Objectives:Failure or reinjury after anterior cruciate ligament (ACL) reconstruction can lead to recurrent instability and concomitant intra-articular injuries. While revision ACL reconstruction (rACLR) can be performed to restore knee stability and improve patient activity level, outcomes after these surgeries are reported to be inferior to primary ACL reconstruction. Further reoperation after rACLR can have an even more profound effect on patient satisfaction and outcome. Yet, there is a current lack of information regarding the rate and risk factors for subsequent surgery after rACLR.Methods:1205 patients who underwent rACLR were enrolled between 2006 and 2011, comprising the prospective cohort. Two-year questionnaire follow-up was obtained on 989 (82%), while telephone follow-up was obtained on 1112 (92%). If a patient reported having a subsequent surgery, operative reports detailing the subsequent procedure(s) were obtained and categoriezed. A repeated meaures ANOVA was used to reveal significatnt differences in patient reported outcomes. Multivariate regression analysis was performed to determine independent risk factors for reoperation.Results:One hundred and twenty-two patients (10.1%) underwent a total of 172 subsequent procedures on the ipsilateral knee at 2-year follow-up. Of the reoperation procedures, 26.7% were meniscus procedures (69% meniscectomy, 26% repair), 18.6% were subsequent rACLR, 17.4% were cartilage procedures (61% chondroplasty, 17% microfracture, and 13% mosaicplasty), 10% hardware removal, and 9.3% were procedures for arthrofibrosis such has lysis of adhesions and synovectomy. Patients who had reoperations had significantly lower IKDC, KOOS symptoms and pain scores, and WOMAC stiffness scores at two-year follow up. Multivariate analysis revealed that patients under 20 years old were 2.1 times more likely than patients aged 20-29 to have a reoperation. Use of allograft at the time of rACLR and staged revision (bone grafting of tunnels before rACLR) were also significant predictors for need for reoperation within 2 years. Patients with grade IV cartilage damage seen during rACLR were 47% less likely to undergo subsequent operations within 2 years. Gender, BMI, smoking history, Marx activity score, technique for femoral tunnel placement and meniscal tear or meniscal treatment at the time of rACLR showed no significant effect on reoperation rate.Conclusion:There is a significant reoperation rate following rACLR at two years (10.1%). The most prevalent reoperations involved meniscal procedures. Independent risk factors for subsequent surgery on the ipsilateral knee include age<20 years old, a staged revision and use of allograft tissue at the time of rACLR.
Objectives: Most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome. The purpose of this study was to determine if revision ACL graft choice predicts outcomes related to sports function, activity level, OA symptoms, graft re-rupture, and reoperation at six years following revision reconstruction. We hypothesized that autograft use would result in increased sports function, increased activity level, and decreased OA symptoms (as measured by validated patient reported outcome instruments). Additionally, we hypothesized that autograft use would result in decreased graft failure and reoperation rate 6 years following revision ACL reconstruction. Methods: Revision ACL reconstruction patients were identified and prospectively enrolled by 83 surgeons over 52 sites. Data collected included baseline demographics, surgical technique and pathology, and a series of validated patient reported outcome instruments (IKDC, KOOS, WOMAC, and Marx activity rating score). Patients were followed up for 6 years, and asked to complete the identical set of outcome instruments. Incidence of additional surgery and re-operation due to graft failure were also recorded. Multivariate regression models were used to determine the predictors (risk factors) of IKDC, KOOS, WOMAC, Marx scores, graft re-rupture, and re-operation rate at 6 years following revision surgery. Results: 1234 patients were successfully enrolled with 716 (58%) males. Median age was 26. In 87% this was their first revision. 367 (30%) were undergoing revision by the surgeon that had performed the previous reconstruction. 598 (48%) underwent revision reconstruction utilizing an autograft, 599 (49%) allograft, and 37 (3%) both autograft and allograft. Median time since their last ACL reconstruction was 3.4 years. Questionnaire follow-up was obtained on 810 subjects (65%), while phone follow-up was obtained on 949 subjects (76%). The IKDC, KOOS, and WOMAC scores (with the exception of the WOMAC stiffness subscale) all significantly improved at the 6-year follow-up time point (p<0.001). Contrary to the IKDC, KOOS, and WOMAC scores, the 6-year MARX activity scale demonstrated a significant decrease from the initial score at enrollment (p<0.001). Graft choice proved to be a significant predictor of 6-year Marx activity level scores (p=0.005). Specifically, the use of an autograft for revision reconstruction predicted improved activity levels [Odds Ratio (OR) = 1.54; 95% confidence intervals (CI) = 1.14, 2.04]. Graft choice proved to be a significant predictor of 6-year IKDC scores (p=0.018), in that soft tissue grafts predicted higher 6-year IKDC scores [OR = 1.62; 95% confidence intervals (CI) = 1.09, 2.414]. For the KOOS subscales, graft choice did not predict outcome score. Graft re-rupture was reported in 55/949 (5.8%) of patients by their 6-year follow-up: 37 allografts, 16 autografts, and 2 allograft + autograft. Use of an autograft for revision resulted in patients 6.04 times less likely to sustain a subsequent graft rupture than if an allograft was utilized (p=0.009; 95% CI=1.57, 23.2). Conclusion: Improved sports function and patient reported outcome measures are obtained when an autograft is utilized. Additionally, autograft type shows a decreased risk in graft re-rupture at six years follow-up. Surgeon education regarding the findings in this study can result in potentially improved revision ACLR results for our patients.
Background It has not been known what drives revision ACL reconstruction graft choice in the past. We undertook this study to utilize the MARS (Multicenter ACL Revision Study) cohort and propensity score statistical analysis to determine the drivers of revision ACL reconstruction graft choice. We hypothesized that propensity analysis would demonstrate that individual surgeons still have significant impact on revision ACL reconstruction. Methods Twelve hundred patients were enrolled in this longitudinal revision cohort by 83 surgeons at 52 sites. The median age was 26 years and 505 (42%) were females. 1049 (87%) were undergoing their first ACL revision. Graft choice for revision ACL reconstruction for these patients was 48% autograft, 49% allograft, and 3% combination. The independent variables of this model included gender, age, ethnicity, BMI, smoking status, sport, activity level, previous graft, revision number, surgeon, surgeon’s opinion of failure, previous technical aspects, etc. Surgeon was defined as those who contributed more than 15 patients during the enrollment period. We calculated a propensity score for graft type based on the predicted probability of receiving an allograft from a logistic regression model. Results Propensity scores demonstrated that surgeon, prior graft choice, and patient age each had significant influence on which graft type was chosen for the revision ACL reconstruction (p<0.0001). The revising surgeon had the largest impact upon graft choice: approximately 5 times that of the second most important factor (prior graft). If the prior graft type was an autograft, then an allograft was 3.6 times more likely to be chosen for the revision. Conclusions This current study demonstrates that the individual surgeon is ultimately the most important factor in revision ACL reconstruction graft choice. Additional statistically significant influences of graft choice included age, gender, previous graft choice, ACL revision number, concurrent MCL/PM repair, and opinion of the previous failure. This demonstrates that if graft choice is determined to impact outcome then surgeons have the ability to change and determine the graft utilized.
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