Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus part III-indications for different clinical scenarios using the RAND/UCLA appropriateness method

Abstract

Purpose: The aim of the ESSKA 2022 consensus Part III was to develop patient-focused, contemporary, evidence-based, guidelines on the indications for revision anterior cruciate ligament surgery (ACLRev).

Methods: The RAND/UCLA Appropriateness Method (RAM) was used to provide recommendations on the appropriateness of surgical treatment versus conservative treatment in different clinical scenarios based on current scientific evidence in conjunction with expert opinion. A core panel defined the clinical scenarios with a moderator and then guided a panel of 17 voting experts through the RAM tasks. Through a two-step voting process, the panel established a consensus as to the appropriateness of ACLRev for each scenario based on a nine-point Likert scale (in which a score in the range 1-3 was considered 'inappropriate', 4-6 'uncertain', and 7-9 'appropriate').

Results: The criteria used to define the scenarios were: age (18-35 years vs 36-50 years vs 51-60 years), sports activity and expectation (Tegner 0-3 vs 4-6 vs 7-10), instability symptoms (yes vs no), meniscus status (functional vs repairable vs non-functional meniscus), and osteoarthritis (OA) (Kellgren-Lawrence [KL] grade 0-I-II vs grade III). Based on these variables, a set of 108 clinical scenarios was developed. ACLRev was considered appropriate in 58%, inappropriate in 12% (meaning conservative treatment is indicated), and uncertain in 30%. Experts considered ACLRev appropriate for patients with instability symptoms, aged ≤ 50 years, regardless of sports activity level, meniscus status, and OA grade. Results were much more controversial in patients without instability symptoms, while higher inappropriateness was related to scenarios with older age (51-60 years), low sporting expectation, non-functional meniscus, and knee OA (KL III).

Conclusion: This expert consensus establishes guidelines as to the appropriateness of ACLRev based on defined criteria and provides a useful reference for clinical practice in determining treatment indications.

Level of evidence: II.

Keywords: Anterior cruciate ligament; Consensus; Guidelines; Knee; Revision.

Fig. 1

Example of the clinical scenarios presented to the voting panelists. Chapter 1 (18–35 years old patients). Two specific scenarios are shown in detail

Fig. 2

Clinical scenarios for the age range 18–35 (chapter 1). M median value, DIS disagreement, A appropriate, U uncertain, I inappropriate, + without disagreement, − with disagreement, green appropriate scenarios, yellow uncertain scenarios, red inappropriate scenarios

Fig. 3

Clinical scenarios for the age range 36–50 (chapter 2). M median value, DIS disagreement, A appropriate, U uncertain, I inappropriate, + without disagreement, − with disagreement, green appropriate scenarios, yellow uncertain scenarios, red inappropriate scenarios

Fig. 4

Clinical scenarios for the age range 51–60 (chapter 3). M median value, DIS disagreement, A appropriate, U uncertain, I inappropriate, + without disagreement, − with disagreement, green appropriate scenarios, yellow uncertain scenarios, red inappropriate scenarios

Fig. 5

Rating of scenarios evaluated as appropriate, uncertain, or inappropriate, for each parameter considered. Green indicates the highest rates of appropriateness, yellow the most uncertain parameters, and red the highest rate of inappropriateness when considering the indication for ACLRev based on the different parameters evaluated. A appropriate, U uncertain, I inappropriate, OA osteoarthritis, KL Kellgren Lawrence, Funct functional, Repair repairable

Fig. 6

Graphic representation of the overall RAM consensus results on the appropriateness of ACLRev in adults (Green: appropriate; yellow: uncertain; red: inappropriate). OA: osteoarthritis, Funct: Functional, Repair: Repairable, Men: Meniscus