Case series: Revision anterior cruciate ligament reconstructions using patellar tendon autografts

Failure modes after anterior cruciate ligament reconstruction: a systematic review and meta-analysis

PURPOSE

The reason for graft failure after anterior cruciate ligament reconstruction (ACLR) is multifactorial. Controversies remain regarding the predominant factor and incidence of failure aetiology in the literature. This review aimed to provide a meta-analysis of the literature to evaluate the relative proportion of various failure modes among patients with ACLR failure.

METHODS

The PubMed, Embase, Cochrane Library, Web of Science, and EBSCO databases were searched for literature on ACLR failure or revision from 1975 to 2021. Data related to causes for ACLR surgical failure were extracted, and a random effects model was used to pool the results, which incorporates potential heterogeneity. Failure modes were compared between different populations, research methods, graft types, femoral portal techniques, and fixation methods by subgroup analysis or linear regression. Funnel plots were used to identify publication bias and small-study effects.

RESULTS

A total of 39 studies were analyzed, including 33 cohort studies and six registry-based studies reporting 6578 failures. The results showed that among patients with ACLR failure or revision, traumatic reinjury was the most common failure mode with a rate of 40% (95% CI: 35-44%), followed by technical error (34%, 95% CI: 28-42%) and biological failure (11%, 95% CI: 7-15%). Femoral tunnel malposition was the most common cause of the technical error (29%, 95% CI: 18-41%), with more than two times higher occurrence than tibial tunnel malposition (11%, 95% CI: 6-16%). Traumatic reinjury was the most common factor for ACLR failure in European populations and in recent studies, while technical errors were more common in Asian populations, earlier studies, and surgery performed using the transtibial (TT) portal technique. Biological factors were more likely to result in ACLR failure in hamstring (HT) autografts compared to bone-patellar tendon-bone (BPTB) autografts.

CONCLUSION

Trauma is the most important factor leading to surgical failure or revision following ACLR. Technical error is also an important contributing factor, with femoral tunnel malposition being the leading cause of error resulting in failure.

Controversies in ACL revision surgery: Italian expert group consensus and state of the art

Background

Revision ACL reconstruction is a complex topic with many controversies and not-easy-to-make decisions. The authors’ aim is to provide some feasible advice that can be applied in daily clinical practice with the goal of facilitating the decision-making process and improving the outcomes of patients subjected to revision ACL reconstruction.

Methods

A national survey with seven questions about the most controversial topics in revision ACL reconstruction was emailed to members of two societies: SIOT and SIAGASCOT. The participants’ answers were collected, the most recent literature was analyzed, and a consensus was created by the authors, according to their long-term surgical experience.

Conclusions

The decision-making process in revision ACL reconstruction starts with a standardized imaging protocol (weight-bearing radiographs, CT scan, and MRI). One-stage surgery is indicated in almost all cases (exceptions are severe tunnel enlargement and infection), while the choice of graft depends on the previously used graft and the dimensions of the tunnels, with better clinical outcomes obtained for autografts. Additional procedures such as lateral extra-articular tenodesis in high-grade pivot-shift knees, biplanar HTO in the case of severe coronal malalignment, and meniscal suture improve the clinical outcome and should be considered case by case.

Level of evidence

V (Expert opinion).

Effect of Patient Height and Sex on the Patellar Tendon and Anterior Cruciate Ligament

Background:

Graft-tunnel mismatch is an avoidable complication in anterior cruciate ligament (ACL) reconstruction. Patient height and sex may be predictors of patellar tendon length (PTL) and intra-articular ACL length (IAL). Understanding these relationships may assist in reducing graft-tunnel mismatch during ACL reconstruction with bone–patellar tendon–bone (BTB) autograft.

Purpose:

To determine the association of patient height and sex with PTL and IAL.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

Magnetic resonance imaging (MRI) studies were obtained on the healthy knees of 100 male and 100 female patients. Patients with prior surgery, open physes, significant degenerative changes, ACL rupture, or extensor mechanism injury were excluded. Three independent readers measured PTL, IAL, and Caton-Deschamps Index (CDI) on MRI. Bivariate and linear regression analysis was performed to detect the association of anthropometric data with anatomic parameters measured on MRI studies.

Results:

The mean age and body mass index were not significantly different between the male and female patients; however, male patients were significantly taller than female patients (1.75 vs 1.72 m, respectively; P < .001). There was a substantial agreement between the 3 readers for all parameters (κ > 0.75). Overall, female patients had significantly longer PTL (47.38 vs 43.92 mm), higher CDI (1.146 vs 1.071), and shorter IAL (33.05 vs 34.39 mm) (P < .001 for all). Results of the linear regression analysis demonstrated that both height and female sex were predictive of longer PTL. Further, height was independently predictive of IAL but sex was not.

Conclusion:

PTL was correlated more with patient sex than height. IAL was also correlated with patient sex. Longer BTB grafts are expected to be harvested in female patients compared with male patients of the same height despite shorter IAL. These associations should be considered during BTB ACL reconstruction to minimize graft-tunnel mismatch.

Trauma and femoral tunnel position are the most common failure modes of anterior cruciate ligament reconstruction: a systematic review

PURPOSE

To improve outcomes of anterior cruciate ligament reconstruction (ACLR), it is important to understand the reasons for failure of this procedure. This systematic review was performed to identify current failure modes of ACLR.

METHODS

A systematic search was performed using PubMed, EMBASE, Cochrane, and annual registries for ACLR failures. Studies were included when failure modes were reported (I) of ≥ 10 patients and (II) at a minimum of two-year follow-up. Modes of failure were also compared between different graft types and in femoral tunnel positions.

RESULTS

This review included 24 cohort studies and 4 registry-based studies (1 level I, 1 level II, 10 level III, and 16 level IV studies). Overall, a total of 3657 failures were identified. The most common single failure mode of ACLR was new trauma (38%), followed by technical errors (22%), combined causes (i.e. multiple failure mechanisms; 19%), and biological failures (i.e. failure due to infection or laxity without traumatic or technical considerations; 8%). Technical causes also played a contributing role in 17% of all failures. Femoral tunnel malposition was the most common cause of technical failure (63%). When specifically looking at the bone-patellar tendon-bone (BPTB) or hamstring (HT) autografts, trauma was the most common failure mode in both, whereas biological failure was more pronounced in the HT group (4% vs. 22%, respectively). Technical errors were more common following transtibial as compared to anteromedial portal techniques (49% vs. 26%).

CONCLUSION

Trauma is the single leading cause of ACLR failure, followed by technical errors, and combined causes. Technical errors seemed to play a major or contributing role in large part of reported failures, with femoral tunnel malposition being the leading cause of failure. Trauma was also the most common failure mode in both BPTB and HT grafts. Technical errors were a more common failure mode following transtibial than anteromedial portal technique.

LEVEL OF EVIDENCE

IV.

DETERMINANTS OF RETURN TO PLAY AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

Objective:

To systematically review and meta-analyze the performance of return to play (RTP) and non-RTP patients in different assessment tools after anterior cruciate ligament reconstructions (ACLR).

Methods:

Out of 182 studies searched on PubMed, 11 presented RTP and non-RTP groups assessing the performance of young individuals, practitioners of different sports, with different tools.

Results:

There was higher limb symmetry (7.13% [95%CI 4.55; 9.70], p < 0.001), Tegner activity scale (2.41 [95%CI 0.18; 4.64], p = 0.03), functional scores such as International Knee Documentation Committee (x7.44 [95%CI 4.69; 10.19], p < 0.001), Knee Osteoarthritis Outcome score for quality of life (14.75 [95%CI 10.96; 18.54], p < 0.001) and for sports/recreation (11.86 [95%CI 8.87; 14.86], p < 0.001); and lower knee laxity (-0.25 mm [95%CI -0.36; -0.14], p < 0.001) in RTP compared to non-RTP patients following ACLR.

Conclusion:

We confirmed that these different tools can differentiate RTP for non-RTP patients, which may contribute to the physician’s decision about the ideal time for RTP. Level of Evidence III, Systematic review of Level III studies.

Return to Sport Following Revision Anterior Cruciate Ligament Reconstruction in Athletes: A Systematic Review

PURPOSE

To report the rate of return to sport following revision anterior cruciate ligament (ACL) reconstruction in athletes.

METHODS

A systematic review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted for athletes undergoing revision ACL reconstruction at a minimum 1-year follow-up. The primary outcome measure was return to sport following revision ACL reconstruction. Secondary outcomes were International Knee Documentation Committee score, Knee Injury and Osteoarthritis Outcome Score, Tegner and Lysholm scores, KT-1000 arthrometer measurements, and rates of ACL rerupture. A subjective analysis was performed, and data were summarized using forest plots, ranges, and tables.

RESULTS

Thirteen studies met the inclusion criteria. The rate of return to sport at any level ranged from 56% to 100%. The rate of return to sport at preinjury level ranged from 13% to 69%. The average time to return to sport ranged from 6.7 to 12 months. The average patient-reported outcome scores ranged from 43% to 86% (International Knee Documentation Committee score), 45% to 95% (Knee Injury and Osteoarthritis Outcome Score), 4.3 to 9 (Tegner), and 84% to 91% (Lysholm). KT-1000 arthrometer measurements ranged from 1.2 to 3.1 mm. Rates of ACL rerupture ranged from 0% to 20%.

CONCLUSIONS

This systematic review demonstrated a relatively high rate of return to sport at any level in patients who underwent revision ACL reconstruction, but a relatively low rate of return to sport at preinjury level of play. Patient-reported outcomes were favorable, showing improvement at follow-up from preoperative scores. Rates of ACL rerupture were high relative to those reported for primary ACL reconstruction. This study suggests that athletes may have difficulty resuming their previous level of sport following revision ACL reconstruction but have a good chance of returning to a lower level of play.

LEVEL OF EVIDENCE

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

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.

Double-bundle revision anterior cruciate ligament reconstruction is effective in rescuing failed primary reconstruction and re-introducing patients to physical exercise

The anterior cruciate ligament (ACL) is one of a pair of cruciate ligaments in the human knee and is critical for knee stability, as it limits anterior tibial translation on the femur, restrains rotation and resists varus and valgus joint forces. The present study aimed to assess the effect of double-bundle revision anterior cruciate ligament (ACL) reconstruction in improving the subjective and objective functions and re-introducing patients to physical activity after primary ACL reconstruction had failed. A total of 34 patients who underwent double-bundle ACL revision surgeries were included in the present retrospective study. Lysholm, Tegner and IKDC scores as well as KT-2000 arthrometry measures were obtained pre- and post-operatively. The follow-up time was at least 2 years. The results indicated that the IKDC, Lysholm and Tegner scores as well as KT-2000 flexion scores were significantly improved after revision ACL reconstruction. All patients resumed to performing physical exercise activities after revision surgeries, 65% of whom reached pre-injury levels. In conclusion, these results demonstrated that double-bundle revision ACL reconstruction was consistently effective in rescuing failed primary ACL reconstruction and re-introducing patients to physical exercise.

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 Play of Rugby Players After Anterior Cruciate Ligament Reconstruction Using Hamstring Autograft: Return to Sports and Graft Failure According to Age

PURPOSE

To assess return to play and the frequencies of graft failure in rugby players after anterior cruciate ligament (ACL) reconstruction using a hamstring autograft augmented with an artificial ligament and to compare outcomes between rugby players aged <20 and ≥20 years over the long term.

METHODS

A consecutive series of 146 rugby players who underwent ACL reconstruction with a hamstring autograft augmented with an artificial ligament were retrospectively reviewed. The study population was further divided into 2 groups aged <20 years and >20 years and compared.

RESULTS

Twenty-five patients could not be followed up, and 121 (83%) were evaluated. Most patients (90%, <20 years; 92%, ≥20 years) returned to play after ACL reconstruction. At an average follow-up period of 56.5 months, 16% of the patients sustained an ACL graft rupture. Regarding age, <20 years (n = 58, 48%) and ≥20 years (n = 63, 52%), younger players had a significantly higher failure rate (23% vs 5%, respectively; P = .006) and a shorter time to failure (22.8 ± 13.2 vs 35.4 ± 15.4 months, respectively; P = .006) than older players.

CONCLUSIONS

Rugby players were likely to return to play after ACL reconstruction with a hamstring autograft. However, there was a higher risk of graft failure in younger players than in older players. On the basis of this study, we conclude that the hamstring autograft may not be an appropriate graft source to use in a younger active population, including rugby players.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.