Risk Factors for Early Subsequent (Revision or Contralateral) ACL Reconstruction: A Retrospective Database Study

Revision Anterior Cruciate Ligament Reconstruction and Associated Procedures

Failure of anterior cruciate ligament reconstruction (ACLR) is a common yet devastating complication due to inferior clinical outcomes associated with revision ACLR. Identifying the cause and associated risk factors for failure is the most important consideration during preoperative planning. Special attention to tunnel quality, concomitant injuries, and modifiable risk factors will help determine the optimal approach and staging for revision ACLR. Additional procedures including lateral extra-articular tenodesis and osteotomy may be considered for at-risk populations. The purpose of this review is to explore causes of ACLR failure, clinical indications and appropriate patient evaluation, and technical considerations when performing revision ACLR.

Association of Emergency Department Evaluation With Public Insurance Use and Treatment Delays for ACL Injury

Background

Utilization of an emergency department (ED) visit for anterior cruciate ligament (ACL) injury is associated with high cost and diagnostic unreliability.

Hypothesis

Patients initially evaluated at an ED for an ACL injury would be more likely to be from a lower income quartile, use public insurance, and experience a delay in treatment.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients in the Rhode Island All Payers Claims Database who underwent ACL reconstruction (ACLR) between 2012 and 2021 were identified using the Current Procedure Terminology (CPT) code 29888. Patients were stratified into 2 cohorts based on CPT codes for ED or in-office services within 1 year of ACLR. A chi-square analysis was used to test for differences between cohorts in patient and surgical characteristics. Multivariable linear and logistic regression were used to determine how ED evaluation affected timing and outcome variables.

Results

While adjusting for patient and operative characteristics, patients in the ED cohort were more likely to have Medicaid (29% vs 12.5%; P < .001) and be in the lowest income quartile (44.6% vs 32.1%; P < .001). ED visit and Medicaid status were associated with increased time to (1) diagnostic magnetic resonance imaging, adding 7.97 days on average (95% CI, 4.14-11.79 days; P < .001) and 8.40 days (95% CI, 3.44-13.37 days; P = .001), respectively; and (2) surgery, adding 20.30 days (95% CI, 14.10-26.49 days; P < .001) and 12.88 days (95% CI, 5.15-20.60 days; P = .001), respectively. Patients >40 years who were evaluated in the ED were 2.5 times more likely to require subsequent ACLR (odds ratio, 2.50 [95% CI, 1.01-6.21]; P = .049).

Conclusion

In this study, patients who visited the ED within 1 year before ACLR were more likely to have a lower income, public insurance, increased time to diagnostic imaging, and increased time to surgery, as well as decreased postoperative physical therapy use and increased subsequent ACLR rates in the 40-49 years age-group.

Revision Rates After Primary ACL Reconstruction Performed Between 1969 and 2018: A Systematic Review and Metaregression Analysis

Background:

Numerous studies, including randomized controlled trials (RCTs), have been published on the optimal graft choice for primary anterior cruciate ligament (ACL) reconstruction.

Purpose:

To review existing studies to investigate whether advances in orthopaedics have affected revision rates after primary ACL reconstruction.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

The PubMed database was searched from inception to December 31, 2020, using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Patient series, observational studies, clinical trials, and registry-based studies investigating primary ACL reconstruction were included, as were high-quality RCTs from an additional study. The minimum required follow-up time for inclusion was 1 year. The primary outcome measure was the pooled prevalence of revision ACL reconstruction. The effect of the year the surgery was performed on revision rates was evaluated with metaregression analysis. All graft types were analyzed simultaneously, and all analyses were repeated separately for each graft type.

Results:

Overall, 330 articles with 52,878 patients were included, with a median patient age of 28 years (range, 15-57 years). The primary ACL reconstructions were performed between 1969 and 2018. At a median of 2.3 years of follow-up, the overall revision rate was 3.14% (95% CI, 2.76% to 3.56%); it was 2.71% (95% CI, 2.25% to 3.27%) for hamstring autografts, 2.38% (95% CI, 1.82% to 3.11%) for bone–patellar tendon–bone (BPTB) autografts, and 5.24% (95% CI, 4.02% to 6.80%) for other graft types. For hamstring grafts, the revision rate increased over time (year of surgery), with a 0.0434 (95% CI, 0.0150 to 0.0718) increase effect in the logit-transformed scale for every additional year. There was a slight decrease in revision rates for BPTB (β = –0.0049; 95% CI, –0.0352 to 0.0254) and other graft types (β = –0.0306; 95% CI, –0.0608 to −0.0005) over time; however, confidence intervals for BPTB included the zero change.

Conclusion:

Based on this systematic review and meta-analysis, ACL reconstruction is a reliable procedure with overall low historical revision rates. BPTB autograft had the lowest revision rate and a slightly decreasing trend of failures during the past 45 years, although both BPTB and hamstring autografts are reliable graft choices.

Optimal Graft Choice in Athletic Patients with Anterior Cruciate Ligament Injuries: Review and Clinical Insights

Anterior cruciate ligament (ACL) rupture is a common sporting-related knee injury with a potentially detrimental impact on the athlete’s career, yet there is no formal consensus on the optimal graft choice for reconstructing the ruptured ACL in this specific population. Options for reconstruction include autograft, allograft, and artificial grafts. However, each has associated failure risk and donor site morbidity. Our operational definition of the athlete is a skeletally mature individual participating in high level activity with the expectation to return to pre-injury level of activity. The athlete has unique injury characteristics, post-operative expectations, and graft demands that differ to the general population. Long-term outcomes are of particular importance given on-going mechanical demands on the reconstructed knee. Therefore, the purpose of this review is to consolidate current literature on the various ACL reconstruction graft options, with a focus on the optimal graft for returning the athlete to activity with the lowest rate of re-injury.

Health disparities in the management of ACL injuries: How socioeconomic status, insurance, and race influence care

Health care disparities and racial health inequities significantly influence health care delivery and patient outcomes, including for people with injuries of the anterior cruciate ligament (ACL). This narrative review explores factors that may influence the management of ACL injuries. Studies that have discussed potential social barriers to treatment such as socioeconomic status (SES), insurance status, educational level, and cost of treatment were identified by searching databases such as EBSCO Host, PubMed, and Galileo for the index years from 2008 to 2020. The influence of health care inequities on ACL injury management was explored. Twelve studies met inclusion criteria and described a total of 219,708 participants. Barriers to surgical management of ACL injury were higher cost of surgery, greater time to evaluation and treatment, lower SES, lack of private insurance, and being identified as a racial minority. In addition, surgical environment, whether within a private or community-based health care system, and access to care affected post-surgical complication rates. Finally, risk of revision, lack of physical therapy access, and odds of additional injuries to include chondral and meniscal derangement were higher in racial minority, lower SES, and government insurance populations. These findings suggest health disparity and inequity exist in the care of ACL injury for patients with lower SES and without commercial insurance, and in minority populations. These patients appear to have a significantly reduced ability to access timely care, which can impact healing and ability to return to preferred activities of daily life or sport.

Social Determinants of Health Influence Access to Care and Outcomes in Patients Undergoing Anterior Cruciate Ligament Reconstruction: A Systematic Review

PURPOSE

To investigate the impact social determinants of health (SDOH) have on accessing orthopaedic treatment after an anterior cruciate ligament injury, as well as patient-reported and surgical outcomes after anterior cruciate ligament reconstruction (ACLR).

METHODS

A systematic search of the PubMed, MEDLINE, Epub Ahead of Print, Embase, and Web of Science databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify studies that reported at least 1 SDOH and its effect on patient-reported outcomes or surgical outcomes after anterior cruciate ligament reconstruction. Our search identified 937 studies. After eliminating 273 duplicates, 2 authors screened 664 articles on the basis of title and abstract. After this initial screening, 76 studies were evaluated for data extraction. Studies were categorized based on the social determinant(s) of health reported.

RESULTS

Twenty-two articles published between 2002 and 2020 were included in this study, encompassing 15 retrospective cohort studies, 3 prospective cohort studies, 3 cross-sectional studies, and 1 case-control study from 9 journals across 3 countries. Of these articles, 9 investigated race/ethnicity, 8 investigated insurance status, 4 investigated income, 5 investigated education level, 2 investigated employment status, and 5 investigated socioeconomic status. Reported outcomes included time to treatment, concomitant knee injury, patient-reported outcome measurement scores, postoperative complications, need for additional surgery, and postoperative healthcare utilization.

CONCLUSIONS

Certain SDOH, including black race, Hispanic ethnicity, public health insurance, and lower socioeconomic status contribute to a delay in access to care, which may result in increased severity of concomitant knee injuries encountered at the time of anterior cruciate ligament reconstruction and inferior outcomes.

STUDY DESIGN

Level III, systematic review of level I-III evidence.

Disparities in ACL Reconstruction: the Influence of Gender and Race on Incidence, Treatment, and Outcomes

PURPOSE OF REVIEW

Anterior cruciate ligament (ACL) rupture is a common injury that has important clinical and economic implications. We aimed to review the literature to identify gender, racial and ethnic disparities in incidence, treatment, and outcomes of ACL injury.

RECENT FINDINGS

Females are at increased risk for ACL injury compared to males. Intrinsic differences such as increased quadriceps angle and increased posterior tibial slope may be contributing factors. Despite lower rates of injury, males undergo ACL reconstruction (ACLR) more frequently. There is conflicting evidence regarding gender differences in graft failure and ACL revision rates, but males demonstrate higher return to sport (RTS) rates. Females report worse functional outcome scores and have worse biomechanical metrics following ACLR. Direct evidence of racial and ethnic disparities is limited, but present. White athletes have greater risk of ACL injury compared to Black athletes. Non-White and Spanish-speaking patients are less likely to undergo ACLR after ACL tear. Black and Hispanic youth have greater surgical delay to ACLR, increased risk for loss to clinical follow-up, and less physical therapy sessions, thereby leading to greater deficits in knee extensor strength during rehabilitation. Hispanic and Black patients also have greater risk for hospital admission after ACLR, though this disparity is improving. Females have higher rates of ACL injury with inconclusive evidence on anatomic predisposition and ACL failure rate differences between genders. Recent literature has suggested inferior RTS and functional outcomes following ACLR in females. Though there is limited and mixed data on incidence and outcome differences between races and ethnic groups, recent studies suggest there may be disparities in those who undergo ACLR and time to treatment.

Age, time from injury to surgery and hop performance after primary ACLR affect the risk of contralateral ACLR

PURPOSE

To evaluate factors affecting the risk of contralateral anterior cruciate ligament reconstruction (ACLR) within 5 years of primary ACLR.

METHODS

Primary ACLRs performed at Capio Artro Clinic, Stockholm, Sweden, during the period 2005-2014, were reviewed. The outcome of the study was the occurrence of contralateral ACLR within 5 years of primary ACLR. Univariable and multivariable logistic regression analyses were employed to identify preoperative [age, gender, body mass index (BMI), time from injury to surgery, pre-injury Tegner activity level], intraoperative [graft type, medial meniscus (MM) and lateral meniscus (LM) resection or repair, cartilage injury] and postoperative [limb symmetry index (LSI) for quadriceps and hamstring strength and single-leg-hop test performance at 6 months] risk factors for contralateral ACLR.

RESULTS

A total of 5393 patients who underwent primary ACLR were included. The incidence of contralateral ACLR within 5 years was 4.7%. Univariable analysis revealed that age ≥ 25 years, BMI ≥ 25 kg/m², time from injury to surgery ≥ 12 months and the presence of a cartilage injury reduced the odds, whereas female gender, pre-injury Tegner activity level ≥ 6, quadriceps and hamstring strength and a single-leg-hop test LSI of ≥ 90% increased the odds of contralateral ACLR. Multivariable analysis showed that the risk of contralateral ACLR was significantly affected only from age ≥ 25 years (OR 0.40; 95% CI 0.28-0.58; P < 0.001), time from injury to surgery ≥ 12 months (OR 0.48; 95% CI 0.30-0.75; P = 0.001) and a single-leg-hop test LSI of ≥ 90% (OR 1.56; 95% CI 1.04-2.34; P = 0.03).

CONCLUSION

Older age (≥ 25 years) and delayed primary ACLR (≥ 12 months) reduced the odds, whereas a symmetrical (LSI ≥ 90%) 6-month single-leg-hop test increased the odds of contralateral ACLR within 5 years of primary ACLR. Knowledge of the factors affecting the risk of contralateral ACLR is important when it comes to the appropriate counselling for primary ACLR. Patients should be advised regarding factors affecting the risk of contralateral ACLR.

LEVEL OF EVIDENCE

Level III.