Revision anterior cruciate ligament surgery: experience from Miami

Biomechanical evaluation of anterior cruciate ligament femoral fixation techniques

BACKGROUND

A number of different femoral anterior cruciate ligament fixation techniques are currently in use. Slippage of the graft caused by excessive early loading or aggressive rehabilitation may negate benefits of surgery and result in a knee with undesirable laxity.

HYPOTHESIS

Anterior cruciate ligament femoral graft slippage varies by fixation technique and amount of cyclic loading.

STUDY DESIGN

Controlled laboratory study.

METHODS

Graft slippage in 5 different soft tissue anterior cruciate ligament femoral fixation techniques (Bio-TransFix cross-pin technique, Stratis ST cross-pin technique, Bilok ST transverse femoral screw, Delta tapered bio-interference screw, and single-loop TensionLok) was compared by cyclic loading of double-bundle grafts in porcine femurs. Graft slippage was measured using a differential variable reluctance transducer.

RESULTS

The Bio-TransFix had significantly less (P = .002) total graft slippage (1.14 +/- 0.43 mm) compared to the Delta (3.74 +/- 3.25 mm), Bilok ST (3.92 +/- 2.28 mm), and TensionLok (5.09 +/- 1.12 mm) but not the Stratis ST (1.92 +/- 1.55 mm). All techniques showed the greatest amount of dynamic excursion (P < .001), slippage (P < .001), and percentage of total slippage (mean 68%, P < .001) during the first 100 cycles of loading. The TensionLok had the greatest amount of dynamic excursion during the first 100 cycles (4.15 +/- 1.00 mm) followed by the Bilok ST (3.37 +/- 2.07 mm), Delta (1.76 +/- 0.93 mm), and Stratis ST (1.75 +/- 0.96 mm); the Bio-TransFix demonstrated the least (1.26 +/- 0.48 mm). There was no statistical difference in failure load between repair techniques (P = .103).

CONCLUSION

Graft slippage was statistically different between anterior cruciate ligament femoral fixation techniques for static and dynamic loading. All techniques exhibited the greatest amount of slippage during the first 100 cycles of loading. The differential variable reluctance transducer permitted evaluation of dynamic graft-construct-bone displacement during experimental loading, simulating the loading experienced during early rehabilitation.

CLINICAL RELEVANCE

The optimal method of graft fixation for anterior cruciate ligament reconstruction remains unknown. In the current study, cross-pin constructs appeared to be superior to certain other available fixation systems.

[Allografts for cruciate ligament reconstruction]

Allografts have an essential significance in the surgical reconstruction of ligamentous injuries around the knee joint. While in primary anterior cruciate ligament reconstruction allografts are less important than autografts, at least in the European countries, the usage of allografts in anterior cruciate ligament revision surgery is increasing. In addition, allografts represent a good alternative for the reconstruction of the posterior cruciate ligament and the posterolateral structures. Especially in multiligament reconstructions of the knee joint, the usage of allografts may prevent iatrogenic damage of the already traumatized periarticular soft tissue. The present article focuses on the application and clinical results of allografts for ligament reconstruction around the knee joint. Furthermore, the immunological and biological principles of tendon allografts, their availability, processing, and security are discussed.

Comparison of revision surgery with primary anterior cruciate ligament reconstruction and outcome of revision surgery between different graft materials

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.

Anterior cruciate ligament revision reconstruction: results in 107 patients

BACKGROUND

Although techniques and options for suitable graft substitutes for anterior cruciate ligament surgery continue to improve, failures occur because of many reasons. Errors in surgical techniques seem to be important reasons.

HYPOTHESIS

Inappropriate positioning of the tunnels may be the most important reason for these failures. Anatomical anterior cruciate ligament revision reconstruction, using autografts, may yield acceptable outcomes.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This retrospective study involved 148 anterior cruciate ligament revision reconstructions performed in our hospital using autografts. One hundred and seven patients were followed up at a mean of 72.9 +/- 20.6 months. Clinical evaluation was performed using the Lysholm score, the Tegner rating system, the International Knee Documentation Committee evaluation form, and the KT-1000 arthrometer. Radiographs were evaluated for signs of osteoarthritis according to the Jaeger and Wirth classification.

RESULTS

Inappropriate positioning of the tunnels was the most important reason (63.5%) for anterior cruciate ligament reconstruction failure. The average Lysholm score improved significantly at the follow-up (88.5 +/- 12.4 vs 51.5 +/- 24.9; P < .001). Moreover, the average Tegner activity score improved significantly compared with the activity score before revision surgery (6.3 +/- 1.8 vs 2.8 +/- 1.8; P < .001). The International Knee Documentation Committee score was A in 17 cases, B in 45, C in 37, and D in 8. Radiographic evaluation revealed that 33 patients had degenerative findings of grade I, 35 of grade II, 16 of grade III, and 2 of grade IV.

CONCLUSION

Anatomical anterior cruciate ligament revision reconstruction provides satisfactory midterm results as far as stability and function of the knee are concerned. In spite of these favorable subjective and objective results, the radiological evaluation revealed a significant progression of osteoarthritis.

Results of revision anterior cruciate ligament surgery

BACKGROUND

Revision anterior cruciate ligament surgery remains challenging.

PURPOSE

To analyze the authors' experience with revision anterior cruciate ligament surgery and determine the association between stability and functional results.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between 1991 and 2002, 95 of 102 patients who underwent revision anterior cruciate ligament reconstruction at the authors' institution met the criteria for inclusion in the study. Of those, the 63 (66%) who returned for complete clinical and radiologic evaluation (mean follow-up, 72.7 months) formed the study group. Subjective evaluation focused on return to sports, arthritic symptoms, and subjective International Knee Documentation Committee criteria. Clinical evaluation included examination, KT-1000 arthrometer and functional testing, and radiographic analysis of alignment and arthritis.

RESULTS

Based on International Knee Documentation Committee subjective scores and return to sports, results were rated as excellent/good in 45 patients (71%), fair in 6 (10%), and poor in 12 (19%). A grade IA or IIA Lachman and a KT-1000 arthrometer side-to-side difference of <3 mm (32/63 patients) was associated with a good/excellent result (P < .05). The mechanical axis was midline in 78% (49/63 patients). Radiographic arthritis (16 patients, 25%) was associated with duration of instability after primary failure (P < .03). Return to sports occurred in 59% (37/63 patients). Sixteen patients (25%) required a second revision surgery.

CONCLUSION

Revision anterior cruciate ligament surgery allowed approximately 60% of patients to go back to sports, most of them at lower levels than their prerevision function. Instrumented laxity of <3 mm was associated with a better result. Radiographic arthritis was associated with duration of instability symptoms after primary failure. Patients who undergo revision anterior cruciate ligament surgery should be counseled as to the expected outcome and cautioned that this procedure probably represents a salvage situation and may not allow them to return to their desired levels of function.

Allograft safety in anterior cruciate ligament reconstruction

Allograft tissue seems to provide an excellent option for reconstruction of the ACL in the primary and revision setting. Although in general the risks of using allograft tissue in ACL reconstruction are low, the consequences of complications associated with disease or infection transmission or of recurrent instability secondary to graft failure are large. Surgeons should provide patients with the information available regarding allograft risks and should have thorough knowledge of the source and preparation of the grafts by their tissue bank before implantation for ACL reconstruction.

[Anterior cruciate ligament revision: analysis and results from a series of 74 cases]

PURPOSE OF THE STUDY

This was a retrospective series of patients who underwent revision ligamentoplasty of the anterior cruciate ligament (ACL). We wanted to assess the functional outcome after this type of surgery and search for potential prognostic factors.

MATERIAL AND METHODS

The series included 74 patients, mean age 34 years (range 21-59 years). The initial ligamentoplasty was performed with a synthetic ligament (n=16), an autograft (n=57) or an allograft (n=1). Differential laxity (KT-1000 maximal manual) was 7 +/- 2.5 mm. Anterior drawer was measured on the stress x-rays in 20 degrees flexion: medial 8 +/- 4.7 mm, lateral 8.3 +/- 4.9 mm. Mean time to revision surgery was 78 months. Reconstruction was performed arthroscopically in 69 knees. The implant used for the revision reconstruction was an autograft: patellar tendon (n=42), quadriceps tendon (n=15), hamstring tendon (n=13), patellar tendon and quadriceps tendon (MacInJones) (n=3), fascia lata (n=1). A meniscal tear was noted in 24 knees and a cartilage lesion in 35.

RESULTS

Outcome was assessed at mean 21.2 months follow-up. The mean IKDC function score was 71.7 (range 21.8-100). 78% of patients considered their knee normal or nearly normal and 88% presented a positive Lachmann. Mean differential laxity measured with KT-1000 (maximal manual) was 2 +/- 1.7 mm. Stress x-rays revealed a mean differential laxity measured at 3.7 +/- 2.3 mm medially and 6.3 +/- 4.3 mm laterally. The presence of a meniscal lesion favored osteoarthritic degradation. Presence of chondral lesions altered the functional outcome significantly and limited resumption of sports activities. An initial repair using a synthetic ligament affected the functional outcome after revision surgery and favored or aggravated chondral lesions.

DISCUSSION

The clinical results we have obtained with revision ACL ligamentoplasty are comparable to previous series reported in the literature. The functional outcome is not as good as after first-intention repair, especially if the initial plasty was done with a synthetic ligament and the knee presented meniscal or cartilage damage.

Primary versus single-stage revision anterior cruciate ligament reconstruction using autologous hamstring tendon grafts: a prospective matched-group analysis

BACKGROUND

There is a low level of evidence about clinical results after anterior cruciate ligament (ACL) revision reconstruction using autologous hamstring tendon grafts.

HYPOTHESIS

Anterior cruciate ligament revision reconstruction improves knee stability but shows inferior results for functional and subjective outcome and knee stability compared with primary reconstruction.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Between October 1997 and July 2005, 166 single-stage or 2-stage revision ACL reconstructions were done using different graft types. One hundred twenty-four cases underwent a single-stage revision reconstruction with autologous hamstring tendon grafts. At the time of data analysis, 67 cases fulfilled the criteria of minimum 2-year follow-up. Five patients were lost to follow-up (follow-up rate, 91%). Four patients (6%) who experienced graft rupture were counted as failures but not subjected to further detailed analysis. Because of loss to follow-up and exclusion criteria (n = 12), 50 patients were included in the study. For a comparative matched-group analysis, patients with a primary hamstring tendon graft ACL reconstruction were selected out of a database with minimum 2 years' follow-up (N = 284). Patients were followed using the International Knee Documentation Committee (IKDC) and Lysholm scores, KT-1000 arthrometer testing, and additional functional tests.

RESULTS

Four of 62 available patients (6.5%) in the revision group experienced graft failure, which was comparable to 16 of 284 (5.6%) in the primary reconstruction group. When the 2 matched groups of 50 patients were further compared, postoperative IKDC results showed no significant differences between groups. The manual maximum KT-1000 arthrometer side-to-side difference was 2.1 +/- 1.6 mm for the revision group and 2.2 +/- 1.1 mm for the primary reconstruction group. The Lysholm score was significantly better in the primary reconstruction group (P = .014). The incidence of postoperative positive pivot-shift test results was not significantly different. The primary reconstruction group showed significantly less extension deficits. Functional testing revealed significantly better results for the primary reconstruction group for stair climbing, squatting, knee bending, and duck walk.

CONCLUSIONS

In our patient series, primary ACL reconstruction showed significantly better results in Lysholm score, although the IKDC score and objective knee stability showed no significant difference between the groups. Thus, parameters other than measurable knee stability must be responsible for the inferior results of the revision reconstruction group.

Revision anterior cruciate ligament reconstruction

We reviewed 87 patients who underwent revision reconstruction of the anterior cruciate ligament. The incidence of meniscal tears and degenerative change was assessed and related to the interval between failure of the primary graft and revision reconstruction. Patients were divided into two groups: early revision surgery within six months of graft failure, and delayed revision. Degenerative change was scored using the French Society of Arthroscopy system.

There was a significantly higher incidence of articular cartilage degeneration in the delayed group (Mann-Whitney U-test, 53.2% vs 24%, p < 0.01). No patient in the early group had advanced degenerative change, compared to 9.2% of patients in the delayed group. There was no significant difference (Mann-Whitney U-test, p = 0.3) in the incidence of meniscal tears between the two groups.

We conclude that revision reconstruction should be carried out within six months of primary graft failure, in order to minimise the risk of degenerative change.

Revision anterior cruciate ligament reconstruction due to knee instability

Introduction. The primary goal of anterior cruciate ligament reconstruction is to provide stability to the knee and regain full range of motion. Although great improvement has been achieved in surgical techniques and rehabilitation, some patients are not completely satisfied with the results of surgery and a revision anterior cruciate ligament reconstruction is necessary. Material and Methods. Revision arthroscopic anterior cruciate ligament reconstruction was carried out in eleven patients with bone-tendon-bone autografts. The surgery was performed in a standard manner and the graft was taken from the opposite knee. Eight men and three women were evaluated. The mean age of patients was 26 (17-34) years. Repeated instability of the knee was caused by injury in five patients, while six patients were unsatisfied with the position of the graft. Results. The follow up was 4,2 years (2-8) respectively. The mean Lysholm and Gillquist score after operation was 88 (65-90). Preoperative and postoperative tibial shift was 9mm (6-15) and 2mm (0-4), respectively. The preoperative pivot shift test was grade 2 and 3 in all patients. Postoperative pivot shift test was negative in seven patients, in three it was grade 1 and grade 2 in one patient. According to the IKDC scale, preoperative results were abnormal in three patients and in eight they were severely abnormal. Postoperative IKDC score was normal in five patients, in four nearly normal, and in one patient the score was still abnormal. Five patients continued to be active in sports activities, four patients decreased the level of sports activity and two stopped all sports activities. Conclusion. Success of revision anterior cruciate ligament reconstruction requires detailed preoperative evaluation of the repeated instability of the knee. The treatment plan is then decided upon. The patients must be preoperatively informed about the real possibilities of revision surgery. Only a mutual collaboration between the patient, physiatrist and a surgeon is a key for successful treatment and return to previous level of sports activities.

Current concepts review: revision anterior cruciate ligament reconstruction

Failed anterior cruciate ligament (ACL) reconstruction presents a difficult clinical challenge. Successful revision ACL reconstruction depends on identifying the causes of failure and correcting technical or diagnostic errors. Failed ACL reconstruction may be either traumatic or atraumatic. Atraumatic failures may be attributable to technical errors, diagnostic errors, or failure of graft incorporation. Published outcomes of revision ACL reconstruction have been worse than for primary ACL reconstruction. The preoperative evaluation, surgical techniques, and clinical outcomes of revision ACL reconstruction are reviewed.

Revision anterior cruciate ligament reconstruction with doubled semitendinosus and gracilis tendons and lateral extra-articular reconstruction

BACKGROUND

The outcome of revision anterior cruciate ligament reconstruction has only rarely been reported. The purpose of this study was to evaluate the results of revision anterior cruciate ligament surgery with use of an autogenous doubled semitendinosus and gracilis graft in association with an extra-articular procedure.

METHODS

Between 1997 and 2003, thirty patients underwent a repeat reconstruction of a previously reconstructed torn anterior cruciate ligament with use of a doubled semitendinosus and gracilis graft combined with an extra-articular reconstruction. Primary reconstruction had been done with an autogenous patellar tendon graft in twenty-six patients and with a prosthetic ligament in four patients; the average time from the primary reconstruction to the revision was five years. Functional outcomes, graft survival, and radiographic outcomes were evaluated at a mean of five years. A graft was considered to have failed when a revision was done or when the side-to-side difference on KT-1000 arthrometer testing was >5 mm and/or the pivot-shift test grade was greater than a trace.

RESULTS

One patient underwent another revision reconstruction because of graft failure at three years postoperatively. The mean International Knee Documentation Committee (IKDC) subjective knee score for the remaining twenty-nine patients was 84 +/- 12 points, and the mean Lysholm knee score was 90 +/- 10 points. The side-to-side difference as measured with the KT-1000 arthrometer with maximum manual force was <3 mm in twenty patients (of the twenty-eight who returned for follow-up), between 3 and 5 mm in six patients, and >5 mm in two patients. The result of the pivot shift examination was normal in fifteen patients, slightly positive in eleven patients, and positive in two patients. Twenty-five percent of the patients showed no radiographic signs of degenerative joint disease.

CONCLUSIONS

Revision anterior cruciate ligament reconstruction with use of an autogenous doubled semitendinosus and gracilis graft combined with an extra-articular procedure provided satisfactory functional outcomes, with a failure rate of 10%.

Anterior cruciate ligament revision reconstruction: results using a quadriceps tendon-patellar bone autograft

BACKGROUND

The quadriceps tendon is a viable graft source for revision anterior cruciate ligament reconstruction.

PURPOSE

To determine the functional results and graft failure rates in knees in which the patellar tendon had been previously harvested or was unavailable, expanded tunnels precluded the use of a semitendinosus-gracilis graft, or patients requested autogenous tissues instead of allografts for revision reconstruction.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The authors observed 21 patients for a mean of 49 months postoperatively after revision anterior cruciate ligament reconstruction with a quadriceps tendon graft. The results were determined by KT-2000 arthrometer testing, the Cincinnati Knee Rating System, and the International Knee Documentation Committee Rating System. Fifteen knees required a concurrent procedure, including reconstruction of posterolateral structures in 5 knees, meniscal repairs in 5 knees, and high tibial osteotomy in 2 knees.

RESULTS

Significant improvements occurred in symptoms (P < .0001), daily activities (P < .05), sports activities (P < .01), and the overall rating scores (P < .0001). Eighteen patients rated their knee condition as improved. Total mean anterior-posterior displacements decreased from 8.4 +/- 3.1 mm preoperatively to 2.0 +/- 2.3 mm at follow-up (P < .001). On the International Knee Documentation Committee knee ligament rating, 17 knees were graded as normal or nearly normal, 3 were graded as abnormal, and 1 was graded as severely abnormal.

CONCLUSION

The revision operation provided reasonable results in this group of complex knees. However, the functional and overall results were inferior to those reported for primary anterior cruciate ligament reconstruction. Many knees (90%) had compounding problems of articular cartilage damage, meniscectomy, varus malalignment, or additional ligamentous injury that most likely affected the results.

Extensor mechanism disruption after contralateral middle third patellar tendon harvest for anterior cruciate ligament revision reconstruction

The contralateral central third patellar tendon autograft is a reliable graft choice for revision, and recently, for primary reconstruction of the anterior cruciate ligament (ACL). We report 2 complications including a lateral third tibial tuberosity fracture and a distal patellar tendon avulsion with contralateral patellar tendon autograft with disruption of the extensor mechanism of the donor knee. A patient sustained a lateral tibial tuberosity fracture of the donor knee and underwent open reduction and internal fixation. At 1-year follow-up, she had no extensor lag and full range of motion. Another patient sustained a distal patellar tendon avulsion of the donor knee and underwent primary repair. Three years postoperatively, she had a full range of motion and no extensor lag. Although contralateral middle third patellar tendon autograft for primary and revision ACL reconstruction is established in the literature, extensor mechanism complications can occur. Technical considerations are important to avoid weakening the remaining patellar tendon insertion. Postoperative nerve blocks or local anesthetics may alter pain feedback for regulation of weight bearing and contribute to overload of the donor knee.

Graft selection in anterior cruciate ligament reconstruction

The ideal graft for use in anterior cruciate ligament reconstruction should have structural and biomechanical properties similar to those of the native ligament, permit secure fixation and rapid biologic incorporation, and limit donor site morbidity. Many options have been clinically successful, but the ideal graft remains controversial. Graft choice depends on surgeon experience and preference, tissue availability, patient activity level, comorbidities, prior surgery, and patient preference. Patellar tendon autograft, the most widely used graft source, appears to be associated with an increased incidence of anterior knee pain compared with hamstring autograft. Use of hamstring autograft is increasing. Quadriceps tendon autograft is less popular but has shown excellent clinical results with low morbidity. Improved sterilization techniques have led to increased safety and availability of allograft, although allografts have a slower rate of incorporation than do most types of autograft. No graft has clearly been shown to provide a faster return to play. However, in general, patellar tendon autografts are preferable for high-performance athletes, and hamstring autografts and allografts have some relative advantages for lower-demand individuals. No current indications exist for synthetic ligaments.

Posterior cruciate ligament revision reconstruction, part 1: causes of surgical failure in 52 consecutive operations

BACKGROUND

Posterior cruciate ligament reconstructions have not shown uniformly predictable results in restoration of normal posterior tibial translation. The authors are unaware of any study that has assessed the causes of failure of these operations, and they investigated 52 prior unsuccessful posterior cruciate ligament procedures to determine the factors that contributed to failure of the operations.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The authors studied 52 prior failed posterior cruciate ligament surgeries that had been done in 41 knees (40 patients). Graft reconstructions had been done in 31 cases, primary repairs in 14, synthetic replacements in 4, and thermoplasties in 3. Medical records, operative notes, radiographs, and magnetic resonance imaging scans were reviewed, and a comprehensive knee examination was conducted.

RESULTS

A single factor that caused the operations to fail was identified in 23 (44%) of 52 operations, and multiple factors were identified in 29 (56%). The most common probable causes of failure were associated posterolateral ligament deficiency (40%), improper graft tunnel placement (33%), associated varus malalignment (31%), and primary suture repair (25%). Sixteen of 21 (76%) prior posterolateral ligament procedures had failed, as had 9 of 19 (47%) prior anterior cruciate ligament reconstructions. Twenty-nine knees (71%) presented with pain with activities of daily living. Thirty-four knees (83%) had compounding problems of joint arthritis, prior meniscectomy, associated ligament deficiencies, or varus malalignment. Posterior cruciate revision surgery was done in 22 knees (54%). Eleven knees (27%) had severe joint damage that contraindicated revision, and 8 (19%) declined further operations.

CONCLUSIONS

Failure to restore associated ligament instabilities and incorrect tunnel placement were major factors contributing to surgical failure. The results suggest the need for greater emphasis on the initial reconstruction in graft tunnel placement, correction of associated ligament instabilities, and correction of varus osseous malalignment. Failure of concurrent posterolateral ligament reconstructions was frequently encountered, suggesting the need for higher strength augmentation procedures or anatomical graft replacement.

Posterior cruciate ligament revision reconstruction, part 2: results of revision using a 2-strand quadriceps tendon-patellar bone autograft

BACKGROUND

Posterior cruciate ligament reconstructions fail for similar reasons as to why anterior cruciate ligament reconstructions fail. Revision surgery is an option after failure.

PURPOSE

To prospectively study the results of 15 posterior cruciate ligament revision surgeries using a 2-strand quadriceps tendon-patellar bone autograft.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The authors observed 15 knees that received the revision procedure a mean of 44 months (range, 23-84 months) postoperatively. The results were determined by a comprehensive knee examination including stress radiography and several grading scales. A tibial inlay technique was used in 9 knees, and an arthroscopic tibial tunnel technique was done in 6 knees. Six knees required 1 or more concomitant ligament reconstructions.

RESULTS

Significant improvements occurred in pain, function, and patient perception scores (P < .05). However, only 53% returned to light sports without problems. Stress radiograph posterior tibial translation values improved from 11.7 +/- 3.0 mm pre-operatively to 5.1 +/- 2.4 mm at follow-up (P < .001). Two of the 15 revisions failed. Associated knee ligament reconstructive procedures restored anterior, medial, and posterolateral stability. There were no complications from the quadriceps tendon graft harvest site. Abnormal articular cartilage surfaces were found during the revision in 8 (53%) knees.

CONCLUSIONS

The quadriceps tendon 2-strand revision provided reasonable results in this group of complex-injured knees. The tibial inlay approach is advantageous to bypass prior tibial tunnels, and the all-inside arthroscopic technique is advantageous when major concurrent ligament reconstructions are required.

Revision anterior cruciate ligament reconstruction: three- to nine-year follow-up

PURPOSE

With the increasing number of primary anterior cruciate ligament (ACL) reconstructions, revisions are more frequent. The literature quotes inferior results for revision cases when compared with primary ACL reconstruction. The purpose of the study was to review our institution's experience with revision ACL reconstruction.

TYPE OF STUDY

Retrospective case series.

METHODS

Thirty-five revision cases were performed between 1993 and 1999. Twenty-nine were available for follow-up. Subjective scores were calculated for Lysholm, Tegner, and International Knee Documentation Committee (IKDC) forms. Objective IKDC scores were determined. KT-1000 measurements were performed as well as isokinetic strength testing of quadriceps and hamstrings. Plain film radiographs were obtained to assess degenerative changes.

RESULTS

The average patient age at time of revision was 30.2 years, the average time to revision was 56 months, the follow-up from last revision was 67 months. Twenty-two patients had bone-patellar tendon-bone (BPTB) allograft, 6 had contralateral BPTB autograft, and 1 patient had Achilles allograft. Overall, KT-1000 measurement showed an average of 2.78 mm side-to-side difference of displacement. The allograft versus the autograft group was 3.21 mm versus 1.33 mm, respectively. Prerevision data were unavailable. However, all patients had a positive pivot-shift test before revision. Average postrevision Lysholm, Tegner, and subjective IKDC scores were 86.6, 11.86, and 85.86, respectively. Concerning the IKDC objective scores, 15 patients had an A score, 8 had a B score, and 4 had a C score. All 29 patients available for follow-up reported that they would have the surgery again. The average strength of quadriceps and hamstrings ranged from 82% to 88% of uninvolved side.

CONCLUSIONS

This study provides long-term follow-up with good results for revision ACL reconstruction. Attention to principles when performing revision ACL surgery is critical to provide satisfactory results.

LEVEL OF EVIDENCE

Level IV.

Revision arthroscopically assisted anterior cruciate ligament reconstruction with previously unharvested ipsilateral autografts

BACKGROUND

Revision anterior cruciate ligament reconstruction requires flexibility and variability in treatment options. This study analyzed the functional outcomes and graft stability of 48 consecutive revision anterior cruciate ligament reconstructions using previously unharvested ipsilateral autografts.

HYPOTHESIS

Using previously unharvested ipsilateral autografts will achieve similar outcomes to other graft choices in revising previously failed anterior cruciate ligament reconstructions.

STUDY DESIGN

Prospective nonrandomized clinical trial.

METHODS

Forty-eight patients (48 operations) were observed for 2 to 13 years (mean, 90 months). All agreed to have revision reconstruction with ipsilateral autografts. The details of the technique varied according to the original graft choice and the abnormality encountered. Concomitant procedures were necessary in 40 (84%) of 48 knees. Twenty-three patients (48%) had revision reconstruction with previously unharvested ipsilateral autogenous hamstring tendons. Ten (21%) were 2-stranded grafts, and 13 (27%) were 4-stranded (quadrupled) autografts. Twenty-five patients (52%) had revision reconstruction with previously unharvested ipsilateral patellar tendon autografts, 6 (12%) using the 2-incision rear-entry method and 19 (40%) using the single-incision technique.

RESULTS

Results were evaluated with Lysholm and Gillquist scores and International Knee Documentation Committee ratings, including KT-2000 arthrometer examinations. Seventy-three percent of the patients had International Knee Documentation Committee normal (A) or nearly normal (B) knees (42% of the patients had A knees and 42% had B knees). Twelve percent of patients had C knees, and 4% had a D rating. Sixty-seven percent of the knees had a KT-2000 arthrometer side-to-side difference of 3 mm or less, and an additional 21% of the knees had a side-to-side difference of 3 to 5 mm; therefore, 94% of the grafts were functional or partially functional. Six percent of grafts had more than 5 mm of laxity and were considered failures.

CONCLUSIONS

Previously unharvested ipsilateral autografts proved reliable in improving function and stability in revision anterior cruciate ligament reconstruction. However, outcomes were less favorable with revision reconstructions than with primary reconstructions.

Transtibial tubercle fixation without hardware for anterior cruciate ligament and posterior cruciate ligament reconstruction: A new technique

Tibial fixation with implants for both anterior and posterior cruciate ligament reconstructions (ACLR and PCLR) can be associated with a wide variety of problems. Common problems encountered include graft-tunnel mismatch when using grafts with bone blocks, graft damage or poor graft fixation using metal or absorbable implants, painful retained hardware requiring removal, and hardware interference during revision surgery. A new technique is presented using transosseous graft suture passage across the tibial tubercle followed by knot tying over a bone bridge. The technique provides a quick, simple, safe, and reproducible alternative for primary or supplemental tibial graft fixation without hardware in ACLR and PCLR.

A biomechanical comparison of initial soft tissue tibial fixation devices: the Intrafix versus a tapered 35-mm bioabsorbable interference screw

BACKGROUND

Biomechanical testing of the Intrafix device has not been performed using human tibiae.

HYPOTHESIS

The Intrafix device would provide comparable or superior tibial fixation of a quadrupled hamstring tendon graft to a 35-mm-long bioabsorbable interference screw.

STUDY DESIGN

In vitro, biomechanical study.

METHODS

Eight paired human tibiae and 16 quadrupled hamstring tendon grafts were divided into 2 groups. Each quadrupled hamstring tendon graft was fixed in a tunnel sized to 0.5 mm graft diameter with either an Intrafix device or a screw.

RESULTS

Displacement at failure was greater in the Intrafix group (17.3 +/- 4.6 mm versus 10.9 +/- 4.4 mm, P =.002). Load at failure (796 +/- 193 N versus 647 +/- 269 N), stiffness (49.2 +/- 21.9 N/mm versus 64.5 +/- 22 N/mm), and bone mineral density (0.74 +/- 0.15 gm/cm(3) versus 0.74 +/- 0.14 gm/cm(3)) did not display significant differences for the Intrafix device and the screw, respectively (P >.05).

CONCLUSIONS

Displacement at failure was greater for the Intrafix device.

CLINICAL RELEVANCE

Increased displacement at failure for the Intrafix group suggests slippage from sheath channel deployment. Concentric fixation may not occur when less than optimal tibial bone mineral density increases the difficulty of attaining precise sheath deployment and quadrupled hamstring tendon graft strand alignment.

Mechanical properties of soft tissue femoral fixation devices for anterior cruciate ligament reconstruction

PURPOSE

To evaluate femoral soft tissue fixation for anterior cruciate ligament reconstruction.

HYPOTHESIS

Femoral fixation devices have different ultimate strengths and slippage under cyclic loading.

STUDY DESIGN

Controlled laboratory study.

METHODS

Thirty-three porcine femora were used to study interference screw (9), Endobutton (8), Rigidfix cross-pin (8), and Bio-Transfix cross-pin (8) fixation methods. Fixation slippage was evaluated under cyclical load from 50 N to 250 N using a materials testing machine. Ultimate load was determined with a single load to failure.

RESULTS

Total graft slippage was greater (P <.001) for the Rigidfix (6.02 +/- 2.12 mm) and the interference screw (5.44 +/- 3.25 mm) compared to the Endobutton (1.75 +/- 0.97 mm) and the Bio-Transfix (1.14 +/- 0.53 mm). All techniques showed the greatest slippage during the first 100 cycles (Rigidfix 84%, Endobutton 70%, interference screw 56%, and Bio-Transfix 55%). The failure load for the interference screw technique (539 +/- 114 N) was lower (P =.0008) than for the other 3 techniques (737 +/- 140 N for Rigidfix, 746 +/- 119 N for Bio-Transfix, and 864 +/- 164 N for Endobutton).

CONCLUSIONS

The interference screw and the Rigidfix fixation demonstrated inferior fixation biomechanics compared to the Bio-Transfix and the Endobutton techniques.

Revision anterior cruciate ligament reconstruction: a midterm patient assessment

Twenty patients who underwent revision anterior cruciate reconstruction were retrospectively reviewed. Before revision surgery all patients reported functional instability with daily and or sporting activities. The causes of primary graft failure have been identified. Four different types of graft were used for the revision reconstruction. A comprehensive knee analysis was used to assess the graft performance both subjectively and objectively at an arranged follow-up visit. In general our study shows that although there is residual antero-posterior laxity on clinical assessment and KT-1000 instrumentation after revision surgery, the majority of patients thought the results were subjectively good or excellent. The study highlights the well-recognised technical failures of primary anterior cruciate ligament reconstruction and confirms good subjective results. The poor correlation between the physical examination (objective) and the patient's perception (subjective) of the revision surgery is discussed.

Revision anterior cruciate ligament reconstruction using autografts with a polyester fixation device

Twenty-nine patients who had undergone anterior cruciate ligament (ACL) revision were evaluated retrospectively between 1992 and 2000. A similar surgical technique was used in all cases. Twenty-six patients underwent revision following failed primary and revision surgery with the ABC scaffold ligament. There were 2 failed primary semitendinosus/gracilis (STG) autografts and one failed bone patella tendon bone (BPTB) autograft. Autologous hamstring tendons (STG) were used in 26 knees, quadriceps tendon in 2 and BPTB autograft in 1 knee. The Mark I Soffix soft tissue fixation device was used in 16 patients and 13 patients underwent reconstruction with the Mark II BH (Button Hole ) Soffix. Follow up evaluation included clinical examination, KT 2000 arthrometric side to side difference (SSD) assessment, Lysholm, Tegner and IKDC scoring. The average follow up time was 50+/-22 months. The overall SSD was 1.66+/-1.5 mm, a mean Lysholm score of 87.2+/-12.5 was obtained and 22 patients had an IKDC score of nearly normal (B). In the Mark II (BH Soffix) group knees were significantly tighter than in the Mark I Soffix group (P<0.05) with a mean SSD of 1.23+/-1.3 and 2.0+/-1.6 mm, respectively. However there were no significant differences in the other measured parameters between the two fixation devices. Multiply re-operated knees tended to have lower IKDC and Lysholm scores (not statistically significant). We concluded that the technique reported in this study can restore stability to the knee following failed primary or revision ACL reconstruction and the results in the non-multiply operated knees are comparable to primary reconstruction.

Clinical outcomes after combined meniscal allograft transplantation and anterior cruciate ligament reconstruction

BACKGROUND

Concomitant meniscal transplantation performed at the time of ligament surgery may help to protect the anterior cruciate ligament graft.

PURPOSE

To determine the objective and subjective clinical outcomes after combined anterior cruciate ligament reconstruction and meniscal allograft transplantation.

STUDY DESIGN

Uncontrolled retrospective review.

METHODS

Twenty-eight patients who underwent anterior cruciate ligament reconstruction along with meniscal transplantation were retrospectively evaluated postoperatively at an average of 2.8 years (range, 1.8 to 5.6).

RESULTS

On the International Knee Documentation Committee overall subjective assessment, 86% had normal or nearly normal scores. The SF-36 physical and mental component summary scores were at higher levels than those of the patients' age- and sex-matched populations. Objectively, nearly 90% had normal or nearly normal Lachman and pivot shift test scores. The KT-1000 arthrometer testing at 30 pounds and maximum manual both demonstrated an average increased anterior translation of 1.5 mm compared with the contralateral knee. Joint space narrowing of the transplanted compartments was not significantly different from that of the contralateral knee.

CONCLUSIONS

Meniscal transplantation with anterior cruciate ligament reconstruction can be a beneficial procedure in properly selected patients with either chronic anterior cruciate ligament insufficiency or failed anterior cruciate ligament surgery. Restoration of meniscal function may provide protection for the articular cartilage and improve joint stability.

Revision anterior cruciate ligament reconstruction

Revision ACL surgery is indicated in patients who present with pathologic anterior laxity on clinical examination that reproduces their symptoms of instability during activities of daily living or athletic activities. The goals of the revision ACL surgery are to stabilize the knee, prevent further injury to the articular cartilage and menisci, and maximize the patient's function. Successful revision ACL surgery requires a thorough preoperative evaluation, including a detailed history, physical examination, and radiographic evaluation. Preoperative planning begins with a determination of the mechanisms of failure for the initial ACL reconstruction. Often a primary, as well as secondary cause, for failure can be identified. The determination of the cause of failure is the first step in a carefully-constructed treatment plan, which includes consideration of skin incisions to be used, method of graft removal, hardware removal, the need for a staged procedure or concomitant surgery, graft material selection, tunnel placement, graft fixation, and postoperative rehabilitation protocol. Despite the most meticulous planning, unanticipated findings may be encountered in the operating room, and the preoperative plan should have enough flexibility to accommodate these developments. Finally, it is crucial to counsel the patient preoperatively to limit his or her expectations regarding their surgical outcome. Given the complexity of revision ACL reconstruction, patient expectations must be adjusted to realistically match the potential for success. With proper planning, attention to detail, and appropriate patient expectations, revision ACL surgery can result in a beneficial and satisfying patient outcome.

Revision anterior cruciate surgery with use of bone-patellar tendon-bone autogenous grafts

BACKGROUND

A prospective study was done to determine the functional results, patient satisfaction, and graft failure rate after fifty-seven consecutive revision replacements of the anterior cruciate ligament with use of a bone-patellar tendon-bone autogenous graft.

METHODS

Fifty-four patients (fifty-five operations) were followed in this study. Concurrent operative procedures were performed during the revision procedure in thirty-seven knees (67%). These procedures included repair of a meniscal tear in twenty knees (36%) and reconstruction of deficient posterolateral or medial ligament structures in seventeen knees (31%). Nine knees (16%) had a high tibial osteotomy to correct varus malalignment before the revision operation. The results were evaluated with the Cincinnati Knee Rating System.

RESULTS

There were significant improvements in the scores for pain (p < 0.0001), activities of daily living (p < 0.01), sports participation (p < 0.001), patient satisfaction (p < 0.0001), and overall rating of the knee (p < 0.0001). Thirty-three (60%) of the replaced ligaments were functional, nine (16%) were partially functional, and thirteen (24%) had failed.

CONCLUSIONS

Many knees (93%) had compounding problems, including articular cartilage damage, prior meniscectomy, loss of secondary ligament restraints, varus malalignment, and concomitant ligament replacement or meniscal repair. Therefore, the results were generally less favorable than those following primary operations. The rate of graft failure was three times higher than our previously reported failure rate after primary replacements of the anterior cruciate ligament with a bone-patellar tendon-bone autogenous graft. Even so, symptoms and functional limitations with regard to daily and sports activities were found to have decreased and patient satisfaction improved. We advocate correction of varus malalignment prior to anterior cruciate procedures. Associated posterolateral ligament deficiencies should be surgically corrected during anterior cruciate procedures to prevent excessive loading on the graft from abnormal lateral tibiofemoral joint opening. Meniscal tears, including complex tears that extend into the avascular zone, can be concurrently repaired successfully during the revision.

Graft fixation in cruciate ligament reconstruction

Cruciate ligament reconstruction has progressed dramatically in the last 20 years. Anatomic placement of ligament substitutes has fostered rehabilitation efforts that stress immediate and full range of motion, immediate weightbearing, neuromuscular strength and coordination, and early return to athletic competition (3 months). This has placed extreme importance on secure graft fixation at the time of ligament reconstruction. Current ligament substitutes require a bony or soft tissue component to be fixed within a bone tunnel or on the periosteum at a distance from the normal ligament attachment site. Fixation devices have progressed from metal to biodegradable and from far to near-normal native ligament attachment sites. Ideally, the biomechanical properties of the entire graft construct would approach those of the native ligament and facilitate biologic incorporation of the graft. Fixation should be done at the normal anatomic attachment site of the native ligament (aperture fixation) and, over time, allow the biologic return of the histologic transition zone from ligament to fibrocartilage, to calcified fibrocartilage, to bone. The purpose of this article is to review current fixation devices and techniques in cruciate ligament surgery.

Technical pitfalls of anterior cruciate ligament surgery

Anterior cruciate ligament (ACL) reconstruction is extremely common. Although the number of primary reconstructions is increasing, failures and revision procedures continue to occur at approximately the same frequency. ACL reconstruction is a technically difficult procedure, and many failures can be attributed to surgical error. This article addresses the causes for failure of primary ACL reconstruction that lie within the surgeon's control. Preoperative assessment, surgical technique, and rehabilitation are addressed.

Revision anterior cruciate ligament reconstruction surgery

Revision anterior cruciate ligament (ACL) reconstruction is indicated for selected patients with recurrent instability after a failed primary procedure. The cause of the failure must be carefully identified to avoid pitfalls that may cause the revision to fail as well. Associated instability patterns must be recognized and corrected to achieve a successful result. The choice of graft, the problem of retained hardware, and tunnel placement are the major challenges of revision ACL reconstruction. The patient must have reasonable expectations and understand that the primary goal of surgery is restoration of the ability to perform activities of daily living, rather than a return to competitive athletics. The results of revision ACL reconstructions are not as good as those after primary reconstructions; however, the procedure appears to be beneficial for most patients.

Revision anterior cruciate ligament surgery

An increasing number of revision ACL reconstructions are being performed each year. Revision ACL surgery is challenging and cannot be approached in the same manner as primary ACL surgery. Successful revision ACL surgery requires a detailed history, a comprehensive physical examination, appropriate radiologic studies, and careful preoperative planning. The results of revision ACL surgery do not equal the results of primary ACL surgery, and this should be explained to the patient prior to surgery. In order to avoid repeating errors that led to failure of the primary reconstruction, the etiology of the primary failure must be clearly understood before proceeding with the revision procedure. Although graft failure is the most common reason for failure of the original reconstruction and revision surgery, other non-graft-related problems, such as loss of motion, extensor mechanism dysfunction, and degenerative arthritis, can also result in an unsatisfactory outcome and residual complaints. Errors in surgical technique, specifically nonanatomic graft placement and failure to address associated ligamentous injuries at the time of the original procedure, are responsible for graft failures in most reported series. Preoperative planning must address the issues of graft selection, skin incisions, hardware removal, tunnel placement, graft fixation, and associated ligamentous injuries. Loss of motion and in some cases enlarged bone tunnels may require a staged approach. Because of the weaker initial graft fixation, laxity of secondary restraints, the potential need to address associated ligamentous injuries, and the presence of more significant articular cartilage changes, an accelerated rehabilitation program is inappropriate in most revision cases. Successful revision ACL surgery requires a motivated and compliant patient, a well thought out plan, and an experienced surgeon who is knowledgeable and proficient with a variety of different surgical techniques, graft sources, and graft fixation techniques.

Ipsi- or contralateral patellar tendon graft in anterior cruciate ligament revision surgery. A comparison of two methods

Twenty-four patients who underwent anterior cruciate ligament revision surgery were studied postoperatively (12 with reharvested ipsilateral patellar tendon grafts and 12 with contralateral patellar tendon grafts). For comparison purposes, 12 matched patients with primary anterior cruciate ligament reconstruction, who had been operated on using the same technique by the same surgeons, were chosen. The median time since the first reconstruction was 57 months (range, 15 to 132) in the ipsilateral tendon group and 54 months (range, 20 to 108) in the contralateral tendon group. Follow-up examination showed that there were no significant differences in total KT-1000 arthrometer side-to-side measurements between the groups, but the Lysholm score was higher for patients with contralateral tendon grafts than for patients with ipsilateral grafts. Only two patients with ipsilateral grafts were classified as having excellent or good results. Functional testing outcomes were similar for all groups, and magnetic resonance imaging screening showed no differences between the reharvest and primary harvest groups in terms of length, width, thickness, or donor site gap of the patellar tendon. However, there were two major complications in the group with revision surgery with the ipsilateral reharvested patellar tendon. Reharvesting the ipsilateral patellar tendon resulted in lower functional scores and a higher rate of complications than revision with the contralateral patellar tendon or primary anterior cruciate ligament reconstruction.

Anterior cruciate ligament reconstruction with fresh-frozen patellar tendon allografts: sixty cases with 2 years' minimum follow-up

A prospective study was performed on 101 patients who underwent an arthroscopic anterior cruciate ligament (ACL) reconstruction with fresh-frozen patellar tendon allograft (bone-patellar tendon-bone). We present the results of the first 60 patients with a minimum follow-up of 2 years. Thirty-four were men and 26 women with a mean age of 23. In 45 patients, a postoperative arthroscopy was performed, and tissue biopsies of the reconstructed ACL were obtained. Patients were evaluated according to the International Knee Documentation Committee evaluation form. After a mean follow-up of 47 months, the overall results were normal or nearly normal in 85%. Under postoperative arthroscopy, the macroscopic appearance of the implant was similar to that of a normal ligament. The ACL allograft was covered with a normal, well-vascularized synovium. There were no cases of infection, disease transmission or tissue rejection. We conclude that the use of fresh-frozen patellar tendon allografts is a good method of ACL reconstruction.