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

Tunnel Management in Revision Anterior Cruciate Ligament Reconstruction: Current Concepts

Bone tunnel-related complications are frequently encountered during revision anterior cruciate ligament reconstruction (ACLR). Issues with tunnel positioning, enlargement, containment, and hardware interference may complicate surgery and compromise outcomes. As a result, several strategies have emerged to address these issues and optimize results. However, a systematic, unified approach to tunnel pathology in revision ACLR is lacking. The purpose of this review is to highlight the current state of the literature on bone tunnel complications and, although extensive literature on the subject is lacking, present an updated approach to the evaluation and management of tunnel-related issues in revision ACLR.

Two-Stage Revision Anterior Cruciate Ligament Reconstruction with Cannulated Allograft Bone Dowels Soaked in Bone Marrow Aspirate Concentrate

Anterior cruciate ligament reconstruction (ACLR) is one of the most common orthopedic procedures performed each year. The majority of patients undergoing these reconstructions will experience long-term stability and symptomatic relief; however, some will require a revision ACLR procedure. In general, revision ACLRs are more challenging than primary ACLRs due to several diagnostic and technical considerations. A revision ACLR can be performed with either a one-stage or two-stage procedure, which is based on the presence or absence of malpositioned tunnels, bone loss, and tunnel expansion. Recently, the introduction of preshaped allograft bone dowels as a bone grafting option has gained popularity. They provide immediate structural stability and avoid donor site morbidity associated with autografts. The purpose of this article is to outline a bone-grafting tunnel technique with cannulated allograft bone dowels soaked in bone marrow aspirate concentrate (BMAC) used in the first stage of a staged revision ACLR procedure.

Economic Reliable Technique for Tunnel Grafting Using Iliac Crest Bone Graft in Two-Staged Revision Anterior Cruciate Ligament Surgery

Revision anterior cruciate ligament surgery is a technically demanding procedure. Mal-positioned tunnels together with bone loss and its management are some of the difficulties and challenges faced. Two-staged procedures have successfully been used to tackle those challenges. We present a technique that is safe, reliable, reproducible, and economic in the management of bone defects faced in anterior cruciate ligament revision surgery by using iliac crest bone graft. Preoperative assessment of tunnel position and size is done by computed tomography. Tri-cortical iliac crest bone graft is harvested through a trap door. It is then shaped to fit the tunnels to be filled. It is tapered at the advancing end to facilitate introduction. Mounted on a passing pin and a drill bit, the graft is arthroscopically introduced into the femoral and tibial tunnels. The second stage is performed after the graft has incorporated, as seen on postoperative computed tomography, done at approximately 3 months after the first stage. Iliac crest provides a natural abundant reservoir for bone graft and has all the advantages of being an autograft. With good meticulous technique, complications can be avoided with less donor-site morbidity. This technique is safe, reliable, and reproducible. It provides an ample amount of graft and harvest does not rely on implants; hence, it is economic.

Two-stage revision anterior cruciate ligament reconstruction: Our experience using allograft bone dowels

The incidence of anterior cruciate ligament reconstruction (ACLR) is continuously increasing. As a result so has the need for revision ACLR, which unfortunately has worse functional outcomes and rate of return to sport. Revision ACLR can be performed as a single stage or in two stages. The latter is recommended in the presence of enlarged and/or malpositioned tunnels. We describe our surgical technique, experience and outcome of our first 19 patients in whom we used allograft bone dowels in the first stage of revision ACLR.

Outcomes of revision anterior cruciate ligament reconstruction secondary to reamer-irrigator-aspirator harvested bone grafting

INTRODUCTION

Patients with widened or misplaced tunnels may require bone grafting prior to revision anterior cruciate ligament (ACL) reconstruction. Utilising reamer-irrigator-aspirator (RIA) harvested bone from the femur showed promising filling rates. Nevertheless, the procedure has neither been validated in a larger population nor been assessed with regards to radiological and clinical outcome of the subsequently conducted revision ACL reconstruction. Therefore, the aim of this study was to evaluate tunnel filling rates, positioning of the revision tunnels and outcome parameters of such two-staged revision ACL reconstructions.

MATERIAL AND METHODS

A total of 15 consecutive patients were prospectively enrolled in this case series. CT scans were analysed before and after autologous RIA harvested bone grafting. Tunnel volumes and filling rates were calculated based on manual segmentation of axial CT scans. Revision ACL reconstruction was carried out after a mean interval of 6.2 months (±3.7) and positioning of the revision tunnels was assessed by plane radiographs. The mean follow-up was 19.8 months (±8.4) for objective evaluation and 37.1 months (±15.4) for patient reported outcomes. The clinical outcome was assessed by the quantification of the anterior tibial translation, the IKDC objective score, the Tegner activity scale and the Lysholm score.

RESULTS

Initial CT scans revealed mean tunnel volumes of 3.8cm³ (±2.7) femoral and 6.1cm³ (±2.4) tibial. Filling rates of 76.1% (±12.4) femoral and 87.4% (±5.9) tibial were achieved. Postoperative radiographs revealed significantly improved tunnel positioning with anatomical placement in all but one case at the femur and in all cases at the tibia. At follow up, patients showed significantly improved anterior tibial translations with residual side-to-side differences of 1.7 mm (±0.8) and significantly improved IKDC objective scores. Furthermore, significantly higher values were achieved on the Tegner activity scale (5.3 ± 1.4 vs. 2.8 ± 0.5) and the Lysholm score (85.4 ± 7.9 vs. 62.5 ± 10.5) compared to the preoperative status.

CONCLUSION

Autologous RIA harvested bone grafting ensures sufficient bone stock consolidation allowing for anatomical tunnel placement of the subsequently conducted revision ACL reconstruction. The two-staged procedure reliably restores stability and provides satisfying subjective and objective outcomes. Thus, RIA harvested bone grafting is an eligible alternative to autologous iliac crest or allogenic bone grafting.

Femoral press-fit fixation versus interference screw fixation in anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft: 20-year follow-up

INTRODUCTION

The aim of this paper is to present our experience with femoral press-fit fixation in anterior cruciate ligament reconstruction using bone-patellar tendon-bone autograft.

METHODS

The patient population was randomly placed in two groups: group A (58 patients), who underwent femoral screw fixation; group B (62 patients), who underwent femoral press-fit fixation.

RESULTS

At last follow-up 9.2% of patients were lost; 28% of patients in group A and 64% of patients in group B had excellent International Knee Documentation Committee score (grade A); 66% of patients in group A and 32% of patients in group B had good International Knee Documentation Committee scores (grade B). The difference was statistically significant (p < 0.05).

CONCLUSIONS

Femoral press-fit fixation of bone- patellar tendon- bone autograft provides stable fixation at low cost, it ensures unlimited bone-to-bone healing and high primary stability, avoiding the disadvantages of hardware and the need for removal in case of revision.

Two-Stage Revision Anterior Cruciate Ligament Reconstruction Using Allograft Bone Dowels

Revision anterior cruciate ligament (ACL) reconstruction is substantially more challenging than primary reconstruction. Management of previously malpositioned or widened tunnels often requires innovative approaches for managing bony defects. Massive osteolysis with poor bone stock and convergence or overlapping of revision tunnels into the previously placed tunnels may necessitate a staged revision procedure. In this surgical technique description, we describe a method for the management of bony deficiencies using allograft bone dowels in staged revision ACL reconstruction.

Bone Incorporation of Silicate-Substituted Calcium Phosphate in 2-Stage Revision Anterior Cruciate Ligament Reconstruction: A Histologic and Radiographic Study

PURPOSE

To evaluate the histologic and radiographic outcomes of using silicate-substituted calcium phosphate (Si-CaP) as bone graft substitute for the augmentation of tunnel defects in 2-stage revision anterior cruciate ligament (ACL) reconstruction.

METHODS

Forty patients undergoing 2-stage revision ACL reconstruction were included in a prospective, randomized controlled clinical trial between 2012 and 2015. The inclusion criteria were tunnel diameter of the tibial and/or femoral tunnel of 10 mm or greater after failed ACL reconstruction. Twenty patients received autologous bone from the iliac crest and 20 patients received Si-CaP as a bone graft substitute for tunnel grafting at the first-stage procedure. Punch biopsy specimens of the augmented tunnels were taken at the second-stage procedure, and histologic examination included quantitative analysis of the area of immature bone formation, lamellar bone, and bone marrow. Radiographic analysis included determination of the filling rates of the tunnels on postoperative computed tomography scans.

RESULTS

Forty patients with a mean age of 32 years (standard deviation [SD], 11.0 years) were analyzed. Histologic examination of the tunnels filled with Si-CaP showed that 15% (SD, 14%) of the area was covered with immature bone formation, 41% (SD, 10%) with well-organized lamellar bone, and 44% (SD, 8%) with bone marrow. In the control group (autologous bone), 58% (SD, 3%) of the area was covered with well-organized lamellar bone and 42% (SD, 3%) with bone marrow. Quantitative evaluation of the postoperative computed tomography scans showed a trend of better filling rates in patients with Si-CaP for the tibial tunnel (86% [SD, 17%] vs 78% [SD, 14%]; P = .131). Intraoperatively, Si-CaP was completely integrated into the original bone tunnel providing good stability for tunnel placement and tendon graft fixation comparable to autologous bone.

CONCLUSIONS

Si-CaP as bone graft substitute for tunnel augmentation in 2-stage revision ACL reconstruction shows good histologic, radiographic, and intraoperative integration comparable to autologous bone.

LEVEL OF EVIDENCE

Level I, prospective randomized controlled trial.

Revision Anterior Cruciate Ligament Reconstruction: Results of a Single-stage Approach Using Allograft Dowel Bone Grafting for Femoral Defects

INTRODUCTION

The purpose of this study was to present results of single-stage revision anterior cruciate ligament (ACL) reconstruction using an allograft bone dowel for isolated femoral bony deficiency.

METHODS

Sixteen patients underwent single-stage revision ACL reconstruction using an allograft bone dowel for isolated femoral bony deficiency between 2007 and 2012. Twelve patients (75%) completed study visits, which included CT scans as well as completion of validated outcomes measures.

RESULTS

The average KT-1000 side-to-side difference was 1.0 mm ± 2.9 mm. The average International Knee Documentation Committee score was 70.2 ± 17.8, the Tegner score was 4.8 ± 2.8, and the visual analog scale pain score was 2.8 ± 2.4. An analysis of CT scans showed that all 12 dowels had excellent (>75%) incorporation.

CONCLUSIONS

A single-stage approach for revision ACL reconstruction using allograft dowels for isolated femoral bony deficiency yields objective and subjective outcomes comparable to those reported in the literature for two-stage and other single-stage techniques, with good incorporation of the dowels.

LEVEL OF EVIDENCE

Retrospective case series, level IV.

Two-Stage Revision Anterior Cruciate Ligament Reconstruction: Bone Grafting Technique Using an Allograft Bone Matrix

Outcomes of primary anterior cruciate ligament (ACL) reconstruction have been reported to be far superior to those of revision reconstruction. However, as the incidence of ACL reconstruction is rapidly increasing, so is the number of failures. The subsequent need for revision ACL reconstruction is estimated to occur in up to 13,000 patients each year in the United States. Revision ACL reconstruction can be performed in one or two stages. A two-stage approach is recommended in cases of improper placement of the original tunnels or in cases of unacceptable tunnel enlargement. The aim of this study was to describe the technique for allograft ACL tunnel bone grafting in patients requiring a two-stage revision ACL reconstruction.

Arthroscopic delivery of cancellous tibial autograft for unstable osteochondral lesions in the adolescent knee

The appropriate surgical technique for the treatment of unstable osteochondral lesions of the knee remains unclear and had been traditionally described with an open arthrotomy. Administration of bone grafting material in the knee may be performed for a variety of pathologic conditions, including unstable osteochondritis dissecans, traumatic osteochondral defects, or subchondral fracture nonunion, or for preparation of residual tunnels during revision anterior cruciate ligament reconstruction. Although various grafting materials have been described in the literature, cancellous autograft remains the gold standard for treatment safety and efficacy. We describe a successful technique for arthroscopic delivery of autogenous bone graft during fixation of unstable osteochondral lesions of the knee. When the indication for grafting is established, cancellous autograft is harvested from the proximal tibia, undergoes morcellation, and is soaked in bone marrow aspirate obtained through the harvest window. The bone graft is then packed into a modified tuberculin syringe. After arthroscopic preparation of the unstable osteochondral fragment and the respective donor surface, the tuberculin syringe is placed through a standard arthroscopy portal and the bone graft is introduced into the defect under direct visualization, followed by an appropriate osteochondral fixation technique.

One-stage revision anterior cruciate ligament reconstruction with impacted bone graft after failed primary reconstruction

Revision anterior cruciate ligament reconstruction can be performed in a 1- or 2-stage procedure. Restoration of bone stock using bone grafting is often required for good results. The authors performed 1-stage revision surgery with a more lateral and oblique femoral tunnel and an impacted bone graft to avoid the bone defect caused by the previous screw removal from a malpositioned tunnel. No evidence existed of revision surgery failure or viral transmission in any of 17 cases at 2-year follow-up. The authors' technique is also useful for a slightly misplaced femoral tunnel.

Revision anterior cruciate ligament reconstruction: an update

With the rising number of anterior cruciate ligament (ACL) reconstructions performed, revision ACL reconstruction is increasingly common nowadays. A broad variety of primary and revision ACL reconstruction techniques have been described in the literature. Recurrent instability after primary ACL surgery is often due to non-anatomical ACL graft reconstruction and altered biomechanics. Anatomical reconstruction must be the primary goal of this challenging revision procedure. Recently, revision ACL reconstruction has been described using double bundle hamstring graft. Successful revision ACL reconstruction requires an exact understanding of the causes of failure and technical or diagnostic errors. The purpose of this article is to review the causes of failure, preoperative evaluation, graft selection and types of fixation, tunnel placement, various types of surgical techniques and clinical outcome of revision ACL reconstruction.

Revision anterior cruciate ligament reconstruction

Revision reconstruction of the anterior cruciate ligament (ACL) introduces several diagnostic and technical challenges in comparison with primary ACL reconstruction. With the increasing numbers of original reconstructions combined with the continued expectation of high-level athletic participation, revision ACL reconstruction is likely to become more frequent. The purpose of this article was to summarize the causes of failure and the evaluation of the patient with recurrent instability. A review of the literature regarding results after revision ACL reconstruction was performed to assist in the decision-making process and patient counseling. Good results can be obtained in terms of functional stability after revision reconstruction, but chondral and meniscal injury as well as unrecognized associated pathologic instability may play a role in diminished outcomes. In addition, a wide variety of surgical techniques are reviewed to address problems associated with tunnel malposition, widening, and pre-existing hardware.

Implant-free press-fit fixation for bone-patellar tendon-bone ACL reconstruction: 10-year results

OBJECTIVE

The aim of this study is to determine the outcome of anterior cruciate ligament (ACL) reconstruction without foreign material with patellar tendon bone graft in the fixation with bone dowels near the native insertion.

MATERIALS AND METHODS

Between 1998 and 1999, 189 patients were operated with ACL reconstruction with BTB patellar tendon graft. In a prospective study, 148 (78%) (91M, 57F) patients could be seen for a mean follow-up of 10.3 years. All had foreign material-free press-fit and a bottom-to-top (BTT) fixation in 120 degrees knee flexion. All patients were evaluated with detailed history, clinical examinations, radiographic examination with weight bearing which could be compared to the time of surgery in 64 (43%) patients. Laxity testing was performed in Lachman position with the Rolimeter and pivot shift. All patients were graded according to the IKDC and Tegner activity score.

RESULTS

87% of the patients achieved an IKDC score of A/B. The subjective IKDC score was A/B in 94.6% of the subjects. The average side-to-side difference was 1.42 +/- 0.88 mm for the Lachman test, 97% of the patients were rated between 0 and 2 mm. The pivot-shift test was negative in 90% and was observed with a glide in 7% of the patients. Radiological joint space narrowing was found in the medial compartment in 8 (12.4%) cases, and laterally in 9 (14.1%) cases. All these patients had partial or total meniscus resections. The patello-femoral joint space was reduced in 21 (23%) cases. The Tegner activity score changed from 6.9 pre-injury to 5.0 at the 10-year follow-up.

CONCLUSION

The implant-free fixation of the graft with bone dowels and BTT implantation has good and excellent results after 10 years in more than 80% of the patients. Loss of the meniscus is a main factor contributing to osteoarthritis. Advantages of patellar tendon bone press-fit fixation include anatomical positioning and fast bone-to-bone healing, ease for revision surgery and cost effectiveness.

Minimally invasive bone grafting of cysts of the femoral head and acetabulum in femoroacetabular impingement: arthroscopic technique and case presentation

Femoroacetabular impingement (FAI) has been recently established as a risk factor in the development of osteoarthritis of the hip. Intraosseous cysts are commonly seen on imaging of FAI. In most cases these cysts are incidental and do not require specific treatment at the time of surgical treatment of hip impingement. However, in some cases the cysts may mechanically compromise the acetabular rim or femoral neck. We present a technique for treating such cysts with an all-arthroscopic technique using a commercially available bone graft substitute composed of cancellous bone and demineralized bone matrix placed within an arthroscopic cannula for direct delivery into the cysts. This technique may be of benefit to surgeons treating FAI with an all-arthroscopic technique.