Optimizing anterior cruciate ligament reconstruction: Individualizing the decision‐making process using data from the Kaiser Permanente ACLR Registry: 2018 OREF award paper

Abstract

Despite years of study, controversy remains regarding the optimal graft for anterior cruciate ligament reconstruction (ACLR), suggesting that a single graft type is not ideal for all patients. A large community based ACLR Registry that collects prospective data is a powerful tool that captures information and can be analyzed to optimize surgery for individual patients. The studies highlighted in this paper were designed to optimize and individualize ACLR surgery and have led to changes in surgeon behavior and improvements in patient outcomes. Kaiser Permanente (KP) is an integrated health care system with 10.6 million members and more than 50 hospitals. Every KP member who undergoes an ACLR is entered into the Registry, and prospectively monitored. The Registry uses a variety of feedback mechanisms to disseminate Registry findings to the ACLRR surgeons and appropriately influence clinical practices and enhance quality of care. Allografts were found to have a 3.0 times higher risk of revision than bone‐patellar tendon‐bone (BPTB) autografts. Allograft irradiation >1.8 Mrad, chemical graft processing, younger patients, BPTB allograft, and male patients were all associated with a higher risk of revision surgery. By providing feedback to surgeons, overall allograft use has decreased by 27% and allograft use in high‐risk patients ≤21 years of age decreased 68%. We have identified factors that influence the outcomes of ACLR. Statement of Clinical Significance: We found that information derived from an ACLR Registry and shared with the participating surgeons directly decreased the use of specific procedures and implants associated with poor outcomes.

A Triple-Strand Anatomic Medial Collateral Ligament Reconstruction Restores Knee Stability More Completely Than a Double-Strand Reconstruction: A Biomechanical Study In Vitro

“… 13 , 15 , 21 , 23 Allografts avoid the effect of reducing dynamic control of the medial knee, 13 but in ACL reconstruction, at least, they have higher failure rates. 28 Furthermore, there is no reason to suspect that the findings of this biomechanical study should not be applicable with autogenic or allogenic tendon grafts.…”

Surgeon’s experience, sports participation and a concomitant MCL injury increase the use of patellar and quadriceps tendon grafts in primary ACL reconstruction: a nationwide registry study of 39,964 surgeries

“…Previous registry-based studies confirm the use of HT as the most common autograft choice [ 25 , 32 , 33 ]. Additionally, studies investigating surgeon preference found a predilection for HT autografts in primary ACLR [ 14 , 52 ].…”

“…The graft choice based on patient sex is in agreement with previous reports from national ACL registries and surgeon surveys [ 21 , 33 , 52 ], but the underlying reasons are still somewhat unclear. While female sex has been identified as a risk factor for primary ACL injury, there is conflicting evidence regarding the risk of graft rupture and revision rates between the sexes [ 3 , 5 , 25 , 43 , 45 ]. In terms of graft characteristics, a few studies have found an increase in objective knee stability and a lower incidence of graft rupture in primary ACLRs with PT compared with HT autografts among young females [ 35 , 39 ].…”

Revision Rates After Primary Allograft ACL Reconstruction by Allograft Tissue Type in Older Patients

“… 24 , 39 This evidence led to a decrease in allograft use in patients aged ≤21 years from a peak of 28% in 2009 down to 9% in 2015 in one large registry. 20 In 2014, the American Academy of Orthopedic Surgeons published a clinical practice guideline that stated surgeons could use “autograft or appropriately processed allograft…because the measured outcomes are similar, although these results may not be generalizable to all allografts or all patients, such as young patients or highly active patients.” 1 This literature suggests that around 2015 is when more narrowed indications for allograft use became widespread. This aligns with the beginning of the time interval for patient collection used in the present study to ensure that most allograft use was applied with a modern understanding of indications for allograft use in ACL reconstruction.…”