Revision anterior cruciate ligament reconstruction

Allograft anterior cruciate ligament reconstruction: indications, techniques, and outcomes

The anterior cruciate ligament (ACL) is an important stabilizer of the knee against translational and rotational forces. The goal of anatomic reconstruction of the ACL-deficient knee is to re-create a stable knee that will allow for return to sport and prevent recurrent injury. Multiple graft options exist for ACL reconstruction, and each option has unique advantages and disadvantages. With appropriate patient selection, each graft can be utilized to optimize patient outcomes. Allograft options limit morbidity following ACL reconstruction, but care must be taken with surgical technique and postoperative rehabilitation to allow for graft incorporation. An understanding of the surgical technique and differences between graft options will allow the patient, surgeon, and physical therapist to maximize outcomes following ACL reconstruction.

Does computer navigation system really improve early clinical outcomes after anterior cruciate ligament reconstruction? A meta-analysis and systematic review of randomized controlled trials

Inaccurate tunnel placement is an important cause of failure in conventional anterior cruciate ligament (ACL) reconstruction. Controversy currently exists over the usefulness of computer-assisted navigation systems in addressing this problem. Five randomized or quasi-randomized, controlled trials comparing computer-navigated versus conventional technique in ACL reconstructions until December 1, 2009 were identified through a systematical database search. The clinical outcomes of the trials were analyzed by Lachman test, pivot-shift test, International Knee Documentation Committee knee score, Lysholm score, and Tegner score. Mean difference or risk ratio with 95% confidence interval was calculated using a fixed-effects or random-effects model. Heterogeneity across the studies was also assessed. We found that the use of computer-assisted navigation systems led to additional operative time (8-17min). No significant differences between computer-navigated and conventional groups were found in terms of knee stability and functional assessment during short-term follow-up. The role of computer-assisted navigation systems on clinical performance and longevity needs further investigation in large sample, long-term randomized trials.

Analysis of Revision Anterior Cruciate Ligament Reconstruction according to the combined injury, degenerative change, and MRI findings

The purposes of this study were to analyze the results of revision ACL reconstruction, and to determine the effects of pre-revision combined injuries, degenerative changes, and post-revision magnetic resonance imaging (MRI) findings on clinical results. Forty patients (41 operations) were enrolled in this study. Clinical results and stabilities were evaluated. Radiological results were evaluated using Fairbank scale. For the subgroup analysis, Fairbank scale and preoperative combined injuries were used. Follow-up MRIs were also available for 31(75.6%) patients and we searched for relations between MRI findings and clinical results. Significant improvements in subjective, objective scores (p<0.0001), and stability (p<0.0001) were observed between pre-revision surgery and final follow-up results. In the subgroup analysis according to the degenerative change, the mild group achieved better clinical results than the severe group (p=0.015 and 0.035, respectively). In the subgroup analysis according to the combined injuries, no significant difference was observed between 2 groups in terms of final follow-up Lysholm and IKDC subjective scores (p=0.083 and 0.085, respectively). No relation was found between clinical or stability results and MRI findings (p=0.26~0.99). Our results show that the severities of combined injuries were not correlated with clinical results, but the severities of degenerative changes were correlated with clinical results and that results were better in the no or mildly degenerated group. We also found that MRI is helpful for evaluating revision ACL, but that no relation was found between clinical or stability results and MRI findings of the graft after revision surgery.

Anatomic single- and double-bundle anterior cruciate ligament reconstruction, part 2: clinical application of surgical technique

The anterior cruciate ligament has been and is of great interest to scientists and orthopaedic surgeons worldwide. Anterior cruciate ligament reconstruction was initially performed using an open approach. When the approach changed from open to arthroscopic reconstruction, a 2- and, later, 1-incision technique was applied. With time, researchers found that traditional arthroscopic single-bundle reconstruction did not fully restore rotational stability of the knee joint and a more anatomic approach to reconstruct the anterior cruciate ligament has been proposed. Anatomic anterior cruciate ligament reconstruction intends to replicate normal anatomy, restore normal kinematics, and protect long-term knee health. Although double-bundle anterior cruciate ligament reconstruction has been shown to result in better rotational stability in both biomechanical and clinical studies, it is vital to differentiate between anatomic and double-bundle anterior cruciate ligament reconstruction. The latter is merely a step closer to reproducing the native anatomy of the anterior cruciate ligament; however, it can still be done nonanatomically. To evaluate the potential benefits of reconstructing the anterior cruciate ligament in an anatomic fashion, accurate, precise, and reliable outcome measures are needed. These include, for example, T2 magnetic resonance imaging mapping of cartilage and quantification of graft healing on magnetic resonance imaging. Furthermore, there is a need for a consensus on which patient-reported outcome measures should be used to facilitate homogeneous reporting of outcomes.

Current concepts in anatomic single- and double-bundle anterior cruciate ligament reconstruction

An anterior cruciate ligament (ACL) tear is one of the most common orthopedic sport injuries. The ACL consists of 2 functional bundles-the anteromedial and posterolateral-which are named for the position of their insertion sites on the tibia. Anatomic ACL reconstruction can be defined as the restoration of the ACL to its native dimensions, collagen orientation, and insertion sites. Some biomechanical studies have demonstrated that anatomic ACL reconstruction can restore knee motion significantly similar to that of the normal knee, as compared with traditional, nonanatomic single-bundle procedures. In vivo kinematic studies have also shown that nonanatomic single-bundle reconstruction fails to restore normal dynamic knee stability in all cases. Accurate restoration of knee kinematics with anatomic ACL reconstruction is critical to protect against the possibility that nonatomic surgical technique could result in early osteoarthritis, which is common in patients who sustain ACL tears. Surgical techniques for ACL reconstruction vary, and if different aspects of the surgery are compared for superiority (eg, single- vs double-bundle techniques), it is necessary that both procedures meet criteria to be designated as "anatomic." By emphasizing the importance of restoring the native anatomy of the knee, surgeons can give their patients the best chance at restoration of joint function and preservation of long-term knee health.

Gravity-assisted pivot-shift test can predict the function of the reconstructed anterior cruciate ligament

PURPOSE

The gravity-assisted pivot-shift (GAPS) test is a newly advocated test for anterior cruciate ligament (ACL) injury. We retrospectively investigated the relationships between the result of preoperative GAPS test and the function of the reconstructed ACL using autogenous hamstring tendon grafts.

METHODS

Seventy-eight patients with unilateral ACL injury and a minimum of 1-year follow-up were enrolled in this study. According to the result of preoperative GAPS test, they were divided into two groups, i.e., positive test group (Group P) and negative test group (Group N). At the time of follow-up, the operated knee was examined manually and using KT-1000 arthrometer. According to these results, the function of the reconstructed ACL was classified.

RESULTS

The proportion of the knees with a negative abnormal laxity test was less in Group P than Group N with the significant difference in Lachman test (P = 0.0029) and N-test (P = 0.0081). The proportion of the cases having greater than 3 mm of the side-to-side difference in anterior knee laxity using KT-1000 arthrometer was greater in Group P, in spite of no statistically significant difference. Regarding the classification of the function of the reconstructed ACL, Group P was worse than Group N (P = 0.0187), and all 4 knees classified as failed belonged to Group P.

CONCLUSION

The knees with a preoperative positive GAPS test showed worse postoperative function of the reconstructed ACL than those with a negative test. Preoperative positive GAPS test is considered to be a predisposing factor to poor functional outcome after ACL reconstruction. It is possible that the use of hamstring tendons as a graft source should be avoided for the ACL-injured patients with a positive GAPS test.

Fifteen-year outcome of endoscopic anterior cruciate ligament reconstruction with patellar tendon autograft for "isolated" anterior cruciate ligament tear

BACKGROUND

Few studies report the long-term results of anterior cruciate ligament rupture and single-incision endoscopic reconstructive surgery. Outcomes are often clouded by concomitant meniscal, chondral, or ligament injuries.

PURPOSE

To determine the 15-year outcomes of anterior cruciate ligament ruptures treated with endoscopic anterior cruciate ligament reconstruction using middle-third patellar tendon autograft.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between January 1993 and April 1994, 333 consecutive patients underwent anterior cruciate ligament reconstruction. Patients with associated ligamentous injury requiring surgery, previous meniscectomy, or meniscal injury requiring more than one-third meniscectomy; chondral injury diagnosed at arthroscopy; and an abnormal contralateral knee were excluded. Ninety patients met the inclusion criteria. Outcomes included range of motion, Lachman and pivot-shift tests, instrumented ligament testing, single-legged hop test, Lysholm Knee Score, the International Knee Documentation Committee evaluation, and radiographic assessment.

RESULTS

Thirty percent of patients had further anterior cruciate ligament injury. Twenty-four percent of patients (n = 22) sustained contralateral anterior cruciate ligament ruptures, and 8% (n = 7) ruptured the graft (P = .009). Graft rupture was associated with a graft inclination angle <17° (P = .02). Contralateral anterior cruciate ligament rupture was associated with age <18 years at time of primary injury (P = .001). All patients had normal or nearly normal (International Knee Documentation Committee evaluation) Lachman and instrumented testing, and 91% had a negative pivot-shift result. Seventy percent of patients had kneeling pain. Median subjective International Knee Documentation Committee evaluation was 91 of 100. Fifty-one percent of patients had radiographic evidence of osteoarthritis (41% grade B; 10% grade C).

CONCLUSION

Good results are maintained at 15 years after surgery with respect to ligamentous stability, subjective outcomes, and range of motion. Kneeling pain remains a significant problem. Concern remains regarding the incidence of further anterior cruciate ligament injury and the increasing number of patients with radiographic and clinical signs of osteoarthritis despite surgical stabilization.

COMPLICATIONS OF THE SCREW/WASHER TIBIAL FIXATION TECHNIQUE FOR KNEE LIGAMENT RECONSTRUCTION

To evaluate the presence of pain at the site of the surgical incision and the need to remove the tibial fixation screw in anterior cruciate ligament (ACL) reconstruction, in relation to sex and body mass index (BMI). Methods: A group of 265 patients who underwent ACL reconstruction with ipsilateral flexor tendon grafts from the thigh in which the tibial fixation technique consisted of using a cortical screw and metal washer, between July 2000 and November 2007, were evaluated. Results: 176 patients were evaluated for an average of 33.3 ± 19.5 months; median of 29.5 months; IIQ: 17-45 months; minimum of 8 and maximum of 87 months. There was no statistical difference regarding complaints of pain at the site of the screw (p = 0.272) and the need to remove the tibial screw (p = 0.633) between sexes. There was no statistical difference regarding complaints of pain at the site of the screw (p = 0.08) and the need to remove the tibial screw (p = 0.379) according to BMI. Conclusion: The pain complaint rate at the screw site from the screw and metal washer method used for tibial fixation in ACL reconstruction was of the order of 25%, and the screw had to be removed in 10.8% of the cases. There was no predominance of pain complaints at the surgical wound between the sexes. There was a greater tendency to complain about pain among patients with BMI < 25. There was no predominance of screw and washer removal between the sexes or between individuals with different BMIs.

Single-stage anterior cruciate ligament revision with bone-patellar tendon-bone: a case-control series of revision of failed synthetic anterior cruciate ligament reconstructions

PURPOSE

The purpose of this study was to investigate the clinical results of single-stage revision anterior cruciate ligament reconstruction (ACLR) after synthetic ligament failure.

METHODS

The subjects comprised 20 patients who underwent revision ACLR after synthetic ligament failure. All revisions were performed with bone-patellar tendon-bone graft, and bone tunnel expansion after removal of synthetic materials was treated with bone plugs sized and trimmed as necessary to fill the bone tunnels. Clinical results were assessed at a mean of 2.8 years postoperatively, followed by comparison with the results of 20 primary ACLRs selected as case-matched controls. Assessment included the Lysholm score, International Knee Documentation Committee (IKDC) evaluation, instrumented laxity testing, and radiologic examination.

RESULTS

Bone tunnel enlargement to 11 mm in diameter or greater was found in 10 of 20 revision ACLRs. However, favorable anteroposterior stability was obtained at final follow-up (1.4 +/- 2.0 mm in revision ACLR group and 1.5 +/- 1.5 mm in primary ACLR group). The overall Lysholm score improved significantly from preoperatively to final follow-up, but the revision ACLR group showed significantly worse results for the pain parameter than the primary ACLR group. The final IKDC results also showed significant postoperative improvement, but the number of cases with grade C was significantly higher in the revision ACLR group than in the primary ACLR group, which was attributed to radiologically confirmed osteoarthritis in the revision ACLR group.

CONCLUSIONS

Single-stage revision ACLR with bone-patellar tendon-bone graft after synthetic ligament failure yielded favorable results in terms of IKDC grade, Lysholm score, and anteroposterior stability, despite enlarged bone tunnels after removal of synthetic material. Inferior results for the radiologic and pain parameters of the IKDC and Lysholm scores were attributed to osteoarthritic changes inherent to the revision ACLR group.

LEVEL OF EVIDENCE

Level III, therapeutic case-control study.

Development and in situ application of an adjustable aiming device to guide extra- to intraarticular tibial tunnel drilling for the insertion of the cranial cruciate ligament in dogs

OBJECTIVE

To develop and test an arthroscopic aiming device for extra- to intraarticular tibial tunnel drilling emerging at the center of the tibial insertion (CenterTib) of the cranial cruciate ligament (CCL) in medium to large breed dogs.

STUDY DESIGN

Descriptive experimental study.

SAMPLE POPULATION

Fifty-two cadaveric hind limbs of dogs >or=20 kg BW.

METHODS

The mediolateral position and craniocaudal position (ccPos) of CenterTib in relation to the caudomedial meniscotibial ligament were measured on photographs of 46 dissected tibial plateaus. The proximal tibial depth (TibDepth) was determined on lateral radiographs and its correlation with ccPos was assessed using linear regression analysis. Extra- to intraarticular arthroscopic tibial tunnel drilling was performed in 6 independent cadaveric stifles. A C-guide with an adjustable craniocaudal offset was constructed and adjusted according to ccPos estimated based on TibDepth. The position of the resulting bone tunnels was compared with the position of the CenterTib.

RESULTS

Pearson's correlation between TibDepth and ccPos was strong (R=0.86; P<.001). ccPos (y) as a function of TibDepth (x) can be expressed as y=-4.8+0.3x. Arthroscopic tunnel drilling resulted in a median deviation of the drill tunnels around the CenterTib of 1 mm.

CONCLUSION

The regression equation and aiming device permit localization and targeting of CenterTib during extra- to intraarticular tibial bone tunnel drilling in vitro.

CLINICAL RELEVANCE

The proposed technique may reduce tibial tunnel misplacement when performing intraarticular CCL repair using a tibial bone tunnel.

Revision anterior cruciate ligament reconstruction by double-bundle technique using multi-strand semitendinosus tendon

PURPOSE

The purpose of the study was to compare the outcome of revision anterior cruciate ligament (ACL) reconstruction by the double-bundle (DB) technique using multi-strand semitendinosus tendon with that of primary reconstruction by use of the same technique.

METHODS

The study included 21 patients who underwent revision ACL reconstruction (mean follow-up, 40 months) with the semitendinosus tendon DB technique between 1995 and 2006 and 86 unilateral primary DB ACL reconstructions (mean follow-up, 33 months) between 2000 and 2004. The outcome of both groups was compared based on differences between operated and unoperated limbs and modified International Knee Documentation Committee grades. Both the overall and sports-related subjective scores were evaluated between the 2 groups.

RESULTS

The KT measurements (MEDmetric, San Diego, CA) averaged 1.7 mm (SD, 1.8 mm) in the revision group and 1.5 mm (SD, 1.6 mm) in the primary group. There was no significant difference in KT measurements between the 2 groups. The Lachman test was negative in 83% of revision cases and 87% of primary cases; the anterior drawer test was negative in 83% and 91%, respectively, and the pivot-shift test was negative in 78% and 90%, respectively. There was a tendency for a positive pivot-shift test in the revision group being higher. The Lysholm score and subjective recovery score were significantly lower in the revision group.

CONCLUSIONS

The semitendinosus tendon DB revision procedure provided range of motion and anterior stability comparable to those after primary DB surgery and a comparable return to athletic activities. However, the patients tended to have positive pivot-shift test results. The revision cases were also inferior in terms of the general evaluation of recovery of knee condition. The outcome scores were lower overall in the revision group.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Anteromedial portal versus transtibial drilling techniques in ACL reconstruction: a blinded cross-sectional study at two- to five-year follow-up

Drilling of the femoral tunnel with the transtibial (TT) technique is widely used in bone-patellar tendon-bone (BPTB) anterior cruciate ligament (ACL) reconstruction. Recent studies suggest higher knee stability with the use of the anteromedial portal (AMP). The purpose of this study was to compare functional and clinical outcomes of BPTB ACL reconstruction using the TT or the AMP technique for drilling the femoral tunnel. All ACL reconstructions between January 2003 and April 2006 were approached for eligibility. Forty-seven patients met inclusion criteria (21 TT group and 26 AMP group). Blinded assessments of IKDC score, knee stability and range of motion, one-leg hop test, mid-quadriceps circumference, VAS for satisfaction with surgery, Lysholm and Tegner scores, and SF-12 questionnaire were obtained for both groups. Data on preoperative and postoperative surgical timing were retrospectively reviewed through the charts. The AMP group demonstrated a significantly lower recovery time from surgery to walking without crutches (p < 0.01), to return to normal life (p < 0.03), to return jogging (p < 0.03), to return training (p < 0.03), and to return to play (p < 0.03). Knee stability values measured with KT-1000, Lachman test, pivot-shift sign, and objective IKDC score assessments were significantly better for the AMP compared to TT group (p < 0.002, p < 0.03, p < 0.02, p < 0.015, respectively). No differences were found for VAS for satisfaction with surgery, Lysholm, Tegner, and SF-12 between both groups. The use of the AMP technique significantly improved the anterior-posterior and rotational knee stability, IKDC scores, and recovery time from surgery compared to the TT technique.

The effect of medial meniscectomy and meniscal allograft transplantation on knee and anterior cruciate ligament biomechanics

PURPOSE

Our purpose was to evaluate the effect of meniscectomy and meniscal allograft transplant on anterior cruciate ligament (ACL) and knee biomechanics.

METHODS

A differential variable reluctance transducer was placed in the ACL of 10 human cadaveric knees to record strain. Tibial displacement from a neutral reference was recorded relative to the position of the femur. Testing was performed at 30 degrees, 60 degrees, and 90 degrees of knee flexion. Six cycles of anterior-posterior loads were applied to the limit of 150 N. After a testing cycle, a medial meniscectomy was performed and the testing cycle was repeated. A meniscal allograft transplant was performed, and a final testing cycle was conducted. ACL strain and tibial displacement in the meniscectomy and meniscal allograft states were compared with the intact-knee state.

RESULTS

Tibial displacement after meniscectomy significantly increased at all angles. The meniscal allograft transplant restored tibial displacement to normal values at 30 degrees and 90 degrees. ACL strain increased significantly after meniscectomy at 60 degrees and 90 degrees of flexion, and meniscal allograft transplant returned the strain values to normal at 60 degrees and 90 degrees.

CONCLUSIONS

In most cases medial meniscectomy produced a significant increase in tibial displacement relative to the femur, and meniscal allograft transplantation restored displacement values to normal. Meniscectomy increased ACL strain and meniscal allograft transplant restored strain values to normal in 2 of 3 tested flexion angles.

CLINICAL RELEVANCE

The absence of the medial meniscus exposes the ACL to increased strain, whereas meniscal allograft lowered the strain on the native ACL. This could have implications for those patients undergoing ACL reconstruction who have concomitant removal of the medial meniscus.

Anatomic single- and double-bundle anterior cruciate ligament reconstruction flowchart

Anatomy is the foundation of orthopaedic surgery, and the advancing knowledge of the anterior cruciate ligament (ACL) anatomy has led to the development of improved modern reconstruction techniques that approach the anatomy of the native ACL. Current literature on the anatomy of the ACL and its reconstruction techniques, as well as our surgical experience, was used to develop a flowchart that can aid the surgeon in performing anatomic ACL reconstruction. We define anatomic ACL reconstruction as the functional restoration of the ACL to its native dimensions, collagen orientation, and insertion sites. A guideline was written to accompany this flowchart with more detailed information on anatomic ACL reconstruction and its pitfalls, all accompanied by relevant literature and helpful figures. Although there is still much to learn about anatomic ACL reconstruction methods, we believe this is a helpful document for surgeons. We continue to modify the flowchart as more information about the anatomy of the ACL, and how to more closely reproduce it, becomes available.

Femoral tunnel placement during anterior cruciate ligament reconstruction: an in vivo imaging analysis comparing transtibial and 2-incision tibial tunnel-independent techniques

BACKGROUND

Recent studies have questioned the ability of the transtibial technique to place the anterior cruciate ligament graft within the footprint of the anterior cruciate ligament on the femur. There are limited data directly comparing the abilities of transtibial and tibial tunnel-independent techniques to place the graft anatomically at the femoral attachment site of the anterior cruciate ligament in patients.

HYPOTHESIS

Because placement with the tibial tunnel-independent technique is unconstrained by the tibial tunnel, it would allow for more anatomic tunnel placement compared with the transtibial technique.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

High-resolution, multiplanar magnetic resonance imaging and advanced 3-dimensional modeling techniques were used to measure in vivo femoral tunnel placement in 8 patients with the transtibial technique and 8 patients with a tibial tunnel-independent technique. Femoral tunnel placement in 3 dimensions was measured relative to the center of the native anterior cruciate ligament attachment on the intact contralateral knee.

RESULTS

The tibial tunnel-independent technique placed the graft closer to the center of the native anterior cruciate ligament attachment compared with the transtibial technique. The transtibial technique placed the tunnel center an average of 9 mm from the center of the anterior cruciate ligament attachment, compared with 3 mm for the tibial tunnel-independent technique. The transtibial technique resulted in a more anterior and superior placement of the tunnel compared with the tibial tunnel- independent technique.

CONCLUSION

The tibial tunnel-independent technique allowed for more anatomic femoral tunnel placement compared with the transtibial technique.

Biomechanical evaluation of a 1-stage revision anterior cruciate ligament reconstruction technique using a structural bone void filler for femoral fixation

PURPOSE

The purpose of this study was to develop a method of femoral fixation for complex revision anterior cruciate ligament (ACL) reconstructions that would avoid a staged bone grafting approach. We evaluated the use of a calcium phosphate cement as a structural bone void filler that would allow for a single-stage revision ACL reconstruction with initial biomechanical properties equivalent to standard autologous bone-patellar tendon-bone primary ACL reconstruction.

METHODS

We tested 11 matched pairs of fresh-frozen cadaveric knees (N = 22). Controls were treated with autologous bone-patellar tendon-bone primary ACL reconstruction fixed with bioabsorbable interference screws with a 1-mm back wall. The contralateral knee of each pair had a large bone void created that would hamper subsequent femoral fixation to simulate revision ACL reconstruction conditions. This defect was filled with calcium phosphate cement arthroscopically. After solidification, the femoral tunnel was drilled through the bone void filler and native bone with a 1-mm back wall, allowing anatomic positioning. The autologous graft was then placed and fixed with a bioabsorbable interference screw. Specimens were then tested in an MTS machine (MTS Systems, Eden Prairie, MN) for load to failure according to a standard protocol and compared with matched controls.

RESULTS

Failure loads for the control group averaged 312 N (standard deviation [SD], 127 N) and were not significantly different compared with the calcium phosphate cement revision group, which averaged 301 N (SD, 95 N) (P = .80). Failure occurred at the femoral bone block in both groups but without screw pullout.

CONCLUSIONS

Statistical analysis failed to show a significant difference between the control group and the group undergoing structural bone void filler revision in this biomechanical evaluation of initial fixation strength.

CLINICAL RELEVANCE

This technique may allow surgeons to perform a single-stage revision ACL reconstruction in the presence of a contained bone void and avoid the need for a staged procedure if clinical studies verify long-term incorporation of the bone void filler.

Anterior cruciate ligament revision of a relatively new implant system

Cayenne AperFix (Cayenne Medical, Inc, Scottsdale, Arizona) is a relatively new implant used in anterior cruciate ligament (ACL) reconstruction. To date, there have been more than 4500 primary reconstructions performed using the device, and removal of the implant during revision surgery has not been discussed in any published literature. The focal point of the procedure involves removing the center screw within the femoral component, followed by using a core reamer to extract the entire device, leaving behind a femoral tunnel with no defects that can accept a new graft. We present the case of failed primary ACL reconstruction in a 23-year-old man due to a single traumatic event. We discuss the technical challenges associated with this implant as well as the technique used for removal.

Does the use of fluoroscopy and isometry during anterior cruciate ligament reconstruction affect surgical decision making?

OBJECTIVE

Poor results after anterior cruciate ligament (ACL) reconstruction are often due to inaccurate graft placement. Numerous strategies have been advocated to improve accuracy and consistency of tunnel positioning, including computer-assisted navigation. Less expensive alternatives, such as intraoperative fluoroscopy and isometry, have also been advocated for confirming guide pin placement before reaming the femoral tunnel. It is unknown how often these techniques cause surgeons to change the location of their femoral tunnel at the time of surgery. We undertook this study to determine how often this approach results in repositioning of the guide pin before final graft placement. We hypothesized that a lower level of surgeon experience would lead to a higher frequency of repositioning compared to a higher level of experience.

DESIGN

Prospective, case series.

SETTING

Institutional.

PATIENTS

Intraoperative data were gathered prospectively from 413 consecutive, primary ACL reconstructions performed by the sports medicine group at our institution. Of the 413 procedures enrolled in this study, 407 were available for analysis. Six procedures were excluded because the tension isometer was unavailable during the procedure.

INTERVENTIONS

Isometry and fluoroscopy were used in all cases to aid in the accurate placement of the femoral tunnel. Femoral pin change based on the results of isometry or fluoroscopy was recorded. The percentage of cases involving a change in the femoral pin resulting from the use of these techniques was calculated. This percentage was also calculated separately for cases performed by a staff surgeon (fellowship-trained sports medicine staff) as well as less experienced surgeons (current sports medicine fellows).

MAIN OUTCOME MEASURES

The main outcome measurement was whether the femoral pin was changed.

RESULTS

Of the 407 procedures available for review, 62 (15%) of them involved a change in femoral pin position secondary to information provided by intraoperative isometry or fluoroscopy. In the procedures performed by more experienced surgeons, the pin was changed in 40 (16%) of 253 cases; in those performed by less experienced surgeons, it was changed in 22 (14%) of 154 cases.

CONCLUSIONS

The intraoperative use of isometry and fluoroscopy during ACL reconstruction led to changes in the femoral tunnel placement 15% of the time. The influence of these instruments on intraoperative decision making does not seem to diminish with surgical experience.

Comparison of revision surgery with primary anterior cruciate ligament reconstruction and outcome of revision surgery between different graft materials

BACKGROUND

The number of primary anterior cruciate ligament reconstructions is increasing rapidly; the number of failing grafts and need for revision surgery have also risen.

HYPOTHESIS

Revision anterior cruciate ligament reconstruction will produce similar results to those of primary reconstruction, and there may be different results according to graft materials.

STUDY DESIGN

Case control study; Level of evidence, 3.

METHODS

Fifty-nine revision surgeries were performed at 1 institution between January 1997 and October 2005. Fifty-five patients (56 operations) were followed. The results of 117 patients (117 knees) treated with arthroscopic primary anterior cruciate ligament reconstruction using double-looped semitendinosus and gracilis autograft from September 2001 to November 2002 were also evaluated. Clinical and stability results between primary and revision anterior cruciate reconstruction were compared. For the revision surgery, 21 (37.5%) knees had revision reconstruction with previously unharvested ipsilateral double-looped semitendinosus and gracilis autograft. Twenty (35.7%) were bone-patellar tendon-bone allograft, and 15 (26.8%) were Achilles allograft. The details of the technique varied according to the original graft choice and the abnormality encountered. Concomitant procedures were necessary in 32 (57.1%) of 56 knees. Clinical and stability results according to the different graft materials were also compared.

RESULTS

There were significant improvements in the scores for subjective, objective forms (P < .001), and stability (P < .001). However, the clinical results of revision surgery were inferior to primary reconstruction (P < .001), but as regards stability, the difference between primary and revision cases was not significant (P = .338). There was no difference in clinical and stability results in different groups of graft material (P = .160-.690).

CONCLUSION

Revision anterior cruciate ligament reconstruction could improve clinical and stability results, but the clinical results were inferior to those of primary reconstruction. This study also demonstrated that the success of the operation did not depend on the choice of graft materials.

Anterior cruciate ligament revision reconstruction: results in 107 patients

BACKGROUND

Although techniques and options for suitable graft substitutes for anterior cruciate ligament surgery continue to improve, failures occur because of many reasons. Errors in surgical techniques seem to be important reasons.

HYPOTHESIS

Inappropriate positioning of the tunnels may be the most important reason for these failures. Anatomical anterior cruciate ligament revision reconstruction, using autografts, may yield acceptable outcomes.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This retrospective study involved 148 anterior cruciate ligament revision reconstructions performed in our hospital using autografts. One hundred and seven patients were followed up at a mean of 72.9 +/- 20.6 months. Clinical evaluation was performed using the Lysholm score, the Tegner rating system, the International Knee Documentation Committee evaluation form, and the KT-1000 arthrometer. Radiographs were evaluated for signs of osteoarthritis according to the Jaeger and Wirth classification.

RESULTS

Inappropriate positioning of the tunnels was the most important reason (63.5%) for anterior cruciate ligament reconstruction failure. The average Lysholm score improved significantly at the follow-up (88.5 +/- 12.4 vs 51.5 +/- 24.9; P < .001). Moreover, the average Tegner activity score improved significantly compared with the activity score before revision surgery (6.3 +/- 1.8 vs 2.8 +/- 1.8; P < .001). The International Knee Documentation Committee score was A in 17 cases, B in 45, C in 37, and D in 8. Radiographic evaluation revealed that 33 patients had degenerative findings of grade I, 35 of grade II, 16 of grade III, and 2 of grade IV.

CONCLUSION

Anatomical anterior cruciate ligament revision reconstruction provides satisfactory midterm results as far as stability and function of the knee are concerned. In spite of these favorable subjective and objective results, the radiological evaluation revealed a significant progression of osteoarthritis.

Results of revision anterior cruciate ligament surgery

BACKGROUND

Revision anterior cruciate ligament surgery remains challenging.

PURPOSE

To analyze the authors' experience with revision anterior cruciate ligament surgery and determine the association between stability and functional results.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between 1991 and 2002, 95 of 102 patients who underwent revision anterior cruciate ligament reconstruction at the authors' institution met the criteria for inclusion in the study. Of those, the 63 (66%) who returned for complete clinical and radiologic evaluation (mean follow-up, 72.7 months) formed the study group. Subjective evaluation focused on return to sports, arthritic symptoms, and subjective International Knee Documentation Committee criteria. Clinical evaluation included examination, KT-1000 arthrometer and functional testing, and radiographic analysis of alignment and arthritis.

RESULTS

Based on International Knee Documentation Committee subjective scores and return to sports, results were rated as excellent/good in 45 patients (71%), fair in 6 (10%), and poor in 12 (19%). A grade IA or IIA Lachman and a KT-1000 arthrometer side-to-side difference of <3 mm (32/63 patients) was associated with a good/excellent result (P < .05). The mechanical axis was midline in 78% (49/63 patients). Radiographic arthritis (16 patients, 25%) was associated with duration of instability after primary failure (P < .03). Return to sports occurred in 59% (37/63 patients). Sixteen patients (25%) required a second revision surgery.

CONCLUSION

Revision anterior cruciate ligament surgery allowed approximately 60% of patients to go back to sports, most of them at lower levels than their prerevision function. Instrumented laxity of <3 mm was associated with a better result. Radiographic arthritis was associated with duration of instability symptoms after primary failure. Patients who undergo revision anterior cruciate ligament surgery should be counseled as to the expected outcome and cautioned that this procedure probably represents a salvage situation and may not allow them to return to their desired levels of function.

Primary versus single-stage revision anterior cruciate ligament reconstruction using autologous hamstring tendon grafts: a prospective matched-group analysis

BACKGROUND

There is a low level of evidence about clinical results after anterior cruciate ligament (ACL) revision reconstruction using autologous hamstring tendon grafts.

HYPOTHESIS

Anterior cruciate ligament revision reconstruction improves knee stability but shows inferior results for functional and subjective outcome and knee stability compared with primary reconstruction.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Between October 1997 and July 2005, 166 single-stage or 2-stage revision ACL reconstructions were done using different graft types. One hundred twenty-four cases underwent a single-stage revision reconstruction with autologous hamstring tendon grafts. At the time of data analysis, 67 cases fulfilled the criteria of minimum 2-year follow-up. Five patients were lost to follow-up (follow-up rate, 91%). Four patients (6%) who experienced graft rupture were counted as failures but not subjected to further detailed analysis. Because of loss to follow-up and exclusion criteria (n = 12), 50 patients were included in the study. For a comparative matched-group analysis, patients with a primary hamstring tendon graft ACL reconstruction were selected out of a database with minimum 2 years' follow-up (N = 284). Patients were followed using the International Knee Documentation Committee (IKDC) and Lysholm scores, KT-1000 arthrometer testing, and additional functional tests.

RESULTS

Four of 62 available patients (6.5%) in the revision group experienced graft failure, which was comparable to 16 of 284 (5.6%) in the primary reconstruction group. When the 2 matched groups of 50 patients were further compared, postoperative IKDC results showed no significant differences between groups. The manual maximum KT-1000 arthrometer side-to-side difference was 2.1 +/- 1.6 mm for the revision group and 2.2 +/- 1.1 mm for the primary reconstruction group. The Lysholm score was significantly better in the primary reconstruction group (P = .014). The incidence of postoperative positive pivot-shift test results was not significantly different. The primary reconstruction group showed significantly less extension deficits. Functional testing revealed significantly better results for the primary reconstruction group for stair climbing, squatting, knee bending, and duck walk.

CONCLUSIONS

In our patient series, primary ACL reconstruction showed significantly better results in Lysholm score, although the IKDC score and objective knee stability showed no significant difference between the groups. Thus, parameters other than measurable knee stability must be responsible for the inferior results of the revision reconstruction group.

Strategies for prevention and management of musculoskeletal conditions. Lower limb pain

This article summarises lower limb pathology, which results in lower limb pain. It mainly addresses injuries and deliberately omits osteoarthritis and rheumatoid arthritis, since these entities are described in detail in other chapters in this volume. As major trauma is not a focal point for rheumatologists and repetitive strain injuries of the lower limb are rare, sports and leisure injuries are the main focus. Regarding lower limb pain, this chapter describes the most important problems and quantifies the size of the problem. Furthermore, it informs the reader about different treatment modalities, their goals and methods of measuring the effectiveness of the treatment. Evidence is given for different interventions, such as lifestyle, pharmacological, surgery and rehabilitation. In addition, opportunities to apply these interventions for prevention and treatment to those who will potentially benefit most are shown. Finally, strategies (care pathways) are given for prevention and treatment based on this evidence.

Radiographic landmarks for femoral tunnel placement in medial patellofemoral ligament reconstruction

BACKGROUND

Reconstruction of the medial patellofemoral ligament has recently become popular for restoring patellofemoral stability. Femoral insertion site anatomy of the medial patellofemoral ligament has been described. This anatomical insertion has been inferred to be the isometric point in medial patellofemoral ligament reconstruction, but data about radiographic landmarks for a postoperative or intraoperative control are missing.

PURPOSE

To determine the radiographic landmarks for control of postoperative and intraoperative femoral medial patellofemoral ligament insertion.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Eight fresh-frozen human knees were dissected, and the medial patellofemoral ligament was exposed. After identification of the femoral medial patellofemoral ligament insertion site, the insertion center was marked with a lead ball of 2-mm diameter. Straight lateral radiographs were taken, and posterior-anterior as well as proximal-distal position were evaluated.

RESULTS

Six of 8 insertion points were anterior to a line representing an extension of the posterior cortex, 1 point was touching this line, and 1 point was posterior to it. All points were situated distal to the posterior origin of the medial femoral condyle and proximal to the most posterior point of the Blumensaat line.

CONCLUSION

A reproducible anatomical and radiographic point, 1 mm anterior to the posterior cortex extension line, 2.5 mm distal to the posterior origin of the medial femoral condyle, and proximal to the level of the posterior point of the Blumensaat line on a lateral radiograph with both posterior condyles projected in the same plane, shows the mean femoral medial patellofemoral ligament center.

CLINICAL RELEVANCE

This radiographic point may be useful both intraoperatively and postoperatively.

A new harvest site for bone graft in anterior cruciate ligament revision surgery

During revision anterior cruciate ligament (ACL) surgery, femoral interference screws frequently require removal. This may lead to significant tunnel widening and possible graft fixation failure as a result. Solutions include drilling the revision tunnel in a different location, using stacked interference screws, or using bone graft to fill the defect. Autogenous iliac crest graft and allograft are both used, but there are significant comorbidities associated with each. We developed a new technique for harvesting autogenous bone graft that avoids many of the complications associated with other graft sources. By use of the existing surgical incision from the initial harvest of the bone-patellar tendon-bone autograft, bone from the medial tibial metaphyseal safe zone is harvested via an OATS tube harvester (Arthrex, Naples, FL). A bone plug 1 mm larger in size than the femoral defect is harvested and arthroscopically inserted via a press-fit technique. At 3 months after bone grafting, patients undergo revision ACL reconstruction. The proximal tibial metaphysis is a safe bone graft harvest site in revision ACL surgery and offers an effective method for filling large bony defects, allowing anatomic reconstruction of the ACL after bone healing has occurred. Furthermore, it eliminates the problems associated with allograft or use of a remote graft donor site.

Revision anterior cruciate ligament reconstruction due to knee instability

Introduction. The primary goal of anterior cruciate ligament reconstruction is to provide stability to the knee and regain full range of motion. Although great improvement has been achieved in surgical techniques and rehabilitation, some patients are not completely satisfied with the results of surgery and a revision anterior cruciate ligament reconstruction is necessary. Material and Methods. Revision arthroscopic anterior cruciate ligament reconstruction was carried out in eleven patients with bone-tendon-bone autografts. The surgery was performed in a standard manner and the graft was taken from the opposite knee. Eight men and three women were evaluated. The mean age of patients was 26 (17-34) years. Repeated instability of the knee was caused by injury in five patients, while six patients were unsatisfied with the position of the graft. Results. The follow up was 4,2 years (2-8) respectively. The mean Lysholm and Gillquist score after operation was 88 (65-90). Preoperative and postoperative tibial shift was 9mm (6-15) and 2mm (0-4), respectively. The preoperative pivot shift test was grade 2 and 3 in all patients. Postoperative pivot shift test was negative in seven patients, in three it was grade 1 and grade 2 in one patient. According to the IKDC scale, preoperative results were abnormal in three patients and in eight they were severely abnormal. Postoperative IKDC score was normal in five patients, in four nearly normal, and in one patient the score was still abnormal. Five patients continued to be active in sports activities, four patients decreased the level of sports activity and two stopped all sports activities. Conclusion. Success of revision anterior cruciate ligament reconstruction requires detailed preoperative evaluation of the repeated instability of the knee. The treatment plan is then decided upon. The patients must be preoperatively informed about the real possibilities of revision surgery. Only a mutual collaboration between the patient, physiatrist and a surgeon is a key for successful treatment and return to previous level of sports activities.

Infrapatellar heterotopic ossification after anterior cruciate ligament reconstruction

Reconstruction of the anterior cruciate ligament (ACL) is currently a common procedure. We report a case of ACL reconstruction using an autologous patellar tendon graft, where great infrapatellar heterotopic ossification occurred post-operatively. We found no similar cases in the literature. We discuss about the probable origin.

Current concepts review: revision anterior cruciate ligament reconstruction

Failed anterior cruciate ligament (ACL) reconstruction presents a difficult clinical challenge. Successful revision ACL reconstruction depends on identifying the causes of failure and correcting technical or diagnostic errors. Failed ACL reconstruction may be either traumatic or atraumatic. Atraumatic failures may be attributable to technical errors, diagnostic errors, or failure of graft incorporation. Published outcomes of revision ACL reconstruction have been worse than for primary ACL reconstruction. The preoperative evaluation, surgical techniques, and clinical outcomes of revision ACL reconstruction are reviewed.

A new technique for femoral and tibial tunnel bone grafting using the OATS harvesters in revision anterior cruciate ligament reconstruction

Revision anterior cruciate ligament (ACL) reconstruction is becoming more frequent, especially in specialized centers, because of the large numbers of primary ACL procedures performed. In 2-stage revisions, bone grafting of the tunnels may be undertaken if the primary position was inaccurate or if osteolysis has caused widening of the tunnels. This will allow the desired placement of the new tunnels without the risk of loss of structural integrity. It is technically difficult to deliver and impact bone graft into the femoral tunnel with the standard surgical and arthroscopic instruments. We describe a new technique for femoral and tibial tunnel impaction grafting in 2-stage ACL revisions, using the OATS grafting instruments (Osteochondral Autologous Transfer System; Arthrex, Naples, FL). The appropriately sized OATS harvester is chosen 1 mm larger than the tunnel size and is used to harvest bone graft from the iliac crest through a percutaneous approach. This provides a cylindrical graft, which is delivered to the femoral tunnel through the arthroscopic portal. The inside punch of the harvester is tapped and this allows delivery of the graft in a controlled manner and its impaction into the tunnel. The same is repeated for the tibial tunnel while providing support for the proximal end of the tunnel.

Anterior cruciate ligament revision: double-bundle augmentation of primary vertical graft

A variety of factors contribute to the failure of primary anterior cruciate ligament (ACL) reconstruction; most commonly, it is technical error related to tunnel placement. Recently, the increasing popularity of the all-endoscopic ACL reconstruction and concern about graft impingement may have led to more posterior placement of the tibial tunnel by surgeons. Working through a tibial tunnel placed too posterior makes it more difficult to recognize the correct starting position on the femur, and more likely to start the femoral tunnel in a central 12 o'clock position. The combination of subtle posterior placement of the tibial tunnel and central placement of the femoral tunnel results in a graft that is malpositioned in both the sagittal and coronal planes--a "vertical graft." We present a novel method of ACL revision surgery applicable to a specific subset of ACL revision patients with an intact "vertical graft" and instability that is rotational more than translational. In these patients, a double-bundle revision ACL augmentation technique can be used, leaving the original graft in place. A new tibial tunnel is placed anterior to the original and a new femoral tunnel lateral to the original. Reconstruction is performed with allograft and the combined ACL construct provides robust translational and rotational stability to the tibiofemoral joint.

Comparison of initial mechanical properties of 4 hamstring graft femoral fixation systems using nonpermanent hardware for anterior cruciate ligament reconstruction: an in vitro animal study

PURPOSE

To compare the initial mechanical characteristics of 4 systems used to fix tendons to the femur during anterior cruciate ligament reconstruction.

METHODS

A total of 32 porcine femurs were used to study the following fixation systems: Bioabsorbable interference screw (Stryker, Kalamazoo, MI), Bio-Transfix Cross-pin (Arthrex, Naples, FL), Biosteon Cross-pin (Stryker), and a fixation technique based on wrapping the graft around the femoral condyle itself, thus allowing it to be fixed in place without the use of any hardware. The mechanical characteristics of each system were obtained by a preconditioned failure tensile test.

RESULTS

The yield load values (990.9 +/- 242.6 N for Bio-Transfix, 905.1 +/- 158.8 N for Biosteon Cross-pin, 684.4 +/- 119.7 N for the without-hardware system (WHS), and 369.4 +/- 120.1 N for the interference screw) revealed significant differences between the techniques that used cross-pins and the other 2 techniques (P < .006) on the one hand, and between the without hardware technique and the interference screw (P < .004) on the other. The stiffness of the 2 cross-pin fixation systems (117.6 +/- 22.5 N for Bio-Transfix and 112.6 +/- 22.5 N for Biosteon) was greater (P < .01) than those of the other systems (79.4 +/- 15.2 N for the WHS and 68.5 +/- 13 N for the interference screw).

CONCLUSIONS

The initial biomechanical properties of the 2 cross-pin fixation systems proved to be superior to those of the other 2 systems studied. The WHS fixation system exhibited better mechanical properties than its interference screw counterpart.

CLINICAL RELEVANCE

The better initial mechanical characteristics encountered using the Bio-Transfix and Biosteon Cross-pin systems indicate that these systems are better equipped to bear the loads generated by aggressive rehabilitation. The WHS fixation system provides an alternative to interference screw fixation.

Revision anterior cruciate ligament reconstruction using a 2-stage technique with bone grafting of the tibial tunnel

BACKGROUND

Revision anterior cruciate ligament surgery is often considered a salvage procedure with limited goals. However, this limitation need not be the case. Similar to primary reconstruction, the goal should be to choose an appropriate graft and place it in an anatomical position in a good quality bone. The issue of good quality bone seems to have been ignored.

HYPOTHESIS

A 2-stage anterior cruciate ligament revision reconstruction with bone grafting of the tibial tunnel and the use of a different femoral tunnel will produce measured knee laxity and International Knee Documentation Committee scores similar to a primary anterior cruciate ligament reconstruction.

STUDY DESIGN

Case control study; Level of evidence, 3.

METHODS

This prospective study involved 49 consecutive 2-stage anterior cruciate ligament revisions (group R) performed by a single surgeon from 1993 to 2000. Two-stage revision surgery was performed if the tibial tunnel from a previous reconstruction surgery would overlap (either partially or fully) the correctly placed revision tunnel. The first stage consisted of removal of the old graft and interfering metalwork, together with bone grafting of the tibial tunnel. After ensuring adequate bone graft incorporation using computed tomography scan, the second stage revision was undertaken. This stage comprised harvesting the autograft, its anatomical placement, and its adequate fixation. The results were compared with the results of a matched group of patients with primary anterior cruciate ligament reconstruction (group P).

RESULTS

In group R, as meniscal and chondral lesions were more common, the International Knee Documentation Committee scores were lower than those of group P (61.2 for group R and 72.8 for group P; P = .006). Objective laxity measurement was similar in both groups (1.36 mm for group R and 1.2 mm for group P; P = .25).

CONCLUSION

This study establishes that the laxity measurements achieved with a 2-stage revision anterior cruciate ligament reconstruction can be similar to those achieved after primary anterior cruciate ligament reconstruction, although the International Knee Documentation Committee rating is lower.

Treatment of anterior cruciate ligament injuries, part I

Anterior cruciate ligament injuries are common among athletes. Although the true natural history remains unclear, anterior cruciate ligament injuries are functionally disabling; they predispose the knee to subsequent injuries and the early onset of osteoarthritis. This article, the first in a 2-part series, was initiated with the use of the PubMed database and a comprehensive search of articles that appeared between January 1994 to the present, using the keywords anterior cruciate ligament. A total of 3810 citations were identified and reviewed to determine the current state of knowledge about the treatment of these injuries. Articles pertaining to the biomechanical behavior of the anterior cruciate ligament, the prevalence of anterior cruciate ligament injury, the natural history of the anterior cruciate ligament-deficient knee, injuries associated with anterior cruciate ligament disruption, risk factors for anterior cruciate ligament injury, indications for treatment of anterior cruciate ligament injuries, and nonoperative and operative treatments were obtained, reviewed, and served as the basis for part I. Part II, to be presented in another issue of this journal, includes technical aspects of anterior cruciate ligament surgery, bone tunnel widening, graft healing, rehabilitation after reconstruction, and the effect of sex, age, and activity level on the outcome of surgery. Our approach was to build on prior reviews and to provide an overview of the literature for each of the before-mentioned areas of study by summarizing the highest level of scientific evidence available. For the areas that required a descriptive approach to research, we focused on the prospective studies that were available; for the areas that required an experimental approach, we focused on the prospective, randomized controlled trials and, when necessary, the highest level of evidence available. We were surprised to learn that considerable advances have been made during the past decade regarding the treatment of this devastating injury.

Computer-assisted navigation and anterior cruciate ligament reconstruction: accuracy and outcomes

As many as 175,000 anterior cruciate ligament (ACL) reconstructions are performed annually in the United States at a cost >1 billion dollars. Estimates of the rate of revision surgery are as high as 10%-20%, potentially resulting in as many as 35,000 revisions a year. In addition, errors that are not obvious at short-term or mid-term follow-up may have significant long--term effects in young patients. Studies have demonstrated that the majoriity of visions are related to technical errors, primarily tunnel placement. Computer-aided navigation systems provide enhanced precision in tunnel placement and may reduce the rate of revision surgery. Computer-aided systems can provide valuable data on rotational and translational laxity of the knee.

Management of bony deficiency in revision anterior cruciate ligament reconstruction using allograft bone dowels: surgical technique

Revision anterior cruciate ligament (ACL) reconstruction surgery has become increasingly common over the past decade and its popularity is likely to rise further as the number of primary ACL reconstructions increases each year. More than 75% of all cases of failed ACL reconstruction are the result of technical error and, of these, more than 70% are attributed specifically to malpositioned tunnels. Management of tunnel malposition in revision surgery often requires innovative approaches for dealing with the resultant bony defects. In addition, tunnel osteolysis may create bone loss that interferes with desired tunnel placement. A number of options have been described for handling these bony deficiencies, many of which are technically difficult and time consuming. We describe a novel technique to address bony defects during revision ACL reconstruction using freeze-dried allograft bone dowels. These allografts are readily available and can be used easily to fill deficiencies resulting from previous tunnels or osteolysis. The grafts provide sufficient structural support for redrilling of new tunnels through or next to the bony plug, allowing uncompromised tunnel placement.