Outcomes of 1- Versus 2-Stage Revision Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

Considerations for revision anterior cruciate ligament reconstruction: A review of the current literature

Background

Failure rates among primary Anterior cruciate ligament reconstruction range from 3.2 to 11.1 %. Recently, there has been increased focus on surgical and anatomic considerations which predispose patients to failure, including excessive posterior tibial slope (PTS), unaddressed high-grade pivot shift, and improper tunnel placement.

Methods

The purpose of this review was to provide a current summary and analysis of the literature regarding patient-related and technical factors surrounding revision ACLR, rehabilitation considerations, overall outcomes, and return to sport (RTS) for patients who undergo revision ACLR.

Results

In revision ACLR patients, those receiving autografts are 2.78 times less likely to experience a re-rupture compared to patients who receive allografts. Additionally, individuals with properly positioned tunnels and removable implants are considered strong candidates for one-stage revision procedures. Conversely, cases involving primary tunnel widening of approximately 15 mm are typically indicative of two-stage revision ACLR. These findings underscore the importance of graft selection and surgical approach in optimizing outcomes for patients undergoing revision ACLR.

Conclusion

Given the high rates of revision surgery in young, active patients who return to pivoting sports, the literature recommends strong consideration of a combined ACLR + anterolateral ligament (ALL) or lateral extra-articular tenodesis (LET) procedure in this population. Unrecognized posterolateral corner (PLC) injury is a common cause of ACLR failure and current literature suggests concurrent operative management of high-grade PLC injuries. Excessive PTS has been identified as an independent risk factor for ACL graft failure. Consider revision ACLR with combined slope-reducing tibial osteotomy in cases of posterior tibial slope greater than 12°.

Trends in Anterior Cruciate Ligament Reconstruction Techniques and Postoperative Care Among Leaders in the Field: A Survey of the Herodicus Society

Background

Despite a growing body of literature regarding anterior cruciate ligament reconstruction (ACLR), there remains a wide diversity in surgical technique and clinical practice across providers.

Purpose

To (1) describe current ACLR practice preferences among members of the Herodicus society and (2) determine whether these preferences are influenced by years in practice and overall surgical volume.

Study Design

Cross-sectional study.

Methods

A 24-question survey investigating surgeons' practices and preferred ACLR surgical techniques was sent via email to all active Herodicus Society members. Survey responses were subdivided by years of experience and overall ACLR annual case volume. Descriptive statistics were compiled and chi-square testing was utilized to determine the significance of experience and case volume on survey responses.

Results

Of the 113 invited Herodicus Society members who perform ACLR, 69 (61%) completed the survey. Respondents had a mean ± SD of 30.9 ± 9.8 years of experience in clinical practice and performed a mean of 96.0 ± 50.7 primary and 21.6 ± 16.9 revision ACLR annually. Of revision cases, 72.1% were performed using a single-stage technique. Mean frequency of graft usage by surgeon was bone-patellar tendon-bone autograft (58.6%), quadriceps autograft (14.6%), hamstring tendon autograft (14.0%), and allograft (11.8%). The plurality of surgeons responded that they used anterolateral augmentation "rarely" in primary ACLR (39.1%) and "sometimes" in revision ACLR (31.9%), with the majority performing lateral extra-articular tenodesis (66.7%) rather than anterolateral ligament reconstruction (14.5%). Most surgeons would not allow a 20-year-old football player to return before 7 months after ACLR (71.0%) but highly valued return-to-sports testing to determine readiness (94.2%). Higher volume surgeons performed single-stage revision ACLR at a significantly higher rate (79.8% vs 62.9%, P = .02) and significantly differed in return-to-sports criteria, with a greater proportion relying primarily on biometric testing (P = .01).

Conclusion

The survey demonstrated that, in the Herodicus Society, a wide range of preferences exist regarding ACLR surgical technique. Bone-patellar tendon-bone autograft is the most frequent primary ACLR graft choice. Most participants have not embraced newer techniques such as anterolateral or suture tape augmentation. Return to sports is generally not allowed before 7 months and heavily factors-in return-to-sports testing metrics, suggesting that purely time-based criteria for return to sports is not modern practice among elite sports medicine surgeons.

Clinical Outcomes of Single-Stage Revision Anterior Cruciate Ligament Reconstruction Using a Fast-Setting Bone Graft Substitute

Revision anterior cruciate ligament reconstruction (ACLR) can be achieved in a single-stage or two-stage approach. Single-stage revisions have several advantages, including one less operation, decreased cost, and a quicker recovery for patients. Revision ACLR can be complicated by malpositioned or dilated bone tunnels, which makes a single-stage revision more challenging or sometimes necessitates a two-stage approach. The use of fast-setting bone graft substitutes (BGS) has been described in recent literature as a strategy to potentially help address this problem in the setting of single-stage revision ACLR. The aim of this study was to evaluate patient-reported clinical outcomes of patients who have undergone single-stage revision ACLR using fast-setting BGS to address prior malpositioned or dilated tunnels. A retrospective review was conducted of the first nine consecutive patients who had undergone single-stage revision ACLR using a fast-setting BGS by a single surgeon between May 2017 and February 2020 with a minimum of 2-year follow-up. Patient-reported clinical outcomes, including the International Knee Documentation Committee (IKDC) questionnaire, the Tegner Lysholm Knee Scoring Scale, patient satisfaction questions, and the need for additional surgery were evaluated for this group between 26 and 49 months postoperative. Of the nine patients eligible for inclusion, eight patients (88.9%) were evaluated, and one was lost to follow-up. At an average follow-up of 37.9 months (range: 27.8-55.7), the mean postoperative IKDC score was 75.0 ± 11.3, and the mean postoperative Tegner Lysholm Knee Score was 83.0 ± 17.6. None of the patients required additional revision surgery or experienced construct failure at the time of follow-up. Seven of eight respondents (87.5%) had their preoperative expectations met with the surgery, and 100% of patients stated they would have the surgery again. Single-stage revision ACLR using fast-setting BGS showed overall positive clinical outcomes for this pilot group of patients at a minimum 2-year follow-up. In select revision scenarios, these materials may be a valuable option to allow the filling of defects without compromising fixation or clinical outcomes.

Single- or two-stage revision after failed ACL reconstruction: No differences in re-revision rates and clinical outcomes

PURPOSE

The surgeons' choice of a single-stage or a two-stage procedure in revision anterior cruciate ligament reconstruction (ACLr) is based on the possibility of reuse of the tibia and femoral bone tunnels after primary ACLr. The purpose of this study was to compare failure rates and clinical outcomes following single-stage and two-stage ACL revisions in a cohort of patients from The Danish Knee Ligament Reconstruction Registry.

METHODS

Patients identified from 2005 to 2022 with ACL revision and met the following criteria: minimum 2-year follow-up, isolated ACL revision and registered single- or two-stage ACL revision. The primary outcome was ACL re-revision rate. Secondary outcomes were arthrometer sagittal knee laxity (side-to-side difference) and pivot shift (rotational stability difference) evaluated at 1-year follow up.

RESULTS

One thousand five hundred seventy-four ACL revisions were included in the study (1331 = single-stage and 243 = two stage). Baseline characteristics showed no difference in relation to age, gender, knee laxity, pivot shift, meniscus injury, cartilage damage or injury mechanism between the two groups. Significant differences were found in relation to the type of graft. No statistical difference in 2-years revision rates between single-stage group 2.79 (95% CI 2.03-3.84) and two-stage group 2.93 (95% CI 1.41-6.05) was found. No significant difference was seen in knee laxity and pivot shift between stage-groups at 1-year follow up. Both groups demonstrated significant improvements in knee stability from baseline to 1-year follow-up.

CONCLUSION

The present study found that ACL revision outcomes were similar in terms of rerevision rates and knee laxity for patients managed with a single- or a two-stage surgical strategy.

LEVEL OF EVIDENCE

Level III.

Consistent Indications and Good Outcomes Despite High Variability in Techniques for Two-Stage Revision Anterior Cruciate Ligament Reconstruction: A Systematic Review

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.

Good stability and mid-term subjective outcomes after repeated anterior cruciate ligament (ACL) revision surgery using allografts

PURPOSE

To evaluate the mid-term clinical outcomes of a cohort of patients who underwent multiple ACL revision reconstructions. The hypothesis was that patients with pre-existing meniscal deficiency conditions, malalignment and cartilage degeneration would have obtained lower results.

METHODS

All cases of multiple ACL revisions performed with allograft tissue at one single sport-medicine institution were extracted and patients with a minimum 2 years of follow-up were included. WOMAC, Lhysolm, IKDC, and Tegner activity level before the injury and at last follow-up was collected and laxity evaluated with KT-1000 arthrometer and KiRA triaxial accelerometer.

RESULTS

From a cohort of 241 ACL revisions, 28 patients (12%) with Repeated ACL Revision reconstructions were included. Fourteen cases (50%) were considered "Complex" due to the addition of meniscal allograft transplantation (8) or meniscal scaffold (3) or high tibial osteotomy (3). The remaining 14 cases (50%) were considered as "Isolate". The mean WOMAC score was 84.6 ± 11.4, Lysholm 81.7 ± 12.3, subjective IKDC 77.2 ± 12.1, and median Tegner score 6 (IQR 5-6) at pre-injury and at final follow-up. Statistically significant inferior values of WOMAC (p = 0.008), Lysholm (p = 0.02) and Subjective IKDC (p = 0.0193) were detected between "Complex" and "Isolate" revision groups. Higher average values of anterior translation at KT-1000 at both 125 N (p = 0.03) and manual maximum displacement test (p = 0.03) were reported in "Complex" with respect to "Isolate" revisions. Four patients were considered as failures and occurred in patients with "Complex" revisions, none occurred in the "Isolate" (30% vs 0%; p = 0.04).

CONCLUSION

Good mid-term clinical results can be obtained after repeated ACL revision with allograft in patients who experienced multiple failures; however, those who need additional procedure due to malalignment or post-meniscectomy syndrome reported lower objective and subjective results.

LEVEL OF EVIDENCE

III.

Comparison of the Clinical Outcomes of Revision and Primary ACL Reconstruction: A Matched-Pair Analysis With 3-5 Years of Follow-up

BACKGROUND

There are limited studies designed by matching related factors to compare clinical outcomes and return to sport (RTS) between patients undergoing revision anterior cruciate ligament reconstruction (R-ACLR) and primary ACLR (P-ACLR).

PURPOSE

(1) To compare the outcomes between R-ACLR and P-ACLR in a matched-pair analysis with 3- to 5-year follow-up and (2) to evaluate patient-reported factors for not returning to preinjury-level sport.

STUDY DESIGN

Cohort study; Level of evidence, 4.

METHODS

Patients who underwent R-ACLR between September 2016 and November 2018 were propensity matched by age, sex, body mass index, passive anterior tibial subluxation, and generalized hypermobility in a 1:1 ratio to patients who underwent P-ACLR during the same period. By combining in person follow-up at 2 years postoperatively and telemedicine interview at the final follow-up (January 2022), knee stability and clinical scores were compared, including International Knee Documentation Committee (IKDC), Lysholm, and Tegner. Status of RTS was requested, specifically whether the patient returned to preinjury level of sport. Patient-reported reasons for not returning were analyzed.

RESULTS

There were 63 matched pairs in the present study. Knee stability was similar in terms of KT-2000 arthrometer, Lachman test, and pivot-shift test results between the groups at 2 years of follow-up. At the final follow-up, no significant difference was found between groups for postoperative clinical scores (IKDC, Tegner, and Lysholm) (P > .05). There was a significant difference in total RTS: 53 (84.1%) in the P-ACLR cohort and 41 (65.1%) in the R-ACLR cohort (P = .014). No significant difference was shown in terms of RTS at the same level: 35 (55.6%) in P-ACLR and 31 (49.2%) in R-ACLR (P = .476). Significantly more patients showed fear of reinjury: 26 of 32 (81.3%) in the R-ACLR group as compared with 15 of 28 (53.5%) in the P-ACLR group (P < .021).

CONCLUSION

R-ACLR resulted in similar clinical scores (IKDC, Tegner, and Lysholm) but significantly lower RTS versus P-ACLR at 3 to 5 years of follow-up. Fear of reinjury was the most common factor that caused sport changes in patients with R-ACLR.

Multiple revision anterior cruciate ligament reconstruction: not the best but still good

PURPOSE

Given the paucity of literature on the re-revision of ACL, the current study was undertaken. The purpose of this systematic review was to synthesise and qualitatively assess the currently available evidence in the literature regarding the re-revision of ACL reconstruction (rrACLR).

METHODS

A systematic review was conducted based on the PRISMA guidelines. The following search terms were used in the title, abstract and keywords fields: "ACL" or "anterior cruciate ligament" AND "revision" or "multiple" or "repeat". The outcome data extracted from the studies were the Lysholm score, Subjective IKDC, Marx Score, Tegner, Marx Score, KOOS score, radiological changes and the rate of return to sports. Complications, failures and/or revision surgery were also analysed.

RESULTS

The cohort consisted of 295 patients [191 (64.7%) men and 104 (35.3%) women] with a mean age of 29.9 ± 2.8 years (range 14-58 years) from 10 studies. The mean postoperative follow-up (reported in all studies except one) was 66.9 ± 44.7 months (range 13-230.4 months). Associated injuries were 103 (34.9%) medial meniscus tears, 57 (19.3%) lateral meniscus tears, 14 (4.7%) combined medial plus lateral meniscus tears, 11 (3.7%) meniscal tears (not specified), 252 (85.4%) cartilage lesions, 6 (2.0%) medial collateral ligament injury and 2 (0.7%) lateral collateral ligament injuries. In 47 (15.9%) patients an extra-articular plasty was performed for the anterolateral ligament. In all studies that reported pre- and post-operative IKDC (subjective and objective) and Lysholm score, there was a significant improvement compared to the pre-operative value (p < 0.05). At the final follow-up, laxity measured with KT-1000 was found to be 2.2 ± 0.6 mm. 31 (10.5%) out of 295 patients returned to their pre-injury activity level. A total of 19 (6.4%) re-ruptures were found, while only 4 (1.4%) complications (all minors) were reported, out of which 2 (0.7%) were superficial infections, 1 (0.3%) cyclops lesion and 1 (0.3%) flexion loss.

CONCLUSION

Multiple revisions of anterior cruciate ligament reconstruction allow acceptable clinical results and a good degree of knee stability with a low rate of subsequent new re-ruptures but the possibility of regaining pre-injury sports activity is poor; whenever possible, it is preferred to revise the ligament in one stage. This surgery remains a challenge for orthopaedic surgeons and many doubts persist regarding the ideal grafts, additional extra-articular procedures and techniques to use.

LEVEL OF EVIDENCE

IV.

STUDY REGISTRATION

PROSPERO-CRD42022352164 ( https://www.crd.york.ac.uk/prospero/ ).

Functional results of multiple revision anterior cruciate ligament with anterolateral tibial tunnel associated with anterolateral ligament reconstruction

Background

Revision anterior cruciate ligament (ACL) reconstructions are usually complex owing to previous tunnels. The objective of this study is to report the results of a revision ACL reconstruction technique with a tibial tunnel performed from the anterolateral plateau associated with an anterolateral ligament (ALL) reconstruction.

Methods

Patients with at least two ACL reconstructions that failed and who had significant enlargement and confluence of tunnels in the medial tibial plateau and underwent revision ACL reconstruction associated with ALL reconstruction with the tibial tunnel for the ACL performed from the lateral plateau between 2017 and 2019 were evaluated. All patients were evaluated by physical examination, International Knee Documentation Committee (IKDC), and Lysholm functional scales.

Results

Six patients who underwent this surgical procedure were evaluated. All patients were sports practitioners and presented a grade 3 pivot shift. The mean age was 28.5 ± 8.2 years, and the mean follow-up time was 34.1 ± 12.8 months. No patient had a new graft rupture, but three (50%) had grade 1 pivot shift. Four patients had minor complications with no clinical impact on the final result. All except one patient were able to return to pre-injury type of sports, at a mean time of 14.6 ± 2.3 months after surgery.

Conclusion

The anterolateral tibial tunnel technique using an Achilles tendon allograft for revision ACL reconstruction after multiple failures associated with an ALL reconstruction showed good results and no major complications. The anterolateral tunnel can be considered a good alternative in cases of medial tibial confluence or significant enlargement of the medial tunnels in re-revision procedures.

One-Stage ACL Revision Using a Bone Allograft Plug for a Semianatomic Tibial Tunnel That Is Too Anterior

Revision of an anterior cruciate ligament (ACL) reconstruction can be performed as a one-stage or two-stage surgery. Several factors must be taken into consideration when making this choice, especially the size and position of the existing tunnels. When the tibial tunnel is semianatomic, it is difficult to make a new tunnel in the correct position without overlapping the existing tunnel. For this reason, we have developed a one-stage ACL revision surgery that uses a bone allograft plug. When it comes to choosing a reconstruction technique, we believe that combined intra-articular and extra-articular reconstruction with the iliotibial band is suitable when the hamstring tendons are not available, combined with clinical findings of translational and rotational instability. Because the existing tunnels require reorientation, a new femoral tunnel can be created by outside-in drilling to eliminate the risk of overlap, while an allograft bone plug can be used to fill the overly anterior tibial tunnel and allow us to drill the correct tibial tunnel right away. In our hands, this is a safe and effective technique, but longer follow-up is needed to validate its indications.

Laxity measurement of internal knee rotation after primary anterior cruciate ligament rupture versus rerupture

PURPOSE

The aim of the current study was to objectify the rotational laxity after primary anterior cruciate ligament (ACL) rupture and rerupture after ACL reconstruction by instrumented measurement. It was hypothesized that knees with recurrent instability feature a higher internal rotation laxity as compared to knees with a primary rupture of the native ACL.

STUDY DESIGN

Cross-sectional study, Level of evidence III.

METHODS

In a clinical cross-sectional study successive patients with primary ACL rupture and rerupture after ACL reconstruction were evaluated clinically and by instrumented measurement of the rotational and antero-posterior laxity with a validated instrument and the KT1000^®, respectively. Clinical examination comprised IKDC 2000 forms, Lysholm Score, and Tegner Activity Scale. Power calculation and statistical analysis were performed (p value < 0.05).

RESULTS

24 patients with primary ACL rupture and 23 patients with ACL rerupture were included. There was no significant side-to-side difference in anterior translation. A side-to side difference of internal rotational laxity ≥ 10° was found significantly more frequent in reruptures (53.6%) compared to primary ruptures (19.4%; p < 0.001). A highly significant relationship between the extent of the pivot-shift phenomenon and side-to-side difference of internal rotation laxity could be demonstrated (p < 0.001). IKDC 2000 subjective revealed significantly better scores in patients with primary ACL tear compared to patients with ACL rerupture (56.4 ± 7.8 vs. 50.8 ± 6.2; p = 0.01). Patients with primary ACL tears scored significantly better on the Tegner Activity Scale (p = 0.02). No significant differences were seen in the Lysholm Score (p = 0.78).

CONCLUSION

Patients with ACL rerupture feature significantly higher internal rotation laxity of the knee compared to primary ACL rupture. The extend of rotational laxity can be quantified by instrumented measurements. This can be valuable data for the indication of an anterolateral ligament reconstruction in ACL revision surgery.

Revision Anterior Cruciate Ligament Reconstruction: Tibial Tunnel-First Graft-Sizing Technique

Revision anterior cruciate ligament reconstruction (R-ACLR) has become more common as the number of failed primary ACLRs increase. Although increasingly common, R-ACLR has a greater failure rate than a primary reconstruction. Technical errors, particularly in tunnel placement, account for a large proportion of graft failure in R-ACLR as well as re-revision cases. Tunnel placement and trajectory is particularly important in R-ACLR and becomes more challenging with each additional revision attempt. This is in part because any tunnels created for revision may converge with formerly drilled tunnels or face interference hardware creating, complicating proper graft fixation. While there are many approaches to revision ACL surgery, our technique describes a simple, tibial tunnel-first graft-sizing method initially reaming tunnels with very small diameters and sequentially working your way up to more anatomic diameters.

Influence of Preoperative Tunnel Widening On the Outcomes of a Single Stage-Only Approach to Every Revision Anterior Cruciate Ligament Reconstruction: An Analysis of 409 Consecutive Patients From the SANTI Study Group

BACKGROUND

Preoperative tunnel widening is a frequently reported indication for performing a 2-stage revision anterior cruciate ligament reconstruction (ACLR) instead of a single-stage procedure. However, the strength of the available evidence to support a 2-stage strategy is low.

PURPOSE/HYPOTHESIS

The purpose was to evaluate the clinical outcomes of a single stage-only approach to revision ACLR. It was hypothesized that this approach would be associated with significant improvements from baseline in patient-reported outcome measures (PROMs) and knee stability and that there would be no significant differences in any postoperative outcomes between patients with and without preoperative tunnel widening.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective analysis was conducted of a large series of consecutive patients undergoing revision ACLR with a minimum follow-up of 2 years. Preoperative tunnel widening was assessed using digital radiographs. All patients underwent single-stage surgery with an outside-in technique, regardless of the degree of tunnel widening. Clinical outcomes were compared according to whether tunnel widening was present (either tunnel ≥12 mm) or not (both tunnels <12 mm).

RESULTS

The study included 409 patients with a mean ± SD follow-up of 69.6 ± 29.0 months. After revision ACLR, there was a significant reduction in the side-to-side anteroposterior laxity difference, from 7.7 ± 2.2 mm preoperatively to 1.2 ± 1.1 mm at 2 years (P < .001). The mean International Knee Documentation Committee (IKDC) and all subscales of the Knee injury and Osteoarthritis Outcome Score (KOOS) exceeded the thresholds for the Patient Acceptable Symptom State defined for primary ACLR. An overall 358 patients had retrievable preoperative radiographs. According to the tunnel diameter measurements, 111 patients were allocated to group A (both tunnels <12 mm) and 247 patients to group B (either/both tunnels ≥12 mm). There were no significant differences between groups with respect to anteroposterior side-to-side laxity difference, graft rupture rates, non-graft rupture related reoperations, or contralateral anterior cruciate ligament injury rates. There was also no significant difference between groups that exceeded minimal detectable change thresholds for any of the PROMs recorded (ACL-RSI [Anterior Cruciate Ligament-Return to Sports After Injury], Lysholm, Tegner, IKDC, KOOS).

CONCLUSION

A single-stage approach to revision ACLR is associated with excellent clinical results when an outside-in drilling technique is utilized. The presence of preoperative tunnel widening does not significantly influence PROMs, knee stability, graft rupture rates, or non-graft rupture related reoperation rates.