Patient Perception of Autograft Options in ACL Reconstruction Using a Validated Online Survey Marketplace

Abstract

Background:

Anterior cruciate ligament reconstruction (ACLR) is a common surgery performed with a variety of different autograft options. While there is much research that highlights the benefits and drawbacks of each of these options, there is little known about the knowledge of the general population regarding these options and how patient education may influence their choice.

Purpose:

To evaluate the general population's perception of commonly utilized autografts in ACLR.

Study Design:

Cross-sectional study.

Methods:

Using an online marketplace, a random selection of participants from the general population were asked about demographic data and preferences for autograft type. All respondents then participated in a survey sent in August 2024, reviewed information from an evidence-based sheet, and completed a posteducation test. Participants were again asked about graft preferences. Participants were asked whether they would change their preference based on surgeon recommendation and what factors influenced their decisions. Statistical analysis was performed using Shapiro-Wilks test to determine normality, and Student paired t test was used for comparison.

Results:

There were 491 participants with a mean age of 39.9 (range, 19-72). Before participant education regarding graft types, 19.3% preferred bone–patellar tendon–bone (BPTB), 18.7% preferred quadriceps tendon (QT), 12.6% preferred hamstring tendon (HT), and 53.4% had no preference. Following education, a significantly greater number of participants chose each graft type; 37.7% (P < .01) preferred BPTB, 21.6% (P < .01) preferred QT, and 13.8% (P < .01) preferred HT. Significantly fewer participants had no preference (26.9%; P < .01). Among the most important factors in patient preference was surgeon preference (n = 357; 72.7%), as 424 (86.4%) participants said they would switch their graft preference if their surgeon recommended it.

Conclusion:

The findings of this study imply that informed patients can participate in medical decision making with respect to their graft choices in ACLR and that providing educational information can help surgeons and patients work together to optimize patient care.

Anterior cruciate ligament (ACL) tears continue to be one of the most frequent orthopaedic injuries with an annual occurrence rate of 68.6 per 100,000 person-years. ¹⁰ Over the past 2 decades, there has been a notable rise in ACL reconstructions (ACLRs).^7,12,17 The progress in ACL research has been instrumental in enabling surgeons to devise an array of graft selections, encompassing both autografts and allografts. ¹⁰ There are a variety of different autograft options, including hamstring tendon (HT), quadriceps tendon (QT) and bone–patellar tendon–bone (BPTB) grafts.

QT, BPTB, and HT autografts are among the primary graft options for ACLR, with each offering distinct advantages and drawbacks.^12,17 QT autografts exhibit robust biomechanical properties while clinical results have demonstrated encouraging return to sport and patient-reported outcome scores.^7,9 However, the harvesting procedure may involve a larger incision and carry the risk of potential donor-site complications. ⁴ BPTB autografts have long been favored for their established track record of successful clinical outcomes, rapid graft incorporation, and low graft failure rates. ⁶ But concerns about anterior knee pain and potential patellar fractures after harvesting are considerations. ⁴ HT autografts are appreciated for their minimally invasive harvesting technique, reduced donor-site morbidity, and favorable aesthetic outcomes.^8,16 Yet their comparatively lower initial graft strength and potential for increased postoperative laxity warrant careful consideration. In addition to graft choice, some surgeons will perform other procedures such as extra-articular tenodesis for additional stability in select patients, although the use of these varies between surgeons. Surgeons weigh these positives and negatives alongside patient-specific factors to optimize ACLR outcomes. ¹⁶

While multiple comparative studies report on clinical outcomes after BPTB, HT, and QT autograft ACLRs, there is little known about the general population and their opinions on ACL autograft options. This study sought to utilize a previously validated online marketplace to evaluate the general population's perception of commonly utilized autografts in ACLR. The null hypothesis was that there would be no difference in patient preferences between BPTB, QT, or HT autograft use in ACLR. We also hypothesized that patient education would help patients develop preferences regarding graft type.

Methods

This research project employed Amazon Mechanical Turk (MTurk), an online platform where researchers and other individuals can outsource virtual tasks, such as survey participation. Once participants completed the survey, the platform generated unique codes verifying their completion, which enabled compensation. This process ensured the reliability of participants' responses. The current study included only adult participants aged ≥18 years residing in the United States. Compensation of $1.50 was provided for each completed survey, funded by the authors’ orthopaedic department. We targeted 500 unique responses. The survey was sent once to each respondent over the course of a week in August 2024. Surveys that were incomplete or exhibited duplicate internet protocol (IP) addresses were excluded from the analysis. This study was exempted from ongoing institutional review board approval.

The survey included 36 questions designed to identify participant demographic factors perceived to potentially influence their opinions and baseline knowledge about HT, QT and BPTB grafts used in ACLR (see Supplemental Material, available separately). The survey then asked questions regarding ACL autograft preferences. Afterward, participants were provided with an information sheet based on evidence, outlining key distinctions between HT, BPTB and QT autografts (Supplemental Material Figure S1, available separately). Following review of the educational sheet, a posteducation test was provided. The objective of this section of the survey was to confirm participants' engagement with and comprehension of the presented information. Last, participants were asked about their inclination to alter their viewpoints as well as about the most important factors that guided their decision-making process.

Statistical Analysis

Descriptive statistics were calculated for all included patients using the open-source R software (Version 2.14.1). The distribution of data points was analyzed with the Shapiro-Wilks test. Student paired t tests were used to compare pre- and posteducation test scores. P values ≤ .05 were deemed to be statistically significant.

Results

There were 491 participants who completed the survey. There were 244 (49.7%) men, 241 (49.1%) women, and 6 (1.2%) who preferred not to answer. The mean age was 39.9 ± 11.3 years (range, 19-72). The most frequently reported races were 388 (79.0%) White, 54 (11.0%) Black or African American, and 33 (6.7%) Asian. Of the total cohort, 362 (73.7%) participants reported earning at least a bachelor's degree. Additionally, 362 (73.6%) participants reported that they did not work in health care.

Before being provided access to the educational information sheet, 19.3% (n = 95) preferred BPTB, 18.7% (n = 92) preferred QT, 12.6% (n = 62) preferred HT, and 53.4% (n = 262) had no preference. Following access to the informational sheet, a significantly greater number of participants chose each graft type: 37.7% (n = 185; P < .01) preferred BPTB, 21.6% (n = 106; P < .01) preferred QT, and 13.8% (n = 68; P < .01) preferred HT. There were significantly fewer participants who reported no preference after education, at 26.9% (n = 132; P < .01). The mean score on the preeducation test was 35.0% while the mean score on the postinformation test was significantly greater, 50.0% (P < .01).

There were 424 (86.4%) participants who reported that they would switch their graft preference if their surgeon recommended it. The most important reported factors in participant preference were surgeon preference (n = 357; 72.7%), the provided education sheet (n = 104; 21.2%), and previous experiences with ACL autografts (n = 30; 6.1%). Specifically, the number of preferences before and after education can be seen in Table 1. Those who preferred BPTB before education were most likely to maintain their preference after education (54.7%) and those who initially preferred HT were least likely to maintain their preference (25.8%).

Table 1

Patient Preference Changes After Education ^a

Preeducation Preference	Posteducation Preference	Number of Participants
BPTB	BPTB	52
BPTB	QT	22
BPTB	HT	14
BPTB	No preference	7
QT	BPTB	25
QT	QT	40
QT	HT	21
QT	No preference	6
HT	BPTB	18
HT	QT	20
HT	HT	16
HT	No preference	8
No preference	BPTB	90
No preference	QT	24
No preference	HT	17
No preference	No preference	111

a

BPTB, bone–patellar tendon–bone autograft; HT, hamstring tendon; QT, quadriceps tendon.

The mean age of the participants by graft choice in the preeducation portion of the study was 38.7 ± 11.8 for BPTB, 38.6 ± 11.5 for HT, 38.0 ± 9.78 for QT, and 41.4 ± 11.4 for no preference. The mean age of participants by graft choice in the posteducation portion of the analysis was 41.2 ± 12.2 for BPTB, 37.1 ± 9.8 for HT, 38.8 ± 10.7 for QT, and 40.5 ± 10.8 for the no preference. There was no significant difference between preeducation age and posteducation age by graft type for each graft preference (P > .05 for each)

In terms of educational information influencing their decision for autograft type, the risks/disadvantages (n = 190) were most frequently identified as being the most influential information from the educational sheets, followed by the treatment outcomes (n = 154), and graft advantages (n = 112).

The most frequently observed change between preeducation preference and posteducation preference was from “no preference” to “BPTB” (n = 90; 18.3%). After education, participants most frequently switched to preferring BPTB grafts from other graft choice options that they preferred before education (ie, they selected a different graft choice before education and selected BPTB following education) (n = 133; 27.1%) (Table 1).

Discussion

The primary findings of this study were that after providing participants with an education sheet, most participants formulated their own preferences with respect to autograft options commonly used in ACLR, specifically, HT, BPTB, and QT autografts. Additionally, BPTB was the most frequently selected autograft option after education; however, a vast majority of participants admitted that they would be willing to undergo surgery with the other autograft options if their surgeon recommended it. Knee surgeons can translate this information to their practice by understanding the importance of providing objective information about graft types to patients before ACLR. This study demonstrates that with clinical and biomechanical data, members of the general population can make informed decisions but are also willing to change their choices based on discussion with their knee surgeon.

Before providing educational information, less than half of participants had a preference regarding ACL autograft type; however, after having the opportunity to view a brief informational sheet, nearly three-fourths of participants preferred an autograft type. While all showed a statistically significant increase, HT preference increase was only 1.2% and is likely not clinically significant. Participants who initially preferred HT were also least likely to maintain their preference after education (25.8%). While we did not collect specific opinions regarding each unique graft, this is most likely related to the educational materials and possibly inclusion of the increased rate of failure with HT graft.

This decrease in preference of HT graft is a similar finding to recent conclusions about patient preferences for autograft versus allograft, which showed that 84% of participants would be willing to undergo surgery with a graft other than their primary choice if recommended by their surgeon. ⁵ In a study conducted in 2005 involving 202 patients who were undergoing invasive procedures, it was reported that most patients indicated that clinician opinion was the most significant factor in their decision making. ¹¹ This trend was further amplified in in elderly patients in the same study. Additionally, a study from Sepucha et al ¹³ compared patients who were well-informed with respect to subsequent orthopaedic surgical interventions with those that were not and found that those patients who had informed, patient-centered treatments had better overall outcomes and greater disease-specific quality of life compared with those that did not have informed, patient-centered decisions about their care. Historically, an integral part of informed consent is education, including discussion with the patient; participating in shared decision making and individualized patient education is an essential step in deciding the best ACL autograft for each patient. ³ The results of this study, however, highlight the importance of shared decision making. Despite placing importance on the surgeon's preference, 73% of participants had a preference of graft choice after education. Surgeons need to recognize and value the patient's perceptions in order for true shared decision to occur, particularly in instances where one graft type is not strongly indicated over another. Previous studies report on the unique biomechanical properties of autografts including the cross-sectional area, Young modulus, graft stiffness, and tensile strength of these grafts. ¹ Despite the complexities of these reports, it remains the role of the surgeon to simplify these findings and convey them to patients in a succinct fashion, similar to the one supplied in the current analysis, to facilitate a personalized decision.

The current study found that BPTB was the most frequently selected graft by participants after education. Following education, for those who had altered their preference, BPTB was most commonly the selected preference (ie, participants selected a different graft before education but preferred BPTB after education). The preferences demonstrated in this study align with the preferences of surgeons as demonstrated by a recent survey study from Bowman etal, ² who reported that patellar tendon and QT autografts were strongly preferred for young athletes within the United States. Synovec etal ¹⁴ surveyed 75 military surgeons and reported that surgeons preferred BPTB in 51% of young men, but only 34% of young women. These reports on surgeon preference coincide with the participant preferences observed in the current study. Surgeons may use these findings to understand the ways patients interpret educational information about graft choices and more effectively discuss these options for each patient.

A recent study by Thorstensson etal ¹⁵ interviewed 34 young and active patients with ACL tears. Participants in the study expressed a variety of views, including a vast array of assumptions and understandings of what to expect after surgery. These findings support the results of the current survey study, as both allude to the importance of standardized information about ACL surgery and graft options as well as individualized conversations about goals of care after these procedures.

Limitations

We acknowledge that this study has limitations. Even though the information sheet was formulated from evidence-based and objective data, it is not exhaustive. We believed that brevity of the education sheet would be crucial to ensure participant engagement and review. This was supported by the fact that the posteducation quiz scores were higher than the preeducation scores. An additional limitation of this study is the inherent bias of online crowd-sourced studies. To be included in our study, participants had to be >18, with an IP address in the United States, and inherently capable of and willing to use an online marketplace to answer surveys. The mean age of our study sample was older than the typical ACLR candidate, and while this population did not precisely mirror the ideal demographic, we believe it was an effective and informative proxy. This study also does not address the biases known to influence patients in the clinical setting, such as affinity bias and the influence of patients seeking out their information outside the office setting. Finally, this survey was provided to the same cohort of participants that responded to the study on allografts and autografts (see Supplemental Material). We do not believe that the previous allograft versus autograft educational sheet influenced the current study, because there was no information about specific autograft types in the previous study. However, we acknowledge that even this limited exposure could influence the current findings.

Conclusion

The main conclusion of this study was that informed patients can participate in medical decision making with respect to graft choices in ACLR. Providing patient educational information can help surgeons and patients work together to optimize patient care. The most significant factor influencing their choice was the surgeon's preference, and patients were more likely to choose a specific graft type (BPTB, QT, HT) after reading an evidence-based information sheet on the graft types.

Supplemental Material

sj-pdf-1-ojs-10.1177_23259671251362631 – Supplemental material for Patient Perception of Autograft Options in ACL Reconstruction Using a Validated Online Survey Marketplace

Supplemental material, sj-pdf-1-ojs-10.1177_23259671251362631 for Patient Perception of Autograft Options in ACL Reconstruction Using a Validated Online Survey Marketplace by Robert S. Dean, Tanner Hafen, Ryan McNassor, Collin Braithwaite, Kevin X. Farley, Robert F. LaPrade, Joseph H. Guettler and James Bicos in Orthopaedic Journal of Sports Medicine