The Knee 23 (2016) 237240

Contents lists available at ScienceDirect

The Knee

Limited utility of routine early postoperative radiography after primary

ACL reconstruction
Brian C. Werner , M. Tyrrell Burrus, Michelle E. Kew, Ian J. Dempsey, F. Winston Gwathmey,
Mark D. Miller, David R. Diduch
Department of Orthopaedic Surgery, University of Virginia Health System, PO Box 800159, Charlottesville, VA 22908, USA

a r t i c l e

i n f o

Article history:
Received 16 March 2015
Received in revised form 2 July 2015
Accepted 2 September 2015
Keywords:
ACL reconstruction
X-ray
Radiographs
Cost-effective
Healthcare economics

a b s t r a c t
Background: Given the overall success of anterior cruciate ligament (ACL) reconstruction and the infrequent
occurrence of complications detectable on radiographs, the clinical utility and cost-effectiveness of routine radiographs in the early postoperative setting is questionable.
Methods: Nine hundred thirty-three consecutive adult patients undergoing uncomplicated ACL reconstruction at
a single institution were retrospectively reviewed to determine whether a postoperative knee radiograph
was obtained within the rst three months postoperatively. Images, reports and clinical notes were reviewed
to determine if any clinical management change occurred due to x-ray ndings. Radiograph charges, including
imaging, technical and professional charges were calculated.
Results: Five hundred ninety-nine of 933 primary ACL reconstruction patients (64.8%) had postoperative knee
radiography at an average of 6.3 3.5 weeks postoperatively. A musculoskeletal radiologist read 97.7% of x-rays
as normal. In the associated visit note, 70.3% of x-ray results were documented. Only 14.1% of patients with a postoperative x-ray had subsequent imaging. There were no signicant management changes based on the routine
postoperative radiographs using the dened criteria. A total of $336,683 ($562 per patient) was billed to patients
for postoperative radiographs.
Conclusions: Routine early postoperative radiography after primary ACL reconstruction is of questionable utility.
The signicant per-patient expense is not balanced by the low yield of clinically meaningful data, as nearly all
radiographs in the present series were normal and none resulted in signicant changes in postoperative clinical
management. These results suggest that routine radiographs after uncomplicated ACL reconstruction may be
unnecessary although larger, multicenter studies are necessary to conrm these ndings.
Level of evidence: Level IV, retrospective case series.
2015 Elsevier B.V. All rights reserved.

1. Introduction
Postoperative radiographs are routinely obtained in many medical
centers after ambulatory sports medicine procedures such as anterior
cruciate ligament (ACL) reconstruction despite lack of evidence
supporting such a practice [13]. Given the overall success of this
procedure and the infrequent occurrence of complications detectable
on radiographs, the clinical utility and cost-effectiveness of routine radiographs in the early postoperative setting is questionable [48].
Numerous studies have found little utility or economic justication
for the use of routine postoperative imaging after other orthopedic
procedures, including both total knee and total hip arthroplasty
[915]. Recent studies have also not demonstrated any cost benet or
Corresponding author at: University of Virginia Health System, 400 Ray C. Hunt Dr,
Suite 330, Charlottesville, VA 22908-0159, USA. Tel.: +1 434 243 0265; fax: +1 434 243
0242.
E-mail address: bcw4x@virginia.edu (B.C. Werner).

http://dx.doi.org/10.1016/j.knee.2015.09.006
0968-0160/ 2015 Elsevier B.V. All rights reserved.

clinical utility in obtaining routine radiography following either cervical

or lumbar spine procedures up to a year postoperatively [1619]. Similar conclusions have been made regarding the routine use of immediate
postoperative radiography following total shoulder arthroplasty [20].
Non-orthopedic disciplines have come to similar conclusions regarding
the use of routine post-procedure radiography in asymptomatic or uncomplicated cases [2123].
Reducing wasteful spending and eliminating unnecessary risk are
important issues that are at the center of the current shift toward
value-based orthopedic care delivery. There is substantial redundancy
and waste existing in the current practice of orthopedic surgery, and
excessive postoperative imaging is one redundancy that can potentially
be eliminated without signicant negative clinical effects.
The purpose of the present study was to comprehensively assess the
clinical utility and cost-effectiveness of early postoperative radiographs
after uncomplicated ACL reconstruction. We hypothesized that there is
limited clinical utility of routine radiographs in this setting with signicant associated cost, making their cost utility low.

238

B.C. Werner et al. / The Knee 23 (2016) 237240

2. Material and methods

After obtaining Institutional Review Board approval, a retrospective chart review was performed on all patients who underwent
arthroscopic-assisted ACL reconstruction (CPT 29888) in the past
12 years for all orthopedic sports medicine surgeons at a single institution. Once the appropriate patients were identied by CPT code, a chart
review was performed to identify epidemiologic data, other procedures
performed (including meniscal repair or meniscectomy, microfracture),
details of the operation performed (including type of graft and implant
in ACL patients), as well as any available postoperative follow-up information, including complications.
The inclusion criteria was 1) having undergone arthroscopicassisted ACL reconstruction between 2000 and 2013. The exclusion
criteria was 1) imaging no longer available in PACS system for review,
2) multiple ligament reconstruction, 3) concomitant high tibial
osteotomy or 4) revision procedure. One thousand one hundred twenty
patients met the inclusion criteria and 187 were excluded (97 revision
ACL reconstructions, 83 multiligament knee reconstructions, seven
concomitant high tibial osteotomy), leaving 933 available for nal
data analysis. Demographic and operative information for the nal
cohort is presented in Table 1.
A retrospective evaluation of postoperative radiographs and radiologist reports was completed for all included patients. Patients were
considered to have had early postoperative radiography if an x-ray of
the operative knee was obtained within three months postoperatively.
Postoperative radiographs were rst classied as normal or abnormal based on the radiologist's read. Second, the postoperative clinic
notes were reviewed to assess if radiograph results or radiologist
reads were documented. Lastly, the results of the radiograph were
assessed to determine if the radiograph yielded a clinically signicant
impact. A radiograph was considered to have caused a change in
Table 1
Cohort characteristics.
Patient demographics
Age (yrs, avg. S.D.)
Gender (n, % male)
BMI (kg/m2, S.D.)
Laterality (n, % right)

28.7 yrs 12.2 yrs

356 (59.4%)
27.8 7.1
291 (48.6%)

Operative details
Graft
Hamstring autograft (n, %)
Patellar tendon autograft (n, %)
Allograft (n, %)

468 (78.1%)
126 (21.0%)
5 (0.8%)

Femoral xation
Interference screw (n, %)
Suspensory (n, %)
Cross pin (n, %)

193 (32.2%)
186 (31.1%)
220 (36.7%)

Tibial xation
Interference screw (n, %)
Cross pi n (n, %)

594 (99.2%)
5 (0.8%)

Postoperative x-rays
Number of x-rays
1 (n, %)
2 (n, %)
3 (n, %)
4 (n, %)
5 (n, %)
N5 (n, %)
Key:
yrs: years
avg: average
S.D.: standard deviation
BMI: body mass index
kg: kilograms
m: meter

490 (81.8%)
76 (12.7%)
22 (3.7%)
8 (1.3%)
3 (0.5%)
0 (0.0%)

management if any of the following criteria were met: 1) notation of

postoperative fracture requiring intervention, 2) notation of postoperative effusion not noted on physical examination that led to aspiration,
3) notation of malpositioned hardware that led to eventual revision
surgery or patient counseling, 4) notation of aberrant ACL tunnel placement that resulted in patient counseling, change in physical therapy, or
later graft instability, or 5) initial radiograph was referred to in a later radiograph or magnetic resonance imaging (MRI) for comparison
(i.e., later radiograph noted to have tunnel widening based on comparison to initial postoperative radiograph). Cost was determined by
obtaining 2013 institutional charges and Medicare reimbursement
rates for knee radiographs based on number of views obtained (CPT
73560, 62, 64).
The primary outcome variable was if postoperative radiographs lead
to a change in management as dened above. The secondary outcome
variables were 1) radiologist read of postoperative x-ray (normal or
abnormal), 2) documentation of radiograph interpretation or radiologist read in note, 3) total hospital charges for radiographs, and 4) total
Medicare reimbursement for radiographs.
3. Results
Five hundred ninety-nine (64.8%) of the 933 patients included in the study had postoperative knee radiographs obtained at an average of 6.3 3.5 weeks postoperatively.
Demographic and operative details for the 599 patients who had early postoperative radiographs are presented in Table 1. Normal postoperative ndings were reported in
97.9% (592/599) of the radiographs, and only 70.3% (418/599) of the radiographs were
mentioned in a postoperative clinic note. If two sets of knee radiographs were obtained
in the postoperative period, the rst one was mentioned in comparison in 67.1% (57/84)
of the cases. The number of postoperative radiographs obtained for patients, which ranged
between one and ve total, is presented in Table 1. The majority of patients had a single
postoperative radiograph (81.8%).
Radiopaque femoral xation was placed in 56.2% (311/599) of the knees with postoperative radiographs and radiopaque tibial xation in 21.5% (119/599) of the knees with
postoperative radiographs. No additional procedures were performed in any patients
that required radiopaque xation or implants. The details of the type of femoral and tibial
xation used are included in Table 1. There were no intraoperative complications.
No changes in postoperative management or rehabilitation were made based on
the postoperative radiographs. A total of $336,683 was billed to patients for postoperative
x-rays, which equates to an average of $562 per patient with radiographs.

4. Discussion
Fiscal responsibility has become an important objective for efcient
and efcacious health care. As reimbursements decline and bundled
care initiatives gain traction, appropriately allocating monetary resources is imperative for the long-term survival of individual practices
and the health care systems. The present study found that routine
early postoperative radiography after uncomplicated primary ACL
reconstruction does not appear to be cost-effective. The signicant
per-patient expense was not balanced by the low yield of clinically
meaningful data, as nearly all radiographs in the present series were
normal, subsequent imaging was rarely obtained and no imaging resulted in signicant changes in postoperative clinical management.
Previous studies in other orthopedic subspecialties have found that
routine postoperative imaging is obtained too frequently and without
benet to the patient. Glaser and Lotke evaluated early postoperative
imaging following total knee arthroplasty (TKA) [9]. Of the 192 radiographs in a cohort of patients who had radiographs prior to discharge,
none altered the management of these patients, and the authors noted
that only 36% of those images were of sufcient quality to even provide
an accurate baseline for further studies. The second cohort of 550 patients who only obtained imaging at their rst postoperative clinic
visit did not experience any adverse outcome as a result of delayed imaging. This nding has been echoed in prior studies that also found minimal utility for routine TKA imaging prior to discharge and suggested
that the low quality of portable techniques is partly to be blame [1012].
Early radiographic evaluation following spine surgery has also been
found to have little utility. For single level cervical or lumbar fusion

B.C. Werner et al. / The Knee 23 (2016) 237240

procedures performed under uoroscopy, Molinari et al. demonstrated

no signicant differences in various radiographic parameters or implant
positioning between the intra and immediate postoperative imaging
[16]. The authors concluded that the additional $600 per patient for
the postoperative radiographs was not justied given that they resulted
in no changes in management. For lumbar spine fusions, Romero et al.
argued that, during the rst postoperative year, radiographs are best obtained only if the history or physical exam is abnormal as they rarely
alter management otherwise [17]. A recent study of 451 consecutive
pediatric patients who underwent correction of scoliosis found that routine postoperative radiographs had extremely low utility in guiding
course of treatment for asymptomatic patients.
One argument for the use of routine postoperative radiography after
ACL reconstruction is to evaluate radiopaque hardware, particularly suspensory xation, to assure that it is not perched or fallen into the femoral tunnel. Over half of the patients in the present study had radiopaque
femoral xation and 186 patients (31.1%) had suspensory xation and
no instances of hardware failure were noted on radiography. Proponents of routine postoperative knee radiographs after ACL reconstruction also may cite concern for intraoperative femur or tibial fractures
as an indication. In one of the few case reports of an intraoperative
femur fracture, a Hoffa fragment was produced during tunnel dilation
and was detected during the procedure and addressed [24]. Conversely,
posterior wall blowout, although similar to the above situation, involves
tunnel placement too far posterior and thus leaves a very thin posterior
femoral cortical shell [25]. During tunnel dilation or interference screw
placement, this posterior wall is breached which may compromise the
xation of the graft and thus the stability of the graft. Adequate attention to tunnel positioning, careful tunnel dilation, and manual testing
of graft stability and tension help to avoid and recognize this complication [25,26]. While posterior wall blowout may be seen on postoperative radiographs even if it is not recognized intraoperatively, most
surgeons would not recommend revision surgery if the knee is clinically
stable [25,26]. Several case reports discuss fractures through ACL femoral or tibial tunnels which occurred well after the initial procedure
mostly due to major or minor trauma [6,8,2729]. Additionally, many
of these fractures occurred after revision ACL reconstructions where
larger stress rises are created from a second femoral tunnel. These
patients would likely present with pain and potentially instability, in
which case radiographs would be indicated.
Plain radiography does have utility after ACL reconstruction but is
likely best reserved for patients with knee pain or episodes of recurrent
instability. Delayed implant migration, such as an Endobutton (Smith &
Nephew, Andover, MA, USA) into the femoral tunnel, and tibial and
femoral interference screw dislodgement have been reported to occur
postoperatively [26,3033]. This risk may be higher with bioabsorbable
screws as they degrade, lose their structure, and then loosen [33]. Additionally, plain radiographs can elucidate tunnel widening which is
important to note prior to revision ACL reconstruction; however,
this process is not an acute phenomenon and takes months to years to
develop [5,26].
The value of early postoperative radiographs after uncomplicated
procedures has also been evaluated by non-orthopedic specialities,
and similar conclusions have been reached. Keckler et al. performed a
retrospective chart review of 237 patients who underwent uoroscopic
placement of central venous catheters followed by routine chest radiographs to evaluate positioning and to rule out signicant complications
(e.g. pneumothorax). With a total cost of $56,196 for the chest radiographs which resulted in no management alterations, the authors recommended that the radiographs are redundant when uoroscopy
is utilized. In a similar study by Tarnoff et al., post-tracheostomy chest
radiography was not deemed cost effective based on the low likelihood
of altering patient management [22].
One limitation of the current study is that no cost-effective analysis
was performed as it is difcult to quantify the cost of all of the possible
missed diagnoses that would be obtained from postoperative radiography.

239

Additionally, we did not include a comparison group who did not receive
radiographs to see if management differed between the two groups. Furthermore, although the study included a large sample size, the outcomes
for which a postoperative radiograph would have changed management
are rare, necessitating a much larger, multicenter study to denitively
state that routine radiographs are not of benet in all patients after
uncomplicated ACL reconstruction. Based on the results of this study, the
sports medicine surgeons at our institution have discontinued the use
of routine postoperative radiography after primary ACL reconstruction. If
there is any concern for hardware breakage or intraoperative fracture,
then uoroscopy is used to evaluate the knee intraoperatively.
5. Conclusions
Routine early postoperative radiography after primary ACL reconstruction is of questionable utility. The signicant per-patient expense
is not balanced by the low yield of clinically meaningful data, as nearly
all radiographs in the present series were normal, subsequent imaging
was rarely obtained, and none resulted in signicant changes in postoperative clinical management. These results suggest that routine radiographs after uncomplicated ACL reconstruction may be unnecessary
although larger, multicenter studies are necessary to conrm these
ndings.
References
[1] Brand Jr JC, Cole J, Sumida K, Caborn DN, Johnson DL. Radiographic analysis of
femoral tunnel position in postoperative posterior cruciate ligament reconstruction.
Arthroscopy 2002;18:68894.
[2] Shah AA, Brien A, Lowe WR. Radiographic results of femoral tunnel drilling through
the anteromedial portal in anterior cruciate ligament reconstruction. Arthroscopy
2010;26:158692.
[3] Xu Y, Ao Y, Wang J, Yu J, Cui G. Relation of tunnel enlargement and tunnel placement
after single-bundle anterior cruciate ligament reconstruction. Arthroscopy 2011;27:
92332.
[4] Neviaser AS, Flatow EL, Omid R, Yamaguchi K, Levine WN. How to minimize complications in shoulder instability and rotator cuff surgery. Instr Course Lect 2012;61:
13141.
[5] Choi NH, Son KM, Yoo SY, Victoroff BN. Femoral tunnel widening after hamstring anterior cruciate ligament reconstruction with bioabsorbable transx. Am J Sports Med
2012;40:3837.
[6] Coobs BR, Spiridonov SI, LaPrade RF. Intra-articular lateral femoral condyle fracture
following an ACL revision reconstruction. Knee Surg Sports Traumatol Arthrosc
2010;18:12903.
[7] Crawford DC, Hallvik SE, Petering RC, Quilici SM, Black LO, Lavigne SA, et al. Postoperative complications following primary ACL reconstruction using allogenic
and autogenic soft tissue grafts: increased relative morbidity risk is associated
with increased graft diameter. Knee 2013;20:5205.
[8] Jayadev C, Kochhar T, Back DL, Ratnakumar K. Supracondylar femoral fracture after
anterior cruciate ligament reconstruction with transfemoral xation. J Knee Surg
2009;22:3646.
[9] Glaser D, Lotke P. Cost-effectiveness of immediate postoperative radiographs after
uncomplicated total knee arthroplasty: a retrospective and prospective study of
750 patients. J Arthroplasty 2000;15:4758.
[10] Kosashvili Y, Alvi M, Mayne IP, Sar O, Gross A, Backstein D. Immediate recovery
room radiographs after primary total knee arthroplastywhy do we keep doing
them? Int Orthop 2010;34:116773.
[11] Moskal JT, Diduch DR. Postoperative radiographs after total knee arthroplasty:
a cost-containment strategy. Am J Knee Surg 1998;11:8993.
[12] Mulhall KJ, Masterson E, Burke TE. Routine recovery room radiographs after total hip
arthroplasty: ineffective for screening and unsuitable as baseline for longitudinal
follow-up evaluation. J Arthroplasty 2004;19:3137.
[13] Ndu A, Jegede K, Bohl DD, Keggi K, Grauer JN. Recovery room radiographs after total
hip arthroplasty: tradition vs utility? J Arthroplasty 2012;27:10516.
[14] Niskanen RO. Early repetitive radiography is unnecessary after an uncomplicated
cemented hip or knee arthroplasty for osteoarthritis. Acta Orthop Belg 2005;71:
6925.
[15] Ververeli PA, Masonis JL, Booth RE, Hozack WJ, Rothman RH. Radiographic cost
reduction strategy in total joint arthroplasty. A prospective analysis. J Arthroplasty
1996;11:27780.
[16] Molinari RW, Hunter JG, McAssey RW. In-hospital postoperative radiographs for
instrumented single-level degenerative spinal fusions: utility after intraoperative
uoroscopy. Spine J 2012;12:55967.
[17] Romero NC, Glaser J, Walton Z. Are routine radiographs needed in the rst year after
lumbar spinal fusions? Spine (Phila Pa 1976) 2009;34:157880.
[18] Shau DN, Bible JE, Samade R, Gadomski SP, Mushtaq B, Wallace A, et al. Utility
of postoperative radiographs for cervical spine fusion: a comprehensive evaluation

240

[19]

[20]

[21]

[22]
[23]

[24]

[25]

B.C. Werner et al. / The Knee 23 (2016) 237240

of operative technique, surgical indication, and duration since surgery. Spine (Phila
Pa 1976) 2012;37:19942000.
Shau DN, Bible JE, Gadomski SP, Samade R, Armaghani S, Mencio GA, et al. Utility of
postoperative radiographs for pediatric scoliosis: association between history and
physical examination ndings and radiographic ndings. J Bone Joint Surg Am
2014;96:112734.
Namdari S, Hsu JE, Baron M, Huffman GR, Glaser D. Immediate postoperative radiographs after shoulder arthroplasty are often poor quality and do not alter care. Clin
Orthop Relat Res 2013;471:125762.
Keckler SJ, Spilde TL, Ho B, Tsao K, Ostlie DJ, Holcomb 3rd GW. Chest radiograph after
central line placement under uoroscopy: utility or futility? J Pediatr Surg 2008;43:
8546.
Tarnoff M, Moncure M, Jones F, Ross S, Goodman M. The value of routine
posttracheostomy chest radiography. Chest 1998;113:16479.
Tyroch AH, Kaups K, Lorenzo M, Schreiber M, Solis D. Routine chest radiograph is not
indicated after open tracheostomy: a multicenter perspective. Am Surg 2002;68:
802.
Werner BC, Miller MD. Intraoperative Hoffa fracture during primary ACL reconstruction: can hamstring graft and tunnel diameter be too large? Arthroscopy 2014;30:
64550.
Rue JP, Busam ML, Detterline AJ, Bach Jr BR. Posterior wall blowout in anterior cruciate ligament reconstruction: avoidance, recognition, and salvage. J Knee Surg
2008;21:23540.

[26] Giaconi JC, Allen CR, Steinbach LS. Anterior cruciate ligament graft reconstruction:
clinical, technical, and imaging overview. Top Magn Reson Imaging 2009;20:
12950.
[27] Wilson TC, Rosenblum WJ, Johnson DL. Fracture of the femoral tunnel after an anterior cruciate ligament reconstruction. Arthroscopy 2004;20:e457.
[28] Radler C, Wozasek GE, Seitz H, Vecsei V. Distal femoral fracture through the screw
hole of a ligament augmentation device xation. Arthroscopy 2000;16:7379.
[29] Gobbi A, Mahajan V, Karnatzikos G. Tibial plateau fracture after primary anatomic
double-bundle anterior cruciate ligament reconstruction: a case report. Arthroscopy
2011;27:73540.
[30] Casagranda BU, Maxwell NJ, Kavanagh EC, Towers JD, Shen W, Fu FH. Normal appearance and complications of double-bundle and selective-bundle anterior cruciate
ligament reconstructions using optimal MRI techniques. AJR Am J Roentgenol 2009;
192:140715.
[31] Bush-Joseph CA, Bach Jr BR. Migration of femoral interference screw after anterior
cruciate ligament reconstruction. Am J Knee Surg 1998;11:324.
[32] Pereira H, Correlo VM, Silva-Correia J, Oliveira JM, Reis RL, Espregueira-Mendes J.
Migration of bioabsorbable screws in ACL repair. How much do we know?
A systematic review. Knee Surg Sports Traumatol Arthrosc 2013;21:98694.
[33] Krappel FA, Bauer E, Harland U. The migration of a BioScrew as a differential diagnosis of knee pain, locking after ACL reconstruction: a report of two cases. Arch Orthop
Trauma Surg 2006;126:61520.