title: Surgical Technique Trends in Primary ACL Reconstruction from 2007 to 2014.
abstract: BACKGROUND
  The surgical technique for anterior cruciate ligament (ACL) reconstruction has evolved as a result of improved understanding of ligament biomechanics, anatomy, device development, and failed reconstructions. Studies on surgical technique preferences have been limited to surgeon surveys, which are subject to selection and recall bias. The purpose of this study was to evaluate ACL reconstruction surgical technique and yearly revision rate trends in a community-based setting.
  
  
  METHODS
  A population-based epidemiological study was conducted using data on primary ACL reconstruction procedures registered in an ACL reconstruction registry from 2007 to 2014. Changes in the incidence rates of different types of femoral tunnel drilling methods, different types of grafts and graft fixation, and revisions were studied. Adjusted incidence rate ratios (IRRs) are provided.
  
  
  RESULTS
  Of the 21,686 ACL reconstructions studied, 72.4% were performed by sports medicine fellowship-trained surgeons. The incidence rate of femoral tunnel drilling via a tibial tunnel decreased at an adjusted rate of 26% per year (IRR = 0.74, 95% confidence interval [CI] = 0.71 to 0.78), from 56.4% to 17.6% during the study period. The incidence rate of medial portal drilling increased from 41.3% to 65.1% at an adjusted rate of 11% per year (IRR = 1.11, 95% CI = 1.09 to 1.13), and the incidence rate of drilling through a lateral approach increased from 2.3% to 17.3% at an adjusted rate of 53% per year (IRR = 1.53, 95% CI = 1.39 to 1.67). There was no change in the use of hamstring autograft, bone-patellar tendon-bone autograft, or tibial tendon allograft. Use of first-generation bioabsorbable femoral and tibial fixation decreased for all graft types. For soft-tissue grafts, usage of suspensory metal femoral fixation increased 12% to 13% per year (IRR = 1.12, 95% CI = 1.09 to 1.15 for tibial tendon grafts; IRR = 1.13, 95% CI = 1.10 to 1.15 for hamstring grafts). For bone-patellar tendon-bone autografts, the use of femoral fixation with interference biocomposite screws increased 7% per year (IRR = 1.07, 95% CI = 1.04 to 1.10). On the tibial side, utilization of biocomposite screws increased for all graft types. No association was found between revision rate and the year of the primary operation.
  
  
  CONCLUSIONS
  Surgeons changed their femoral tunnel drilling technique over the study period, whereas the incidence rates of specific graft utilization remained stable. There has been a shift away from first-generation bioabsorbable fixation and increasing use of biocomposite fixation across all graft types. Early cumulative revision rates remained stable.
authors.affiliation: The Permanente Medical Group, Redwood City, California Lisa.M.Tibor@kp.org.
authors.forename: Lisa
authors.initials: L
authors.lastname: Tibor
authors.affiliation: Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, California.
authors.forename: Priscilla H
authors.initials: PH
authors.lastname: Chan
authors.affiliation: Southern California Permanente Medical Group, Anaheim, California.
authors.forename: Tadashi T
authors.initials: TT
authors.lastname: Funahashi
authors.affiliation: The Permanente Medical Group, Walnut Creek, California.
authors.forename: Ronald
authors.initials: R
authors.lastname: Wyatt
authors.affiliation: Southern California Permanente Medical Group, Baldwin Park, California.
authors.forename: Gregory B
authors.initials: GB
authors.lastname: Maletis
authors.affiliation: Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, California.
authors.forename: Maria C S
authors.initials: MC
authors.lastname: Inacio
mesh_terms: D000293:Adolescent; D000328:Adult; D000070598:Anterior Cruciate Ligament Injuries / Q000601:surgery*; D059549:Anterior Cruciate Ligament Reconstruction / Q000379:methods / Q000639:trends*; D016025:Bone Transplantation / Q000379:methods / Q000639:trends*; D005260:Female; D006801:Humans; D008297:Male; D012086:Reoperation / Q000639:trends; D055815:Young Adult