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Boksh K, Sheikh N, Chong HH, Ghosh A, Aujla R. The Role of Anterolateral Ligament Reconstruction or Lateral Extra-articular Tenodesis for Revision Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Comparative Clinical Studies. Am J Sports Med 2024; 52:269-285. [PMID: 36960926 DOI: 10.1177/03635465231157377] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
BACKGROUND After its success in restoring rotational stability and reducing failure rates in primary anterior cruciate ligament reconstruction (ACLR), lateral extra-articular tenodesis (LET) or anterolateral ligament reconstruction (ALLR) has been endorsed for use in revision ACLR surgery, where failure rates are historically higher. PURPOSE To perform a systematic review and meta-analysis on whether the addition of a LET or ALLR results in superior clinical outcomes and stability compared with isolated revision ACLR (iACLR). STUDY DESIGN Meta-analysis; Level of evidence, 4. METHODS The Cochrane Controlled Register of Trials, PubMed, Medline, and Embase were used to perform a systematic review and meta-analysis of comparative studies using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms: ("extra-articular" OR "tenodesis" OR "anterolateral ligament" OR "iliotibial") AND ("anterior cruciate ligament") AND ("revision" OR "re-operation"). Data pertaining to all patient-reported outcome measures (PROMs), rotational stability, and postoperative complications were extracted from each study. RESULTS After abstract and full-text screening, 10 clinical comparative studies were included. There were 793 patients, of whom 390 had an iACLR while 403 had an ACLR augmented with a LET or an ALLR (augmented ACLR [aACLR]). The mean time for assessment of PROMs was 35 months. The aACLR group had superior International Knee Documentation Committee (IKDC) scores (standardized mean difference [SMD], 0.27; 95% CI, 0.01 to 0.54; P = .04), rotational stability (odds ratio [OR], 2.77; 95% CI, 1.91 to 4.01; P < .00001), and lower side-to-side difference (OR, -0.53; 95% CI, -0.81 to -0.24; P = .0003) than those without the augmentation. Furthermore, they were less likely to fail (OR, 0.44; 95% CI, 0.24 to 0.80; P = .007). Subgroup analysis in the higher-grade laxity cohort (grade ≥2) revealed an even greater IKDC score (SMD, 0.51; 95% CI, 0.16 to 0.86; P = .005) and an improved Lysholm score (SMD, 0.45; 95% CI, 0.24 to 0.67; P < .0001) in the aACLR group. CONCLUSION Revision aACLR with a LET or an ALLR can improve subjective IKDC scores, restore rotational stability, and reduce failure rates compared with iACLR. Although controversy remains on the necessity of augmenting all revision ACLRs, the present meta-analysis advocates adding a lateral procedure, particularly in those with a higher-grade pivot shift.
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Affiliation(s)
- Khalis Boksh
- Department of Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Nomaan Sheikh
- Department of Trauma and Orthopaedics, Kettering General Hospital, Kettering, UK
| | - Han Hong Chong
- Department of Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Arijit Ghosh
- Department of Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Randeep Aujla
- Department of Trauma and Orthopaedics, University Hospitals of Leicester NHS Trust, Leicester, UK
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Sørensen OG, Faunø P, Konradsen L, Nielsen T, Schaarup S, Mygind-Klavsen B, Krogsgaard M, Lind M. Combined anterior cruciate ligament revision with reconstruction of the antero-lateral ligament does not improve outcome at 2-year follow-up compared to isolated acl revision; a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 2023; 31:5077-5086. [PMID: 37733288 PMCID: PMC10598101 DOI: 10.1007/s00167-023-07558-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 08/29/2023] [Indexed: 09/22/2023]
Abstract
PURPOSE It is essential to obtain rotational stability of the knee after anterior cruciate ligament reconstruction (ACL-R) and it is suggested that a supplementary reconstruction of the antero-lateral ligament (ALL-R) may supports this. Theoretically, ALL-R may be particularly advantageous to support revision of failed ACL-Rs. It was hypothesized that ACL revision combined with ALL-R will result in superior outcome compared to isolated ACL revision. METHODS The study was designed as a randomized controlled trial. Patients eligible for first time ACL revision were randomized to either isolated ACL revision (- ALL group) or ACL revision combined with a single-stranded allograft ALL-reconstruction (+ ALL group). Patient reported outcomes and function were evaluated at two-year follow-up by KNEES-ACL, KOOS, and Tegner activity scale. Objective knee laxity was evaluated at one-year follow-up using an instrumented Rolimeter test, the pivot shift test, and a manual Lachman test. RESULTS A total of 103 patients were enrolled with 49 patients randomized to the + ALL group and 54 patients in the - ALL group. There were no differences at baseline between groups regarding age, gender, body mass index, preoperative patient reported outcome scores and concomitant meniscus or cartilage injury. The ACL revision was performed with an allograft in 10 patients (20%) in the + ALL group and 8 patients (15%) in the -ALL group. At follow-up there was no significant difference between the groups in patient reported outcome scores and clinical knee laxity. CONCLUSION Supplementary ALL-R does not improve subjective outcome of first time ACL revision at two-years and clinical knee stability at one-year follow-up compared to isolated ACL revision. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- Ole Gade Sørensen
- Department of Sports Traumatology, University Hospital of Aarhus, Aarhus, Denmark.
| | - Peter Faunø
- Department of Sports Traumatology, University Hospital of Aarhus, Aarhus, Denmark
| | - Lars Konradsen
- Section for Sports Traumatology, Bispebjerg, Frederiksberg University Hospital, Copenhagen, Denmark
| | - Torsten Nielsen
- Department of Sports Traumatology, University Hospital of Aarhus, Aarhus, Denmark
| | - Susanne Schaarup
- Section for Sports Traumatology, Bispebjerg, Frederiksberg University Hospital, Copenhagen, Denmark
| | | | - Michael Krogsgaard
- Section for Sports Traumatology, Bispebjerg, Frederiksberg University Hospital, Copenhagen, Denmark
| | - Martin Lind
- Department of Sports Traumatology, University Hospital of Aarhus, Aarhus, Denmark
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Marshall DC, Silva FD, Goldenberg BT, Quintero D, Baraga MG, Jose J. Imaging Findings of Complications After Lateral Extra-Articular Tenodesis of the Knee: A Current Concepts Review. Orthop J Sports Med 2022; 10:23259671221114820. [PMID: 36062159 PMCID: PMC9434692 DOI: 10.1177/23259671221114820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 05/11/2022] [Indexed: 11/16/2022] Open
Abstract
Background Despite successful anterior cruciate ligament (ACL) reconstruction, many patients continue to experience persistent anterolateral rotatory instability. Lateral extra-articular tenodesis (LET) is used to address this instability by harvesting a portion of the iliotibial band, passing it underneath the fibular collateral ligament, and attaching it just proximal and posterior to the lateral femoral epicondyle. Based on the most recent clinical evidence, the addition of LET to ACL reconstruction improves clinical outcomes, which has led to an increase in the use of this technique. Purpose To provide an overview of the postoperative complications of the LET procedure and their associated imaging findings, with a focus on magnetic resonance imaging (MRI). Study Design Narrative review. Methods In this scoping review, the authors reviewed available radiographic, computed tomography, and MRI scans of patients who experienced postoperative complications after ACL reconstruction with LET, in which the complication was determined to be from the LET procedure. Images were reviewed and subsequently described by an on-staff musculoskeletal radiologist. Results The authors found 9 different complications associated with LET: graft failure, hematoma, infection, chronic pain, tunnel convergence, fixation device migration, muscular hernia, peroneal nerve palsy, and knee stiffness. They supplemented these findings with radiographic evidence from 6 patients. Conclusion As extra-articular reconstruction techniques including LET become more popular among orthopaedic surgeons, it is important that radiologists and surgeons be adept at recognizing the normal imaging findings of LET and associated complications.
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Affiliation(s)
- Danielle C. Marshall
- Department of Orthopaedics, University of Miami/Jackson Memorial
Hospital, Miami, Florida, USA
| | - Flavio D. Silva
- Department of Radiology, Grupo Osteomuscular, Fleury Medicine e
Saúde, São Paulo, Brazil
| | - Brandon T. Goldenberg
- Department of Orthopaedics, University of Miami/Jackson Memorial
Hospital, Miami, Florida, USA
| | - Daniel Quintero
- Department of Orthopaedics, University of Miami/Jackson Memorial
Hospital, Miami, Florida, USA
- Department of Radiology, University of Miami/Jackson Memorial
Hospital, Miami, Florida, USA
| | - Michael G. Baraga
- Department of Orthopaedics, University of Miami/Jackson Memorial
Hospital, Miami, Florida, USA
| | - Jean Jose
- Department of Radiology, University of Miami/Jackson Memorial
Hospital, Miami, Florida, USA
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Rayes J, Ouanezar H, Haidar IM, Ngbilo C, Fradin T, Vieira TD, Freychet B, Sonnery-Cottet B. Revision Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Graft Combined With Modified Lemaire Technique Versus Hamstring Graft Combined With Anterolateral Ligament Reconstruction: A Clinical Comparative Matched Study With a Mean Follow-up of 5 Years From The SANTI Study Group. Am J Sports Med 2022; 50:395-403. [PMID: 34898285 DOI: 10.1177/03635465211061123] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Additional lateral extra-articular tenodesis (LET) has recently been correlated with improved clinical outcomes and reduced failure rates in revision anterior cruciate ligament (ACL) reconstruction (ACLR). However, no data are available on clinical outcomes and reoperation after revision ACLR using different LET procedures. PURPOSE To compare the clinical outcomes of ACL + anterolateral ligament (ALL) reconstruction using hamstring tendon graft (HT-ALL) and a bone-patellar tendon-bone (BPTB) graft + modified Lemaire tenodesis procedure (BPTB-Lemaire) in the setting of revision ACLR and to determine whether ALL reconstruction is associated with an increased rate of adverse outcomes when compared with a modified Lemaire tenodesis procedure. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Descriptive data and clinical outcomes were prospectively collected from patients who underwent revision ACLR with LET between 2009 and 2018 with a minimum follow-up of 2 years. Patients with an HT autograft combined with ALL reconstruction (HT-ALL group) were matched in a 1:1 propensity ratio to patients with a BPTB autograft combined with a modified Lemaire LET procedure (BPTB-Lemaire group). The evaluated parameters included complications and reoperations; knee laxity tests; return to sports; and various scores, including the Lysholm knee score, Tegner activity scale, Anterior Cruciate Ligament Return to Sport After Injury scale, Marx activity rating scale, International Knee Documentation Committee subjective knee evaluation form, and Knee injury and Osteoarthritis Outcome Score. RESULTS In total, 36 matched pairs were included in the analysis. The mean follow-up durations for the BPTB-Lemaire and HT-ALL groups were 56 ± 35 and 57 ± 23 months, respectively (P = .91). No significant differences were found in graft rupture rate (HT-ALL, 0%; BPTB-Lemaire, 11.1%; P = .13) or reoperations (HT-ALL, 8.3%; BPTB-Lemaire, 22.2%; P = .23). No specific complications with regard to LET were noted in either group. Additionally, there were no significant differences in knee laxity parameters, return to sports, or clinical scores between the groups at the final follow-up, except for the Tegner activity scale score (HT-ALL, 6.4; BPTB-Lemaire, 7.3; P = .03). HT-ALL was associated with a shorter surgical time (41.4 vs 59.8 minutes; P < .0001). CONCLUSION HT-ALL was at least equivalent, in terms of clinical outcomes, to the more commonly performed procedure, BPTB-Lemaire. Performing ALL reconstruction in the setting of revision ACLR is therefore safe and effective.
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Affiliation(s)
- Johnny Rayes
- Centre Orthopédique Santy, Lyon, France.,Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | | | - Ibrahim M Haidar
- Centre Orthopédique Santy, Lyon, France.,Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Cedric Ngbilo
- Centre Orthopédique Santy, Lyon, France.,Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Thomas Fradin
- Centre Orthopédique Santy, Lyon, France.,Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Thais Dutra Vieira
- Centre Orthopédique Santy, Lyon, France.,Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Benjamin Freychet
- Centre Orthopédique Santy, Lyon, France.,Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
| | - Bertrand Sonnery-Cottet
- Centre Orthopédique Santy, Lyon, France.,Hôpital Privé Jean Mermoz, Ramsay-Générale de Santé, Lyon, France
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Aryana IGNW, Subawa IW, Dusak IWS, Dharmayuda CGO, Nugraha HK, Deslivia MF. Resultado funcional do procedimento de tenodese extra-articular lateral (TEL) como complemento à reconstrução do ligamento cruzado anterior: Uma metanálise. Rev Bras Ortop 2022; 57:33-40. [PMID: 35198106 PMCID: PMC8856850 DOI: 10.1055/s-0041-1736514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 06/15/2021] [Indexed: 11/06/2022] Open
Abstract
Objectives
The aim of the present study is to systematically review and analyze the functional outcome of lateral extraarticular tenodesis (LET) procedure in addition to anterior cruciate ligament reconstruction (ACLR) in studies with a high level of evidence.
Methods
We performed a literature search for clinical studies comparing the LET method as an augmentation to ACL reconstruction with ACL reconstruction alone. The primary outcomes were the International Knee Documentation Committee (IKDC) score, the Lysholm score, and graft failures. Continuous variables were reported as means and 95% confidence intervals (CIs).
Results
Six clinical studies with 1,049 patients were included in the metaanalysis. The follow-up period was, in average, 24 months (range, 6–63 months). The addition of the LET procedure to ACLR results in better functional outcome based on the IKDC score (
p
< 0.05). Graft failure was found to be lower in the ACLR plus LET group (16 of 342 patients) compared with the ACLR-only group (46 of 341 patients) (
p
< 0.05).
Conclusion
There is high-level evidence that LET procedure in addition to ACLR is preferable in terms of functional outcome and graft failure.
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Affiliation(s)
- I Gusti Ngurah Wien Aryana
- Departamento de Ortopedia e Traumatologia, Faculdade de Medicina Udayana University, Sanglah General Hospital, Bali, Indonésia
| | - I Wayan Subawa
- Departamento de Ortopedia e Traumatologia, Faculdade de Medicina Udayana University, Sanglah General Hospital, Bali, Indonésia
| | - I Wayan Suryanto Dusak
- Departamento de Ortopedia e Traumatologia, Faculdade de Medicina Udayana University, Sanglah General Hospital, Bali, Indonésia
| | - Cokorda Gde Oka Dharmayuda
- Departamento de Ortopedia e Traumatologia, Faculdade de Medicina Udayana University, Sanglah General Hospital, Bali, Indonésia
| | - Hans Kristian Nugraha
- Departamento de Ortopedia e Traumatologia, Faculdade de Medicina Udayana University, Sanglah General Hospital, Bali, Indonésia
| | - Maria Florencia Deslivia
- Departamento de Ortopedia e Traumatologia, Faculdade de Medicina Udayana University, Sanglah General Hospital, Bali, Indonésia
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Eggeling L, Drenck TC, Frings J, Krause M, Korthaus A, Krukenberg A, Frosch KH, Akoto R. Additional lateral extra-articular tenodesis in revision ACL reconstruction does not influence the outcome of patients with low-grade anterior knee laxity. Arch Orthop Trauma Surg 2022; 142:291-299. [PMID: 34455475 PMCID: PMC8783865 DOI: 10.1007/s00402-021-04145-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 08/20/2021] [Indexed: 01/26/2023]
Abstract
INTRODUCTION There is limited evidence on the indications of lateral extra-articular tenodesis (LET) in revision ACLR. The aim of this study was to evaluate the influence of the LET in patients with revision ACLR with preoperative low-grade anterior knee laxity. METHODS Between 2013 and 2018, 78 patients who underwent revision ACLR with preoperative low-grade anterior knee laxity [≤ 5 mm side-to-side difference (SSD)] were included in the retrospective cohort study. An additional modified Lemaire tenodesis was performed in 23 patients during revision ACLR and patients were clinically examined with a minimum of 2 years after revision surgery. Postoperative failure of the revision ACLR was defined as SSD in Rolimeter® testing ≥ 5 mm or pivot-shift grade 2/3. RESULTS In total, failure of the revision ACLR occurred in 11.5% (n = 9) of the cases at a mean follow-up of 28.7 ± 8.8 (24-67) months. Patients with an additional LET and revision ACLR did not show a significantly reduced failure rate (13% vs. 11%) or an improved clinical outcome according to the postoperative functional scores or pain in regards to patients with an isolated revision ACLR (Tegner 5.7 ± 1.3 vs. 5.9 ± 1.5, n.s.; IKDC 77.5 ± 16.2 vs. 80.1 ± 14.9, n.s., Lysholm 81.9 ± 14.2 vs. 83.8 ± 14.5, n.s.; VAS 1.9 ± 2.2 vs. 1.2 ± 1.7, n.s.). CONCLUSIONS An additional LET in patients with revision ACLR with low-grade anterior knee laxity does not influence patient-related outcomes or failure rates. Subjects with preoperative low-grade anterior knee laxity may not benefit from a LET in revision ACLR. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Lena Eggeling
- Asklepios Clinic St. Georg, Lohmühlenstraße 5, 20099, Hamburg, Germany
- Department of Trauma and Orthopaedic Surgery, Sports Traumatology, BG Hospital Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany
| | - T C Drenck
- Department of Trauma and Orthopaedic Surgery, Sports Traumatology, BG Hospital Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany
| | - J Frings
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - M Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Alexander Korthaus
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Anna Krukenberg
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, Sports Traumatology, BG Hospital Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Ralph Akoto
- Asklepios Clinic St. Georg, Lohmühlenstraße 5, 20099, Hamburg, Germany.
- Department of Trauma and Orthopaedic Surgery, Sports Traumatology, BG Hospital Hamburg, Bergedorfer Str. 10, 21033, Hamburg, Germany.
- Cologne Merheim Medical Center, University of Witten/Herdecke, Cologne, Germany.
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Ventura A, Legnani C, Boisio F, Borgo E, Peretti GM. The association of extra-articular tenodesis restores rotational stability more effectively compared to contralateral hamstring tendon autografts ACL reconstruction alone in patients undergoing ACL revision surgery. Orthop Traumatol Surg Res 2021; 107:102739. [PMID: 33390331 DOI: 10.1016/j.otsr.2020.06.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/27/2020] [Accepted: 06/22/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Recent years have seen a resurgence of interest about lateral extra-articular procedures performed in association with anterior cruciate ligament (ACL) surgery, as they can reduce the positivity to pivot shift test by acting on rotational instability. The purpose of the present study is to compare the postoperative functional outcomes of ACL revision surgery using contralateral hamstring tendon autografts with or without extra-articular tenodesis. HYPOTHESIS The hypothesis is that combined extra-articular tenodesis gives better rotational stability following revision ACL surgery. PATIENTS AND METHODS Twenty-four patients who underwent ACL revision surgery were retrospectively reviewed at an average follow-up of 4.5 years; 12 underwent contralateral hamstring tendon autografts reconstruction (group A) while in 12 extra-articular tenodesis was associated (group B). Assessment included Lysholm score, International Knee Documentation Committee (IKDC) Subjective Knee Form, Tegner activity level and objective evaluation (range of motion, Lachman test, pivot-shift test and KT-1000 instrumented laxity testing). RESULTS Follow-up examination showed that there were no statistically significant differences in Lysholm, IKDC and Tegner scores between the groups (p=n.s.). Similarly, no differences concerning anterior tibial translation as measured with KT-1000 arthrometer were reported between the groups (p=n.s.); the percentage of positivity to pivot shift test was significantly higher in patients in group A (p<0.05). CONCLUSIONS The association of extra-articular tenodesis restores rotational stability more effectively compared to contralateral hamstring tendon autografts ACL revision surgery alone. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Alberto Ventura
- IRCCS Istituto Ortopedico Galeazzi, Sports Traumatology and Minimally Invasive Articular Surgery Center, Milan, Italy
| | - Claudio Legnani
- IRCCS Istituto Ortopedico Galeazzi, Sports Traumatology and Minimally Invasive Articular Surgery Center, Milan, Italy.
| | | | - Enrico Borgo
- IRCCS Istituto Ortopedico Galeazzi, Sports Traumatology and Minimally Invasive Articular Surgery Center, Milan, Italy
| | - Giuseppe M Peretti
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy; Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
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Legnani C, Boisio F, Borgo E, Ventura A. Autograft for anterior cruciate ligament revision surgery : Lateral extra-articular tenodesis in skeletally mature patients under 25 years of age. DER ORTHOPADE 2019; 48:858-861. [PMID: 31289891 DOI: 10.1007/s00132-019-03779-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Lateral extra-articular procedures in association with anterior cruciate ligament (ACL) reconstruction can act as a protection against undesired loads occurring in the early postoperative phase. The purpose of the present study was to retrospectively review the clinical outcome of contralateral hamstring tendon autografts with extra-articular tenodesis for ACL revision surgery in skeletally mature patients under 25 years of age, specifically with respect to patient satisfaction, return to preinjury activity level and postoperative functional outcome. METHODS In this study 9 patients (<25 years old at surgery) who underwent ACL revision surgery using contralateral hamstring tendon autografts and extra-articular tenodesis were contacted and retrospectively reviewed at an average follow-up of 3.6 years (range 2-7 years). The Tegner activity scale, Lysholm knee score and International Knee Documentation Committee (IKDC) questionnaire were used. Objective evaluation included range of motion, Lachmann test, pivot-shift test and KT-1000 instrumented laxity testing. RESULTS No cases of re-rupture were observed. The Lysholm knee score as well as the IKDC score improved at follow-up reaching a mean value of 87.9 and 85.6, respectively, with a statistically significant improvement compared to preoperative status (p < 0.001). In terms of knee stability anterior tibial translation has changed from a preoperative mean value of 5.4 mm to a postoperative value of 2.9 mm, which was statistically significant (p < 0.001). No subjective loss of motion or strength of the contralateral knee, rotational injuries following tendon harvesting or significant morbidity at follow-up were reported. CONCLUSION Revision ACL reconstruction with contralateral hamstrings and associated extra-articular tenodesis provides satisfying subjective outcomes and restores knee stability in skeletally mature patients under 25 years of age. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Claudio Legnani
- IRCCS Istituto Ortopedico Galeazzi, Sport Traumatology and Minimally Invasive Surgery Center, Milan, Italy.
| | - Francesca Boisio
- Scuola di Specializzazione in Ortopedia e Traumatologia, Università degli Studi di Milano, Milan, Italy
| | - Enrico Borgo
- IRCCS Istituto Ortopedico Galeazzi, Sport Traumatology and Minimally Invasive Surgery Center, Milan, Italy
| | - Alberto Ventura
- IRCCS Istituto Ortopedico Galeazzi, Sport Traumatology and Minimally Invasive Surgery Center, Milan, Italy
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Abstract
In the anterior cruciate ligament (ACL) deficient knee, excellent outcomes are achieved in many patients with an isolated, intra-articular ACL reconstruction. Some patients, however, have ongoing instability or suffer graft rupture. Failure after ACL reconstruction is multifactorial, but residual anterolateral rotatory laxity is 1 potential contributing factor. Lateral extra-articular procedures are a heterogenous group of operations that were initially described as isolated treatments for the ACL deficient knee, and subsequently used in combination with intra-articular reconstructions. Initial observational studies were encouraging, however, comparative studies were less flattering and lead to a general abandonment of these procedures. With improved understanding of the anatomy and biomechanics of the anterolateral capsuloligamentous complex there has been a renewed interest in these procedures. Recent systematic reviews suggest efficacy of these procedures in improving rotational control, though data showing improved patient reported outcomes or reduced graft rupture rates are lacking. Preliminary results from ongoing clinical trials are supportive for lateral extra-articular tenodesis when used as an augment to modern, intra-articular ACL reconstructions in targeted, high-risk patients.
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Redler A, Iorio R, Monaco E, Puglia F, Wolf MR, Mazza D, Ferretti A. Revision Anterior Cruciate Ligament Reconstruction With Hamstrings and Extra-articular Tenodesis: A Mid- to Long-Term Clinical and Radiological Study. Arthroscopy 2018; 34:3204-3213. [PMID: 30292594 DOI: 10.1016/j.arthro.2018.05.045] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 04/20/2018] [Accepted: 05/22/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE To present the mid- to long-term clinical and radiographic outcomes of a series of patients who underwent revision anterior cruciate ligament (ACL) reconstruction with doubled gracilis and semitendinosus (DGST) autograft and a lateral extra-articular tenodesis (LET). METHODS Patients who underwent revision ACL reconstruction with DGST and LET by a single surgeon between January 1997 and December 2013 were included. Revision was indicated by ACL failure noted on magnetic resonance imaging, persistent clinical instability, or laxity on clinical exam. Patients were evaluated preoperatively and at latest follow-up by an independent board-certified orthopaedic surgeon. Outcomes included Lachman and pivot shift tests, validated clinical and patient reported outcomes scores, and radiographic analysis. The presence of previous meniscectomy or chondral injury was recorded intraoperatively. RESULTS A total of 118/132 potential patients (89.4%) was available for follow-up at a mean 10.6 years (3-19 years) postoperatively. Lachman and pivot shift examinations as well as the side-to-side difference on an KT-1000 arthrometer demonstrated significant improvement at latest follow-up (P < .05) versus preoperative evaluation. Severe degenerative disease was present in 25% of patients on radiograph and correlated with worsened clinical outcomes. Previous meniscectomy was the only risk factor analyzed that correlated with worsened radiographic grade. No patients had a graft tear based on clinical and/or magnetic resonance imaging evaluation, but 9 (7.6%) failed based on a side-to-side difference of >5 mm on the KT-1000, a grade ≥2+ on pivot shift, or report of continued instability. CONCLUSIONS Revision ACL reconstruction with DGST and LET at mid- to long-term follow-up provides continued improvement in clinical and radiological outcomes from preoperative assessment. Meniscectomy was the only factor related to worsened radiological grades and clinical outcomes. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Andrea Redler
- Orthopaedic Unit and Kirk Kilgour Sports Injury Centre, Sant Andrea Hospital, University of Rome Sapienza, Rome, Italy.
| | - Raffaele Iorio
- Orthopaedic Unit and Kirk Kilgour Sports Injury Centre, Sant Andrea Hospital, University of Rome Sapienza, Rome, Italy
| | - Edoardo Monaco
- Orthopaedic Unit and Kirk Kilgour Sports Injury Centre, Sant Andrea Hospital, University of Rome Sapienza, Rome, Italy
| | - Francesco Puglia
- Orthopaedic Unit and Kirk Kilgour Sports Injury Centre, Sant Andrea Hospital, University of Rome Sapienza, Rome, Italy
| | - Megan R Wolf
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, Connecticut, U.S.A
| | - Daniele Mazza
- Orthopaedic Unit and Kirk Kilgour Sports Injury Centre, Sant Andrea Hospital, University of Rome Sapienza, Rome, Italy
| | - Andrea Ferretti
- Orthopaedic Unit and Kirk Kilgour Sports Injury Centre, Sant Andrea Hospital, University of Rome Sapienza, Rome, Italy
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11
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Noyes FR, Huser LE, West J, Jurgensmeier D, Walsh J, Levy MS. Two Different Knee Rotational Instabilities Occur With Anterior Cruciate Ligament and Anterolateral Ligament Injuries: A Robotic Study on Anterior Cruciate Ligament and Extra-articular Reconstructions in Restoring Rotational Stability. Arthroscopy 2018; 34:2683-2695. [PMID: 30173809 DOI: 10.1016/j.arthro.2018.04.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 04/18/2018] [Accepted: 04/25/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the effect of 2 extra-articular reconstructions on pivot-shift rotational stability and tibial internal rotation as a basis for clinical recommendations. METHODS A robotic simulator tested 15 cadaver knees. Group 1 (anterior cruciate ligament [ACL] cut) underwent ACL bone-patellar tendon-bone reconstruction followed by sectioning the anterolateral structures and an extra-articular, manual-tension iliotibial band (ITB) tenodesis. Group 2 (ACL intact) tested the rotational stabilizing effect of a low-tension ITB tenodesis before and after sectioning the anterolateral ligament/ITB structures. Lateral and medial tibiofemoral compartment translations and internal-external tibial rotations were measured under Lachman, 5N·m tibial rotation, and 2 pivot-shift simulations using 4-degree-of-freedom loading. Statistical equivalence was defined within 2 mm tibiofemoral compartment translation and 2° tibial rotation at P < .05. RESULTS The bone-patellar tendon-bone ACL reconstruction (group 1) restored pivot-shift lateral compartment translation within 0.7 mm (95% confidence interval [CI], -0.6 to 1.9; P = .70) of normal. The internal rotation limit was not affected by ACL sectioning or reconstruction. After anterolateral ligament/ITB sectioning there was no change in pivot-shift lateral compartment translation, however internal rotation increased 2.9° (95% CI, 0.6-5.2; P = .99) at 90° flexion. The manual-tension ITB tenodesis (fixated 13-22 N tension) decreased pivot-shift lateral compartment translation 4.8 mm (95% CI, 1.4-8.1; P = .99) and internal rotation by 21.9° (95% CI, 13.2-30.6; P = .99) at 90° flexion. The ACL forces decreased 45.8% in the pivot-shift test. In group 2 knees, with the ACL intact, the anterolateral ligament/ITB sectioning had no effect on pivot-shift translations; however, the internal rotation limit increased by 4.3° (95% CI, 1.9-6.8; P = .99) at 60° flexion. The low-tension ITB tenodesis (fixated 8.9 N tension) had no effect on pivot-shift translations and corrected internal tibial rotation with a mild overconstraint of 4.2° (95% CI, 1.9-6.8; P = .99) at 60° flexion. CONCLUSIONS A low-tension ITB tenodesis, fixated at neutral tibial rotation to avoid constraining internal tibial rotation, has no effect in limiting abnormal pivot-shift subluxations. CLINICAL RELEVANCE A low-tension ITB tenodesis has limited clinical utilization as the pivot-shift subluxations are not affected, assuming appropriate tensioning to not overconstrain internal tibial rotation.
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Affiliation(s)
- Frank R Noyes
- Cincinnati Sports Medicine and Orthopaedic Center, Mercy Health, Cincinnati, Ohio, U.S.A.; The Noyes Knee Institute, Cincinnati, Ohio, U.S.A
| | - Lauren E Huser
- Cincinnati Sports Medicine and Orthopaedic Center, Mercy Health, Cincinnati, Ohio, U.S.A.; The Noyes Knee Institute, Cincinnati, Ohio, U.S.A..
| | - John West
- Cincinnati Sports Medicine and Orthopaedic Center, Mercy Health, Cincinnati, Ohio, U.S.A.; The Noyes Knee Institute, Cincinnati, Ohio, U.S.A
| | - Darin Jurgensmeier
- Cincinnati Sports Medicine and Orthopaedic Center, Mercy Health, Cincinnati, Ohio, U.S.A.; The Noyes Knee Institute, Cincinnati, Ohio, U.S.A
| | - James Walsh
- Cincinnati Sports Medicine and Orthopaedic Center, Mercy Health, Cincinnati, Ohio, U.S.A.; The Noyes Knee Institute, Cincinnati, Ohio, U.S.A
| | - Martin S Levy
- College of Business, Operations and Business Analytics, University of Cincinnati, Cincinnati, Ohio, U.S.A
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Clinical Outcomes in Revision Anterior Cruciate Ligament Reconstruction: A Meta-analysis. Arthroscopy 2018; 34:289-300. [PMID: 28866344 DOI: 10.1016/j.arthro.2017.06.029] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 05/08/2017] [Accepted: 06/20/2017] [Indexed: 02/06/2023]
Abstract
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.
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Grassi A, Kim C, Marcheggiani Muccioli GM, Zaffagnini S, Amendola A. What Is the Mid-term Failure Rate of Revision ACL Reconstruction? A Systematic Review. Clin Orthop Relat Res 2017; 475:2484-2499. [PMID: 28493217 PMCID: PMC5599393 DOI: 10.1007/s11999-017-5379-5] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND When anterior cruciate ligament (ACL) reconstruction fails, a revision procedure may be performed to improve knee function, correct instability, and allow return to activities. The results of revision ACL reconstruction have been reported to produce good but inferior patient-reported and objective outcomes compared with primary ACL reconstruction, but the degree to which this is the case varies widely among published studies and may be influenced by heterogeneity of patients, techniques, and endpoints assessed. For those reasons, a systematic review may provide important insights. QUESTIONS/PURPOSES In a systematic review, we asked: (1) What is the proportion of revision ACL reconstruction cumulative failures defined as rerupture or objective failure using prespecified clinical criteria at mean followup of at least 5 years? (2) What are the most common complications of revision ACL reconstruction? METHODS A systematic review was performed by searching PubMed/Medline, EMBASE, and CENTRAL. We included studies that reported the clinical evaluation of revision ACL reconstruction with Lachman test, pivot shift test, side-to-side difference with KT-1000/2000 arthrometer, and with a mean followup of at least 5 years. We excluded studies that incompletely reported these outcomes, that reported only reruptures, or that were not in the English language. Extracted data included the number of graft reruptures and objective clinical failure, defined as a knee that met one of the following endpoints: Lachman test Grade II to III, pivot shift Grade II to III, KT-1000/2000 > 5-mm difference, or International Knee Documentation Committee Grade C or D. For each study, we determined the proportion of patients who had experienced a rupture of the revision ACL graft as well as the proportion of patients who met one or more of our clinical failure endpoints. Those proportions were summed for each study to generate a percentage of patients who met our definition of cumulative failure. Complications and reoperations were recorded but not pooled as a result of inconsistency of reporting and heterogeneity of populations across the included studies. Of the 663 screened studies, 15 articles were included in the systematic review. Because one study reported two separate groups of patients with different treatments, 16 case series were considered in the evaluation. RESULTS The proportion of reruptures (range, 0%-25%) was > 5% in only four of 16 series and > 10% in only one of them. The objective clinical failures (range, 0%-82%) was > 5% in 15 of 16 series and > 10% in 12 of them. The proportion exceeded 20% in five of 16 series. The cumulative failures (range, 0%-83%) was > 5% in all except one series and > 10% in 12 of 16 series; five series had a cumulative failure proportion > 20%. The most frequent complications were knee stiffness and anterior knee pain, whereas reoperations were primarily débridement and meniscectomies. CONCLUSIONS Considering rerupture alone as a failure endpoint in patients who have undergone revision ACL reconstruction likely underestimates the real failure rate, because the percentage of failures noticeably increases when objective criteria are also considered. Whether patient-reported and subjective scores evaluating knee function, level of activity, satisfaction, and pain might also contribute to the definition of failure may be the focus of future studies. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Alberto Grassi
- 0000000100241216grid.189509.cDepartment of Orthopaedic Surgery, Duke Sports Sciences Institute, Duke University Medical Center, Durham, NC USA ,0000 0001 2154 6641grid.419038.7Rizzoli Sicilia Department, Rizzoli Orthopaedic Institute, Bagheria, PA Italy ,0000 0001 2154 6641grid.419038.7Rizzoli Sicilia Department, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Christopher Kim
- 0000000100241216grid.189509.cDepartment of Orthopaedic Surgery, Duke Sports Sciences Institute, Duke University Medical Center, Durham, NC USA
| | | | - Stefano Zaffagnini
- 0000 0001 2154 6641grid.419038.7Rizzoli Sicilia Department, Rizzoli Orthopaedic Institute, Bagheria, PA Italy
| | - Annunziato Amendola
- 0000000100241216grid.189509.cDepartment of Orthopaedic Surgery, Duke Sports Sciences Institute, Duke University Medical Center, Durham, NC USA
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Grassi A, Nitri M, Moulton SG, Marcheggiani Muccioli GM, Bondi A, Romagnoli M, Zaffagnini S. Does the type of graft affect the outcome of revision anterior cruciate ligament reconstruction? a meta-analysis of 32 studies. Bone Joint J 2017; 99-B:714-723. [PMID: 28566389 DOI: 10.1302/0301-620x.99b6.bjj-2016-0929.r2] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 02/16/2017] [Indexed: 01/02/2023]
Abstract
AIMS Our aim was to perform a meta-analysis of the outcomes of revision anterior cruciate ligament (ACL) reconstruction, comparing the use of different types of graft. MATERIALS AND METHODS A search was performed of Medline and Pubmed using the terms "Anterior Cruciate Ligament" and "ACL" combined with "revision", "re-operation" and "failure". Only studies that reported the outcome at a minimum follow-up of two years were included. Two authors reviewed the papers, and outcomes were subdivided into autograft and allograft. Autograft was subdivided into hamstring (HS) and bone-patellar tendon-bone (BPTB). Subjective and objective outcome measures were analysed and odds ratios with confidence intervals were calculated. RESULTS A total of 32 studies met the inclusion criteria. Five studies used HS autografts, eight reported using BPTB autografts, two used quadriceps tendon autografts and eight used various types. Seven studies reported using allografts, while the two remaining used both BPTB autografts and allografts. Overall, 1192 patients with a mean age of 28.7 years (22.5 to 39) and a mean follow-up of 5.4 years (2.0 to 9.6) were treated with autografts, while 269 patients with a mean age of 28.4 years (25 to 34.6) and a mean follow-up of 4.0 years (2.3 to 6.0) were treated with allografts. Regarding allografts, irradiation with 2.5 mrad was used in two studies while the graft was not irradiated in the seven remaining studies. Reconstructions following the use of autografts had better outcomes than those using allograft with respect to laxity, measured by KT-1000/2000 (MEDmetric Corporation) and the rates of complications and re-operations. Those following the use of allografts had better mean Lysholm and Tegner activity scores compared with autografts. If irradiated allografts were excluded from the analysis, outcomes no longer differed between the use of autografts and allografts. Comparing the types of autograft, all outcomes were similar except for HS grafts which had better International Knee Documentation Committee scores compared with BPTB grafts. CONCLUSION Autografts had better outcomes than allografts in revision ACL reconstruction, with lower post-operative laxity and rates of complications and re-operations. However, after excluding irradiated allografts, outcomes were similar between autografts and allografts. Overall, the choice of graft at revision ACL reconstruction should be on an individual basis considering, for instance, the preferred technique of the surgeon, whether a combined reconstruction is required, the type of graft that was previously used, whether the tunnels are enlarged and the availability of allograft. Cite this article: Bone Joint J 2017;99-B:714-23.
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Affiliation(s)
- A Grassi
- Orthopedic Institute Rizzoli, 90011 Bologna, Italy
| | - M Nitri
- Orthopedic Institute Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy
| | - S G Moulton
- Oregon Health & Science University, 3181 SW, Sam Jackson Park Rd, Portland, Oregon, USA
| | | | - A Bondi
- Orthopedic Institute Rizzoli, 90011 Bologna, Italy
| | - M Romagnoli
- Orthopedic Institute Rizzoli, 90011 Bologna, Italy
| | - S Zaffagnini
- Orthopedic Institute Rizzoli, 90011 Bologna, Italy
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15
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Noyes FR, Huser LE, Jurgensmeier D, Walsh J, Levy MS. Is an Anterolateral Ligament Reconstruction Required in ACL-Reconstructed Knees With Associated Injury to the Anterolateral Structures? A Robotic Analysis of Rotational Knee Stability. Am J Sports Med 2017; 45:1018-1027. [PMID: 28056513 DOI: 10.1177/0363546516682233] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The effect of an anterolateral ligament (ALL) reconstruction on rotational knee stability and corresponding anterior cruciate ligament (ACL) graft forces using multiple knee loading conditions including the pivot-shift phenomenon has not been determined. PURPOSE First, to determine the rotational stability and ACL graft forces provided by an anatomic bone-patellar tendon-bone ACL reconstruction in the ACL-deficient knee alone and with an associated ALL/iliotibial band (ITB) injury. Second, to determine the added rotational stabilizing effect and reduction in ACL graft forces provided by an ALL reconstruction. STUDY DESIGN Controlled laboratory study. METHODS A 6 degrees of freedom robotic simulator was used to test 7 fresh-frozen cadaveric specimens during 5 testing conditions: intact, ACL-sectioned, ACL-reconstructed, ALL/ITB-sectioned, and ALL-reconstructed. Lateral and medial tibiofemoral compartment translations and internal tibial rotations were measured under Lachman test conditions, 5-N·m internal rotation, and 2 pivot-shift simulations. Statistical equivalence within 2 mm and 2° was defined as P < .05. RESULTS Single-graft ACL reconstruction restored central tibial translation under Lachman testing and internal rotation under 5-N·m internal rotation torque ( P < .05). A modest increase in internal rotation under 5-N·m internal rotation torque occurred after ALL/ITB sectioning of 5.1° (95% CI, 3.6° to 6.7°) and 6.7° (95% CI, 4.3° to 9.1°) at 60° and 90° of flexion, respectively ( P = .99). Lateral compartment translation increases in the pivot-shift tests were <2 mm. ALL reconstruction restored internal rotation within 0.5° (95% CI, -1.9° to 2.9°) and 0.7° (95% CI, -2.0° to 3.4°) of the ACL-reconstructed state at 60° and 90° of flexion, respectively ( P < .05). The ALL procedure reduced ACL graft forces, at most, 75 N in the pivot-shift tests and 81 N in the internal rotation tests. CONCLUSION Although the ALL reconstruction corrected the small abnormal changes in the internal rotation limit at high flexion angles, the procedure had no effect in limiting tibiofemoral compartment translations in the pivot-shift test and produced only modest decreases in ACL graft forces. Accordingly, the recommendation to perform an ALL reconstruction to correct pivot-shift abnormalities is questioned. CLINICAL RELEVANCE The small changes in rotational stability after ALL/ITB sectioning would not seem to warrant the routine addition of an ALL reconstruction in primary ACL injuries. Clinical exceptions may exist, as in grossly unstable grade 3 pivot-shift knees and revision knees. However, the concern exists of overconstraining normal tibial rotations.
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Affiliation(s)
- Frank R Noyes
- Cincinnati Sports Medicine and Orthopaedic Center-Mercy Health, Cincinnati, Ohio, USA.,The Noyes Knee Institute, Cincinnati, Ohio, USA
| | - Lauren E Huser
- Cincinnati Sports Medicine and Orthopaedic Center-Mercy Health, Cincinnati, Ohio, USA.,The Noyes Knee Institute, Cincinnati, Ohio, USA
| | - Darin Jurgensmeier
- Cincinnati Sports Medicine and Orthopaedic Center-Mercy Health, Cincinnati, Ohio, USA.,The Noyes Knee Institute, Cincinnati, Ohio, USA
| | - James Walsh
- Cincinnati Sports Medicine and Orthopaedic Center-Mercy Health, Cincinnati, Ohio, USA.,The Noyes Knee Institute, Cincinnati, Ohio, USA
| | - Martin S Levy
- Department of Operations and Business Analytics, College of Business, University of Cincinnati, Cincinnati, Ohio, USA
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16
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Di Benedetto P, Di Benedetto E, Fiocchi A, Beltrame A, Causero A. Causes of Failure of Anterior Cruciate Ligament Reconstruction and Revision Surgical Strategies. Knee Surg Relat Res 2016; 28:319-324. [PMID: 27894180 PMCID: PMC5134790 DOI: 10.5792/ksrr.16.007] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 07/26/2016] [Accepted: 07/29/2016] [Indexed: 01/09/2023] Open
Abstract
Purpose Long-term outcomes of anterior cruciate ligament (ACL) reconstruction are good or excellent; however, 0.7%–20% of patients suffer from recurrent instability due to graft failure. The purpose of this paper was to analyse failure aetiology and the possibilities of revision surgical strategies, with a description of our experience. We obtained optimal and good results in most of our patients. Materials and Methods We retrospectively reviewed 42 patients who underwent revision surgery (43 revisions) due to relapsing instability after ACL reconstruction between 2006 and 2015. We used allografts in 39 cases and autografts in 4 cases. Results The 85.7% of the patients obtained optimal results (normal knee; group A) and the 7.2% obtained good results (nearly normal knee; group B) according to the International Knee Documentation Committee score. The most frequent failure causes were traumatic events, non-anatomic tunnel placement, and lack of graft incorporation. Conclusions A correct revision surgery requires accurate patient evaluation and knee imaging. Preoperative planning starts with the identification of the cause of failure of the primary reconstruction. Then, the most suitable procedure should be determined for each case. It is also important to accurately inform the patient of all the complexity of an ACL revision surgery even if it is a procedure with high rates of excellent and good outcomes.
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Affiliation(s)
| | | | - Andrea Fiocchi
- Clinic of Orthopaedics, Academic Hospital of Udine, Udine, Italy
| | | | - Araldo Causero
- Clinic of Orthopaedics, Academic Hospital of Udine, Udine, Italy
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Mirouse G, Rousseau R, Casabianca L, Ettori MA, Granger B, Pascal-Moussellard H, Khiami F. Return to sports and functional results after revision anterior cruciate ligament reconstruction by fascia lata autograft. Orthop Traumatol Surg Res 2016; 102:863-866. [PMID: 27720633 DOI: 10.1016/j.otsr.2016.06.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Revised: 06/11/2016] [Accepted: 06/17/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The surgical revision rate following anterior cruciate ligament (ACL) surgery is 3% at 2 years and 4% at 5 years. Revision ACL surgery raises the question of the type of graft to be used. The present study assessed return to sports and functional results after revision ACL reconstruction by fascia lata graft. The hypothesis was that fascia lata provides a reliable graft in revision ACL surgery. MATERIAL AND METHODS A single-center retrospective continuous study included 30 sports players with a mean age of 26.8±8 years undergoing surgical revision for iterative ACL tear between 2004 and 2013. Multi-ligament lesions were excluded. Type and level of sports activity were assessed preoperatively, after primary surgery and at end of follow-up. Clinical assessment used subjective IKDC, Lysholm and KOOS scores. RESULTS At a mean 4.6±1.6 years' follow-up, all patients had resumed sport activity, but only 12 with the same sport at the same level. Median subjective IKDC score increased from 57 [54.3; 58.5] preoperatively to 82 [68.3; 90] at last follow-up, and Lysholm score from 46 [42.3; 51] to 90.5 [80.8; 96.8]; KOOS score at last follow-up was 94.7 [83; 100]. CONCLUSION Functional results in revision ACL reconstruction by fascia lata graft were satisfactory, with similar return-to-sports rates as with other techniques. Fascia lata provides a reliable graft in revision ACL surgery. LEVEL OF EVIDENCE IV, retrospective study.
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Affiliation(s)
- G Mirouse
- Département de Chirurgie Orthopédique et Traumatologie du Sport, Groupe Hospitalier Pitié-Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France.
| | - R Rousseau
- Département de Chirurgie Orthopédique et Traumatologie du Sport, Groupe Hospitalier Pitié-Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - L Casabianca
- Département de Chirurgie Orthopédique et Traumatologie du Sport, Groupe Hospitalier Pitié-Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - M A Ettori
- Département de Chirurgie Orthopédique et Traumatologie du Sport, Groupe Hospitalier Pitié-Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - B Granger
- Département de Biostatistiques, de Santé Publique et d'Information Médicale, Groupe Hospitalier Pitié-Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - H Pascal-Moussellard
- Département de Chirurgie Orthopédique et Traumatologie du Sport, Groupe Hospitalier Pitié-Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - F Khiami
- Département de Chirurgie Orthopédique et Traumatologie du Sport, Groupe Hospitalier Pitié-Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
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Extra-articular tenodesis combined with an anterior cruciate ligament reconstruction in acute anterior cruciate ligament tear in elite female football players. INTERNATIONAL ORTHOPAEDICS 2016; 40:2091-2096. [DOI: 10.1007/s00264-016-3261-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 07/25/2016] [Indexed: 01/26/2023]
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19
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Al-Bluwi MT, Azam MQ, Sadat-Ali M. The effect of bone growth factor in the tendon to bone healing in anterior cruciate ligament reconstruction: An experimental study in rabbits. Int J Appl Basic Med Res 2016; 6:23-7. [PMID: 26958518 PMCID: PMC4765269 DOI: 10.4103/2229-516x.174004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Reconstruction of the anterior cruciate ligament (ACL) involves use of semintendinosis and gracilis tendons graft that is transplanted into bone tunnels at the femoral and tibial insertion sites and the sites and the bone tendon interface is a weak link in the early healing period due to slow rate of healing. We hypothesized that an addition of bone growth factor like Sadat-Habdan mesenchymal stimulating peptide (SHMSP) could enhance bone tendon healing rate so that re-rupture of the tendon does not take place. METHODOLOGY Twenty skeletally mature rabbits underwent ACL reconstruction of the right knee. In 10 of the rabbits at the site of the tendon-graft 5 mg/kg body weight of SHMSP was put in the bone tunnel. In 10 other animals, nothing was added. At eight and 12 weeks 5 animals from each group were sacrificed. The tendon-graft site was harvested and sent for histopathological examination to assess the healing at the tendon-bone graft to the tibial tunnel. RESULTS There were no deaths in both the groups. One rabbit of the control group developed an infection. In all the animals of the study group from 4 weeks onward showed bone formation, wherein the control group only granulation tissue was observed. By 8 weeks in the study group, the canal was totally obliterated with the new bone formation which extended onto the periosteal area. In the control, there was minimal change in the formation of the new bone formation. CONCLUSION Addition of a growth factor like SHMSP would enhance the osteo-integration of the tendon-graft in the bony tunnel after ACL reconstruction in vivo.
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Affiliation(s)
- Mohammed T Al-Bluwi
- Department of Orthopedic Surgery, College of Medicine, University of Dammam, King Fahd Hospital of the University, Al Khobar, Saudi Arabia
| | - Md Q Azam
- Department of Orthopedic Surgery, College of Medicine, University of Dammam, King Fahd Hospital of the University, Al Khobar, Saudi Arabia
| | - Mir Sadat-Ali
- Department of Orthopedic Surgery, College of Medicine, University of Dammam, King Fahd Hospital of the University, Al Khobar, Saudi Arabia
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Grassi A, Ardern CL, Marcheggiani Muccioli GM, Neri MP, Marcacci M, Zaffagnini S. Does revision ACL reconstruction measure up to primary surgery? A meta-analysis comparing patient-reported and clinician-reported outcomes, and radiographic results. Br J Sports Med 2016; 50:716-24. [PMID: 26809259 DOI: 10.1136/bjsports-2015-094948] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 12/17/2015] [Indexed: 02/03/2023]
Abstract
PURPOSE To compare patient-reported and clinician-reported outcomes, and radiographic results between patients who had had revision ACL reconstruction and those who had had primary ACL reconstruction. DESIGN Systematic review and meta-analysis DATA SOURCES The MEDLINE, CINAHL, EMBASE and SPORTDiscus electronic databases were searched on 6 August 2015, using 3 main concepts: (1) revision ACL reconstruction, (2) primary ACL reconstruction and (3) treatment outcomes. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Articles that compared patient-reported or clinician-reported outcomes or radiographic results between patients who had had revision ACL reconstruction and those who had had primary surgery with a minimum of 2 years follow-up were included. The outcomes evaluated were the Lysholm Knee Scoring Scale, objective International Knee Documentation Committee (IKDC) classification, Tegner Activity Scale, side-to-side difference in anterior tibial translation measured with KT-1000/2000 arthrometer, pivot shift test, tibiofemoral osteoarthritis grading on plain radiographs and subsequent knee surgeries. RESULTS 8 studies (300 revision ACL reconstructions and 413 primary ACL reconstructions) were included in the meta-analysis. Patients who had had revision surgery reported inferior Lysholm Knee Scoring Scale scores (mean difference: 7.8 points), had inferior clinician-reported knee function as assessed with the objective IKDC classification (IKDC category A: 27% vs 57%; IKDC category C or D: 22% vs 8%) and pivot shift test (grade II or III: 7% vs 2%), and more radiographic evidence of tibiofemoral osteoarthritis (50% vs 25%) compared with patients who had had primary surgery. CONCLUSIONS Revision ACL reconstruction restored similar anterior-posterior knee laxity compared with primary ACL reconstruction. Patients who had had revision surgery reported inferior Lysholm Knee Scoring Scale scores, had inferior clinician-reported knee function and more radiographic signs of tibiofemoral osteoarthritis compared with patients with primary ACL reconstruction.
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Affiliation(s)
- Alberto Grassi
- II Clinica Ortopedica e Traumatologica, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Clare L Ardern
- Aspetar Orthopaedic & Sports Medicine Hospital, Doha, Qatar Division of Physiotherapy, Linköping University, Linköping, Sweden School of Allied Health, La Trobe University, Melbourne, Australia
| | | | - Maria Pia Neri
- II Clinica Ortopedica e Traumatologica, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Maurilio Marcacci
- II Clinica Ortopedica e Traumatologica, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Stefano Zaffagnini
- II Clinica Ortopedica e Traumatologica, Istituto Ortopedico Rizzoli, Bologna, Italy
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Andriolo L, Filardo G, Kon E, Ricci M, Della Villa F, Della Villa S, Zaffagnini S, Marcacci M. Revision anterior cruciate ligament reconstruction: clinical outcome and evidence for return to sport. Knee Surg Sports Traumatol Arthrosc 2015. [PMID: 26202138 DOI: 10.1007/s00167-015-3702-9] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE An increasing number of patients undergo revision anterior cruciate ligament (ACL) reconstruction, with the intention of returning to sport being a major indication. The aim of this study is to assess the available evidence for clinical improvement and return to sport, to understand the real potential of this procedure in regaining functional activity, and to facilitate improved counselling of patients regarding the expected outcome after revision ACL reconstruction. METHODS The search was conducted on the PubMed database. Articles reporting clinical results for revision ACL reconstruction were included. A meta-analysis was performed on return to sport, and results were compared to the literature on primary ACL reconstruction. Other specific clinical outcomes (Lysholm, Tegner, IKDC Objective scores) were also included in the meta-analysis. RESULTS Of the 503 identified records, a total of 59 studies involving 5365 patients were included in the qualitative data synthesis. Only 31 articles reported the rate of return to sport. Whereas 73 % of good objective results and satisfactory subjective results were documented, 57 % of patients did not return to the same level of sport activity, significantly inferior to that of a primary procedure. CONCLUSION The real potential of revision ACL reconstruction should not be overestimated due to the low number of patients able to return to their previous activity level, significantly inferior with respect to that reported for primary ACL reconstruction. This finding will help physicians in the clinical practice providing realistic expectations to the patients. Future studies should focus on participation-based outcome measures such as return to sport and in strategies to improve the results in terms of return to previous activities after revision ACL reconstruction. LEVEL OF EVIDENCE Systematic review and meta-analysis including Level IV studies, Level IV.
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Affiliation(s)
- Luca Andriolo
- II Orthopaedic and Traumatologic Clinic - Biomechanics and Technology Innovation Laboratory, Rizzoli Orthopaedic Institute, Via Di Barbiano, 1/10, 40136, Bologna, Italy.
| | - Giuseppe Filardo
- II Orthopaedic and Traumatologic Clinic - Biomechanics and Technology Innovation Laboratory, Rizzoli Orthopaedic Institute, Via Di Barbiano, 1/10, 40136, Bologna, Italy
| | - Elizaveta Kon
- II Orthopaedic and Traumatologic Clinic - Biomechanics and Technology Innovation Laboratory, Rizzoli Orthopaedic Institute, Via Di Barbiano, 1/10, 40136, Bologna, Italy.,Nano-Biotechnology Laboratory, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Margherita Ricci
- Isokinetic Medical Group, FIFA Medical Centre of Excellence, Bologna, Italy
| | | | | | - Stefano Zaffagnini
- II Orthopaedic and Traumatologic Clinic - Biomechanics and Technology Innovation Laboratory, Rizzoli Orthopaedic Institute, Via Di Barbiano, 1/10, 40136, Bologna, Italy
| | - Maurilio Marcacci
- II Orthopaedic and Traumatologic Clinic - Biomechanics and Technology Innovation Laboratory, Rizzoli Orthopaedic Institute, Via Di Barbiano, 1/10, 40136, Bologna, Italy
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Grassi A, Zaffagnini S, Marcheggiani Muccioli GM, Neri MP, Della Villa S, Marcacci M. After revision anterior cruciate ligament reconstruction, who returns to sport? A systematic review and meta-analysis. Br J Sports Med 2015; 49:1295-304. [PMID: 26062956 DOI: 10.1136/bjsports-2014-094089] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND Return to sport and to pre-injury level represents an important outcome after both primary and revision anterior cruciate ligament (ACL) reconstructions. PURPOSE The aim of the present meta-analysis was to determine the return to sport rate after revision ACL reconstruction. MATERIAL AND METHODS A systematic search was performed of the MEDLINE, Embase and the Cochrane Central Register of Controlled Trials Databases. All the studies that reported return to sport, return to pre-injury sport level and return to high level/competitive sport was considered for the meta-analysis. The overall pooled mean of post-operative knee laxity and pooled rate of positive pivot-shift and objective International Knee Documentation Committee (IKDC) categories was calculated as well. RESULTS Overall, 472 abstracts were identified and screened for inclusion and only 16 studies reported the rate of return to any level of sport activity at the final follow-up of 4.7 years (range 1.0-13.2 years), showing a pooled rate of 85.3% (CI 79.7 to 90.2). The return to pre-injury sport level was achieved in 53.4% (CI 37.8 to 68.7) of cases. Normal or quasi-normal objective IKDC, less than 5 mm of side-to-side difference at arthrometric evaluations and grade I-II pivot-shift test were reported in 84%, 88% and 93% patients, respectively. CONCLUSIONS In spite of almost 8 patients out of 10 returning to sport after revision ACL reconstruction and showing good stability, only half of the patients returned to the same pre-injury sport level.
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Affiliation(s)
- Alberto Grassi
- Clinica Ortopedica e Traumatologica II-Lab. di Biomeccanica, ed Innovazione Tecnologica, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Stefano Zaffagnini
- Clinica Ortopedica e Traumatologica II-Lab. di Biomeccanica, ed Innovazione Tecnologica, Istituto Ortopedico Rizzoli, Bologna, Italy
| | | | - Maria Pia Neri
- Clinica Ortopedica e Traumatologica II-Lab. di Biomeccanica, ed Innovazione Tecnologica, Istituto Ortopedico Rizzoli, Bologna, Italy
| | | | - Maurilio Marcacci
- Clinica Ortopedica e Traumatologica II-Lab. di Biomeccanica, ed Innovazione Tecnologica, Istituto Ortopedico Rizzoli, Bologna, Italy
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Abstract
Context: Reconstruction of the anterior cruciate ligament (ACL) is one of the most common surgical procedures, with more than 200,000 ACL tears occurring annually. Although primary ACL reconstruction is a successful operation, success rates still range from 75% to 97%. Consequently, several thousand revision ACL reconstructions are performed annually and are unfortunately associated with inferior clinical outcomes when compared with primary reconstructions. Evidence Acquisition: Data were obtained from peer-reviewed literature through a search of the PubMed database (1988-2013) as well as from textbook chapters and surgical technique papers. Study Design: Clinical review. Level of Evidence: Level 4. Results: The clinical outcomes after revision ACL reconstruction are largely based on level IV case series. Much of the existing literature is heterogenous with regard to patient populations, primary and revision surgical techniques, concomitant ligamentous injuries, and additional procedures performed at the time of the revision, which limits generalizability. Nevertheless, there is a general consensus that the outcomes for revision ACL reconstruction are inferior to primary reconstruction. Conclusion: Excellent results can be achieved with regard to graft stability, return to play, and functional knee instability but are generally inferior to primary ACL reconstruction. A staged approach with autograft reconstruction is recommended in any circumstance in which a single-stage approach results in suboptimal graft selection, tunnel position, graft fixation, or biological milieu for tendon-bone healing. Strength-of-Recommendation Taxonomy (SORT): Good results may still be achieved with regard to graft stability, return to play, and functional knee instability, but results are generally inferior to primary ACL reconstruction: Level B.
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Affiliation(s)
- Jeffrey Wilde
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Asheesh Bedi
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
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Chougule S, Tselentakis G, Stefan S, Stefanakis G. Revision of failed anterior cruciate ligament reconstruction with quadrupled semitendinosus allograft: intermediate-term outcome. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2014; 25:515-23. [DOI: 10.1007/s00590-014-1549-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 09/17/2014] [Indexed: 11/28/2022]
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Monaco E, Maestri B, Conteduca F, Mazza D, Iorio C, Ferretti A. Extra-articular ACL Reconstruction and Pivot Shift: In Vivo Dynamic Evaluation With Navigation. Am J Sports Med 2014; 42:1669-74. [PMID: 24799424 DOI: 10.1177/0363546514532336] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The pivot-shift test is considered a reliable examination to evaluate the results of anterior cruciate ligament (ACL) reconstruction, as it strongly correlates with patient satisfaction, giving-way episodes, and activity level. The addition of lateral tenodesis (LT) to current techniques of intra-articular reconstruction with a hamstring graft could potentially improve knee laxity in cases of severe rotational instability. PURPOSE To biomechanically investigate the effect of intra- and extra-articular ACL reconstructions on knee laxity and the pivot-shift phenomenon. STUDY DESIGN Controlled laboratory study. METHODS Twenty patients underwent anatomic single-bundle ACL reconstruction with doubled semitendinosus and gracilis tendons with the addition of extra-articular reconstruction. In patients in group A, intra-articular reconstruction was performed first and LT thereafter; in patients in group B, LT was performed first and intra-articular reconstruction thereafter. A navigator equipped with software designed for both static and dynamic evaluations was used to measure maximum anterior tibial translation (ATT) and axial tibial rotation (ATR) at 30° of flexion (static evaluation) and during the pivot-shift test (dynamic evaluation). Measurements were performed before reconstruction, after the first procedure, and after the second procedure. RESULTS For the static evaluation, in group A, the mean ATT significantly decreased from 14.1 ± 3.7 mm in the preoperative (ACL-deficient) condition to 6.0 ± 1.9 mm after ACL reconstruction and to 5.3 ± 1.6 mm after LT. The mean ATR at 30° of knee flexion significantly decreased from 35.7° ± 4.8° to 28.9° ± 4.1° and to 20.9° ± 4.8°, respectively. In group B, the mean ATT significantly decreased from 13.5 ± 6.5 mm in the preoperative (ACL-deficient) condition to 10.2 ± 3.2 mm after LT and to 4.0 ± 1.6 mm after ACL reconstruction. The mean ATR at 30° of knee flexion significantly decreased from 36.7° ± 4.8° to 26.2° ± 6.2° and to 23.5° ± 4.9°, respectively. For the dynamic evaluation (pivot-shift test), in group A, the mean ATT significantly decreased from 15.0 ± 6.8 mm in the preoperative (ACL-deficient) condition to 9.4 ± 6.4 mm after ACL reconstruction and to 8.5 ± 5.4 mm after LT. The mean ATR significantly decreased from 16.9° ± 4.7° to 11.6° ± 4.1° and to 6.1° ± 2.2°, respectively. In group B, the mean ATT significantly decreased from 12.5 ± 3.3 mm in the preoperative (ACL-deficient) condition to 9.1 ± 5.9 mm after LT and to 8.1 ± 5.4 mm after ACL reconstruction. The mean ATR significantly decreased from 16.0° ± 4.5° to 9.2° ± 4.3° and to 7.5° ± 4.0°, respectively. CONCLUSION/CLINICAL RELEVANCE Extra-articular reconstruction had little effect in reducing the anterior displacement of the tibia at 30° of flexion, but it was more effective than intra-articular reconstruction in reducing ATR. Anatomic ACL reconstruction and LT were synergic in controlling the pivot-shift phenomenon.
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Affiliation(s)
- Edoardo Monaco
- Kirk Kilgour Sports Injury Center, Sant'Andrea Hospital, University of Rome La Sapienza-II School of Medicine, Rome, Italy
| | - Barbara Maestri
- Kirk Kilgour Sports Injury Center, Sant'Andrea Hospital, University of Rome La Sapienza-II School of Medicine, Rome, Italy
| | - Fabio Conteduca
- Kirk Kilgour Sports Injury Center, Sant'Andrea Hospital, University of Rome La Sapienza-II School of Medicine, Rome, Italy
| | - Daniele Mazza
- Kirk Kilgour Sports Injury Center, Sant'Andrea Hospital, University of Rome La Sapienza-II School of Medicine, Rome, Italy
| | - Carlo Iorio
- Kirk Kilgour Sports Injury Center, Sant'Andrea Hospital, University of Rome La Sapienza-II School of Medicine, Rome, Italy
| | - Andrea Ferretti
- Kirk Kilgour Sports Injury Center, Sant'Andrea Hospital, University of Rome La Sapienza-II School of Medicine, Rome, Italy
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Shelbourne KD, Benner RW, Gray T. Return to Sports and Subsequent Injury Rates After Revision Anterior Cruciate Ligament Reconstruction With Patellar Tendon Autograft. Am J Sports Med 2014; 42:1395-400. [PMID: 24627577 DOI: 10.1177/0363546514524921] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The return-to-sport and reinjury rates are not well defined after revision anterior cruciate ligament (ACL) reconstruction. HYPOTHESIS School-age athletes would have a higher rate of return to sports and reinjury to either knee after revision ACL surgery compared with college or recreational athletes. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Patients were prospectively studied after revision ACL reconstruction with bone-patellar tendon-bone (BPTB) autograft. Participants were grouped by competitive sport levels of school age (mean age, 16.6 ± 0.9 years; n = 84), college (19.6 ± 1.2 years; n = 58), or recreational adult (27.6 ± 4.1 years; n = 117). An activity survey was used to determine the specific sport and sport level patients participated in before and after surgery. The International Knee Documentation Committee (IKDC) knee survey and Cincinnati Knee Rating System (CKRS) survey responses were also obtained. RESULTS The rate of return to the same sport at the same level was 62 of 84 school-age athletes (74%), 43 of 58 college athletes (74%), and 73 of 117 recreational athletes (62%) (P = .1065). The number of patients who had a subsequent ACL graft tear rate after revision surgery was 2 of 84 (2.3%) in the high school group, 3 of 58 (5.1%) in the college group, and 4 of 117 (3.4%) in the recreational group (P = .6706). The number of patients who had a subsequent ACL tear in the contralateral knee was 1 of 84 (1.1%) in the school-age group, 1 of 58 (1.7%) in the college group, and 2 of 117 (1.7%) in the recreational group (P = .9501). At 2 years postoperatively, the mean IKDC subjective total score was 86.1 ± 11.7 points and the mean CKRS total score was 89.7 ± 11.1 points. CONCLUSION Revision ACL reconstruction with BPTB autograft and perioperative rehabilitation allowed high school and college athletes to return to sports at the preinjury level at a rate of 74%; the return rate for recreational-level adults was 62%. Reinjury rates in the first 5 years after revision surgery ranged from 2% to 5%, which is lower than what has been reported for young competitive athletes after primary surgery.
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Affiliation(s)
| | | | - Tinker Gray
- Shelbourne Knee Center, Indianapolis, Indiana, USA
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Reverte-Vinaixa MM, Minguell J, Joshi N, Diaz-Ferreiro EW, Duarri G, Carrera L, Castellet E. Revision anterior cruciate ligament reconstruction using tibial or hamstring tendon allografts. J Orthop Surg (Hong Kong) 2014; 22:60-4. [PMID: 24781616 DOI: 10.1177/230949901402200116] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To report outcomes of revision anterior cruciate ligament (ACL) reconstruction using tibial or hamstring tendon allografts and to compare with another study using non-irradiated fresh-frozen bone-patellar tendon-bone allografts. METHODS Records of 12 men and 7 women aged 18 to 53 (mean, 33) years who underwent revision ACL reconstructions using tibial tendon (n=17) or hamstring tendon (n=2) allografts were retrospectively reviewed. At the time of primary ACL reconstruction, hamstring autografts (n=8) and bonepatellar tendon-bone allografts (n=11) were used. The mean time interval between surgeries was 93 (range, 11-225) months. The causes of failure were traumatic injury (n=7) and technical or biological reasons (n=12). The physical activity level was high in 2 patients, medium in 10, and low in 7. For clinical assessment, the Lysholm test, International Knee Documentation Committee (IKDC) scale, and visual analogue scale (VAS) for pain were used. Patient satisfaction was also assessed. RESULTS Four of the patients had laxity and were dissatisfied or very dissatisfied with the outcome; the failure rate was 21%. The mean IKDC score was 63% (range, 25-100%), and the mean Lysholm score was 74% (range, 30-100%). Comparing our patients with those in another study using bone-patellar-bone allografts, there was no significant difference in terms of the VAS for pain, IKDC score, and Lysholm score. Comparing our patients with and without chondral and/or meniscal lesions, there was significant difference in terms of the Lysholm score only (86±11 vs. 57±28, p=0.043). Comparing patients who had used hamstring tendon autografts at the primary ACL reconstruction with those who had used bonepatellar tendon-bone autografts, there was significant difference in terms of the VAS for pain only (4.4±3.1 vs. 1.6±1.0, p=0.020). CONCLUSION Revision ACL reconstruction using tibial or hamstring tendon allografts provided acceptable results, similar to those using the bone-patellar tendon-bone allografts.
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Affiliation(s)
- Maria Mercedes Reverte-Vinaixa
- Department of Trauma and Orthopaedic Surgery, Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
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Ferretti A, Monaco E, Caperna L, Palma T, Conteduca F. Revision ACL reconstruction using contralateral hamstrings. Knee Surg Sports Traumatol Arthrosc 2013; 21:690-5. [PMID: 22572869 DOI: 10.1007/s00167-012-2039-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Accepted: 04/19/2012] [Indexed: 11/26/2022]
Abstract
PURPOSE Due to the increasing number of primary anterior cruciate ligament (ACL) reconstructions, the need for revision surgery has risen. The aim of this study was to evaluate the use of contralateral doubled semitendinosus and gracilis tendon (DGST) for revision anterior cruciate ligament reconstruction. METHODS Twelve patients undergoing revision ACL reconstruction with hamstring tendon were examined at an average follow-up of 3 years. All patients underwent a thorough subjective and objective evaluation, which included a KT-1000 arthrometric evaluation, and a radiographic examination. RESULTS Subjective evaluation yielded a median score of 5.5 (range 2-9) on the Tegner activity scale. The mean Lysholm score was 95 (SD 9.5), and the mean subjective IKDC 2000 score was 95.4 (SD 7.8). At physical examination, a negative Lachman test was found in ten patients; one patient had a positive Lachman test with a firm end-point, and one other patient had a clearly positive Lachman test. Two patients had a grade 1+ on pivot shift testing. Only 1 patient showed a side-to-side difference more than 5 mm at the maximum manual KT-1000 arthrometer. Three patients (25 %) showed initial signs of osteoarthritis. CONCLUSIONS The results of the study show that the use of hamstring tendons harvested from the unaffected knee represents a valid option for revision surgery following a failed primary ACL reconstruction using DGST grafts. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Andrea Ferretti
- Azienda Ospedaliera S. Andrea, Via di Grottarossa, 1035, Rome, Italy.
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Duthon VB, Magnussen RA, Servien E, Neyret P. ACL Reconstruction and Extra-articular Tenodesis. Clin Sports Med 2013. [DOI: 10.1016/j.csm.2012.08.013] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Abstract
Failure after anterior cruciate ligament reconstruction is a potentially devastating event that affects a predominantly young and active population. This review article provides a comprehensive analysis of the potential causes of failure, including graft failure, loss of motion, extensor mechanism dysfunction, osteoarthritis, and infection. The etiology of graft failure is discussed in detail with a particular emphasis on failure after anatomic anterior cruciate ligament reconstruction.
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Revision ACL reconstruction: influence of a lateral tenodesis. Knee Surg Sports Traumatol Arthrosc 2012; 20:1565-70. [PMID: 22102009 DOI: 10.1007/s00167-011-1765-9] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Accepted: 11/03/2011] [Indexed: 10/15/2022]
Abstract
PURPOSE The aims of this article were to report the objective results of revision ACL reconstruction and to assess the influence of an associated lateral extra-articular tenodesis on knee stability and IKDC score. METHODS This study focused on revision ACL reconstruction and was conducted over a 10-year period, from 1994 to 2003 with ten French orthopedic centers participating. The minimum follow-up required was 2 years. To be included, patients had to be evaluated at follow-up with the objective International Knee Documenting Committee (IKDC) scoring system. In 2006, 163 patients met the inclusion criteria. RESULTS The objective IKDC knee score improved significantly after revision ACL reconstruction, with 72% IKDC A + B (26% A). When a lateral tenodesis was performed, 80% had a negative pivot shift, versus 63% without (P = 0.03), but there was no significant difference in the IKDC score. CONCLUSION This study shows a significant improvement in the IKDC score after revision ACL reconstruction. The association of a lateral extra-articular tenodesis with the intra-articular graft increases knee stability after revision ACL reconstruction; however, this additional procedure does not significantly alter the IKDC score at follow-up. LEVEL OF EVIDENCE Retrospective case series, Level IV.
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32
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Lee YHD, Kuroda R, Zhao J, Chan KM. A tale of 10 European centres - 2010 APOSSM travelling fellowship review in ACL surgery. Sports Med Arthrosc Rehabil Ther Technol 2012; 4:27. [PMID: 22839644 PMCID: PMC3500227 DOI: 10.1186/1758-2555-4-27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Accepted: 07/03/2012] [Indexed: 11/10/2022]
Abstract
The purpose of ESSKA- APOSSM Travelling fellowship is to better understand the epidemiology, management and surgical techniques for sports across continents. There has been a progressive evolution in ACL reconstruction and there is variation in technique in ACL reconstruction amongst the most experienced surgeons in different continents. During this one month fellowship, we saw various ACL reconstruction techniques using different graft sources, with a variety of graft fixation methods, with the common aim of recreating an anatomical ACL reconstruction.
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Affiliation(s)
- Yee Han Dave Lee
- Department of Orthopedic Surgery, Changi General Hospital, 2 Simei St 3, Singapore, 529889, Singapore.
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Wright RW, Gill CS, Chen L, Brophy RH, Matava MJ, Smith MV, Mall NA. Outcome of revision anterior cruciate ligament reconstruction: a systematic review. J Bone Joint Surg Am 2012; 94:531-6. [PMID: 22438002 PMCID: PMC3298683 DOI: 10.2106/jbjs.k.00733] [Citation(s) in RCA: 192] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Revision anterior cruciate ligament (ACL) reconstruction is believed to have an inferior outcome compared with primary ACL reconstruction. The available literature on the outcome of revision ACL reconstruction is sparse compared with that for primary reconstruction. The purpose of this systematic review was to test the hypothesis that the outcome of revision ACL reconstruction compares unfavorably with the historical outcome of primary ACL reconstruction. METHODS A systematic review of studies evaluating the outcome of revision ACL reconstructions with a minimum of two years of follow-up was performed. Pooled data were collected when appropriate and a mixed-effect-model meta-analysis was performed for important outcome measures that were reported in several studies (objective graft failure, Lysholm score, International Knee Documentation Committee [IKDC] subjective score, and IKDC objective score). Objective failure was defined as repeat revision, a side-to-side difference of >5 mm measured with use of a KT1000 arthrometer, or a pivot-shift grade of 2+ or 3+. RESULTS Twenty-one studies were included, and 863 of the 1004 patients in these studies had a minimum of two years of follow-up and were analyzed. The pooled mean age of the patients at the time of the revision procedure was 30.6 years, and 66% were male. Objective failure occurred in 13.7% ± 2.7% of the patients (95% confidence interval, 8.0% to 19.4%). The mean Lysholm score in 491 patients was 82.1 ± 3.3 (95% confidence interval, 74.6 to 89.5) according to a mixed-model meta-analysis. The mean IKDC subjective score in 202 patients was 74.8 ± 4.4 (95% confidence interval, 62.5 to 87.0). CONCLUSIONS Revision ACL reconstruction resulted in a worse outcome compared with primary ACL reconstruction. Patient-reported outcome scores were inferior to previously published results of primary ACL reconstruction, but these differences may not be clinically important. A dramatically elevated failure rate was noted after revision ACL reconstruction; this rate was nearly three to four times the failure rate in prospective series of primary ACL reconstructions.
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Affiliation(s)
- Rick W. Wright
- Department of Orthopaedic Surgery, Washington University School of Medicine, 1 Barnes Hospital Plaza, Suite 11300 West Pavilion, St. Louis, MO 63110. E-mail address for R.W. Wright:
| | - Corey S. Gill
- Department of Orthopaedic Surgery, Washington University School of Medicine, 1 Barnes Hospital Plaza, Suite 11300 West Pavilion, St. Louis, MO 63110. E-mail address for R.W. Wright:
| | - Ling Chen
- Division of Biostatistics, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8067, St. Louis, MO 63110
| | - Robert H. Brophy
- Department of Orthopaedic Surgery, Washington University School of Medicine, 1 Barnes Hospital Plaza, Suite 11300 West Pavilion, St. Louis, MO 63110. E-mail address for R.W. Wright:
| | - Matthew J. Matava
- Department of Orthopaedic Surgery, Washington University School of Medicine, 1 Barnes Hospital Plaza, Suite 11300 West Pavilion, St. Louis, MO 63110. E-mail address for R.W. Wright:
| | - Matthew V. Smith
- Department of Orthopaedic Surgery, Washington University School of Medicine, 1 Barnes Hospital Plaza, Suite 11300 West Pavilion, St. Louis, MO 63110. E-mail address for R.W. Wright:
| | - Nathan A. Mall
- Department of Orthopaedic Surgery, Washington University School of Medicine, 1 Barnes Hospital Plaza, Suite 11300 West Pavilion, St. Louis, MO 63110. E-mail address for R.W. Wright:
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Abstract
BACKGROUND We developed the rectangular tunnel ACL reconstruction (RT ACLR) using a 10-mm wide bone-patellar tendon-bone (BTB) graft through rectangular tunnels with a rectangular aperture to reduce tunnel size: the cross-sectional area of the tunnels of 50 mm(2) (5 × 10 mm) in RT ACLR is less than that of 79 mm(2) in a conventional 10-mm round tunnel technique presuming the technique would be more suitable in revision ACLR with previous improperly placed tunnels. DESCRIPTION OF TECHNIQUE Two contiguous 5-mm tunnels inside the anatomic ACL femoral and tibial attachment areas along their long axes, and they are expanded with a 5 × 10-mm dilator into parallelepiped ones. PATIENTS AND METHODS We indicated and intended to perform the RT ACLR procedure in 31 patients requiring revision between 2004 and 2008. Eighteen of the 31 patients treated with the procedure were followed a minimum of 24 months (mean, 38 months; range, 24 to 73 months). We evaluated ROM, obtained IKDC scores, and determined stability with KT-1000. RESULTS The procedure could be applied in 30 of the 31 cases. One of the 18 reruptured the graft at 28 months. Of the remaining 17 patients with followup of 24 months or longer, 15 had full ROM, while the remaining two lost 5° of flexion; 11 were classified as normal and six were nearly normal according to the IKDC evaluation. Stability measured with KT-1000 was 1.0 ± 1.5 mm. CONCLUSION The RT ACLR technique provided acceptable results after one-stage revision ACLR. LEVEL OF EVIDENCE Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Reinhardt KR, Hammoud S, Bowers AL, Umunna BP, Cordasco FA. Revision ACL reconstruction in skeletally mature athletes younger than 18 years. Clin Orthop Relat Res 2012; 470:835-42. [PMID: 21739323 PMCID: PMC3270189 DOI: 10.1007/s11999-011-1956-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Young, active, skeletally mature patients have higher failure rates after various surgical procedures, including stabilization for shoulder instability and primary ACL reconstruction. It is unclear whether young, active, skeletally mature patients share similarly high failure rates after revision ACL reconstruction. QUESTIONS/PURPOSES We therefore determined whether revision ACL reconstruction restores knee stability and allows young (younger than 18 years), active, skeletally mature patients to return to preinjury activity levels. PATIENTS AND METHODS We retrospectively identified 36 patients who had an initial ACL reconstruction between the ages of 12 and 17 years (mean, 15.4 years) and subsequent revision between the ages of 13 and 18 years (mean, 16.9 years); of these, 2-year followup was available for 21 (75%). Mechanisms of primary graft failure included traumatic rerupture (23 noncontact, seven contact), persistent instability (five), and infection (one). One patient had open physes at the time of revision. All revisions were single-stage transosseous reconstructions. The minimum followup was 24 months (mean, 36 months; range, 24-63 months). RESULTS At last followup, 19 of 21 patients had a negative or IA Lachman and 20 of 21 had a negative pivot shift. Mean International Knee Documentation Committee subjective score was 89 (range, 64-99). Eleven of the 21 patients returned to the same or higher activity/sport level as before their original injury. Two patients reported subjective knee instability, with two having repeat revision reconstruction for failure. CONCLUSIONS Single-stage transosseous revision ACL reconstruction in young, active, skeletally mature patients restores knee stability but returns only 52% of patients to their prior level of activity or sport. LEVEL OF EVIDENCE Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Keith R. Reinhardt
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY USA
| | - Sommer Hammoud
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY USA
| | - Andrea L. Bowers
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | | | - Frank A. Cordasco
- Sports Medicine and Shoulder Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA ,Department of Orthopaedic Surgery, Weill Cornell Medical College, New York, NY USA
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LaFrance RM, Gorczyca JT, Maloney MD. Anterior cruciate ligament reconstruction failure after tibial shaft malunion. Orthopedics 2012; 35:e267-71. [PMID: 22310418 DOI: 10.3928/01477447-20120123-24] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Anterior cruciate ligament (ACL) reconstruction is common, with >100,000 procedures performed each year in the United States. Several factors are associated with failure, including poor surgical technique, graft incorporation failure, overly aggressive rehabilitation, and trauma. Tibial shaft fracture is also common and frequently requires operative intervention. Failure to reestablish the anatomic alignment of the tibia may cause abnormal forces across adjacent joints, which can cause degenerative joint disease or attritional failure of the surrounding soft tissues. This article describes a case of ACL reconstruction failure after a tibial fracture that resulted in malunion. Excessive force across the graft from lower-extremity malalignment and improper tunnel placement likely contributed to the attritional failure of the graft. This patient required a staged procedure for corrective tibial osteotomy followed by revision ACL reconstruction. This article describes ACL reconstruction failure, tibial shaft malunions, their respective treatments, the technical details of each procedure, and the technical aspects that must be considered when these procedures are done in a staged manner by 2 surgeons.
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Affiliation(s)
- Russell M LaFrance
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, New York, USA.
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Dodds AL, Gupte CM, Neyret P, Williams AM, Amis AA. Extra-articular techniques in anterior cruciate ligament reconstruction: a literature review. ACTA ACUST UNITED AC 2012; 93:1440-8. [PMID: 22058292 DOI: 10.1302/0301-620x.93b11.27632] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This annotation considers the place of extra-articular reconstruction in the treatment of anterior cruciate ligament (ACL) deficiency. Extra-articular reconstruction has been employed over the last century to address ACL deficiency. However, the technique has not gained favour, primarily due to residual instability and the subsequent development of degenerative changes in the lateral compartment of the knee. Thus intra-articular reconstruction has become the technique of choice. However, intra-articular reconstruction does not restore normal knee kinematics. Some authors have recommended extra-articular reconstruction in conjunction with an intra-articular technique. The anatomy and biomechanics of the anterolateral structures of the knee remain largely undetermined. Further studies to establish the structure and function of the anterolateral structures may lead to more anatomical extra-articular reconstruction techniques that supplement intra-articular reconstruction. This might reduce residual pivot shift after an intra-articular reconstruction and thus improve the post-operative kinematics of the knee.
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Affiliation(s)
- A L Dodds
- Imperial College NHS Trust/St Mary's and Charing Cross Hospitals, Praed Street, London W2 1NY, UK
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Lind M, Lund B, Faunø P, Said S, Miller LL, Christiansen SE. Medium to long-term follow-up after ACL revision. Knee Surg Sports Traumatol Arthrosc 2012; 20:166-72. [PMID: 21800165 DOI: 10.1007/s00167-011-1629-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2011] [Accepted: 07/14/2011] [Indexed: 02/01/2023]
Abstract
PURPOSE The aim of the present study is to present epidemiology and clinical outcome after revision anterior cruciate ligament (ACL) reconstruction with an intermediate follow-up time of up to 9 years. METHODS A retrospective study of patients treated with ACL revision from 2001 to 2007 at a university referral clinic was conducted. Study follow-up was performed in 2010; this follow-up included objective IKDC scores, KOOS, Tegner and SANE subjective scores, KT-1000 knee laxity measurements and registration of reoperations and complications. RESULTS One hundred and twenty-eight patients were available for follow-up. Median follow-up time was 6 (2-9) years. Mean age was 32 years, 50% were men. Eleven percent required staged procedures, 30% were reconstructed with allograft tendons and 23% had collateral ligament reconstruction in combination with the ACL revision. SANE knee global score (0-100) was 74 at follow-up, KOOS sub-scores were preoperatively 66, 69, 77, 42 and 39 for pain, symptoms, activity of daily living, sports and quality of life, respectively. At follow-up, scores were 70, 76, 81, 50 and 50, respectively. Sport and quality of life scores increased significantly. KT-1000 was 6.2 mm preoperatively and 2.5 at follow-up (P < 0.05). Six percent were re-revised and 2 patients had total knee replacements. CONCLUSION Despite objective findings of acceptable sagittal knee stability at follow-up, subjective outcome scores indicate significant knee impairment with low scores in sport and quality of life. A re-revision rate of 6% after 6 years is acceptable. It is imperative that patients eligible for ACL revision receive proper counseling in terms of outcome expectancies. LEVEL OF EVIDENCE Retrospective case series, Level IV.
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Affiliation(s)
- Martin Lind
- Division of Sports Trauma, Orthopedic Department, Aarhus University Hospital, Tage Hansensgade 2, 8000, Aarhus C, Denmark.
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Ahn JH, Lee YS, Chang MJ, Yim HS. Analysis of Revision Anterior Cruciate Ligament Reconstruction according to the combined injury, degenerative change, and MRI findings. Knee 2011; 18:382-6. [PMID: 21185729 DOI: 10.1016/j.knee.2010.11.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Revised: 10/12/2010] [Accepted: 11/01/2010] [Indexed: 02/02/2023]
Abstract
The purposes of this study were to analyze the results of revision ACL reconstruction, and to determine the effects of pre-revision combined injuries, degenerative changes, and post-revision magnetic resonance imaging (MRI) findings on clinical results. Forty patients (41 operations) were enrolled in this study. Clinical results and stabilities were evaluated. Radiological results were evaluated using Fairbank scale. For the subgroup analysis, Fairbank scale and preoperative combined injuries were used. Follow-up MRIs were also available for 31(75.6%) patients and we searched for relations between MRI findings and clinical results. Significant improvements in subjective, objective scores (p<0.0001), and stability (p<0.0001) were observed between pre-revision surgery and final follow-up results. In the subgroup analysis according to the degenerative change, the mild group achieved better clinical results than the severe group (p=0.015 and 0.035, respectively). In the subgroup analysis according to the combined injuries, no significant difference was observed between 2 groups in terms of final follow-up Lysholm and IKDC subjective scores (p=0.083 and 0.085, respectively). No relation was found between clinical or stability results and MRI findings (p=0.26~0.99). Our results show that the severities of combined injuries were not correlated with clinical results, but the severities of degenerative changes were correlated with clinical results and that results were better in the no or mildly degenerated group. We also found that MRI is helpful for evaluating revision ACL, but that no relation was found between clinical or stability results and MRI findings of the graft after revision surgery.
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Affiliation(s)
- Jin Hwan Ahn
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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40
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Arthroscopic intra- and extra-articular anterior cruciate ligament reconstruction with gracilis and semitendinosus tendons: a review. Curr Rev Musculoskelet Med 2011; 4:73-7. [PMID: 21594691 DOI: 10.1007/s12178-011-9075-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The purposes of this paper are to summarize the concepts relating to the use of a combined intra-articular and extra-articular reconstructive procedure in the arthroscopic treatment of a torn ACL and to review several operative techniques utilizing gracilis and semitendinosus tendons that are currently in use to treat this instability. The highly satisfactory results obtained over the time show that a combination of intra- and extra-articular procedures for ACL reconstruction is a valid surgical option.
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Colombet P. Knee laxity control in revision anterior cruciate ligament reconstruction versus anterior cruciate ligament reconstruction and lateral tenodesis: clinical assessment using computer-assisted navigation. Am J Sports Med 2011; 39:1248-54. [PMID: 21335352 DOI: 10.1177/0363546510395462] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Rotational laxity control is one of the different options to improve functional results after anterior cruciate ligament reconstruction. Lateral extra-articular tenodesis has been proposed to reduce the rotational laxity, especially in challenging situations such as revision reconstruction after biological failure. We currently lack the practical clinical tools to objectively assess knee rotational laxities. HYPOTHESIS Addition of a lateral tenodesis to anatomic single-bundle anterior cruciate ligament reconstruction with hamstring tendon graft could improve the knee laxity control, particularly the internal rotation, compared with a standard single-bundle anterior cruciate ligament reconstruction. STUDY DESIGN Controlled laboratory study. METHODS Twenty patients underwent navigated anatomic anteromedial bundle revision anterior cruciate ligament reconstruction with addition of percutaneous extra-articular tenodesis using the same hamstring tendon graft. The navigation was used to optimize femoral and tibial tunnel positions and to measure the knee kinematics in response to the anterior drawer test, Lachman test, maximum internal/external rotation test, and pivot-shift test. All patients underwent revision after failure without any technical error found or new trauma. Two sequential reconstruction protocols were used to assess the contribution of the extra-articular tenodesis and single anteromedial bundle anterior cruciate ligament reconstruction to restrain tibial translations and coupled axial rotation occurring with the manually performed clinical laxity tests. In group A, the intra-articular reconstruction was fixed first and then the lateral tenodesis was fixed, and in group B, the protocol was reversed. Measurements were performed before the reconstruction, after the first part was fixed, and after the second part was fixed in each protocol. RESULTS At 90° of flexion, addition of lateral tenodesis had a significant effect on coupled internal rotation (P = .003). Addition of the intra-articular reconstruction to lateral tenodesis had a significant effect (P = .001) in reducing anterior tibial translation of the medial compartment, and the effect was also significant (P = .0001) in reduction of lateral compartment translation. For the rotational envelope, lateral tenodesis had a significant effect (P = .0001) in reducing maximum internal rotation at 90° of flexion. CONCLUSION Addition of an extra-articular procedure provided no significant improvement to anterior tibial translation and improved internal tibial rotation control only at 90° of flexion.
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Affiliation(s)
- Philippe Colombet
- Centre de Chirurgie Orthopédique et Sportive, Bordeaux-Mérignac, 9 Rue Jean Moulin, Mérignac 33700, France.
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Hart JM, Turman KA, Diduch DR, Hart JA, Miller MD. Quadriceps muscle activation and radiographic osteoarthritis following ACL revision. Knee Surg Sports Traumatol Arthrosc 2011; 19:634-40. [PMID: 21110004 DOI: 10.1007/s00167-010-1321-z] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2010] [Accepted: 10/25/2010] [Indexed: 01/11/2023]
Abstract
PURPOSE Quadriceps strength and activation may play an important role in the recovery from ACL revision surgery. The purpose of this study was to describe quadriceps strength and central activation ratio (CAR) and correlate with radiographic findings in patients with ACL revision surgery. METHODS Twenty-one patients who were on average 47.5 ± 21.1 months [range: 14-85 months] post-revision ACL reconstruction. We performed knee joint physical examination and radiographic evaluation. Quadriceps strength testing consisted of maximal voluntary isometric contractions (MVIC) with the knee bent to 90-degrees bilaterally. We calculated quadriceps central activation ratio using the superimposed burst technique. Radiographs (bilateral standing antero-posterior in knee flexion and lateral in full extension) were evaluated by a fellowship-trained orthopedic surgeon using the International Knee Documentation Committee (IKDC) grading system. RESULTS Mean CAR was 83.9 ± 12.0% on the reconstructed limb and 85.5 ± 9.5% on the contralateral limb. Average, normalized MVIC torque was 2.5 ± 1.0 Nm/kg on the reconstructed limb and 2.7 ± 1.0 N m/kg for the contralateral limb. Patient age at the time of follow-up evaluation was related to severity of knee joint degeneration, particularly the medial, anterior and patellofemoral compartments. Younger patients with lower CARs tended to have more severe degeneration in the patellofemoral joint. Older patients with lower normalized MVIC torque values tended to exhibit more severely graded degeneration in the patellofemoral joint. CONCLUSION Bilateral quadriceps central activation deficits and radiographic osteoarthritis are evident in patients with revision ACL reconstruction.
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Affiliation(s)
- Joseph M Hart
- Department of Orthopaedic Surgery, University of Virginia, 400 Ray C. Hunt Drive, Suite 330, PO Box 800159, Charlottesville, VA 22908, USA.
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Colombet PD. Navigated intra-articular ACL reconstruction with additional extra-articular tenodesis using the same hamstring graft. Knee Surg Sports Traumatol Arthrosc 2011; 19:384-9. [PMID: 20811736 DOI: 10.1007/s00167-010-1223-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Accepted: 07/09/2010] [Indexed: 11/29/2022]
Abstract
PURPOSE In some complex cases, standard anterior cruciate ligament reconstruction is not enough and could lead to a new failure. Lateral extra-articular reconstruction should be added. We describe a new mini-invasive technique using the same hamstring graft for intra-articular reconstruction and lateral tenodesis, optimized with navigation. METHOD This arthroscopic technique is precisely described, different graft setting are possible, four strands graft inside the joint and two strands for the tenodesis or two strands graft for all the whole graft. As the lateral tenodesis is not anatomic, tunnel placement could be tricky. The use of navigation system is a real advantage for this technique with optimal tunnels placement. RESULTS No results are given. CONCLUSION This technique is comparable to others reported previously, showing a clinical advantage and no increasing of osteoarthritis. The use of the same graft avoids collateral damages, and navigation improves the graft placement.
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Trojani C, Sbihi A, Djian P, Potel JF, Hulet C, Jouve F, Bussière C, Ehkirch FP, Burdin G, Dubrana F, Beaufils P, Franceschi JP, Chassaing V, Colombet P, Neyret P. Causes for failure of ACL reconstruction and influence of meniscectomies after revision. Knee Surg Sports Traumatol Arthrosc 2011; 19:196-201. [PMID: 20644911 DOI: 10.1007/s00167-010-1201-6] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2008] [Accepted: 06/14/2010] [Indexed: 11/26/2022]
Abstract
The purpose of this multicenter retrospective study was to analyze the causes for failure of ACL reconstruction and the influence of meniscectomies after revision. This study was conducted over a 12-year period, from 1994 to 2005 with ten French orthopaedic centers participating. Assessment included the objective International Knee Documenting Committee (IKDC) 2000 scoring system evaluation. Two hundred and ninety-three patients were available for statistics. Untreated laxity, femoral and tibial tunnel malposition, impingement, failure of fixation were assessed, new traumatism and infection were recorded. Meniscus surgery was evaluated before, during or after primary ACL reconstruction, and then during or after revision ACL surgery. The main cause for failure of ACL reconstruction was femoral tunnel malposition in 36% of the cases. Forty-four percent of the patients with an anterior femoral tunnel as a cause for failure of the primary surgery were IKDC A after revision versus 24% if the cause of failure was not the femoral tunnel (P = 0.05). A 70% meniscectomy rate was found in revision ACL reconstruction. Comparison between patients with a total meniscectomy (n = 56) and patients with preserved menisci (n = 65) revealed a better functional result and knee stability in the non-meniscectomized group (P = 0.04). This study shows that the anterior femoral tunnel malposition is the main cause for failure in ACL reconstruction. This reason for failure should be considered as a predictive factor of good result of revision ACL reconstruction. Total meniscectomy jeopardizes functional result and knee stability at follow-up.
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Affiliation(s)
- Christophe Trojani
- Service de Chirurgie Orthopédique, Hôpital de l'Archet 2, 151 rte St A. de Ginestière, 06200 Nice, France.
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45
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Abstract
Revision reconstruction of the anterior cruciate ligament (ACL) introduces several diagnostic and technical challenges in comparison with primary ACL reconstruction. With the increasing numbers of original reconstructions combined with the continued expectation of high-level athletic participation, revision ACL reconstruction is likely to become more frequent. The purpose of this article was to summarize the causes of failure and the evaluation of the patient with recurrent instability. A review of the literature regarding results after revision ACL reconstruction was performed to assist in the decision-making process and patient counseling. Good results can be obtained in terms of functional stability after revision reconstruction, but chondral and meniscal injury as well as unrecognized associated pathologic instability may play a role in diminished outcomes. In addition, a wide variety of surgical techniques are reviewed to address problems associated with tunnel malposition, widening, and pre-existing hardware.
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Affiliation(s)
- Ganesh V Kamath
- Department of Orthopaedic Surgery, University of North Carolina at Chapel Hill, USA.
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Osteointegration of soft tissue grafts within the bone tunnels in anterior cruciate ligament reconstruction can be enhanced. Knee Surg Sports Traumatol Arthrosc 2010; 18:1038-51. [PMID: 19779894 DOI: 10.1007/s00167-009-0910-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Accepted: 08/21/2009] [Indexed: 01/10/2023]
Abstract
Anterior cruciate ligament reconstruction with a soft tissue autograft (hamstring autograft) has grown in popularity in the last 10 years. However, the issues of a relatively long healing time and an inferior histological healing result in terms of Sharpey-like fibers connection in soft tissue grafts are still unsolved. To obtain a promising outcome in the long run, prompt osteointegration of the tendon graft within the bone tunnel is essential. In recent decades, numerous methods have been reported to enhance osteointegration of soft tissue graft in the bone tunnel. In this article, we review the current literature in this research area, mainly focusing on strategies applied to the local bone tunnel environment. Biological strategies such as stem cell and gene transfer technology, as well as the local application of specific growth factors have been reported to yield exciting results. The use of biological bone substitute and physical stimulation also obtained promising results. Artificially engineered tissue has promise as a solution to the problem of donor site morbidity. Despite these encouraging results, the current available evidence is still experimental. Further clinical studies in terms of randomized control trial in the future should be conducted to extrapolate these basic science study findings into clinical practice.
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47
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Muneta T, Hara K, Ju YJ, Mochizuki T, Morito T, Yagishita K, Sekiya I. Revision anterior cruciate ligament reconstruction by double-bundle technique using multi-strand semitendinosus tendon. Arthroscopy 2010; 26:769-81. [PMID: 20511035 DOI: 10.1016/j.arthro.2009.09.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2009] [Revised: 09/13/2009] [Accepted: 09/15/2009] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of the study was to compare the outcome of revision anterior cruciate ligament (ACL) reconstruction by the double-bundle (DB) technique using multi-strand semitendinosus tendon with that of primary reconstruction by use of the same technique. METHODS The study included 21 patients who underwent revision ACL reconstruction (mean follow-up, 40 months) with the semitendinosus tendon DB technique between 1995 and 2006 and 86 unilateral primary DB ACL reconstructions (mean follow-up, 33 months) between 2000 and 2004. The outcome of both groups was compared based on differences between operated and unoperated limbs and modified International Knee Documentation Committee grades. Both the overall and sports-related subjective scores were evaluated between the 2 groups. RESULTS The KT measurements (MEDmetric, San Diego, CA) averaged 1.7 mm (SD, 1.8 mm) in the revision group and 1.5 mm (SD, 1.6 mm) in the primary group. There was no significant difference in KT measurements between the 2 groups. The Lachman test was negative in 83% of revision cases and 87% of primary cases; the anterior drawer test was negative in 83% and 91%, respectively, and the pivot-shift test was negative in 78% and 90%, respectively. There was a tendency for a positive pivot-shift test in the revision group being higher. The Lysholm score and subjective recovery score were significantly lower in the revision group. CONCLUSIONS The semitendinosus tendon DB revision procedure provided range of motion and anterior stability comparable to those after primary DB surgery and a comparable return to athletic activities. However, the patients tended to have positive pivot-shift test results. The revision cases were also inferior in terms of the general evaluation of recovery of knee condition. The outcome scores were lower overall in the revision group. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- Takeshi Muneta
- Department of Orthopaedic Surgery, School of Medicine, Tokyo Medical and Dental University Hospital, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan.
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Ahn JH, Lee YS, Ha HC. Comparison of revision surgery with primary anterior cruciate ligament reconstruction and outcome of revision surgery between different graft materials. Am J Sports Med 2008; 36:1889-95. [PMID: 18490470 DOI: 10.1177/0363546508317124] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The number of primary anterior cruciate ligament reconstructions is increasing rapidly; the number of failing grafts and need for revision surgery have also risen. HYPOTHESIS Revision anterior cruciate ligament reconstruction will produce similar results to those of primary reconstruction, and there may be different results according to graft materials. STUDY DESIGN Case control study; Level of evidence, 3. METHODS Fifty-nine revision surgeries were performed at 1 institution between January 1997 and October 2005. Fifty-five patients (56 operations) were followed. The results of 117 patients (117 knees) treated with arthroscopic primary anterior cruciate ligament reconstruction using double-looped semitendinosus and gracilis autograft from September 2001 to November 2002 were also evaluated. Clinical and stability results between primary and revision anterior cruciate reconstruction were compared. For the revision surgery, 21 (37.5%) knees had revision reconstruction with previously unharvested ipsilateral double-looped semitendinosus and gracilis autograft. Twenty (35.7%) were bone-patellar tendon-bone allograft, and 15 (26.8%) were Achilles allograft. The details of the technique varied according to the original graft choice and the abnormality encountered. Concomitant procedures were necessary in 32 (57.1%) of 56 knees. Clinical and stability results according to the different graft materials were also compared. RESULTS There were significant improvements in the scores for subjective, objective forms (P < .001), and stability (P < .001). However, the clinical results of revision surgery were inferior to primary reconstruction (P < .001), but as regards stability, the difference between primary and revision cases was not significant (P = .338). There was no difference in clinical and stability results in different groups of graft material (P = .160-.690). CONCLUSION Revision anterior cruciate ligament reconstruction could improve clinical and stability results, but the clinical results were inferior to those of primary reconstruction. This study also demonstrated that the success of the operation did not depend on the choice of graft materials.
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Affiliation(s)
- Jin Hwan Ahn
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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49
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Ferretti A, Monaco E, Labianca L, Conteduca F, De Carli A. Double-bundle anterior cruciate ligament reconstruction: a computer-assisted orthopaedic surgery study. Am J Sports Med 2008; 36:760-6. [PMID: 17702998 DOI: 10.1177/0363546507305677] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The biomechanical function of single-bundle anterior cruciate ligament reconstruction, in cadaveric studies, is successful in limiting anterior tibial translation in response to an anterior tibial load but seems to be insufficient to control a combined rotator load of internal and valgus torque. Anatomical double-bundle anterior cruciate ligament reconstruction might produce a better biomechanical outcome. HYPOTHESIS The addition of the posterolateral bundle to the anteromedial bundle, in an in vivo double-bundle computer-assisted anterior cruciate ligament reconstruction, is able to reduce internal rotation of the tibia at 30 degrees of knee flexion, compared with a standard single-bundle reconstruction. STUDY DESIGN Controlled laboratory study. METHODS Twenty consecutive anterior cruciate ligament reconstructions were performed in male patients in April and May 2006 with double-bundle gracilis and semitendinosus tendon grafts using the 2.0 OrthoPilot navigation system. Group A (10 patients) underwent standard single-bundle anterior cruciate ligament reconstruction with doubled gracilis and semitendinosus tendon graft; group B (10 patients) underwent double-bundle reconstruction with doubled gracilis and semitendinosus tendon graft. Anteroposterior displacement and internal and external rotation at 30 degrees of knee flexion were evaluated before and after reconstruction, using manual maximum force. RESULTS Both techniques significantly reduced anteroposterior displacement and internal and external rotation of the tibia with respect to preoperative anterior cruciate ligament-deficient condition (P < .05). Comparing groups, no differences in anteroposterior tibial displacement and internal and external rotation of the tibia were found (anteroposterior, 3.7 mm and 5.2 mm; internal rotation, 16.3 degrees and 16.6 degrees; external rotation, 15.7 degrees and 15.1 degrees, respectively) in group A and B (P = .06, .90, and .72, respectively). CONCLUSION The hypothesis that addition of the posterolateral bundle to the anteromedial bundle is able to reduce internal rotation of the tibia at 30 degrees of knee flexion is not confirmed. CLINICAL RELEVANCE The effective role of the anatomical double-bundle procedure in better restoring knee kinematics should be questioned in an in vivo model.
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Affiliation(s)
- Andrea Ferretti
- Orthopaedic Unit and Kirk Kilgour Sports Injury Center, Sant'Andrea Hospital, University of Rome La Sapienza, Rome, Italy.
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