ArticleLiterature Review

Revision Anterior Cruciate Ligament Reconstruction Surgery

November 1998
The Journal of the American Academy of Orthopaedic Surgeons 7(3):189-98

November 1998
7(3):189-98

DOI:10.5435/00124635-199905000-00005

Source
PubMed

Authors:

Revision anterior cruciate ligament (ACL) reconstruction is indicated for selected patients with recurrent instability after a failed primary procedure. The cause of the failure must be carefully identified to avoid pitfalls that may cause the revision to fail as well. Associated instability patterns must be recognized and corrected to achieve a successful result. The choice of graft, the problem of retained hardware, and tunnel placement are the major challenges of revision ACL reconstruction. The patient must have reasonable expectations and understand that the primary goal of surgery is restoration of the ability to perform activities of daily living, rather than a return to competitive athletics. The results of revision ACL reconstructions are not as good as those after primary reconstructions; however, the procedure appears to be beneficial for most patients.

Revision Anterior Cruciate Ligament Reconstruction: Tibial Tunnel-First Graft-Sizing Technique

Article

Full-text available

Nov 2021

Revision anterior cruciate ligament reconstruction (R-ACLR) has become more common as the number of failed primary ACLRs increase. Although increasingly common, R-ACLR has a greater failure rate than a primary reconstruction. Technical errors, particularly in tunnel placement, account for a large proportion of graft failure in R-ACLR as well as re-revision cases. Tunnel placement and trajectory is particularly important in R-ACLR and becomes more challenging with each additional revision attempt. This is in part because any tunnels created for revision may converge with formerly drilled tunnels or face interference hardware creating, complicating proper graft fixation. While there are many approaches to revision ACL surgery, our technique describes a simple, tibial tunnel-first graft-sizing method initially reaming tunnels with very small diameters and sequentially working your way up to more anatomic diameters.

Ön çapraz bağ cerrahisi revizyonları

Article

Jan 2020

Outcome of revision Anterior Cruciate Ligament Reconstruction: Quadriceps Tendon Autograft Compared with BONE-Patellar Tendon-Bone Autograft

Article

Full-text available

Jan 2024

Background: Reconstruction of the anterior cruciate ligament (ACL) is one of the most common

Double-bundle non-anatomic ACL revision reconstruction with allograft resulted in a low revision rate at 10 years

Article

Full-text available

Sep 2022

Purpose: This study aimed at reporting the long-term second revision rate and subjective clinical outcomes from a cohort of patients who underwent a double-bundle (DB) ACLR first revision with allograft at a single institution. Methods: The Institutional database was searched according to the following inclusion criteria: (1) patients that underwent DB-ACL first revision with Achilles tendon allograft, (2) surgery performed between January 2000 and December 2012, (3) age at revision ≥ 18 y/o. Patients' general information, history, surgical data, and personal contacts were extracted from charts. An online survey platform was implemented to collect responses via email. The survey questions included: date of surgeries, surgical data, date of graft failure and subsequent second ACL revision surgery, any other surgery of the index knee, contralateral ACLR, KOOS score, and Tegner scores. Results: Eighty-one patients were included in the survival analysis, mean age at revision 32 ± 9.2 y/o, 71 males, mean BMI 24.7 ± 2.7, mean time from ACL to revision 6.8 ± 5.4 years, mean follow-up time 10.7 ± 1.4 years. There were 12 (15%) second ACL revisions during the follow-up period, three females and nine males, at a mean of 4.5 ± 3 years after the index surgery. The overall survival rates were 85% from a second ACL revision and 68% from all reoperations of the index knee. Considering only the successful procedures (61 patients), at final follow-up, the mean values for the KOOS subscales were 84 ± 15.5 for Pain, 88.1 ± 13.6 for Symptoms, 93 ± 11.6 for ADL, 75 ± 24.5 for Sport, and 71 ± 19.6 for Qol. Twenty-nine (48%) patients performed sports activity at the same level as before ACLR failure. Conclusions: Double-bundle ACL revision with fresh-frozen Achilles allograft yields satisfactory results at long-term follow-up, with an 85% survival rate from a second ACL revision at mean 10 years' follow-up and good patient-reported clinical scores. Level of evidence: Level IV.

The Multivariate Relationship Between Primary Anterior Cruciate Ligament Reconstruction Timing and Revision Rates: A 10-Year Analysis

Article

Full-text available

Jan 2022

Background and objective The optimal timing of anterior crucial ligament reconstruction (ACLR) remains a matter of controversy. A revision procedure is performed to improve knee function, correct instability, and enable a safe return to daily function when primary ACLR fails. The present study aimed to determine if the timing of primary ACLR is predictive of revision surgery. Methods All patients who underwent primary ACLR at the West Virginia University from January 2008 to December 2018 were identified. Patients were initially grouped into early (≤30 days) and late (>30 days) ACLR based on the onset of the initial injury. The major outcome measure of this study was the incidence of revision ACLR following primary ACLR. Results A total of 233 primary ACLRs were included. The incidence of ACLR revisions was 9.4%. The timing of primary ACLR, when categorized into early and late ACLRs, was not found to influence revision risk (p=0.384). Additionally, the damaged anatomical structures based on the postoperative diagnosis at the time of ACLR did not influence the odds of revision ACLR (p=0.9721). Conclusion Our study found that the timing of primary ACLR did not influence the revision rates when categorizing primary surgery time into early and late subgroups.

Hypermobility, ACL reconstruction & Shoulder instability: A clinical, mechanical and histological analysis

Thesis

Full-text available

Apr 2020

Muhammad Adeel Akhtar

Joint movements are essential for the function of human body during the activities of daily living and sports. The movement of human joints varies from normal to those which have an increased range of joint movement (gymnasts) to those with extreme disabling laxity in patients with a connective tissue disorder (Ehlers Danlos Syndrome). "Hypermobility" is most commonly used to describe excessive movement. Hypermobility was assessed by using the current criteria of the Beighton score for signs and the Brighton criteria for symptoms of hypermobility in a group of orthopaedic patients attending the specialist knee and shoulder injury clinics. The Beighton score was found to be higher in patients attending for primary ACL reconstruction (mean 2.9, p = 0.002) and revision ACL reconstruction (mean 4, p < 0.001) when compared with the control group. Hypermobility was a risk factor for the failure of ACL reconstruction (30% vs 0%). The mean Beighton score was higher in both the primary shoulder dislocation group (mean difference 1.8, p=0.001) and the recurrent shoulder dislocation group (mean difference 1.4, p=0.004). Bone defects were studied on the CT scan following shoulder dislocations. There was no correlation between hypermobility and the bone defects. The bone defect was a risk factor for recurrent shoulder instability (48% vs 16%). A material testing system was used to assess the tissue laxity of discarded hamstring tendon and shoulder capsule obtained during stabilisation procedures. The mean gradient of slope for both tendon and capsule graphs was 23.8 (range 3.08-52.63). The tissue laxity was compared to the Beighton score, however no correlation was detected between the Beighton score and the gradient of the tissue laxity. An electronic goniometer was used to measure the angle of the MCP joint of the little finger, whilst a force plate system simultaneously measured the force required to hyperextend the MCP joint. The little finger MCP joints of each hand were assessed in this manner in a group of patients undergoing primary ACL reconstruction or open shoulder stabilization. The mean force required to produce the 40 degrees angle at the little finger MCP joint was 0.04 kg with a range from 0-0.11 kg. There was a positive correlation between the gradient of tissue laxity and the force required to produce 40 degrees angle at the little finger of the dominant hand. The expression of Collagen V and Small leucine rich proteoglycans (Decorin and Biglycan) was studied in the skin, hamstring tendon and shoulder capsule of the patients described above attending with shoulder or knee instability. These patients had different levels of hypermobility (as assessed by the Beighton score) and symptoms of hypermobility (as assessed by the Brighton criteria to diagnose Benign Joint Hypermobility Syndrome). The weaker tendon group was found to have a lower mean Beighton score, while the weaker skin group had a higher mean Beighton score. Collagen V expression was higher in the skin dermal papillae of the weaker group. The Beighton Scores were higher in patients with ACL and shoulder injuries. Hypermobility was a risk factor for the failure of ACL reconstruction. There was no correlation between hypermobility and the bone defects on the CT scan following shoulder dislocation. Bone defects were a risk factor for recurrence. There was no correlation between the Beighton Score and the tissue laxity. There was a correlation between the tissue laxity and the clinical assessment of laxity at the little finger MCPJ by using a force-goniometer system. There was a correlation between the collagen V expression in the dermal papillae of the skin and the Beighton score.

Generalized Joint Hypermobility and Specific Knee Laxity - Aspects of Influence on the Anterior Cruciate Ligament-injured Knee

Thesis

Full-text available

Aug 2019

David Sundemo

Injury to the anterior cruciate ligament (ACL) is one of the most serious sports-related injuries, with significant short- and long-term morbidity. Generalized joint hypermobility (GJH) and specific knee laxity are factors that have been associated with an increased risk of ACL injury and inferior postoperative outcome, but the state of the evidence is unclear and the available information is limited. This thesis consists of five studies with the overall aim of investigating how two main concepts, GJH and specific knee laxity, affect the outcome after ACL reconstruction and how the two concepts affect each other. Study I is a systematic review aiming to investigate the influence of GJH on ACL injury risk and postoperative outcome. Study I comprised 21 studies. While the data synthesis demonstrated GJH as a risk factor for ACL injury in males, the results were conflicting in females. Moreover, there was limited evidence indicating that GJH is associated with increased postoperative knee laxity and inferior patient-reported outcome after ACL reconstruction. Study II is a register-based cohort study comprising 142 patients undergoing ACL reconstruction. The outcome variables were assessed one year after ACL reconstruction and were analyzed using two methods: (1) dichotomization based on the presence of GJH and (2) linear regression to investigate continuous associations with the Beighton score. Interestingly, and contrary to the hypothesis, the analysis revealed that the KOOS sports and recreation subscale was associated with the continuous Beighton score. Functional performance, evaluated with hop and strength tests, was acceptable, regardless of the presence of GJH. Study III is an international multicenter cohort study investigating the correlation between the Beighton score and rotatory knee laxity in 96 ACL-injured patients. Rotatory knee laxity was evaluated using with the pivot-shift test, using two devices to quantify laxity. No correlations between GJH and quantitative rotatory knee laxity were observed in the ACLinjured knee. However, in the contralateral healthy knee, a weak yet significant correlation was observed. Study IV is a retrospective registerbased cohort study comprising 8,502 patients undergoing ACL reconstruction. The patients were divided into four subgroups based on the degree of hyperextension of the contralateral healthy knee. The degree of contralateral hyperextension was analyzed in relation to anterior tibial translation (ATT), using the KT-1000 arthrometer, and in relation to the frequency of concomitant intra-articular injuries in the ACL-injured knee. The ATT was examined six months postoperatively. The study identified an association between contralateral knee hyperextension and greater ATT in the ACL injured knee. Interestingly, there was an inverse relationship between the degree of contralateral hyperextension and the frequency of meniscal injuries. Study V is a retrospective cohort study, based on two previous randomized, controlled cohorts, comprising 147 patients undergoing ACL reconstruction. The study analyzed the influence of increased knee laxity assessed two years postoperatively on clinical outcome variables 16 years postoperatively. This study determined that increased ATT, measured with the Lachman test and the anterior drawer test, was associated with inferior patient-reported outcome 16 years postoperatively. Moreover, increased rotatory knee laxity, measured with the pivotshift test, was associated with inferior patient-reported outcome and a lower level of physical activity after 16 years. Taken together, this thesis provides an overview of all the currently available studies on the subject of the influence of GJH on ACL injury risk and postoperative outcome. It further demonstrates that acceptable short-term functional results could be found in patients with GJH after ACL reconstruction and that patients with increased hypermobility may have short-term subjectively perceived advantages. Moreover, the thesis provides the first correlation analysis between quantitative pivot shift and GJH, finding no association in the ACL-injured knee but a weak correlation in the contralateral healthy knee. Knee hyperextension, a part of GJH, is demonstrated to be associated with increased anterior knee laxity. As identified by Study V, increased anterior and rotatory knee laxity is associated with inferior long-term patient-reported outcome and a lower level of activity after 16 years, results that elucidate the importance of reducing postoperative knee laxity. Considering the accumulated evidence from the current thesis, reduction of postoperative knee laxity is probably particularly important in the susceptible group of individuals with GJH.

Revision Anterior Cruciate Ligament Reconstruction in the Nonathlete Population

Article

Full-text available

Feb 2019

Background There is considerable literature about revision anterior cruciate ligament (ACL) reconstruction in athletes vut there is little published evidence about the same in the nonathletes. The injury itself may remain underdiagnosed and untreated in nonsports persons. This study highlights the high incidence of ACL injury in the nonathletic patient cohort, revision rates, and the outcomes of revision ACL reconstruction. Materials and Methods 856 nonathletic patients who underwent primary ACL reconstruction were included in this retrospective study. Patients were asked on phone whether they had undergone revision surgery and whether they had symptoms severe enough to seek reintervention. Clinical assessment and preoperative and postoperative International Knee Documentation Committee (IKDC) and Lysholm scoring were used to followup patients who underwent revision intervention. Results Clinically, symptomatic revision rate was 5.9% (51 out of 856 patients), and 33 out of these 856 patients (3.9%) underwent revision ACL reconstruction. The reasons for revision were rupture of the previous graft in 21 and laxity (incompetence) of the graft in 12 patients. The mean preoperative and postoperative IKDC scores were 44.1 and 69.8, respectively, and the improvement was statistically significant (P < 0.001). The IKDC score following revision ACL reconstruction was significantly better in those patients who underwent revision <1 year following the onset of recurrent symptoms (P = 0.015). Meniscal tears were present in 47.6%, and chondral injuries were seen in 33.3% of patients. The tibial tunnel positioning was abnormal in 70% of patients. Femoral tunnel positioning was aberrant in all the patients. Conclusions The revision rate of primary ACL reconstruction of 5.9% in nonathletes and revision ACL reconstruction rate of 3.9% are similar to the reported revision rates of 2.9%–5.8% in athletic patients. Similar to athletes, suboptimal tunnel placement is the major contributor to failure in nonathletes also.

A Comparison of Results in Older, Middle-aged, and Younger Patients after Primary Anterior Cruciate Ligament Reconstruction: Minimum 10-Year Follow-up

Article

Full-text available

Jan 2024

Background Anterior cruciate ligament (ACL) reconstruction is commonly performed to prevent decreased knee function and restore stability in middle-aged and even older patients. However, few studies have compared the long-term clinical outcomes of ACL reconstruction between older, younger, and middle-aged patients. The purpose of this study was to compare the long-term clinical outcomes of ACL reconstruction in older patients with those in younger and middle-aged patients. Methods A total of 352 patients who underwent primary ACL reconstruction between January 2003 and March 2008 were retrospectively reviewed and classified into three groups (group A: 246 [age, 20–29 years], group B: 72 [age, 40–49 years], group C: 34 [age, 50–65 years]). The mean follow-up period was 14.2 ± 1.6 years. Clinical outcomes were evaluated and compared between groups. Results The differences in the range of motion, clinical scores, and stability tests were not statistically significant among the three groups. The difference in the graft failure rate among the three groups was significant (group A: 16 [6.5%], group B: 7 [9.7%], group C: 6 [17.6%]; p = 0.040). In particular, when compared between the two groups, there was a significant difference between group A and group C (p = 0.036). The 10-year survival rates were 93.5%, 90.3%, and 82.4% for groups A, B, and C, respectively (p = 0.048). Conclusions Although graft failure rates were higher in older patients than younger and middle-aged patients, clinical outcomes of ACL reconstruction in older patients were comparable to those of younger and middle-aged patients in terms of the range of motion, clinical scores, and stability tests at a minimum follow-up of 10 years.

Good validity in the Norwegian Knee Ligament Register: assessment of data quality for key variables in primary and revision cruciate ligament reconstructions from 2004 to 2013

Article

Full-text available

Mar 2022
BMC MUSCULOSKEL DIS

Background The Norwegian Knee Ligament Register was founded in 2004 to provide representative and reliable data on cruciate ligament surgery. The aim of this study was to evaluate the validity of key variables in the Norwegian Knee Ligament Register to reveal and prevent systematic errors or incompleteness, which can lead to biased reports and study conclusions. Method We included a stratified cluster sample of 83 patients that had undergone both primary and revision anterior cruciate ligament surgery. A total of 166 medical records were reviewed and compared with their corresponding data in the database of the Norwegian Knee Ligament Register. We assessed the validity of a selection of key variables using medical records as a reference standard to compute the positive predictive values of the register data for the variables. Results The positive predictive values for the variables of primary and revision surgery ranged from 92 to 100% and from 39 to 100% with a mean positive predictive value of 99% and 88% respectively. Data on intraoperative findings and surgical details had high positive predictive values, ranging from 91 to 100% for both primary and revision surgery. The positive predictive value for the variable “date of injury” was 92% for primary surgeries but only 39% for revision surgeries. The positive predictive value for “activity at the time of injury” was 99% for primary surgeries and 52% for revisions. Conclusion Overall, the data quality of the key variables examined in the Norwegian Knee Ligament Register was high, making the register a valid source for research.

Clinical and Radiological Outcomes of Anteromedial Portal Versus Transtibial Technique in ACL Reconstruction: A Systematic Review

Article

Full-text available

Jul 2021

Background The drilling technique used to make a femoral tunnel is critically important for determining outcomes after anterior cruciate ligament (ACL) reconstruction. The 2 most common methods are the transtibial (TT) and anteromedial (AM) techniques. Purpose To determine whether graft orientation and placement affect clinical outcomes by comparing clinical and radiological outcomes after single-bundle ACL reconstruction with the AM versus TT technique. Study Design Systematic review; Level of evidence, 3. Methods Articles in PubMed, EMBASE, the Cochrane Library, ISI Web of Science, Scopus, and MEDLINE were searched from inception until April 25, 2020, using the following Boolean operators: transtibial OR trans-tibial AND (anteromedial OR trans-portal OR independent OR three portal OR accessory portal) AND anterior cruciate ligament. Results Of 1270 studies retrieved, 39 studies involving 11,207 patients were included. Of these studies, 14 were clinical, 13 were radiological, and 12 were mixed. Results suggested that compared with the TT technique, the AM technique led to significantly improved anteroposterior and rotational knee stability, International Knee Documentation Committee (IKDC) scores, and recovery time from surgery. A higher proportion of negative Lachman ( P = .0005) and pivot-shift test ( P = .0001) results, lower KT-1000 arthrometer maximum manual displacement ( P = .00001), higher Lysholm score ( P = .001), a higher incidence of IKDC grade A/B ( P = .05), and better visual analog scale score for satisfaction ( P = .00001) were observed with the AM technique compared with the TT technique. The AM drilling technique demonstrated a significantly shorter tunnel length ( P = .00001). Significant differences were seen between the femoral and tibial graft angles in both techniques. Low overall complication and revision rates were observed for ACL reconstruction with the AM drilling technique, similar to the TT drilling technique. Conclusion In single-bundle ACL reconstruction, the AM drilling technique was superior to the TT drilling technique based on physical examination, scoring systems, and radiographic results. The AM portal technique provided a more reproducible anatomic graft placement compared with the TT technique.

Additive Manufacturing: The Next Generation of Scapholunate Ligament Reconstruction

Article

Jun 2021

Background Ligament reconstruction, as a surgical method used to stabilize joints, requires significant strength and tissue anchoring to restore function. Historically, reconstructive materials have been fraught with problems from an inability to withstand normal physiological loads to difficulties in fabricating the complex organization structure of native tissue at the ligament-to-bone interface. In combination, these factors have prevented the successful realization of nonautograft reconstruction. Methods A review of recent improvements in additive manufacturing techniques and biomaterials highlight possible options for ligament replacement. Description of Technique In combination, three dimensional-printing and electrospinning have begun to provide for nonautograft options that can meet the physiological load and architectures of native tissues; however, a combination of manufacturing methods is needed to allow for bone-ligament enthesis. Hybrid biofabrication of bone-ligament tissue scaffolds, through the simultaneous deposition of disparate materials, offer significant advantages over fused manufacturing methods which lack efficient integration between bone and ligament materials. Results In this review, we discuss the important chemical and biological properties of ligament enthesis and describe recent advancements in additive manufacturing to meet mechanical and biological requirements for a successful bone–ligament–bone interface. Conclusions With continued advancement of additive manufacturing technologies and improved biomaterial properties, tissue engineered bone-ligament scaffolds may soon enter the clinical realm.

Insufficient evidence to support peroneus longus tendon over other autografts for primary anterior cruciate ligament reconstruction: A systematic review

Article

Full-text available

Dec 2020

Importance: Graft choice for anterior cruciate ligament reconstruction (ACLR) remains a subject of interest among orthopaedic surgeons because no ideal graft has yet been found. Peroneus longus tendon (PLT) has emerged as an alternative autograft for reconstruction in kneeling populations and in simultaneous anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries. Objective: To evaluate the current evidence on the outcome of primary ACLR with PLT autograft in adults and donor ankle morbidity, in addition to determining the average PLT graft dimensions from published studies. Evidence review: Two independent reviewers searched PubMed, CENTRAL, EMBASE, Scopus and Virtual Health Library databases using the terms “anterior cruciate ligament,” “peroneus longus” and “fibularis longus” alone and in combination with Boolean operators AND/OR. Studies evaluating clinical and stability outcomes, graft-donor ankle morbidity and graft dimensions of PLT in ACLR were included. Methodological quality was assessed using the Modified Coleman Methodology Score (mCMS). A narrative analysis is presented using frequency-weighted means wherever feasible. Publication bias was assessed using the ROBIS tool. Findings: Twelve articles with intermediate-level methodological quality were included. Eight studies assessing the clinical and stability outcomes of reconstruction with PLT showed satisfactory outcomes, similar to those of hamstring tendons (HT). No studies assessed anterior knee pain as an outcome. Six studies evaluated the graft-donor ankle morbidity using general functional foot and ankle scores and non-validated tools, showing favourable outcomes. Nine studies assessed PLT graft diameter, revealing grafts consistently larger than 7mm among the different preparation techniques, which is comparable with reports of HT grafts. Conclusions: and relevance The clinical and stability outcomes of ACLR with different PLT autograft preparation techniques are comparable with those of HT during short-term follow-up; however, there is insufficient evidence to support its use in the populations that motivated its implementation. Thus, stronger evidence obtained with the use of validated tools reporting negligible donor-graft ankle morbidity after PLT harvesting is required prior to recommending its routine use, despite the consistency of its dimensions. Level of evidence Level III.

ACL Reconstruction Graft Angle and Outcomes: Transtibial vs Anteromedial Reconstruction

Article

Aug 2019

Background The importance of creating an anatomic anterior cruciate ligament (ACL) reconstruction has been receiving significant attention. The best technique by which to achieve this anatomic reconstruction continues to be debated. The two most common methods are the transtibial (TT) and anteromedial (AM) techniques. Each has its advantages and disadvantages, and the literature comparing the two remains uncertain. Questions/Purposes In this prospective comparative study, we aimed to compare the ACL graft and tunnel angles achieved using the anatomic transtibial (TT) and anteromedial (AM) techniques; compare the ACL graft and tunnel angles in knees that have undergone ACL reconstruction and knees with intact ACLs; and determine whether differences in the graft or tunnel angle produce differences in clinical outcomes, as measured using both physical exam and patient-reported outcomes, after ACL reconstruction. Methods Patients who underwent primary ACL reconstruction with bone–tendon–bone grafts using a TT or AM technique were included. Femoral graft angle (FGA), tibial graft angle (TGA), and sagittal orientation of the reconstructed ACL and contralateral native ACL were measured on post-operative magnetic resonance imaging. Post-operatively, patients underwent measurement of knee stability and completed the Knee Injury and Osteoarthritis Outcome Score (KOOS) survey. Results Twenty-nine patients were enrolled (AM group, 14; TT group, 15); at follow-up, KOOS data were available for 26 patients (13 in each group). There were no differences in sagittal ACL graft angle between groups or in comparison with the normal knee. The FGA was more vertical after TT reconstructions; the TGA was comparable between groups. There were no significant differences in 2-year post-operative physical exam measurements or in KOOS scores. Conclusion Anatomic ACL angle was restored after reconstruction with both the TT and AM techniques, despite different FGAs. No significant differences in clinical outcome were noted between groups on physical exam or KOOS at 2 years after surgery. These results suggest that TT reconstruction results in a graft position similar to that seen in AM reconstruction and that the location of the intra-articular tunnel aperture matters more than the orientation of the tunnel.

How to Avoid Graft-Tunnel Length Mismatch in Modified Transtibial Technique for Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Graft

Article

Full-text available

Dec 2018

Background We conducted this study to determine the optimal length of patellar and tibial bone blocks for the modified transtibial (TT) technique in anterior cruciate ligament (ACL) reconstruction using the bone-patellar tendon-bone (BPTB) graft. Methods The current single-center, retrospective study was conducted in a total of 64 patients with an ACL tear who underwent surgery at our medical institution between March 2015 and February 2016. After harvesting the BPTB graft, we measured its length and that of the patellar tendon, patellar bone block, and tibial bone block using the arthroscopic ruler and double-checked measurements using a length gauge. Outcome measures included the length of tibial and femoral tunnels, inter-tunnel distance, length of the BPTB graft, patellar tendon, patellar bone block, and tibial bone block and graft-tunnel length mismatch. The total length of tunnels was defined as the sum of the length of the tibial tunnel, inter-tunnel distance and length of the femoral tunnel. Furthermore, the optimal length of the bone block was calculated as (the total length of tunnels − the length of the patellar tendon) / 2. We analyzed correlations of outcome measures with the height and body mass index of the patients. Results There were 44 males (68.7%) and 20 females (31.3%) with a mean age of 31.8 years (range, 17 to 65 years). ACL reconstruction was performed on the left knee in 34 patients (53%) and on the right knee in 30 patients (47%). The optimal length of bone block was 21.7 mm (range, 19.5 to 23.5 mm). When the length of femoral tunnel was assumed as 25 mm and 30 mm, the optimal length of bone block was calculated as 19.6 mm (range, 17 to 21.5 mm) and 22.1 mm (range, 19.5 to 24 mm), respectively. On linear regression analysis, patients' height had a significant correlation with the length of tibial tunnel (p = 0.003), inter-tunnel distance (p = 0.014), and length of patellar tendon (p < 0.001). Conclusions Our results indicate that it would be mandatory to determine the optimal length of tibial tunnel in the modified TT technique for ACL reconstruction using the BPTB graft. Further large-scale, multi-center studies are warranted to establish our results.

A Mini Review on Graft Fixation Devices for Anterior Cruciate Ligament Reconstruction - Techniques, Materials and Complications

Conference Paper

Full-text available

Jul 2018

Accuracy of the femoral tunnel position in robot-assisted anterior cruciate ligament reconstruction using a magnetic resonance imaging-based navigation system: A preliminary report

Article

Jun 2018

Background Tunnel misplacement is a common cause of failed anterior cruciate ligament (ACL) reconstruction. In this study, the accuracy of the femoral tunnel position was evaluated in robot‐assisted ACL reconstruction using a magnetic resonance imaging (MRI)‐based navigation system. We hypothesized that a difference of less than 2 mm between the planned femoral tunnel position and the created one was achievable. Methods Four cadaveric knees underwent robot‐assisted ACL reconstruction. A 3‐dimensional model using pre‐operative MRI images was used for preoperative planning, and a computed tomography (CT) scan was performed postoperatively. The planned and the created femoral tunnels were compared to assess the accuracy of the femoral tunnel position. Results The distance between the intra‐articular points of the planned and the created tunnels was 7.78 mm in the first experiment and 1.47 mm in the last one. The difference in tunnel length was 4.62 mm in the first experiment and 0.99 mm in the last one. Conclusions Accuracy of the femoral tunnel position improved with each robot‐assisted ACL reconstruction using an MRI‐based navigation system. In the last experiment, the accuracy of the femoral tunnel position was satisfactory.

Allograft Use Results in Higher Re-revision Rate for Revision Anterior Cruciate Ligament Reconstruction

Article

Full-text available

Jun 2018

Background The literature on revision anterior cruciate ligament (ACL) reconstruction (ACLR) outcomes is generally sparse, but previous studies have demonstrated that autograft use results in improved sports function and patient-reported outcome measures compared with allograft. However, knowledge is still lacking regarding the impact of graft type on rates of re-revision. Purpose To investigate the clinical outcomes and failure rates of revision ACLRs performed with either allograft or autograft. Study Design Cohort study; Level of evidence, 3. Methods A search of the Danish Knee Ligament Reconstruction Registry identified 1619 revision ACLRs: 1315 were autograft procedures and 221 were allograft procedures (type of graft was not identified for 83 procedures). Clinical outcomes after 1 year were reported via the Knee injury and Osteoarthritis Outcome Score (KOOS), the Tegner activity score, and an objective knee stability measurement that determined side-to-side differences in instrumented sagittal knee laxity. Failure was determined as re-revision. Outcomes for revision were provided for the full life of the registry, up to 10 years. Results The re-revision rate was significantly higher for allograft compared with autograft (12.7% vs 5.4%; P < .001), leading to a hazard ratio for re-revision of 2.2 (95% CI, 1.4-3.4) for allografts compared with autografts when corrected for age. At 1-year follow-up, objective knee stability was significantly different (2.1 ± 2.1 mm for allograft vs 1.7 ± 1.8 mm for autograft; P = .01), and the KOOS subscale scores for symptoms, pain, activities of daily living, sports, and quality of life were 67, 76, 84, 49, and 46 for allograft and 67, 78, 84, 51, and 48 for autograft, respectively, with no difference between groups. Conclusion In this observational population-based study, the ALCR re-revision rate was 2.2 times greater for allograft compared with autograft procedures. Allograft was associated with greater knee laxity at 1-year follow-up. However, subjective clinical outcomes and knee function were not inferior for allograft patients. These results indicate that autograft is a better graft choice for revision ALCR.

Outside-In vs. Anteromedial Portal Drilling During Primary ACL Reconstruction: Comparison at Two Years

Article

Jan 2017

Background: Anteromedial (AM) and outside-in (OI) are two commonly used techniques for drilling the femoral tunnel during anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to compare clinical and radiographic outcomes of patients undergoing primary ACLR using either AM or OI femoral drilling with minimum two year follow-up. Methods: Overall, 138 prospectively enrolled patients undergoing primary ACLR underwent AM or OI femoral drilling. Patients were categorized by femoral drilling technique and were evaluated pre-operatively as well as at six weeks and two years post-operatively. Outcomes scores were collected at each visit using SF-36 PCS and MCS components, KOOS, and the Knee Activity Rating Scale. Complications, including graft failure, stiffness requiring manipulation under anesthesia, and revision surgery were also collected. Results: Overall, 47 (34.1%) patients underwent AM femoral drilling and 91 (65.9%) patients underwent OI femoral drilling. Univariate analysis revealed no difference in pre-operative outcomes with the exception of the AM group having higher KOOS Knee Pain (p=0.023) and WOMAC Pain (p=0.036) scores. Postoperatively, OI femoral tunnels had a higher radiographic coronal angle (68.8°±8.6° vs 51.4°±11.3°; p<0.001) and knee extension (1.2°±2.7 vs 2.9°±4.0°; p=0.010). There were no differences in knee flexion, complications, or graft failure. Postoperatively, the AM group had higher KOOS ADL and WOMAC Functional (85 vs. 79 ,p=0.030) scores at the six week mark, although these differences did not meet the minimal clinically importance difference1. Graft failure at two years were similar in the AM and OI groups (8.5% vs. 6.6%, p=0.735). Multivariate analysis showed no clinical outcome differences between AM and OI techniques. Conclusions: ACL reconstruction using the AM technique yielded lower radiographic coronal tunnel angle and slightly decreased knee extension. The theoretical risk of graft failure secondary to higher coronal angle of the graft as it passes around a sharper femoral tunnel aperture was not observed. Additionally, differences in pre-operative KOOS Knee pain existed but these differences were not significant postoperatively. We conclude no clinically relevant differences by two years in patients undergoing primary ACL reconstruction using either AM or OI femoral drilling techniques. Level of Evidence: Level II Prospective Comparative Study.

Considerations for Revision Anterior Cruciate Ligament Reconstruction: A Review of the Current Literature

Article

May 2024

Race and Gender Differences in Anterior Cruciate Ligament Femoral Footprint Location and Orientation: A 3D-MRI Study

Article

Nov 2023

Objective The femoral tunnel position is crucial to anatomic single‐bundle anterior cruciate ligament (ACL) reconstruction, but the ideal femoral footprint position are mostly based on small‐sized cadaveric studies and elderly patients with a single ethnic background. This study aimed to identify potential race‐ or gender‐specific differences in the ACL femoral footprint location and ACL orientation, determine the correlation between the ACL orientation and the femoral footprint location. Methods Magnetic resonance images (MRIs) of 90 Caucasian participants and 90 matched Chinese subjects were used for reconstruction of three‐dimensional (3D) femur and tibial models. ACL footprints were sketched by several experienced orthopedic surgeons on the MRI photographs. The anatomical coordinate system was applied to reflect the ACL footprint location and orientation of scanned samples. The femoral ACL footprint locations were represented by their distance from the origin in the anteroposterior (A/P) and distal‐proximal (D/P) directions. The orientation of the ACL was described with the sagittal, coronal and transverse deviation angles. The ACL orientation and femoral footprint position were compared by the two‐sided t ‐test. Multiple regression analysis was used to study the correlation between the orientation and femoral footprint position. Results The average femur footprint A/P position was −6.6 ± 1.6 mm in the Chinese group and −5.1 ± 2.3 mm in the Caucasian group, ( p < 0.001). The average femur footprint D/P position was −2.8 ± 2.4 mm in Chinese and − 3.9 ± 2.0 mm in Caucasians, ( p = 0.001). The Chinese group had a mean difference of a 1.5 mm (6.1%) more posterior and 1.1 mm (5.3%) more proximal in the position from the flexion‐extension axis (FEA). And the males have a sagittal plane elevation about 4–5° higher than females in both racial groups. Furthermore, for every 1% (0.40 mm) increase in A/P and D/P values, the sagittal angle decreased by about 0.12° and 0.24°, respectively; the coronal angle decreased by about 0.10° and 0.30°, respectively. For every 1% (0.40 mm) increase in D/P value, the transverse angle increased by about 0.14°. Conclusion The significant race‐ and gender‐specific differences in the femoral footprint and orientation of the ACL should be taken in consideration during anatomic single‐bundle ACL reconstruction. Furthermore, the quantitative relationship between the ACL orientation and the footprint location might provide some reference for surgeons to develop a surgical strategy in ACL single‐bundle reconstruction and revision.

The Principles of Knee Joint Preservation: Operative Treatment Strategies

Article

Aug 2023
J BONE JOINT SURG AM

Joint alignment, meniscal status, and ligament stability are codependent factors involved in knee joint preservation, and any injury or imbalance can impact the knee articular cartilage status and can result in adverse clinical outcomes. ➤ Cartilage preservation procedures in the knee will not result in optimal outcomes if there is joint malalignment, meniscal deficiency, or ligamentous instability. ➤ Lower-extremity varus or valgus malalignment is a risk factor for the failure of an anterior cruciate ligament (ACL) reconstruction. It represents an indication for a high tibial osteotomy or distal femoral osteotomy in the setting of failed ACL reconstruction, and may even be considered in patients who have an initial ACL injury and severe malalignment. ➤ An elevated posterior tibial slope increases the risk of failure of ACL reconstruction, whereas a decreased posterior tibial slope increases the risk of failure of posterior cruciate ligament reconstruction.

The Role of Anterolateral Ligament Reconstruction or Lateral Extra-articular Tenodesis for Revision Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Comparative Clinical Studies

Article

Mar 2023
AM J SPORT MED

Background: After its success in restoring rotational stability and reducing failure rates in primary anterior cruciate ligament reconstruction (ACLR), lateral extra-articular tenodesis (LET) or anterolateral ligament reconstruction (ALLR) has been endorsed for use in revision ACLR surgery, where failure rates are historically higher. Purpose: To perform a systematic review and meta-analysis on whether the addition of a LET or ALLR results in superior clinical outcomes and stability compared with isolated revision ACLR (iACLR). Study Design: Meta-analysis; Level of evidence, 4. Methods: The Cochrane Controlled Register of Trials, PubMed, Medline, and Embase were used to perform a systematic review and meta-analysis of comparative studies using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms: (“extra-articular” OR “tenodesis” OR “anterolateral ligament” OR “iliotibial”) AND (“anterior cruciate ligament”) AND (“revision” OR “re-operation”). Data pertaining to all patient-reported outcome measures (PROMs), rotational stability, and postoperative complications were extracted from each study. Results: After abstract and full-text screening, 10 clinical comparative studies were included. There were 793 patients, of whom 390 had an iACLR while 403 had an ACLR augmented with a LET or an ALLR (augmented ACLR [aACLR]). The mean time for assessment of PROMs was 35 months. The aACLR group had superior International Knee Documentation Committee (IKDC) scores (standardized mean difference [SMD], 0.27; 95% CI, 0.01 to 0.54; P = .04), rotational stability (odds ratio [OR], 2.77; 95% CI, 1.91 to 4.01; P < .00001), and lower side-to-side difference (OR, −0.53; 95% CI, −0.81 to −0.24; P = .0003) than those without the augmentation. Furthermore, they were less likely to fail (OR, 0.44; 95% CI, 0.24 to 0.80; P = .007). Subgroup analysis in the higher-grade laxity cohort (grade ≥2) revealed an even greater IKDC score (SMD, 0.51; 95% CI, 0.16 to 0.86; P = .005) and an improved Lysholm score (SMD, 0.45; 95% CI, 0.24 to 0.67; P < .0001) in the aACLR group. Conclusion: Revision aACLR with a LET or an ALLR can improve subjective IKDC scores, restore rotational stability, and reduce failure rates compared with iACLR. Although controversy remains on the necessity of augmenting all revision ACLRs, the present meta-analysis advocates adding a lateral procedure, particularly in those with a higher-grade pivot shift.

Managing the Tibial Tunnel in Revision Anterior Cruciate Ligament (ACL) Reconstruction

Chapter

Jun 2022

Managing the tibial tunnel in revision anterior cruciate ligament reconstruction poses unique challenges. In order to optimize the postoperative outcome, careful preoperative planning is crucial, including obtaining the index surgical operative report, any available imaging prior to the index surgery and new imaging including plain radiographs, magnetic resonance imaging, and in many cases, three-dimensional computed tomographic scanning. This information can then be used to guide the physician-patient preoperative discussion regarding the potential for single or staged revision reconstruction with or without bone tunnel grafting. Moreover, graft selection must be tailored to the patient’s activity level, age, and tibial tunnel position and length. Bone-tendon-bone autograft selection requires an even more carefully detailed tunnel analysis to ensure that graft-tunnel mismatch does not occur. Multiple intraoperative techniques can be utilized to manage non-anatomic tunnel position including single-stage dowel grafting, convergent tunnel technique, and interference fixation with post fixation backup, among others. Two-stage bone tunnel grafting followed by revision ACL reconstruction after graft incorporation should always be discussed preoperatively. Intraoperative tibial tunnel evaluation should be performed prior to graft harvest and, if an optimal single-stage revision cannot be performed, bone tunnel grafting should be used. The evaluation algorithm and techniques contained in this chapter will allow the treating orthopedic surgeon to manage the entire spectrum of tibial tunnel variations and optimize postoperative outcomes.

Management of Bone Loss/Osteolysis in Revision ACL Reconstruction: The Role of Two-Stage Reconstruction

Chapter

Jun 2022

As the number of primary anterior cruciate ligament (ACL) reconstructions performed annually continues to rise, the number of revision ACL reconstructions required is expected to climb in parallel. Depending on the type and location of fixation, size and location of existing tunnels, and bone quality, the surgeon must be prepared to perform a two-stage reconstruction when indicated. The most common indication to perform a two-stage revision ACL reconstruction with bone grafting is tunnel expansion from osteolysis or a bone defect. Furthermore, other clinical scenarios such as index tunnel malposition, malalignment requiring a corrective osteotomy, or infection may influence the decision to perform a two-stage reconstruction. To optimize outcomes, the index tunnels should not compromise the accurate placement of femoral and tibial tunnels. Furthermore, tunnel expansion from hardware removal or osteolysis must not jeopardize graft fixation and incorporation. In this chapter, we discuss the role of two-stage ACL reconstruction and present cases highlighting techniques and pearls for managing bone loss and tunnel osteolysis.

Indications for Revision Anterior Cruciate Ligament Reconstruction

Chapter

Jun 2022

ACL graft tears pose challenges to both patients and surgeons. Multiple patient and technical factors need to be taken into account when deciding whether to embark on revision surgery. The intent of this chapter is to review the indications and contraindications to performing revision ACL surgery. Performing ACL revision surgery for the correct indications is critical to a successful outcome.

Knee Malignment: Is There a Role for Correction in Primary ACLR?

Article

Jun 2021
OPER TECHN SPORT MED

Sagittal and coronal knee alignment impacts the biomechanics of the surrounding ligamentous structures, including the anterior cruciate ligament (ACL). Biomechanical studies have shown that increased degrees of varus alignment (>3-5°) and increased amount of posterior tibial slope (>12°) significantly increase the force on the native ACL. Malalignment in the coronal and sagittal planes have been implicated as primary contributing factors in graft failure following ACL reconstruction. Clinical series have demonstrated encouraging results following either valgus-producing or slope-reducing proximal tibial osteotomy, although largely in the setting of revision ACL reconstruction, with lower rates of graft failure and improved patient-reported outcomes. However, few studies have reported on the success of osteotomy in the setting of a primary ACL rupture.

A retrospective study of patient outcomes in revision anterior cruciate ligament reconstruction in non-sportspersons

Article

Jan 2021

Dr. Abhishek Mungarwadi

RADIOLOGIC CASE STUDY

Article

Mar 2002

A Newer Technique of Extended Cortical Fixation to Salvage Intratunnel Blowout during Revision Anterior Cruciate Ligament Reconstruction - A Case Report

Article

Full-text available

Nov 2020

Introduction: Posterior femur wall blowout and consequent loss of femoral graft fixation are commonly encountered distally at the aperture of the tunnel facing into the joint during anterior cruciate ligament (ACL) reconstruction. However, intratunnel blowout of femoral tunnel at its outer cortical opening during a revision ACL reconstruction is very rare. It compromises the mechanical strength of the cortical bone at the tunnel opening on lateral cortex, making it weaker for providing stability to endobutton. We report this very rare event of intratunnel blowout of femoral tunnel at its proximal opening on the lateral femoral cortex during a revision ACL reconstruction, where the patient was treated with a modification in the suspensory fixation technique using a suture disc. Case report: Two years following a primary ACL reconstruction, our patient presented with a lax knee. Radiography and magnetic resonance imaging images showed malpositioning of femoral endobutton, lax, and degenerated autograft. During revision, we encountered intratunnel blowout at outer opening on lateral femoral cortex. It was rescued with a modification in the suspensory fixation technique by tying the endobutton with a suture-disc, placed directly over the proximal opening of femoral tunnel on lateral cortex. Conclusion: Our case report highlights, this rare critical surgical event during revision ACL reconstruction managed successfully with a suture disc, which is cost-effective, readily available and using the same prepared graft within a lesser operative time. Functional outcome was excellent and usage of a suture disc.

Femoral Tunnel Placement to Restore Normal Knee Laxity After Anterior Cruciate Ligament Reconstruction

Chapter

Jan 2008

Andrew A Amis

Flexible reamers for primary anatomical ACL reconstruction- a systematic review

Article

Jan 2021

Introduction Surgery for ACL reconstruction has evolved a lot. To fulfil the ever increasing patient demand and to lower the failure rates, emphasis is now being laid on reproducing the anatomic origins of ACL during reconstruction. Use of conventional rigid reamers does address this concern; however, it has its own pitfalls and difficulties. Of late, flexible reamers systems are increasingly being used for drilling of femoral tunnels and are becoming a popular alternative to the rigid systems. The aim of this systematic review is to summarize the data published on the use of flexible ACL reamer systems for ACL reconstruction. Method A systematic search of literature was performed on PubMed, Cochrane Library and DOAJ using the keywords ‘flexible ACL’ and ‘flexible cruciate’. Data was analysed and compiled. Results A total of 17 studies met the inclusion criteria. We incorporated original studies (cadaveric as well as patient based) on “primary Anatomical ACL reconstruction using flexible reamer”. Conclusion Flexible reamer system can be used as an alternative to the conventional rigid reamers as they avoid the need for hyperflexion of knee without compromising the tunnel length. Even though flexible reamers do have lower risk of injury to the posterior structures and produce minor variations in the tunnel characteristics, its impact on clinical outcomes needs to be further investigated.

Biomaterials developed for facilitating healing outcome after anterior cruciate ligament reconstruction: Efficacy, surgical protocols, and assessments using preclinical animal models

Article

Dec 2020
BIOMATERIALS

Anterior cruciate ligament (ACL) reconstruction is the recommended treatment for ACL tear in the American Academy of Orthopaedic Surgeons (AAOS) guideline. However, not a small number of cases failed because of the tunnel bone resorption, unsatisfactory bone-tendon integration, and graft degeneration. The biomaterials developed and designed for improving ACL reconstruction have been investigated for decades. According to the Food and Drug Administration (FDA) and the International Organization for Standardization (ISO) regulations, animal studies should be performed to prove the safety and bioeffect of materials before clinical trials. In this review, we first evaluated available biomaterials that can enhance the healing outcome after ACL reconstruction in animals and then discussed the animal models and assessments for testing applied materials. Furthermore, we identified the relevance and knowledge gaps between animal experimental studies and clinical expectations. Critical analyses and suggestions for future research were also provided to design the animal study connecting basic research and requirements for future clinical translation.

Complications of Anterior Cruciate Ligament Reconstruction

Chapter

Jan 2012

Complications in Anterior Cruciate Ligament Revision Reconstruction

Chapter

Jan 2019

Reconstructive Anterior Cruciate Ligament surgery (ACLR) is a common sports related injury, with success rates of above 75% in the literature. Many patients are athletes that expect to return to their previous level of play postoperatively. Despite the high success rate of ACL reconstruction, the procedure is not without complications that ultimately require a revision operation. While some literature suggests comparable outcomes of revision ACL reconstruction (RACLR), others purport only a 54% return to previous activity level in patients. Furthermore, the procedure can be more technically challenging depending on the patient anatomy, activity level, and type of graft used in the index procedure. This chapter highlights the various pitfalls that may occur throughout the process of ACLR revision surgery. The surgeon should meticulously evaluate factors that may have led to the initial graft’s failure, as covered in the preoperative section. The most common reason for failure is improperly positioned tunnels at the time of initial reconstructive surgery, however several other factors may predispose patients to ruptured grafts including tibial slope, concomitant ligamentous injuries, and osteolysis at the bone-graft interface. Oftentimes, RACLR requires a staged procedure to address initial tunnel issues. The algorithm for utilizing bony dowels to reposition tunnels, complications that arise with their use, and the evaluation of graft incorporation is outlined in the intraoperative section. Lastly, RACLR has many of the same complications as the index reconstructive procedure, notably arthrofibrosis, venous thrombi, and infection, which is highlighted in the postoperative section. Ultimately, more high-level research is needed to identify the exact method of maximizing patient outcomes in RACLR and rehabilitation protocols in the postoperative period.

Revision Anterior Cruciate Ligament Reconstruction

Chapter

Jan 2008

Computer-Assisted Navigation for Anterior Cruciate Ligament Reconstruction

Chapter

Jan 2008

Jason Koh

Anterior Cruciate Ligament Reconstruction of Partial Tears

Chapter

Jan 2008

Knee Injuries

Chapter

Jan 2008

Graft Options for Anterior Cruciate Ligament Revision Reconstruction

Chapter

Jan 2010

Chapter 5: Techniques For ACL Revision Reconstruction

Article

Jun 2020

Anterior cruciate ligament (ACL) reconstruction is a commonly performed procedure, with an increasing frequency leading to an increased number of revision procedures. Etiologies for graft rupture are varied and can include technical issues, repeat trauma, and graft choice. The preoperative evaluation before a revision ACL reconstruction should include a detailed history and physical exam, as well as radiographs, magnetic resonance imaging to evaluate graft integrity and for concomitant injuries, as well as computed tomography to measure for bone tunnel osteolysis. Surgical techniques for revision ACL reconstruction include a 1-stage or 2-stage procedure with possible bone grafting and repair of associated injuries. Recent studies show worse clinical outcomes after a revision procedure; however, research continues to emerge with novel techniques and rehabilitation protocols to improve patient outcomes after revision ACL reconstruction.

Techniques for Femoral Socket Creation in ACL Reconstruction

Article

Jun 2020

Anterior cruciate ligament (ACL) injury is common and affects a wide variety of individuals. An ACL reconstruction is the treatment of choice for patients with subjective and objective symptoms of instability and is of particular importance to cutting or pivoting athletes. With many variables involved in ACL reconstruction, femoral tunnel placement has been found to affect clinical outcomes with nonanatomic placement being identified as the most common technical error. Traditionally the femoral tunnel was created through the tibial tunnel or transtibial with the use of a guide and a rigid reaming system. Because of proximal, nonanatomic tunnel placement using the transtibial technique, the use of the anteromedial portal and outside-in drilling techniques has allowed placement of the tunnel over the femoral footprint. In this paper, we discuss the difference between the 3 techniques and the advantages and disadvantages of each. The authors then explore the clinical differences and outcomes in techniques by reviewing the relevant literature.

The 50 Most Cited Articles in the Indications, Risk Factors, Techniques, and Outcomes of ACL Revision Surgery

Article

May 2020

The rate of anterior cruciate ligament (ACL) retear remains high and revision ACL reconstruction has worse outcomes compared with primaries. To make advances in this area, a strong understanding of influential research is necessary. One method for systematically evaluating the literature is by citation analysis. This article aims to establish and evaluate “classic” articles. With consideration of these articles, this article also aims to evaluate gaps in the field and determine where future research should be directed. The general approach for data collection and analysis consisted of planning objectives, employing a defined strategy, reviewing search results using a multistep and multiauthor approach with specific screening criteria, and analyzing data. The collective number of citations for all publications within the list was 5,203 with an average of 104 citations per publication. “Biomechanical Measures during Landing and Postural Stability Predict Second Anterior Cruciate Ligament Injury after Anterior Cruciate Ligament Reconstruction and Return to Sport” by Paterno et al contained both the highest number of total citations and the highest number of citations per year, with 403 total citations and 43.9 citations per year. The most recurring level of evidence were level II (n = 18) and level III (n = 17). “Clinical Outcomes” was the most common article type (n = 20) followed by “Risk Factors” (n = 10). The American Journal of Sports Medicine had the highest recorded Cite Factor with over 50% of the articles (n = 27) published. The most productive authors included R.W. Wright (n = 6), S.D. Barber-Westin (n = 5), F.R. Noyes (n = 5), and K.P. Spindler (n = 5). Historically, influential studies have been published in the realms of clinical outcome and risk factor identification. It has been established that revision ACL reconstruction has worse outcomes and more high-level studies are needed. Additionally, prospective studies that apply the knowledge for current known risk factor mitigation are needed to determine if graft tear rates can be lowered.

Biomineralizaion of hydroxyapatite on polyethylene terephthalate artificial ligaments promotes graft-bone healing after anterior cruciate ligament reconstruction: An in vitro and in vivo study

Article

Apr 2020

The purpose of the present study is to modify the polyethylene terephthalate ligament with hydroxyapatite via biomineralization and to investigate its effect on graft-bone healing. After biomineralization of hydroxyapatite, the surface characterization of polyethylene terephthalate ligament was examined by scanning electron microscopy, Fourier transform infrared spectroscopy, X-ray diffraction, and water contact angle measurements. The compatibility and osteoinduction, along with the underlying signaling pathway involved of hydroxyapatite-polyethylene terephthalate ligament, were evaluated in vitro. Moreover, a rabbit anterior cruciate ligament reconstruction model was established, and the polyethylene terephthalate or hydroxyapatite-polyethylene terephthalate artificial ligament was implanted into the knee. The micro-computed tomography analysis, histological, and immunohistochemical examination as well as biomechanical test were performed to investigate the effect of hydroxyapatite coating in vivo. The results of scanning electron microscopy, Fourier transform infrared spectroscopy, and X-ray diffraction showed that the hydroxyapatite was successfully deposited on the polyethylene terephthalate ligament. Water contact angle of the hydroxyapatite-polyethylene terephthalate group was significantly smaller than that of the polyethylene terephthalate group. The in vitro study showed that hydroxyapatite coating significantly improved adhesion and proliferation of MC3T3-E1 cells. The osteogenic differentiation of cells was also enhanced through the activation of ERK1/2 pathway. The micro-computed tomography, histological, and immunohistochemical results showed that biomineralization of hydroxyapatite significantly promoted new bone and fibrocartilage tissue formation at 12 weeks postoperatively. Moreover, the failure load and stiffness in the hydroxyapatite-polyethylene terephthalate group were higher than that in the polyethylene terephthalate group. Therefore, biomineralizaion of hydroxyapatite enhances the biocompatibility and osseointegration of the polyethylene terephthalate artificial ligament, thus promoting graft-bone healing for anterior cruciate ligament reconstruction through the activation of ERK1/2 pathway.

Modified Iliotibial Band Tenodesis Is Indicated to Correct Intraoperative Residual Pivot Shift After Anterior Cruciate Ligament Reconstruction Using an Autologous Hamstring Tendon Graft: A Prospective Randomized Controlled Trial

Article

Mar 2020
AM J SPORT MED

Background The indications for the addition of anterolateral soft tissue augmentation to anterior cruciate ligament (ACL) reconstruction and its effectiveness remain uncertain. Purpose To determine if modified iliotibial band tenodesis (MITBT) can improve clinical outcomes and reduce the recurrence of ACL ruptures when added to ACL reconstruction in patients with a residual pivot shift. Study Design Randomized controlled trial; Level of evidence, 2. Methods Patients with a primary ACL rupture satisfying the following inclusion criteria were enrolled: first ACL rupture, involved in pivoting sports, skeletally mature, no meniscal repair performed, and residual pivot shift relative to the contralateral uninjured knee immediately after ACL reconstruction. Patients were randomized to group A (no further surgery) or group B (MITBT added) and were followed up for 2 years. The patient-reported outcome (PRO) measures used were the International Knee Documentation Committee (IKDC) score, Knee injury and Osteoarthritis Outcome Score (KOOS) subscale of sport/recreation (Sport/Rec), KOOS subscale of quality of life (QoL), Lysholm knee score (LKS), Tegner activity scale (TAS), recurrent ACL ruptures, or need for further surgery in either knee. Analysis of variance was used to compare PROs; the Wilcoxon test was used for the TAS; and the chi-square test was used for recurrence of ACL ruptures, meniscal injuries, and contralateral ACL ruptures ( P < .05). Results A total of 55 patients were randomized: 27 to group A (female:male ratio = 15:12; mean age, 22.3 ± 3.7 years) and 28 to group B (female:male ratio = 17:11; mean age, 21.8 ± 4.1 years). At 2-year follow-up, group A had a similar IKDC score (90.9 ± 10.7 vs 94.2 ± 11.2; respectively; P = .21), lower KOOS Sport/Rec score (91.5 ± 6.4 vs 95.3 ± 4.4, respectively; P = .02), similar KOOS QoL score (92.0 ± 4.8 vs 95.1 ± 4.3, respectively; P = .14), lower LKS score (92.5 ± 4.8 vs 96.8 ± 8.0, respectively; P = .004), lower TAS score (median, 7 [range, 7-9] vs 8 [range, 8-10], respectively; P = .03), higher rate of recurrence (14.8% vs 0.0%, respectively; P < .001), similar rate of meniscal tears (14.8% vs 3.6%, respectively; P = .14), and similar rate of contralateral ACL ruptures (3.7% vs 3.6%, respectively; P = .99) relative to group B. Conclusion The augmentation of ACL reconstruction with MITBT reduced the risk of recurrent ACL ruptures in knees with a residual pivot shift after ACL reconstruction and improved KOOS Sport/Rec, LKS, and TAS scores. Registration ACTRN12618001043224 (Australian New Zealand Clinical Trials Registry)

Multiple ACL Revision: Failure Analysis and Clinical Outcomes

Article

Nov 2019

Anterior cruciate ligament (ACL) reconstruction represents one of the most successful orthopedic surgical procedures. Nevertheless, ACL revisions are still very frequent, with a small but relevant number of failures. The purpose of this study is to analyze the failure causes and the clinical outcomes of patients who underwent a re-revision ACL reconstruction. Between January 2009 and December 2017, 263 ACL revisions were performed by a single senior surgeon. Seventeen patients (12 males and 5 females) underwent re-revision ACL reconstruction meeting the inclusion criteria. The mean age was 28.4 years (range, 19–41 years). Before the re-revision, the patients were evaluated preoperatively and after a mean follow-up of 29 months (range, 13–58 months). Assessment included subjective and objective evaluations (Lysholm and International Knee Documentation Committee [IKDC]), KT-2000 arthrometer, radiographic study, and preoperative computed tomography scan. Five patients showed a too anterior previous femoral tunnel and seven a too vertical and posterior tibial tunnel; eight meniscal tears were found. Five patients had grade III–IV according to Outerbridge cartilage lesions. IKDC showed a statistically significant improvement (A + B 35%, C + D 65% preop, A + B 82%, C + D 18% postop, odds ratio: 0.1169; p = 0.0083). The mean Lysholm score ranged from 43 ± 9 to 87 ± 7 (p < 0.001). The KT-2000 arthrometer showed a statistically significant improvement from a mean of 5.8 ± 1.4 to 1.5 ± 1.1 (p < 0.001) at last follow-up. Out of 17 patients, only 4 returned to sports activity at the same preinjury levels. Postoperatively at the last follow-up after last revision surgery, no osteoarthritis evolution was observed. This study showed good clinical and radiological results after the last revision ACL surgery in patients with multiple failures of ACL reconstruction but only one-fourth of the patients returned to the same preoperative sport level. Traumatic events, technical errors, and untreated peripheral lesions are the main causes of multiple previous failures; the worst clinical outcomes were found in the patients with high grade of chondral lesions.

Single-stage revision anterior cruciate ligament reconstruction using bone grafting for posterior or widening tibial tunnels restores stability of the knee and improves clinical outcomes

Article

Apr 2019

Purpose Revision ACL surgery may be complicated by tunnel malposition and/or tunnel widening and often requires a staged treatment approach that includes bone grafting, a period of several months to allow bone graft incorporation and then definitive revision ACL reconstruction. The purpose of this study was to evaluate the results of a single-staged ACL revision reconstruction technique using a cylindrical dowel bone graft for patients who have existing posteriorly placed and/or widened tibial tunnels in the tibia at a minimum of 2 years follow-up. Methods Between 2010 and 2014, patients undergoing single-stage revision ACL reconstruction with the described technique were prospectively enrolled and evaluated. At a minimum of 24 months, patients were evaluated by physical examination, multiple clinical outcome instruments including KOOS, Tegner and Lysholm, and preoperative and postoperative MRIs. Results At a mean of 35.1 months, 18 consecutive patients had no revision surgery and no subjective knee instability. There were statistically significant improvements in the Tegner (median 2, interquartile range 2.25; p < 0.01), Lysholm (20.0 ± 15.0; p < 0.01), KOOS symptoms scale (12.9 ± 11.8; p < 0.01), KOOS pain scale (15.4 ± 18.7; p < 0.01), KOOS ADL scale (13.5 ± 19.0; p < 0.01), KOOS sports scale (32.8 ± 26.4; p < 0.01), and KOOS QoL scale (18.1 ± 16.9; p < 0.01). Postoperative MRI demonstrated statistically significant anteriorization of the tibial tunnel and a statistically significant decrease in tunnel widening. Conclusion Revision ACL reconstruction utilizing a single-staged tibial tunnel grafting technique resulted in improved knee pain, function, and stability at a minimum of 24-month follow-up. Level of evidence IV.

Proposed Autograft Superiority to Allograft Use in Return to Sport Rates Following Revision ACL Reconstruction: A Literature Review

Article

Full-text available

Sep 2018

Effects of Remnant Tissue Preservation on Tunnel Enlargement After Anatomic Double-Bundle Anterior Cruciate Ligament Reconstruction Using the Hamstring Tendon

Article

Full-text available

Dec 2018

Background The effects of remnant tissue preservation on tunnel enlargement after anatomic double-bundle anterior cruciate ligament (ACL) reconstruction have not yet been established. Hypothesis The preservation of ACL remnant tissue may significantly reduce the degree and incidence of tunnel enlargement after anatomic double-bundle ACL reconstruction, while the remnant-preserving procedure may not significantly increase the incidence of tunnel coalition after surgery. Study Design Cohort study; Level of evidence, 2. Methods A total of 79 patients underwent anatomic double-bundle ACL reconstruction. Based on the Crain classification of ACL remnant tissue, 40 patients underwent the remnant-preserving procedure (group P), and the remaining 39 patients underwent the remnant-resecting procedure (group R). There were no differences between the 2 groups concerning all background factors, including preoperative knee instability and intraoperative tunnel positions. All patients were examined using computed tomography and a standard physical examination at 2 weeks and 1 year after surgery. Results During surgery, the femoral and tibial anteromedial (AM) tunnel sizes in both groups averaged 6.6 and 6.5 mm, respectively. The femoral and tibial posterolateral (PL) tunnel sizes in both groups averaged 6 and 6 mm, respectively. There were no differences in the intraoperative tunnel positions and tunnel sizes between groups. Concerning the femoral AM tunnel, the degree of tunnel enlargement in the oblique coronal and oblique axial views in group P was significantly less than that in group R (P = .0068 and .0323, respectively). Regarding the femoral AM tunnel cross-sectional area, the degree and incidence of tunnel enlargement in group P were significantly less than those in group R (P = .0086 and .0278, respectively). There were no significant differences in tunnel coalition between groups. In each group, there were no significant relationships between tunnel enlargement and each clinical outcome. Conclusion Remnant preservation in anatomic double-bundle ACL reconstruction reduced enlargement of the femoral AM tunnel and did not increase the incidence of tunnel coalition. This is one of the advantages of remnant-preserving ACL reconstruction.

Posterior laxity increases over time after PCL reconstruction

Article

Jul 2018

PurposeRestoration of posterior tibial translation (PTT) after reconstruction of the posterior cruciate ligament (PCL) is deemed necessary to restore physiological knee kinematics. However, current surgical techniques have failed to show a complete reduction of posterior laxity. It was hypothesized that early postoperative PTT increases over time. Methods The study comprised of 46 patients (10 female, 36 male; 30 ± 9 years), who underwent PCL reconstruction in a single-surgeon series. Patients were evaluated by bilateral stress radiographs in a prospective manner preoperatively; at 3, 6, 12 and 24 months; and at a final follow-up (FFU) of at least 5 years. Covariants included age, gender, BMI, tibial slope (TS) and the number of operated ligaments. Two blinded observers reviewed all radiographs, evaluating the TS and the posterior tibial translation. ResultsAll patients were evaluated at a mean final follow-up of 102 (range 65–187) months. Mean side-to-side difference of the PTT significantly improved from preoperative to 3-month postoperative values (10.9 ± 3.1 vs. 3.6 ± 3.8 mm; P < 0.0001). The PTT increased to 4.6 ± 3.7 mm at 6 months, to 4.8 ± 3.3 mm at 12 months, to 4.8 ± 3.2 mm at 24 months, to 5.4 ± 3.4 mm at FFU. Consequently, there was a significant increase of PTT between 3-month and final follow-up (3.6 ± 3.8 vs. 5.4 ± 3.4 mm; P = 0.02). Flattening of the TS resulted in a significantly higher PTT compared to subjects with a high TS at 24 months and FFU. There was no significant influence by BMI, age, gender and the number of operated ligaments. Conclusions Early results after PCL reconstruction seem promising as posterior tibial translation is significantly improved. However, there is a significant increase in PTT from early postoperative values to the final follow-up of at least 5 years. This is particularly notable in patients with flattening of the TS. As a consequence, surgeons and patients need to be aware that initial posterior stability should not be equated with the final outcome. Level of evidenceCohort study, Level III.

Use of allografts after failed treatment of rupture of the anterior cruciate ligament

Article

Full-text available

Aug 1994

A prospective study was done of the use of allogeneic tissue to reconstruct the anterior cruciate ligament in knees in which an intra-articular or an extra-articular operation had failed. Sixty-six consecutive patients (sixty-six knees) had such an operation with use of bone-patellar ligament-bone allografts; all but one returned for follow-up evaluation twenty-three to seventy-eight months (mean, forty-two months) after the operation. A total of 235 previous operations had been performed in these sixty-six knees, including eighty-one procedures for rupture of the anterior cruciate ligament. The results of the allograft procedure were evaluated with a subjective and objective system that rated twenty factors. The anterior-posterior displacement was substantially improved in most of the patients. According to data derived from arthrometric studies and pivot-shift tests of the fifty-seven patients who were so evaluated and in whom the condition was unilateral, 53 per cent (thirty) of the reconstructed ligaments were determined to be functional; 21 per cent (twelve ligaments), partially functional; and 26 per cent (fifteen ligaments), a failure. When we calculated the rate of failure by including ten failures that had occurred within two years after the operation with the fifteen that occurred in patients who had been followed for at least two years, the over-all rate of failure was 33 per cent (twenty-five of seventy-five operations). There was significant improvement in the subjective ratings of functional limitations and symptoms (p < 0.01) and in the over-all rating score (p < 0.0001). However, there was a significant difference between the scores of the patients in whom the surfaces of the articular cartilage had appeared normal at the index operation and those of the patients in whom there had been noteworthy fissuring and fragmentation or exposure of subchondral bone. After the program of rehabilitation, which included immediate motion of the knee, a range of motion of 0 to 135 degrees was restored in all but five knees, four of which lacked only 5 degrees of this extent of flexion or extension. The results demonstrate that bone-patellar ligament-bone allografts may be used when proper autogenous tissues are not available and that symptoms and abnormal displacement were reduced in most of our patients.

Revision anterior cruciate ligamentreconstruction

Article

Jul 1996
Operat Tech Orthop

Anterior cruciate ligament (ACL) reconstruction has gained, wide acceptance as the treatment of choice for thefunctionally unstable ACL-deficient knee and is now performed on about a half million individuals, per year. The documented long-term good or excellent result rates for functional stability, relief of symptoms, and return to activity for intra-articular ACL reconstructions is approximately 75% to 95%. This leaves a substantial group of patients with an unsatisfactory result secondary to a variety of reasons. Review of the literature reveals that recurrent instability and graft failure are responsible for unsatisfactory results in as high as 8% of these patients. In this article, the factors responsible for graft failure and recurrent instability are discussed. In addition, the planning and difficulties that the orthopedic surgeon must address before, during, and after the procedure, are also reviewed.

Serial Magnetic Resonance Study Assessing the Effects of Impingement on the MR Image of the Patellar Tendon Graft

Article

Feb 1992

This study was designed to serially analyze the magnetic resonance (MR) appearance of patella tendon grafts during the first year of implantation, and to determine if the sagittal location of the tibial tunnel affects the MR appearance of the graft. An additional goal was to analyze the effect of the sagittal placement of the tibial tunnel placement on knee extension and stability. Two groups were defined by comparing the sagittal relationship of the tibial tunnel to the slope of the intercondylar roof from a lateral roentgenogram of the knee in full extension. The roof impinged group consisted of nine patients who had the tibial tunnel placed anterior to the tibial intersection of the slope of the intercondylar roof. The unimpinged group was composed of eleven patients who had the tibial tunnel placed posterior and parallel to the slope of the intercondylar roof. MR scans were obtained at 0-2, 12, 24, 36, and greater than 48 weeks postoperatively. The signal intensities of grafts in both groups were identical at 1 week, but increased in the impinged group by 3 months and remained increased at 12 months postoperatively (p less than 0.01). In contrast, the MR signal of grafts in the unimpinged group remained unchanged during the first year. Knees with impinged grafts had extension deficits but remained stable. Roof impingement was impossible to view directly with the knee in full extension.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of gamma irradiation on the initial mechanical and material properties of goat bone-patellar tendon-bone allografts

Article

Mar 1991

The effects of 60Co gamma irradiation on the initial mechanical properties of the composite bone-patellar tendon-bone unit (CU) and the tendon midsubstance (TM) were studied. Frozen specimens were exposed to either 2 or 3 Mrad of gamma irradiation. Paired frozen specimens served as intraanimal controls. Treatment effects on the CU were assessed using four mechanical parameters. Effects on the TM were assessed using four material parameters measured using an optical surface-strain analysis system. The maximum force and strain energy to maximum force of the composite unit were significantly reduced 27% and 40%, respectively, after 3 Mrad of irradiation (p less than .05). Mechanical properties of the CU were not significantly altered, however, following 2 Mrad of irradiation. Based on individual paired contrasts between treatment and control, significant differences were also found in the material properties of the tendon midsubstance. The maximum stress, maximum strain, and strain energy density to maximum stress were significantly reduced following 3 Mrad, but not 2 Mrad, of irradiation. The results provide important "time zero" material property data, which will be useful for later anterior cruciate ligament reconstruction studies using irradiated allograft patellar tendons in the goat model and other animal models as well.

Reconstruction of the chronically insufficient anterior cruciate ligament with the central third of the patellar ligament

Article

Mar 1991

The results of reconstruction of the anterior cruciate ligament with the central third of the patellar ligament as a free, autogenous, non-vascularized graft were retrospectively reviewed at our institution. Eighty reconstructions in seventy-nine patients were evaluated after a minimum of two years. In forty-eight (60 per cent) of the knees, the reconstruction was augmented with an extra-articular lateral sling of iliotibial band. The patients were evaluated with a physical examination, a KT-1000 arthrometer, radiographs, a subjective questionnaire, and a revision of the scale of The Hospital for Special Surgery for rating ligaments. Postoperatively, seventy-six (95 per cent) of the eighty knees no longer gave way, and the pivot-shift test was negative in sixty-seven (84 per cent) of the knees. The average score on the ligament-rating scale was 93 points. All of the patients who had clinical instability at the time of the most recent follow-up had associated ligamentous instability that had not been appreciated or addressed at the time of reconstruction. Arthrometric evaluation revealed that the laxity differed by three millimeters or less from that of the untreated knee in sixty (76 per cent) of the treated knees. In the patient who had bilateral reconstruction, the laxity was the same in both knees. Seventeen patients, who had more than three millimeters of translation, also had additional related ligamentous instability, most commonly posterolateral instability and insufficiency of the medial collateral ligament. We think that major associated ligamentous instability predisposes the reconstruction to failure and should be corrected in conjunction with the reconstruction.(ABSTRACT TRUNCATED AT 250 WORDS)

Complications of Intra-articular Anterior Cruciate Reconstruction

Article

Nov 1988
CLIN SPORT MED

Intra-articular reconstruction of the ACL is a powerful technique, but is associated with a variety of potential complications. Careful patient selection, precise intraoperative technique, and aggressive rehabilitation can help minimize these problems. Our most common complication, postoperative limitation of motion, was nearly eliminated by a change to arthroscopic surgical technique and early motion.

Graft tension in anterior cruciate ligament reconstruction: An in vivo study in dogs

Article

Sep 1987
AM J SPORT MED

The purpose of this study was to examine the effect of initial tensioning on the outcome of reconstruction of the ACL. The ACLs of 15 adult mongrel dogs were excised and reconstructed. In the first five dogs, the ACLs of both knees were reconstructed using the medial one- third of the patellar tendon. The graft was fixed under a tension of 1 N (0.22 pounds) in one knee and 39 N (8.8 pounds) in the opposite knee. In the remainder of the dogs, the reconstructions were augmented with Dacron prostheses. Tensioning of both graft compo nents in the augmented reconstructions was either with 1 N in one knee and 39 N in the contralateral knee or disproportionate tensions of 1 N and 39 N applied to the autogenous material and to the prosthesis. Sacrifice was 3 months postsurgery and results were examined with microangiography/histology and mechanical test ing. In the reconstructions with the patellar tendon alone, the biologic study showed poor vascularity and focal myxoid degeneration within the graft pretensioned with a load of 39 N. In the augmented reconstructions, the knees in which both graft materials were fixed with 1 N tension showed the strongest and stiffest reconstruc tion at 3 months. The study suggests that minimal tension should be applied to the graft materials during surgical reconstruction of the ACL.

The natural history of the anterior cruciate ligament autograft of patellar tendon origin

Article

Dec 1986
AM J SPORT MED

A rabbit model for ACL reconstruction using autoge nous patellar tendon (PT) was used to study graft viability, its response to new physical forces, and the intrasynovial milieu. The autograft was assessed grossly, histologically, and biochemically with respect to time. Histologic observations demonstrated that autografts were centrally acellular with a peripheral rim of cells at 2 weeks, and had a central focal proliferation of cells at 3 weeks and cellular homogeneity by 4 weeks pos toperation. Necrosis followed by cellular proliferation suggested that a population of cells other than the native PT fibroblasts may be inhabiting the graft. Graft sequestration experiments demonstrated that autografts are repopulated by cells of extrinsic origin after transplantation. Autografts showed a gradual as sumption of the microscopic properties of normal ACL; by 30 weeks posttransplant the tissue characteristics were ligamentous in appearance. Histologic changes paralleled the biochemical metamorphosis: Type III col lagen was not observed in PT; however, a gradual increase in its concentration was seen in the grafts; by 30 weeks its concentration (10%) was the same as in normal ACL. Similarly, glycosaminoglycan content in creased from its normally low level in PT to that found in native ACL. Collagen-reducible cross-link analysis revealed that grafted tissue changed from the normal PT pattern of low dihydroxylysinonorleucine and high histidinohydroxymerodesmosine to the opposite pat tern seen in normal ACL by 30 weeks. These data suggest that PT autografts undergo a process of "ligamentization" when placed in the ACL environment, and that cells responsible for this meta morphosis are of extragraft origin.

The effects of tibial tunnel placement and roofplasty on reconstructed anterior cruciate ligament knees

Article

Mar 1995

Seventy-five anterior cruciate ligament (ACL) reconstructions augmented with the Kennedy Ligament Augmentation Device were evaluated according to classification of tibial drill-hole position on the basis of the anatomic landmarks of the ACL by two-dimensional radiographic imaging of the fully extended knee. The effects of roofplasty to avoid graft impingement were also assessed. The tibial drill-hole position was classified in relation to the medial intercondylar tubercle on anterior-posterior (AP) view, and in relation to Blumensaat's line (B-line) on lateral view. Arthroscopic evaluation of the ACL and incidence of chronic synovitis as well as Lysholm knee score, manual knee tests, knee extension and flexion angles, and knee tester measurements were performed. The results indicated that the knee joints in which the tibial drill hole was positioned laterally from the medial intercondylar tubercle or in which the tibial drill hole was positioned anteriorly to the B-line showed a tendency to develop more postoperative chronic synovitis. The knees in which the tibial drill hole was positioned anteriorly to the B-line also showed larger AP laxity. There was no difference between the non-roofplasty and roofplasty groups.

Infrapatellar Contracture Syndrome: Diagnosis, Treatment, and Long-Term Followup

Article

Jul 1994
AM J SPORT MED

Infrapatellar contracture syndrome is an uncommon but recalcitrant cause of reduced range of motion after knee surgery or injury. The results and conclusions presented here are based on a retrospective clinical study evaluating the long-term outcome in 75 patients who developed infrapatellar contracture syndrome. These 75 patients (76 knees) were evaluated at an average followup of 53 months after the index (inciting) procedure or injury. Comparing subgroups within the study population, factors that correlated with poorer results or more severe infrapatellar contracture syndrome were found to be acute anterior cruciate ligament repair or reconstruction, the use of patellar tendon autograft for anterior cruciate ligament reconstruction, nonisometric graft placement, multiple surgical procedures, use of closed manipulation, and the development of patella infera. We concluded that appropriate procedures can substantially increase the range of motion in patients with infrapatellar contracture syndrome. However, residual functional morbidity persists in many patients, and the outcome, as determined by subjective knee function scores, is only fair. The natural history of an anterior cruciate ligament-deficient knee appears to be more benign than the natural history of a knee that develops infrapatellar contracture syndrome.

Case report: Revision anterior cruciate ligament reconstruction

Article

Apr 1994

A case report is presented in which a professional football player, who was 4 years status post anterior cruciate ligament (ACL) reconstruction with autogenous patellar tendon, ruptured his graft. The contralateral patellar tendon was not available as a graft because of a more recent ACL reconstruction using that autogenous patellar tendon. This case reports the use of a previous donor site for supplying a patellar tendon autograft. Biopsy of the donor graft was consistent with normal tendon. The use of a healed patellar tendon donor site is a viable option for revision anterior cruciate reconstructive surgery. This option prevents the possibility of disease transmission with use of an allograft. We have shown grossly and histologically that the donor site has the potential to regenerate to tissue that has the appearance of normal tendon. This option could be available for revision surgery, but would not be recommended if the initial surgery was < 18 months-2 years in the past.

Bone Tunnel Enlargement After Anterior Cruciate Ligament Replacement

Article

Jun 1994
AM J SPORT MED

Radiographic increase in the size of tibial and femoral tunnels has been observed. This retrospective study compared tibial tunnel diameter in 56 autograft and 87 allograft patellar tendon bone-tendon-bone anterior cruciate ligament replacements whose observed tunnel changes were correlated with clinical results at 1 year postoperatively. Tibial tunnel sclerotic margins were measured approximately 1 cm below the joint line. Exact tunnel dimension was calculated by using a magnification factor determined by the interference screw of known diameter within the same tunnel. Average allograft tunnel enlargement was 1.2 mm (-2.5 to 6.0) compared with the autograft tunnel enlargement of 0.26 mm (-2.5 to 2.7); the difference was significant (P > 0.0002). No significant difference was seen in KT-1000 arthrometer measurements between autograft or allograft groups, and no correlation was seen between increased tunnel size and clinical outcome as determined by the modified Hughston knee evaluation system. Tunnel measurement reproducibility was confirmed by independent repeated measurements. The significance of this tunnel enlargement is unknown and does not appear to adversely affect clinical outcome of allograft utilization. Possible explanations include an immune response with resorption, stress shielding proximal to the interference screw resulting in resorption, or an inflammatory response by synovium in the tunnel.

Isolated Autogenous Bone-Patellar Tendon-Bone Graft Site Morbidity

Article

Jun 1994
AM J SPORT MED

To distinguish between morbidity caused by the isolated patellar tendon graft harvest and morbidity associated with anterior cruciate ligament reconstruction when the graft is harvested from the involved knee, we studied 20 patients who had an isolated contralateral graft harvest for anterior cruciate ligament reconstruction in the opposite knee. We defined and quantitated the morbidity by evaluating the uninjured knee from preoperative studies to current followup (range, 0.5 to 5 years; average, 2 years). All graft harvest surgeries were performed in an identical fashion. Rehabilitation of the harvest knee included immediate range of motion, weightbearing, and closed chain kinetic exercises with a emphasis on early strengthening. All patients regained full knee range of motion by 3 weeks. At final followup, there was no clinical or radiographic evidence of patella contracture or baja. Quadriceps strength averaged 69% at 6 weeks and returned to 93% at 1 year and 95% at 2 years. Activity-related soreness at the donor site (patellar tendinitis) was rarely restricting and resolved after the 1st year. No patient complained of patellofemoral joint pain in the donor knee. The modified Noyes subjective questionnaire score averaged 97 of 100 at last followup. The morbidity of an isolated autogenous patellar tendon graft harvest appears to be of short duration and largely reversible.

Revision Anterior Cruciate Ligament Surgery: Causes Of Graft Failure And Technical Considerations Of Revision Surgery

Article

Nov 1993
CLIN SPORT MED

The frequency of revision ACL surgery is sure to become more common as the number of primary intraarticular reconstructions increase. Identifying the potential causes of failure through a detailed history, physical examination, and radiographic evaluation is of paramount importance prior to planning a revision surgery if the repetition of errors is to be avoided.

Failure of Reconstruction of the Anterior Cruciate Ligament Due to Impingement by the Intercondylar Roof

Article

Aug 1993

The relationship between impingement of the roof of the intercondylar notch on a reconstructed anterior cruciate ligament, and the subsequent stability and range of extension of the joint, was analyzed in forty-seven knees. The extent of the impingement was determined by analysis of the relationship of the tibial tunnel to the intersection of the line of slope of the intercondylar roof with the plane of the subchondral bone of the articular surface of the tibial plateau. These lines were drawn on a lateral roentgenogram that was made with the knee in maximum extension, two years after the operation. In all four knees in which the entire articular opening of the tibial tunnel was anterior to the slope of the intercondylar roof, there was severe impingement on the graft, and all four grafts failed. In the fourteen knees in which a portion of the articular opening of the tibial tunnel was anterior to the slope of the intercondylar roof, there was moderate impingement on the graft, and four grafts failed (an unacceptable rate of failure). There was no impingement in the knees in which the entire articular opening of the tibial tunnel was posterior to the slope of the intercondylar roof, and these knees were associated with the lowest rate of failure of the grafts (three of twenty-nine). Knees that had an impinged graft and regained a complete range of extension became unstable.

Revision Anterior Cruciate Ligament Surgery: Experience From Miami

Article

May 1996

Failed anterior cruciate ligament reconstruction as defined by recurrent patholaxity is increasingly commonplace. This report presents the findings of 54 patients who had unsuccessful intraarticular anterior cruciate ligament reconstruction to correct persistent instability and who subsequently underwent revision anterior cruciate ligament surgery. Before revision, patients were evaluated by clinical examination, KT-1000 arthrometer, radiographs, Lysholm knee score, Tegner activity scale, and subjective questionnaire. The results were compared at a mean of 32 months following revision surgery. There was an average of 16 months from index procedure to the time of revision. Autogenous patellar tendon grafts were used in 61% of the cases with 30% of these harvested from the contralateral knee. Fresh frozen patellar tendon was used in 35% and autogenous hamstring tendons in 4%. Revision was successful in objectively improving stability in all patients with an average KT-000 of 2.8 mm. Autogenous tissue grafts provided greater objective stability when compared with allograft tissue with average KT-1000 of 2.2 and 3.3, respectively. Functionally, however, there was no significant difference in outcome between the 2 groups. Harvesting of the contralateral patellar tendon was found to have no adverse long term effect. Subjectively, the results were significantly worse depending on the degree of articular cartilage degeneration. Only 54% of patients returned to their preanterior cruciate ligament injury activity level. Competence in various anterior cruciate ligament reconstruction techniques will facilitate revision surgery especially in avoiding preexisting tunnels and hardware. Correct graft placement and addressing the secondary restraints are critical to successful revision surgery.

Graft Selection in Anterior Cruciate Ligament Revision Surgery

Article

May 1996

Revision anterior cruciate ligament surgery can be very demanding. Graft selection for revision surgery is a pivotal part of this procedure. Often, the usual first choice of tissue is not available. Therefore, familiarity with alternative graft sources and understanding their advantages and disadvantages is imperative for the surgeon who does anterior cruciate ligament revision surgery. This study will review the advantages and disadvantages of each graft choice available to the surgeon for this procedure.

Technical Considerations of Revision Anterior Cruciate Ligament Surgery

Article

May 1996

Revision anterior cruciate ligament surgery will become more common as the number of primary anterior cruciate ligament reconstructions increases. Also contributing to this increase are those patients who had anterior cruciate ligament reconstruction using synthetic ligaments and other nonanatomic techniques that are no longer used. Preoperative planning is imperative to a successful outcome. This begins with determining the primary, and often times secondary, mechanism of failure for each patient. The determination of the etiology of failure is the first step in a carefully constructed preoperative plan, including the type of revision, skin incision, graft removal, hardware removal, tunnel placement, graft selection, graft fixation, and rehabilitation. The precise preoperative plan should have enough flexibility to accommodate unanticipated findings in the operating room. Rehabilitation protocols must be designed specifically for the revision surgery patient and be flexible enough to accommodate changes based on surgical findings and techniques. Finally, the importance of counseling the patient preoperatively regarding the potential results which, in general, are somewhat less satisfactory than with most primary reconstructions, must be emphasized. However, with proper planning, attention to detail, and adherence to basic principles of anterior cruciate ligament reconstruction, revision anterior cruciate ligament surgery can provide a satisfying solution to difficult knee instability cases.

Failure of Anterior Cruciate Ligament Reconstruction

Article

May 1996

The replacement tissue used for anterior cruciate ligament reconstruction undergoes extensive biologic remodeling and incorporation after implantation. Successful biologic incorporation of the graft is dependent on a number of factors including graft placement, tensioning, and the nature of the tissue (allograft versus autograft). Failure of an anterior cruciate ligament reconstruction may occur on the basis of either technical, mechanical, or biological factors. Biologic factors include cellular repopulation, matrix remodeling, the ultimate small diameter collagen fibril orientation, the final cross sectional area of the graft, a favorable vascularization, and not overloading the graft during the remodeling process. The fully incorporated graft never duplicates the native anterior cruciate ligament but works as a check reign that makes the knee more functional.

Why Grafts Fail

Article

May 1996

Significant advances in anterior cruciate ligament reconstructive surgery have been made in the past decade and, as a result, the number of anterior cruciate ligament reconstructive procedures being done have increased. Unfortunately, graft failure continues to occur and has resulted in an emphasis on revision surgery. Successful anterior cruciate ligament reconstruction is dependent on a number of factors including: patient selection, surgical technique, postoperative rehabilitation, and associated secondary restraint ligamentous instability. A particular emphasis both in scientific and clinical research has been placed on surgical technique. Errors in graft selection, tunnel placement, tensioning, or fixation methods chosen may lead to graft failure. Improper postoperative rehabilitation may lead to graft failure; however, current protocols seem to minimize its occurrence. Finally, failure to recognize or treat a significant secondary restraint instability can place excessive stress on the anterior cruciate ligament graft which may lead to failure. Care must be taken at every step of the process to ensure graft failure does not occur, because revision anterior cruciate ligament surgery results are not as predictable as primary anterior cruciate ligament reconstruction.

Revision Anterior Cruciate Ligament Surgery: Experience From Cincinnati

Article

May 1996

Prospective studies were done to determine the outcome of allografts and autografts used for revision anterior cruciate ligament reconstruction. The allograft group was comprised of 65 patients observed for a mean of 42 months postoperatively; the autograft (bone-patellar ligament-bone) group contained 20 patients observed for a mean of 27 months postoperatively. KT-2000 testing and a comprehensive knee examination were done on all the patients. The Cincinnati Knee Rating System was used for assessment. Significant improvements were noted in all patients for symptoms, functional limitations, anteroposterior displacements, pivot shift tests, and overall rating scores. KT-2000 results showed 53% of the allograft group and 67% of the autograft group had less than 3 mm increased displacement (not statistically significant). The overall failure rates were 33% for the allografts and 27% for the autografts. Preoperative planning and technical aspects of anterior cruciate ligament revision procedures are described. The authors prefer bone-patellar ligament-bone autografts for anterior cruciate ligament revision, although the data presented were considered preliminary. Bone-patellar ligament-bone allografts may be used when autogenous tissues are not available, because they offer reasonable success rates for patients who are symptomatic with daily activities.

Revision Anterior Cruciate Ligament Surgery: Experience From Pittsburgh

Article

May 1996

Twenty-five patients who underwent revision anterior cruciate ligament reconstruction after failure of a previous intraarticular reconstruction were retrospectively reviewed. Before revision, all patients reported functional instability with sports or activities of daily living and exhibited increased anterior patholaxity on physical examination. Fresh frozen irradiated allograft tissue was used for all revisions. A comprehensive knee analysis using a subjective and objective system was done for all patients preoperatively and at the time of final followup. The mean age at revision surgery was 25 years and average time from primary to revision surgery was 30 months. Average length of followup was 28 months. The anteroposterior displacement was improved in all patients. Sixty-four percent of patients had less than 5 mm side to side difference on arthrometric testing. Eighty percent had either a Grade 0 or Grade 1 pivot shift. The average modified Cincinnati Knee Score was 68 with the results of 88% of patients rated abnormal by International Knee Documentation Committee guidelines. Seventy-six percent of patients were satisfied with their results and would elect to have revision surgery again. These results show that patients having revision anterior cruciate ligament reconstruction for a failed intraarticular reconstruction had improvement in their functional status compared with prerevision; however, they did not achieve the same level of satisfactory results as primary anterior cruciate ligament reconstruction.

Revision Anterior Cruciate Ligament Reconstruction Surgery

Abstract

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