Page 41 - ISAKOS 2021 Newsletter Volume 1

Quadriceps tendon is currently only used in 2% of NZ cases, compared with 6% worldwide, but recently there has been significantly increased use of this type of graft, reflecting the worldwide trend. Allograft is used in <1% of procedures in NZ, compared with 4% worldwide. Transportal femoral drilling technique is predominant (72.3% in NZ vs. 78.4% worldwide), with almost the same proportion utilizing a transtibial approach (10.3% vs. 11%). The worldwide survey indicated that 10.5% of surgeons use a retrodrill-type technique, and while this technique is used in only 1.1% of NZ cases, a significant proportion (16%) of surgeons in NZ have not described their technique, which may account for this discrepancy.
Differences
There are several differences between the NZ data and the worldwide survey. The first difference is in surgeon case volume. Worldwide there is a fairly even spread between low, medium, and high-volume ACL surgeons, whereas in NZ there is a definite preponderance toward a larger number of low-volume surgeons, with approximately 8 of 10 ACLRs being performed by surgeons who do <25 cases annually and over half being performed by surgeons who do <10 cases annually. Another significant difference is that antibiotic graft soaking is used in only 8.5% of ACLRs in NZ, compared with more than half of the cases in the worldwide survey. Tibial fixation for hamstring grafts differed significantly as interference screw fixation was predominant in the worldwide survey (77% [62% bioabsorbable + 15% metallic screws]), whereas cortical suspensory fixation was used in over half (54%) of NZ cases. Another striking feature is the regional difference in the type of screw used; worldwide there is fairly even split between metal and bioabsorbable screws for BTB grafts, whereas in NZ there is extremely low use of bioabsorbable screws (used in only 1% and 2.5% of cases on the femoral and tibial sides, respectively, compared with 73% and 85% for metal screws in the same locations).
North America ACL Study Group Survey
In January 2020, the most recent International ACL Study Group survey was distributed to the membership ahead of the biennial meeting in Kitzbühel, Austria. The survey consisted of 87 questions and 16 categories, addressing common practices relating to ACL injury and surgery. A total of 140 responses were received, 38 (27%) of which were from North American surgeons; those responses are the focus of this section. Care must be taken when interpreting these data as opposed to national registry data as the group consisted of high-volume subspecialists in knee ligament surgery.
Similarities
There are a few similarities between North American surgeons and the rest of the world. The majority of surgeons use anteromedial portal drilling for the femoral tunnel (53.13% for North America, compared with 78.4% worldwide).The majority of surgeons around the world (55%) and in North America (74.19%) use postoperative bracing for ACLR. Additionally, the majority of surgeons worldwide do not routinely add extra-articular procedures during primary (10%) or revision (36%) ACLR. Most North American surgeons (84%) never or rarely use lateral tenodesis for primary ACLR, whereas 48% sometimes or often utilize lateral tenodesis for revision ACLR.
Differences
Graft choice for primary ACLR is a large difference between North American surgeons and the world. The most popular graft in North America is BTB autograft (59.38% in North America vs. 21% worldwide). The second most popular graft choice is hamstrings autograft (25% in North America vs. 64% worldwide). The transtibial technique was twice as common among North American surgeons compared with worldwide (25% vs 11%). The majority of North American surgeons (51.6%) allow return to play after 6 months, whereas the most popular answer in the worldwide survey was 9 months.
Sweden and UK National Ligament Registries
The Swedish National Knee Ligament Registry (SNKLR) (established in 2005) has two sections: (1) a section in which surgeons report baseline and surgical data and (2) a section in which patients report PROMs preoperatively and at 1, 2, 5, and 10 years after surgery. From 2005 to 2019, 49,095 primary ACLRs were registered. Currently, surgeon compliance in reporting baseline and surgical data is excellent, with >90% of ACLRs registered.
The UK National Ligament Registry (UKNLR) (established 2013) requires contributions from both surgeon (baseline and surgical data) and patient (PROMs preoperatively and 6 months as well as 1, 2, and 5 years postoperatively). From December 1, 2012 to December 31, 2019, 11,861 primary ACLRs were registered. Sadly, surgeon compliance is low (<10%). For comparison to the present survey, surgical data from the year 2019 were extracted from both registries (including 3,951 primary ACLRs from the SNKLR and 1,856 from the UKNLR).
Similarities
In both countries, hamstrings tendon (HT) autograft is the most commonly used type of graft (84.9% in Sweden and 90% in the UK vs. 64% worldwide), followed by BTB graft (7.5% in Sweden and 9% in the UK vs. 21% worldwide). Quadriceps tendon usage in Sweden (6%) is comparable with that worldwide (5.6%). Allograft is used in 0.8% and 1% of Swedish and UK reconstructions, respectively, compared with 4% worldwide.
CURRENT CONCEPTS
ISAKOS NEWSLETTER 2021: VOLUME I 39