One-stage revision anterior cruciate ligament reconstruction in cases with excessive tunnel osteolysis. Results of a new technique using impaction bone grafting

One-stage anterior cruciate ligament revision surgery after primary failed double-bundle reconstruction: a systematic review

INTRODUCTION

Anterior cruciate ligament (ACL) revision surgery after failed double-bundle (DB) reconstruction is a challenging procedure. This study aimed to systematically review the research on ACL revision surgery following failed DB reconstruction, providing an overview on indications, surgical techniques, clinical outcomes and potential pitfalls occurring while performing this therapeutic approach.

MATERIALS AND METHODS

Literature published from exception to February 2023 was searched in the Pubmed/MEDLINE, Embase and CINAHL databases. Studies in English reporting on patients who underwent ACL revision surgery after prior failed DB reconstruction were considered. Review articles and expert opinion or editorial pieces were excluded. Outcomes of interest included indications and pre-operative planning, surgical technique and associated procedures, type of revision surgery (either one- or two-stage), graft choice, clinical and functional outcomes, rate of complications, failure rate.

RESULTS

Overall, 4 studies met all the inclusion criteria for this review. All were published between 2007 and 2020. The search resulted in two retrospective comparative studies, one case series, and one case report. Average follow-up periods ranged from 24 to 45 months. From these studies, 66 patients (66 knees) were identified. One-stage revision surgery was performed in 64 on 66 patients (97%) with pathologic laxity following DB ACL reconstruction. Most frequently reported outcome was Lysholm score in five studies: average postoperative Lysholm score ranged from 90.5 to 91.0 while Tegner activity level ranged from 5.6 to 7.0. In 4 patients (6%) re-revision surgery was performed due to graft re-rupture.

CONCLUSIONS

One-stage ACL revision surgery following DB ACL reconstruction appears feasible providing satisfying outcomes and limited complications. The literature on this subject is limited and further comparative studies reporting long-term outcomes are needed, as high-level studies on this topic are still lacking.

Satisfactory outcomes after one-stage revision anterior cruciate ligament reconstruction using rectangular tunnel technique

PURPOSE

One-stage revision anterior cruciate ligament reconstruction (ACLR) with the anatomic rectangular tunnel (RT) technique using bone-patellar tendon-bone (BTB) grafts results in anatomically precise tunnel placement and secure graft fixation. This study evaluated knee joint laxity and clinical outcomes in terms of femoral tunnel overlap. It was hypothesised that there would be no significant differences in knee joint laxity or clinical outcomes regardless of femoral tunnel overlap.

METHODS

Between 2012 and 2021, a single surgeon conducted 196 one-stage revision ACLRs with the RT technique using BTB grafts. Patients were divided based on the presence of femoral tunnel overlap. Knee joint laxity was evaluated using the Lachman test, pivot shift test, and side-to-side difference measured with a KT-1000 arthrometer. Clinical outcomes were assessed using the Lysholm score, Knee Injury and Osteoarthritis Outcome Score (KOOS), and International Knee Documentation Committee (IKDC) Knee Examination Form 2000. Knee joint laxity and clinical outcomes were compared between groups after a median follow-up of 2.5 years (range 2.0-8.0).

RESULTS

The study included 30 and 73 patients in the overlap and non-overlap groups, respectively. No significant differences were observed in the results of the Lachman test, pivot shift test, or KT-1000 arthrometer as well as in the Lysholm, KOOS, or IKDC scores between the two groups. Based on the IKDC scores, all patients were graded as normal or nearly normal.

CONCLUSION

One-stage revision ACLR with the RT technique using BTB grafts improved knee joint laxity and had favourable clinical outcomes regardless of femoral tunnel overlap. To achieve optimal results in one-stage revision ACLR, it is crucial to create a tunnel within the anatomical attachment area and ensure proper graft fixation and tensioning.

LEVEL OF EVIDENCE

III.

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

PURPOSE

To systematically review the current literature regarding the indications, techniques, and outcomes after 2-stage revision anterior cruciate ligament reconstruction (ACLR).

METHODS

A literature search was performed using SCOPUS, PubMed, Medline, and the Cochrane Central Register for Controlled Trials according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta Analyses statement. Inclusion criteria was limited to Level I-IV human studies reporting on indications, surgical techniques, imaging, and/or clinical outcomes of 2-stage revision ACLR.

RESULTS

Thirteen studies with 355 patients treated with 2-stage revision ACLR were identified. The most commonly reported indications were tunnel malposition and tunnel widening, with knee instability being the most common symptomatic indication. Tunnel diameter threshold for 2-stage reconstruction ranged from 10 to 14 mm. The most common grafts used for primary ACLR were bone-patellar tendon-bone (BPTB) autograft, hamstring graft, and LARS (polyethylene terephthalate) synthetic graft. The time elapsed from primary ACLR to the first stage surgery ranged from 1.7 years to 9.7 years, whereas the time elapsed between the first and second stage ranged from 21 weeks to 13.6 months. Six different bone grafting options were reported, with the most common being iliac crest autograft, allograft bone dowels, and allograft bone chips. During definitive reconstruction, hamstring autograft and BPTB autograft were the most commonly used grafts. Studies reporting patient-reported outcome measures showed improvement from preoperative to postoperative levels in Lysholm, Tegner, and objective International Knee and Documentation Committee scores.

CONCLUSIONS

Tunnel malpositioning and widening remain the most common indications for 2-stage revision ACLR. Bone grafting is commonly reported using iliac crest autograft and allograft bone chips and dowels, whereas hamstring autograft and BPTB autograft were the most used grafts during the second-stage definitive reconstruction. Studies showed improvements from preoperative to postoperative levels in commonly used patient reported outcomes measures.

LEVEL OF EVIDENCE

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

Tunnel Management in Revision Anterior Cruciate Ligament Reconstruction: Current Concepts

Bone tunnel-related complications are frequently encountered during revision anterior cruciate ligament reconstruction (ACLR). Issues with tunnel positioning, enlargement, containment, and hardware interference may complicate surgery and compromise outcomes. As a result, several strategies have emerged to address these issues and optimize results. However, a systematic, unified approach to tunnel pathology in revision ACLR is lacking. The purpose of this review is to highlight the current state of the literature on bone tunnel complications and, although extensive literature on the subject is lacking, present an updated approach to the evaluation and management of tunnel-related issues in revision ACLR.

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

Background

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

Methods

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

Results

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

Conclusion

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

Stacked Biocomposite Screws in a Single-Stage Revision Anterior Cruciate Ligament Reconstruction Has Acceptable Fixation Strength in a Porcine Cadaveric Model

BACKGROUND

Stacked screws is a commonly used technique in single-stage revision anterior cruciate ligament (ACL) reconstruction in the setting of bone loss, but there are limited data to support its use.

HYPOTHESIS

Two configurations of a biocomposite stacked screws construct have similar fixation strength and linear stiffness as a primary ACL reconstruction construct in a biomechanical model.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 30 porcine legs were divided into 3 groups. Group 1 underwent primary ACL reconstruction with a patellar tendon graft fixed into the femur, with an 8-mm biocomposite interference screw of beta-tricalcium phosphate and poly lactide-co-glycolide. For a revision ACL reconstruction model, groups 2 and 3 had bone tunnels created and subsequently filled with 12-mm biocomposite screws. New bone tunnels were drilled through the filler screw and the surrounding bone, and the patellar bone plug was inserted. Group 2 was fixed with 8-mm biocomposite screws on the side of the graft opposite the filler screw, while group 3 had the interference screw interposed between the graft and the filler screw. The construct was loaded at 1.5 mm/s in line with the tunnel until failure. Load to failure, linear stiffness, and mode of failure were recorded.

RESULTS

The mean pullout strength for groups 1, 2, and 3 was 626 ± 145 N, 653 ± 152 N, and 720 ± 125 N, respectively (P = .328). The mean linear stiffness of the construct in groups 1, 2, and 3 was 71.4 ± 9.9 N/mm, 84.1 ± 11.1 N/mm, and 82.0 ± 10.8 N/mm, respectively. Group 2 was significantly stiffer than group 1 (P = .037).

CONCLUSION

Two configurations of a biocomposite stacked screws construct for a single-stage revision ACL reconstruction in the setting of bone loss show a similar fixation strength and linear stiffness to a primary ACL reconstruction at time zero in a porcine model.

CLINICAL RELEVANCE

In the setting of bone loss from tunnel malpositioning, a single-stage revision ACL reconstruction using a stacked screws construct may provide adequate fixation strength and linear stiffness.

Single-Stage Anterior Cruciate Ligament Revision Reconstruction Using an Allograft Bone Dowel for a Malpositioned and Widened Femoral Tunnel

Tunnel widening, osteolysis, and/or malposition can be a cause of anterior cruciate ligament (ACL) reconstruction failure and a challenging problem to treat when performing revision ACL reconstruction (RACLR). Traditionally, problematic tunnels that interfere with bony stability and incorporation of the new graft at the time of revision have been treated with staged procedures-bone grafting first, followed by a return several months later for the revision reconstruction after bony incorporation has occurred. Multiple staged procedures increase the level of risk the patient may encounter and increase cost and resource utilization. In addition, they prolong the recovery period for the patient. In recent years, several studies have evaluated the clinical outcomes of performing bone grafting of tunnels and concomitant RACLR in a single-stage setting in an effort to mitigate these issues. We describe a technique by which a malpositioned and widened femoral tunnel from a primary ACL failure is treated with bone grafting using an allograft dowel, as well as immediate RACLR using a bone-patellar tendon-bone allograft.

One-Stage Anatomical Revision Anterior Cruciate Ligament Reconstruction: Results According to Tunnel Overlaps

PURPOSE

To present clinical results according to tunnel overlap in 1-stage anatomical revision anterior cruciate ligament reconstruction (ACLR).

METHODS

All patients who underwent revision ACLR performed by a single surgeon (J.H.A.) from 2012 to 2017 and were followed up for >24 months were retrospectively evaluated. The exclusion criteria were concomitant ligament injury, including medial collateral ligament injury, modified Outerbridge grade ≥3 cartilage lesion, and severe meniscus defects. Tunnel overlap was measured on 3-dimensionally reconstructed computed tomography images. Patients in the nonoverlapped femoral tunnel group (group NO, n = 52) were treated with new tunnel drilling that completely avoided previous tunnels, and those in the overlapped femoral tunnel group (group O, n = 41) were treated with a new tunnel that overlapped with previous tunnels. Clinical outcomes were evaluated using the subjective International Knee Documentation Committee (IKDC) and Lysholm scores. Knee joint stability was measured using the Lachman and pivot shift tests. Patients with femoral tunnel widening of ≥14 mm underwent 2-stage ACLR.

RESULTS

The mean follow-up duration of 93 patients was 46.9 months (range, 24-97 months). All preoperative subjective and objective IKDC (P<0.001) and Telos stress test scores (P = .016) were significantly improved at the last follow-up. Forty-one patients had overlapping femoral tunnels, whereas 87 had overlapping tibial tunnels. At the last follow-up, subjective IKDC and Lysholm scores (73.6 ± 15.3 vs 74.9 ± 12.1, P = .799 and 80.0 ± 19.2 vs 81.44 ± 13.5, P = .505, respectively) and objective pivot shift (IKDC grade) in the Lachman test (P = .183 and P = .450, respectively) did not differ significantly between groups NO and O, respectively.

CONCLUSIONS

One-stage anatomical revision ACLR significantly improved the clinical results. Most tibial tunnels (94%) and approximately one-half (44%) of the femoral tunnels overlapped. The overlapped femoral tunnel group did not show inferior outcomes or stability.

LEVEL OF EVIDENCE

Level III, cohort study.