Monday, March 28, 2016

Revision ACL Reconstruction

Revision (redo) ACL reconstruction which occurs when the original ACL reconstruction fails is not necessarily common, but is an important issue for those unfortunate patients and those of us that care for these patients. This began to be evident to us with the publication of one of the early ACL reconstruction studies that utilized patient reported outcome measures. These outcome scores ask patients how they are doing rather than surgeons declaring how well the patient was doing. While maybe intuitive that asking patients how they are functioning after an ACL reconstruction is the correct way to assess outcome it was an unusual approach at the time. These outcome measures are validated and can be as accurate as any outcome measure available. These patient reported outcome measures have formed the backbone of our approach in the Multi-center Orthopaedic Outcomes Network (MOON) group and the Multi-center ACL Revision Study (MARS).

The study Kurt Spindler and I wrote and published was a minimum 5 year outcome analysis of ACL
reconstruction. Read the study Here In that study we found that gaining weight(> 15 lbs) and failing to advance your educational status following ACL reconstruction resulted in worse patient reported outcomes (PROs) at 5 years. Interestingly, the strongest predictor for a worse outcome was if the reconstruction was a revision ACL reconstruction. The journal (Journal of Bone and Joint Surgery) did not want or allow us to include the revision reconstructions and so we published a paper of just first time (primary) reconstructions. This made us curious and we began to pay more attention to the outcomes of revision ACL reconstructions. We noted following the formation of the MOON Group similar findings with worse results with the revision ACL reconstructions. Revisions made up only ~10% of our reconstructions and that even with 17 surgeons in the group we could not accumulate enough patients quickly enough to do the sophisticated statistical analysis and modeling to answer the question of “Why do these patients do worse?”.

It was not intuitive why they necessarily would have worse function, more pain and lower activity levels compared to primary reconstructions. For this reason we knew we needed at least 50 surgeons contributing patients and thus formed the nationwide Multi-center ACL Revision Study (MARS). MARS is an 83 surgeon, 52 site study for which Washington University Sports Medicine Division is the coordinating center and I serve as principle investigator for the study. The American Orthopaedic Society for Sports Medicine supported the concept and offered participation to its members. We enrolled 1215 patients and obtained NIH funding to support 2 year follow up. The demographics of the study and our initial study can be found HERE. Future blogs will discuss our findings that are changing and shaping the care of the revision ACL reconstruction patient. We recently submitted a competitive renewal grant to the NIH to support 10 year follow up analysis of these 1215 patients. See the MARS Facebook page for additional information. MARS

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