Achilles Allograft in the Upper Extremity: A Systematic Review

Purpose: Achillies tendon allografts (ATAs) are used in a variety of upper-extremity reconstructive procedures. The purpose of this study was to systematically review the existing literature on the complications, reoperation rates and outcomes associated with the use of ATAs in upper-extremity reconstructions. Methods: Following Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, a systematic review was conducted of studies published between January 1990 and August 2024. Eligible studies included adult patients who underwent shoulder, elbow and wrist tendon reconstruction using ATAs to provide insight into the overall performance of ATA reconstruction in the upper extremity. Studies which did not report complications and/or functional outcomes were excluded. Retrospective, prospective, and randomized controlled trials were included, whereas cadaveric, biomechanical, and nonhuman studies were excluded. Results: A total of 23 studies comprising 408 cases met inclusion criteria. The most common indications for ATA use were distal biceps reconstruction (26%), irreparable rotator cuff tears (24%) and failed distal ulna resection (20%). The overall complication rate was 19%, with graft-related failure (43%) and infection (20%) as the most frequent complications. Reoperation was required in 10% of cases; predominantly because of graft failure (42%) and deep infection (29%). Despite these complications, patient-reported outcomes were favorable, with a mean postoperative-visual analog scale score of two and a Mayo Elbow Performance Score of 88, indicating substantial pain relief and functional improvement. Conclusions: ATAs in upper-extremity reconstructive procedures appear to result in low levels of postoperative pain and improvements in function. However, overall complication and reoperations rates following ATA use were 19% and 10%, respectively. Clinical relevance: ATA is advantageous in the sense that it can be used for a variety of shoulder, elbow, and wrist procedures; however, surgeons need to carefully weigh the benefits of decreased donor-site morbidity against the relatively high rates of complications.