Clinical failure of anterior cruciate ligament (ACL) reconstructions continues to be a too-common scenario. The increasing incidence of ACL revision is due to a variety of factors, including greater intensity of postsurgical physical activity, technical issues, and anatomical influences of the proximal tibia and distal femur. Registries are important sources of data for ACL-related investigations, but I think they are most useful in clarifying experimental designs for more sophisticated clinical research.

In a cohort study in the October 16, 2019 issue of The Journal, Snaebjornsson et al. examined the influence of ACL graft diameter on the risk of revision surgery over 2 years in >18,000 subjects whose data resided in the national knee ligament registries of Sweden and Norway. The vast majority of those patients (92.8%) received a hamstring autograft, with 7.2% receiving a patellar tendon autograft. Overall, the 2-year rate of ACL revision was 2.63% for patellar tendon autografts and 2.08% for hamstring autografts, a statistically nonsignificant difference in relative risk.

However, the authors found an important correlation between graft diameter in the hamstring tendon cohort, with autografts <8 mm in diameter being associated with a higher risk of revision, compared with larger-diameter hamstring autografts. Additionally, patients treated with hamstring graft diameters of ≥9 mm or ≥10 mm had a lower risk of ACL revision surgery than those treated with patellar tendon grafts of any size.

One key limitation that should influence our interpretation of this study is a lack of detail regarding how compliant surgeons were intraoperatively with the use of the measurement device that is depicted in the manuscript and shown above. In addition, the limitations of registry data did not permit the authors to adjust for postsurgical exposures, such as return to sport, the increasing intensity of which makes rerupture more likely. Additional relevant information that would have aided interpretation of the findings includes the relative size of the tibia and femur, lateral condyle size and shape, and proximal tibial slope.

Despite these limitations, this study should prompt further research that uses robust clinical designs to more fully investigate the impact of graft diameter on ACL rerupture rates.

Marc Swiontkowski, MD

JBJS Editor-in-Chief