Surgeon-Perceived Risk Factors for Revision After Anterior Cruciate Ligament Reconstruction Show Global Agreement with Regional Differences

INTRODUCTION/OBJECTIVES: To conduct a survey of orthopedic surgeons asking them to rank factors they believed to be most strongly influential on revision risk following primary anterior cruciate ligament reconstruction (ACLR), and to evaluate whether these perceptions differed across global regions and years in practice. METHODS: An international cross-sectional survey was distributed to five professional orthopedic societies. Factors were broken down into the following domains: demographic and anatomic variables, injury-related variables, and surgical and rehabilitation variables, ranked from one (least important) to 50 (most important). Descriptive statistics were reported, and differences in medians between factors within each domain, and medians between continents and practice volumes, were analyzed using the Kruskal-Wallis and Dunn's post-hoc tests with Benjamini-Hochberg correction. RESULTS: A total of 136 surgeons completed the survey. Respondents were primarily from North America (n = 53; 39%), Asia (n = 42; 30.9%), and Europe (n = 37; 27.2%). A total of 118 (86.8%) had received fellowship training in performing ACLRs. Involvement in high-pivoting sports had the highest demographic/anatomical rating (median 45, [IQR 10]). Overall, surgeons demonstrated substantial agreement in factor rankings, with high-pivoting sports, concomitant collateral or posterolateral corner injury, early return to sport, smaller graft diameter, and lack of lateral extra-articular procedure (LEAP) consistently rated among the most important risk factors worldwide. Ratings stratified by practice volume or financial practice model did not differ significantly statistically. CONCLUSION: Surgeons worldwide generally demonstrated agreement regarding key demographic, injury-related, and surgical risk factors for ACLR revision, although regional variation did exist in perceived importance of certain variables. Highly rated demographic factors included involvement in high-pivoting sports, while highly rated injury factors included concomitant collateral injury, posterolateral corner injury, and preoperative pivot shift of greater than grade two. Highly rated surgical and rehabilitation factors included early return to sport, graft diameter below 8 mm, and lack of concomitant LEAP. LEVEL OF EVIDENCE: V.