Perspective

Patient race, ethnicity may predict revision risk of ACL reconstruction

Larger datasets are needed to confirm race/ethnicity differences.

Asian, Hispanic and black patients who underwent ACL reconstruction had a similar or lower risk of undergoing elective ACL revision compared with white patients. In results of this published study, white patients had the lowest unadjusted revision-free survival over time.

In a retrospective cohort study, Ronald A. Navarro, MD, regional chief of orthopedic surgery for Southern California Permanente Medical Group, and colleagues used multivariable Cox proportional-hazard models to evaluate the association between race/ethnicity and revision risk among 27,258 patients who underwent ACL reconstruction from 2008 to 2015.

Differences between race, ethnicity

Ronald A. Navarro

Researchers categorized race/ethnicity as non-Hispanic white (49.8%), black (8.3%), Hispanic (28.3%) and Asian (13.7%), and adjusted for age, sex, highest educational attainment, annual household income, graft type and geographic region in which the ACL reconstruction was performed.

Results showed the lowest unadjusted revision-free survival over time among white patients, with the cumulative probability of revision highest for white patients followed by Hispanic, black and Asian patients at 5 years postoperatively. When adjusted for potential confounders, researchers found a lower risk of undergoing revision surgery among Asian and Hispanic patients vs. white patients. Although revision risk did not differ between black and white patients before 3.5 years after primary ACL reconstruction, results showed black patients had a lower risk of undergoing revision surgery after 3.5 years.

“It is surprising that we find the non-white population would have a lower risk, but a revision for an ACL reconstruction is largely a choice,” Navarro told Orthopedics Today. “It is only the most unstable knees that would probably have to be revised without regard to choice, but a lot of people just cope with a loose knee. Because our endpoint was a revision surgery, we do not know how many patients are walking around out there with a potentially failed ACL and have chosen not to revise it.”

Larger datasets needed

According to Navarro, future research should focus on why there is a difference in revision rates among different races/ethnicities and whether such differences are due to coping, socioeconomic status or there are, in fact, biologic differences. Larger datasets with more specific race and ethnicity designations are needed to confirm these differences between race/ethnicity exist, he said.

“It would be nice to do a population health study asking why [patients] chose not to undergo revision,” Navarro said. “That would be a big contribution to the ACL injury and reconstruction literature, to know why certain people choose not to go back to get their re- reconstruction done in a way that is more patient survey based. That type of study would not be about the kinematics or the stability of the knee, but more about patient notions as to why they would choose to get another surgery because it is an elective surgical revision for a failed ACL reconstruction,” he said. – by Casey Tingle

Disclosure: Navarro reports no relevant financial disclosures.

Asian, Hispanic and black patients who underwent ACL reconstruction had a similar or lower risk of undergoing elective ACL revision compared with white patients. In results of this published study, white patients had the lowest unadjusted revision-free survival over time.

In a retrospective cohort study, Ronald A. Navarro, MD, regional chief of orthopedic surgery for Southern California Permanente Medical Group, and colleagues used multivariable Cox proportional-hazard models to evaluate the association between race/ethnicity and revision risk among 27,258 patients who underwent ACL reconstruction from 2008 to 2015.

Differences between race, ethnicity

Ronald A. Navarro

Researchers categorized race/ethnicity as non-Hispanic white (49.8%), black (8.3%), Hispanic (28.3%) and Asian (13.7%), and adjusted for age, sex, highest educational attainment, annual household income, graft type and geographic region in which the ACL reconstruction was performed.

Results showed the lowest unadjusted revision-free survival over time among white patients, with the cumulative probability of revision highest for white patients followed by Hispanic, black and Asian patients at 5 years postoperatively. When adjusted for potential confounders, researchers found a lower risk of undergoing revision surgery among Asian and Hispanic patients vs. white patients. Although revision risk did not differ between black and white patients before 3.5 years after primary ACL reconstruction, results showed black patients had a lower risk of undergoing revision surgery after 3.5 years.

“It is surprising that we find the non-white population would have a lower risk, but a revision for an ACL reconstruction is largely a choice,” Navarro told Orthopedics Today. “It is only the most unstable knees that would probably have to be revised without regard to choice, but a lot of people just cope with a loose knee. Because our endpoint was a revision surgery, we do not know how many patients are walking around out there with a potentially failed ACL and have chosen not to revise it.”

Larger datasets needed

According to Navarro, future research should focus on why there is a difference in revision rates among different races/ethnicities and whether such differences are due to coping, socioeconomic status or there are, in fact, biologic differences. Larger datasets with more specific race and ethnicity designations are needed to confirm these differences between race/ethnicity exist, he said.

“It would be nice to do a population health study asking why [patients] chose not to undergo revision,” Navarro said. “That would be a big contribution to the ACL injury and reconstruction literature, to know why certain people choose not to go back to get their re- reconstruction done in a way that is more patient survey based. That type of study would not be about the kinematics or the stability of the knee, but more about patient notions as to why they would choose to get another surgery because it is an elective surgical revision for a failed ACL reconstruction,” he said. – by Casey Tingle

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Disclosure: Navarro reports no relevant financial disclosures.

    Perspective

    In a retrospective, and primarily observational, study, Ronald A. Navarro, MD, and colleagues reported that Asian, Hispanic and African American patients had a similar or lower risk of having a revision ACL reconstruction compared with white patients within the database of a large integrated health care system. With this being a retrospective study, it raises questions about if there is truly a difference in ACL graft tears and subsequent reconstruction among these races/ethnicities or if the difference is due to socioeconomic issues with a lack of diagnosis of a graft tear or an inability to proceed with a revision ACL reconstruction after diagnosis. Clarifying this question could lead to improved optimization of surgical treatment and postoperative care and follow-up to benefit patients.

    Further research on this topic should be prospective and should consider the effects of modifiable factors, such as socioeconomic factors, and nonmodifiable factors (age, gender and bony geometry differences, such as coronal and sagittal plan tibial slope), which can be assessed at the initial time of presentation of an ACL tear to help improve treatment going forward. Identifying risk factors and addressing concomitant injuries is important to mitigate the risk of ACL graft failure and subsequent revision surgery. In addition, ensuring that all patients with an ACL graft tear are identified and counselled as to their individual best treatment is recommended. In summary, further research on this topic is needed to shed light onto these newly identified factors that could play a role in a prevalent procedure, such as an ACL reconstruction.

    – Robert F. LaPrade, MD, PhD

    Twin Cities Orthopedics

    Eagan, Minnesota

    – Jorge Chahla, MD, PhD

    Rush University

    Chicago

    • Gilbert Moatshe, MD, PhD
    • University of Western Ontario London, Ontario

    Disclosures: LaPrade reports he is a consultant for Smith & Nephew, Ossur, Arthrex and Linvatec; receives royalties from Arthrex, Ossur and Smith & Nephew; and received educational grants from Ossur and Smith & Nephew. Chahla reports he is a consultant for Smith & Nephew, Ossur, Arthrex and Conmed; receives royalties from Elsevier; and receives educational grants from Ossur, Conmed and Smith & Nephew. Moatshe reports he receives research grants from Arthrex and South Eastern Norway Health Authorities.