Predictors of Revision Surgery After Anterior Cruciate Ligament Reconstruction

Abstract

Background: Arthroscopically assisted anterior cruciate ligament (ACL) reconstruction is a common orthopaedic procedure. Graft failure after reconstruction remains a devastating complication, often requiring revision surgery and less aggressive or modified rehabilitation. Worse functional and patient-reported outcomes are reported compared with primary reconstruction. Moreover, both rates and risk factors for revision are variable and inconsistent within the literature. Purpose: To determine the rate of revision surgery after ACL reconstruction in a large cohort of patients, to assess the influence of patient characteristics on the odds of revision, and to compare revision rates between active-duty military members and non–active-duty beneficiaries. Study Design: Descriptive epidemiology study. Methods: Using administrative data from the Military Health System, a retrospective study was designed to characterize the rate of ACL revision surgery among patients treated within a military facility. All patients ≥18 years at the time of ACL reconstruction were identified using the American Medical Association Current Procedural Terminology (CPT) for ACL reconstruction (CPT code 29888) over 7 years (2005-2011). Revision ACL reconstructions were identified as having ≥2 ACL reconstruction procedure codes on the ipsilateral knee at least 90 days apart. Univariate analysis was performed to calculate odds ratios (ORs) for demographic, perioperative medication use, and concomitant procedure–related risk factors. A multivariate logistic regression model determined risk covariates in the active-duty cohort. Results: The study population consisted of 17,164 ACL reconstructions performed among 16,336 patients, of whom 83.3% were male with a mean ± SD age of 28.9 ± 7.6 years for the nonrevision group, and was predominantly active duty (89.2%). Patients undergoing ACL reconstruction on both knees only contributed their index knee for analyses. There were 587 patients who underwent revision surgery, corresponding to an overall revision rate of 3.6%. The median time from the index surgery to revision surgery was 500 days (interquartile range, 102-2406 days). Revision rates were higher in the active-duty cohort as compared with non–active-duty beneficiaries (3.8% vs 1.8%, respectively; OR, 2.14; 95% CI, 1.49-3.07). Based on multivariate logistic regression in the active-duty cohort, age ≥35 years (OR, 0.44; 95% CI, 0.33-0.58) and concomitant meniscal repair (OR, 0.69; 95% CI, 0.53-0.91) were found to be protective with regard to the odds of revision surgery. Perioperative medication use of nonsteroidal anti-inflammatory drugs (NSAIDs) (OR, 1.33; 95% CI, 1.12-1.58; number needed to harm [NNH], 100) and COX-2 inhibitors (OR, 1.31; 95% CI, 1.04-1.66; NNH, 333) was associated with increased odds of revision surgery. No significant findings were detected among sex, race, nicotine use, body mass index, or other concomitant procedures of interest. Conclusion: In this large cohort study, the rate of revision ACL reconstruction was 3.6%, which is consistent with the existing literature. Increased odds of revision surgery among active-duty personnel were associated with the perioperative use of NSAIDs and COX-2 inhibitors. Age ≥35 years and concomitant meniscal repair were found to be protective against ACL revision.

Revision surgery in anterior cruciate ligament reconstruction: a cohort study of 17,682 patients from the Swedish National Knee Ligament Register

“…There is a possibility that other biological factors play a part too; however, this is not confirmed in current literature. The association between younger patient age and increased risk of graft failure and revision surgery is well established in current literature [ 2 , 9 , 14 , 17 , 18 , 22 , 27 , 30 ].…”

Management of Anterior Cruciate Ligament Injury

“…Multiple studies have reported increasing age to be a protective factor against revision ACLR, 111 114 and the average time between primary ACLR and revision ACLR ranges from 1.5 to 3.5 years in the literature. 111 114 115 116 117 118 Some graft processing techniques as well as increased graft irradiation (>1.8 Mrad) have been associated with higher revision rates. 118 In a retrospective analysis, posterior tibial tunnel placement (placement 50% or more posterior to Amis and Jakob line) has also been associated with increased revision rates in those using a 70° “anti-impingement” tibial tunnel guide.…”

Imaging the Anterior and Posterior Cruciate Ligaments

“…In recent years ACL repair with different techniques is being performed. The early outcome studies show some promises, however a revision rate of 18% after repair in the two first years is higher than with the revision rate after reconstruction (3.6%) [ 19 20 ]. Imaging findings after these new repair techniques are still unchartered territory.…”