Statistical Analysis
Chi square tests were used to compare dichotomous outcomes. A type I error of less than 5% (P < .05) was considered statistically significant.
Results
At least 1 year following ACL reconstruction, 213 of 304 patients (70%) successfully completed the same questionnaire as they did at their first postoperative follow-up appointment. The mean age of these patients at the time of surgery was 31.9 ± 11.0 years (range, 13.9 to 58.0 years). The mean follow-up time was 1.4 ± 0.4 years (range, 1.0 to 2.6 years), and 59% of these patients were male.
Autografts were used for 139 patients (139/304, 46%), allografts for 156 patients (156/304, 51%), and hybrid grafts for 9 patients (9/304, 3%). Overall, 77% of patients were accurate in stating the type of graft used for their ACL reconstruction, including 88% of autograft patients, 71% of allograft patients, and 11% of hybrid graft patients (Table 1). Patients who underwent reconstruction with an autograft were significantly more accurate in stating their graft type compared to patients with an allograft (P < .001). Graft type by surgeon is shown in Table 2. A statistically significant difference was found in the proportion of patients choosing autograft versus allograft based on surgeon (P < .0001).
When asked which type of graft was used for their surgery, 12 of 304 patients (4%) did not know their graft type or harvest location. Twenty-nine patients stated that their graft was an allograft but did not know the harvest location. Five patients stated that their graft was an autograft but did not know the harvest location. The 34 patients who classified their choice of graft but did not know the harvest site (11%) stated their surgeon never told them where their graft was from or they did not remember. A complete list of graft type responses is shown in Table 3.
Of the 29 patients who stated that their graft was an allograft but did not know the harvest location, 19 (66%) had a tibialis anterior allograft, 7 (24%) had a BPTB allograft, 2 (7%) had an Achilles tendon allograft, and 1 (3%) had a tibialis anterior autograft.
Physician recommendation was the most important decision-making factor listed for 82% of patients at their first postoperative appointment (Table 4). In addition to the 4 factors listed on our survey, patients were allowed to write in other factors involved in their decision. The most popular answers included recovery time, personal research on graft types, and prior personal experience with ACL reconstruction on the contralateral knee.
At the time of 1-year follow-up, 205 of 213 patients (96%) said they were satisfied with their graft choice (Table 5). All 4 unsatisfied autograft patients received a hamstring autograft, 3 of which were performed by the same surgeon. No significant difference was found in satisfaction rates between patients with autograft vs allograft (P = .87). There was a higher satisfaction rate among patients with a BPTB autograft compared to those with a hamstring autograft (P = .043). Of the unsatisfied patients, 3 patients stated that their graft had failed in the time prior to follow-up and 2 patients stated that they were having donor site pain following surgery with hamstring autograft and would consider an allograft if the reconstruction were repeated (Table 6). Two patients stated that they were unsatisfied with their graft but would need to do more research before deciding on a different graft type.
As shown in Tables 5 and 6, there is a discrepancy between the number of patients who were unsatisfied with their graft and the number of patients who stated that they would switch to a different graft type if they were to have ACL reconstruction again. A number of patients stated that they were satisfied with their graft, yet they would switch to a different graft. The main reasons for this related to issues from a hamstring autograft harvest site. One patient noted that although she was satisfied with her graft, she would switch after doing further research.
Discussion
Determining the decision-making factors for patients choosing between graft types for ACL reconstruction is important to ensure that patients can make a decision based on objective information. Several previous studies have evaluated patient selection of ACL grafts.8-10 All 3 of these studies showed that surgeon recommendation is the primary factor in a patient’s decision. Similar to previous studies, we also found that physician recommendation is the most influential factor involved in this decision.
At an average follow-up of 41 months, Cohen and colleagues8 found that 1.3% of patients did not know whether they received an autograft or allograft for their ACL reconstruction. Furthermore, 50.7% of patients stating they received an allograft in Cohen’s study8 were unsure of the harvest location. In our study, 4% of patients at their first postoperative visit did not know whether they had received an autograft or allograft and 10% of patients stating they received an allograft selected an unknown harvest site. In contrast, only 2% of autograft patients in our study were unsure of the harvest location at their first postoperative appointment. It is likely that, over time, patients with an allograft forget the harvest location, whereas autograft patients are more likely to remember the location of harvest. This is especially true in patients with anterior knee pain or hamstring pain following ACL reconstruction with a BPTB or hamstring tendon autograft, respectively.