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McMellen CJ, Sinkler MA, Calcei JG, Hobson TE, Karns MR, Voos JE. Management of Bone Loss and Tunnel Widening in Revision ACL Reconstruction. J Bone Joint Surg Am 2023; 105:1458-1471. [PMID: 37506198 DOI: 10.2106/jbjs.22.01321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/30/2023]
Abstract
➤ 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.
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Affiliation(s)
- Christopher J McMellen
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Margaret A Sinkler
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Jacob G Calcei
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
- University Hospitals Drusinsky Sports Medicine Institute, Cleveland, Ohio
| | - Taylor E Hobson
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
- University Hospitals Drusinsky Sports Medicine Institute, Cleveland, Ohio
| | - Michael R Karns
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
- University Hospitals Drusinsky Sports Medicine Institute, Cleveland, Ohio
| | - James E Voos
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
- University Hospitals Drusinsky Sports Medicine Institute, Cleveland, Ohio
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Gopinatth V, Casanova FJ, Knapik DM, Mameri ES, Jackson GR, Khan ZA, McCormick JR, Yanke AB, Cole BJ, Chahla J. Consistent Indications and Good Outcomes Despite High Variability in Techniques for Two-Stage Revision Anterior Cruciate Ligament Reconstruction: A Systematic Review. Arthroscopy 2023; 39:2098-2111. [PMID: 36863622 DOI: 10.1016/j.arthro.2023.02.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 12/12/2022] [Accepted: 02/03/2023] [Indexed: 03/04/2023]
Abstract
PURPOSE To systematically review the current literature regarding the indications, techniques, and outcomes after 2-stage revision anterior cruciate ligament reconstruction (ACLR). METHODS A literature search was performed using SCOPUS, PubMed, Medline, and the Cochrane Central Register for Controlled Trials according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta Analyses statement. Inclusion criteria was limited to Level I-IV human studies reporting on indications, surgical techniques, imaging, and/or clinical outcomes of 2-stage revision ACLR. RESULTS Thirteen studies with 355 patients treated with 2-stage revision ACLR were identified. The most commonly reported indications were tunnel malposition and tunnel widening, with knee instability being the most common symptomatic indication. Tunnel diameter threshold for 2-stage reconstruction ranged from 10 to 14 mm. The most common grafts used for primary ACLR were bone-patellar tendon-bone (BPTB) autograft, hamstring graft, and LARS (polyethylene terephthalate) synthetic graft. The time elapsed from primary ACLR to the first stage surgery ranged from 1.7 years to 9.7 years, whereas the time elapsed between the first and second stage ranged from 21 weeks to 13.6 months. Six different bone grafting options were reported, with the most common being iliac crest autograft, allograft bone dowels, and allograft bone chips. During definitive reconstruction, hamstring autograft and BPTB autograft were the most commonly used grafts. Studies reporting patient-reported outcome measures showed improvement from preoperative to postoperative levels in Lysholm, Tegner, and objective International Knee and Documentation Committee scores. CONCLUSIONS Tunnel malpositioning and widening remain the most common indications for 2-stage revision ACLR. Bone grafting is commonly reported using iliac crest autograft and allograft bone chips and dowels, whereas hamstring autograft and BPTB autograft were the most used grafts during the second-stage definitive reconstruction. Studies showed improvements from preoperative to postoperative levels in commonly used patient reported outcomes measures. LEVEL OF EVIDENCE Level IV, systematic review of Level I, III, and IV studies.
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Affiliation(s)
- Varun Gopinatth
- Saint Louis University School of Medicine, St. Louis, Missouri, U.S.A.; Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Felipe J Casanova
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Derrick M Knapik
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - Enzo S Mameri
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Garrett R Jackson
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Zeeshan A Khan
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, U.S.A
| | | | - Adam B Yanke
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Brian J Cole
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Jorge Chahla
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, U.S.A..
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Götschi T, Hodel S, Kühne N, Bachmann E, Li X, Zimmermann SM, Snedeker JG, Fucentese SF. Osteoconductive Scaffold Placed at the Femoral Tunnel Aperture in Hamstring Tendon ACL Reconstruction: A Randomized Controlled Trial. Orthop J Sports Med 2023; 11:23259671231174478. [PMID: 37347015 PMCID: PMC10280525 DOI: 10.1177/23259671231174478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/22/2023] [Indexed: 06/23/2023] Open
Abstract
Background Bone tunnel enlargement after single-bundle anterior cruciate ligament reconstruction remains an unsolved problem that complicates revision surgery. Hypothesis Positioning of an osteoconductive scaffold at the femoral tunnel aperture improves graft-to-bone incorporation and thereby decreases bone tunnel widening. Study Design Randomized controlled trial; Level of evidence, 1. Methods In a 1:1 ratio, 56 patients undergoing primary anterior cruciate ligament reconstruction were randomized to receive femoral fixation with cortical suspension fixation and secondary press-fit fixation at the tunnel aperture of the tendon graft only (control) or with augmentation by an osteoconductive scaffold (intervention). Adverse events, patient-reported outcomes, and passive knee stability were recorded over 2 years after the index surgery. Three-dimensional bone tunnel widening was assessed using computed tomography at the time of surgery and 4.5 months and 1 year postoperatively. Results The intervention group exhibited a similar number of adverse events as the control group (8 vs 10; P = .775) including 2 partial reruptures in both groups. The approach was feasible, although 1 case was encountered where the osteoconductive scaffold was malpositioned without adversely affecting the patient's recovery. There was no difference between the intervention and control groups in femoral bone tunnel enlargement, as expressed by the relative change in tunnel volume from surgery to 4.5 months (mean ± SD, 36% ± 25% vs 40% ± 25%; P = .644) and 1 year (19% ± 20% vs 17% ± 25%; P =.698). Conclusion Press-fit graft fixation with an osteoconductive scaffold positioned at the femoral tunnel aperture is safe but does not decrease femoral bone tunnel enlargement at postoperative 1 year. Registration NCT03462823 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Tobias Götschi
- Department of Orthopaedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland
- Institute for Biomechanics, ETH Zurich,
Zurich, Switzerland
| | - Sandro Hodel
- Department of Orthopaedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland
| | - Nathalie Kühne
- Department of Orthopaedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland
| | | | - Xiang Li
- ZuriMED Technologies AG, Zurich,
Switzerland
| | - Stefan M. Zimmermann
- Department of Orthopaedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland
| | - Jess G. Snedeker
- Department of Orthopaedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland
- Institute for Biomechanics, ETH Zurich,
Zurich, Switzerland
| | - Sandro F. Fucentese
- Department of Orthopaedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland
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Wolfson TS, Mannino B, Owens BD, Waterman BR, Alaia MJ. Tunnel Management in Revision Anterior Cruciate Ligament Reconstruction: Current Concepts. Am J Sports Med 2023; 51:545-556. [PMID: 34766840 DOI: 10.1177/03635465211045705] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
| | | | - Brett D Owens
- Brown University Alpert Medical School, East Providence, Rhode Island, USA
| | - Brian R Waterman
- Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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Wei B, Ji M, Lin Y, Geng R, Wang Q, Lu J. Investigation of the medium-term effect of osteoprotegerin/bone morphogenetic protein 2 combining with collagen sponges on tendon-bone healing in a rabbit. J Orthop Surg (Hong Kong) 2023; 31:10225536231163467. [PMID: 36893748 DOI: 10.1177/10225536231163467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Osteoprotegerin (OPG) and bone morphogenetic protein-2 (BMP-2) could be administered sequentially to promote tendon-bone healing. There remain several unresolved issues in our previously published study: a) the release kinetics of OPG/BMP-2 from the OPG/BMP-2/collagen sponge (CS) combination in vitro remained unclear; b) the medium-term effect of the OPG/BMP-2/CS combination was not analyzed. Hence, we design this study to address the issues mentioned above. METHODS 30 rabbits undergoing anterior cruciate ligament reconstruction (ACLR) with an Achilles tendon autograft randomly received one of the 3 delivery at the femoral and tibial tunnels: OPG/BMP-2, OPG/BMP-2/CS combination, and nothing (blank control). At 8 and 24 weeks post-surgery, the biomechanical tests and histologic analysis were used to evaluate the tendon-bone healing. RESULTS In mechanical tests, the OPG/BMP-2/CS group showed a higher final failure load and stiffness than the other groups at 8 and 24 weeks. Additionally, the maximum stretching distance showed a decreasing trend. The mechanical failure pattern of samples shifted from a tunnel pull-away to a graft midsubstance rupture after OPG/BMP-2/CS-treated. From histological analysis, the OPG/BMP-2/CS treatment increased the amount of collagen fibers (collagen I and II) and promoted fibrocartilage attachment. CONCLUSION CS as a carrier promotes the medium-term effect of OPG and BMP-2 on tendon-bone healing at the tendon-bone interface in a rabbit ACLR model. OPG, BMP-2 and CS were already applied in several clinical practice, but a further study of clinic use of OPG/BMP-2/CS is still needed.
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Affiliation(s)
- Bing Wei
- School of Medicine, 66334Southeast University, Nanjing, China.,Department of Orthopaedic Surgery/Joint and Sports Medicine Center, Zhongda Hospital, School of Medicine, 162752Southeast University, Nanjing, China
| | - Mingliang Ji
- School of Medicine, 66334Southeast University, Nanjing, China.,Department of Orthopaedic Surgery/Joint and Sports Medicine Center, Zhongda Hospital, School of Medicine, 162752Southeast University, Nanjing, China
| | - Yucheng Lin
- School of Medicine, 66334Southeast University, Nanjing, China.,Department of Orthopaedic Surgery/Joint and Sports Medicine Center, Zhongda Hospital, School of Medicine, 162752Southeast University, Nanjing, China
| | - Rui Geng
- School of Medicine, 66334Southeast University, Nanjing, China.,Department of Orthopaedic Surgery/Joint and Sports Medicine Center, Zhongda Hospital, School of Medicine, 162752Southeast University, Nanjing, China
| | - Qing Wang
- Department of Orthopaedic Surgery, The First People's Hospital of Yongkang Affiliated to Hangzhou Medical College, Jinhua, China
| | - Jun Lu
- School of Medicine, 66334Southeast University, Nanjing, China.,Department of Orthopaedic Surgery/Joint and Sports Medicine Center, Zhongda Hospital, School of Medicine, 162752Southeast University, Nanjing, China
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Tang L, Zhu L, Zhao SY, Zhang WY, Li YZ. Reconstruction of Rabbit Anterior Cruciate Ligament by Bone Marrow-Derived Mesenchymal Stem Cell Implantation Through a Weft-Knitted Silk Mesh Scaffold Covering a Whip-Shaped Core. J BIOMATER TISS ENG 2022. [DOI: 10.1166/jbt.2022.3121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
To investigate the feasibility of using whip core wrapped by silk weft knitted mesh sheath as a scaffold and bone marrow-derived mesenchymal stem cells (BMSCs) to reconstruct the rabbit anterior cruciate ligament (ACL), BMSC implantation using the mesh-whip scaffold was performed to
construct a BMSC-scaffold complex. Then, the BMSC-scaffold complex was implanted into an animal model of an ACL deficient rabbit. Regenerated ACLs were then taken from the animal model three and six months after implantation, followed by hematoxylin-eosin and Masson staining, quantitative
RT-PCR detection, as well as mechanical performance evaluation. The results showed that many Sharpey’s fibers had arranged regularly between the neo-ACL and the bone three months after surgery, and an interface structure formed six months after surgery. Regenerated ligaments contained
silk fibers and suficient collagen. Type I collagen, type III collagen, and tenascin-C were all highly expressed in the experimental group compared to the control group (no BMSC implantation) in the regenerated ligaments. In addition, the maximum pullout force values of neo-ACL in the three-
and six-month experimental groups were 70.6±17.8 N and 122.8±25.7 N, respectively. The findings suggest that BMSC implantation using the mesh-whip scaffold is a promising method to reconstruct rabbit ACL.
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Affiliation(s)
- Liang Tang
- School of Food Science and Engineering, Hangzhou Medical College, Hangzhou, 310013, Zhejiang, China
| | - Lian Zhu
- School of Basic Medicine and Forensic Medicine, Hangzhou Medical College, Hangzhou, 310013, Zhejiang, China
| | - Si-Yu Zhao
- School of Bioengineering, Hangzhou Medical College, Hangzhou, 310013, Zhejiang, China
| | - Wen-Yuan Zhang
- School of Bioengineering, Hangzhou Medical College, Hangzhou, 310013, Zhejiang, China
| | - Yue-Zhong Li
- School of Food Science and Engineering, Hangzhou Medical College, Hangzhou, 310013, Zhejiang, China
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Anterior Cruciate Ligament Revision Reconstruction. J Am Acad Orthop Surg 2021; 29:723-731. [PMID: 34096902 DOI: 10.5435/jaaos-d-21-00088] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 05/03/2021] [Indexed: 02/01/2023] Open
Abstract
Revision anterior cruciate ligament (ACL) reconstruction is used in patients with recurrent instability after primary ACL reconstruction. Identifying the etiology of graft failure is critical to the success of revision reconstruction. The most common etiologies include technical errors, trauma, failure to recognize concomitant injuries, young age, incomplete rehabilitation, and hardware failure. Patients should undergo a complete history and physical examination with a specific focus on previous injury mechanism and surgical procedures. A revision ACL reconstruction is a technically demanding procedure, and the surgeon should be prepared to address bone tunnel osteolysis, concurrent meniscal, ligamentous, or cartilage lesions, and limb malalignment. Surgical techniques described in this article include both single-stage and two-stage reconstruction procedures. Rates of return to sport after a revision reconstruction are lower than after primary reconstruction. Future research should be focused on improving both single-stage and two-stage revision techniques, as well as concomitant procedures to address limb malalignment and associated injuries.
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