Preoperative Planning for ACL Revision Surgery

Computer Patient-Specific 3D Modeling and Custom-Made Guides for Revision ACL Surgery

Revision anterior cruciate ligament reconstruction (ACLR) is a challenging surgery occurring in 3 to 24% of primary reconstructions. A meticulous planning to study the precise size and location of both femoral and tibial bone tunnels is mandatory. The aim of the study was to evaluate the intra- and interoperator differences in the decision-making process between experienced surgeons after they were asked to make preoperative planning for ACL revision reconstruction with the use of both the computed tomography (CT) scan and a three-dimensional (3D)-printed model of the knee. Data collected from 23 consecutive patients undergoing revision of ACLR for graft failure at a single institute between September 2018 and February 2020 were prospectively reviewed. The double-blinded collected data were presented to three board-certificate attending surgeons. Surgeons were asked to decide whether to perform one-stage or two-stage revision ACLR based on the evaluation of the CT scan images and the 3D-printed custom-made models at two different rounds, T0 and T1, respectively, 7 days apart one from the other. Interoperator consensus following technical mistake was 52% at T0 and 56% at T1 using the CT scans, meanwhile concordance was 95% at T0 and 94% at T1 using the 3D models. Concordance between surgeons following new knee injury was 66% at T0 and 70% at T1 using CT scans, while concordance was 96% both at T0 and T1 using 3D models. Intraoperative variability using 3D models was extremely low: concordance at T0 and T1 was 98%. McNemar test showed a statistical significance in the use of 3D model for preoperative planning (p < 0.005). 3D-printed model reliability resulted to be higher compared with CT as intraoperator surgery technique selection was not modified throughout time from T0 to T1 (p < 0.005). The use of 3D-printed models had the most impact when evaluating femoral and tibial tunnels, resulting to be a useful instrument during preoperative planning of revision ACLR between attending surgeons with medium-high workflow.

The Role of Osteotomy in Anterior Cruciate Ligament Reconstruction

Coronal and sagittal plane knee malalignments have been shown to increase the forces on anterior cruciate ligament (ACL) grafts after ACL reconstruction (ACLR). Studies have shown the benefit of high tibial osteotomy to address coronal and sagittal imbalance in revision ACLR. The purpose of this article is to further describe the use of osteotomy by reviewing preoperative planning, indications, techniques, and outcomes of high tibial opening and closing wedge as well as anterior tibial closing wedge osteotomies in the setting of ACLR.

Inconsistent Return to Sport Despite Improved Outcomes After Re-revision Anterior Cruciate Ligament Reconstruction: An Updated Systematic Review

PURPOSE

To systematically review the literature evaluating patient-reported outcomes and return to sport after re-revision anterior cruciate ligament reconstruction (ACLR) procedures. The secondary objectives were 2-fold: to identify the risk factors that lead to revision ACLR failure and to assess the secondary knee structure injuries after the initial revision ACLR.

METHODS

A systematic review of the literature was performed using the MEDLINE/PubMed and Cochrane databases. The inclusion criteria were outcomes of re-revision ACLR, minimum of 2 years' follow-up, human studies, and English language. Basic science articles, epidemiologic studies, editorials, surgical technique articles, surveys, cadaveric studies, and animal studies were excluded.

RESULTS

Fifteen studies met the inclusion criteria and were considered for review. There were 6 Level III and 9 Level IV studies that included 399 patients undergoing re-revision ACLR. The rate of concomitant meniscal lesions at the time of re-revision ranged from 35% to 90%. The prevalence of concomitant cartilaginous lesions at the time of re-revision ranged from 13.6% to 90%. Compared with preoperative scores, patient-reported outcomes overall improved after re-revision ACLR, with mean preoperative Lysholm scores ranging from 38.4 to 73.15 that improved to postoperative scores ranging from 68 to 87.8. However, return to sport at preinjury levels was inconsistent, with rates ranging from 12.5% to 80%.

CONCLUSIONS

Re-revision ACLR was found to restore knee stability and improve functional outcomes. Despite this improvement, there was a low rate of return to sport at the preinjury level. Functional outcomes were also inferior when compared with primary ACLR. In addition, concomitant knee pathologies were found to rise in prevalence compared with revision and primary ACLR cases.

LEVEL OF EVIDENCE

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

Revision anterior cruciate ligament reconstruction using the ipsilateral Quadriceps tendon autograft: a modular reconstructive option

PURPOSE

Failed ACL reconstruction is a common occurrence nowadays due to the increased incidence of ACL surgeries and return to full activities following the surgery. Several challenges might stand in the face of this revision surgery particularly the graft harvest and its suitability to the situation with possible widening of the tunnel and the avoidance of additional morbidity at the contralateral side or anterior knee pain as in patellar tendon harvest. The aim of this study is to evaluate the ipsilateral quadriceps tendon as a source of autograft in revision ACL surgery which constitutes a viable option that can potentially decrease the morbidity of the procedure, and meanwhile provide a graft substitute that can be tailored to suit the dilated tunnels commonly encountered in revision surgery, thus giving the patients a good potential for better functional outcome.

METHODS

Revision anterior cruciate ligament reconstruction was done in 30 patients using the ipsilateral quad tendon as a pure soft tissue or with a bony fragment.

RESULTS

The mean subjective international Knee Documentation Committee score (IKDC score) at two years follow-up was 65.83 ± 7.20. There is statistically significant improvement of the objective as well as the subjective IKDC scores at the end of follow-up when compared to the preoperative as well as the 6-month evaluation figures. The KT1000 arthrometer recorded a mean of 4.50 ± 1.07. Significant improvement of the limb symmetry index was at two years duration.

CONCLUSIONS

The quadriceps tendon can be a solution for several challenges that might appear during the revision ACL surgery with comparable results to other tendons and with minimal morbidity on the function of the harvested muscle tendon.

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.

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).

Revision Anterior Cruciate Ligament Reconstruction with the All-Soft Tissue Quadriceps Tendon Autograft Has Acceptable Early and Intermediate-Term Outcomes

PURPOSE

The purposes were to (1) examine early to intermediate-term clinical outcomes and complications of revision anterior cruciate ligament reconstruction (ACLR) using all-soft tissue quadriceps tendon (QT) autografts, and (2) compare quadriceps strength between patients who had hamstring versus patella tendon autografts in their previous reconstruction.

METHODS

One hundred patients (52 males/48 females; 22.6 ± 8.0 years) undergoing revision ACLR with all-soft tissue QT autografts were prospectively followed. All revision procedures were performed by a single surgeon, using a minimally invasive graft harvest technique and suspensory fixation. Subjective assessment of knee function was obtained before and after surgery with the International Knee Documentation Committee (IKDC) survey. Postoperative knee laxity and isokinetic quadriceps strength were collected at regular intervals. Strength was reported as limb symmetry index (LSI; surgical side divided by nonsurgical side). Complications including hematomas, postoperative loss of knee extension, and graft failures were recorded. To determine clinical significance (P ≤ .05), outcomes were compared using analysis of variance or paired samples t-tests.

RESULTS

The mean IKDC scores significantly improved (54.3 ± 13.0 vs 82.8 ± 13.8), with an average follow-up of 42.2 ± 21.2 months. There were no significant changes in knee laxity side-to-side differences: 6 weeks (1.2 ± 1.5 mm), 3 months (1.2 ± 1.8 mm), 6 months (1.4 ± 1.6 mm). Quadriceps LSIs significantly improved from 71.6% ± 19.3% at 6 months to 81.5% ± 19.3% at 12 months for 60°/s isokinetic testing and 76.6% ± 16.4% at 6 months to 83.9% ± 16.9% at 12 months for 180°/s testing. Graft harvest site hematomas developed in 2 patients, postoperative loss of knee extension in 4 patients, and graft failure in 11 patients. No significant differences in quadriceps or hamstrings LSIs were noted between patients with previous hamstring versus patella tendon autografts (P > .050).

CONCLUSION

Revision ACLR with all-soft tissue QT autografts has acceptable early and intermediate-term outcomes with reasonable complication rates (11/80 patients with follow-up). Secondary insult to the extensor mechanism via QT autograft harvest does not adversely affect strength after prior patellar tendon versus hamstring autograft.

LEVEL OF EVIDENCE

Level IV, cases series subgroup analysis.

Ultrasound-Assisted Endoscopic Removal of Pretibial Cysts Related to Biointerference Screw Degradation

We report on the treatment of cases of painful subcutaneous pretibial cyst due to broken and displaced materials of only partly absorbed bioabsorbable interference screws used for anterior cruciate ligament reconstruction. Ultrasound examination was used to both make the definite diagnosis and determine the exact localization of dislodged screw parts. The broken and loose bioabsorbable screw parts and surrounding cyst-like structure were removed endoscopically by a soft-tissue resector.

Revision ACL Reconstruction: Principles and Practice

INTRODUCTION

The incidence of anterior cruciate ligament reconstruction (ACLR) surgeries is increasing and so is the number of revision surgeries for a failed ACLR. The spectrum of ACL failure includes symptoms of recurrent instability, pain, and/or stiffness.

DISCUSSION

Factors contributing to ACL failure may be classified as patient-related, surgeon-related, and biological factors. Of these, tunnel malposition and recurrent trauma are the most common causes. Detailed patient assessment, imaging, and studying details of the index surgery are critical prior to planning revision surgery. Infection has to be ruled out prior to planning any reconstructive surgical procedure. Osseous malalignment in the coronal or sagittal planes would also need correction along with or prior to revision ACL surgery. Revision ACL reconstruction maybe performed as a one-stage or two-stage procedure. Severe tunnel dilatation, infection, or arthrofibrosis necessitates a two-stage approach. Autografts are preferred for revision ACL due their lesser re-tear rates and better outcomes. Associated meniscus tears and cartilage injuries are more common in revision than in primary surgery and need to be managed appropriately. Extra-articular reconstruction for controlling anterolateral instability is frequently required as well.

CONCLUSION

Revision ACL reconstruction is a complex undertaking due to limited graft options, compromised anatomy and high frequency of associated injuries. Patient expectations must be tempered because functional outcomes and return to pre-injury sports are inferior to a primary surgery.

Stem Cell-Infused Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament (ACL) tears are unfortunate but common injuries in the athletic population. The standard of care for ACL tears is a surgical intervention to reconstruct the ACL to restore knee functionality as well as quality of life. In recent years, bone marrow aspirate concentrate (BMAC) has seen increasing use in various orthopaedic settings. This increase can be attributed to the potential beneficial qualities that mesenchymal stem cells, progenitor cells, and growth factors, all of which are present in BMAC, can provide. In this technical note and accompanying video, we describe an anatomic allograft ACL reconstruction infused with BMAC to utilize BMAC's potential benefits.