Two-stage revision anterior cruciate ligament reconstruction

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°.

Reasons for Not Returning to Pre-injury Sport Level After ACL-Reconstruction

The study aimed to identify athlete-reported reasons for not returning to pre-injury sports level after anterior cruciate ligament reconstruction (ACLR) and to identify the factors associated with these reasons. Ninety-one athletes with 2 years post-ACLR indicated whether or not they had returned to their pre-injury sport level (same frequency, duration, and intensity). Athletes who did not return were asked to provide the reasons. Athletes' characteristics and injury-related factors were used to determine factors associated with the reasons for not returning. Only nine athletes (10%) returned to pre-injury sport level after ACLR. The most common reasons for not returning were lack of confidence or concerns about re-injury (48.8%), followed by continued post-surgical impairments in the reconstructed knee (39%). Having episodes of the knee giving way after ACLR was the only significant predictor of post-surgical impairments (48.8%; OR=8.3, 95%CI=2.48-27.42, p=0.001). Lack of confidence, concerns about re-injury, or post-surgical impairments in the reconstructed knee were the most frequently reported reasons for not returning to pre-injury sports level with 2 years post-ACLR. Reported dynamic knee instability was the only factor associated with ongoing post-surgical knee impairments after ACLR. Rehabilitation programs should address athletes' psychological responses and resolve knee impairments to optimize return to pre-injury sport level after ACLR.

Management of Meniscus Pathology with Concomitant Anterior Cruciate Ligament Injury

PURPOSE OF REVIEW

The purpose of this review is to summarize current clinical knowledge on the prevalence and types of meniscus pathology seen with concomitant anterior cruciate ligament (ACL) injury, as well as surgical techniques, clinical outcomes, and rehabilitation following operative management of these pathologies.

RECENT FINDINGS

Meniscus pathology with concomitant ACL injury is relatively common, with reports of meniscus pathology identified in 21-64% of operative ACL injuries. These concomitant injuries have been associated with increased age and body mass index. Lateral meniscus pathology is more common in acute ACL injury, while medial meniscus pathology is more typical in chronic ACL deficiency. Meniscus tear patterns associated with concomitant ACL injury include meniscus root tears, lateral meniscus oblique radial tears of the posterior horn (14%), and ramp lesions of the medial meniscus (8-24%). These meniscal pathologies with concomitant ACL injury are associated with increased rotational laxity and meniscal extrusion. There is a paucity of comparative studies to determine the optimal meniscus repair technique, as well as rehabilitation protocol, depending on specific tear pattern, location, and ACL reconstruction technique. There has been a substantial increase in recent publications demonstrating the importance of meniscus repair at the time of ACL repair or reconstruction to restore knee biomechanics and reduce the risk of progressive osteoarthritic degeneration. Through these studies, there has been a growing understanding of the meniscus tear patterns commonly identified or nearly missed during ACL reconstruction. Surgical management of meniscal pathology with concomitant ACL injury implements the same principles as utilized in the setting of isolated meniscus repair alone: anatomic reduction, biologic preparation and augmentation, and circumferential compression. Advances in repair techniques have demonstrated promising clinical outcomes, and the ability to restore and preserve the meniscus in pathologies previously deemed irreparable. Further research to determine the optimal surgical technique for specific tear patterns, as well as rehabilitation protocols for meniscus pathology with concomitant ACL injury, is warranted.

Optimization of Graft Position at the Tibia Footprint in Anterior Cruciate Ligament Revision-Lasso Technique

In anterior cruciate ligament (ACL) revision cases, the resultant bigger aperture at the tibia footprint can cause graft instability. The increased movement hinders bone-graft integration and leads to graft abrasion. This article describes a technique to optimize graft stability when using a soft tissue graft for ACL revision. The technique is used when there is suspicion of size mismatch between the new tibia footprint aperture and the graft. The first stage involves passing a suture via an anterolateral tibial tunnel connecting with the revision tibia tunnel distal to the tibia footprint aperture. The new graft is subsequently deployed, and the potential discrepancy between graft diameter and aperture is confirmed. The second stage involves placing 2 pulling sutures on the new graft and passing them into the anterolateral tibial tunnel. The tensioned and anchored pulling sutures secure graft stability at the tibia footprint, and the graft distal to that is fixed routinely. The lasso technique stabilizes the new graft at the tibia footprint by tensioning it in a distal and anterolateral direction. For selected cases, this technique enables a 1-stage ACL revision with a soft tissue graft when faced with graft instability at the tibia footprint.

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.

The Development and Biomechanical Analysis of an Allograft Interference Screw for Anterior Cruciate Ligament Reconstruction

Graft fixation during cruciate ligament reconstruction using interference screws is a common and frequently used surgical technique. These interference screws are usually made of metal or bioabsorbable materials. This paper describes the development of an allograft interference screw from cortical human bone. During the design of the screw, particular attention was paid to the choice of the screw drive and the screw shape, as well as the thread shape. Based on these parameters, a prototype was designed and manufactured. Subsequently, the first biomechanical tests using a bovine model were performed. The test procedure comprised a torsion test to determine the ultimate failure torque of the screw and the insertion torque during graft fixation, as well as a pull-out test to asses the ultimate failure load of the graft fixation. The results of the biomechanical analysis showed that the mean value of the ultimate failure torque was 2633 Nmm, whereas the mean occurring insertion torque during graft fixation was only 1125 Nmm. The mean ultimate failure load of the graft fixation was approximately 235 N. The results of this work show a good overall performance of the allograft screw compared to conventional screws, and should serve as a starting point for further detailed investigations and studies.

Management of Bone Loss and Tunnel Widening in Revision ACL Reconstruction

➤ 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.

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.

Increased Bone Plug Depth From the Joint Increases Tunnel Enlargement in Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Autograft With Suspensory Femoral Fixation

Purpose

To determine a safe bone plug depth fixation zone based on early tunnel enlargement rates in anterior cruciate ligament (ACL) reconstruction using bone-patellar tendon-bone (BPTB) autograft with suspensory femoral fixation.

Methods

Patients who had undergone rectangular tunnel ACL reconstruction using BPTB autograft with suspensory femoral fixation were retrospectively identified. Femoral and tibial tunnel aperture areas were measured on computed tomography 2 weeks and 6 months after surgery to calculate rates of femoral and tibial tunnel enlargement (FTE and TTE), respectively. Femoral bone plug depth (FBPD) and tibial bone plug depth (TBPD) were defined as the distance of the tip of the plug from the respective joint lines. Optimal FBPD and TBPD cutoff values were calculated for the following rates of FTE and TTE, respectively: 0%, 15%, 30%, and 50%.

Results

Sixty-four patients (19 females, 45 males; mean age, 29.5 ± 12.3 years) were included in the study. The femoral and tibial tunnel apertures significantly enlarged over time. FBPD (P < .001; r = 0.607) and TBPD (P = .013; r = 0.308) were positively correlated with FTE and TTE, respectively. The optimal FBPD cutoff value was 2.8 mm for FTE rates of 0% and 15%, 3.6 mm for 30%, and 6.0 mm for 50%. The optimal TBPD cutoff value was 1.48 mm for a 0% TTE rate and 5.1 mm for those higher. The cutoff value specificities were lower for the tibial tunnel than the femoral tunnel for each tunnel enlargement rate.

Conclusion

Early tunnel enlargement and bone plug depth were significantly correlated in bone the femoral and tibial tunnels. The degree of correlation was higher in the femoral tunnel. To minimize bone tunnel enlargement, the distal end of the femoral bone plug should be placed less than 2.8 mm from the tunnel aperture.

Level of Evidence

Level IV, therapeutic case series.

Editorial Commentary: Autograft, Early Surgery, 2-Stage Surgery for 1 cm of Tunnel Widening or Greater, and Anterolateral Ligament Reconstruction or Lateral Extra-articular Tenodesis May Improve Outcomes of Anterior Cruciate Ligament Revision Surgery

Revision anterior cruciate ligament reconstruction (ACLR) is a challenging procedure. Results are less satisfactory than those of primary ACLR owing to bone defects, altered anatomic landmarks, and concomitant injuries. Modifiable factors such as autograft, early surgery, 2-stage surgery for 1 cm of tunnel widening or greater, and anterolateral ligament reconstruction or lateral extra-articular tenodesis may improve outcomes of anterior cruciate ligament revision surgery. Finally, it is important to consider patients' expectations after revision ACLR when counseling patients and making surgical decisions.

The Multivariate Relationship Between Primary Anterior Cruciate Ligament Reconstruction Timing and Revision Rates: A 10-Year Analysis

Background and objective

The optimal timing of anterior crucial ligament reconstruction (ACLR) remains a matter of controversy. A revision procedure is performed to improve knee function, correct instability, and enable a safe return to daily function when primary ACLR fails. The present study aimed to determine if the timing of primary ACLR is predictive of revision surgery.

Methods

All patients who underwent primary ACLR at the West Virginia University from January 2008 to December 2018 were identified. Patients were initially grouped into early (≤30 days) and late (>30 days) ACLR based on the onset of the initial injury. The major outcome measure of this study was the incidence of revision ACLR following primary ACLR.

Results

A total of 233 primary ACLRs were included. The incidence of ACLR revisions was 9.4%. The timing of primary ACLR, when categorized into early and late ACLRs, was not found to influence revision risk (p=0.384). Additionally, the damaged anatomical structures based on the postoperative diagnosis at the time of ACLR did not influence the odds of revision ACLR (p=0.9721).

Conclusion

Our study found that the timing of primary ACLR did not influence the revision rates when categorizing primary surgery time into early and late subgroups.

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.

[Effectiveness of double-bundle anterior cruciate ligament reconstruction combined with anterolateral ligament reconstruction for revision]

Objective

To investigate the effectiveness of double-bundle anterior cruciate ligament (ACL) reconstruction combined with anterolateral ligament (ALL) reconstruction in the treatment of revision patients with ACL graft failure.

Methods

Between January 2018 and June 2019, 15 patients underwent ACL revision with double-bundle ACL reconstruction combined with ALL reconstruction. There were 12 males and 3 females with an average age of 30.1 years (range, 17-49 years). The technique of primary ACL reconstruction included single-bundle reconstruction in 13 cases and double-bundle reconstruction in 2 cases. These reconstructions applied autografts in 14 cases and allograft in 1 case. The causes of ACL reconstruction failure were identified as traumatic rupture in 9 cases and non-traumatic failure in 6 cases, including 2 cases of graft absorption and 3 cases of graft laxity. The average time from the primary ACL reconstruction to revision was 28.5 months (range, 8-60 months). The subjective and objective indicators of knee joint function were compared before operation and at last follow-up to evaluate the effectiveness. The subjective indicators included International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner score. The objective indicators included anterior tibial translation (dynamic and static) and side-to-side difference (SSD), pivot-shift test, Lachman test, the difference of single-legged hop test, and the loss ratio of extensor muscle strength on the affected side.

Results

All incisions healed by first intetion, and no complications such as infection, venous thrombosis of lower extremity, or neurovascular injury occurred. All patients were followed up for an average of 19.1 months (range, 12-30 months). At last follow-up, all patients had returned to pre-injury sports level. The IKDC score, Lysholm score, and Tegner score were significantly improved ( P<0.05); anterior tibial translations (dynamic and static) significantly decreased when compared with preoperative one ( P<0.05) and returned to the physiological range. The SSD, Lachman test, pivot-shift test, the difference of single-legged hop test, and the loss ratio of extensor muscle strength on the affected side were significantly better than those before operation ( P<0.05).During the follow-up, there was no re-rupture of the graft, no stiffness of the knee joint and limitation of mobility; 1 case had a protruding femoral end compression screw, which was removed through the original incision under local anesthesia.

Conclusion

Double-bundle ACL reconstruction combined with ALL reconstruction can significantly improve the knee function in revision patients with ACL graft failure. It can reduce the anterior translation of tibia, and effectively prevent postoperative rotational instability of the knee.