Summary

A wide range of surgical technique preferences exist in ACL-R amongst members in the Herodicus Society, with higher volume surgeons more commonly performing single-stage revisions and utilizing primarily biometric testing to determine return to sports.

Abstract

Background

Anterior cruciate ligament reconstruction (ACL-R) is one of the most performed and widely researched procedures in orthopaedics. Research efforts have led to many advances in patient outcomes; yet many questions surrounding surgical technique remain unanswered, leading to a diversity in clinical practice. The Herodicus Society is a small society of orthopaedic sports medicine surgeons who are among the most experienced and well-respected in the field. The purpose of this study was (1) to describe current ACL-R practice preferences amongst members of the Herodicus society, and (2) to determine if these preferences are influenced by time in practice and surgical volume.

Methods

A survey invitation was distributed through email to all active Herodicus Society members. The survey was prepared using QualtricsXM services and consisted of 24 questions regarding their practice and preferred surgical technique. Participation was voluntary and replies were kept confidential. Descriptive statistics were computed using the responses. Additionally, survey responses were further subdivided by years of experience (threshold of 30 years) and overall ACL-R case volume (threshold of 100 ACL-R cases per year). Chi-squared testing was utilized to determine significance of experience and case volume on survey responses.

Results

Of the 113 invited Herodicus Society members, 69 members (61%) completed the survey. Among respondents, the average years in clinical practice was 30.9 years. Respondents performed an average of 96.0 primary and 21.6 revision ACL-R annually, with an average of 72.1% of revision cases performed single-stage. Average graft usage was bone-patellar-bone (BTB) autograft (57.6%), quadriceps autograft (14.6%), hamstring autograft (14.0%), and allograft (11.8%). A greater proportion of respondents preferred metal interference screw fixation for BTB grafts (51.5% for femoral and 43.9% tibial fixation), adjustable loop suspensory fixation for soft tissue graft fixation on the femur (44.8%), and bioabsorbable interference screw fixation for soft tissue graft fixation on the tibia (45.3%). Surgeons reported utilization of anterolateral augmentation “rarely” in primary ACL-R (39.1%) and “sometimes” in revision ACL-R (31.9%), with the majority performing lateral extraarticular tenodesis (LET) technique (67.7%) over anterolateral ligament reconstruction (14.7%). A greater proportion of surgeons reported performing primary ACL-R within 2-3 weeks of injury (38.2%), and they use a combination of time-based and biometric testing to determine return to play (53.6%). Higher volume surgeons reported performing single-stage revision ACL-R at significantly higher rate (79.8% versus 62.9%, p = 0.02) and were more likely to utilize primarily biometric return to sport testing rather than a combination of testing and time-based criteria (p = 0.01). No significant difference in responses was seen with years of experience.

Conclusion

A wide range of surgical technique preferences exist in ACL-R amongst members in the Herodicus Society. BTB autograft without anterolateral augmentation is the most frequent graft choice for a primary reconstruction. In the revision setting, single-stage reconstruction with possible addition of a LET is most common. Of the higher volume surgeons, 80% commonly perform single-stage revisions and 39% utilize primarily biometric testing to determine return to sports.