Anterior cruciate ligament (ACL) injuries affect >175,000 people each year,1 with >100,000 Americans undergoing ACL reconstruction annually.2 Due to the high impact this injury has on the general population, and especially on athletes, it is important to determine the factors that influence a patient’s selection of a particular graft type. With increasing access to information and other outside influences, surgeons should attempt to provide as much objective information as possible in order to allow patients to make appropriate informed decisions regarding their graft choice for ACL surgery.
While autografts are used in >60% of primary ACL reconstructions, allografts are used in >80% of revision procedures.3 Both autografts and allografts offer advantages and disadvantages, and the advantages of each may depend on patient age, activity level, and occupation.4 For example, graft rerupture rates have been shown to be higher in patients with ACL allografts4, while kneeling pain has been shown to be worse in patients with bone-patellar tendon-bone (BPTB) autografts compared to hamstring autografts5 as well as BPTB allografts.4
Patient satisfaction rates are high for ACL autografts and allografts. Boonriong and Kietsiriroje6 have shown visual analog scale (VAS) patient satisfaction score averages to be 88 out of 100 for BPTB autografts and 93 out of 100 for hamstring tendon autografts. Fox and colleagues7 showed that 87% of patients were completely or mostly satisfied following revision ACL reconstruction with patellar tendon allograft. Cohen and colleagues8 evaluated 240 patients undergoing primary ACL reconstruction; 63.3% underwent ACL reconstruction with an allograft and 35.4% with an autograft. Of all patients enrolled in the study, 93% were satisfied with their graft choice, with 12.7% of patients opting to choose another graft if in the same situation again. Of those patients, 63.3% would have switched from an autograft to allograft. Although these numbers represent high patient satisfaction following a variety of ACL graft types, it is important to continue to identify graft selection factors in order to maximize patient outcomes.
The purposes of this prospective study were to assess patients’ knowledge of their graft type used for ACL reconstruction, to determine the most influential factors involved in graft selection, and to determine the level of satisfaction with the graft of choice at a minimum of 1-year follow-up. Based on a previous retrospective study,8 we hypothesized that physician recommendation would be the most influential factor in ACL graft selection. We also hypothesized that patients receiving an autograft would be more accurate in stating their graft harvest location compared to allograft patients.
Materials and Methods
We prospectively enrolled 304 patients who underwent primary ACL reconstruction from January 2008 to September 2013. Surgery was performed by 9 different surgeons within the same practice. All patients undergoing primary ACL reconstruction were eligible for the study.
All surgeons explained to each patient the pros and cons of each graft choice based upon peer-reviewed literature. Each patient was allowed to choose autograft or allograft, although most of the surgeons strongly encourage patients under age 25 years to choose autograft. One of the surgeons specifically encourages a patellar tendon autograft in patients under age 30 to 35 years, except for those patients with a narrow patellar tendon on magnetic resonance imaging, in which case he recommends a hamstring autograft. Another surgeon also specifically encourages patellar tendon autograft in patients under 35 years, except in skeletally immature patients, for whom he encourages hamstring autograft. However, none of the surgeons prohibited patients from choosing autograft or allograft, regardless of age.
The Institutional Review Board at our institution provided approval for this study. At the first postoperative follow-up appointment, each patient completed a questionnaire asking to select from a list the type (“your own” or “a cadaver”) and harvest site of the graft that was used for the surgery. Patients were also asked how they decided upon that graft type by ranking a list of 4 factors from 1 to 4. These included (1) physician recommendation, (2) family/friend’s recommendation, (3) coach’s recommendation, and (4) the media. Patients had the option of ranking more than one factor as most important in their decision. In addition, patients were asked to list any other factors that influenced their decision regarding graft type.
At a minimum of 1 year following surgery, patients completed the same questionnaire described above. In addition, patients were asked if they were satisfied with their graft and whether they would choose the same graft type if undergoing ACL reconstruction again. Patients who would have chosen a different graft were asked which graft they would have chosen and why. Any patient who experienced graft rupture prior to follow-up was included in the analysis.