• Hip & Knee Conditions Clinical Trials
• Orthopaedic Procedures

• Orthopaedics
• Hip & Knee Conditions
• Orthopaedics Clinical Trials
• Orthopaedic Procedures

Inferior outcomes are often noted following revision anterior cruciate ligament reconstruction (ACLR) compared with primary ACLR. This finding is supported by a consensus of ∼ 90 authors in the Multicenter ACL Revision Study (MARS) Group, as well as a number of studies [Wright RW et al. J Bone Joint Surg Am 2012; Wright R et al. J Knee Surg 2011; Spindler KP et al. J Bone Joint Surg Am 2005].

Previous studies have demonstrated that the odds of graft rupture following allograft primary reconstruction are four times higher than reconstructions employing autografts [Kaeding CC et al. Sports Health 2011]. In addition, for each 10-year decrease in age, the odds of graft rupture increase by 2.3 times. Whether this was true with revision reconstructions was unknown.

The MARS Group gathered a mix of > 80 US academic and private surgeons at 52 sites to compare patient outcomes after ACLR with autografts versus allografts. Autografts, more than allografts, improved sports outcomes and decreased rerupture rate, but had no impact on subsequent reoperation rate. No outcome differences were seen between soft tissue and bone-patella tendon-bone (BTB) grafts for either type of graft.

Patient reported outcomes (PRO) using standardized patient questionnaires and surgeon questionnaires were employed in the study [NCT00625885]. Multivariable regression models were utilized to examine the independent variables. The study employed the Musculoskeletal Transplant Foundation's approach using The Vanguard Method. The purpose of the study was to determine if the use autograft versus allograft affected sports function, re-rupture rates, and reoperation rates. In addition, a comparison was made between soft tissue and BTB grafts within the autograft and allograft groups.

There were 1205 subjects (697 males and 508 females) enrolled; median age was 26 years (range, 12 to 63). At the 2-year follow-up, 82% of patients had responded to the questionnaire and 92% had responded via a phone interview. The International Knee Documentation Committee scores improved with autograft reconstruction (Table 1). The Knee Injury and Osteoarthritis Outcome Score for the Sports and Recreation and Quality of Life subscales were significantly improved with the use of autografts as compared with allografts. Activities of Daily Living and Symptom scores were not predicted by graft choice. Marx activity level improved with an autograft plus allograft combination graft in 31 patients.

Overall, autografts, more than allografts, improved sports outcomes and decreased the re-rupture rate but had no impact on subsequent reoperation rate. No outcome differences were seen between soft tissue and BTB grafts for either type of graft. Re-rupture occurred in 37 of 1112 patients (3.3%; 12 autografts, 24 allografts, and 1 combination graft). Re-rupture was 2.78 times less likely to occur in patients who received autografts (95% CI, 1.01 to 7.69; p = .047). Re-rupture rates were not different between BTB versus soft tissue when using either autograft or allograft.

At 2 years, 150 of 1112 patients (13.5%) having revision ACLR underwent re-operation. Graft choice did not predict the need for re-operation. For those experiencing a third revision, patients were 4.7 times more likely to require re-operation (95% CI, 1.34 to 16.4; p = .016).

These findings are strengthened by the large study size that allowed modeling to control for a high number of variables and the use of PRO questionnaires and phone call follow-ups that avoided attrition bias. A longer-term study is needed with future onsite follow-ups of a nested cohort. The surgeon is the number one driving force to determine graft choice, surpassing previous graft type, patient age, sport, or revision number (MARS unpublished data). Improved outcomes can occur if surgeons are educated on graft choice.

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