Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus part III—indications for different clinical scenarios using the RAND/UCLA appropriateness method

Consensus design

The RAM was used to develop recommendations on the appropriateness of ACLRev in adult patients affected by primary ACLR graft failure [8]. ACL revision was defined as “all surgical procedures involving replacement of the ACL graft with a new graft”. For the purpose of this consensus, failure has been defined by abnormal knee function associated with a previous primary reconstruction. This could be due to graft failure itself with abnormal laxity (IKDC C/D) or failure to recreate a functional knee according to the expected outcome [18]. The RAM process involved a core panel including a moderator and an expert panel. The core panel (FG, TT, PB, LA, VC) defined the scenarios of the RAM and guided the expert panel through the RAM tasks. The expert panel, composed of 17 voting members selected based on their expertise and at the same time ensuring geographical representation, used the data provided by the core panel to come to a consensus. The members were selected based on their scientific and clinical expertise in ACLRev while ensuring the geographical representation of ESSKA European members.

Clinical scenarios development

The RAM process was preceded by an extensive literature review undertaken by the steering group of the parallel “Formal Consensus Project”, set up by ESSKA, on the diagnosis, preoperative planning, and surgical strategy for ACLRev (parts I and II). This literature review ensured that panelists had access to the body of evidence for the rating procedure and was used by the core panel to develop the consensus scenarios. These clinical scenarios were presented in the form of a matrix detailing demographic data, characteristics of the joint and association with combined lesions. These factors were based on literature evidence suggesting a correlation with the clinical outcomes after surgery, potentially influencing the appropriateness of the procedure:

Age (18–35 years old vs 36–50 years old vs 51–60 years old)

Sports participation expectation (tegner activity level 0–3 vs 4–6 vs 7–10)

Instability symptoms (yes vs no)

Meniscus status (functional meniscus vs repairable meniscus vs non-functional meniscus)

OA (Kellgren–Lawrence [KL] [11] grade 0–I–II vs grade III)

For the scenarios, it was assumed that patients lacked gross osseous malalignment (varus/valgus within 5°, tibial sagittal slope less than 12°), had no additional ligamentous injuries and did not have advanced OA (KL IV).

Sport expectation participation was considered as not only the sporting level previously practiced by the patient, but also the desired activity level following surgical reconstruction. Instability was defined as a functional symptom (subjective) where “an abnormal dynamic joint motion occurs in response to the complex, high-magnitude loads encountered during activities of daily living and sport activities.” On the other hand, pathological laxity (objective) was defined as “an increased passive response of a joint to an externally applied force or torque in biomechanical terms”. Meniscus status was classified as “functional meniscus” in the case of no meniscal lesion or limited lesions requiring meniscectomy but not compromising meniscal function; “repairable meniscus” was represented by a lesion suitable for meniscal suture or repair; “non-functional meniscus” included patients with previous meniscectomy or large irreparable meniscal lesions.

Patients aged over 60 were excluded in view of the lack of evidence available on the outcomes of ACLRev in this age group. Similarly, patients with advanced OA (KL IV) were also excluded. However, the indications for ACLRev in patients over the age of 60 and in patients with advanced OA (KL IV) were addressed in two further questions following the ESSKA formal consensus process. Although ACLRev can be combined with a high tibial osteotomy to improve symptomatic ACL instability in patients with OA knee [20], realignment procedures were excluded from the consensus, as it was felt that the inclusion of malalignment would have created too many variables for consideration, Similarly, the presence of combined ligamentous injury (e.g. posterior cruciate ligament, collateral ligaments, posterolateral corner, etc.) was also excluded from the clinical scenarios. Smoking status, BMI, gender and the interval between ACL graft rupture and reconstruction were also excluded from the scenarios in view of a lack of evidence suggesting these factors can influence outcomes.

Based on the five clinical variables considered most relevant by the core expert panel, a set of 108 clinical scenarios were produced. Panelists were asked to individually assess the appropriateness of the indication for ACLRev for each of the scenarios. The scenarios were grouped into three “chapters” based on patient age. (Fig. 1). The scenarios were presented to the voting experts in the form of a question: “A … years old patient with ACL re-rupture presents to your attention with an aligned knee, increased laxity, and the following characteristics. How appropriate do you rate the indication for ACLRev?”.

Fig. 1figure 1

Example of the clinical scenarios presented to the voting panelists. Chapter 1 (18–35 years old patients). Two specific scenarios are shown in detail

Consensus process

The appropriateness of the indication for surgical treatment in each of the different scenarios was rated in two rounds. The two-round RAM process is designed to identify whether discrepant ratings are due to real clinical disagreement over the use of the procedure ("real" disagreement) or to fatigue or misunderstanding ("artefactual" disagreement) [8].

In the first round, the expert panel received the clinical scenarios by email and was asked to rate the appropriateness of the indication for ACLRev. According to the RAM [8], each panelist ranked, independently from the other panelists, the appropriateness for each scenario on a nine-point Likert scale, in which a score in the range 1–3 is considered ‘inappropriate’, 4–6 ‘uncertain’, and 7–9 ‘appropriate’. They were invited to consider the synthesized evidence from the literature review provided by the core panel overseeing the consensus process. The expert panelists were asked to discount the cost of the procedure in rating the appropriateness of the scenarios.

In the second round, the experts’ panel and the core panel met under the leadership of a moderator. Each panelist received an individualized document showing their round one rating and the distribution of all the expert group’s first-round ratings. During the meeting, panelists discussed the ratings, focusing on areas of disagreement. The opportunity was given to modify the original list of indications and/or definitions if desired. The panel was not forced to reach a consensus and, after discussing each chapter of scenarios, experts individually re-rated the appropriateness of the indication for ACLRev for each scenario [8].

Data analysis

The final nine-point Likert-scale scores of each expert were then pooled to generate a median appropriateness score for each scenario. In addition, according to the RAM, the presence of “disagreement” was calculated according to the following definition: at least six panelists rated the indication in the 1–3 region and at least six panelists rated it in the 7–9 region [8]. Finally, the indication for ACLRev for each clinical scenario was classified:

The rating of “Inappropriate” indicated that the expert consensus favored conservative management rather than ACLRev for that specific clinical scenario.

A scenario receiving a score between 4 and 6, or a scenario with disagreement, was classified as “uncertain”. An “uncertain” recommendation can reflect either the ambiguous state of currently available evidence or equivocal appropriateness either due to a moderately unfavorable risk profile or to limited efficacy. The ‘uncertain’ classification is not intended to be a negative recommendation or to preclude the use of the treatment for the specific scenario based on surgeon–patient shared decision making in the context of individual circumstances, co-morbidities, and preferences.

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