In terms of patients’ knowledge of their graft type, we found an overall accuracy of 77%, with 88% of autograft patients, 71% of allograft patients, and 11% of hybrid graft patients remembering their graft type and harvest location. Although we do not believe it to be critical for patients to remember these details, we do believe that patients who do not know their graft type likely relied on the recommendation of their physician.
We found a significant difference in the proportion of patients choosing autograft vs allograft based on surgeon, despite these surgeons citing available data in the literature to each patient and ultimately allowing each patient to make his or her own decision. This is partly due to the low sample size of most of the surgeons involved. However, the main reason for this distortion is likely that different surgeons may highlight different aspects of the literature to “spin” patients towards one graft or another in certain cases.
Currently, there remains a lack of clarity in the literature on appropriate ACL graft choices for patients. With constant new findings being published on different aspects of various grafts, it is important for surgeons to remain up to date with the literature. Nevertheless, we believe that certain biases are inevitable among surgeons due to unique training experiences as well as experience with their own patients.
Cohen and colleagues8 found that only 7% of patients reported that their own personal research influenced their decision, and only 6.4% of patients reported the media as their primary decision-making factor. Cheung and colleagues9 conducted a retrospective study and found that more than half of patients did significant personal research prior to making a decision regarding their graft type. Most of this research was done using medical websites and literature. Koh and colleagues10 noted that >80% of patients consulted the internet for graft information before making a decision. Koh’s study10 was performed in Korea and therefore the high prevalence of internet use may be culturally-related.
Overall, quality of information for patients undergoing ACL reconstruction is mixed across the internet, with only 22.5% of top websites being affiliated with an academic institution and 35.5% of websites authored by private physicians or physician groups.11 Although a majority of internet websites offer discussion into the condition and surgical procedure of ACL reconstruction, less than half of these websites share the equally important information on the eligibility for surgery and concomitant complications following surgery.11In our study, only 39 patients (13%) listed the media as either the first (13, 4%) or second (26, 9%) most important factor in their graft decision. Clearly there is some discrepancy between studies regarding the influence of personal research and media. There are a few potential reasons for this. First, we did not explicitly ask patients if their own personal research had any influence on their graft decision. Rather, we asked patients to rank their decision-making factors, and few patients ranked the media as their first or second greatest influence. Second, the word “media” was used in our questionnaire rather than “online research” or “internet.” It may seem somewhat vague to patients what the word “media” really means in terms of their own research, whereas listing “online research” or “internet” as selection options may have influenced patient responses.
In our study, we asked patients for any additional factors that influenced their graft choice. Thirteen patients (4%) noted that “personal research” through internet, orthopaedic literature, and the media influenced their graft decision. This corroborates the idea that “media” may have seemed vague to some patients. Of these patients, 9 chose an autograft and 4 chose an allograft. The relative ease in accessing information regarding graft choice in ACL reconstruction should be noted. Numerous websites offer advice, graft options, and commentary from group practices and orthopaedic surgeons. Whether or not these sources provide reasonable support for one graft vs another graft remains to be answered. The physician should be responsible for providing the patient with this collected objective information.
In our study, 205 patients (96%) were satisfied with their graft choice at the time of follow-up, with 15 patients (7%) stating that they would have chosen a different graft type if they could redo the operation. Cheung and colleagues9 found a satisfaction rate of 87.4% at an average follow-up time of 19 months, with 4.6% stating they would have chosen a different graft type. Many factors can contribute to patient satisfaction after ACL reconstruction. Looking at patient variables such as age, demographics, occupation, activity level, surgical technique including tunnel placement and fixation, postoperative rehabilitation, and graft type may influence the success of the patient after ACL reconstruction.