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].

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
(activities of daily living)
, 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

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

Related Posts:

Kim SJ, Lee SK, Choi CH, Kim SH, Kim SH, & Jung M (2013). Graft Selection in Anterior Cruciate Ligament Reconstruction for Smoking Patients. The American Journal of Sports Medicine PMID: 24114749