Pullen W Michael, Bryant Brandon, Gaskill Trevor, Sicignano Nicholas, Evans Amber M, DeMaio Marlene
Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA.
Department of Orthopaedic Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
Am J Sports Med. 2016 Dec;44(12):3140-3145. doi: 10.1177/0363546516660062. Epub 2016 Aug 12.
Arthroscopically assisted anterior cruciate ligament (ACL) reconstruction is a common orthopaedic procedure. Graft failure after reconstruction remains a devastating complication, often requiring revision surgery and less aggressive or modified rehabilitation. Worse functional and patient-reported outcomes are reported compared with primary reconstruction. Moreover, both rates and risk factors for revision are variable and inconsistent within the literature.
To determine the rate of revision surgery after ACL reconstruction in a large cohort of patients, to assess the influence of patient characteristics on the odds of revision, and to compare revision rates between active-duty military members and non-active-duty beneficiaries.
Descriptive epidemiology study.
Using administrative data from the Military Health System, a retrospective study was designed to characterize the rate of ACL revision surgery among patients treated within a military facility. All patients ≥18 years at the time of ACL reconstruction were identified using the American Medical Association Current Procedural Terminology (CPT) for ACL reconstruction (CPT code 29888) over 7 years (2005-2011). Revision ACL reconstructions were identified as having ≥2 ACL reconstruction procedure codes on the ipsilateral knee at least 90 days apart. Univariate analysis was performed to calculate odds ratios (ORs) for demographic, perioperative medication use, and concomitant procedure-related risk factors. A multivariate logistic regression model determined risk covariates in the active-duty cohort.
The study population consisted of 17,164 ACL reconstructions performed among 16,336 patients, of whom 83.3% were male with a mean ± SD age of 28.9 ± 7.6 years for the nonrevision group, and was predominantly active duty (89.2%). Patients undergoing ACL reconstruction on both knees only contributed their index knee for analyses. There were 587 patients who underwent revision surgery, corresponding to an overall revision rate of 3.6%. The median time from the index surgery to revision surgery was 500 days (interquartile range, 102-2406 days). Revision rates were higher in the active-duty cohort as compared with non-active-duty beneficiaries (3.8% vs 1.8%, respectively; OR, 2.14; 95% CI, 1.49-3.07). Based on multivariate logistic regression in the active-duty cohort, age ≥35 years (OR, 0.44; 95% CI, 0.33-0.58) and concomitant meniscal repair (OR, 0.69; 95% CI, 0.53-0.91) were found to be protective with regard to the odds of revision surgery. Perioperative medication use of nonsteroidal anti-inflammatory drugs (NSAIDs) (OR, 1.33; 95% CI, 1.12-1.58; number needed to harm [NNH], 100) and COX-2 inhibitors (OR, 1.31; 95% CI, 1.04-1.66; NNH, 333) was associated with increased odds of revision surgery. No significant findings were detected among sex, race, nicotine use, body mass index, or other concomitant procedures of interest.
In this large cohort study, the rate of revision ACL reconstruction was 3.6%, which is consistent with the existing literature. Increased odds of revision surgery among active-duty personnel were associated with the perioperative use of NSAIDs and COX-2 inhibitors. Age ≥35 years and concomitant meniscal repair were found to be protective against ACL revision.
关节镜辅助下前交叉韧带（ACL）重建是一种常见的骨科手术。重建后移植物失败仍然是一种极具破坏性的并发症，通常需要翻修手术以及不太积极或改良的康复治疗。与初次重建相比，功能和患者报告的结果更差。此外，文献中翻修的发生率和危险因素各不相同且不一致。
确定一大群患者ACL重建后的翻修手术率，评估患者特征对翻修几率的影响，并比较现役军人和非现役受益人的翻修率。
描述性流行病学研究。
利用军事卫生系统的管理数据，设计了一项回顾性研究，以描述军事设施内接受治疗的患者中ACL翻修手术的发生率。使用美国医学协会现行手术术语（CPT）中关于ACL重建的代码（CPT代码29888），在7年（2005 - 2011年）内识别出所有在ACL重建时年龄≥18岁的患者。翻修ACL重建被确定为同侧膝关节至少间隔90天有≥2个ACL重建手术代码。进行单因素分析以计算人口统计学、围手术期药物使用和相关手术相关危险因素的比值比（OR）。多因素逻辑回归模型确定现役队列中的风险协变量。
研究人群包括在16336名患者中进行的17164例ACL重建，其中非翻修组83.3%为男性，平均年龄±标准差为28.9±7.6岁，且主要为现役军人（89.2%）。双膝进行ACL重建的患者仅将其首次手术的膝关节纳入分析。有587名患者接受了翻修手术，总体翻修率为3.6%。从初次手术到翻修手术的中位时间为500天（四分位间距，102 - 2406天）。与非现役受益人相比，现役队列中的翻修率更高（分别为3.8%和1.8%；OR，2.14；95%CI，1.49 - 3.07）。基于现役队列的多因素逻辑回归，年龄≥35岁（OR，0.44；95%CI，0.33 - 0.58）和半月板修复（OR，0.69；95%CI，0.53 - 0.91）被发现对翻修手术几率有保护作用。围手术期使用非甾体抗炎药（NSAIDs）（OR，1.33；95%CI，1.12 - 1.58；伤害所需人数[NNH]，100）和COX - 2抑制剂（OR，1.31；95%CI，1.04 - 1.66；NNH，333）与翻修手术几率增加相关。在性别、种族、吸烟、体重指数或其他感兴趣的相关手术中未发现显著结果。
在这项大型队列研究中，ACL重建的翻修率为3.6%，与现有文献一致。现役人员翻修手术几率增加与围手术期使用NSAIDs和COX - 2抑制剂有关。发现年龄≥35岁和半月板修复对ACL翻修有保护作用。
