Skip to main content

Revision ACL reconstruction has higher incidence of 30-day hospital readmission, reoperation, and surgical complications relative to primary procedures

Abstract

Purpose

Although there has been substantial improvement in ACL reconstructive surgery, graft failure remains a devastating complication for some patients. Revision procedures are inherently more complex and technically challenging. The purpose of this study is to 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 using Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes between January 1, 2012 and December 31, 2017. Demographics, patient variables, and surgical variables were compared between primary and revision groups using Chi-squared tests. Logistic regression was used to identify independent risk factors for revision ACL reconstruction. Various 30-day outcome measures were compared between the primary and revision ACL reconstruction groups. Various measures of valuation—including total relative value units (RVU) and reimbursement per minute—were calculated and compared between the two groups.

Results

A total of 8292 patients—8135 primary and 157 revision procedures—were included in the final cohort. Higher 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 (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 (n.s.).

Conclusions

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, considering the increased operative time and complexity of such procedures.

Level of evidence

Level III.

This is a preview of subscription content, access via your institution.

Fig. 1

Data availability

The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used; herein, they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors. The datasets generated and/or analyzed during the current study are available in the ACS NSQIP Participant Use Data File repository, https://www.facs.org/quality-programs/acs-nsqip/participant-use.

References

  1. 1.

    Ahmed I, Salmon L, Roe J, Pinczewski L (2017) The long-term clinical and radiological outcomes in patients who suffer recurrent injuries to the anterior cruciate ligament after reconstruction. Bone Joint J 99:337–343

    Article  Google Scholar 

  2. 2.

    Beynnon BD, Johnson RJ, Fleming BC, Kannus P, Kaplan M, Samani J et al (2002) Anterior cruciate ligament replacement: comparison of bone-patellar tendon-bone grafts with two-strand hamstring grafts: a prospective, randomized study. JBJS 84:1503–1513

    Article  Google Scholar 

  3. 3.

    Boddapati V, Fu MC, Nwachukwu BU, Camp CL, Spiker AM, Williams RJ et al (2020) Procedure length is independently associated with overnight hospital stay and 30-day readmission following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 28:432–438

    Article  Google Scholar 

  4. 4.

    Boyle C, Pagoti R, Eng KH, McMahon SE, Nicholas R (2019) Revision ACL reconstruction with autograft: long-term functional outcomes and influencing factors. Eur J Orthop Surg Traumatol 29:157–161

    Article  Google Scholar 

  5. 5.

    Carolan D, King E, Richter C, Franklyn-Miller A, Moran R, Jackson M (2020) Differences in strength, patient-reported outcomes, and return-to-play rates between athletes with primary versus revision ACL reconstruction at 9 months after surgery. Orthop J Sports Med 8:2325967120950037

    Article  Google Scholar 

  6. 6.

    Condello V, Zdanowicz U, Di Matteo B, Spalding T, Gelber P, Adravanti P et al (2019) Allograft tendons are a safe and effective option for revision ACL reconstruction: a clinical review. Knee Surg Sports Traumatol Arthrosc 27:1771–1781

    CAS  Article  Google Scholar 

  7. 7.

    Feng JE, Anoushiravani AA, Schoof LH, Gabor JA, Padilla J, Slover J et al (2020) Barriers to revision total hip service lines: a surgeon’s perspective through a deterministic financial model. Clin Orthop Relat Res 478:1657–1666

    Article  Google Scholar 

  8. 8.

    Grassi A, Ardern CL, Muccioli GMM, Neri MP, Marcacci M, Zaffagnini S (2016) Does revision ACL reconstruction measure up to primary surgery? A meta-analysis comparing patient-reported and clinician-reported outcomes, and radiographic results. Br J Sports Med 50:716–724

    Article  Google Scholar 

  9. 9.

    Grassi A, Kim C, Muccioli GMM, Zaffagnini S, Amendola A (2017) What is the mid-term failure rate of revision ACL reconstruction? A systematic review. Clin Orthop Relat Res 475:2484–2499

    Article  Google Scholar 

  10. 10.

    Grassi A, Zicaro JP, Costa-Paz M, Samuelsson K, Wilson A, Zaffagnini S et al (2020) Good mid-term outcomes and low rates of residual rotatory laxity, complications and failures after revision anterior cruciate ligament reconstruction (ACL) and lateral extra-articular tenodesis (LET). Knee Surg Sports Traumatol Arthrosc 28:418–431

    Article  Google Scholar 

  11. 11.

    MARS Group (2019) Reoperation and failure rate at six years following revision ACL reconstruction: a MARS cohort study. Orthop J Sports Med 7:2325967119S2325900292

    Article  Google Scholar 

  12. 12.

    MARS Group, Wright RW (2019) Effect of graft choice on the 6 year outcome of revision anterior cruciate ligament reconstruction in the Multicenter ACL Revision Study (MARS) Cohort. Orthop J Sports Med 7:2325967119S2325900281

    Article  Google Scholar 

  13. 13.

    Hardy A, Casabianca L, Andrieu K, Baverel L, Noailles T (2017) Complications following harvesting of patellar tendon or hamstring tendon grafts for anterior cruciate ligament reconstruction: systematic review of literature. Orthop Traumatol Surg Res 103:S245–S248

    CAS  Article  Google Scholar 

  14. 14.

    Herzog MM, Marshall SW, Lund JL, Pate V, Mack CD, Spang JT (2018) Trends in incidence of ACL reconstruction and concomitant procedures among commercially insured individuals in the United States, 2002–2014. Sports Health 10:523–531

    Article  Google Scholar 

  15. 15.

    Maletis GB, Chen J, Inacio MC, Funahashi TT (2016) Age-related risk factors for revision anterior cruciate ligament reconstruction: a cohort study of 21,304 patients from the Kaiser Permanente anterior cruciate ligament registry. Am J Sports Med 44:331–336

    Article  Google Scholar 

  16. 16.

    Maletis GB, Inacio MC, Funahashi TT (2015) Risk factors associated with revision and contralateral anterior cruciate ligament reconstructions in the Kaiser Permanente ACLR registry. Am J Sports Med 43:641–647

    Article  Google Scholar 

  17. 17.

    Mayhew D, Mendonca V, Murthy B (2019) A review of ASA physical status–historical perspectives and modern developments. Anaesthesia 74:373–379

    CAS  Article  Google Scholar 

  18. 18.

    Orr RD, Sodhi N, Dalton SE, Khlopas A, Sultan AA, Chughtai M et al (2018) What provides a better value for your time? The use of relative value units to compare posterior segmental instrumentation of vertebral segments. Spine J 18:1727–1732

    Article  Google Scholar 

  19. 19.

    Peterson J, Sodhi N, Khlopas A, Piuzzi NS, Newman JM, Sultan AA et al (2018) A comparison of relative value units in primary versus revision total knee arthroplasty. J Arthroplasty 33:S39–S42

    Article  Google Scholar 

  20. 20.

    Redler A, Iorio R, Monaco E, Puglia F, Wolf MR, Mazza D et al (2018) Revision anterior cruciate ligament reconstruction with hamstrings and extra-articular tenodesis: a mid-to long-term clinical and radiological study. Arthroscopy 34:3204–3213

    Article  Google Scholar 

  21. 21.

    Sodhi N, Piuzzi NS, Khlopas A, Newman JM, Kryzak TJ, Stearns KL et al (2018) Are we appropriately compensated by relative value units for primary vs revision total hip arthroplasty? J Arthroplasty 33:340–344

    Article  Google Scholar 

  22. 22.

    Sodhi N, Yao B, Newman JM, Jawad M, Khlopas A, Sultan AA et al (2017) A comparison of relative value units in primary versus revision total ankle arthroplasty. Surg Technol Int 31:322–326

    PubMed  Google Scholar 

  23. 23.

    Zaffagnini S, Di Sarsina TR, Bonanzinga T, Nitri M, Macchiarola L, Stefanelli F et al (2018) Does donor age of nonirradiated Achilles tendon allograft influence mid-term results of revision ACL reconstruction? Joints 6:10

    Article  Google Scholar 

Download references

Funding

None.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Mark A. Plantz.

Ethics declarations

Conflict of interest

Marx: none; Plantz: none; Gerlach: none; Carney: none; Swiatek: none; Cantrell: none; Tjong: Smith & Nephew Consultant.

Ethical approval

Institutional Review Board approval was not required for this study, which utilized de-identified data from an available national surgical outcomes database. All data were deidentified prior to access and research was conducted according to ethical guidelines established at the participating institution.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Marx, J.S., Plantz, M.A., Gerlach, E.B. et al. Revision ACL reconstruction has higher incidence of 30-day hospital readmission, reoperation, and surgical complications relative to primary procedures. Knee Surg Sports Traumatol Arthrosc (2021). https://doi.org/10.1007/s00167-021-06646-0

Download citation