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Anterior Cruciate Ligament Reconstruction Graft Preference Most Dependent on Patient Age: A Survey of United States Surgeons

Published:February 01, 2021DOI:https://doi.org/10.1016/j.arthro.2021.01.042

      Purpose

      The purpose of this study was to define the anterior cruciate ligament (ACL) reconstruction (ACLR) graft preference of surgeons and to explore factors associated with their predilection.

      Methods

      A 15-question survey regarding ACLR graft preference in various situations was completed by 514 American Orthopaedic Society for Sports Medicine and Arthroscopy Association of North America surgeons. Surgeon and practice demographics, along with various patient factors, were evaluated with bivariate and multivariable models for association with surgeon preference. Surgeons were also queried about their preference for their own ACLR. For surgeons who personally sustained an ACL, an additional 6 questions inquired about their experience.

      Results

      Surgeons reported the 5 most important factors in patient graft choice, in order: patient age, graft failure in literature and practice, pivot sport, and patient preference. Autograft patellar and quadriceps tendon were strongly preferred for younger, pivoting athletes (P < .001), among those with fellowship training (47% vs 33%, P = .006), in academic practices (52% vs 44%, P = .003), and in more sports medicine–specific practices, with a higher number of ACLRs performed per year (P < .001). Northeast, Southeast, Midwest, and Southwest surgeons had lower hamstring autograft preference (P < .001). Non-fellowship-trained surgeons preferred hamstring autograft (P = .010). Allograft was preferred for older patients (P < .001). Nonsignificant predictors included highest level of athlete for whom an ACLR had been performed, level of athlete serving as team physician, and years in practice. No factors were associated with surgeon preference for their own ACLR despite deeming these factors important for patients. ACL tears were reported by 13% of respondents, with 86% stating it influenced their decision to enter orthopaedics.

      Conclusions

      Patient age was the most important factor in graft choice, with patellar and quadriceps tendon autograft the preferred graft for ACLR for younger, pivoting athletes. Fellowship training and practice demographics were also correlated with graft choice for patients.

      Clinical Relevance

      Graft preference for ACLR varies among surgeons and is associated with surgeon experience and patient characteristics, including patient age, type of sport, and patient preference.
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      References

        • Matava M.J.
        • Howard D.R.
        • Polakof L.
        • Brophy R.H.
        Public perception regarding anterior cruciate ligament reconstruction.
        J Bone Joint Surg Am. 2014; 96: e85
        • Cheung S.C.
        • Allen C.R.
        • Gallo R.A.
        • Ma C.B.
        • Feeley B.T.
        Patients' attitudes and factors in their selection of grafts for anterior cruciate ligament reconstruction.
        Knee. 2012; 19: 49-54
        • Cohen S.B.
        • Yucha D.T.
        • Ciccotti M.C.
        • Goldstein D.T.
        • Ciccotti M.A.
        • Ciccotti M.G.
        Factors affecting patient selection of graft type in anterior cruciate ligament reconstruction.
        Arthroscopy. 2009; 25: 1006-1010
        • Mall N.A.
        • Chalmers P.N.
        • Moric M.
        • et al.
        Incidence and trends of anterior cruciate ligament reconstruction in the United States.
        Am J Sports Med. 2014; 42: 2363-2370
        • Sanders T.L.
        • Maradit Kremers H.
        • Bryan A.J.
        • et al.
        Incidence of anterior cruciate ligament tears and reconstruction: A 21-year population-based study.
        Am J Sports Med. 2016; 44: 1502-1507
        • Agel J.
        • Rockwood T.
        • Klossner D.
        Collegiate ACL injury rates across 15 sports: National Collegiate Athletic Association injury surveillance system data update (2004-2005 Through 2012-2013).
        Clin J Sport Med. 2016; 26: 518-523
        • Dragoo J.L.
        • Braun H.J.
        • Durham J.L.
        • Chen M.R.
        • Harris A.H.
        Incidence and risk factors for injuries to the anterior cruciate ligament in National Collegiate Athletic Association football: Data from the 2004-2005 through 2008-2009 National Collegiate Athletic Association Injury Surveillance System.
        Am J Sports Med. 2012; 40: 990-995
        • Carver T.J.
        • Schrock J.B.
        • Kraeutler M.J.
        • McCarty E.C.
        The evolving treatment patterns of NCAA Division I football players by orthopaedic team physicians over the past decade, 2008-2016.
        Sports Health. 2018; 10: 234-243
        • Erickson B.J.
        • Harris J.D.
        • Fillingham Y.A.
        • et al.
        Anterior cruciate ligament reconstruction practice patterns by NFL and NCAA football team physicians.
        Arthroscopy. 2014; 30: 731-738
        • Bradley J.P.
        • Klimkiewicz J.J.
        • Rytel M.J.
        • Powell J.W.
        Anterior cruciate ligament injuries in the National Football League: Epidemiology and current treatment trends among team physicians.
        Arthroscopy. 2002; 18: 502-509
        • Mirza F.
        • Mai D.D.
        • Kirkley A.
        • Fowler P.J.
        • Amendola A.
        Management of injuries to the anterior cruciate ligament: Results of a survey of orthopaedic surgeons in Canada.
        Clin J Sport Med. 2000; 10: 85-88
        • Erickson B.J.
        • Harris J.D.
        • Fillingham Y.A.
        • et al.
        Orthopedic practice patterns relating to anterior cruciate ligament reconstruction in elite athletes.
        Am J Orthop (Belle Mead NJ). 2015; 44: E480-E485
        • Kaeding C.C.
        • Pedroza A.D.
        • Reinke E.K.
        • et al.
        Change in anterior cruciate ligament graft choice and outcomes over time.
        Arthroscopy. 2017; 33: 2007-2014
        • Houck D.A.
        • Kraeutler M.J.
        • Vidal A.F.
        • et al.
        Variance in anterior cruciate ligament reconstruction graft selection based on patient demographics and location within the Multicenter Orthopaedic Outcomes Network Cohort.
        J Knee Surg. 2018; 31: 472-478
        • Tegner Y.
        • Lysholm J.
        Rating systems in the evaluation of knee ligament injuries.
        Clin Orthop Relat Res. 1985; 198: 43-49
        • Tibor L.
        • Chan P.H.
        • Funahashi T.T.
        • Wyatt R.
        • Maletis G.B.
        • Inacio M.C.
        Surgical technique trends in primary ACL reconstruction from 2007 to 2014.
        J Bone Joint Surg Am. 2016; 98: 1079-1089
        • Grassi A.
        • Carulli C.
        • Innocenti M.
        • et al.
        New trends in anterior cruciate ligament reconstruction: A systematic review of national surveys of the last 5 years.
        Joints. 2018; 6: 177-187
        • Budny J.
        • Fox J.
        • Rauh M.
        • Fineberg M.
        Emerging trends in anterior cruciate ligament reconstruction.
        J Knee Surg. 2017; 30: 63-69
        • Monk A.P.
        • Davies L.J.
        • Hopewell S.
        • Harris K.
        • Beard D.J.
        • Price A.J.
        Surgical versus conservative interventions for treating anterior cruciate ligament injuries.
        Cochrane Database Syst Rev. 2016; 4: CD011166
        • Frobell R.B.
        • Roos E.M.
        • Roos H.P.
        • Ranstam J.
        • Lohmander L.S.
        A randomized trial of treatment for acute anterior cruciate ligament tears.
        N Engl J Med. 2010; 363: 331-342
        • Frobell R.B.
        • Roos H.P.
        • Roos E.M.
        • Roemer F.W.
        • Ranstam J.
        • Lohmander L.S.
        Treatment for acute anterior cruciate ligament tear: Five year outcome of randomised trial.
        Br J Sports Med. 2015; 49: 700
        • Daniel D.M.
        • Stone M.L.
        • Dobson B.E.
        • Fithian D.C.
        • Rossman D.J.
        • Kaufman K.R.
        Fate of the ACL-injured patient: A prospective outcome study.
        Am J Sports Med. 1994; 22: 632-644
        • Nebelung W.
        • Wuschech H.
        Thirty-five years of follow-up of anterior cruciate ligament–deficient knees in high-level athletes.
        Arthroscopy. 2005; 21: 696-702
        • Hawkins R.J.
        • Misamore G.W.
        • Merritt T.R.
        Followup of the acute nonoperated isolated anterior cruciate ligament tear.
        Am J Sports Med. 1986; 14: 205-210
        • Wellsandt E.
        • Failla M.J.
        • Axe M.J.
        • Snyder-Mackler L.
        Does anterior cruciate ligament reconstruction improve functional and radiographic outcomes over nonoperative management 5 years after injury?.
        Am J Sports Med. 2018; 46: 2103-2112
        • Marx R.G.
        • Jones E.C.
        • Angel M.
        • Wickiewicz T.L.
        • Warren R.F.
        Beliefs and attitudes of members of the American Academy of Orthopaedic Surgeons regarding the treatment of anterior cruciate ligament injury.
        Arthroscopy. 2003; 19: 762-770
        • Grevnerts H.T.
        • Faltstrom A.
        • Sonesson S.
        • Gauffin H.
        • Carlfjord S.
        • Kvist J.
        Activity demands and instability are the most important factors for recommending to treat ACL injuries with reconstruction.
        Knee Surg Sports Traumatol Arthrosc. 2018; 26: 2401-2409
        • Goldblatt J.P.
        • Fitzsimmons S.E.
        • Balk E.
        • Richmond J.C.
        Reconstruction of the anterior cruciate ligament: Meta-analysis of patellar tendon versus hamstring tendon autograft.
        Arthroscopy. 2005; 21: 791-803
        • Samuelsen B.T.
        • Webster K.E.
        • Johnson N.R.
        • Hewett T.E.
        • Krych A.J.
        Hamstring autograft versus patellar tendon autograft for ACL reconstruction: Is there a difference in graft failure rate? A meta-analysis of 47,613 patients.
        Clin Orthop Relat Res. 2017; 475: 2459-2468
        • Mohtadi N.G.
        • Chan D.S.
        • Dainty K.N.
        • Whelan D.B.
        Patellar tendon versus hamstring tendon autograft for anterior cruciate ligament rupture in adults.
        Cochrane Database Syst Rev. 2011; 9: CD005960
        • Ciccotti M.C.
        • Secrist E.
        • Tjoumakaris F.
        • Ciccotti M.G.
        • Freedman K.B.
        Anatomic anterior cruciate ligament reconstruction via independent tunnel drilling: A systematic review of randomized controlled trials comparing patellar tendon and hamstring autografts.
        Arthroscopy. 2017; 33: 1062-1071.e1065
        • Beynnon B.D.
        • Johnson R.J.
        • Fleming B.C.
        • et al.
        Anterior cruciate ligament replacement: Comparison of bone-patellar tendon-bone grafts with two-strand hamstring grafts. A prospective, randomized study.
        J Bone Joint Surg Am. 2002; 84: 1503-1513
        • Freedman K.B.
        • D'Amato M.J.
        • Nedeff D.D.
        • Kaz A.
        • Bach Jr., B.R.
        Arthroscopic anterior cruciate ligament reconstruction: A metaanalysis comparing patellar tendon and hamstring tendon autografts.
        Am J Sports Med. 2003; 31: 2-11
        • Spindler K.P.
        • Huston L.J.
        • et al.
        • MOON Knee Group
        Anterior cruciate ligament reconstruction in high school and college-aged athletes: Does autograft choice influence anterior cruciate ligament revision rates?.
        Am J Sports Med. 2020; 48: 298-309
        • Persson A.
        • Fjeldsgaard K.
        • Gjertsen J.E.
        • et al.
        Increased risk of revision with hamstring tendon grafts compared with patellar tendon grafts after anterior cruciate ligament reconstruction: A study of 12,643 patients from the Norwegian Cruciate Ligament Registry, 2004-2012.
        Am J Sports Med. 2014; 42: 285-291
        • Kim S.J.
        • Moon H.K.
        • Kim S.G.
        • Chun Y.M.
        • Oh K.S.
        Does severity or specific joint laxity influence clinical outcomes of anterior cruciate ligament reconstruction?.
        Clin Orthop Relat Res. 2010; 468: 1136-1141
        • Cooper D.E.
        • Dunn W.R.
        • et al.
        • MARS Group
        Physiologic preoperative knee hyperextension is a predictor of failure in an anterior cruciate ligament revision cohort: A report from the MARS Group.
        Am J Sports Med. 2018; 46: 2836-2841
        • Hurley E.T.
        • Calvo-Gurry M.
        • Withers D.
        • Farrington S.K.
        • Moran R.
        • Moran C.J.
        Quadriceps tendon autograft in anterior cruciate ligament reconstruction: A systematic review.
        Arthroscopy. 2018; 34: 1690-1698
        • Eagan M.J.
        • McAllister D.R.
        Biology of allograft incorporation.
        Clin Sports Med. 2009; 28: 203-214
        • Weber A.E.
        • Mayer E.N.
        • Nathani A.
        • et al.
        How variable are Achilles allografts used for anterior cruciate ligament reconstruction? A biomechanical study.
        Am J Sports Med. 2018; 46: 1870-1876
        • Maletis G.B.
        • Inacio M.C.
        • Desmond J.L.
        • Funahashi T.T.
        Reconstruction of the anterior cruciate ligament: Association of graft choice with increased risk of early revision.
        Bone Joint J. 2013; 95B: 623-628
        • Wasserstein D.
        • Sheth U.
        • Cabrera A.
        • Spindler K.P.
        A systematic review of failed anterior cruciate ligament reconstruction with autograft compared with allograft in young patients.
        Sports Health. 2015; 7: 207-216
        • Krych A.J.
        • Jackson J.D.
        • Hoskin T.L.
        • Dahm D.L.
        A meta-analysis of patellar tendon autograft versus patellar tendon allograft in anterior cruciate ligament reconstruction.
        Arthroscopy. 2008; 24: 292-298
        • Maletis G.B.
        • Chen J.
        • Inacio M.C.S.
        • Love R.M.
        • Funahashi T.T.
        Increased risk of revision after anterior cruciate ligament reconstruction with soft tissue allografts compared with autografts: Graft processing and time make a difference.
        Am J Sports Med. 2017; 45: 1837-1844
        • Murray M.M.
        Current status and potential of primary ACL repair.
        Clin Sports Med. 2009; 28: 51-61
        • Feagin Jr., J.A.
        • Curl W.W.
        Isolated tear of the anterior cruciate ligament: 5-year follow-up study.
        Am J Sports Med. 1976; 4: 95-100
        • van der List J.P.
        • Mintz D.N.
        • DiFelice G.S.
        The location of anterior cruciate ligament tears: A prevalence study using magnetic resonance imaging.
        Orthop J Sports Med. 2017; 5 (2325967117709966)
        • DiFelice G.S.
        • van der List J.P.
        Clinical outcomes of arthroscopic primary repair of proximal anterior cruciate ligament tears are maintained at mid-term follow-up.
        Arthroscopy. 2018; 34: 1085-1093
        • Sherman M.F.
        • Lieber L.
        • Bonamo J.R.
        • Podesta L.
        • Reiter I.
        The long-term followup of primary anterior cruciate ligament repair: Defining a rationale for augmentation.
        Am J Sports Med. 1991; 19: 243-255
        • van Eck C.F.
        • Limpisvasti O.
        • ElAttrache N.S.
        Is there a role for internal bracing and repair of the anterior cruciate ligament? A systematic literature review.
        Am J Sports Med. 2018; 46: 2291-2298