Practice Patterns for Revision Anterior Cruciate Ligament Reconstruction in an Integrated Health Care System

Background: While surgeons with high caseload volumes deliver higher value care when performing primary anterior cruciate ligament reconstruction (ACLR), the effect of surgeon volume in the revision setting is unknown. Purposes: To determine the percentage of revision ACLR procedures that comprise the practice of high-, medium-, and low-volume surgeons and to analyze associated referral and practice patterns. Study Design: Cross-sectional study; Level of evidence, 3. Methods: We retrospectively investigated all revision ACLR procedures performed between 2015 and 2020 in a single health care system. Surgeons were categorized as low (<= 17), medium (18-34), or high (>= 35) volume based on the number of annual ACLR procedures performed. Patient characteristics, activity level, referral source, concomitant injuries, graft type, and treatment variables were recorded, and a comparison among surgeon groups was performed. Results: Of 4555 ACLR procedures performed during the study period, 171 (4%) were revisions. The percentage of revision ACLR procedures was significantly higher for high-volume (5%) and medium-volume (4%) surgeons compared with low-volume surgeons (2%) (P < .01). Patients undergoing revision ACLR by a high-volume surgeon had a significantly higher baseline activity level (P = .01). Allografts were used significantly more often by low-volume surgeons (70%) compared with medium-volume (35%) and high-volume (25%) surgeons (P < .01). Bone-patellar tendon-bone (BPTB) and quadriceps tendon (QT) autografts were used significantly more often by high-volume (32% BPTB, 39% QT) and medium-volume (38% BPTB, 14% QT) surgeons compared with low-volume surgeons (15% BPTB, 10% QT) (P < .01). High-volume surgeons were more likely to perform revision on patients with cartilage injuries (P = .01), perform staged revision ACLR (P = .01), and choose meniscal repair (54% high vs 22% medium and 36% low volume; P = .03), despite similar rates of concomitant meniscal tears, compared with low- and medium-volume surgeons. Conclusion: In this registry study of an integrated health care system, high-volume surgeons were more likely to perform revision ACLR on patients with higher activity and competition levels. Additionally, high-volume surgeons more commonly performed staged revision ACLR, chose meniscus-sparing surgery, and favored the use of autografts compared with low-volume surgeons.