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Low annual hospital volume of anterior cruciate ligament reconstruction is not associated with higher revision rates

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Surgery performed in low-volume centres has been associated with longer operating time, longer hospital stays, lower functional outcomes, and higher rates of revision surgery, complications and mortality. This has been reported consistently in the arthroplasty literature, but there is a paucity of data regarding the relationship between surgical volume and outcome following anterior cruciate ligament (ACL) reconstruction. The purpose was to compare ACL reconstruction failure rates between hospitals performing different annual surgical volumes.

Methods

All patients from the Norwegian Knee Ligament Register having primary autograft ACL reconstruction between 2004 and 2016 were included. Hospital volume was divided into quintiles based on the number of ACL reconstructions performed annually, defined arbitrarily as: 1–12 (V1), 13–24 (V2), 25–49 (V3), 50–99 (V4) and ≥ 100 (V5) annual procedures. Kaplan–Meier estimated survival curves and survival percentages were calculated with revision ACL reconstruction as the end point. Secondary outcome measures included (1) mean change in Knee Injury and Osteoarthritis Outcome Score (KOOS) Quality of Life (QoL) and Sport subsections from pre-operative to 5-year follow-up and (2) subjective failure defined as KOOS QoL < 44.

Results

Twenty thousand eight hundred and fifty patients met the inclusion criteria and 1195 (5.7%) underwent subsequent revision ACL reconstruction over the study period. Revision rates were lower in the lower volume hospitals compared with the higher volume hospitals (p < 0.001). There was no clinically significant difference in improvement between pre-operative and 5-year follow-up KOOS scores between hospital volume categories, but a higher proportion of patients having surgery at lower volume hospitals reported a subjective failure. Patients in the lower volume categories (V1-3) were more often male and older compared to the higher volume hospitals (V4-5). Concomitant meniscal injuries and participation in pivoting sports were most common in V5 compared with V1 (p < 0.001). Median operative time decreased as hospital volume increased, ranging from 90 min at V1 hospitals to 56 min at V5 hospitals (p < 0.001).

Conclusion

Patients having ACL reconstruction at lower volume hospitals had a lower rate of subsequent revision surgery relative to higher volume hospitals. However, complications occurred more frequently, operative duration was longer, and the number of patients reporting a subjective failure of ACL reconstruction was highest at these lower volume hospitals.

Level of evidence

Level III

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA

    R. Kyle Martin

  2. Department of Orthopaedic Surgery, University of Minnesota, 1900 CentraCare Circle, Saint Cloud, MN, 56303, USA

    R. Kyle Martin

  3. Oslo Sports Trauma Research Center, Norwegian School of Sports Sciences, Oslo, Norway

    Andreas Persson, Gilbert Moatshe, Lars Engebretsen & Håvard Visnes

  4. Department of Orthopedic Surgery, Martina Hansens Hospital, Baerum, Norway

    Andreas Persson

  5. Norwegian National Knee Ligament Register, Haukeland University Hospital, Bergen, Norway

    Andreas Persson, Anne Marie Fenstad, Jon Olav Drogset & Håvard Visnes

  6. Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway

    Gilbert Moatshe & Lars Engebretsen

  7. Department of Orthopaedic Surgery, Trondheim University Hospital, Trondheim, Norway

    Jon Olav Drogset

  8. Department of Orthopaedics, Sorlandet Hospital Kristiansand, Kristiansand, Norway

    Håvard Visnes

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Correspondence to R. Kyle Martin.

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Ethical approval

All patients participating in the Norwegian Knee Ligament Register (NKLR) have provided informed consent. Based on this consent, the NKLR her permission from the Norwegian Data Inspectorate to collect, analyze, and publish on health data. The registration of data and the present study were performed confidentially and according to Norwegian and EU data protection rules, with all data de-identified prior to retrieval from the NKLR. The Regional Ethics Committee (REK) has previously determined that it is not necessary to obtain further ethical approval for Norwegian register-based studies.

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Martin, R.K., Persson, A., Moatshe, G. et al. Low annual hospital volume of anterior cruciate ligament reconstruction is not associated with higher revision rates. Knee Surg Sports Traumatol Arthrosc 30, 1575–1583 (2022). https://doi.org/10.1007/s00167-021-06655-z

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