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. 2017 May;25(5):1542-1554.
doi: 10.1007/s00167-016-4399-0. Epub 2016 Dec 19.

Revision surgery in anterior cruciate ligament reconstruction: a cohort study of 17,682 patients from the Swedish National Knee Ligament Register

Neel Desai  1   2 , Daniel Andernord  3   4   5 , David Sundemo  6   3 , Eduard Alentorn-Geli  7 , Volker Musahl  8 , Freddie Fu  8 , Magnus Forssblad  9 , Kristian Samuelsson  6   3
Affiliations

Revision surgery in anterior cruciate ligament reconstruction: a cohort study of 17,682 patients from the Swedish National Knee Ligament Register

Neel Desai et al. Knee Surg Sports Traumatol Arthrosc. 2017 May.

Abstract

Purpose: To investigate the association between surgical variables and the risk of revision surgery after ACL reconstruction in the Swedish National Knee Ligament Register.

Methods: This cohort study was based on data from the Swedish National Knee Ligament Register. Patients who underwent primary single-bundle ACL reconstruction with hamstring tendon were included. Follow-up started with primary ACL reconstruction and ended with ACL revision surgery or on 31 December, 2014, whichever occurred first. Details on surgical technique were collected using an online questionnaire. All group comparisons were made in relation to an "anatomic" reference group, comprised of essential AARSC items, defined as utilization of accessory medial portal drilling, anatomic tunnel placement, visualization of insertion sites and pertinent landmarks. Study end-point was revision surgery.

Results: A total of 108 surgeons (61.7%) replied to the questionnaire. A total of 17,682 patients were included [n = 10,013 males (56.6%) and 7669 females (43.4%)]. The overall revision rate was 3.1%. Older age as well as cartilage injury evident at index surgery was associated with a decreased risk of revision surgery. The group using transtibial drilling and non-anatomic bone tunnel placement was associated with a lower risk of revision surgery [HR 0.694 (95% CI 0.490-0.984); P = 0.041] compared with the anatomic reference group. The anatomic reference group showed no difference in risk of revision surgery compared with the transtibial drilling groups with partial anatomic [HR 0.759 (95% CI 0.548-1.051), n.s.] and anatomic tunnel placement [HR 0.944 (95% CI 0.718-1.241), n.s.]. The anatomic reference group showed a decreased risk of revision surgery compared with the transportal drilling group with anatomic placement [HR 1.310 (95% CI 1.047-1.640); P = 0.018].

Conclusion: Non-anatomic bone tunnel placement via transtibial drilling resulted in the lowest risk of revision surgery after ACL reconstruction. The risk of revision surgery increased when using transportal drilling. Performing anatomic ACL reconstruction utilizing eight selected essential items from the AARSC lowered the risk of revision surgery associated with transportal drilling and anatomic bone tunnel placement. Detailed knowledge of surgical technique using the AARSC predicts the risk of ACL revision surgery.

Level of evidence: III.

Keywords: Anatomic; Anterior cruciate ligament; Drilling; Reconstruction; Register; Revision.

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Conflict of interest statement

Conflict of interest

Desai, Sundemo, Andernord, Alentorn-Geli, Musahl, Fu, Forssblad and Samuelsson declare that they have no conflict of interest.

Funding

No outside funding or grants directly related to the research presented in this manuscript. The department of Orthopaedic Surgery from the University of Pittsburgh receives funding from Smith and Nephew to support research related to reconstruction of the ACL.

Ethical approval

The Regional Ethical Review Board in Gothenburg, Sweden, approved this study (Ref: 760-14).

Informed consent

As this is a study based on data from a register, informed consent statements for patient enrollment is not applicable. No such informed consent statement for surgeon participation in the study through the survey was aquired either.

Figures

Fig. 1
Fig. 1
Flow diagram of inclusion and exclusion criteria
Fig. 2
Fig. 2
Flow diagram of questionnaire distribution
Fig. 3
Fig. 3
Current national frequency of use of surgical variable amongst questionnaire respondents
Fig. 4
Fig. 4
Mean AARSC score based on respondents questionnaire answers
Fig. 5
Fig. 5
Kaplan–Meier survival function of patient sex and revision ACL surgery
Fig. 6
Fig. 6
Kaplan–Meier survival function of age at index surgery and revision ACL surgery
Fig. 7
Fig. 7
Kaplan–Meier survival function of meniscus injury and revision ACL surgery
Fig. 8
Fig. 8
Kaplan–Meier survival function of cartilage injury and revision ACL surgery
Fig. 9
Fig. 9
Kaplan–Meier survival function of surgical group and revision ACL surgery
Fig. 10
Fig. 10
Kaplan–Meier survival function of femoral drilling technique and revision ACL surgery
See this image and copyright information in PMC

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