Summary

The purpose of this study is to identify risk factors for revision ACL surgery, determine the incidence of short-term complications after these procedures, and to compare trends in operative length, relative valuation, and reimbursement after primary versus revision ACL reconstruction.

Abstract

Introduction

Although there has been substantial improvement in ACL reconstructive surgery, graft failure remains a devastating complication for some patients. Furthermore, revision procedures are inherently more complex and technically challenging. The purpose of this study is to identify risk factors for revision ACL surgery, determine the incidence of short-term complications after these procedures, and to compare trends in operative length, relative valuation, and reimbursement after primary versus revision ACL reconstruction.

Methods

Primary and revision arthroscopic ACL reconstruction cases were identified on the American College of Surgeons’ NSQIP database between January 1, 2012 and December 31, 2017 using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes. Any cases with concurrent procedures, such as partial meniscectomy, meniscal repair, or other ligament reconstructive procedures, were excluded from the final analysis. Demographics, patient variables, and surgical variables were compared between primary and revision groups using Chi-squared tests. Additionally, the incidence of various 30-day outcome measures, including unplanned readmission, reoperation, non-home discharge, mortality, medical complications, and surgical complications, were compared between the primary and revision groups using Chi-squared tests. Multivariate logistic regression was used to identify independent risk factors for revision ACL reconstruction. Various measures of valuation – including total relative value units (RVU), total reimbursement, and reimbursement per minute – were calculated and compared between the two groups.

Results

A total of 8,292 patients were included in the final cohort (8,135 primary and 157 revision procedures). Higher American Society of Anesthesiologist (ASA) scores were associated with revision ACL reconstructions. Patients undergoing revision procedures were less likely to have an ASA score of 1 (p<0.001) and more likely to have an ASA score of 2 (p=0.004) or 3 (p=0.020). Revision ACL reconstruction was associated with higher rates of poor 30-day outcome measures, including unplanned readmission (p=0.029), reoperation within 30 days (p=0.012), return to the OR (p=0.012), and surgical complications (p=0.021). The total RVUs and reimbursement for revision procedures were significantly greater than those for primary procedures (p<0.001). However, when accounting for operative time, the RVU/minute and reimbursement/minute were similar between the two groups (p=0.899).

Conclusion

Relative to primary ACL reconstruction, revision ACL procedures are associated with worse short-term outcomes, including unplanned readmission, reoperation, return to the OR, and surgical complications. A greater ASA score was independently predictive of revision ACL surgery. The current RVU system undervalues revision ACL procedures when accounting for the increased operative time and complexity of such procedures.