Association Between Graft Choice and 6-Year Outcomes of Revision Anterior Cruciate Ligament Reconstruction in the MARS Cohort

MARS Group¹; Rick W Wright^{2

1}, Laura J Huston^{2

1}, Amanda K Haas^{3

1}, Jacquelyn S Pennings^{2

1}, Christina R Allen^{4

1}, Daniel E Cooper^{5

1}, Thomas M DeBerardino^{6

1}, Warren R Dunn^{7

1}, Brett Brick A Lantz^{8

1}, Kurt P Spindler^{9

1}, Michael J Stuart^{10

1}, John P Albright^{11

1}, Annunziato Ned Amendola^{12

1}, Jack T Andrish^{9

1}, Christopher C Annunziata^{13

1}, Robert A Arciero^{14

1}, Bernard R Bach Jr^{15

1}, Champ L Baker 3rd^{16

1}, Arthur R Bartolozzi^{17

1}, Keith M Baumgarten^{18

1}, Jeffery R Bechler^{19

1}, Jeffrey H Berg^{20

1}, Geoffrey A Bernas^{21

1}, Stephen F Brockmeier^{22

1}, Robert H Brophy^{3

1}, Charles A Bush-Joseph^{15

1}, J Brad Butler V^{23

1}, John D Campbell^{24

1}, James L Carey^{25

1}, James E Carpenter^{26

1}, Brian J Cole^{15

1}, Jonathan M Cooper^{27

1}, Charles L Cox^{2

1}, R Alexander Creighton^{28

1}, Diane L Dahm^{10

1}, Tal S David^{29

1}, David C Flanigan^{30

1}, Robert W Frederick^{31

1}, Theodore J Ganley^{32

1}, Elizabeth A Garofoli^{3

1}, Charles J Gatt Jr^{19

1}, Steven R Gecha^{33

1}, James Robert Giffin^{34

1}, Sharon L Hame^{35

1}, Jo A Hannafin^{36

1}, Christopher D Harner^{37

1}, Norman Lindsay Harris Jr^{38

1}, Keith S Hechtman^{39

1}, Elliott B Hershman^{40

1}, Rudolf G Hoellrich^{8

1}, David C Johnson^{41

1}, Timothy S Johnson^{41

1}, Morgan H Jones^{9

1}, Christopher C Kaeding^{30

1}, Ganesh V Kamath^{28

1}, Thomas E Klootwyk^{42

1}, Bruce A Levy^{10

1}, C Benjamin Ma^{43

1}, G Peter Maiers 2nd^{44

1}, Robert G Marx^{36

1}, Matthew J Matava^{3

1}, Gregory M Mathien^{45

1}, David R McAllister^{35

1}, Eric C McCarty^{46

1}, Robert G McCormack^{47

1}, Bruce S Miller^{26

1}, Carl W Nissen^{48

1}, Daniel F O'Neill^{49

1}, Brett D Owens^{50

1}, Richard D Parker^{9

1}, Mark L Purnell^{51

1}, Arun J Ramappa^{52

1}, Michael A Rauh^{21

1}, Arthur C Rettig^{42

1}, Jon K Sekiya^{26

1}, Kevin G Shea^{53

1}, Orrin H Sherman^{54

1}, James R Slauterbeck^{55

1}, Matthew V Smith^{3

1}, Jeffrey T Spang^{28

1}, Ltc Steven J Svoboda^{56

1}, Timothy N Taft^{28

1}, Joachim J Tenuta^{57

1}, Edwin M Tingstad^{58

1}, Armando F Vidal^{46

1}, Darius G Viskontas^{59

1}, Richard A White^{60

1}, James S Williams Jr^{61

1}, Michelle L Wolcott^{46

1}, Brian R Wolf^{11

1}, James J York^{62

1}

Affiliations

¹ Investigation performed at Vanderbilt University Medical Center, Nashville, Tennessee, USA.
² Vanderbilt University, Nashville, Tennessee, USA.
³ Washington University in Saint Louis, Saint Louis, Missouri, USA.
⁴ Yale University, New Haven, Connecticut, USA.
⁵ W.B. Carrell Memorial Clinic, Dallas, Texas, USA.
⁶ The San Antonio Orthopaedic Group, San Antonio, Texas, USA.
⁷ Texas Orthopedic Hospital, Houston, Texas, USA.
⁸ Slocum Research and Education Foundation, Eugene, Oregon, USA.
⁹ Cleveland Clinic, Cleveland, Ohio, USA.
¹⁰ Mayo Clinic, Rochester, Minnesota, USA.
¹¹ University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
¹² Duke University, Durham, North Carolina, USA.
¹³ Commonwealth Orthopaedics & Rehabilitation, Arlington, Virginia, USA.
¹⁴ University of Connecticut Health Center, Farmington, Connecticut, USA.
¹⁵ Rush University Medical Center, Chicago, Illinois, USA.
¹⁶ The Hughston Clinic, Columbus, Georgia, USA.
¹⁷ 3B Orthopaedics, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA.
¹⁸ Orthopedic Institute, Sioux Falls, South Dakota, USA.
¹⁹ University Orthopaedic Associates LLC, Princeton, New Jersey, USA.
²⁰ Town Center Orthopaedic Associates, Reston, Virginia, USA.
²¹ State University of New York at Buffalo, Buffalo, New York, USA.
²² University of Virginia, Charlottesville, Virginia, USA.
²³ Orthopedic and Fracture Clinic, Portland, Oregon, USA.
²⁴ Bridger Orthopedic and Sports Medicine, Bozeman, Montana, USA.
²⁵ University of Pennsylvania, Philadelphia, Pennsylvania, USA.
²⁶ University of Michigan, Ann Arbor, Michigan, USA.
²⁷ HealthPartners Specialty Center, Saint Paul, Minnesota, USA.
²⁸ University of North Carolina Medical Center, Chapel Hill, North Carolina, USA.
²⁹ Synergy Specialists Medical Group, San Diego, California, USA.
³⁰ The Ohio State University, Columbus, Ohio, USA.
³¹ The Rothman Institute/Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
³² Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
³³ Princeton Orthopaedic Associates, Princeton, New Jersey, USA.
³⁴ Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada.
³⁵ David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
³⁶ Hospital for Special Surgery, New York, New York, USA.
³⁷ University of Texas Health Center, Houston, Texas, USA.
³⁸ Grand River Health, Rifle, Colorado, USA.
³⁹ UHZ Sports Medicine Institute, Coral Gables, Florida, USA.
⁴⁰ Lenox Hill Hospital, New York, New York, USA.
⁴¹ National Sports Medicine Institute, Leesburg, Virginia, USA.
⁴² Methodist Sports Medicine, Indianapolis, Indiana, USA.
⁴³ University of California, San Francisco, California, USA.
⁴⁴ Methodist Sports Medicine Center, Indianapolis, Indiana, USA.
⁴⁵ Knoxville Orthopaedic Clinic, Knoxville, Tennessee, USA.
⁴⁶ University of Colorado Denver School of Medicine, Denver, Colorado, USA.
⁴⁷ University of British Columbia/Fraser Health Authority, New Westminster, British Columbia, Canada.
⁴⁸ Connecticut Children's Medical Center, Hartford, Connecticut, USA.
⁴⁹ Littleton Regional Healthcare, Littleton, New Hampshire, USA.
⁵⁰ Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA.
⁵¹ Aspen Orthopedic Associates, Aspen, Colorado, USA.
⁵² Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
⁵³ Intermountain Orthopaedics, Boise, Idaho, USA.
⁵⁴ NYU Hospital for Joint Diseases, New York, New York, USA.
⁵⁵ University of South Alabama, Mobile, Alabama, USA.
⁵⁶ Keller Army Community Hospital, United States Military Academy, West Point, New York, USA.
⁵⁷ Albany Medical Center, Albany, New York, USA.
⁵⁸ Inland Orthopaedic Surgery and Sports Medicine Clinic, Pullman, Washington, USA.
⁵⁹ Royal Columbian Hospital, New Westminster, British Columbia, Canada.
⁶⁰ Fitzgibbon's Hospital, Marshall, Missouri, USA.
⁶¹ Cleveland Clinic, Euclid, Ohio, USA.
⁶² Orthopaedic and Sports Medicine Center, LLC, Pasadena, Maryland, USA.

PMID: 34260326
PMCID: PMC9236596
DOI: 10.1177/03635465211027170

Association Between Graft Choice and 6-Year Outcomes of Revision Anterior Cruciate Ligament Reconstruction in the MARS Cohort

MARS Group et al. Am J Sports Med. 2021 Aug.

. 2021 Aug;49(10):2589-2598.

doi: 10.1177/03635465211027170. Epub 2021 Jul 14.

Authors

Affiliations

¹ Investigation performed at Vanderbilt University Medical Center, Nashville, Tennessee, USA.
² Vanderbilt University, Nashville, Tennessee, USA.
³ Washington University in Saint Louis, Saint Louis, Missouri, USA.
⁴ Yale University, New Haven, Connecticut, USA.
⁵ W.B. Carrell Memorial Clinic, Dallas, Texas, USA.
⁶ The San Antonio Orthopaedic Group, San Antonio, Texas, USA.
⁷ Texas Orthopedic Hospital, Houston, Texas, USA.
⁸ Slocum Research and Education Foundation, Eugene, Oregon, USA.
⁹ Cleveland Clinic, Cleveland, Ohio, USA.
¹⁰ Mayo Clinic, Rochester, Minnesota, USA.
¹¹ University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
¹² Duke University, Durham, North Carolina, USA.
¹³ Commonwealth Orthopaedics & Rehabilitation, Arlington, Virginia, USA.
¹⁴ University of Connecticut Health Center, Farmington, Connecticut, USA.
¹⁵ Rush University Medical Center, Chicago, Illinois, USA.
¹⁶ The Hughston Clinic, Columbus, Georgia, USA.
¹⁷ 3B Orthopaedics, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA.
¹⁸ Orthopedic Institute, Sioux Falls, South Dakota, USA.
¹⁹ University Orthopaedic Associates LLC, Princeton, New Jersey, USA.
²⁰ Town Center Orthopaedic Associates, Reston, Virginia, USA.
²¹ State University of New York at Buffalo, Buffalo, New York, USA.
²² University of Virginia, Charlottesville, Virginia, USA.
²³ Orthopedic and Fracture Clinic, Portland, Oregon, USA.
²⁴ Bridger Orthopedic and Sports Medicine, Bozeman, Montana, USA.
²⁵ University of Pennsylvania, Philadelphia, Pennsylvania, USA.
²⁶ University of Michigan, Ann Arbor, Michigan, USA.
²⁷ HealthPartners Specialty Center, Saint Paul, Minnesota, USA.
²⁸ University of North Carolina Medical Center, Chapel Hill, North Carolina, USA.
²⁹ Synergy Specialists Medical Group, San Diego, California, USA.
³⁰ The Ohio State University, Columbus, Ohio, USA.
³¹ The Rothman Institute/Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
³² Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
³³ Princeton Orthopaedic Associates, Princeton, New Jersey, USA.
³⁴ Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada.
³⁵ David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
³⁶ Hospital for Special Surgery, New York, New York, USA.
³⁷ University of Texas Health Center, Houston, Texas, USA.
³⁸ Grand River Health, Rifle, Colorado, USA.
³⁹ UHZ Sports Medicine Institute, Coral Gables, Florida, USA.
⁴⁰ Lenox Hill Hospital, New York, New York, USA.
⁴¹ National Sports Medicine Institute, Leesburg, Virginia, USA.
⁴² Methodist Sports Medicine, Indianapolis, Indiana, USA.
⁴³ University of California, San Francisco, California, USA.
⁴⁴ Methodist Sports Medicine Center, Indianapolis, Indiana, USA.
⁴⁵ Knoxville Orthopaedic Clinic, Knoxville, Tennessee, USA.
⁴⁶ University of Colorado Denver School of Medicine, Denver, Colorado, USA.
⁴⁷ University of British Columbia/Fraser Health Authority, New Westminster, British Columbia, Canada.
⁴⁸ Connecticut Children's Medical Center, Hartford, Connecticut, USA.
⁴⁹ Littleton Regional Healthcare, Littleton, New Hampshire, USA.
⁵⁰ Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA.
⁵¹ Aspen Orthopedic Associates, Aspen, Colorado, USA.
⁵² Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
⁵³ Intermountain Orthopaedics, Boise, Idaho, USA.
⁵⁴ NYU Hospital for Joint Diseases, New York, New York, USA.
⁵⁵ University of South Alabama, Mobile, Alabama, USA.
⁵⁶ Keller Army Community Hospital, United States Military Academy, West Point, New York, USA.
⁵⁷ Albany Medical Center, Albany, New York, USA.
⁵⁸ Inland Orthopaedic Surgery and Sports Medicine Clinic, Pullman, Washington, USA.
⁵⁹ Royal Columbian Hospital, New Westminster, British Columbia, Canada.
⁶⁰ Fitzgibbon's Hospital, Marshall, Missouri, USA.
⁶¹ Cleveland Clinic, Euclid, Ohio, USA.
⁶² Orthopaedic and Sports Medicine Center, LLC, Pasadena, Maryland, USA.

PMID: 34260326
PMCID: PMC9236596
DOI: 10.1177/03635465211027170

Abstract

Background: Although graft choice may be limited in the revision setting based on previously used grafts, most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome.

Hypothesis: In the ACL revision setting, there would be no difference between autograft and allograft in rerupture rate and patient-reported outcomes (PROs) at 6-year follow-up.

Study design: Cohort study; Level of evidence, 2.

Methods: Patients who had revision surgery were identified and prospectively enrolled in this cohort study by 83 surgeons over 52 sites. Data collected included baseline characteristics, surgical technique and pathology, and a series of validated PRO measures. Patients were followed up at 6 years and asked to complete the identical set of PRO instruments. Incidence of additional surgery and reoperation because of graft failure were also recorded. Multivariable regression models were used to determine the predictors (risk factors) of PROs, graft rerupture, and reoperation at 6 years after revision surgery.

Results: A total of 1234 patients including 716 (58%) men were enrolled. A total of 325 (26%) underwent revision using a bone-patellar tendon-bone (BTB) autograft; 251 (20%), soft tissue autograft; 289 (23%), BTB allograft; 302 (25%), soft tissue allograft; and 67 (5%), other graft. Questionnaires and telephone follow-up for subsequent surgery information were obtained for 809 (66%) patients, while telephone follow-up was only obtained for an additional 128 patients for the total follow-up on 949 (77%) patients. Graft choice was a significant predictor of 6-year Marx Activity Rating Scale scores (P = .024). Specifically, patients who received a BTB autograft for revision reconstruction had higher activity levels than did patients who received a BTB allograft (odds ratio [OR], 1.92; 95% CI, 1.25-2.94). Graft rerupture was reported in 5.8% (55/949) of patients by their 6-year follow-up: 3.5% (16/455) of patients with autografts and 8.4% (37/441) of patients with allografts. Use of a BTB autograft for revision resulted in patients being 4.2 times less likely to sustain a subsequent graft rupture than if a BTB allograft were utilized (P = .011; 95% CI, 1.56-11.27). No significant differences were found in graft rerupture rates between BTB autograft and soft tissue autografts (P = .87) or between BTB autografts and soft tissue allografts (P = .36). Use of an autograft was found to be a significant predictor of having fewer reoperations within 6 years compared with using an allograft (P = .010; OR, 0.56; 95% CI, 0.36-0.87).

Conclusion: BTB and soft tissue autografts had a decreased risk in graft rerupture compared with BTB allografts. BTB autografts were associated with higher activity level than were BTB allografts at 6 years after revision reconstruction. Surgeons and patients should consider this information when choosing a graft for revision ACL reconstruction.

Keywords: ACL reconstruction; anterior cruciate ligament; graft failure; outcomes; revision.

PubMed Disclaimer

Figures

**Figure 1.**
Patient Enrollment Flow Diagram

**Figure 2.**
Plot of effects of predictors in the model on subsequent graft failure. The independent covariates in this model are listed along the y-axis, with the comparisons listed afterwards. The second variable within each line is considered the reference value. The adjusted odds ratios for each variable are listed along the right side, with their 95% confidence intervals listed in parentheses. For example, for sex, a female is 54% less likely to sustain a graft re-rupture at 6 years as compared to a male. For age, a 35-year old is 59% less likely to sustain a graft re-rupture at 6 years as compared to a 20-year old. For baseline Marx activity level, a person with a high activity level of 16 points is 2.24 times more likely to sustain a graft re-rupture at 6 years as compared to a person with very low activity level (scoring 4 points on the Marx activity rating scale). For ACL graft, a person with a BTB allograft is 4.19 more likely to sustain a graft re-rupture at 6 years as compared to a person with a BTB autograft. A person with a soft tissue allograft is 1.87 times more likely to sustain a graft re-rupture at 6 years compared to a person with a BTB autograft. A person with a soft tissue autograft is 60% less likely to sustain a graft re-rupture at 6 years as compared to a person with a BTB autograft. Any line that crosses ‘1’ on the x-axis is not significant. Key: btb=bone-patellar tendon-bone.

See this image and copyright information in PMC

References

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Association Between Graft Choice and 6-Year Outcomes of Revision Anterior Cruciate Ligament Reconstruction in the MARS Cohort

Affiliations

Association Between Graft Choice and 6-Year Outcomes of Revision Anterior Cruciate Ligament Reconstruction in the MARS Cohort

Authors

Affiliations

Abstract

Figures

References

Publication types

MeSH terms

Grants and funding

LinkOut - more resources

Full Text Sources

Medical

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