Graft Selection in Anterior Cruciate Ligament Reconstruction for Smoking Patients

Background: There has been no previous study regarding graft selection in anterior cruciate ligament (ACL) reconstruction for smoking patients. Purpose: To compare the clinical outcomes of ACL reconstruction between smokers and nonsmokers and to find an optimal graft in ACL reconstruction with regard to clinical outcomes for smoking patients. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 487 patients who underwent unilateral ACL reconstruction were retrospectively reviewed. Included patients were divided into 2 groups according to their history of smoking. Group 1 was composed of patients who had never smoked (n = 322), and group 2 consisted of patients who had reported smoking before ACL reconstruction and during rehabilitation (n = 165). Additionally, each group was divided into 4 subgroups according to the selected graft type (bone-patellar tendon-bone autograft, hamstring [semitendinosus-gracilis] tendon autograft, quadriceps tendon-bone autograft, or Achilles tendon-bone allograft). Patients were assessed for knee instability with the Lachman and pivot-shift tests as well as anterior translation measured by the KT-2000 arthrometer. Functional outcomes were evaluated with the Lysholm knee score, International Knee Documentation Committee (IKDC) subjective score, and IKDC objective grade. Results: The minimum follow-up period was 24 months. At the final follow-up evaluation, there were significant mean between-group differences regarding the side-to-side difference in anterior translation (group 1, 2.15 1.11 mm; group 2, 2.88 +/- 1.38 mm; P < .001), Lysholm knee score (group 1, 90.25 +/- 6.18; group 2, 84.79 +/- 6.67; P < .001), IKDC subjective score (group 1, 89.16 +/- 5.01; group 2, 83.60 +/- 7.48; P < .001), and IKDC objective grade (group 1, grade A = 151, B = 130, C = 36, D = 5 patients; group 2, grade A = 48, B = 71, C = 37, D = 9 patients; P < .001). With regard to differences in outcomes between the selected grafts within each group, the Achilles tendon-bone allograft showed the worst outcomes, with statistically significant mean differences for smoking patients in the side-to-side difference in anterior translation (3.59 +/- 1.26 mm), Lysholm knee score (81.05 +/- 2.82), and IKDC subjective score (79.73 +/- 4.29). Conclusion: Unsatisfactory outcomes with regard to stability and functional scores were shown in the smoking group compared with the nonsmoking group. In smokers, the patients receiving an Achilles tendon-bone allograft had poorer outcomes than those with autografts. The bone-patellar tendon-bone autograft is recommendable for ACL reconstruction in a smoking patient.