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

Revision Anterior Cruciate Ligament Reconstruction after Surgical Management of Multiligament Knee Injury

The purpose of this study is to determine factors associated with the need for revision anterior cruciate ligament reconstruction (ACLR) after multiligament knee injury (MLKI) and to report outcomes for patients undergoing revision ACLR after MLKI. This involves a retrospective review of 231 MLKIs in 225 patients treated over a 12-year period, with institutional review board approval. Patients with two or more injured knee ligaments requiring surgical reconstruction, including the ACL, were included for analyses. Overall, 231 knees with MLKIs underwent ACLR, with 10% (n = 24) requiring revision ACLR. There were no significant differences in age, sex, tobacco use, diabetes, or body mass index between cohorts requiring or not requiring revision ACLR. However, patients requiring revision ACLR had significantly longer follow-up duration (55.1 vs. 37.4 months, p = 0.004), more ligament reconstructions/repairs (mean 3.0 vs. 1.7, p < 0.001), more nonligament surgeries (mean 2.2 vs. 0.7, p = 0.002), more total surgeries (mean 5.3 vs. 2.4, p < 0.001), and more graft reconstructions (mean 4.7 vs. 2.7, p < 0.001). Patients in both groups had similar return to work (p = 0.12) and activity (p = 0.91) levels at final follow-up. Patients who had revision ACLR took significantly longer to return to work at their highest level (18 vs. 12 months, p = 0.036), but similar time to return to their highest level of activity (p = 0.33). Range of motion (134 vs. 127 degrees, p = 0.14), pain severity (2.2 vs. 1.7, p = 0.24), and Lysholm's scores (86.3 vs. 90.0, p = 0.24) at final follow-up were similar between groups. Patients requiring revision ACLR in the setting of a MLKI had more overall concurrent surgeries and other ligament reconstructions, but had similar final outcome scores to those who did not require revision surgery. Revision ligament surgery can be associated with increased pain, stiffness, and decrease patient outcomes. Revision surgery is often necessary after multiligament knee reconstructions, but patients requiring ACLR in the setting of a MLKI have good overall outcomes, with patients requiring revision ACLR at a rate of 10%.

Does Revision Anterior Cruciate Ligament (ACL) Reconstruction Provide Similar Clinical Outcomes to Primary ACL Reconstruction? A Systematic Review and Meta-Analysis

More revisionary reconstruction procedures are required following failing anterior cruciate ligament (ACL) reconstructions, which are often regarded as a technique challenge with very limited goals. This study will be performed to compare the outcomes between groups of primary and revision knee reconstruction. Two observers conducted the literature retrieval from the platforms of PubMed, Embase, and CENTRAL. Studies which compared knee function and stability between primary and revisionary reconstructions were included. The data was synthesized by meta‐analysis with fixed‐ or random‐effects models as appropriate. A total of 10 eligible studies were included with 954 subjects in the primary group and 378 in the revision group. The International Knee Documentation Committee International Knee Documentation Committee (IKDC) subscores, side‐to‐side difference, and Lysholm score were demonstrated to be significantly improved at final follow‐up in both groups, while Tegner score was not. The overall IKDC, Knee injury and Osteoarthritis Outcome Score (KOOS), and Lysholm scores were significantly inferior in the revision group compared to the primary group. However, knee laxity according to side‐to‐side difference was demonstrated to be similar between the two groups. Revision ACL reconstruction (RACLR) could provide patients with excellent restoration of knee outcomes compared to the status before revision. Also, while knee function in the revision group was inferior to the primary group, knee stability was equivalent between the two groups at the final follow‐up.

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of anterior cruciate ligament injury - Secondary publication

BACKGROUND

This clinical guideline presents recommendations for the management of patients with anterior cruciate ligament (ACL) injury, endorsed by the Japanese Orthopaedic Association (JOA) and Japanese Orthopaedic Society of Knee, Arthroscopy and Sports Medicine (JOSKAS).

METHODS

The JOA ACL guideline committee revised the previous guideline based on "Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014", which proposed a desirable method for preparing clinical guidelines in Japan. Furthermore, the importance of "the balance of benefit and harm" was also emphasized. This guideline consists of 21 clinical questions (CQ) and 23 background questions (BQ). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design.

RESULTS

We evaluated the objectives and results of each study in order to make a decision on the level of evidence so as to integrate the results with our recommendations for each CQ. For BQ, the guideline committee proposed recommendations based on the literature.

CONCLUSIONS

This guideline is intended to be used by physicians, orthopedic surgeons, physical therapists, and athletic trainers managing ACL injuries. We hope that this guideline is useful for appropriate decision-making and improved management of ACL injuries.

Outcome After Anterior Cruciate Ligament Revision

PURPOSE OF REVIEW

To describe the current literature related to anterior cruciate ligament (ACL) revision in terms of surgical aspects, graft choices, concomitant injuries, patient-reported outcome, return to sport, and objective measurement outcome.

RECENT FINDINGS

An ACL rupture is a common knee injury, and the number of primary ACL reconstructions is increasing, implying a subsequent increase of ACL revisions in the future. It is widely accepted that an ACL revision is surgically challenging with a myriad of graft options to choose from. In many cases, simultaneous injuries to the index limb including meniscal and chondral lesions, respectively, are observed in the setting of a secondary ACL injury. Furthermore, the general understanding is that an ACL revision results in inferior outcome compared with a primary ACL reconstruction. Surgical treatment of an ACL revision can be performed as one-stage or two-stage procedure depending on, for example, the presence of limb malalignments, concomitant injuries, and tunnel widening. Nonirradiated allografts and autologous patella tendon, hamstring tendon, and quadriceps tendon are feasible options for ACL revision. Concomitant injuries to the affected knee such as intraarticular chondral lesions are more common in the setting of an ACL revision compared with primary ACL reconstruction while a lower presence of concomitant meniscal pathology is reported at ACL revision. Patients undergoing ACL revision have lower clinical and patient-reported outcome and lower rates of return to sport when compared with primary ACL surgery cases. However, long-term follow-ups with large study cohorts evaluating outcome of ACL revision are limited. Further research is needed to confirm the present findings of this review.

Contribution of Additional Anterolateral Structure Augmentation to Controlling Pivot Shift in Anterior Cruciate Ligament Reconstruction

BACKGROUND

Several types of anterolateral structure (ALS) augmentation procedures in anterior cruciate ligament (ACL) reconstruction have been reported. However, information is limited regarding the effect of additional ALS augmentation on rotatory stability in a clinical setting.

PURPOSE/HYPOTHESIS

This study aimed to investigate the contribution of additional ALS augmentation in ACL reconstruction in cases with a high risk of residual pivot shift. The 2 hypotheses were as follows. First, additional ALS augmentation would improve rotatory stability as compared with solely reconstructing the ACL. Second, graft tension changes would be different between the ACL and ALS during knee range of motion and against anterior or rotatory loads.

STUDY DESIGN

Controlled laboratory study.

METHODS

Fifteen patients who met at least 1 of the following criteria were included: (1) revision ACL reconstruction, (2) preoperative high-grade pivot shift, or (3) hyperextended knee. The pivot-shift test was performed preoperatively and during surgery after ACL reconstruction and after additional ALS augmentation with acceleration measurements from a triaxial accelerometer. The tension changes of the ACL and ALS grafts were also measured during knee range of motion and against manual maximum anterior tibial translation, internal rotation, and external rotation.

RESULTS

After ACL reconstruction, the pivot-shift acceleration was still greater than that of the uninjured knee. However, additional ALS augmentation further reduced acceleration when compared with ACL reconstruction alone in both primary and revision cases (P < .05 vs preoperative, P < .05 vs ACL). During knee flexion-extension, the tension of the ACL increased as the knee was extended, whereas that of the ALS did not change. Graft tension of the ACL and ALS became higher with internal rotation and lower with external rotation as compared with the neutral position. Tension of the ACL was significantly increased against anterior tibial translational loads, whereas that of the ALS was not.

CONCLUSION

Additional ALS augmentation further improved the rotatory stability during ACL reconstruction in patients with a high risk of residual pivot shift at the time of surgery. Significant differences in graft tension changes were also observed between the ACL and ALS against different loads. Additional ALS augmentation may be considered to eliminate the pivot shift in patients with a high risk of residual pivot shift.

Revision anterior cruciate ligament reconstruction restores knee laxity but shows inferior functional knee outcome compared with primary reconstruction

PURPOSE

To evaluate and compare knee laxity and functional knee outcome between primary and revision anterior cruciate ligament (ACL) reconstruction in the same cohort of patients.

METHODS

Patients who underwent primary and revision ACL reconstruction (ACLR) at Capio Artro Clinic, Stockholm, Sweden, from 2000 to 2015, were identified in our local database. Inclusion criteria were: same patients who underwent primary hamstring tendons (HT) and revision bone-patellar tendon-bone (BPTB) autograft ACLR, no associated ligament injuries and no contralateral ACL injuries/reconstructions. The cause of revision ACLR was graft rupture for all patients. The KT-1000 arthrometer, with an anterior tibial load of 134-N, was used to evaluate knee laxity preoperatively and 6-month postoperatively. The Knee Injury and Osteoarthritis Outcome Score (KOOS) was collected preoperatively and at the 1-year follow-up.

RESULTS

A total of 118 patients with primary and revision ACLR arthrometric laxity measurements were available (51.0% males; mean age at primary ACLR 21.7 ± 7.1 years and revision ACLR 24.3 ± 7.5 years). The mean preoperative and postoperative anterior side-to-side (STS) difference values were not significantly different between primary and revision ACLR. However, primary ACLR showed a significantly higher frequency of postoperative anterior STS difference > 5 mm compared with revision ACLR (8.4 vs 5.0%; P = 0.02). The KOOS was available for primary and revision ACLR for 73 patients (55.4% males; mean age at primary ACLR 21.6 ± 7 years and revision ACLR 24.7 ± 7.3 years). Preoperatively, revision ACLR showed significantly higher scores in all KOOS subscales, except for the activity of daily living (ADL) subscale. For the primary ACLR, the improvement from preoperatively to the 1-year follow-up was significantly greater in all KOOS subscales and, the postoperative scores were superior for Pain, ADL and Sports subscales compared with revision ACLR.

CONCLUSIONS

The findings of this study showed that anterior knee laxity is restored with revision BPTB autograft ACLR after failed primary HT autograft ACLR, in the same cohort of patients. However, revision ACLR showed a significantly inferior functional knee outcome compared with primary ACLR. It is important for clinicians to inform and set realistic expectations for patients undergoing revision ACLR. Patients must be aware of the fact that having revision ACLR their knee function will not improve as much as with primary ACLR and the final postoperative functional outcome is inferior.

LEVEL OF EVIDENCE

Retrospective cohort study, Level III.

Single-stage versus two-stage revision anterior cruciate ligament reconstruction: a systematic review

Importance

Despite advances in surgical techniques and postoperative rehabilitation, long-term anterior cruciate ligament (ACL) graft rupture rate remains high. The increasing number of primary ACL reconstructions in an ageing population will lead to increasing revision reconstructions. Revision cases may have higher failure rates and worse patient-reported outcomes compared with primaries. While two-stage revisions may be indicated in certain complex cases, whether this is comparatively equivalent or even superior to revisions done in a single stage would assist preoperative planning.

Objective

The objective of this systematic review was to analyse and compare patient-reported outcomes and failure rate of single-stage versus two-stage revision ACL reconstruction.

Evidence review

Using PubMed, MEDLINE Complete and Ovid MEDLINE databases, a review was performed using Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines to identify level I–IV outcomes of revision ACL reconstruction with a minimum follow-up of 24 months.

Findings

Three studies reported outcomes of two-stage revisions with mean follow-up of 61.6 months, while 21 studies reported single-stage revisions with mean follow-up of 47.4 months. Pooled rate of two-stage revisions was 3.1% compared with 6.8% in single-stage (p=0.068). Clinical failure was reported in 5.1% of 79 two-stage patients compared with 13.8% of 533 single-stage patients (p<0.05). Within the single-stage cohort, there was a greater clinical failure rate (+8.7%, p<0.05) for patients with less than 48 months follow-up. Those with > 48 months follow-up had a higher rerupture rate (+5%, p<0.05) and a significantly greater sum of squared deviations (p<0.05) compared with those with < 48 months follow-up. Patient-reported outcomes have demonstrated two-stage revision patients with higher IKDC A and B scores than single-stage.

Conclusions and relevance

Although two-stage revisions may be performed in more complex cases, there are limited short-term data available regarding their outcomes. Two-stage revisions demonstrated comparable clinical outcomes and lower rate of revision surgery and clinical failure compared with single-stage revisions. Studies with shorter follow-up (24–48 months) showed higher clinical failure rates. Those with longer follow-up (>48 months) showed higher graft rerupture rates. The decision to perform staged reconstruction should made on whether adequate tunnel placement and fixation can be established in a single setting.

Level of evidence

Level IV.

Comparison of Knee Stability, Strength Deficits, and Functional Score in Primary and Revision Anterior Cruciate Ligament Reconstructed Knees

Comparing to primary surgery, revision ACL reconstruction is more technically demanding and has a higher failure rate. Theoretically, rehabilitation can improve knee function after ACL reconstruction surgery. This study aimed to compare knee stability, strength, and function between primary and revision ACL reconstructed knees. 40 primary and 40 revision ACL reconstruction surgeries were included between April 2013 and May 2016. Patients with revision surgery had a higher anteroposterior translation comparing those with primary reconstruction (median laxity, 2.0 mm vs. 3.0 mm, p = 0.0022). No differences were noted in knee extensor at 60°/sec or 180°/sec (p = 0.308, p = 0.931, respectively) or in flexor muscle strength at 60°/sec or 180°/sec between primary and revision ACL reconstruction knees (p = 0.091, p = 0.343, respectively). There were also no significant differences between functional scores including IKDC score and Lysholm score in primary versus revision surgeries at 12th months after index operation (p = 0.154, p = 0.324, respectively). In conclusion, despite having higher anteroposterior instability, patients with revision ACL reconstruction can have non-inferior outcomes in isokinetic knee strength and function compared to those with primary ACL reconstruction after proper rehabilitation.

Clinical Outcomes in Revision Anterior Cruciate Ligament Reconstruction: A Meta-analysis

PURPOSE

The purpose of this meta-analysis was to determine overall objective graft failure rate, failure rate by graft type (allograft vs autograft reconstruction), instrumented laxity, and patient outcome scores following revision anterior cruciate ligament (ACL) reconstruction. Outcomes of interest were collected for all studies meeting the study inclusion criteria, but lower-level studies (level III/IV) were not pooled for quantitative synthesis due to high levels of heterogeneity in these study populations.

METHODS

A comprehensive search strategy was performed to identify studies reporting outcomes of revision ACL reconstruction. The primary outcome reported was graft failure. A meta-analysis comparing rate of failure by graft type was conducted using a random effects model. Studies also reported patient clinical outcome scores, including International Knee Documentation Committee (IKDC), Lysholm, and knee injury and osteoarthritis outcome scores (KOOS) and graft laxity.

RESULTS

Eight studies with 3,021 patients (56% male, 44% female) with an average age of 30 ± 4 years and mean follow-up time of 57 months were included. The overall objective failure rate was 6% (95% confidence interval [CI], 1.8%-12.3%). Mean instrumented laxity as side-to-side difference was 2.5 mm (95% CI, 1.9-3.1 mm). Mean IKDC subjective score was 76.99 (95% CI, 76.64-77.34), mean KOOS symptoms score was 76.73 (95% CI, 75.85-77.61), and mean Lysholm score was 86.18 (95% CI, 79.08-93.28). The proportion of patients with IKDC grade A or B was 85% (95% CI, 77%-91%). When the available data for failure rate were analyzed by graft type, autograft reconstruction had a failure rate of 4.1% (95% CI, 2.0%-6.9%), similar to allograft reconstruction at 3.6% (95% CI, 1.4%-6.7%).

CONCLUSIONS

In this meta-analysis, revision ACL reconstruction had failure rates similar to autograft or allograft reconstruction. Overall outcome scores for revision reconstruction have improved but appear modest when compared with primary ACL reconstruction surgery.

LEVEL OF EVIDENCE

Meta-analysis of Level II studies, Level II.

Return to sports and functional results after revision anterior cruciate ligament reconstruction by fascia lata autograft

INTRODUCTION

The surgical revision rate following anterior cruciate ligament (ACL) surgery is 3% at 2 years and 4% at 5 years. Revision ACL surgery raises the question of the type of graft to be used. The present study assessed return to sports and functional results after revision ACL reconstruction by fascia lata graft. The hypothesis was that fascia lata provides a reliable graft in revision ACL surgery.

MATERIAL AND METHODS

A single-center retrospective continuous study included 30 sports players with a mean age of 26.8±8 years undergoing surgical revision for iterative ACL tear between 2004 and 2013. Multi-ligament lesions were excluded. Type and level of sports activity were assessed preoperatively, after primary surgery and at end of follow-up. Clinical assessment used subjective IKDC, Lysholm and KOOS scores.

RESULTS

At a mean 4.6±1.6 years' follow-up, all patients had resumed sport activity, but only 12 with the same sport at the same level. Median subjective IKDC score increased from 57 [54.3; 58.5] preoperatively to 82 [68.3; 90] at last follow-up, and Lysholm score from 46 [42.3; 51] to 90.5 [80.8; 96.8]; KOOS score at last follow-up was 94.7 [83; 100].

CONCLUSION

Functional results in revision ACL reconstruction by fascia lata graft were satisfactory, with similar return-to-sports rates as with other techniques. Fascia lata provides a reliable graft in revision ACL surgery.

LEVEL OF EVIDENCE

IV, retrospective study.

Arthroscopic single-bundle anterior cruciate ligament reconstruction with six-strand hamstring tendon allograft versus bone-patellar tendon-bone allograft

PURPOSE

The aim of this study was to compare the clinical outcomes of arthroscopic single-bundle anterior cruciate ligament (ACL) reconstruction with six-strand hamstring tendon (HT) allograft versus bone-patellar tendon-bone (BPTB) allograft.

METHODS

The prospective randomized controlled trial was included 129 patients. Sixty-nine patients received reconstruction with six-strand HT allografts (HT group), whereas 60 patients with BPTB allografts (BPTB group). Outcome assessment included re-rupture findings, International Knee Documentation Committee (IKDC) scores, Lysholm scores, KT-1000 arthrometer, Lachman test, pivot-shift test, range of motion (ROM) and single-leg hop test.

RESULTS

At a mean follow-up of 52 months, 113 patients (HT group, 61 patients; BPTB group, 52 patients) completed a minimum 4-year follow-up. Four patients in HT group and six in BPTB group experienced ACL re-rupture (6.2 vs. 10.3 %) and received revision surgery. Significant between-group differences were observed in KT-1000 outcomes and pivot-shift test 1 (1.2 ± 1.5 vs. 1.8 ± 1.3, p = 0.025; positive rate 6.5 vs. 18.9 %, p = 0.036), 2 (1.1 ± 1.4 vs. 1.6 ± 1.2, p = 0.044; 8.1 vs. 20.7 %, p = 0.039), 4 (1.1 ± 1.5 vs. 1.7 ± 1.4, p = 0.031; 9.7 vs. 25 %, p = 0.012) years postoperatively. The outcomes between the two groups were comparable in terms of IKDC scores, Lysholm scores, Lachman test, ROM and single-leg hop test.

CONCLUSIONS

Six-strand HT allograft achieved superior anteroposterior and rotational stability after single-bundle ACL reconstruction. It is a reasonable graft substitute for ACL reconstruction.

LEVEL OF EVIDENCE

II.

Clinical Outcomes of Combined Lateral Extra-articular Tenodesis and Intra-articular Anterior Cruciate Ligament Reconstruction in Addressing High-Grade Pivot-Shift Phenomenon

PURPOSE

To evaluate the clinical outcomes of combined lateral extra-articular tenodesis (LET) and intra-articular anterior cruciate ligament (ACL) reconstruction (ACLR) in addressing the high-grade pivot-shift phenomenon.

METHODS

The PubMed/Medline database was searched for articles reporting clinical outcomes of combined LET and intra-articular ACLR in treating ACL injuries with high-grade pivot shift. High-grade pivot shift was defined as the presence of moderate to severe rotational instability shown by a grade II or III manual pivot shift preoperatively (grade 0, normal; grade I, glide; grade II, clunk; and grade III, locking, according to International Knee Documentation Committee [IKDC] form). The postoperative manual pivot-shift grading during the clinical follow-up visit was the primary outcome variable. Moreover, the prevalence of residual pivot shift (grade I, II, or III), distribution of objective IKDC scores, and anterior knee stability were also compared between patients with and without an additional LET procedure.

RESULTS

Seven studies were included. Overall, 326 patients (326 knees) with high-grade pivot shift underwent combined LET and intra-articular ACLR with a mean follow-up period of 46.2 months (range, 24 to 76 months). There were 274 patients (84.1%) with grade 0, 42 (12.9%) with grade I, and 10 (3.0%) with grade II pivot shift at the final follow-up. Among the 5 comparative studies, the prevalence of residual pivot shift was significantly lower (P < .05) in patients with LET plus ACLR (13.3%, 30 of 226) than those with isolated ACLR (27.2%, 67 of 246). However, the distribution of objective IKDC scores and anterior knee stability showed no significant differences between groups.

CONCLUSIONS

The combination of LET and intra-articular ACLR was effective in eliminating the high-grade pivot-shift phenomenon. For ACL injuries with high-grade pivot shift, LET plus ACLR provided a significant reduction in the prevalence of residual pivot shift but no differences in objective IKDC scores and anterior knee stability compared with isolated ACLR at short-term follow-up.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I, III, and IV studies.

Does revision ACL reconstruction measure up to primary surgery? A meta-analysis comparing patient-reported and clinician-reported outcomes, and radiographic results

PURPOSE

To compare patient-reported and clinician-reported outcomes, and radiographic results between patients who had had revision ACL reconstruction and those who had had primary ACL reconstruction.

DESIGN

Systematic review and meta-analysis

DATA SOURCES

The MEDLINE, CINAHL, EMBASE and SPORTDiscus electronic databases were searched on 6 August 2015, using 3 main concepts: (1) revision ACL reconstruction, (2) primary ACL reconstruction and (3) treatment outcomes.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Articles that compared patient-reported or clinician-reported outcomes or radiographic results between patients who had had revision ACL reconstruction and those who had had primary surgery with a minimum of 2 years follow-up were included. The outcomes evaluated were the Lysholm Knee Scoring Scale, objective International Knee Documentation Committee (IKDC) classification, Tegner Activity Scale, side-to-side difference in anterior tibial translation measured with KT-1000/2000 arthrometer, pivot shift test, tibiofemoral osteoarthritis grading on plain radiographs and subsequent knee surgeries.

RESULTS

8 studies (300 revision ACL reconstructions and 413 primary ACL reconstructions) were included in the meta-analysis. Patients who had had revision surgery reported inferior Lysholm Knee Scoring Scale scores (mean difference: 7.8 points), had inferior clinician-reported knee function as assessed with the objective IKDC classification (IKDC category A: 27% vs 57%; IKDC category C or D: 22% vs 8%) and pivot shift test (grade II or III: 7% vs 2%), and more radiographic evidence of tibiofemoral osteoarthritis (50% vs 25%) compared with patients who had had primary surgery.

CONCLUSIONS

Revision ACL reconstruction restored similar anterior-posterior knee laxity compared with primary ACL reconstruction. Patients who had had revision surgery reported inferior Lysholm Knee Scoring Scale scores, had inferior clinician-reported knee function and more radiographic signs of tibiofemoral osteoarthritis compared with patients with primary ACL reconstruction.

Patient expectations of primary and revision anterior cruciate ligament reconstruction

PURPOSE

Unrealistic patient expectations have been shown to negatively influence patient-reported outcomes in orthopaedic surgery. Knowledge about patient expectations is important to associate preoperative expectations with the reasonable outcome of a specific procedure. The purpose of this study was to prospectively analyse and to compare patient expectations of primary and revision anterior cruciate ligament reconstruction (ACLR) and to assess the factors associated with patient expectations.

METHODS

Preoperative expectations of 181 consecutive patients undergoing ACLR were assessed prospectively using a 5-item questionnaire. Primary ACLR (P-ACLR) was performed in 133 patients (73%), whereas 48 patients (27%) underwent revision ACLR (R-ACLR). The questionnaire assessed the expectation of the overall condition of the knee joint, return to sports, instability, pain, and risk of osteoarthritis.

RESULTS

All patients expected a normal (38%) or nearly normal (62%) condition of the knee joint. Return to sports at the same level was expected by 91%. With regard to instability (pain), no instability (pain) independent of the activity level was expected by 77% (58%). No or only a slightly increased risk of the development of osteoarthritis was expected by 98%. The R-ACLR group showed a significantly lower expectation of the overall condition (p = 0.001), return to sports (p < 0.001), and pain (p = 0.002). No statistically significant difference was found between female and male patients (n.s.). In the P-ACLR group, patients with a history of previous knee surgery showed inferior expectations of return to sports (p = 0.015) and risk of osteoarthritis (p = 0.011). Age, number of previous knee surgeries, and pre-injury sports level significantly influenced patient expectations.

CONCLUSIONS

Overall, patient expectations of ACL reconstruction are high. Patients undergoing revision ACL reconstruction have lower but still demanding expectations. Younger patients, patients without a history of knee surgery, and highly active patients have higher expectations. Explicit patient information about realistic goals of ACL reconstruction seems to be necessary in order to prevent postoperative dissatisfaction despite a successful operation in the surgeons' point of view.

LEVEL OF EVIDENCE

Prospective case series, Level IV.

Revision anterior cruciate ligament reconstruction: clinical outcome and evidence for return to sport

PURPOSE

An increasing number of patients undergo revision anterior cruciate ligament (ACL) reconstruction, with the intention of returning to sport being a major indication. The aim of this study is to assess the available evidence for clinical improvement and return to sport, to understand the real potential of this procedure in regaining functional activity, and to facilitate improved counselling of patients regarding the expected outcome after revision ACL reconstruction.

METHODS

The search was conducted on the PubMed database. Articles reporting clinical results for revision ACL reconstruction were included. A meta-analysis was performed on return to sport, and results were compared to the literature on primary ACL reconstruction. Other specific clinical outcomes (Lysholm, Tegner, IKDC Objective scores) were also included in the meta-analysis.

RESULTS

Of the 503 identified records, a total of 59 studies involving 5365 patients were included in the qualitative data synthesis. Only 31 articles reported the rate of return to sport. Whereas 73 % of good objective results and satisfactory subjective results were documented, 57 % of patients did not return to the same level of sport activity, significantly inferior to that of a primary procedure.

CONCLUSION

The real potential of revision ACL reconstruction should not be overestimated due to the low number of patients able to return to their previous activity level, significantly inferior with respect to that reported for primary ACL reconstruction. This finding will help physicians in the clinical practice providing realistic expectations to the patients. Future studies should focus on participation-based outcome measures such as return to sport and in strategies to improve the results in terms of return to previous activities after revision ACL reconstruction.

LEVEL OF EVIDENCE

Systematic review and meta-analysis including Level IV studies, Level IV.

High Variability in Outcome Reporting Patterns in High-Impact ACL Literature

BACKGROUND

ACL (anterior cruciate ligament) reconstruction is one of the most commonly performed and studied procedures in modern sports medicine. A multitude of objective and subjective patient outcome measures exists; however, nonstandardized reporting patterns of these metrics may create challenges in objectively analyzing pooled results from different studies. The goal of this study was to document the variability in outcome reporting patterns in high-impact orthopaedic studies of ACL reconstruction.

METHODS

All clinical studies pertaining to ACL reconstruction in four high-impact-factor orthopaedic journals over a five-year period were reviewed. Biomechanical, basic science, and imaging studies were excluded, as were studies with fewer than fifty patients, yielding 119 studies for review. Incorporation of various objective and subjective outcomes was noted for each study.

RESULTS

Substantial variability in reporting of both objective and subjective measures was noted in the study cohort. Although a majority of studies reported instrumented laxity findings, there was substantial variability in the type and method of laxity reporting. Most other objective outcomes, including range of motion, strength, and complications, were reported in <50% of all studies. Return to pre-injury level of activity was infrequently reported (24% of studies), as were patient satisfaction and pain assessment following surgery (8% and 13%, respectively). Of the patient-reported outcomes, the International Knee Documentation Committee (IKDC), Lysholm, and Tegner scores were most often reported (71%, 63%, and 42%, respectively).

CONCLUSIONS

Substantial variability in outcome reporting patterns exists among high-impact studies of ACL reconstruction. Such variability may create challenges in interpreting results and pooling them across different studies.

After revision anterior cruciate ligament reconstruction, who returns to sport? A systematic review and meta-analysis

BACKGROUND

Return to sport and to pre-injury level represents an important outcome after both primary and revision anterior cruciate ligament (ACL) reconstructions.

PURPOSE

The aim of the present meta-analysis was to determine the return to sport rate after revision ACL reconstruction.

MATERIAL AND METHODS

A systematic search was performed of the MEDLINE, Embase and the Cochrane Central Register of Controlled Trials Databases. All the studies that reported return to sport, return to pre-injury sport level and return to high level/competitive sport was considered for the meta-analysis. The overall pooled mean of post-operative knee laxity and pooled rate of positive pivot-shift and objective International Knee Documentation Committee (IKDC) categories was calculated as well.

RESULTS

Overall, 472 abstracts were identified and screened for inclusion and only 16 studies reported the rate of return to any level of sport activity at the final follow-up of 4.7 years (range 1.0-13.2 years), showing a pooled rate of 85.3% (CI 79.7 to 90.2). The return to pre-injury sport level was achieved in 53.4% (CI 37.8 to 68.7) of cases. Normal or quasi-normal objective IKDC, less than 5 mm of side-to-side difference at arthrometric evaluations and grade I-II pivot-shift test were reported in 84%, 88% and 93% patients, respectively.

CONCLUSIONS

In spite of almost 8 patients out of 10 returning to sport after revision ACL reconstruction and showing good stability, only half of the patients returned to the same pre-injury sport level.

Proximal Tibial Anterior Closing Wedge Osteotomy in Repeat Revision of Anterior Cruciate Ligament Reconstruction

BACKGROUND

Physicians should consider an increased posterior tibial slope (PTS) as a risk factor for graft failure when proposing anterior cruciate ligament (ACL) re-revision.

PURPOSE

To describe the surgical technique of combined ACL revision and proximal tibial anterior closing wedge osteotomy and to evaluate its clinical outcome in cases of recurrent graft failure with associated increased tibial slope.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between 2008 and 2010, 5 combined ACL re-revisions with proximal tibial anterior closing wedge osteotomy were retrospectively evaluated after a mean 31.6 months' follow-up (range, 23-45 months). All patients reported subjective knee instability preoperatively and demonstrated increased laxity on physical examination. Intrinsic risk factors for graft failure (excessive tibial slope) were identified in all cases. Preoperative and postoperative functional assessments included the International Knee Documentation Committee (IKDC) score along with the Lysholm score and Tegner activity scale.

RESULTS

The mean Lysholm score was 46.2 preoperatively (range, 26-69) and 87.8 (range, 60-100) postoperatively. The mean IKDC subjective score was 39.5 (range, 21.8-64.4) before surgery and 79.1 (range, 48.3-98.9) at the last follow-up. The mean Tegner activity score was 7.4 (range, 5-9) before the latest ACL injury and 7.2 (range, 5-9) at the last follow-up. The mean PTS was 13.6° (range, 13°-14°) preoperatively and 9.2° (range, 8°-10°) postoperatively (P = .0005). The mean differential anterior laxity was 10.4 mm (range, 8-14 mm), and this significantly decreased to 2.8 mm (range, 2-4 mm) at the last follow-up. Using the Kellgren-Lawrence classification to evaluate the presence of arthritis, 1 patient was grade 1, 3 patients were grade 2, and 1 patient was grade 3.

CONCLUSION

Combined ACL re-revision with proximal tibial anterior closing wedge osteotomy restores knee stability and function with satisfactory clinical outcomes in patients who experience recurrent ACL ruptures with an associated increased PTS.

Remnant volume of anterior cruciate ligament correlates preoperative patients' status and postoperative outcome

PURPOSE

A cohort study was conducted to evaluate the correlation of anterior cruciate ligament (ACL) remnant volume with preoperative status and postoperative outcome of the patients after a remnant-preserving double-bundle (DB) ACL reconstruction.

METHODS

Eighty-eight patients of 105 unilateral DB anatomic ACL reconstructions performed between 2006 and 2008 were followed up for 24 months or more. They were evaluated with regard to preoperative knee laxity data under anaesthesia. Postoperative outcome was evaluated based on knee extension and flexion strength, manual laxity tests, KT measurements, etc. Overall knee condition and sports performance were evaluated with Lysholm knee score and subjective rating scale. Overall correlation of the remnant volume with the preoperative and postoperative evaluation was assessed. Then, the patients were divided into three subgroups based on the remnant volume (remnant volume: ≤ 30, 35-55 and ≤ 60 %). The evaluation was performed and analysed statistically among the three subgroups.

RESULTS

Generally, preoperative laxity tests showed a weak correlation with the ACL remnant volume. Postoperative knee stability also indicated a weak correlation with the ACL remnant volume. Statistical analyses revealed that there were significant differences among the three groups regarding age at surgery, preoperative period, number of giving-way and preoperative KT measurements. Postoperatively, there were significant differences in Lachman test, KT measurements, Lysholm knee scale, subjective and sports performance recovery scores. As the clinical relevance, the study suggests that the remnant volume will be important as a background of preoperative condition and a predictor of operative outcome for each patient and that a remnant preserving surgery may not be simply better than a non-preserving technique with regard to subjective evaluation and sports performance recovery.

CONCLUSION

The preoperative condition of patients with ACL injury was different depending upon the remnant volume. The remnant volume was also weakly correlated with the postoperative outcome regarding objective stability and subjective recovery.

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 ACL reconstruction: influence of a lateral tenodesis

PURPOSE

The aims of this article were to report the objective results of revision ACL reconstruction and to assess the influence of an associated lateral extra-articular tenodesis on knee stability and IKDC score.

METHODS

This study focused on revision ACL reconstruction and was conducted over a 10-year period, from 1994 to 2003 with ten French orthopedic centers participating. The minimum follow-up required was 2 years. To be included, patients had to be evaluated at follow-up with the objective International Knee Documenting Committee (IKDC) scoring system. In 2006, 163 patients met the inclusion criteria.

RESULTS

The objective IKDC knee score improved significantly after revision ACL reconstruction, with 72% IKDC A + B (26% A). When a lateral tenodesis was performed, 80% had a negative pivot shift, versus 63% without (P = 0.03), but there was no significant difference in the IKDC score.

CONCLUSION

This study shows a significant improvement in the IKDC score after revision ACL reconstruction. The association of a lateral extra-articular tenodesis with the intra-articular graft increases knee stability after revision ACL reconstruction; however, this additional procedure does not significantly alter the IKDC score at follow-up.

LEVEL OF EVIDENCE

Retrospective case series, Level IV.

Double bundle arthroscopic Anterior Cruciate Ligament reconstruction with remnant preserving technique using a hamstring autograft

BACKGROUND

Preservation of the Anterior Cruciate Ligament (ACL) remnant is important from the biological point of view as it enhances revascularization, and preserves the proprioceptive function of the graft construct. Additionally, it may have a useful biomechanical function. Double bundle ACL reconstruction has been shown to better replicate the native ACL anatomy and results in better restoration of the rotational stability than single bundle reconstruction.

METHODS

We used the far anteromedial (FAM) portal for creation of the femoral tunnels, with a special technique for its preoperative localization using three dimensional (3D) CT. The central anteromedial (AM) portal was used to make a longitudinal slit in the ACL remnant to allow visualization of the tips of the guide pins during anatomical creation of the tibial tunnels within the native ACL tibial foot print. The use of curved hemostat allow retrieval of the wire loop from the apertures of the femoral tunnels through the longitudinal slit in the ACL remnant thereby, guarding against impingement of the reconstruction graft against the ACL remnant as well as the roof of the intercondylar notch.

CONCLUSION

Our technique allows for anatomical double bundle reconstruction of the ACL while maximally preserving the ACL remnant without the use of intra-operative image intensifier.

Quadriceps muscle activation and radiographic osteoarthritis following ACL revision

PURPOSE

Quadriceps strength and activation may play an important role in the recovery from ACL revision surgery. The purpose of this study was to describe quadriceps strength and central activation ratio (CAR) and correlate with radiographic findings in patients with ACL revision surgery.

METHODS

Twenty-one patients who were on average 47.5 ± 21.1 months [range: 14-85 months] post-revision ACL reconstruction. We performed knee joint physical examination and radiographic evaluation. Quadriceps strength testing consisted of maximal voluntary isometric contractions (MVIC) with the knee bent to 90-degrees bilaterally. We calculated quadriceps central activation ratio using the superimposed burst technique. Radiographs (bilateral standing antero-posterior in knee flexion and lateral in full extension) were evaluated by a fellowship-trained orthopedic surgeon using the International Knee Documentation Committee (IKDC) grading system.

RESULTS

Mean CAR was 83.9 ± 12.0% on the reconstructed limb and 85.5 ± 9.5% on the contralateral limb. Average, normalized MVIC torque was 2.5 ± 1.0 Nm/kg on the reconstructed limb and 2.7 ± 1.0 N m/kg for the contralateral limb. Patient age at the time of follow-up evaluation was related to severity of knee joint degeneration, particularly the medial, anterior and patellofemoral compartments. Younger patients with lower CARs tended to have more severe degeneration in the patellofemoral joint. Older patients with lower normalized MVIC torque values tended to exhibit more severely graded degeneration in the patellofemoral joint.

CONCLUSION

Bilateral quadriceps central activation deficits and radiographic osteoarthritis are evident in patients with revision ACL reconstruction.