Page 42 - ISAKOS 2021 Newsletter Volume 1

CURRENT CONCEPTS
ACL Reconstruction 2020: A Worldwide Survey
The most common femoral drilling technique is via the anteromedial portal in both countries (89.8% in Sweden and 75% in the UK vs. 78.4% worldwide). In Sweden, BTB grafts are usually fixed with interference screws both in the femur (74.8% vs. 83% worldwide) and in the tibia (90.3% vs. 95% worldwide). The most common femoral fixation method for HT grafts is a cortical button (93.5% vs. 82% worldwide). No data on graft fixation are available from the UK.
Differences
Surgeon case volume varies considerably. In Sweden, compared with worldwide, there is a higher prevalence of low-volume surgeons (<25 ACLRs / year) (61.2% vs. 18.8%) and a lower prevalence of high-volume surgeons (>75 ACLRs / year) (6.1% vs. 29.7%). The UK data do not reflect reality because of the poor surgeon compliance, and the registry records only one surgeon who performed >60 ACLRs/year and a high prevalence (40.4%) of surgeons who performed ≤10 ACLRs/year.
In Sweden, the most common tibial fixation method for HT grafts is a cortical button (32.2% vs. 13% worldwide), followed by a screw post (22.8% vs. not reported worldwide). Other significant differences are the lower rate of graft presoaking in an antibiotic solution (23% in Sweden vs. 45.4% worldwide) and anterolateral augmentations performed in primary ACLR (0.6% in Sweden vs. 10% worldwide) and revision ACLR (6.8% in Sweden vs. 36% worldwide). No data on graft fixation, graft presoaking, and anterolateral augmentations are available from the UK.
Asia Consensus 2016
Asia is home to the largest population in the world, and the medical infrastructure is extremely diverse because of prevailing sociopolitical variations. This region does not have a sports surgery registry or an ACL study group, so data from the current survey will be compared with the results of the Asian Consensus Meeting of 20163. This is a major limitation in comparing the two datasets because a consensus meeting is likely to be less representational.
Similarities
The overwhelming favorite graft for primary ACLR was the hamstrings in the worldwide survey (mean, 64%), which was consistent with the Asian perspective. Allografts were used by very few surgeons in Asia, especially because of nonavailability in several countries. Femoral fixation of the hamstrings graft was achieved with use of a cortical button by 90% of respondents, and tibial fixation was achieved with use of a bioabsorbable screw by 90% of respondents, rates that are similar to those in the worldwide survey.
Differences
A major difference was the profile of participants in the current survey as compared with the previous consensus meeting. Of the 794 respondents in the worldwide survey, almost half (49.9%) reported that they have been performing ACL surgery for 6 to 15 years; however, only one-third (30.1%) of all respondents reported that they performed >75 ACL procedures per year. In contrast, the consensus group comprised 10 surgeons who reported performing high-volume knee arthroscopy for >15 years. While 85.7% of surgeons in the current survey reported that they perform anteromedial portal drilling for the femur, this rate was only 50% in the consensus paper. Respondents to the world survey reported that an extra-articular anterolateral augmentation procedure is performed in about 10% of primary ACLRs and 36% of revision ACLRs; in contrast, 67% of respondents in the Asian consensus group were in favor of an extra-articular procedure for grade-3 pivot and all were in favor of adding it to every revision ACLR. While only 55% of the respondents to the worldwide survey use bracing following ACLR, 100% of surgeons in the Asian consensus paper used bracing following ACLR. In the worldwide survey, return to play was allowed after a mean of 9 months, whereas the respondents in the Asian consensus group agreed only on an objective criterion, which was not time-bound.
South America: Argentina ACL Registry
In the ISAKOS survey, the response rate among South American surgeons was 77% (532 of 689). This is an encouraging result, particularly in light of the fact that there is no registry for the whole region and the fact that Argentina is the only South American country with a national registry. This voluntary web-based Argentinian ACL Registry was created in 2017 following the guidelines of the Scandinavian Registry. The survey has been modified for regional convenience. Between 2017 and 2019, 5,460 ACLRs were uploaded to the registry by 168 hospitals and clinics.
Similarities
The results regarding graft choice were similar in the Argentinian registry and the ISAKOS worldwide survey, with hamstrings autografts leading as the preferred graft (76% in Argentina vs. 64% worldwide), followed by BTB grafts (19% in Argentina vs. 21% worldwide). Regarding femoral tunnel drilling technique, the main choice by far was the use of anteromedial portal for both the Argentina registry (71.6%) and the ISAKOS survey (78%). Femoral fixation of hamstrings graft was achieved with a cortical button in 70.4% of cases in Argentina and in 82% of cases worldwide, followed by interferential screws in 27% and 8%, respectively. When BTB graft was chosen, both records showed 95% usage of interference screws (the Argentina registry does not record the type of screw used).
40 ISAKOS NEWSLETTER 2021: VOLUME I