Over-the-top ACL reconstruction restores anterior and rotatory knee laxity in skeletally immature individuals and revision settings

Revision Anterior Cruciate Ligament Reconstruction and Associated Procedures

Failure of anterior cruciate ligament reconstruction (ACLR) is a common yet devastating complication due to inferior clinical outcomes associated with revision ACLR. Identifying the cause and associated risk factors for failure is the most important consideration during preoperative planning. Special attention to tunnel quality, concomitant injuries, and modifiable risk factors will help determine the optimal approach and staging for revision ACLR. Additional procedures including lateral extra-articular tenodesis and osteotomy may be considered for at-risk populations. The purpose of this review is to explore causes of ACLR failure, clinical indications and appropriate patient evaluation, and technical considerations when performing revision ACLR.

Outcomes of "Over the Top" Anterior Cruciate Ligament Reconstruction Associated with a Lateral Extra-Articular Tenodesis in Children

(1) Purpose: The incidence of anterior cruciate ligament (ACL) ruptures in children and adolescents has considerably increased during the last decades due to higher levels of competitive athletic activity, and early sport specialization and professionalization. Contemporary ACL reconstruction techniques have recently been subject to renewed interest in this population. The objective of this study is to report the short- and mid-term results of our physis-sparing ACL reconstruction technique using an "over the top" technique associated with a modified Lemaire procedure. (2) Methods: A retrospective series of 12 junior soccer players who presented to our clinic with a torn ACL between January 2019 and September 2021 was reviewed. The inclusion criteria were patients under 15 years with open tibial and femoral physes, with a stable contralateral knee, a minimum follow-up of 6 months, and a time frame from injury to surgery of <3 months. Patients with previous knee surgery, structural concomitant injuries, muscular, neurological, or vascular abnormalities, or hypersensitivity to metal alloys were excluded. The functional evaluation was performed using the International Knee Documentation Committee (IKDC) rating, Lysholm score, and Tegner activity level. Moreover, clinical and radiological assessments were also performed, including KT-1000 and knee X-rays. (3) Results: We identified 1 female and 11 male patients with ACL tears, with a mean age of 13.17 ± 0.9 months. Concomitant injuries include isolated vertical and bucket-handle tears of the medial meniscus, lateral meniscus tears, bilateral tear of both menisci. The mean follow-up time was 26 ± 12.6 months. The average IKDC, Lysholm and Tegner scores were 93.29 ± 11.04, 95.08 ± 13.2 and 9 ± 0.0 points, respectively. The average KT-1000 score of the participants was 0.96 ± 1.6 points. None of the included patients reported post-surgical complications or required additional surgeries. (4) Conclusions: Our novel ACL reconstruction with LET technique is a safe procedure that resulted in good clinical outcomes, lower failure rate and return to sports in skeletally immature patients.

Various Definitions of Failure Are Used in Studies of Patients Who Underwent Anterior Cruciate Ligament Reconstruction

Purpose

To conduct a literature review to assess the definitions of anterior cruciate ligament reconstruction (ACLR) failure used throughout the orthopaedic literature.

Methods

A systematic search of Embase, Ovid Medline, SPORTDiscus, and Web of Science was conducted by a university librarian to identity level I-IV clinical studies on ACLR failure. Inclusion criteria consisted of patients who underwent ACLR and included a definition of failure of ACLR. Patients who underwent anterior cruciate ligament (ACL) repairs, animal/cadaver studies, review studies, non-English language articles, and non-full text articles were excluded. Failure data were extracted from each study and categorized. Other data that were extracted included follow-up time after ACLR, failure reoperation rate, and failure reoperation procedure. Descriptive statistics was used to analyze the data.

Results

Out of 2,775 studies, 104 (3.75%) met inclusion criteria and were analyzed in this review. The most common definition of ACLR failure included the use of a physical examination, specifically Lachman's test (21/104 [20.2%]), anterior laxity assessment, or a Pivot-Shift test (24/104 [35.2%]) or undergoing or requiring revision ACLR (39/104 [37.5%]). Although some studies used quantitative tests or imaging to help define "failure," others simply defined it as graft rerupture that was otherwise not defined (22/104 [22.5%]). Other common definitions included: the use of imaging (magnetic resonance imaging/radiographs) to confirm graft re-rupture (37/104 [35.6%]), patient-reported outcomes (recurrent instability)/patient reported outcomes measures (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Tegner) (18/104 [17.3%]), and the use of an arthrometer (KT-1000/2000, Rollimeter, or Kneelax) (17/104 [16.3%]). The least common definitions included graft failure or rerupture confirmed by arthroscopy (13/104 [12.5%]) and nonrevision surgery (2/104 [1.0%]). The failure rate of this procedure ranged from 0% to 100% depending on the definition of "failure."

Conclusion

In this study, we found that a variety of definitions of failure are used among studies published in the orthopaedic literature. The most common criteria for failure of ACLR were the results of physical examination tests (35%), the need for undergoing a revision ACLR (36%), and the use of imaging to diagnose the failure (34%). About 17% of studies included in this review used patient-reported outcomes, specifically recurrent instability, or PROMs (IKDC, KOOS, Tegner) in their assessment of failure of ACLR. The least used definitions of "failure" of ACLR included nonrevision ACLR surgery (2%). Although some studies used similar tests or categories in their definition of failure, there were a variety of score and grade cutoff points between them.

Level of Evidence

Level IV, systematic review of Level II-IV studies.

Revision Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients

Revision anterior cruciate ligament (ACL) reconstruction in the skeletally immature patient is a challenging procedure for pediatric patients with recurrent instability after primary ACL reconstruction. The pediatric population presents unique technical challenges and complications secondary to open physes compared with the adult population. Complications can include growth disturbances, recurrent graft failure, instability, and secondary chondral and/or meniscal injury. Moreover, identifying the etiology of graft failure is critical for a successful revision. Patients should undergo a complete history and physical examination with a focus on patient physiologic age, physeal status, mechanical axis, tibial slope, collagen status, injury mechanism, concomitant injuries, and previous surgical procedures. The surgeon must be adept at reconstruction with various grafts as well as socket or tunnel preparation and fixation, including over-the-top, all-epiphyseal, transphyseal, extra-articular augmentation, and staging approaches. Reported rates of return to sport are lower than those of primary reconstruction, with higher rates of cartilage and meniscal degeneration. Future research should focus on optimizing surgical outcomes and graft survivorship after primary ACL reconstruction with minimized trauma to the physis.

Management of Bone Loss and Tunnel Widening in Revision ACL Reconstruction

➤ Both mechanical and biological factors can contribute to bone loss and tunnel widening following primary anterior cruciate ligament (ACL) reconstruction.➤ Revision ACL surgery success is dependent on graft position, fixation, and biological incorporation.➤ Both 1-stage and 2-stage revision ACL reconstructions can be successful in correctly indicated patients.➤ Potential future solutions may involve the incorporation of biological agents to enhance revision ACL surgery, including the use of bone marrow aspirate concentrate, platelet-rich plasma, and bone morphogenetic protein-2.

"Over-the-Top" Anterior Cruciate Ligament Reconstruction Associated With a Lateral Extra-Articular Tenodesis in Children

Anterior cruciate ligament (ACL) tears are one of the most frequent injuries in growing children, and they are often associated with other injuries such as meniscal and chondral injuries. In the past, treatment of ACL tears in growing patients relied on activity modification and bracing. However, surgical treatment has prevailed over conservative treatment in recent years. A surgical technique is presented for ACL reconstruction using an "over-the-top" technique associated with a lateral extra-articular tenodesis procedure in children. An extra-articular lateral tenodesis is done first. The gracilis and semitendinous tendons are then extracted using a tenotome without releasing their distal desinsertions. The tibial guide is then centered over the ACL tibial footprint under arthroscopic vision and an image intensifier, proximal to the physis. Then, a Kocher-type forceps is used to pass a suture "over the top" from the posterolateral window to the tibial tunnel. The double-bundle graft and iliotibial tract graft are fixed within the tunnel in full extension and neutral rotation with an interference screw.

Surgical techniques in the management of pediatric anterior cruciate ligament tears: Current concepts

Background

Anterior cruciate ligament injury in the child and adolescent patient remains a controversial topic when considering management, especially regarding surgical choices. Treatment variations are seen not just when comparing different countries but also within nations. This arises partly as contemporary treatment is mostly inferred from the adult population who physiologically and in terms of outcomes differ significantly from children. There is an increasing body of evidence for this cohort of patients who have specific challenges and difficulties when determining the optimum treatment.

Methods

Within this article, we will summarize the current evidence for surgical management of anterior cruciate ligament injury for the pediatric patient.

Results and Conclusions

There remain many controversies and gaps inthe treatment of Paediatric Anterior cruciate ligament reconstruction and this high risk cohort continues to cause difficulty in identifying the best mode of surgical management.

Level of evidence

level IV.

A Biomechanical Comparison of 2 Over-the-Top Anterior Cruciate Ligament Reconstruction Techniques: A Cadaveric Study Using a Robotic Simulator

Background

For skeletally immature patients, over-the-top (OTT) anterior cruciate ligament (ACL) reconstruction (ACLR) is preferred. However, increased anterior laxity at deep knee flexion angles remains concerning. We modified the procedure to proximally shift the graft fixation site on the femur to prevent graft loosening at higher knee flexion angles and named it the supra-OTT procedure.

Purpose

To compare anterior laxity and in situ forces of the ACL graft between conventional OTT and supra-OTT ACLR in a cadaveric model.

Study Design

Controlled laboratory study.

Methods

A total of 11 fresh-frozen cadaveric knee specimens underwent 4 robotic testing conditions: ACL intact, ACL resected, conventional OTT, and supra-OTT. For each condition, a 100-N load was applied at 0°, 15°, 30°, 60°, and 90° of knee flexion to simulate the Lachman test or anterior drawer test. In addition, a combined load of 5-N·m internal tibial torque and 10-N·m valgus torque was applied at 15° and 30° of knee flexion as a simulated pivot-shift test. Anterior tibial translation and in situ graft forces were recorded. The only difference between conventional OTT and supra-OTT ACLR was the graft fixation site on the femur. For conventional OTT ACLR, graft fixation was performed just on the proximal and lateral ends of the posterior condyle. For supra-OTT ACLR, the fixation point was around the proximal insertion of the lateral head of the gastrocnemius and the lateral edge of the posterior cortex, approximately 2 cm proximal to the conventional OTT position.

Results

On the simulated anterior drawer test at 60° and 90° of knee flexion, anterior tibial translation after supra-OTT ACLR was significantly smaller than after conventional OTT ACLR (P < .01). However, no significant differences were noted at other flexion angles or on the simulated pivot-shift test between the conventional OTT and supra-OTT procedures. Some overconstraint and higher graft forces were noted with both techniques, but the supra-OTT technique caused even more overconstraint at higher flexion angles.

Conclusion

Supra-OTT ACLR showed better biomechanical performance to control anterior laxity than conventional OTT ACLR at higher knee flexion angles.

Clinical Relevance

The supra-OTT procedure may improve anterior stability at deep knee flexion angles.

Slope-Reducing High Tibial Osteotomy and Over-The-Top Anterior Cruciate Ligament Reconstruction With Achilles Tendon Allograft in Multiple Failed Anterior Cruciate Ligament Reconstruction

Graft failure is a challenging complication following anterior cruciate ligament reconstruction (ACL-R). Among the multiple anatomic and nonanatomic risk factors contributing to ACL-R failure, there is accumulating evidence that a posterior tibial slope of 12° or greater may predispose patients to graft failure of primary and revision ACL-R. In addition, previously malpositioned or widened tunnels, as well as limited autograft options, pose challenges in the setting of revision ACL-R. This Technical Note describes a technique to correct an increased posterior tibial slope using slope-reducing high tibial osteotomy, and single stage revision ACL-R with Achilles tendon allograft using the over-the-top route, in a single-stage procedure. The surgical technique involves an anterior approach to the proximal tibia, followed by tibial tubercle osteotomy and anterior closing-wedge osteotomy. The posterior cortical osteotomy hinge is left intact below the insertion of the posterior cruciate ligament. Over-the-top revision ACL-R is then performed using an Achilles tendon allograft passed around the posterior aspect of the lateral femoral condyle and fixed onto the lateral femur.

Combining Anterior Cruciate Ligament Reconstruction With Lateral Extra-Articular Procedures in Skeletally Immature Patients Is Safe and Associated With a Low Failure Rate

Purpose

To analyze the rates of graft ruptures and growth disorders, the level of return to sport, and the clinical results of 2 lateral extra-articular procedures in growing children.

Methods

This study was a retrospective, single-center study of patients undergoing anterior cruciate ligament (ACL) surgery combined with 2 different lateral extra-articular procedures (anatomic reconstruction with a gracilis graft or modified Lemaire technique with a strip of fascia lata). The measurements of side-to-side anterior laxity and pivot shift were performed preoperatively and at the last follow-up. The sports level and the complications rate were assessed. The minimal clinically important differences (MCID) and patient acceptable symptoms state threshold scores were calculated.

Results

Thirty-nine patients (40 ACLs) were included (20 anatomic and 20 modified Lemaire) at an average follow-up of 57 months ± 10 [42-74]. One patient (2.5%) was lost to follow-up. The mean age at surgery was 13.8 ± 1.4 years old [9.8; 16.5]. One graft failure was reported (2.6% [0.06-13.5]) at 35.6 months after surgery. Two cases (5.4%) of femoral overgrowth were observed, and one of them required distal femoral epiphysiodesis. Ninety-two percent of the patients returned to sports. At the final follow-up, side-to-side anterior laxity was significantly improved, and no residual pivot shift was recorded in 95% of patients. Eighty-nine percent of the patients presented a Pedi-International Knee Documentation Committee score greater than the MCID postoperatively, and 77% presented a Lysholm score greater than the MCID.

Conclusions

This series of ACL reconstructions combined with 2 different lateral extra-articular procedures in skeletally immature patients demonstrated promising findings. The low rate of observed complications, including graft rupture and growth disturbance, is encouraging, but the small study population and lack of comparative group precludes reliable conclusions.

Level of Evidence

IV, therapeutic case series.

[Research progress of anterior cruciate ligament reconstruction with over-the-top technique]

OBJECTIVE

To review the research progress regarding the over-the-top technique for anterior cruciate ligament (ACL) reconstruction.

METHODS

The relevant literature on ACL reconstruction using the over-the-top technique was analyzed for its evolution, clinical application, advantages, and limitations.

RESULTS

Over-the-top technique for ACL reconstruction is a combined intra- and extra-articular technique. Because it avoids drilling the femoral tunnel, its advantages are mainly highlighted in the protection of the femur. Therefore, it is widely used in children and adolescents with epiphyseal occlusion and in patients with revision reconstruction. In addition, significant improvements in postoperative joint stability, functional scores, and return to exercise rates are found in long-term follow-up studies of patients with primary ACL reconstruction and combined anterolateral tenodesis. However, the technique also has some limitations, such as poor stability of knee flexion after operation, high requirement for graft length, and easy impact of graft in the intercondylar fossa.

CONCLUSION

The current research results show the effectiveness and safety of the over-the-top technique for primary and revision ACL reconstruction, with the advantages of wide application, simple operation, and quick recovery; however, more researches are needed to further optimize the selection of grafts and femoral condyle management problems, and to clarify the long-term effectiveness.

Equivalent outcomes of ACL revision with over-the-top single and double-bundle reconstruction using hamstring tendon compared to anatomical single and double-bundle reconstruction

Purpose

In revision anterior cruciate ligament reconstruction (ACLR), our procedure of choice is the over-the-top route (OTTR) for cases where it is difficult to use a primary bone tunnel or to create a new bone tunnel due to the enlargement or malposition of the bone tunnel. Depending on the condition of the primary bone tunnel, we choose single (bone tunnel or OTTR) or double (bone tunnel or anteromedial (AM) bundle: OTTR /posterolateral (PL) bundle: bone tunnel) for femoral fixation. This study showed the results of single and double OTTR revision ACLR using the hamstring tendon.

Methods

Seventy-eight patients, who underwent revision ACLR using the hamstring tendon and who could be followed up for more than 2 year, were included in this study. The methods of revision ACLR were single in 54 cases (bone tunnel: 24 cases; OTTR method: 30 cases) and double in 24 cases (bone tunnel: 16 cases; OTTR for AM bundle and bone tunnel for PL bundle: eight cases). The cause of re-injury, the meniscus and cartilage injury, the reconstruction method, and the Lysholm score, Lachman test, Pivot-shift test, and the side-to-side difference in the tibial anterior translation were evaluated before and after surgery.

Results

There was no statistically significant difference in the Lyshom score, Lachman / Pivotshift test and side-to-side difference anterior translation of the tibia between the four groups.

Conclusions

The clinical results of single and double OTTR revision ACLR are equivalent to those of anatomic single and double bone tunnel procedures.

Transepicondylar Distance Can Predict Graft and Tunnel Length for Different Pediatric Anterior Cruciate Ligament Reconstruction Techniques: A Magnetic Resonance Imaging Study

PURPOSE

To find a correlation and mathematical formulas between a linear 2-dimensional (2D) magnetic resonance imaging (MRI) measurement around the knee and the length of the grafts and tunnels required for both all-inside-all-epiphyseal and Kocher-Micheli pediatric anterior cruciate ligament (ACL) reconstruction techniques.

METHODS

At time 0 and 30 days after, 2 observers measured: (1) on standard 2D knee MRI, 7 linear distances, representing morphologic measurements, such as transepicondylar distance (TD), and (2) on 3-dimensional (3D) MRI, 5 curved distances, corresponding to Kocher-Micheli and all-epiphyseal ACL reconstruction techniques. Intra- and interobserver reliability was tested for all measurements. The correlation between 2D and 3D measurements was tested. The 2D measurement with highest repeatability and reproducibility and with strongest correlation with 3D measurements was used to extract formulas to calculate the tunnel and graft length for the 2 techniques.

RESULTS

Seventy-six MRIs were used. The intra- and interobserver reliability of 2D measurement was high, with TD showing the highest reproducibility and repeatability. 3D measurements also showed good intra and inter-observer reliability. A linear correlation was found between 2D and 3D measurements, with TD showing the strongest correlation. TD was used to extract formulas to calculate graft or tunnel length for Kocher-Micheli and all-epiphyseal ACL reconstruction. All formulas were proven to be accurate. A reference chart was also created to be used in the surgical setting.

CONCLUSIONS

With specific formulas, TD can be used to calculate the length of the tunnels, intra-articular portion and graft length for an all-inside all-epiphyseal pediatric ACL reconstruction and the length of the iliotibial band required for the Kocher-Micheli technique.

CLINICAL RELEVANCE

The surgeon can use these formulas in pediatric ACL reconstruction preoperative planning, graft harvesting and tunnel drilling.

A two-portal technique using a flexible reamer system is a safe and effective method for transportal anterior cruciate ligament reconstruction

INTRODUCTION

A flexible reamer system (FRS) for transportal anterior cruciate ligament reconstruction (ACLR) has been developed to overcome the technical challenges of a rigid reamer system. The purpose of this study was to investigate the safety and effectiveness of the two-portal technique using an FRS by evaluating femoral tunnel geometry.

METHODS

This study included 30 patients (mean age 30 ± 12.1) who underwent transportal single-bundle ACLR. Operations were performed with the two-portal technique using an FRS. Three-dimensional computed tomography was performed for all patients 2 days after the operation. The femoral tunnel position, femoral graft bending angle, femoral tunnel length, and posterior wall breakage were evaluated. These radiologic outcomes were compared to previous literature-reported outcomes.

RESULTS

The mean distances (measured as a percentage) from the posterior wall and the intercondylar notch roof to the femoral tunnel center were 29.6 ± 5.5% and 20.1 ± 6.7%, respectively. The femoral graft bending angle (108.4° ± 6.9°) was similar to that associated with the traditional transportal technique using a rigid reamer system, but it was less acute than that associated with the three-portal technique using an FRS. The femoral tunnel length (32.8 ± 4.5 mm) was also similar to the results of the traditional transportal technique using a rigid reamer system, but it was shorter than that of three-portal technique using an FRS. The prevalence of posterior wall breakage was as low as the reported outcomes of the outside-in technique (2 cases, 6.6%).

CONCLUSIONS

The two-portal technique for transportal ACLR using an FRS can achieve comparable femoral graft bending angle and femoral tunnel length compared with the conventional three-portal technique using the rigid reamer system and had a low risk of posterior wall breakage. Therefore, the two-portal technique using the FRS can be considered a safe and effective method for transportal ACLR.

LEVEL OF EVIDENCE

Retrospective case series; level of evidence, 4.