Graft selection in anterior cruciate ligament reconstruction for smoking patients
Kim SJ, Lee SK, Choi CH, Kim SH, Kin, SH, and Jung M. Am J Sports Med. 2013; [Epub ahead of print].
Take Home Message: Patients who smoke tend to have worse subjective and objective outcomes following ACL reconstruction compared with patients who never smoked.
Despite much research attempting to optimize graft selection for the treatment of a ruptured anterior cruciate ligament (ACL), a gold-standard for choosing an ACL graft does not exist. By better understanding the interaction between graft type and recipient’s lifestyle factors, grafts can be matched to allow the patient the greatest possibility of favorable outcomes. Therefore, Kim and colleagues completed a retrospective cohort study to compare the subjective and objective outcomes of ACL reconstruction among smoking and nonsmoking patients. The authors conducted a retrospective review of medical records and identified 487 patients who received a primary single-bundle ACL reconstruction and met 9 inclusion criteria including being over 18 years of age, without concomitant ligamentous injury, and had a minimum follow-up of 24 months. Among the 487 patients, 322 patients reported never smoking (263 males, 59 female) and 165 reported smoking before the ACL reconstruction and during rehabilitation (143 males, 22 female). Patients received four types of ACL graft: bone-patellar tendon-bone (227 patients), hamstring autograft (65 patients), quadriceps tendon-bone autograft (142 patients), and Achilles tendon allograft (53 patients). Following reconstruction the rehabilitation protocol was standardized across all patients. Outcomes assessment was based on values recorded pre-surgery and at least 24 months post-surgery and included clinical assessment of stability and subjective measures: Lachman test, pivot-shift test, KT-2000 arthometer, Lysholm knee score, and International Knee Documentation Committee (IKDC) scores(clinical exam grade and self-reported symptoms and function score). Analysis demonstrated no significant difference between the 2 groups prior to surgery. Post-operatively however, the smoking group demonstrated significantly greater anterior tibial translation measurement, and significantly worse functional scores (IKDC scores and Lysholm score) than the nonsmoking group. While graft type didn’t influence patient outcomes among nonsmokers there was some evidence that 19 smokers with an Achilles allograft did worst compared with the three autograft groups.
Overall, this study presents data to support the notion that smoking leads to poorer outcomes after 24-months post ACL reconstruction. While this study alone may not influence clinicians directly in their choice of ACL graft, it adds to our understanding of outcomes following ACL reconstruction. Clinicians should include questions about smoking habits and history of tobacco use in their pre-surgical assessments. By counseling patients on the possible association between smoking and poor outcomes after an ACL reconstruction perhaps patients will be more inclined to stop smoking. While the data presented is quite interesting and informative for clinicians, clearly more research needs to be conducted to better understand this interaction. It would be helpful if future research recruited patients before surgery (prospective study) and explored if other variables that might explain the difference between smokers and nonsmokers (e.g., overall health, physical activity). By retrospectively analyzing medical records no randomization could occur in terms of which ACL graft was chosen. This would further bolster the applicability of the results. Additionally, we don’t know if the time to follow-up was different between groups nor the smoking habits of the included patients (e.g., intensity of smoking, duration of smoking, age smoking began). Despite these limitations, this study provides another reason for us to encourage our patients to kick the habit.
Questions for Discussion: Do you currently inquire about patients’ smoking habits? If so, how does a patient’s smoking habit influence your treatment?
Written by: Kyle Harris
Reviewed by: Jeffrey Driban