Current status of ACL reconstruction in Germany.

Abstract

Reconstruction of the anterior cruciate ligament (ACL) is characterized by a variety of possibilities concerning its implementation. Different choices for grafts, fixation methods and tunnel positioning, as well as diverse technical tools are available and have clinical significance. Besides specific pre- and post-operative procedures, different indications for surgery and further surgeon-/clinic-related factors add variability to the treatment. In response to the lack of descriptive statistics about the implementation of these factors and the increasing numbers of ACL reconstructions this study has been conducted to display the current state of the treatment for ACL tears throughout Germany. 709 clinics with surgical and orthopedic departments were provided an online-questionnaire that surveyed their statistical records (e.g. annually implemented operations, number of surgeons, duration of operations), implemented techniques (e.g. choice of grafts, construction of drilling tunnel, tibial/femoral fixation) and personal assessment (e.g. frequency/cause of graft failure, frequency/handling of infection). The response rate was 22% (n=155). Based on the statistical records a specialized group within the respondents was identified, enabling a cross-comparison between high- and low-volume surgeons. On average, the German orthopedic surgeons in the clinics surveyed annually performs 35 ACL reconstructions, with each operation lasting an average of 67min. After subdividing the data with references to annually performed surgeries into high- and low-volume-surgeons, differences and common features between the subgroups become apparent. Differences between high- and low-volume-surgeons, respectively, show shorter duration of both ACL reconstructions (55 vs. 71min) and revision ACL reconstructions (75 vs. 90min), higher membership rates in professional associations (83 vs. 38% have at least one membership), more frequent implementation of stability examinations (47 vs. 21%) and different frequencies of femoral drilling techniques (using the anterolateral portal in 71 vs. 54%). With reference to evaluating operation dates, choosing grafts and assessing reasons for graft failure both groups share commonalities, as well as regarding the predominant use of monofixation for femoral fixation (88% of the participants-mainly with endobutton in 38% and transfixation pin in 27%) and for tibial fixation (81% of the participants-mainly with bioabsorbable screw in 60%). The treatment of ACL tears in the group of German clinics studied is characterized by a variety of surgical possibilities. This condition might reflect the entirety of clinics reconstructing ACL in Germany. For the first time, a descriptive statistical survey was implemented to display this variety and to provide insight into the current status quo. Within the entirety of surgeons implementing ACL reconstruction a specialized subgroup with a particular expertise seems to exist.