Why Revision ACL Grafts Are Chosen For Patients

Revision ACL grafts are chosen for a variety of reasons. Read our MARS study HERE to see the most important factors (Hint- It's the surgeon you choose)

MOON-MARS Revision ACL Graft Study Presented Toronto AOSSM Meeting

A combined MOON (Multi-Center Orthopaedic Outcomes Network)- MARS (Multi-Center ACL Revision Study) looked at patellofemoral (kneecap) cartilage changes after allograft or autograft primary ACL reconstruction as identified at the time of revision ACL reconstruction. This study presented by Robert Magnussen of Ohio St. at the Toronto AOSSM (American Orthopaedic Society for Sports Medicine) meeting in July. 134 patients had undergone MOON primary ACL reconstruction followed by MARS revision ACL reconstruction. Progression was identified as progression of one grade worse or a 25% increase in size of the lesion. 31 (23%) had worsening progression of arthritis. Results showed allografts had a 15.5 times higher risk of progression. Odds also increased 10% with each unit increase of BMI. Age, sex, activity level, meniscus status, injury mechanism had no impact. The association between graft choice and damage was surprising. Previously it was thought maybe a patellar tendon (BTB) autograft might be at more riskk. Allografts with more laxity may place more pressure on cartilage, but we cannot be sure. Further work will be necessary to sort this out.

Meniscus Repair in the Setting of a Revision ACL Reconstruction: ISAKOS Presentation Shanghai

Predictors of Outcome from the MARS Cohort: Physical Therapy, Rehabilitation and Bracing Factors

Predictors of Outcome from the MARS Cohort: Surgical Factors

Revision ACL Reconstruction Predictors of Outcome: Meniscus and Cartilage

Revision ACL Reconstruction Predictors of Outcome: Graft Choice

MARS (Multicenter ACL Revision Study) Rehabilitation Predictors of Surgical Outcomes

Revision ACL Reconstruction Graft Choice Part 2

Revision ACL reconstruction Graft choice is an important Issue that impacts patient outcome.  In the AOSSM O'Donoghue award winning study published in American Journal of Sports medicine the MARS group analyzed the impact of allograft versus autograft choice on patient reported outcomes, reoperation and return to sports.Read the full study HERE In this study of 1205 patients that underwent revision anterior cruciate ligament reconstruction at 52 sites by 83 different surgeons 58% were male, median age was 26.  48% underwent autograft reconstruction and 49% underwent allograft reconstruction.  3% had a combination.  We obtained followup on 989 with questionnaires (82%) and an additional 10% phone followup for a total of 92% followup At 2 years. The IKDC Sports score improved with the use of autograft with an odds ratio of 1.33. The Knee Osteoarthritis

Outcome Score subscales sports and recreation and quality of life improved with autograft use with an odds ratio of 1.33.  37/1112 (3.3%) patients sustained a graft rerupture. Use of an autograft resulted in a 2.78 times less risk for graft rerupture.  Graft irradiation versus nonirradiated grafts did not affect the allograft failure rate.  More grafts had not undergone a radiation that ultimately failed.  Many people previously had believed that if the graft had not undergone irradiation then the results were equal to autograft. Reoperation risk was not affected by allograft versus autograft use.

Based on these findings many people now recommend if at all possible using an autograft for revision anterior cruciate ligament reconstruction.  This can involve the quadriceps, patellar tendon or hamstring grafts.  Frequently I will use a graft from the opposite knee if no other autograft options remain. 

Revision ACL Reconstruction Graft Choice Part 1

Revision ACL reconstruction requires careful thought about the appropriate graft to utilize.  In the revision (redo) situation a previous graft has already been used and failed.  This can force surgeons to potentially use a graft that is not their first choice.  As the basis for the MARS (Multicenter ACL Revision Study) we allowed surgeons to choose their graft that they felt most appropriate in the clinical situation.  Many surgeons believed that graft choice was a fait accompli and that they had no real choice in the matter.  They were forced to many times use a graft not of their choice based on other factors including patient's age, patient’s sport, previous graft utilized, gender etc. In a propensity study the MARS Group performed (Accepted for publication in The Journal of Knee Surgery) we analyzed a variety of factors that impacted revision ACL graft choice. Below you can see the factors analyzed and their impact on what graft the patient eventually received.

As can be seen despite a variety of factors that impact graft choice the most important factor was the particular surgeon that treated you.  Thus, a surgeon that wants to use an allograft (cadaver) for the reconstruction can do that.  Likewise, a surgeon that wants to utilize an autograft has the ability to control that decision most of the time.  The top 5 choices are expanded below and as can be seen in this table ---in fact the particular surgeon involved was 5 times higher impact on graft choice than anything else analyzed including the previous graft the patient had utilized for the primary ACL reconstruction.

Following this study we knew that if we could improve what type of graft gave the best results we could then recommend to surgeons to use that graft and impact patient outcomes.  In Part 2 I will discuss the follow-up study that analyzed outcomes depending on the patient's graft utilized in the MARS study.

Sports and ACL Injuries

This blog was created to provide patients with information regarding sports injuries, their treatment and outcomes. I hope to provide more detailed information than can be readily found on the internet. It will highlight research findings from my own work as well as my Sports Division at Washington University. Additionally I will feature research findings coming from our work as part of the Mult-center Orthopaedic Outcomes Network (MOON) and the Multi-center ACL Revision Study (MARS). There will be posts on all anatomical areas and conditions seen in sports injuries. I look forward to your comments and ideas to improve the blog.