older than 30

• Graft availability. Surgery speed. Improved long term results.

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• Increased usage due to older patient population. • Use more often. Better quality with less risk. • I use them more often because my clinical outcomes have been as good or better than autograft • Using more allografts in >40 group based on literature showing good outcomes. • The technology and the positive effect on tissue sterility and allograft mechanical properties • Using for all females • I am using more allografts. I like the decreased morbidity. • Using more allografts because patients’ success is very good and they are requesting it more.... • I've been using more for primary procedures due to less morbidity, excellent results and safety • I use it in individuals over the age of 30 and sometimes in younger individuals if they request it.

Although allograft is a little expensive than autograft, you still save time with allograft, avoid harvesting complications and you are assured to use a desired thickness of graft. It is helpful for individuals like me who do not do thousands of ACL reconstructions like Freddie Fu or Stephen Howell to have allograft as an alternative source.

• Ease of use, faster recovery • More allografts for older individuals none for younger pts • Increased • I am trying to use allograft on most adult pts who are not actively competing in cutting/contact

sports. Decreased donor site morbidity with makes pt's happier in the long run. Also stress the need to strictly follow PT protocol even though pain is less.

• More use of allografts. Reason is graft site morbidity and similar functional results with allografts

• Increase use especially in patients over 30. I use only fresh frozen non-irradiated, non-treated soft tissue grafts

• Increased. Now use tibialis posterior allograft. • Increased. Patient preference. • Increased use, patients' requests, improved clinical data, better graft sterilization • Availability, ease, efficacy, safety • Increase us of autografts • Increased use of allografts to meet competition offerings. Patients locally feel that allografts are

less painful and heal more quickly. • More usage and more requests from patients • Larger source, ease of use • Pt wishes, quicker rehab • Increased use due to pt. request • More likely to use BTB Allograft for revision ACL as well as for primary ACL in patients over age

of 40 (than Tibialis Anterior Allograft) • Increased use • Increased use. Equal results • More patients are asking for it primarily • An increase in use for the athlete over the age of 40 • More primary procedures, using for younger patients than I used to. Better procedures for graft

prep and fixation. • More patients request them. Clinical outcomes good. No increased morbidity. • More allografts because of older patient population in new practice • Mild increase based on patient education and review of current literature

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• More usage - more revisions and some older patients • My use has increased for two reasons. To decrease patient morbidity and to get reliable and

robust graft sizes. • Increased use. Mainly due to improved faith in the processing methods and age of donors we

are able to obtain. • Increased. Studies confirmed older pts do well. Like the graftlink technique. • Patient demand, improved fixation • Nearly all revisions, also is primary consideration for adult reconstructions. • Lack of help in the OR for ACL prep has prompted more allografts. • Increased, surgeon and patient preference • Reconstructing older patients who can’t miss much work • I use them more for revisions than I used to. Primarily because there are options for sizes, bone

grafting, etc. which are helpful in revision surgery. • More common acceptance for relatively older and less active patients. • NOW USING ALMOST EXCLUSIVELY. ALLOGRAFTS SEEM TO BE WORKING WELL AND PATIENTS

RECOVER MUCH QUICKER OTHER COMMENTS

• Age limitation recommendations for allograft usage in primary reconstructions • Autograft for patients under 25 yrs. both personal experience and literature supports this. • The age of the donor vs. the age of the patient. If under 30 yrs -- autograft for primary • Autografts for collision athletes, allografts for my older, employed patients • I have considered using autograft more often in younger patients and athletes, however I still do

discuss and at times use allograft in those patients. I'm very particular about the allografts I use, however.

• Have increased the age at which I recommend allograft. I try not to use allograft in patients under 40 and I keep allograft patients out of sports for longer than auto grafts.

• More conservative w return to play decisions in "older” athlete allowing a change in graft selection

• Better outcome with non-irradiated grafts, shift to older patient population • Use them for non-athletic patient, low demand with instability. • Only for revision setting. I do not like to go to multi source harvesting in a single knee. Only use

one source for graft then move to allograft. • Fellowship experience • To Achilles tendon, stronger • Gone from Achilles to BTB • From BTB allograft to PTT allograft secondary to poor bone quality in allograft tissue and better

fixation with tendon allograft. • In the past I would perform most ACL reconstructions using autogenous hamstring tendons. • The regulation in Germany does allow the use of allograft only in very very specific indications. • I no longer use irradiated grafts • Non-irritated. Use PRP

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• Changed from freeze dried patella tendon to fresh frozen tibialis that is more readily available and suitable to use with endobutton fixation mode.

• Used to use BTB now use Ant Tib • Hamstring rather than BTB • Changed from semitendinosus to Achilles tendon • Was never taught to use at all • Use more types of grafts • Frequently supplement primary hamstring autograft reconstructions with allograft if the 4-

stranded autograft has less than 8mm diameter. • Changed from Achilles Tendon to Anterior Tibialis Folded in half. Stopped using the X trans-tibial

system and changed to the Y Tight Rope System. • Occasional augmentation of auto hamstring grafts if autograft is of insufficient size.

Q5) What is your preferred graft choice for ACL reconstruction in the varying patient situations indicated in the grid below? (Check one response per line.)

Patellar tendon

BTB Autograft

Patellar tendon

BTB Allograft

Hamstring tendon

Autograft

Hamstring tendon

Allograft

Quadriceps tendon

Autograft

Quadriceps tendon

Allograft

Achilles tendon

Allograft

Tibialis anterior Allograft

Tibialis posterior Allograft

Other Total

Primary - High School or College Athlete

N 455 9 316 3 3 0 8 19 10 8 831

% 54.8% 1.1% 38.0% .4% .4% 0.0% 1.0% 2.3% 1.2% 1.0% 100.0%

CI 3.384 0.704 3.301 0.408 0.408 0.000 0.664 1.016 0.741 0.664 Primary - Adult Recreational Athlete

N 159 83 365 24 3 0 40 102 42 12 830

% 19.2% 10.0% 44.0% 2.9% .4% 0.0% 4.8% 12.3% 5.1% 1.4% 100.0%

CI 2.677 2.041 3.377 1.140 0.408 0.000 1.457 2.234 1.491 0.812 Revision - HS/CA Primary Autograft Failure

N 227 175 121 32 16 0 72 104 49 31 827

% 27.4% 21.2% 14.6% 3.9% 1.9% 0.0% 8.7% 12.6% 5.9% 3.7% 100.0%

CI 3.041 2.784 2.409 1.314 0.939 0.000 1.921 2.260 1.609 1.295 Revision - HS/CA Primary Allograft Failure

N 386 77 187 22 12 0 44 50 28 19 825

% 46.8% 9.3% 22.7% 2.7% 1.5% 0.0% 5.3% 6.1% 3.4% 2.3% 100.0%

CI 3.405 1.985 2.857 1.099 0.817 0.000 1.533 1.628 1.236 1.024 Revision - ARA Primary Autograft Failure

N 104 205 94 57 8 1 90 169 71 26 825

% 12.6% 24.8% 11.4% 6.9% 1.0% .1% 10.9% 20.5% 8.6% 3.2% 100.0%

CI 2.265 2.949 2.168 1.731 0.669 0.237 2.127 2.754 1.914 1.192 Revision - ARA Primary Allograft Failure

N 187 139 187 36 7 1 85 104 47 23 816

% 22.9% 17.0% 22.9% 4.4% .9% .1% 10.4% 12.7% 5.8% 2.8% 100.0%

CI 2.884 2.579 2.884 1.409 0.633 0.240 2.096 2.288 1.599 1.136

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Q5 Other - verbatim) If you have selected "Other" for any Primary or Revision response, please specify: PRIMARY - High school or college athlete

1 For athletes over 220 lbs or for hypermobile and small female athletes I perform autograft patellar tendon preferentially, for the rest of the HS and college athletes I prefer hamstring autograft for primary ACL reconstruction.

2

For primary ACLs I will perform autograft only for anyone under the age of approximately 40 years. The patient and I will choose between BPTB and hamstrings based on their concern about possible side effects of the respective harvests. If patients older than forty ask for an allograft I will use BPTB allograft. In a revision situation, if another surgeon had used allograft I will try to use autologous BPTB. We may also consider revision of a failed autograft with another available autograft if the morbidity isn't considered to be high.

3 Freeze-dried fascia lata allograft

4 I reserve BTB autograft for heavier contact sport HS or college athletes.

5 I use both BTB and HS for colegiate and HS athletes depending on anatomy, sport, size of HS

6 I use BTB autografts for collision/contact athletes who are or will be collegiate/elite athletes, but hamstring autografts for non-collision athletes, and high school athletes who do not intend to play in college or at advanced levels.

7 Use Allograft, but consider Hamstring Autograft as well

8 young athletes, in my care, choose BPTB auto or ham auto after discussion

PRIMARY - Adult recreational athlete

9 all inside graftlink usually peroneus longus folded over 4 times

10 depends on primary sport or activity

11



13

I am a pediatric orthopedist and all my patients are under 21 - many high level athletes. I offer everyone the choice of BPB autograft versus Posterior Tibialis allograft. Long discussion about recent literature concerning increased failure rates in young patients with allograft is made, weighed against significantly shorter operative/anesthesia time, improved cosmesis, improved rehabilitation in the early period, and lack of damaging another portion of the knee. In 11 years of practice, I've had less than 2-3 failures in either types of reconstruction and have found no differences in clinical or functional outcomes.

14 I am a pediatric specialist and do not operate on adults

15 If there are Patellofemoral symptoms I will proceed with a hamstring autograft, otherwise a B-PT-B autograft

16 In situations B) and F)the status of the patient, past medical hx, past surgical hx, and underlying chondral/meniscal status will determine my graft choice preference.

17 Other = Peroneus Longus

18 other graft is peroneus longs allograft, goes through tunnels more smoothly than AT

19 Peroneus longus allograft

REVISION - High school or college athlete/ PRIMARY: Autograft failure

20 "other" is dependent on what autograft they had orgiginally. If they had a BTB, I use hamstrings. If hamstrings first, BTB for revision.

21 1. Autograft-allograft hybrid of hamstrings + tibialis posterior allograft in an attempt to create a graft diameter of at least 11mm. 2. If hamstrings previously used, then PT BTB autograft

22 Autograft tissue not used in the index procedure.

23 Biocleanse adjustable length allograft

24 Contra lateral autograft

25 Contra-lateral hamstrings or fresh frozen tibialis

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26 Depends on the tunnels- if I'm happy with the tunnels I may use autograft hamstring. Otherwise I will use either donor or auto patella tendon I there is significant tunnel widening I might also use an Achilles. But. More likely to use hemi-patella allograft.

27 Depends on which primary autograft is used. If BTB, will use hamstring. If hamstring, then will do allograft Same for recreational athletes

28 don't do revision acl

29 Each revision situation is unique, and different grafts are optimal for differing circumstances. This is a poor question, particularly since the primary graft that failed (HS vs. BTB) is not identified.

30


31 For primary autograft failure for high school/college would tend to use that autograft which had not failed (BTB or hamstring). I tend to use allograft as a first choice and revisions in patients over 40.

32 For the primary autograft failure in high school if hamstrings would do BTB and if BTB would do hamstrings or contralateral BTB; in adult autograft failures if BTB would do hamstrings, if hamstrings failed would give pt choice autograft hamstring other knee or allograft


34 graft choice for revisions depends on nature of tunnels, ie tunnel size,location,lysis so can't answer C-F in this format

35 Graft selection for revision depends a great deal on what graft was used as primary

36 Hamstring of contralateral leg if available

37 I do very few revision ACL's

38 I don't do revision ACL surgery

39

I prefer a hamstring autograft in all pts unless >2 Beighton signs positive. In those cases I will either use auto patellar tendon in younger athletes (< 30 yo) and posterior tib allograft in those >30. In revision scenarios, I will use same criteria and prefer to use autograft if available. In young athletes, I will even consider autograft from contralateral side to stay with autograft. In pts > 30 or non athletic population I will use allograft post tib.

40 I would try to use hamstring or patellar tendon autograft if it hasnt been used previously and if the tunnel size allows it. Otherwise i would use a tibialis anterior allograft.

41 I would use autograft HSTG or BTB, whichever one was used in the primary procedure.

42 If the primary autograft was NOT the Patellar tendon BTB, then I will use it. If it was used, then I use a Patellar tendon BTB allograft.

43 In revision situations it depends what was used in the primary case and the age---I always try to use Autograft for revisions (either BTB or HS---whatever was not used the first time

44 Less than 35 y.o., use ipsilateral BPB or hamstring if hasn't been used, or contralateral autograft

45 My preference is highly influenced by the individual patient's circumstances; as a result, I don't have a specific graft preference that I can offer a generalized response. Also note, that I completed fellowship in July 2012, so I only worked from Aug to Dec during 2012.

46 Other - Depends on bone loss or tunnel enlargement. I prefer allograft posterior tib, but if there is bone loss or tunnel enlargement, I will use achilles allograft



49 regarding revision cases-depends on the primary graft used and the amount of tunnel widening

REVISION - High school or college athlete/ PRIMARY: Allograft failure

50 Consideration for contralateral BTB autograft.



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54



56 graft choice for revisions depends on nature of tunnels, ie tunnel size,location,lysis so can't answer C-F in this format 57 Graft selection for revision depends a great deal on what graft was used as primary

58 I do not do allografts in high school and college aged athletes

59 I do very few revision ACL's


61

I prefer a hamstring autograft in all pts unless >2 Beighton signs positive. In those cases I will either use auto patellar tendon in younger athletes (< 30 yo) and posterior tib allograft in those >30. In revision scenarios, I will use same criteria and prefer to use autograft if available. In young athletes, I will even consider autograft from contralateral side to stay with autograft. In pts > 30 or non athletic population I will use allograft post tib.





66 Use Allograft, but consider Hamstring Autograft as well

REVISION - Adult Recreational Athlete/ PRIMARY: Autograft failure

67 "other" is dependent on what autograft they had orgiginally. If they had a BTB, I use hamstrings. If hamstrings first, BTB for revision.

68 1. Autograft-allograft hybrid of hamstrings + tibialis posterior allograft in an attempt to create a graft diameter of at least 11mm. 2. If hamstrings previously used, then PT BTB autograft


70 Biocleanse adjustable length allograft


72 Depends on which primary autograft is used. If BTB, will use hamstring. If hamstring, then will do allograft Same for recreational athletes



75 fan-folded fascia lata allograft

76 Fan-folded tensor fascia lata allograft




80 Hamstring of contralateral leg if available

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81




84 I would try to use hamstring or patellar tendon autograft if it hasnt been used previously and if the tunnel size allows it. Otherwise i would use a tibialis anterior allograft.

85 In revision situations it depends what was used in the primary case and the age---I always try to use Autograft for revisions (either BTB or HS---whatever was not used the first time



88 Other = Peroneus Longus 89 other graft is peroneus longs allograft, goes through tunnels more smoothly than AT



REVISION - Adult Recreational Athlete/ PRIMARY: Allograft failure


93 Consideration for contralateral BTB autograft.




97 fan-folded fascia lata allograft

98 Fan-folded tensor fascia lata allograft




102




105 In situations B) and F)the status of the patient, past medical hx, past surgical hx, and underlying chondral/meniscal status will determine my graft choice preference.


107 No preference: I explain the pros and cons of each and let patient decide.



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110 other graft is peroneus longs allograft, goes through tunnels more smoothly than AT

111 Peroneus longus allograft 112 regarding revision cases-depends on the primary graft used and the amount of tunnel widening

Q6) How would the following influence whether you use an allograft for an ACL reconstruction (excluding multi-ligament procedures) for a given patient:

Less likely to Use Allograft Wouldn't affect More likely to Use Allograft Total Younger patient N 740 65 16 821

% 90.1% 7.9% 1.9% 100.0% CI 2.040 1.847 0.946 Patient intent to return to high ACL demanding activity

N 678 138 12 828 % 81.9% 16.7% 1.4% 100.0%

CI 2.623 2.538 0.814 Female N 200 537 85 822

% 24.3% 65.3% 10.3% 100.0% CI 2.933 3.254 2.082 Cost N 361 450 13 824

% 43.8% 54.6% 1.6% 100.0% CI 3.388 3.399 0.851 Surgical time N 39 548 239 826

% 4.7% 66.3% 28.9% 100.0% CI 1.446 3.223 3.092 Donor site morbidity N 38 265 522 825

% 4.6% 32.1% 63.3% 100.0% CI 1.430 3.186 3.290 Cosmesis N 34 488 303 825

% 4.1% 59.2% 36.7% 100.0% CI 1.356 3.354 3.290 Recovery time in immediate postoperative pain

N 73 375 378 826 % 8.8% 45.4% 45.8% 100.0%

CI 1.936 3.395 3.398 Postoperative pain N 32 385 400 817

% 3.9% 47.1% 49.0% 100.0% CI 1.330 3.423 3.428 Graft failure rates reported in literature

N 698 114 13 825

% 84.6% 13.8% 1.6% 100.0% CI 2.463 2.355 0.850 Graft failures I have experiences in my practice

N 391 386 48 825

% 47.4% 46.8% 5.8% 100.0% CI 3.407 3.405 1.597 Graft incorporation rate/time to return to full activities

N 568 239 18 825

% 68.8% 29.0% 2.2% 100.0%

CI 3.160 3.095 0.997 Disease transmission concerns

N 389 420 4 813

% 47.8% 51.7% .5% 100.0% CI 3.434 3.435 0.481

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Less likely to Use Allograft Wouldn't affect More likely to Use Allograft N/A Total Graft availability for double-bundle procedures

N 47 326 142 277 792

% 5.9% 41.2% 17.9% 35.0% 100.0%

CI 1.646 3.428 2.670 3.322 Q7) To what extent do you believe the following factors affect overall success of an allograft used in ACL reconstruction?

No Impact Small Impact

Moderate Impact

Strong Impact Total

Level of irradiation used in sterilization N 14 118 266 429 827

% 1.7% 14.3% 32.2% 51.9% 100.0% CI 0.879 2.384 3.184 3.405 Use of chemical disinfectants N 40 279 332 175 826

% 4.8% 33.8% 40.2% 21.2% 100.0% CI 1.464 3.225 3.344 2.787 Age of donor N 29 185 389 220 823

% 3.5% 22.5% 47.3% 26.7% 100.0% CI 1.260 2.852 3.411 3.024 Time on the shelf N 63 322 333 99 817

% 7.7% 39.4% 40.8% 12.1% 100.0% CI 1.829 3.351 3.370 2.238 Age of patient (worse outcomes for younger patients) N 24 96 219 486 825

% 2.9% 11.6% 26.5% 58.9% 100.0% CI 1.147 2.188 3.013 3.357 ACL demands of patient after clearance to return to sport/activity/work (worse outcomes for higher demands)

N 40 128 255 404 827

% 4.8% 15.5% 30.8% 48.9% 100.0%

CI 1.462 2.465 3.148 3.407 Rehabilitation strategy (accelerated associated with worse outcomes for allografts)

N 86 247 317 177 827

% 10.4% 29.9% 38.3% 21.4% 100.0%

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Q8) Please indicate your agreement with the following statements: Yes No Total A) Do you have different rehabilitation instructions for patients who receive an allograft for ACL reconstruction from those who had an autograft?

N 319 514 833 % 38.3% 61.7% 100.0%

CI 3.301 3.301 Lower 34.99 58.40 Upper 41.60 65.01 B) With proper rehabilitation and compliance by patients, do your allograft ACLR patients do as well as your autograft ACLR patients?

N 624 209 833 % 74.9% 25.1% 100.0%

CI 2.944 2.944 Lower 71.97 22.15 Upper 77.85 28.03 C) Do you delay return to play timing for your ACLR allograft patients compared with autograft?

N 412 421 833 % 49.5% 50.5% 100.0%

CI 3.395 3.395 Lower 46.06 47.14 Upper 52.86 53.94 D) Do you feel knowledgeable concerning the true amount of irradiation required to completely sterilize (i.e., eradicate everything including spores and viruses) allografts used for ACL reconstruction?

N 285 548 833

% 34.2% 65.8% 100.0%

CI 3.222 3.222

Lower 30.99 62.56

Upper 37.44 69.01

Q8 Follow up A1 – verbatim) You indicated that you have different rehabilitation instructions for patients who receive an allograft for ACL reconstruction from those who had an autograft. How are your instructions different for the allograft patient?

1 150% longer to resume ACL straining exercises

2 2 months longer to return to running & jumping

3 2months longer for return to running or sports

4 6 month for allograft vs 3 month auto

5 6 month return for autograft, 9 month for allograft

6 6 month to return to sport with allograft, 4 months with autograft.

7 9 month RTP for allo, not 6 month

8 9-12 months for allo. 6-7 months for auto

9 ABOUT 50% LONGER TO RETURN TO ACTIVITIES

10 accelerated with allograft

11 Added time to full unrestricted activity

12 Advancement is approximately three months delayed in allograft ACLR

13 allograft 6 weeks protected weight bearing and no active flexion, extension

14 allograft and hamsitrngs autograft same postop, whereas bptb auto has accelerated. based more on bone-bone versus soft tissue-bone healing rather than allo versus auto.

15 Allograft and hamstring autografts in my practice receive a delayed ACL rehab protocol with slower return to running, cutting, and jumping activities. Also a delayed return to sport timeframe.

16 Allograft patient can stop using crutches as soon as comfortable, compared to mandatory 6 weeks for autograft PT. Otherwise rehab is the same for my practice.

17 allograft patients advanced slower

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18 Allograft patients are slower and not cleared for 9-12 months

19 avoid full arc open chain quad pre's for 20 weeks

20 basically just about 6-8 weeks slower

21 basically pivot/duckwalk squatting/impact/sports/accel-decel activities or even uphill running/stair running delayed until 9-12 mos. with allograft, esp soft tissue allograft.

22 Brace for 6 weeks. Autograft d/c brace prn

23 brace for six weeks vs four

24 Brace postoperatively, slower progression

25 Bracing for sports for 18 months postop until graft incorporation occurs.

26 crutches for 4-6 weeks with allograft

27 Crutches partial weight longer ( 4-6 weeks), same rehab program but at about half the speed with same emphasis on weight bearing closed chain exercises.

28 decreased time to functional rehab part of protocol.

29 Delay impact ex and return to sports.

30 delay in cutting and full contact unless patient states they are willing to accept risks of reinjury , otherwise all rehab is the same

31 Delay jogging for an additional month and longer to return to full sports activities

32 delay open chain exercises by one month

33 Delay open chain exercises, delay ultimate return to high demand sports

34 Delay pounding (I.e. running) activities until at least 12 weeks, no jumping until 20 weeks

35 Delay progression with regard to sport specific and jump cutting activity

36 Delay return to full sports to 8 or 9 months vs 6 to 7 in ALC BTB autograft

37 Delay return to play

38 delay return to play and delay sport-specific activity--cut and pivot.

39 delay return to sport

40 Delay return to sport

41 Delay return to sport additional two months

42 delay return to sport by about 2-3 months

43 Delay return to sports to 9 months

44 delay running and cutting activities by at least 4 weeks compared to BTB autograft

45 delay stressing the graft about a month longer.

46 Delay weightbearing in the early post-op period for allograft and delay running/cutting in the later period.

47 Delayed progression for return to running, cutting and sports

48 Delayed progression to aggressive pivoting activity.

49 Delayed quadriceps strengthening.

50 Delayed return to high impact activity

51 Delayed return to impact activities.

52 Delayed return to play until 9 months

53 Delayed return to running , more restricted wgt bearing initially.

54 Delayed return to running and ultimately, return to competitive sports.

55 Delayed return to sport for allograft 9 months vs. 6 months

56 Delayed running and cutting

57 Delayed running until 4 months. Delayed return to sports 9-12 months.

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58 Delayed weight bearing in the allograft and prlonged bracing

59 Delays in advanced muscle training, return to athletics

60 Depends on what it is being compared to. I use different protocols for autograft hamstring and BPTB as well. 61 Diffent PT protocol. Slower return (approx by 4 weeks) in all activities. More akin to ACLR/MMR protocol.

62 do not allow return to running until 6 months.

63 dont use allograft anymore

64 Duration of bracing 8 weeks for allograft patients vs 4 weeks

65 E very thing is just slowed down

66 Earliest rtp8 mth

67 Early post op is the same. My allograft patients are older, less active. The big difference is return to more aggressive sport,or full duty for a fire fighter/police. Autograft in younger pts- full activity (if appropriate) 6 months. Allograft 9 months. However, many of these pt's are not that active and can modify their activity to return by 6 months.

68 elongated protocol to tailor 12 month return to everything vs. 9 months for autograft

69 everything delayed by about 1 month and return to sport 1-2 months

70 everything same just delayed by 6 weeks

71 Expectations and time to return vary. Times and rates of progression are slower

72 faster

73 faster return to rom exercises for allograft due to less donor morbidity site healing with autograft

74 For allograft patients: I brace postoperatively, I delay plometrics / jump training / agility until 9 months postop, I dely return to sports until 1 yr postop (assuming all rehab goals met) and then recommend bracing for sports until 18 months postop.

75 From the start they understand that the the time to full activities, and rehabilitation in general will be slower 76 full activity at 8 months postop with allo vs 6 months with auto 77 Generally similar program but delay most phases or advancements by 4-6 wks. I.e. jogging at 4 months instead of 3 78 Generally slower to return to run and sport. Initial rehab is identical.

79 Globally delayed with open chain, running, cutting, return to sport

80 go slower

81 Go slower and less initial flexion.

82 Go slower for allografts.

83 Go slower in all phases

84 Go slower in the 2 to 6 month range with allograft pts

85 go slower, though pts feel better

86 I am less likely to allow allografts to increase to higher level of rehab due to stretch and rehab

87 I delay aggressive protocol until after six weeks

88 i delay return to high demand torsional activities for the minimum of 9 months

89 I delay when they start running about 1-2 months. I also do not let them back to full activities, cutting and pivoting until 9-10 months.

90 I don't allow my allograft patients to start running quite as soon as autograft patients

91 I don't perform allograft reconstructions because the results have been shown to be inferior. IF I did them I would progress them much more slowly.

92 I don't use allografts anymore, so difficult to answer. But My impression is they incorporate more slowly.

93 I emphasize on Range of motion and quad strength in the initial postoperative period with aggressive ACL rehab 3 mths after surgery. Not every athlete can become like Michael Jordan and similarly all surgeons can't be like John Charnley.

94 I generally advance more slowly through the rehab protocol, but I typically will allow them to fully participate at 6 months if they meet all rehab criteria- same as I would with an autograft

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95 I go slower.Return to sports a little later

96 I have less concern for patellar tendonitis and usually have to slow them down due to less pain and swelling.

97 I hold allograft ACL patients back from functional drills and agility exercises longer than autograft ACL patients.

98 I instruct the allograft patients to advance through strengthening and plyometrics later than the autograft patients.

99 I just go slower and less aggressively, but again, my selection criteria is such that those that get allografts are more sedentary.

100 I progress them more slowly to general activity. They are released to run later than autografts

101 I recommend a slower return to full activity following allograft surgery. However, this is skewed somewhat by the fact that I use allografts in revision cases, where I recommend a slower return to full activity anyway.

102 I rehab allograft patients slower and allow full activity after 8 months versus autograft get aggressive rehab and return after 6 months.

103 I require allograft patients to wear a post op hinged brace for 6 weeks. i delay running for 4 months and return to sport for 8-12 months.

104 I take more time and go more slowly

105 I use my revision protocol which goes slower and and return to full activity i slcoser to 9-12 months

106 I will be a little slower with the initial 4-6 weeks of rehab

107 I would delay mailestones significantly. I would not allow full activity until 1-year as opposed to 6-months with autograft

108 I would recommend slower return to sports. With a healthy BTB autograft, my patient return to full sport at 3 months, with less than 1 percent failure rate. With allograft I would wait closer to 6 months.

109 If hamstring autograft, avoid hamstring strengthening in immediate post-op period.

110 Immmediate post operative weight bearing restrictions are maintained for a longer period of time due to delayed incorporation rates of allograft tissue.

111 In general, slower

112 In the immediate post-op period, for up to 3 months, rehab progresses at a slower rate.

113 Increased time before return to sports

114 Initial rehab identical. Return to run/sport delayed for allograft patients.

115 Is been many years since I used an allograft. I would keep them off sports for at least one year.

116 It is different because of the donor site pain/morbidity.

117 Jog at 4 months and twist activity at 6 months, with full return to sport at 12 months, I feel I am slowing the allo patients down and reminding them not to speed their recovery.

118 Less accelerated rehab

119 Less aggressive early motion. Delayed return to sports or physical activities

120 Less aggressive rehab, delay return to sports

121 Less aggressive with initial rehabilitation. I do not delay their return to activity since I use allograft for those with low activity demands, and allograft incorporation/maturity can take over 2 years.

122 Less formal PT in the first 4-6 weeks as I find that motion comes back easily and I don't want them to progress too rapidly.

123 less time in brace for allograft

124 Limit flex ion to 90 degrees for 6 weeks

125 Limit motion early, NWB x 6 wks

126 Limited weight bearing in the early post-operative period; use of rehab brace for 6 weeks; delay in-line jogging program by one month

127 Longer before return to play

128 Longer delay in full return to activity

129 Longer delay to sports-specific activities after allograft.

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130 Longer for an allograft

131 Longer incorporation times buy less postoperative pain has unique rehab challenges.

132 Longer neuromuscular feedback program with delay in side to side movements

133 longer on crutches and brace. slower progression. need to hold allograft back more since they feel better more quickly, which I think is main reason for increased failures in younger (aka less wise) patients

134 Longer protected time - 3-8 Months time, less aggressive rehab

135 longer protected weight bearing

136 longer protective period

137 longer recommended time to return to full sporting activity

138 longer rehab 12 months

139 longer rehab cautions, lower demand level goals I have had allografts fail at 5 years so early rehab is onew thing, graft acceptance is another.

140 Longer rehab for allo

141 longer return to activity at every stage. I let autograft pt. full return to sport at 6 months. I like to wait until 9 months for allograft

142 Longer return to jumping, cutting, pivoting sports

143 longer return to run, jump, sports

144 Longer return to sports.

145 Longer time before cutting/pivot exercises

146 Longer time before RTP.

147 longer time in post-op brace therapists progress them slower

148 Longer time to rtp

149 longer time to sports participation

150 longer time to weight bear

151 longer tome w/ brace and crutches

152 longer wait unti return

153 longer weight-bearing precautions

154 more conservative approach such as delayed return to open chain exercises, and sports and longer brace times.

155 More likely to protect WB longer with allograft

156 more time for intitial immobilization and to functional activites and athletic activities

157 most strength and ALL activity recommendations and delayed at least 50%

158 Much less aggressive rehab if I were to use an allograft, but I don't use allograft

159 Much longer rehab. Much longer time to pivoting exercises, and full return to sports at 10-11months postop.

160 Much slower progression for allografts especially in the first 4 months.

161 Much slower rehab

162 Much slower rehabilitation protocol for allograft. Will delay return to cutting and pivoting by 3 months compared to autograft. Return to play with allograft is at the earliest one year compared to 9 months with autograft.

163 Must wait one year (compared to 6-9 months for autograft) to return to sports

164 No accelerated rehab

165 no active hamstring strengthening for 8 weeks after surgery w/ dlsg autograft

166 No cyclical loading for 8 weeks after surgery. Limit open chain as long as possible.

167 no jumping, leg presses or cutting activity for 3 to 6 months

168 No resistive quad exercise

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169 No restriction on hamstring use in rehab.

170 No running til 4 mos post-op No return to high level sports til >1year post-op

171 no running until 4 months as opposed to 3 months

172 No use of CPM

173 not really am holding patients longer before return to play, making them pass functional testing before RTP

174 on crutches PWB for one month

175 one month longer to move to next level of activity

176 One year prior to return to sports at risk.

177 Partial weightbearing for 6 weeks as opposed to weightbearing as tolerated Potential to increase the brace wearing time (usually not though)

178 Proceed slower with return to sport/full activities.

179 Progression significantly slowed; progression of weight bearing slowed in 1st 6 weeks; long times for return to running and return to sport/cutting activities

180 Progression through rehabilitation is slower to allow for greater incorporation time

181 Prolong stage III and IV of rehab for 3 months

182 Protected weight bearing for 4 weeks in brace and slow flexion.

183 Rehab goes slower

184 Rehab is a little slower in all aspects

185 Rehab is the same for allograft and autograft hamstrings but different from auto btw

186 Rehabilitation slowed, longer time unti RTP

187 Return to athletics at 6 months for autograft and 9 months for allograft patients. Start treadmill jogging at 3 months for autograft and 4.5 months for allograft.

188 Return to contact sports is delayed for 12 months.

189 Return to full athletics is delayed for one full year. Do not allow any lateral cutting for 6 months.

190 return to paly 9-12 months vs 4-6 mos for autograft

191 return to play is generally 8-9 mo after allograft and generally 6-8 mo after the autograft hamstring or patellar tendon. All soft tissue grafts require ACL knee brace to return to pivot sports

192 Return to play later / protected

193 return to sport delayed with slower transition to open chain activities

194 Return to sport slightly slowly , must complete our ACL rehab testing either way.

195 Return to sports about 9 months post-op.

196 rtn to play at 1 year vs 6 mo auto

197 RTP earliest 9 months not 6 months and have them demonstrate greater strength to progress thru the protoocol

198 Run at 4.5 mos

199 Running starts at 12 weeks instead of 6 weeks. Pivotinng starts at 5 months instead of 3 months. Full return to sports is at 6 months (with a derotational brace) instead of 4 months. Brace wear continues for 24 months instead of 12 months.

200 significantly slower with allografts in all phases of rehab

201 Slight delay until full return to activities

202 Slightly less aggressive in return to play. More time in aquatic treadmill early on.

203 slightly more aggressive protocol

204 slow down rehab in the 6-10 week period where I believe allograft at its weakest

205 Slow them Down

206 Slower (Indicated 6x)

207 Slower (Indicated 4x)

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208 Slower advance to cutting and pivoting activities

209 Slower advancement of rehab.

210 Slower advancement of strengthening program and terminal extension work.

211 Slower e less aggressive return to play

212 slower first six weeks and slower RTP

213 slower for allo

214 Slower in later phases

215 Slower intitial post-operative advancement.

216 Slower introduction of full activity.

217 Slower mobilization, slower loading, longer to return to cutting/loading

218 slower progress

219 Slower progress

220 Slower progress no return to sport for 1year

221 Slower progress to activity levels on protocol

222 slower progression (Indicated 3x)

223 Slower progression (Indicated 3x)

224 slower progression and longer return to sport

225 Slower progression in PT; longer interval before jogging, cutting, plyis, etc

226 Slower progression of strengthening and return to sports after 3 months

227 slower progression the first 3-4 months

228 slower progression through rehab

229 Slower progression through the phases of recovery and return to sports.

230 Slower progression to functional activities with allograft

231 Slower progression to graft stressing activities. Delayed squating in weight bearing positions.

232 slower progression to return to cutting and twisting sports

233 Slower progression, longer time to return to play

234 Slower progression.

235 Slower progression. Longer time to release to full play

236 slower rehab (Indicated 3x)

237 Slower rehab

238 slower rehab and longer return to activities

239 Slower rehab and return to play

240 slower rehab for allograft

241 Slower rehab for allografts

242 Slower rehab in all phases. Minimum 9 months before fully cleared for sports.

243 slower rehab overall with delay in open chain exercises

244 slower rehab process, longer time to return to functional rehab and sports

245 Slower rehab program

246 Slower rehab rate. Longer time to release to sports. 6 mos vs 9 mos

247 slower rehab slower return to pivoting sports

248 Slower rehab time frame.

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249 Slower rehab, later return to running

250 Slower rehab, return to sport delayed to 1 year

251 Slower return

252 slower return for allograft patients.

253 slower return to activities

254 slower return to activities ie running and sport specific drills

255 slower return to activity

256 Slower return to contact and cutting activities

257 Slower return to cutting sports

258 Slower return to cutting, twisting, sports

259 Slower return to cutting/pivoting activities

260 Slower return to full activities

261 Slower return to full unrestricted sports participation

262 Slower return to full weightbearing. Slower progression to impact activity (running)

263 Slower return to impact/balistic/twisting activities.

264 Slower return to open chain activities. Delay jogging until 4 months.

265 slower return to play

266 Slower return to running

267 Slower return to running activities

268 slower return to sport

269 Slower return to sport

270 Slower return to sport specific rehab.

271 slower return to sports

272 Slower return to sports and stress of the graft

273 slower return to sports/pivoting activities with allograft

274 Slower returns

275 Slower rom,block terminal 10 degrees, slower with isotonics

276 Slower sports return

277 Slower time frame to return to activity

278 Slower time to return to full activities

279 Slower to progress to milestones of running, plyometric and open chain activites, and return to sport

280 Slower to return to full sports

281 Slower to return to stage 3 -- agility training and plyometrics

282 slower with allograft

283 slower. No return to sports for 10-12 months

284 tdwb on operative leg for 6 weeks

285 The allograft patients do not need addition rehab for donor site

286 the graft takes longer to incorporate, therefore there rehabe has to be more controlled.

287 The recovery time is longer

288 These patients usually have less pain. They can move more quickly.

289 They rehab faster Get their motion back faster

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290 They start jogging 6 weeks later than BTB autograft and return to sports 3 months later

291 too long for this survey

292 TTWB x4 weeks, prolonged return to running, sports

293 Use a delayed rehab protocol (Noyes delayed vs aggressive)

294 Usually will wait a full year before allow return to play

295 Wait 1year to return to play after allograft

296 We follow the same protocol up to starting agility drills at ~ 6mo. I allow autograft patients to return to sport specific conditioning after clearing agility, and return to play when they feel ready. However, my allograft patients are not allowed to compete in collision/contact sports for 1 yr.

297 We slow down the aggressive strengthening.

298 Weight bearing is partial during first 6 weeks. I use a hinged post up brace for the first 3 months I allow patient to return full sports at the end of 6 months.

299 weightbearing status initially.

Q8 Follow up C1 – verbatim) You indicated that you delay return to play timing for your ACLR allograft patients compared with autograft. When do you typically allow return to play for autograft patients and when for allograft patients?

1 ~6 months auto; 8-9 months allo

2 1 year (Indicated 3x)

3 1 year allograft 6 months autograft

4 1 year allograft, 9 months autograft

5 1 year if strong enough

6 1 yr

7 1-2 years

8 10-11 months post surgery.

9 10-12 months

10 10-12 months versus 9-10 months.

11 12 month return to everything vs. 9 months for autograft

12 12 months (Indicated 3x)

13 12 months autograft 12 months allograft

14 12 months avg for allografts; 8 months avg autografts. Lots of assumptions here though

15 12 months for both

16 12 mos vs 6 mos

17 12 onths and full quad strength

18 12-16 months for allo, 9-12 for auto

19 3 months later

20 3-4 mos autograft 6 0r more allograft

21 3.5-4 mos auto, 4-6 mos all

22 4 - 6 months for autografts; 8 - 12 months for allografts. I tell both groups that I do not expect they will "fully recover until at least one year, however.

23 4 months auto. 6 months allograft. On average the real time is a function of strength.

24 4 months before running

25 4 months for autograft depending on sport, ie college linemen 9 months for allografts who knows we negotiate

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26 4 months for autograft if they do a perfect job on rehab and can pass a functional test. 1 year for allograft if they can pass a functional test.

27 4 mos 6 mos

28 4 to 6 months for autograft. 8 to 12 months for allograft

29 4-6 months autograft. 9-12 allograft

30 4-6 months vs 6-9 months

31 4-6 mos auto 8-12 mos allo

32 4-6 or 9 months vs 6-9 or 12 months.

33 4-6mo for auto graft 6-8 months for allograft

34 4-6mos autograft 6-9mos allograft

35 4-8 auto ,6-10 allo

36 5 month autograft 6 month allograft

37 5 months for autograft, 8 months for allograft

38 5 months in auto, 8-9 in allo.

39 5-6 months Autograft, 9-10 months allograft

40 5-6 months for auto, 12 for allo

41 5-6 months for autograft and 9-10 months for allograft.

42 5-6 months with autograft if have fullROM and strength with single leg hop test equal, 6-9 months with allograft

43 6 - 8 MOS auto, 9-12 mos allo

44 6 for auto, 6-9 for allo

45 6 mnths auto 9 allo

46 6 mo ACLR autograft and 9 months ACLR allograft

47 6 mo auto 6-9 mo allo. Would only use allo on lower demand/older pts

48 6 mo auto, 9 mo allo

49 6 mo, 9 mo

50 6 month auto 9 month allo

51 6 month auto 9 months allo

52 6 month for auto vs 6-9 months for allo

53 6 month return for autograft, 9 month for allograft

54 6 months

55 6 months auto, 12 months allo

56 6 months - 9 months

57 6 MONTHS -7 MONTHS ALLOGRAFT: 9 MONTHS

58 6 months (dependent on strength test) for auto and 6-8 for allograft

59 6 months / 9 months

60 6 months 9 months

61 6 months and 8 months

62 6 months and 9 months

63 6 months auto 12 months allo

64 6 months auto 7-8 months allo

65 6 months auto and 9 months to 1 year allo

66 6 months auto btw, 9 months for all others

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67 6 months auto- and 9 months allo-



70 6 months auto. 8 months allograft

71 6 months auto. 9 months allo.

72 6 months autograft, 12 months allograft but allografts are not high demand patients

73 6 months autograft, 8-9 months allograft

74 6 months autograft; 8-9 months allograft

75 6 months earliest for autograft, 9 months for allograft

76 6 months for auto 9 months for allo

77 6 months for auto-, 12 months for allo-

78 6 months for auto. 8 for allo

79 6 months for autograft Rarely use allograft

80 6 months for autograft 8-9 months for allograft

81 6 months for autograft and 12 months for allograft

82 6 months for autograft and 7-9 for allograft

83 6 months for autograft and 8 months for allograft

84 6 months for autograft and 9 for allo

85 6 months for autograft and 9 months for allograft.

86 6 months for autograft and 9-12 for allografts

87 6 months for autograft if they have their strength back and 1 year for allografts

88 6 months for autograft patients depending on functional testing versus 8-9 months for allograft patients depending on the functional testing of the patient.

89 6 months for autograft provided they pass functional testing by our therapists/trainers. 8 months or longer for allograft and they have to pass functional testing.

90 6 months for autograft pts. Usually 9 months for allograft pts.

91 6 months for autograft versus 7-9 months for allograft

92 6 months for autograft, 1 year for allografts

93 6 months for autograft, 12 months for allograft

94 6 months for autograft, 8-9 months for allograft

95 6 months for autograft, 9 months for allograft (Indicated 2x)

96 6 months for autograft. would not do allograft if intent was to perform sports. would delay as much as possible for allograft up to one year

97 6 months for autografts and 9 months for allografts.

98 6 months for RTP in autograft 8 months for RTP in allograft

99 6 months minimum for autograft if strength is sufficient. Minimum 9 months for allograft if strength is sufficient.

100 6 months versus 8 months

101 6 months versus 9

102 6 months versus 9 months to 1 year

103 6 months vs 12 months minimum(9vs18moths to 18vs 36 months for graft maturity)

104 6 months vs 9 months (Indicated 2x)

105 6 months, 9months

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106 6 months,12 months

107 6 months/12 months

108 6 mos auto 1 yr allo

109 6 mos for auto, 12 mos for allo

110 6 mos for auto, 6-9 for allo.

111 6 mos vs 10mos

112 6 mos vs 9 mos

113 6 mos, 7-8 months

114 6 to 9 mos auto 9 to 12 mos allo

115 6 vs 9 months, but the allografts are mostly revisions

116 6-12 months auto, 2 years allo

117 6-7 months autograft, 9 months allograft

118 6-7 mos for auto 7-8 mos for allo

119 6-8 months

120 6-8 months 10-12 months

121 6-8 months for auto. 9-12 months for allo.

122 6-8 months for autograft. 10-12 months for allograft.

123 6-8 mos autograt 9-12 mos allograft

124 6-8 mos for an allograft, 4-6 mos for autograft

125 6-8 mos for autographs and one year for allographs

126 6-8 mth versus8-12

127 6-9 month rtp for autografts and 9-12 month rtp for allografts.

128 6-9 months

129 6-9 months 9-12 months

130 6-9 months auto 9-12 months allo

131 6-9 months auto vs 9-12 months allo

132 6-9 months autograft. 9-12 months allograft.

133 6-9 months autograft. Prefer 9-12 for allograft.

134 6-9 months for Auto, 7-10 for allo

135 6-9 months for auto, 9-12 for allo

136 6-9 months for auto. 9-12 months for allo

137 6-9 months for autograft and 8-10 months for allograft

138 6-9 months for autograft; 9 months for allograft revisions.

139 6-9 months for autograft; 9-12 months for allo

140 6-9 months for autograft; 9-12 months for allograft

141 6-9 months for autograft. 12months or greater for allograft

142 6-9 months for autograft. 1+ yr for allograft

143 6-9 months for cutting sports for autograft. Greater than 1 year for allograft.

144 6-9 months sutograft 12-18 monthss allograft

145 6-9 months versus 9-12 months

146 6-9 months verus 9-12 months

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147 6-9 months vs 12 months

148 6-9 months vs 9-12 months (Indicated 2x)

149 6-9 months- auto 9-12 months- allo

150 6-9 mos

151 6-9 mos auto , 12 for allo

152 6-9 mos vs 9-12 mos

153 6-9 mos. vs. 5-6 mos.

154 6-9 vs 9-12 months

155 6-9months for autograft patient 12months for allograft patient

156 6mo auto vs 1 yr allo

157 6mo auto, 9-12 allo

158 6mo autograft 8mo allo

159 6mo vs 8mo

160 6months auto:8-10 allo

161 6months auto. 1 year allo

162 6months,8months

163 6mos v 8 moso

164 7 months

165 7 months for autograft, 9 months for allograft but allograft older and usually no set time frame for return to sport

166 7 months to 8 months

167 7 vs 8 month

168 7-8 months allo. 6 months auto

169 7-8 months auto, 9-12 months allo

170 7-9 months autograft 9-12 months allograft

171 7-9 months for auto, 9-12 months for allo

172 7-9 months for autograft, 9-12 months for allograft. Depends on patient factors, strength, etc

173 8 months for autografts and 10 months for allografts.

174 8 months vs 10-12

175 8 months vs 12

176 8 monyhs

177 8 mos allografts 6 mos auto

178 8 to 9 months for auto longer for allograft

179 8 to 9 months if patient passes sports test

180 8-9 months autograft 9-12 months allograft

181 8months auto 12 months allo

182 8mos to 1 year depending on sport

183 9 - 12 months

184 9 mo auto 12 mo allo

185 9 mo for allo, 6 mo for auto. Both need to have FROM and symmetric quad girth prior to pivot sports. Thinking about moving to functional testing as indication to play.

186 9 month RTP for allo, not 6 month

187 9 months (Indicated 3x)

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188 9 months allograft; 6-7 months autograft

189 9 months at the earliest

190 9 months autograft, 12 months allograft

191 9 months autograft. 12 months allograft

192 9 months for allograft; 6 months for autograft

193 9 months for auto and 12 months for allo

194 9 months for autograft 12 months for allograft

195 9 months for autograft, 12 for allograft

196 9 months for autografts, 12-14 months for allografts

197 9 months for both

198 9 MONTHS FOR BOTH

199 9 months post op

200 9 months.

201 9 months. Patients are revision ACLs only

202 9 to 12 months

203 9 to 12 months depending on specific activity

204 9-12 for auto and more than 12 for allo.

205 9-12 months (Indicated 3x)

206 9-12 months 12 -14 months

207 9-12 months allograft, 6 months auto

208 9-12 months for allo. 6-7 months for auto

209 9-12 months for autograft. minimum of 12 months for allograft

210 9-12 months for RTP for allograft

211 9-12 months instead of 6-8 months for autograft

212 9m+ Auto, 12m+ allo

213 9months and 1 year

214 9months autograft if muscle recovery allows....12 months for allograft

215 9mths for autograft and 15mths for allograft.

216 above

217 add 2 months

218 After 9 months with good strength and functional test results

219 Again, because I do so few allo this is hard to say. Do not have specific time- table for auto- let the knee make th decision. With allo try to slow it up but no specific times.

220 allograft - 8 to 9 months autograft - 6 months

221 allograft-- at least 9 months. autograft-- at least 7-8 months

222 approx 9 mos for auto 9-12 mos for allo

223 as above (Indicated 3x)

224 As above 6 months autograft. 9 months allograft. For my younger pt's with an allograft revision ACL reconstruction, I would wait 12 months.

225 As I stated before, I do not use allografts anymore. My impression is that they incorporate more slowly, and therefore should have demands placed on them more slowly.

226 Assuming able to do a single limb squat- RTP for allograft 8 months RTP for BTB auto 5 months

227 At least 1 yr for allograft, 6-12 mo for autograft.

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228 At least one year, maybe longer. Can be upto 18 months.

229

At the USNA we almost never use allograft in our contact collision athletes, and we follow functional criteria for all return to play considerations following ACLR regardless of graft choice. In addition, they have to pass a very rigorous/ formal physical readiness test prior to returning to their sport. Most athletes aren't ready to compete at this level until about 6-7 month mark. If we use an allograft, then it's probably on a revision, in which case we would lilkley hold out until approximately 9-12 months.

230 auto 8 months allo 12 months

231 Auto - 6 months. Allo - 8-9 months.

232 auto - 9 months, allo - 1 year

233 Auto 4-5 months, 5-6 allo

234 auto 4-6 months allo 6-12 months

235 Auto 5 months Allo 6 months

236 auto 5-7 months allo 9-12 mos

237 auto 6 months allo 8

238 Auto 6 months Allo 8-9 months

239 Auto 6 months Allo 9 months

240 auto 6 months allograft 9 months

241 auto 6-8 mo allo 8-12 mo

242 auto 6-8 mo, allo 7-9 mo depending on clinical exam, quad girth and function

243 Auto 6-8 months. Allo 8-12 months

244 Auto 6-9 months. Allo 9-12 months

245 Auto 6-9 months. Allo 9+ months

246 Auto 6m, allo 8m

247 Auto 9-12 m, Allo 12-16 m

248 Auto about 6 mo and allo 9-12 mo

249 auto approx. 6 months but sometimes sooner. allo. not for 8 months and often later.

250 auto graft 6 months allograft 9 months

251 Auto grafts: 8-12 months Allografts: 10-14 months

252 Auto is 6 months while allo is 9 months

253 auto- 7-9 months allo-9-12 months

254 Auto: 5-6 months Allo: 6 1/2 - 7 months

255 Auto: 5-6 months. Allo: 8-9 months

256 auto: 6-8 monts, allo: 9-12 months

257 Auto...9-12 months Allo...min 12 months

258 autograft 6 mos; allograft 8 mos

259 Autograft - 6 months. Allograft - 8 months

260 Autograft - 6-9 months Allograft - 9-12 months

261 Autograft - 9 months, allograft - 12 months.

262 Autograft - full unlimited activity at 6 months. with Allograft, full activity at 12 months

263 autograft = 6 months provided that they have passed functional rehab testing emphasising neuromuscular re-education and core stability. allograft = 9 months provided that... ".

264 Autograft = 9-10 months Allograft = 12 months

265 autograft 4-6 months allograft 9-12 months

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266 autograft 4-6 months Allograft min 6 months

267 Autograft 4-6 months, allograft 9-12

268 Autograft 5-6 months if neuromuscularly competent. Allograft 6-12 months if so.

269 Autograft 5-6 months, Allograft 7-8 months

270 autograft 6 mo, allogrft 1 yr

271 Autograft 6 months Allograft 1year but I don't do these.

272 Autograft 6 months Allograft 8 mos

273 Autograft 6 months with brace, 12 months without brace. Allograft 9 months with brace, 18 months without brace.

274 Autograft 6 months, allograft 9 months

275 Autograft 6 months, Allograft 9 months (though I do not use allograft for athletes).

276 Autograft 6 months, allograft 9-12 months

277 autograft 6 to 8 months allograft 8 to 10 months

278 Autograft 6- 8 months Allograft 1 year

279 Autograft 6-12 months depending on leg symmetry. Allograft 9-15 months depending on leg symmetry

280 Autograft 6-8 months Allograft 9-12 months

281 autograft 6-8 months depending on sport and strength I very rarely do allograft because I feel there is higher failure rate but return would be 8-12 months

282 Autograft 6-8 months. Allograft 8-12 months.


284 autograft 6-9 months allograft 1 year

285 autograft 6-9 months allograft 12 months

286 autograft 8 months, allograft 10 months


288 Autograft 9 mo. Allograft 12 mo

289 Autograft 9 months Allograft 12 months (Indicated 2x)

290 Autograft 9 mos Allograft 12 mos

291 Autograft about 6 months and allograft 9 months

292 autograft about 6- 8 months (also based on functional criteria) allograft about 9-12 months (also based on functional criteria)

293 autograft aclr return to play 6-8 monhths, allograft rtp 9-12 months

294 autograft are cleared typically in 6-8 months allograft are cleared typically in 9-12 months

295 Autograft at 6-8 months depending upon muscle strength/patient ability. Allograft at 8-9 months depending upon above.

296 Autograft at 85% quad strength to cl side ~4.5-8 months post op. allograft no cutting sports < 1 year post op.

297 Autograft BTB at 6 months; Autograft HSTG at 7-8 months; Allograft at 9 months; All patients must have at least 90% quad strength, pass single leg hop test, have good return of core strength and stable knee w/ full ROM and no pain/swelling

298 autograft minimum 6 months allograft probably closer to 9 months

299 Autograft patients allowed when they have demonstrated appropriate neuromuscular recovery and successful completion of sport-specific exercise regimen. Allograft: the above, after 10 months, whichever is longer.

300 Autograft patients are allowed to return to play after completing our rehab program, and then completing sport-specific conditioning to their satisfaction. Allograft patients who are returning to collision/contact sports are delayed for a year.

301 autograft patients may return in 4-6months. allograft patients after 6 months.

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302 Autograft patients: 6 months; allograft: 9-12 months.

303 Autograft pts generally RTP at 8 months, while Allografts RTP at 12 months.

304 autograft ranges from 6-8 months whereas allograft 9-12 months

305 Autograft return occurs when patient had successfully completed their accelerated program - usually 4-6months, but some are ready at 3 months. Allograft - I typically wait for six months.

306 Autograft return to sports at 7-8 months postop. Allograft return to sports 12 months postop (in brace until 18 months postop).

307 Autograft usually 6-9 months. Allograft 9-12 months

308 Autograft when passing functional test at 6 months; Allograft when passing functional test at 9-12 months

309 Autograft when ready....typically 9-12 mos Allograft typically > 1year

310 Autograft when strength has returned, allograft no sooner than 6 months, but I don't use allograft

311 Autograft when they demonstrate appropriate strength, function and progressive sport specific function. Allograft when they have had significant time for healing.

312 Autograft- 4-6 months Allogaft - 6-9 months

313 autograft- minimum 6 months, avg 9-12 months. allograft- minimum 9 months return to sport

314 autograft- usually 6-9 months. Allograft 9-12 months.

315 Autograft-- 4-6 mos Allograft -- 8 mos

316 Autograft-6 months. Allograft-9 months.

317 Autograft: return to run @ approx 4 mos, return to sport @ approx 6 mos Allograft: return to run @ approx 6 mos, return to sport @ 9-12 mos

318 Autograft: 4 months. Allograft: 6 months

319 autograft: 4-5 months; allograft 5-6 months

320 autograft: 6-9 mo allograft: 12 mo

321 Autograft: run without cutting @ 4 mos, sport @ approx 6 mos Allograft: run without cutting @ 6 mos, sport @ 9-12 mos

322 Autograft:6-10 months Allograft: 10-12 months

323 Autografts 9 months, allografts 12 months

324 autografts 9 months, allografts 9-12 months...however, both groups need to demonstarte through cybex testing and/or single-leg hop confidence/strength in the knee before return, otherwise they are extended till they demonstrate they can retrun safely

325 Autografts between 6 and 8 months, allografts at least one year

326 autografts: 6-8 months Allografts: 8-12 months

327 Autos - 6-9 months Allos - 8-12 months

328 Based on achievement of multiple criteria, not time from surgery

329 Because I use allograft in older its return to play in 9-12 months vs 6-9 for autografts who are younger

330 Begin training unrestricted training at 8 months.

331 BTB auto approx 5 months; hamstring auto approx 6 months; allograft approx 6+ months.

332 BTB auto pts return to play 9-12 months. Hamstring auto and allograft return to play no sooner than 12 months.

333 BTB auto- 6 months, Hamstring auto- 7-8 months, Allograft- 8-10 months

334 BTB auto: 6 months minimum, HS auto and allografts 7-9 months minimum

335 criteria, not time based

336 Delay return to sports to 9 months

337 Delayed to 9 months

338 Depends on how do in PT--follow delayed protocol as above--ultimately probably marginal difference in return to sports--do mostly autograft in all comers (mainly slower rehab more so than slower return to sports)

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339 Depends on patient age. Typically 8 months for auto. 2-4 weeks longer for allograft.

340 Depends on quad strength. Usually 6 months for autograft and 9 months for allograft.

341 depends on return of quad strength for autograft, any where from 4 m on if strength is normal for quad and full rom for allograft it is at least 6m

342 depends on sport for contact or high-demand sports in general autograft 8 months but only when meets other criteria allograft 10 months

343 Different for everyone but earliest for auto is 6 months, earliest for allo is 9 but I will stretch it out to one year unless they need to get back

344 Earliest at 6 months for autograft, earliest 9 months for allografts.

345 error i allow both back at 6 months

346 For allograft patients typically by 6 months but dependent on meeting milestones of rehab program. I do not use allografts for my primary cases, but in my revision cases I will allow them to return to full play by 6 months provided the patient has meet milestones of rehab program.

347 Full return to sports is at 6 months (with a derotational brace)for allografts instead of 4 months. Brace wear continues for 24 months instead of 12 months.

348

Generally it is 6 months before contact sports with all ACL reconstructions assuming that they are doing well with core stability, strength, and full range of motion and no swelling or pain. Occasionally, if someone is doing extremely well with a patellar tendon autograft, I will let him participate in some sports like baseball is early as 4 months realizing that they have a higher risk of reinjury according to some studies. This is discussed with the patient and family.

349 generally the same for both, when rehab-is optimized, fully confident, somewhere between 6-9 months , but generally delay the allografts towards the 9 month mark

350 Have strength and functional test performed at 5 months for auto and 6 months for allograft. Can return when functional 90%of opposite side.

351 Historically 4-6 months for autografts. I have slowed it down to 9 months, over the last year, secondary to data and expert opinions at the AOSSM meetings last year. I have historically held allografts to 9 months or later, due to slowere remodelling concerns.

352 Hop test earliest at 6 m autograft, 9 m allograft

353 I haven't done an autograft in more than 15 years, so I don't know

354 I suggest to them that we take more time

355 If quads rehabbed adequately - autograft at 8 months allograft at 10-12

356 In general 8-10 months vs 4-6 for autograft (both pending functional rehabilitation measurements)

357 In higher level athletes I'm far more likely to recommend autograft and let them return at minimum 6 months with appropriate clinical improvement. If I chose allograft for those patients I would probably recommend delaying RTP by a couple of months.

358 light sports (no contact) at 6 months and full sports (contact) at one year

359 longer

360 Longer

361 Longer for an allograft

362 Min 6 months for autograft, typically min 8 months for allograft

363 min 9 months

364 minimum 9 months

365 more around 6 months if they are young, FROM, no effusion, neg pivot, no guarding, able to squat and side-to-side hop.

366 Must wait one year (compared to 6-9 months for autograft) to return to sports

367 My autograft ACLRs are release at 6 months. IF I used an allograft i would delay return to 9-12 months postop

368 Not before 6 months for auto, not before 8-9 months for allograft

369 Not until a yesr

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370 one year

371 Return to athletics at 6 months for autograft and 9 months for allograft (if quad strength and hop test are adequate).

372 return to play is based on functional testing for both patients but I typically am more conservative with the allograft patient

373 Return to play is suggested no earlier than 10 months, but usually around 1 year.

374 return to unrestricted sports at: 10-12 months after surgery for allograft 7-9 months after surgery for autograft

375 running: 3 mths auto, 4 mnths allo. cutting: 6 mths auto, 8 mths allo

376 See above

377 Six months for autograft patients, eight to nine for allograft.

378 Slow them down 379 Slower 380 slower for allo 381 Slower return to impact, jumps, sports (9 months for allograft, 6 months for auto)

382 Sport specific gradual increase to prepare for RTP at 6 months with auto, a month usually behind for allograft but pt specific. Warnings of decreased chance of full incorporation has been discussed.

383 These are generally my older patients and thus they are not rushing back for a season. I typically recommend 9-12 months to return.

384 This is typically delayed by 3 months or so

385 Timing of return is dictated by appropriate progression through rehabilitation program: typically 6+ months for autograft vs 9+ months for allograft for return to high-demand/unrestricted sports

386 Ultimately it's determined by the results of patient's functional testing, but generically 6 months for autograft and 9 months for allograft.

387 Usually I use allografts for revision surgery, and typically I recommend longer time for return to full play in this circumstance (usually 9-12 months postop).

388 Variable depending on function

389 When quad and hamstring strength is within 15% of other leg and I will observe game situation practice.

390 When there is equal quad girth measurement and 80% strength measurement on Biodex machine. Usually not sooner than 6 months with autograft and not sooner than 10 months with allograft.

391 When they are strong enough, usually: Auto-9 mos Allo-11 mos 392 Yes by 3 months

Q8 Follow up D1 – verbatim) You indicated that you feel knowledgeable concerning the true amount of irradiation required to completely sterilize (i.e., eradicate everything including spores and viruses) allografts used for ACL reconstruction. What level is required: _____ mRAD

1 ?

2 ?? not sure

3 .5

4 >1

5 >2.0

6 >3

7

>3 is required which is above safe level assumed to be 2.5. But I personally think that it takes a lot more than 3 mrad and then you throw in the word "completely" and I don't think that it can be done at a level that doesn't damage the graft tissue. This is one of the reasons that I don't use allografts unless I lack other tissue or have s strong request from the patient who is informed of the risks.

8 >3 rads but decreasing structural integrity

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9 >3.0 to kill viruses but this can weaken gradt when >2.5

10 >3.5

11 >3.5 mRAD

12 >5

13 >7-9 mRAD (>5 is too high--leads to loss of biomechanical properties of the graft--I won't accept graft irradiated at 5 or greater)

14 0

15 0 I do not use iterated grafts.

16 0- ie not required

17 1 (Indicated 3x)

18 1-2.5 mRad for low dose, 3-5 for everything

19 1.2 (Indicated 2x)


21 1.5 mRads-2.5mRads

22 1.5 to 2

23 1.5 to 2.5 mRads

24 1.5-2.5---Depends on the study

25 1.8

26 10 (Indicated 3x)

27 100


29 15

30 2 (Indicated 8x)

31 2 mRAD is the max before significant damage to the graft occurs. However, even at this level the graft is not sterile. I believe the dose for 100% sterility is 4 mRAD.

32 2-2.5

33 2-3 (Indicated 2x)

34 2-3 mrads

35 2-5

36 2.0


38 2.5 MRAD

39 2.5mRAD


41 20 -30 kGy

42 2000

43 25

44 250

45 25kGy

46 3 meg

47 3-4

48 3-4 mRads

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49 3-4.5



52 30

53 300

54 3000

55 35 kg gray

56 3500

57 35kGy

58 3mRads to get everything


60 4 mRAD (Indicated 2x)

61 4 mRad for HIV

62 4 Mrad to eradicate everything

63 4 or more

64 4-5 (Indicated 2x)

65

4-5. I do not recommend using irradiated allografts. The literature is difficult to interpret due to many Level 4 evidence retrospective studies. However, there is a growing body of literature demonstrating superior outcomes with fresh frozen grafts compared to irradiated grafts. This is further supported by a growing body of literature using less and less irradiation where the recent published studies out of Rush using 1.2Mrad has little effect on biomechanical properties and biologic incorporation in a rabbit model. I believe we will come to find sterile aseptic processing eliminating radiation will provide the best results with allograft tissue


67 4.0 However this destroys structural integrity of the graft and thus I request un-irradiated allografts only

68 4.0 mRAD

69 4.1

70 4+

71 40

72 4mRAD for everything which makes the graft very weak

73 4mRads


75 5 mrad.

76 5 to eradicate ALL

77 5-10

78 5-6 mRad

79 5-8



82 5000

83 6 (Indicated 4x)

84 60

85 7

86 70

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87 80

88 Above 3.5

89 above 4 mRad

90 Allograft can never be completely "sterilized," but it can be aceullar. I prefer low-dose irradiated grafts of 2.5 mRAD or less when using allograft in order to prevent decreasing the tensile strenght of the tissue

91 approx .2 mRad

92 Appx 3.5

93 at least 2.5 for bacteria i believe greater than 3 for viruses I USE ONLY FRESH FROZEN ALLOGRAFTS FROM DONORS AGE LESS THAN 40YRS AND AT LEAST 9 MM IN CROSS SECTIONAL DIAMETER GRAFT MATTERS REASON FOR URBAN MYTH OF ALLOGRAFTS IS POOR QUALITY OF TISSUE AND SMALL SIZE WITH LESS THAN OPTIMAL FIXATION

94 at least 4

95 busted

96 can't say without looking up again.

97 Cant recall, bu it is quite high for complete sterilization.

98 dependant on whether you are also using additional chemical sterilization 6- high level irradiation with mechanical effects on graft 3- mod irrad low level irrad usually about 1mRAD but with additional chemical sterilization

99 Depends on load, at least 1-2.5 mRAD

100 don't know that, but feel any irradiation is deleterious to graft; use mtf non-irrad grafts only

101 Don't know.

102 dont know

103 Enough

104 greater than 4. In otherwords, the graft would have to be fried to the point of uselessness to truly make it sterile. Therefore, I request non-irradiated allografts whenever they are available.

105 Greater Than 5 megarads

106 I can't tell you this AM. However, our graft source (Allosource) which is a division of UNYTS uses the NTB standards which are essentially the same as MTF.

107 I know what the literature says; are those studies accurate; I don't know that for sure.

108 I only use non-irradiated allografts (Achilles Tendon) age matched to the patient.

109 I thought that I answered the opposite

110 I would have to look it up but I think 2

111 I would prefer less than 1.8 mRADs based off of FA Barber studies.

112 less than 2.5 mRad

113 less than 2mrads

114 less then 2 MRADS...even that is too much...no irradiation...think e Beam?

115 More the better

116 N/a

117 Needs low dose irratiation.

118 None

119 over 1.25 x 10 to the 6th rads

120 over 2

121 radiation is not required

122 Sterilization is a probability function and chance of complete sterilization is dependent on amount of contamination. Higher dose, less chance. 2.5 mRAD is commonly used dose to decrease chance to less that 1 in 1000000 (standard acceptable reduction for medical products ), which assumes a low level of contamination,

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123 The level is unknown, but too large to be considered

124

The level required to 'sterilize' a graft of spores will destroy the effectiveness of the graft. Any irradiation above 2.5mRADs creates a graft that should not be used. There is no truely sterile allograft that has the structural sufficient to provide good outcomes. Conseqeuntly the recovery of the graft material should be within 12 hours and done in a sterile environment. AATB standards are a bare minimum and caustic chemical or irradiation are contraindications for my use of a graft. I use MTF grafts exclusively.

125 This is dose dependant

126 three

127 use RTI which doesnt use radiation

128 x

129 zero i only use non irradiated grafts

Q9) What level irradiation do you believe is harmful to the biomechanical/physiological properties of the graft?

N Valid Percent CI Lower Upper

Any degree of irradiation is harmful 260 31.8 3.194 28.63 35.02 Low dose irradiation (1.0 - 1.2 mRAD) is not harmful but higher levels are 339 41.5 3.379 38.11 44.87

Medium dose irradiation (up to 2.5 mRAD) is not harmful but higher levels are 197 24.1 2.933 21.18 27.05

Higher dose irradiation (up to 5.0 mRAD) is not harmful 21 2.6 1.085 1.49 3.66

Total 817 100.0

Q10) Do you believe that some level of irradiation is essential for allografts used in ACL reconstruction to eliminate pathogens?

N Valid

Percent CI Lower Upper

Yes 281 34.1 3.237 30.87 37.34 No, the donor screening processes and nucleic acid amplification testing (NAT) currently used by processors is sufficient to all but eliminate the risk of disease transmission

135 16.4 2.527 13.86 18.91

No, non-irradiation sterilization processes are able to achieve acceptable levels of sterility 172 20.9 2.775 18.10 23.65

Not sure 236 28.6 3.087 25.55 31.73 Total 824 100.0

Q11) Do you use allografts for ACL reconstruction that have been irradiated?


Yes 360 43.5 3.377 40.10 46.85 No 295 35.6 3.262 32.37 38.89

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Not sure 173 20.9 2.769 18.12 23.66 Total 828 100.0

Q12) Who provides most of the allografts that you use for ACL reconstruction? (Check all that apply.) Frequency Valid Percent Allosource 122 15.0 LifeNet 146 17.9 MTF/ConMed 335 41.2 RTI 147 18.1 Not sure 154 18.9 Other 73 9.0

Q12 Other – verbatim)

1 100% Allosource since 1986

2 AATB source

3 Alamo (indicated 2x)

4 Arthrex

5 Arthrex (perhaps through one of those sources)

6 Arthrex vendor

7 Arthrex/ATSI?

8 Bacterin

9 can't remember

10 Community

11 Community tissue

12 Community Tissue

13 community tissue bank

14 community tissue services

15 Community Tissue Services

16 Community Tissue Services of Dayton, Ohio

17 cts

18 dci

19 DCI

20 DCI - by med center contract, not doctor decision

21 DCI Donor Services (indicated 2x)

22 DCI from Tn

23 DCI Tissue Services

24 Depends on hospital vendor agreements

25 Do not use

26 don't use

27 dont use

28 Eurotransplant Leyden

29 Hema quebec, Halifax

30 Hospital das Clínicas (São Paulo/Brazil)

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31 hospital recently switched

32 I do not use allografts, so do not weight any statement about use of allografts in my answers

33 I don't use allografts

34 I don't use allografts for ACLR

35 I don't use any

36 I have checked this, think it is Allosource, but don't recall with certainty

37 I haven't used one in years

38 Life link

39 lifelink

40 Lifelink (indicated 3x)

41 LifeLink (indicated 3x) 42 local Community Tissue Bank

43 local distributorship

44 miami

45 Miami Soft tissue Bank

46 Miami tissue bank

47 Miami Tissue Bank (indicated 2x)

48 mt sinai toronto

49 MTF

50 N

51 n/a

52 none

53 NW Tissue Bank

54 NW tissue center

55 Ohio Bank

56 Our own regional tissue bank

57 Queensalnd Tissue Bank, Australia 58 R and M distributing

59 Red Cross 60 Smith & Nephew

61 Source dictated by hospital 62 tissue net (indicated 2x) 63 TissueNet 64 Univ of Miami (indicated 3x)

65 University of Miami Tissue Bank (indicated 2x)

66 Victorian Tissue Bank (Australia)

67 Was Northwest Tissue Center, bought by Lifenet. 68 Whatever the hospital arranges

Q13) Do the allografts you use for ACL reconstruction come from a tissue bank that is approved by the American Association of Tissue Banks (AATB)?


Yes 715 87.4 2.274 85.13 89.68 No 7 .9 0.631 0.22 1.49

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Not sure 96 11.7 2.206 9.53 13.94 Total 818 100.0

Q14) Have you personally researched the safety track record and clinical results of the tissue bank from which you get allografts?


Yes 351 42.5 3.374 39.17 45.92 No 474 57.5 3.374 54.08 60.83 Total 825 100.0

Q15 - verbatim) Please use the box below to provide any additional information, thoughts, questions, and concerns you have about allografts for ACL reconstruction.

1 1. Industry leader 2. Low-dose irradiation 3. Long trouble-free track record

2 After recently reviewing our 10 year data of primary allograft acls using only MTF grafts, I will no longer offer allografts to patients under 30-35 for primary reconstructions. Under our ideal circumstances, failure rate is around 30 percent for young folks!

3 Allgrafts are safe to use as long as you are not using soft tissue only grafts. BTB allografts have great outcomes.

4

Allograft sources frequently change based on institutional prices. I do my best to keep up with what is currently being used but must confess that sometimes I use them without knowing the details of the graft and its preparation. Unless the patient is a relatively low activity level and more advanced age, I make every effort to use autograft. My mean primary ACL reconstruction age is between 20 and 22 years old. Most revisions I do had primary ACLs with allograft.

5 allografts in primary ACLR when >40 y/o. Mutliple graft sources, confuses the issue.

6 Allografts are good as long as not irradiated. PRP "not proven" adds benefit to healing.

7 Allografts are overused. Increased costs, increased failure rates justify their use in limited situations

8

Allografts have been shown in meta-analyses to provide poorer results while at the same time being expensive. The tissue bank reps however are very aggressive in pushing allografts for their own profit, and provide skewed date to surgeons. They should only be used in special circumstances. The only rationale for using them is that the surgeon is not comfortable with the use of autografts: which is not a good reaosn. Numerous studies have also shown delayed allograft incorporation (e.g. Sheffler from Berlin in a large animal model)

9 Allografts should not be used

10 Almost never use allograft

11 As a resident we collectively researched MTF As an Attending I did a less thorough research process on RTI based on their own reported data

12 Avoid if possible. Respect pts choices though if they insist. Give info

13 Because we are now reconstructing ACLs more anatomically, the graft experiences more strain early on in the rehab process, as opposed to ones placed nonanatomically. For this reason, I feel more allograft ACLRs fail early.

14 Being part of Mayo Clinic Health Systems - we are required to use AATB approved tissue banks. This is vital to assuring the sterility and safety of the allografts.

15 Best option for women over 40,low-demand patients and revisions

16 can be difficult to assimilate the important data on allograft usage and apply to everyday practice. a regular update on latest data and recommendations for safest and most effective allograft usage would be helpful

17 Currently only using for augment when hamstring autografts are used and are smaller than 8mm

18 Do not use allografts; HIV was transmitted pre 1984 from blood transfusions when the HIV virus was not yet known. I am afraid that there are potential pathogens (prions, etc.) that are not testable that are potentially present in allografts that we do not yet even know exist.

19 don't use allografts

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20

Failure rates among allograft , I believe, is NOT due to nature of graft but due to premature return to activity with inadequate restoration of quads and hamstring proprioceptive strength that results in re injury with subsequent re tear. Reason for premature return to high level activity is secondary to false belief that they are already healed because patients post allograft have very little pain and are able to achieve excellent motion much earlier than autograft. I have had no failure in all comers since I do not allow return to high level activity until at least 9 months when there is excellent muscular strength and control and brace for first year with sports.

21 For years I was in a major medical center and the allografts came from either MTF or Biocleanse. Now I practice in a small community hospital and have not used allograft yet and am not sure of the supplier.

22 Glad to participate in this survey

23 graft cost, sterility, and disease transmission, are the primary reasons I dont use allografts regularly

24 graft properties is only one possible reason for failure. I think the failure mode is always speculative.

25

have no concerns regarding the safe use of allografts for primary and revision ACL reconstruction in patients older than 30 yo age. My biggest concerns relate to the indication for the use of an allograft in elite athletes, or primary ACLR in pts younger than 30 yo age or revision procedures where a failed allograft was used during the primary reconstruction. I have been using allografts in more than 90% of my patients for the last five years with only one serious adverse event which not related to the use of the allograft. Literature review seems to suggest similar outcome in the general population. However, the orthopedic sports medicine community seems to be unable to find a common background on this topic, yet. Cost-related issues of an allograft need to be taken in consideration, too. The latter seems not to be a discriminative factor in Academic practices but it is definetely a burden in the private sector. I would like to see clear cutting-edge information in th e literature from metanalysis of RCT studies regarding outcome and complications of allo- and autografts and, more important, specific recommendations from the AOSSM applicable to different scenario (primary, revision, occasional athletes, collegiate or professional athletes, age, sex etc) based on the general consensus from panel of experts.

26 HIV transmission has always been a concern, but with CRYOLIFE failure in 90's- other disease transmissions a concern. Improved cleansing techniques very beneficial and have alleviated my concerns. Even though studies have not shown it, I believe age of graft is important also.

27

I accept the limitations of the cleaning and irridation and attempt to limit the usgae when I can. However, there are situations where an allograft is a good option so choosing grafts with limited irradition is the best I can hope. However, the disease risk is still there as high dose radition--the amount required to eliminate HIV/Hep C--grafts have too high a failure rate in my opinion.

28 I am a poor one to ask since I never bought into Allografts because of skepticism that they were not as good as Dr. Fu said. I just never felt the benefits outweighed patella tendon autograft. Of course recent literature has almost proven I was right!

29 I am interested in using them more often and hope we can improve the stregnth

30 I am very skeptical of an unregulated industry dealing with human body parts

31

I believe Irradiation and many of the sterilization processes used for Graft sterility are detrimental to the mechanical and structural properties of the grafts. However I believe the primary reason for allograft failure In some studies has to do with graft choice, surgical technique and poor fixation device choice. I have not had major issues with graft failures in patients undergoing acl reconstruction even in younger higher level athletes. However I am continuing to stay up-to-date on the literature, following studies, and give consideration for practice changes if the data clearly supports switching back to autograft.

32 I believe most of the failures in younger people are due to too aggressive of a rehab. minimum 9 months of rehab. really stress squats in the younger population. Dramatic increases in quad and buttock muscles are to key to good rehab.

33 I believe much of my success with allograft has been due to the way the tissue has been processed. Avoiding radiation is important to me.

34 I can not justify the cost and risks of routine use of allograft for questionable/soft benefits (cosmetics, early postop pain).

35 I chose several years ago not to use allografts unless my patients tell me otherwise, but i review with my pts the pros and cons of allograft use and always agree to use their own tissue. If it is a revision and they hve no options on the ipsilateral side i will harvest from the other leg with no cases of morbidity.

36 I discuss allograft with my patients but most don't want them

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37 I do not use allografts for primary ACLs in competitive athletes.

38 I do not use them for primary at all and would be very reluctant even in revision

39 i do this so rarely but when I do I do check on the sterilization process but not the tissue banks track record. I rely on the orthopaedic coordinator to give met he information

40 I don't believe they have broad indications in my practice. More selected indications. I am 48 yo and if I had an ACL recon I would think I am the perfect demographic for the allograft, but if I wanted to get back to sports earlier, I would still have a hamstring autograft.

41 I feel the primary cause for allograft failure is the early return to activity and increased stress on the graft due to less pain and trauma to the joint. Those that follow protocol do well. Younger age patients are not compliant.

42 I generally use autograft for all patients under 30. For all patients I discuss the risks and benefits of both depending on their age and activity level and allow them to decide what they think is best for them.

43 I have a detailed discussion of options risks and benefits with each patient.

44

I have a general algorithm for choosing which graft I use. In a young patient less than 25 years old I use Bone patella Bone Autograft unless the patient has Knee pain, then I use Hamstring Autograft. If the patient is older than 35, then I use Hamstring Allograft. For kids with open physis within a year of Closure I use Hamstring Autograft as well. For patients between 25 and 35 I present the options and let the patient decide. If any of my patients feel strongly about the graft type they have the ultimate choice but I do review the pros and cons with them.

45 I have a partner who does more allo than I and has done the research regarding the bank we use , etc.

46 I have always been a B-PT-B autograft surgeon

47

I have been in practice for over 30 yrs .Fellowship trained in sports medicine. I have used primary repairs, extra articular reconstructions,gortex grafts, Dacron grafts, xenografts, LAD grafts,auto grafts bone patella bone ,hamstring,iliotibial band,quadriceps tendon. Allograft fresh frozen freeze dried irradiated, no irradiated & chemically sterilized Achilles ,bone patella bone, hamstring ,anterior & posterior tibialis tendons. My best results have been with chemically sterilized posterior tibialis tendon double looped.

48 I have found them safe. Tissue quantity usually is excellent. Quality is another issue and I will not implant a graft from donor over 40 years old, this is anecdotal with my practice but I have seen some very poor appearing tissue in older donors

49 I have gotten away from allografts secondary to high failure rates and several rejections

50

I have had no allograft failures in my practice, and very rare autograft failure. I do think that it is important to give the grafts time to mature, and I suspect that the presence of host cells and lack of storage in the graft allow faster incorporation of autografts. I suspect that market forces lead surgeons to allow return to sport too early, but most of the revisions I do are due to inappropriate graft placement, not tissue type.

51 I have had poor results with soft tissue allografts compared to my autografts in my clinical practice for patients younger than 25

52 I have moved toward using allografts significantly less in my practice. I implanted BTB Allografts as a primary graft in "all comers" during 2011. Since then, I have noted a 25-30% re-rupture rate during that short term follow up.

53 I have never trusted allografts because of the risk of disease transmission and the fact that the early animal studies show delayed healing of allografts relative to autografts.

54 I have not noted any significant donor site issues even in older patients when using hamstring autografts.

55

I like the Achilles tendon for the ACLR. I have used it for at least 15 years with no failures. The youngest patient was a 16 year old girl, competitive soccer player that went on to resume her career and went to college with a scholarship. I have not used a double bundle graft, I feel it's not necesary, the donor site is painful, not cosmetically pleasing, recuperation is slower. Before I went into the Achilles tendon I did use the patient's own patellar tendon. There is much more pain and in women the cosmesis is important.

56 I never use allografts. Hamstring tendon autograft has worked well for me since the early 1990's.

57 I now have concerns about allograft ACLR in younger patients, whereas previously I did not.

58 I personally visited the MTF facility in Edison NJ and was briefed on the process. It required a trip from Dallas to do this but I felt that was needed since there is such confusion among clincians and many conflictinng claims are being published. Some of these misconceptions are reflected in how the questions of this survey were composed.

59 I prefer to use MTF non-irradiated grafts. Sometimes, surgical centers or hopsital have other vendors.

60 I really don't use allografts

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61 I reserve the use of allografts for patients over the age of 45 and only if they insist on the use of an allograft. I typically insist on the use of autograft; routinely BTB autograft. when performing double bundle reconstructions, I use an 8mm BTB autograft for the AM bundle and a single hamstring for the PL bundle

62 I talk young patients out of allografts all of the time, citing available literature (especially MOON study). Many other surgeons in my area use allografts more often. I revise several of them, but most of those failures also have tunnel issues.

63 I tend to use them for lower demand athletes and revision cases

64 I think that graft variability (all of the variables that you have brought up) is a big reason that we have had such variability in allograft outcomes studies

65 I think the grafts and outcomes should be compared by type, sterilization process, rehab protocols, fixation methods, notchplasty, gender, and age of patient.

66 I think they are overused by many

67

I trained using many allografts in my fellowship, so I did many when I started my practice. Way too many re-tore with minimal trauma. So I published my results and presented at the academy meeting. I my results were published too soon before everyone else figured this out. I was soundly criticized. Allografts are a complete scam and they often fail. They should not be used often. Now I just use hamstrings for my patients that want an easier recovery or smaller scar. An all inside single strand quadrupled hamstring is much better than an allograft for an adult non-athlete. The athletes need BTB!!

68

I use age 40 as a cut off. Under age 40 I always recommend autograft PAT. Over age 40 I recommend allograft. Under age 40, I will do allograft if significant other damage to the joint/post traumatic arthritis. Over age 40 I will do autograft if patient desires it. I am appalled that any of our colleagues are doing allograft primary ACLs in young athletes. I believe that they do it for marketing purposes (less pain and quicker rehabilitation). 20% fail in young athletes. Perhaps that allows them (the ortho docs) to do 20% more cases.

69 I use allograft so infrequently I no longer recall the tissue bank that we use. My total in 16 plus years is 4 allografts, last used more than 5 years ago. I reseasrched the safety profile when I began practice in mid 90s.

70 I use allograft tissue that is non-irradiated only, age-matched to the age of the patient (+/- 5-7 years), no harsh cleansing, and no female donors for male patients. I have found that these restrictions provide comparable results to autograft hamstring, which is my autograft of choice. Lifenet irradiates, and RTI uses a detrimental cleansing process.

71 I use almost no allografts - only for revisions or if requested

72 I use grafts that are sterilized using supercritical CO2

73 I use only not for profit tissue banks.

74

I use RRi grafts. They have a proprietary cleansing process. Howver, they have had some unfavorable media attention recently. After doing some investigation, I have continued using their grafts. I have impanted >100 without an infection. Regardless, the process of choosing a vendor is difficult and I do not feel that I have satisfactory or guidance from AAOS, AOSSM or AANA to make an educated decision

75 I use very few allografts.

76

I was trained to use allografts in fellowship - prior to that, in residency, I had never used them. In my practice, I give the patients the choice every single time. And most times, they select allograft. My use has not changed over the years, but I see that my peers use them more and more. In my practice, I am unable to tell the difference in stability or outcomes between my allo- and autograft reconstructions. I think it would be useful for you to focus on overall infection rates - the risk of infection from allograft graft vs. host disease is much smaller than the reported infection from local skin bacteria that seeds an autograft. This is much more clinically significant because it is perhaps a factor of 100x greater.

77 I will only use one if I have to

78 I would like to see more series of non-irradiated allografts reported in the literature.

79 i'd love more education on this stuff!

80 I'm having good to excellent results with a very low failure rate using nearly 100% allografts for ACL reconstruction!

81 In Australia access to non-irradiated soft tissue allograft is very limited. As such use of allograft is much lower than what I experienced when doing my fellowship training in the US (Duke University)

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82 In general, I try to avoid the use of allografts for ACL reconstructions. I will use allografts for revision and multiligament cases as needed.

83

In my humble opinion non-irradiated Achilles tendon Allografts, aged matched to the patient undergoing the reconstruction have worked well in my practice with zero failures thus far since 2005 (although we never know for sure if the patient goes elsewhere). My fellowship attendings have used the same grafts since the 1980's and 1990's with excellent results. I use grafts from the University of Miami bone bank. I brace my patients for sports for 18 months to allow the graft to incorporate. In 2009 I switched to anatomical tunnel placement from transtibial (single bundle still) and results have not changed. I use metal interference screw (S&N Softsilk) in femoral tunnel (bone plug from calcaneus) and washer lock system (Biomet Sports) in tibial tunnel. My patients ages range from 14-15yo to mid 40's. Football, Soccer, LaCrosse, Basketball, weekend warrior). Hope this helps. No graft vs. host nor host vs. graft reactions, no infections, thus far. BP

84 interested to hear the findings; please keep me posted!

85 Irradiated allografts have been successful in my practice with over 30 year old recreational athletes with 9 months of protection from rtp. There are legal concerns about an infection occurring in a pt with a non sterile graft, even though they may be unfounded

86

Its not clear what pocessing is performed on allografts. We get fairly limited info from companies including from brochures and reps... I steer toward auto on all comers including rec athletes.. and lean towards allo on almost all revisions.. more options w/allo esp. w/defects on revision.. more of my pts are younger resulting in more getting auto particularly BPTB

87 know your tissue bank...

88 LIke ilicit drugs, I just say no to ACL allografts. Sorry I can be of more help

89 Looking at switching suppliers currently. Leaning toward using non-irradiated grafts when allograft use is chosen.

90 Many of the late failures that I have had were large tubularized achilles grafts.The center of the grafts seen at the time of revison appeared completely avascular. Have switched to Tib ant grafts. I wonder if the multiple strands and increased surface area lead to better incorporation.

91 Morbidity of donor site for a single hamstring (4 strand semitendinosis) that my use of allografts has dropped. Hard to justify a documented higher failure rate with allograft

92 most of the questions are too simplistic. for example, I do use different allograft tissue for revisions depending on whether there is tunnel widening or not

93 MTF does a good job of working with us and tissue quality is high.

94 My confidence in allograft reconstruction continues to decline. I use them primarily for revisions but am considering more use of autograft for revision as well.

95 My lack of control over the allograft is one reason I do not use it

96 My major concern with allografts is their ridiculous price. I get pretty good results with not much pain and quick rehab using auto, even in older folks.

97 My opinion is that allografts should not be used in primary ACL reconstruction in young athletes. If the failure rate is even only 1% greater,, it is unacceptable for a young athlete. We know that autograph reconstruction works at a high percentage. Any young athlete should be able to overcome Any graft site morbidity.

98 My practice is to use autograft bone patellar tendon bone tissue if at all possible, including harvesting from the contralateral knee encases of autograft failure.

99

My review of published literature regarding increased failure rates with allografts indicates that with appropriately modified rehab protocols and delayed return to sports, allografts can have excellent outcomes -- if and only if the biology is respected. Patients have to know this and agree to abide by these rules before I will utilize an allograft. In choosing patient's appropriately, I have been very pleased with my allograft outcomes as have my patients.

100 my surgical center takes care

101 my true answers don't fit neatly in your multiple choice questions

102 NEED LARGE GRAFTS FROM YOUNG DONORS WITH NO STERILIZATION {CHEMICAL OR RADIATION}

103 Need to pre stretch after prep to remove creep prior to placing by using tension board

104 none

105 None

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106 not done many ACL in 2012 usually do up to 10 per year, only use allograft for multiligament and if patient desires after lengthy conversation and for revisions.

107 one of the only times I use allografts is to augment hamstring autografts of a diameter of less than 8 mm in an average sized patient.

108 our hospital estbalished an annual review of our tissue bank acreditation and adverse outcome data. Although I dont know it by memory it is monitored.

109 Our hospital tissue bank monitors and selects the source of allografts.

110 overall concerned higher failure rate with tibialis tendon allografts have moved towards Bone tendon bone for allografts as they are stiffer and I think stretch out less

111

patients and their families are given the choice between allograft versus autograft after full risks/benefits/alternatives reviewed by me. Most skeletally or near skeletally patients opt for the posterior tibial allograft due to significantly shorter operative/anesthesia time, decreased collateral damage to other parts of the knee due to harvesting, better cosmesis, improved pain profiles, less painful post operative courses, and in my practice no differences in outcomes. All patients (auto and allograft ACLRs) are rehabilitated with bracing/CPM for one month, and PT for a strict 6 months. An ACL brace is used to return to sports and is used at 6 months to 1 year postop. AFter one year, the patient has the option to use the brace or not, and has no restrictions. I am in a group of 3 FT Peds Orthopedist with 100/cases per year and have had no problems with allograft. We are worried that this trend to insist on autograft in younger patients is misleading and has not proved clinically relevant in our practice. I am also concerned about harvesting autografts in young patients (hamstrings and BPB, etc) and not knowing if there are any longterm effects yet to be realized.

112 patients have less post-op morbidity and return to work quicker with allograft

113 Personal experience has shown inferior results with allograft and much higher retear rate.

114 please let me know the results

115 probably should check more about the company sterilziation techniques

116 Recently joined group. Allografts kept in house, not sure of prep.

117 Recently switched from RTI after co tamination in plant

118 Results are inferior with higher failure rate compared to autograft

119 RTI fails frequently and have stopped using them. Possible to insert larger patella tendon width with allograft compared to auto graft 10-12mm harvest maximum.

120 See Lawhorn et al. Arthroscopy Aug 2012

121

Studies Re. allografts vs autograft have tended to speak generically about allografts without specifying size(eg 1/2 patellar tendon maybe used instead of 1/3 tendon),type of tissue used,or how its prepared. I have had success rate approaching, if not comparable to autografts in collegiate athletes without the donor site morbidity and with quicker return to competition without the high injury rate that national literature and theory Re. delayed graft incorporation would seem to indicate. Since I have been using allograft 50% 0f the time since 1987 I tend to be skeptical about national literature's high allograft failure rate and need to delay return to sport in view of my own clinical experience; although, I always advise my patients that literature points toward autograft as the superior graft if one discounts graft donor site morbidity.

122 Tend to use autograft. With allograft as back up. I have a graft available that does not cost unless used, other companies charge for delivery even if it is not used

123 Thank you for doing this! I will be very interested in your results.

124 The aaos and the aossm need to condemn the use of allograft for high school/college and high demand athletes. It is an inferior graft with too high a failure rate and our patients are being harmed. Too many surgeons use allografts because its faster and they can "advertise" lower morbidity and quicker rehab.

125

The clinical use of allograft vs autograft assuming no radiation >2.5mRad and no proprietary chemical or other processing should be determined by the data which means high school and college level should not use allograft on primary ACLR. The data from MOON (LOEI) and military academies, and Barret db and peds show very significant higher failure that is clinically relevant in young patients and high demand! Revision MARS will determine auto vs allo in next year

126 The hospital contracts with DCI. I do not agree with these and infact have sent back a few grafts because I thought they were of inferior quality. If a young athletic patient insists on allograft, I will usually use a BTB allograft from RTI (non irradiated). otherwise, for the weekend warrior 30-40 something, the DCI allografts are usually fine.

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127 The literature that depicts allografts having a poor success rate is mostly flawed due to variables such as lack of documentation relative to graft processing as well as usage of irradiation...

128 The most common cause for graft failure is return to activity too soon (doing too much too soon).

129 The number one reason for any ACL failure is surgical technique Regardless of the graft, if it isn't done properly, it will have an increased incidence of failure.

130 There are doctors in my community using allografts for high school athletes and showing unreasonably high failure rates. I am frustrated with having to manage their poor results and hope this study can help protect these young athletes.

131

There is no way that an allograft will ever match the biologic healing of an autograft. The question always has to be the safety of the patient. I let my patient know that allografts are inferior, but there are advantages as well. The patient should be as informed as possible. In my practice, all of the failures I see, from other doctors, is from hamstings. It makes no sense to me that 4 strands are going to be perfectly matched with tension, and induce adequate revascularization. I have seen my own auto graft BTB grafts, they look like native ACLs after 6 months, including full synovial coverage.

132 There is no way to assess the graft prior being obliged to implant it.

133 These parameters are poorly documented in most studies including the MOON

134 they add significant cost to the procedure in the surgery center setting that cannot be absorbed by the institution. My observation, over the years is that many surgeons that push allograft usage just plane don't like taking the time to harvest an autograft; in other words it saves 30 minutes in the OR; is that good or bad?

135

They are used far too frequently in the wrong patients by surgeons who are too lazy or don't know how to harvest an autograft. Anybody with even a casual knowledge of data knows they should not be used in most patients. Especially the high school athlete. The failure rate of this operation even with autograft by the general orthopedist I bet is three times what the literature shows. I would fear to know what it was when the average Joe Slams in an allograft.

136 they mostly benefit surgeon more than patient.

137

To lump allografts is problemmatic. Factors include bone bank, processing, age of donor and surgical technique. The allograft may have a higher failure rate when the graft is not properly positioned. I believe that many allograft failures represent suboptimal technique. All allografts are not created equal. Inour practice we see many tib ant grafts done in the community as failures. Most BTB allograft failures seen in my office I can identify a technical component: vertical femoral tunnel, posteriorized tibial tunnel. Of note with my revision experience I have 31/1806 primary acl R personally revised through 3 /1012. Revision expereince includes 31 of my own and 150+ referred to my practice. Thanks Important survey. BRBach

138 Too many allograft are being used.

139 Unfortunately we are at mercy of our hospitals and surgery centers to obtaining allograft tissue. I hope the evidence does not come out that some vendors are unscrupulous.

140 use as absolute last resort, results are unpredictable

141 Use Tibialis Anterior Fresh Frozen Allograft (irradiated to <2.5-2.7 mRAD's) to augment Hamstring Autograft that size to < or equal 8 mm; Will use BTB Allograft for revision ACL with BTB Autograft already harvested and pt declines contralateral knee and will use BTB Allograft in patients >40 with lower demand life-styles.

142

Very important to discuss pros and cons of graft choice with patients preoperatively. I believe pros are easier early rehab, normalization of gait, driving safely, and avoiding morbidity of autografts, with the trade-off for higher failure rates in young/active patients (I avoid allografts in this group) and longer time frame for rehab/return to full sports participation.

143 very rarely use allografts

144 We need a position white paper from the AOSSM regarding allograft use so that the insurances are not allowed to call them experimental and deny their use.

145 We need a strong recommendation from AOSSM on this issue - what type of allogeneic tissue and with what sterilization process is best?

146 X

147 you did not inquire as to the use of super-critical CO2 processing.

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148 Your questions about "what source we would use for revision, when primary failed...it doesn't state what the primary source was. If primary was allograft or hamstring, I would use Patellar tendon autograft. I answered assuming primary was BTB autograft.

Q16) Are you a member of AOSSM, AAOS, or both?


AOSSM only 11 1.3 0.775 0.55 2.10 AAOS only 187 22.4 2.834 19.62 25.28 I am a member of both AOSSM and AAOS 635 76.2 2.891 73.34 79.12 Total 833 100.0

Q18) How many years have you been in practice (if applicable)?

N Valid

Percent CI Lower Upper

Completing Fellowship 0 0.0 0.000 0.00 0.00 0 - 5 197 23.8 2.903 20.92 26.72 6 - 10 126 15.2 2.449 12.79 17.69 11 - 15 130 15.7 2.481 13.24 18.20 16 - 20 133 16.1 2.504 13.58 18.59 21+ 241 29.1 3.097 26.04 32.24 Total 827 100.0

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Appendix B: Survey Instrument

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Allografts for ACL Reconstruction Survey Report...3 | Page Executive Summary 1) 4,000 orthopaedic...

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