CORR Insights(A (R)): Coronal Limb Alignment and Indications for High Tibial Osteotomy in Patients Undergoing Revision ACL Reconstruction

Clinical Orthopaedics and Related Research (Impact Factor: 2.77). 11/2013; 471(11). DOI: 10.1007/s11999-013-3246-6
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Available from: John P Albright, Aug 01, 2015
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    ABSTRACT: At the time of anterior cruciate ligament (ACL) reconstruction, there are usually concurrent meniscal and articular cartilage injuries. It is unclear if there is a significant difference between intra-articular injuries at the time of a primary ACL reconstruction compared with revision ACL reconstruction. To compare the meniscal and articular cartilage injuries found at the time of primary and revision ACL reconstruction surgery and to determine associations between primary and revision surgery and specific intra-articular findings. Cohort study (prevalence); Level of evidence, 2. Primary and revision ACL surgeries were identified from the Multicenter Orthopedic Outcomes Network (MOON) and Multicenter ACL Revision Study (MARS) study groups, respectively, from January 1, 2007 to November 1, 2008. Demographic data on individual patients were analyzed including age, body mass index (BMI), and gender. Intra-articular findings including the presence of medial or lateral meniscal tears and chondral damage to articular surfaces were analyzed for each patient. Comparisons of intra-articular findings at the time of surgery for the 2 groups were analyzed. Chondral damage in the medial and lateral compartments was analyzed considering previous meniscal tear as a possible confounder. There were 508 patients undergoing primary ACL reconstruction and 281 patients undergoing revision ACL reconstruction who were identified for inclusion. There were no differences in the mean age, BMI, and gender in the 2 study groups. There was a decreased odds ratio (OR) of new untreated lateral meniscal tears (OR, 0.54; P < .01) but not of medial meniscal tears (OR, 0.86; P = .39) in revision compared with primary ACL reconstruction. There was an increased OR of Outerbridge grade 3 and 4 articular cartilage injury in revision compared with primary ACL reconstruction in the lateral compartment (OR, 1.73; P = .04) and in the patellar-trochlear compartment (OR, 1.70; P = .04) but not in the medial compartment (OR, 1.33; P = .23). There was an increased OR of Outerbridge grade 3 and 4 articular cartilage injury in patients from both groups having a prior medial meniscectomy on the medial femoral condyle (OR, 1.44; P < .01) and on the medial tibial plateau (OR, 1.63; P < .01). There was an increased OR of Outerbridge grade 3 and 4 articular cartilage injury in patients from both groups having a prior lateral meniscectomy on the lateral femoral condyle (OR, 1.65; P < .01) and on the lateral tibial plateau (OR, 1.56; P < .01). Meniscal tears are a common finding in both primary and revision ACL reconstruction. These results show a decreased OR of new untreated lateral meniscal tears in revision compared with primary ACL reconstruction. A previous medial or lateral meniscectomy increases the OR of articular cartilage damage in the medial or lateral compartments, respectively. Even when controlling for meniscus status, there is an increased OR in revision compared with primary ACL reconstruction of significant lateral compartment and patellar-trochlear chondral damage but not medial compartment chondral damage.
    The American Journal of Sports Medicine 06/2011; 39(9):1889-93. DOI:10.1177/0363546511406871 · 4.36 Impact Factor
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    ABSTRACT: BACKGROUND:The factors that lead to patients failing multiple anterior cruciate ligament (ACL) reconstructions are not well understood. HYPOTHESIS:Multiple-revision ACL reconstruction will have different characteristics than first-time revision in terms of previous and current graft selection, mode of failure, chondral/meniscal injuries, and outcomes. STUDY DESIGN:Case-control study; Level of evidence, 3. METHODS:A prospective multicenter ACL revision database was utilized for the time period from May 1, 2006 to April 1, 2012. Patients were divided into those who underwent a single-revision ACL reconstruction and those who underwent multiple-revision ACL reconstructions. The primary outcome variable was Marx activity level. Primary data analyses between the groups included a comparison of graft type, perceived mechanism of failure, associated injury (meniscus, ligament, and cartilage), reconstruction type, and tunnel position. Data were compared by analysis of variance with a post hoc Tukey test. RESULTS:A total of 1200 patients (57% men; median age, 26 years) were enrolled, with 1049 (89%) patients having a primary revision and 151 (11%) patients having a second or subsequent revision. Marx activity levels were significantly higher (9.77) in the primary-revision group than in those patients with multiple revisions (6.74). The most common cause of reruptures was a traumatic, noncontact ACL graft injury in 55% of primary-revision patients; 25% of patients had a nontraumatic, gradual-onset recurrent injury, and 12% had a traumatic, contact injury. In the multiple-revision group, a nontraumatic, gradual-onset injury was the most common cause of recurrence (47%), followed by traumatic noncontact (35%) and nontraumatic sudden onset (11%) (P < .01 between groups). Chondral injuries in the medial compartment were significantly more common in the multiple-revision group than in the single-revision group, as were chondral injuries in the patellofemoral compartment. CONCLUSION:Patients with multiple-revision ACL reconstructions had lower activity levels, were more likely to have chondral injuries in the medial and patellofemoral compartments, and had a high rate of a nontraumatic, recurrent injury of their graft.
    The American Journal of Sports Medicine 05/2013; · 4.36 Impact Factor
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    ABSTRACT: Valgus high tibial osteotomy (HTO) has been recommended for ligament stability and enhanced function after anterior cruciate ligament (ACL) reconstruction in varus-angulated knees. However, it is not clear whether HTO should be performed in patients undergoing ACL reconstruction who have primary varus knees without medial compartment arthrosis. We therefore asked whether stability and function differed in patients having ACL reconstruction with differing degrees of preoperative alignment. We retrospectively reviewed 201 patients who had primary, single-bundle ACL reconstructions with primary varus knees based on the preoperative mechanical axis deviation (MAD) on preoperative standing hip-knee-ankle radiographs. Patients were categorized into four groups according to the MAD: Group 1: 0 mm to 4 mm, Group 2: 5 mm to 9 mm, Group 3: 10 mm to 14 mm, and Group 4: greater than 15 mm. A total of 201 patients, 67 in Group 1, 53 in Group 2, 38 in Group 3, and 43 in Group 4, were assessed. Ligament stability was determined with the Lachman test, pivot shift test, and KT 2000™ arthrometer. Functional scores were assessed using the Lysholm score and the International Knee Documentation Committee (IKDC) score. The minimum followup was 24 months (mean, 45 months; range, 24-96 months). We observed no differences in the side-to-side KT 2000™ measurements, Lysholm score, or IKDC functional scores based on the preoperative MAD. The stability and functional scores after ACL reconstruction were not adversely altered by primary varus alignment. Thus, if there is no medial compartment arthritis or varus thrust, we do not believe a correctional tibial osteotomy is crucial in primary varus knees undergoing ACL reconstruction.
    Clinical Orthopaedics and Related Research 05/2011; 469(5):1421-6. DOI:10.1007/s11999-010-1584-1 · 2.77 Impact Factor

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