Recurrent locking of knee joint caused by intraarticular migration of bioabsorbable tibial interference screw after arthroscopic ACL reconstruction

Evaluation of Failed ACL Reconstruction: An Updated Review

Failure rates among primary Anterior Cruciate Ligament Reconstruction (ACLR) range from 3.2% to 11.1%. Recently, there has been increased focus on surgical and anatomic considerations which predispose patients to failure, including excessive posterior tibial slope (PTS), unaddressed high-grade pivot shift, and improper tunnel placement. The purpose of this review was to provide a current summary and analysis of the literature regarding patient-related and technical factors surrounding revision ACLR, rehabilitation considerations, overall outcomes and return to sport (RTS) for patients who undergo revision ACLR. There is a convincingly higher re-tear and revision rate in patients who undergo ACLR with allograft than autograft, especially amongst the young, athletic population. Unrecognized Posterior Cruciate Ligament (PLC) injury is a common cause of ACLR failure and current literature suggests concurrent operative management of high-grade PLC injuries. Given the high rates of revision surgery in young active patients who return to pivoting sports, the authors recommend strong consideration of a combined ACLR + Anterolateral Ligament (ALL) or Lateral extra-articular tenodesis (LET) procedure in this population. Excessive PTS has been identified as an independent risk factor for ACL graft failure. Careful consideration of patient-specific factors such as age and activity level may influence the success of ACL reconstruction. Additional technical considerations including graft choice and fixation method, tunnel position, evaluation of concomitant posterolateral corner and high-grade pivot shift injuries, and the role of excessive posterior tibial slope may play a significant role in preventing failure.

Femoral Interference Screw Fixation in ACL Reconstruction Using Bone-Patellar Tendon-Bone Grafts

» Anterior cruciate ligament (ACL) reconstruction is a commonly performed orthopaedic procedure with numerous reconstructive graft and fixation options. Interference screws have become one of the most commonly utilized methods of securing ACL grafts such as bone-patellar tendon-bone (BPTB) autografts. » The composition of interference screws has undergone substantial evolution over the past several decades, and numerous advantages and disadvantages are associated with each design. » The composition, geometry, and insertional torque of interference screws have important implications for screw biomechanics and may ultimately influence the strength, stability of graft fixation, and biologic healing in ACL reconstruction. » This article reviews the development and biomechanical properties of interference screws while examining outcomes, complications, and gaps in knowledge that are associated with the use of femoral interference screws during BPTB ACL reconstruction.

Complications of Bioabsorbable Tibial Interference Screws After Anterior Cruciate Ligament Reconstruction in Pediatric and Adolescent Athletes

Background:

Interference screw fixation using bioabsorbable implants has become the most common form of tibial-sided graft fixation in anterior cruciate ligament reconstruction (ACLR). Complications related to implant use in the pediatric and adolescent population have not been well studied.

Purpose/Hypothesis:

The purpose of this study was to retrospectively analyze the complications associated with tibial bioabsorbable interference screw use in adolescents after ACLR. We hypothesized that complication rates would be low (<5%) and that different screw types would have similar complication rates and clinical outcomes.

Study Design:

Case series; Level of evidence, 4.

Methods:

Included in this study were patients aged ≤18 years who underwent ACLR with a bioabsorbable tibial interference screw between 2000 and 2011 at a single institution. The subpopulation with screw-related symptoms or complications were identified through chart review. The following 2 outcomes were considered: screw-related symptoms and secondary surgery related to the screw. Multivariable logistic regression was used for adjusted analysis of any screw-related problem.

Results:

There were 925 ACLR procedures in 858 patients (mean age, 15.7 years; range, 10-18 years) who met inclusion criteria. The median follow-up period was 32.0 months. Of the 925 knees, 89 (9.6%) developed a screw-related problem. In 44 (4.8%) cases, no surgery was required; in 45 (4.9%) cases, surgery for a screw-related problem occurred at a median of 24 months postoperatively. The most common surgical indication was pain at the tibial screw site (42/45, 93%), followed by intra-articular screw issues (3/45, 7%). In adjusted analysis, ACLR procedure performed by a “low-volume” ACL surgeon was the only significant predictor identified. After screw removal surgery, 25 of 27 (93%) patients with at least 12 months of follow-up had complete resolution of screw site symptoms, 18 of 23 (78%) evaluable patients returned to sports, while 8 of 27 (30%) patients underwent additional surgeries, 7 of which were unrelated to the screw procedure.

Conclusion:

The rate of clinical sequelae from bioabsorbable tibial interference screws was surprisingly high, with symptoms arising after approximately 1 of 10 ACLRs in adolescents. Reoperation for these symptoms was performed in approximately 5% of the knees in the study, at a median 2 years postoperatively. Most patients were able to return to sports after screw removal surgery.

Severe cartilage damage from a broken absorbable screw head after fixation of an avulsion fracture of the tibial attachment of the posterior cruciate ligament: A case report

INTRODUCTION

The use of bioabsorbable interference screws has become popular for treatment of avulsion fractures of the posterior cruciate ligament (PCL). Complications are uncommon. We report a case of severe chondral damage caused by the early breakage of an absorbable screw head after fixation of an avulsion fracture of the tibial attachment of the PCL. The patient felt a sudden locking of the knee when getting off a car at 4 months after the PCL surgery. MRI revealed intraarticular migration of the head of the interference screw. During revision surgery, the broken part was removed without incident, and severe cartilage damage was observed. The patient experienced a complete resolution of symptoms at the 6-month follow-up.

CONCLUSION

MRI examination is recommended in case of sudden locking of the knee for patients undergoing PCL fixation with bioabsorbable interference screws. Surgical treatment should be performed immediately when screw breakage was confirmed.

Bioabsorbable interference screw failure in anterior cruciate ligament reconstruction: A case series and review of the literature

BACKGROUND

To report a case series of failures of bioabsorbable interference screws with possible identification of a novel failure mechanism.

METHODS

A retrospective review of ACL reconstructions by the senior author utilizing BioComposite™ Interference Screws (Arthrex, Inc., Naples, FL) was performed. Complications related to screw placement, including fracture, breakage or bending were examined. Our rate and methods of failure were compared to those quoted in the current literature.

RESULTS

Eighty-seven patients of average age 23.8 years met inclusion criteria. There were eight screw failures in six patients, with femoral failure in seven and tibial failure in one. The femoral screw fractured halfway between the tip and head in five, while the head of the screw broke in one and the screw bent in another. In the case of tibial interference screw fracture, failure occurred halfway between the tip and head. The insertion device that was used was replaced after recognition of material deformation and considered a potential contributor to the breakage risk as no further screw failures have occurred since.

CONCLUSIONS

We demonstrate a unique failure mechanism of bio-absorbable interference screws. In each case, the reconstruction was salvaged. Regular inspection of materials and implants can ensure optimal outcomes and decrease complications intra-operatively.

Bioabsorbable versus metallic interference screws in anterior cruciate ligament reconstruction: a systematic review of overlapping meta-analyses

PURPOSE

Multiple meta-analyses of randomized controlled trials have been conducted to compare clinical and functional outcomes after anterior cruciate ligament (ACL) reconstruction using metallic interference screw (MIS) versus bioabsorbable interference screw (BIS) fixation, but discrepancies in their findings have prevented a consensus conclusion. The purposes of this study were (1) to conduct a systematic review of meta-analyses comparing MISs and BISs in ACL reconstruction, (2) to provide surgical treatment recommendations for ACL graft fixation based on the highest available evidence, and (3) to propose future research avenues in areas of practice lacking high-level evidence.

METHODS

The literature was systematically reviewed to identify meta-analyses comparing MISs and BISs in ACL reconstruction. Data were extracted for clinical and functional outcomes, and methodologic quality was assessed using the validated Quality of Reporting of Meta-analyses and Oxman-Guyatt systems. To determine which meta-analyses provided the current best available evidence, the Jadad decision algorithm was used.

RESULTS

One Level I and 2 Level II meta-analyses were included. None showed differences between BISs and MISs in validated outcome scores, pivot-shift testing, KT arthrometry (MEDmetric, San Diego, CA), or loss of knee motion. Subgroup analyses found no differences in clinical outcomes or knee stability across biomaterials. All meta-analyses were of high quality according to the Quality of Reporting of Meta-analyses and Oxman-Guyatt systems. Two meta-analyses were determined by the Jadad algorithm to represent the current best available evidence. Both studies showed prolonged knee effusion with BIS use, with 1 also showing an increased incidence of femoral tunnel widening and screw breakage with BIS use.

CONCLUSIONS

Whereas clinical and functional outcomes are similar with MISs and BISs, prolonged knee effusion, femoral tunnel widening, and screw breakage are more common with BIS use. Future cost-effectiveness analyses may help weigh the known advantages of BISs against their costs and adverse-event profile.

LEVEL OF EVIDENCE

Level II, systematic review of Level I and II studies.

Implant-free ACL reconstruction: a review

Implant-free anterior cruciate ligament (ACL) reconstruction is the fixation of ACL grafts without the need for artificial implants. Our aim was to study the evolution of this technique, review the biomechanical evidence and summarise the results. Implant-free graft fixation for bone patella tendon ACL reconstruction was first described in 1987. This concept of implant-free graft fixation was adapted for hamstring and quadriceps tendons as alternative graft sources. Various biomechanical studies have reported that by adhering to certain technical details, this technique provides comparable fixation strength as conventional ACL fixation. The outcome studies of implant-free ACL reconstruction also report clinical results similar to ACL reconstruction with conventional implants.

How to read post-operative radiographs and CT scans after single-bundle anterior cruciate ligament reconstruction

Reconstruction of the anterior cruciate ligament (ACL) is a well-established surgical procedure. However, post-operative imaging in the early phase is not routinely performed. The rationale for performing such imaging is to provide a baseline examination for future controls, to provide immediate feedback to surgeons regarding tunnel placement, and to assess placement of fixation devices. The purpose of this paper is to enable the reader to accurately read post-operative radiographs and CT scans after single-bundle ACL reconstruction.

Bioabsorbable versus metallic interference screw fixation in anterior cruciate ligament reconstruction: a meta-analysis of randomized controlled trials

PURPOSE

The aim of the study was to investigate the outcomes between bioabsorbable and metallic screw fixation in anterior cruciate ligament (ACL) reconstruction.

METHODS

Randomized controlled trials (RCTs) comparing bioabsorbable versus metallic screw fixation in single-bundle ACL reconstruction were identified systematically, and the outcomes were analyzed in terms of infection rate, knee joint effusion, Lysholm score, International Knee Documentation Committee final score, pivot-shift test, and KT-1000/-2000 arthrometer (MEDmetric, San Diego, CA) measurements. The type of grafts was ignored in the meta-analysis. Standard mean difference (SMD) or risk ratio (RR) with 95% confidence interval (CI) was calculated by a fixed-effects or random-effects model. Heterogeneity across the studies was also assessed.

RESULTS

We included 10 studies comprising 790 patients who were treated by bioabsorbable versus metallic screw fixation for single-bundle ACL reconstruction. The meta-analyzed results of these studies showed that there was no statistically significant difference between bioabsorbable and metallic screw fixation in infection rate (RR, 0.91; P = .87; 320 patients in 5 studies), KT-1000/2000 arthrometer testing (SMD, -0.01; P = .95; 438 patients in 7 studies), pivot-shift testing (RR, 1.06; P = .82; 260 patients in 4 studies), International Knee Documentation Committee final score (RR, 0.87; P = .63; 300 patients in 5 studies), and Lysholm score (SMD, 0.03; P = .89; 204 patients in 4 studies). The incidence of knee effusion was higher in the bioabsorbable screw group (RR, 2.57; P = .04; 421 patients in 4 studies).

CONCLUSIONS

There was no significant difference in measurement results of knee joint stability or knee joint function outcome between bioabsorbable and metallic interference screws. Knee joint effusion is more common after ACL reconstruction with bioabsorbable interference screw fixation than with metallic interference screw fixation. More high-methodologic quality randomized controlled trials would be helpful in further meta-analysis.

LEVEL OF EVIDENCE

Level I, meta-analysis.

A clinical review of bioabsorbable interference screws and their adverse effects in anterior cruciate ligament reconstruction surgery

Bioabsorbable material screws are widely used in various surgical specialties. One popular application is their use as interference screws in anterior cruciate ligament (ACL) reconstruction surgery. Despite their routine use, a major concern with bioabsorbable materials in surgery has been the incidence of adverse events. Various case reports, series reports and studies in the past years have reported complications specific to the use of bioabsorbable interference screws intra operatively and at different time periods post operatively. The aim of this literature review is to summarize the clinical studies where bioabsorbable screws have been used in ACL reconstruction surgery and in particular to highlight any specific complications and adverse effects related to the use of these materials.

Anterior cruciate ligament reconstruction using autografts and double biodegradable femoral cross-pin fixation: functional, radiographic and MRI outcome after 2-year minimum follow-up

Double biodegradable cross-pins are increasingly used for femoral fixation in arthroscopically assisted reconstruction of the anterior cruciate ligament (ACL). There are no studies combining functional outcome analysis, radiographs and magnetic resonance images (MRI) to evaluate this technique. The authors examined 45 patients after ACL reconstruction using double biodegradable femoral cross-pin fixation and biodegradable tibial interference screw fixation with a minimum follow-up of 24 months. Clinical evaluation included International Knee Documentation Committee (IKDC) and modified Lysholm score. Radiographic analysis included standard X-rays in anterior-posterior and lateral views and Telos stress device measurements. MRI was analyzed to obtain information about hardware, intra-articular graft, osseous graft-integration and cartilage. IKDC score revealed 28 (62.2%) patients with normal knee function (group A), 15 (33.3%) patients with nearly normal (group B) knee function and 2 (4.4%) patients with abnormal knee function (group C). The Lysholm score was 94.6 (+/-7.2) in the operated knee and 98.8 (+/-7.4) in the non-operated knee. Mean Telos stress device values were +4.6 (+/-2.6) in the operated and +3.9 (+/-2.4) in the non-operated knee. MRI showed an intact intra-articular graft in all but one patient. Complete femoral graft integration was seen in 88.9% and complete tibial graft integration in 86.7%. Biodegradable cross-pins were partially or fully visible in all patients. The biodegradable tibial interference screw was fully visible in 16 (35.6%) and partially visible in 20 (44.4%) patients. Thirty-one (68.9%) patients showed signs of cartilage degeneration on MRI at follow-up. The graft fixation with double biodegradable pin fixation appears to be a reliable technique for ACL reconstruction providing a stable close-to-joint graft fixation.