Effect of Graft Choice on Outcome of Revision Anterior Cruciate Ligament Reconstruction in the Multicenter ACL Revision Study (MARS) Cohort
The MARS Group. American Journal of Sports Medicine. 2014. 42(10):2301-2310. doi: 10.1177/0363546514549005
Take Home Message: Autograft selection for anterior cruciate ligament (ACL) revision has better outcomes post surgery compared with allografts.
Multiple research groups have investigated the influence of primary ACL reconstruction graft choice on patient outcomes; however, there is limited evidence on how graft choice in ACL revision surgery influences patient outcomes. The authors of this multicenter cohort study aimed to determine whether graft choice is related to outcomes at 2 years after revision ACL reconstruction. Eighty-three surgeons at 52 sites enrolled 1205 patients who underwent ACL revision surgery. Patients completed International Knee Documentation Committee (IKDC) questionnaire, Knee injury and Osteoarthritis Outcome Scores (KOOS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Marx activity rating scale at both time points to assess patient outcome measures. After 2 years, patients also reported whether they had graft failure or any other surgeries since the revision ACL reconstruction. The patients were ~26 years of age, 88% of patients were having their first revision, and an autograft was used for revision in 48% while an allograft was used in 49% of patients. Knee symptoms (IKDC, KOOS, and WOMAC scores) all improved at the 2 year follow up. In contrast, the patients became less active (e.g., less patients played high-level sports, more patients became sedentary). The authors found that choice of autograft for revision predicts better 2 year symptoms; specifically, IKDC scores, KOOS sports and recreation subscale scores. Patients with an autograft were 2.78 times less likely to suffer a rerupture compared with those who received an allograft.
A patient with an autograft for revision ACL surgery is more likely to report better outcomes 2 years post surgery than a patient with an allograft. However, it is important to note that these patients also reported less physical activity. Part of the reason their knees may be feeling better is because they are no longer performing high-level activities (e.g., sports) that once bothered them. These results should be interpreted with caution as it remains unclear as to the long-term risks and outcomes affiliated with a revision surgery and the graft selection. The MARS group is a group of physicians who are prospectively studying patients who have had ACL revision surgery. It would be very interesting to continue to follow these patients prospectively to see if there are long-term differences in joint symptoms, the development of osteoarthritis, quality of life, and other health measures. While needing a revision surgery could have direct long-term effects we need to recognize that the decrease in physical activity could also contribute to a greater risk of comorbidities (e.g., cardiovascular disease, obesity) and reduced quality of life. It would be very interesting to see how individuals who have needed an ACL revision surgery compared with those who had their ACL reconstructed without the need for a revision. While graft choice is a very important consideration, some physicians believe that graft placement is more important. The need for a revision can be a result of graft failure or of an acute re-injury. If the initial graft failed, conceptually it could be a result of bad graft placement. Some may point out that this study was not a randomized controlled clinical trial, however, given the relatively unique occurrence of ACL revision surgery, this type of registry may be the best that we can utilize. Regardless of this possible limitation, this study offers us important information that we can use to educate patients about the importance of graft selection for an ACL reconstruction revision.
Questions for Discussion: How many revision patients have you seen? What types of outcomes do patients that need an ACL revision typically see in your practice? Is there a trend towards auto- or allograft selection in the revision patients that you seen?
Written by: Nicole Cattano
Reviewed by: Jeffrey Driban
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