Effect of Graft Choice on Outcome of
Revision Anterior Cruciate Ligament Reconstruction in the Multicenter ACL
Revision Study (MARS) Cohort

MARS Group. American Journal of Sports
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

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.   

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?
by: Nicole Cattano
by: Jeffrey Driban

Related Posts:

Incidence and Outcome after Revision Anterior Cruciate Ligament Reconstruction

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