Factors Influencing Graft Choice in Revision Anterior Cruciate Ligament Reconstruction in the MARS Group

Abstract

It has not been known what drives revision anterior cruciate ligament (ACL) reconstruction graft choice in the past. We undertook this study to utilize the Multicenter ACL Revision Study (MARS) group and propensity score statistical analysis to determine the drivers of revision ACL reconstruction graft choice. We hypothesized that propensity analysis would demonstrate that individual surgeons still have significant impact on revision ACL reconstruction. Twelve hundred patients were enrolled in this longitudinal revision cohort by 83 surgeons at 52 sites. The median age was 26 years and 505 (42%) were females. One thousand forty-nine (87%) patients were undergoing their first ACL revision. Graft choice for revision ACL reconstruction for these patients was 48% autograft, 49% allograft, and 3% combination. The independent variables of this model included gender, age, ethnicity, body mass index, smoking status, sport, activity level, previous graft, revision number, surgeon, surgeon's opinion of failure, previous technical aspects, etc. Surgeons were defined as those who contributed more than 15 patients during the enrollment period. . We calculated a propensity score for graft type based on the predicted probability of receiving an allograft from a logistic regression model. Propensity scores demonstrated that surgeon, prior graft choice, and patient age each had significant influence on which graft type was chosen for the revision ACL reconstruction (p  < 0.0001). The revising surgeon had the largest impact upon graft choice: ∼ 5 times that of the second-most important factor (prior graft). If the prior graft type was an autograft, then an allograft was 3.6 times more likely to be chosen for the revision. This current study demonstrates that the individual surgeon is ultimately the most important factor in revision ACL reconstruction graft choice. Additional statistically significant influences of graft choice included age, gender, previous graft choice, ACL revision number, concurrent medial collateral ligament/posteromedial repair, and opinion of the previous failure. This demonstrates that if graft choice is determined to impact outcome then surgeons have the ability to change and determine the graft utilized.

Level of Evidence Level II (prospective comparative study).

Keywords

ACL revision - propensity - graft choice - surgeon choice

^* The following authors were a part of the MARS Group: Rick W. Wright, MD, Washington University, St. Louis; Laura J. Huston, MS, Vanderbilt University; Amanda K. Haas, MA, Washington University, St. Louis; Kurt P. Spindler, MD, Cleveland Clinic; Christina R. Allen, MD, University of California, San Francisco; Allen F. Anderson, MD, Tennessee Orthopaedic Alliance; Daniel E. Cooper, MD, W.B. Carrell Memorial Clinic; Thomas M. DeBerardino, MD, University of Connecticut Health Center; Brett A. Lantz, MD, Slocum Research and Education Foundation; Michael J. Stuart, MD, Mayo Clinic Rochester; Elizabeth A. Garofoli, Washington University, St. Louis; John P. Albright, MD, University of Iowa Hospitals and Clinics; Annunziato (Ned) Amendola, MD, University of Iowa Hospitals and Clinics; Jack T. Andrish, MD, Cleveland Clinic; Christopher C. Annunziata, MD, Commonwealth Orthopaedics & Rehab; Robert A. Arciero, MD, University of Connecticut Health Center; Bernard R. Bach Jr, MD, Rush University Medical Center; Champ L. Baker, III, MD, The Hughston Clinic; Arthur R. Bartolozzi, MD, 3B Orthopaedics, University of Pennsylvania Health System; Keith M. Baumgarten, MD,Orthopedic Institute; Jeffery R. Bechler, MD, University Orthopedic Associates, LLC; Jeffrey H. Berg, MD, Town Center Orthopaedic Associates; GeoffreyA. Bernas, MD, State University of New York at Buffalo; Stephen F. Brockmeier, MD, University of Virginia; Robert H. Brophy, MD, Washington University, St. Louis; Charles A. Bush-Joseph, MD, Rush University Medical Center; J. Brad Butler, V, MD, Orthopedic and Fracture Clinic; John D. Campbell, MD, Bridger Orthopaedic and Sports Medicine; James L. Carey, MD, MPH, University of Pennsylvania; James E. Carpenter, MD, University of Michigan; Brian J. Cole, MD, Rush University Medical Center; Jonathan M. Cooper, DO, HealthPartners Specialty Clinic; Charles L. Cox, MD, MPH, Vanderbilt University; R. Alexander Creighton, MD, University of North Carolina Medical Center; Diane L. Dahm, MD, Mayo Clinic Rochester; Tal S. David, MD, Arthroscopic and Orthopedic Sports MedicineAssociates; David C. Flanigan, MD, The Ohio State University; Robert W. Frederick, MD, The Rothman Institute/ Thomas Jefferson University; Theodore J. Ganley, MD, Children ' s Hospital of Philadelphia; Charles J. Gatt, Jr., MD, University Orthopedic Associates, LLC; Steven R. Gecha, MD, Princeton Orthopaedic Associates; James Robert Giffin, MD, Fowler Kennedy Sports Medicine Clinic, University of Western Ontario; Sharon L. Hame, MD, David Geffen School of Medicine at UCLA; Jo A. Hannafin, MD, PhD, Hospital for Special Surgery; Christopher D. Harner, MD, University of Pittsburgh Medical Center; Norman Lindsay Harris, Jr., MD,Orthopaedic Associates of Aspen & Glenwood; Keith S. Hechtman, MD, UHZ Sports Medicine Institute; Elliott B. Hershman, MD,Lenox Hill Hospital; Rudolf G. Hoellrich, MD, Slocum Research and Education Foundation; Timothy M. Hosea, MD, University Orthopedic Associates, LLC; David C. Johnson, MD, National Sports Medicine Institute; Timothy S. Johnson, MD, National Sports Medicine Institute; Morgan H. Jones, MD, Cleveland Clinic; Christopher C. Kaeding, MD, The Ohio State University; Ganesh V. Kamath, MD, University of North Carolina Medical Center; Thomas E. Klootwyk, MD, Methodist Sports Medicine Center-The Orthopedic Specialists; Bruce A. Levy, MD, Mayo Clinic Rochester; C. Benjamin Ma, MD, University of California, San Francisco; G. Peter Maiers, II, MD, Methodist Sports Medicine Center-The Orthopedic Specialists; Robert G. Marx, MD, Hospital for Special Surgery; Matthew J. Matava, MD, Washington University, St. Louis; Gregory M. Mathien, MD, Knoxville Orthopedic Clinic; David R. McAllister, MD, David Geffen School of Medicine at UCLA; Eric C. McCarty, MD, University of Colorado Denver School of Medicine; Robert G. McCormack, MD, University of British Columbia; Bruce S. Miller, MD, MS, University of Michigan; Carl W. Nissen, MD, Connecticut Children ' s Medical Center; Daniel F. O ' Neill, MD, EdD, Littleton Regional Hospital; LTC Brett D. Owens, MD, Keller Army Community Hospital-United States Military Academy; Richard D. Parker, MD, Cleveland Clinic; Mark L. Purnell, MD, Orthopaedic Associates of Aspen & Glenwood; Arun J. Ramappa, MD, Beth Israel Deaconess Medical Center; Michael A. Rauh, MD, State University of New York at Buffalo; Arthur C. Rettig, MD, Methodist Sports Medicine Center-The Orthopedic Specialists; Jon K. Sekiya, MD, University of Michigan; Kevin G. Shea, MD, Intermountain Orthopedics; Orrin H. Sherman, MD, NYU Hospital for Joint Diseases; James R. Slauterbeck, MD, University of Vermont College of Medicine; Matthew V. Smith, MD, Washington University, St. Louis; Jeffrey T. Spang, MD, University of North Carolina Medical Center; LTC Steven J. Svoboda, MD, Keller Army Community Hospital-United States Military Academy; Timothy N. Taft, MD, University of North Carolina Medical Center; Col. Joachim J. Tenuta, MD, Keller Army Community Hospital-United States Military Academy; Edwin M. Tingstad, MD, Inland Orthopaedics/ Washington State University; Armando F. Vidal, MD, University of Colorado Denver School of Medicine; Darius G. Viskontas, MD, Royal Columbian Hospital; Richard A. White, MD, University of Missouri-Columbia; James S. Williams Jr, MD, Cleveland Clinic; Michelle L. Wolcott, MD, University of Colorado Denver School of Medicine; Brian R. Wolf, MD, University of Iowa Hospitals and Clinics; James J. York, MD, Chesapeake Orthopaedics & Sports Medicine Center; Warren R. Dunn, MD, MPH, University of Wisconsin.

• References

• 1 Wright RW, Dunn WR, Amendola A , et al; MOON Cohort. Anterior cruciate ligament revision reconstruction: two-year results from the MOON cohort. J Knee Surg 2007; 20 (4) 308-311
• 2 Wright RW, Gill CS, Chen L , et al. Outcome of revision anterior cruciate ligament reconstruction: a systematic review. J Bone Joint Surg Am 2012; 94 (6) 531-536
• 3 Wright RW, Huston LJ, Spindler KP , et al; MARS Group. Descriptive epidemiology of the Multicenter ACL Revision Study (MARS) cohort. Am J Sports Med 2010; 38 (10) 1979-1986
• 4 The MARS Group. Effect of graft choice on the outcome of revision anterior cruciate ligament reconstruction in the multicenter ACL revision study (MARS) cohort. Am J Sports Medicine 2014; 42 (10) 2301-2310
• 5 Austin PC. Type I error rates, coverage of confidence intervals, and variance estimation in propensity-score matched analyses. Int J Biostat 2009; 5 (1) 13
• 6 Rosenbaum PR, Rubin DB. The central role of the propensity score in observational studies for causal effects. Biometrika 1983; 70 (1) 41-55
• 7 Harrel FE. Regression Modeling Strategies. 2011; Available at: http://CRAN.R-project.org/package=rms
• 8 Team RDCR. A Language and Environment for Statistical Computing. 2010; Available at: http://www.R-project.org/
• 9 D'Agostino Jr RB. Propensity score methods for bias reduction in the comparison of a treatment to a non-randomized control group. Stat Med 1998; 17 (19) 2265-2281
• 10 Ertefaie A, Stephens DA. Comparing approaches to causal inference for longitudinal data: inverse probability weighting versus propensity scores. Int J Biostat 2010; 6 (2) 14
• 11 McCandless LC, Douglas IJ, Evans SJ, Smeeth L. Cutting feedback in Bayesian regression adjustment for the propensity score. Int J Biostat 2010; 6 (2) 16
• 12 Feng P, Zhou XH, Zou QM, Fan MY, Li XS. Generalized propensity score for estimating the average treatment effect of multiple treatments. Stat Med 2012; 31 (7) 681-697
• 13 Spindler KP, Kuhn JE, Freedman KB, Matthews CE, Dittus RS, Harrell Jr FE. Anterior cruciate ligament reconstruction autograft choice: bone-tendon-bone versus hamstring: does it really matter? A systematic review. Am J Sports Med 2004; 32 (8) 1986-1995
• 14 Kaeding CC, Aros B, Pedroza A , et al. Allograft versus autograft anterior cruciate ligament reconstruction: predictors of failure from a MOON Prospective Longitudinal Cohort. Sports Health 2011; 3 (1) 73-81