Surgical caseload and annual volume influence cartilage treatment strategies in primary anterior cruciate ligament reconstruction.

Abstract

To evaluate how surgeon and clinic volume, along with patient-, injury- and surgery-related factors, influence cartilage injury management in primary anterior cruciate ligament reconstruction (ACLR). This retrospective cohort study analysed cartilage treatment (debridement, microfracture, other methods or left in situ) in patients undergoing primary ACLR (2008-2022) using data from the Swedish Knee Ligament Registry. Surgeons and clinics were categorised by registry caseload (low [LC]: <50 ACLRs/surgeon, <500/clinic; high [HC]: ≥50, ≥500) and annual volume (low [LV]: <29 ACLRs/year/surgeon, <56/year/clinic; high [HV]: ≥29, ≥56), yielding four groups: LCLV, LCHV, HCLV, and HCHV. Factors influencing cartilage treatment were assessed using adjusted multivariable logistic regression. More than one in four patients (11,729, 26.4%) had cartilage injuries at the time of primary ACLR; 17.9% underwent debridement, 7.1% microfracture and 1.4% other treatments. A higher proportion of HCHV surgeons had performed debridement (81.2% vs. 48.8%-64.3%), microfracture (78.6% vs. 24.4%-51.0%) and other methods (32.5% vs. 3.8%-13.4%) during ACLR compared to all other surgeon groups (all p < 0.001). HCHV clinics were more likely to treat cartilage injuries, leaving fewer in situ (79.2% vs. 80.3%-85.2%, p < 0.001) Adjusted logistic regression analyses showed that LCLV/LCHV clinics had 43.4%-68.5% higher odds of performing microfracture, and that LCHV/HCLV clinics had 41.3%-48.1% lower odds of performing debridement compared to HCHV clinics, all p ≤ 0.023. Microfracture and debridement odds increased with ICRS 3-4 lesions and decreased with non-medial femoral condyle injuries and delayed surgery. Age > 30 years and recent surgery year increased debridement odds, while lesion size ≥ 2 cm² lowered microfracture odds. Surgeons with the highest caseload and volume performed the broadest range of cartilage treatment techniques, yet treatment strategies appeared driven more by clinic caseload and volume. Cartilage management was also influenced by injury location, size, depth, patient age, time to surgery and year of surgery. Level III.