Abstract
PurposeTo compare clinical outcomes, radiographic characteristics, and surgical factors between patients with single and multiple anterior cruciate ligament (ACL) graft failures. It was hypothesized that patients experiencing multiple ACL graft failures exhibit lower patient-reported outcome scores (PROs) and a higher (steeper) posterior tibial slope (PTS) than patients with single ACL graft failure.MethodsPatients undergoing revision ACL reconstruction with a minimum follow-up of 12 months were included in this retrospective cohort study. Based on the number of ACL graft failures, patients were assigned either to the group “single ACL graft failure “or” multiple ACL graft failures “. The PTS was measured on strict lateral radiographs. Validated PROs including the International Knee Documentation Committee (IKDC) subjective knee form, Knee Injury and Osteoarthritis Outcome Score, Lysholm Score, Tegner Activity Scale, ACL-Return to Sport after Injury Scale, and Visual Analogue Scale for pain were collected.ResultsOverall, 102 patients were included with 58 patients assigned to the single ACL graft failure group and 44 patients to the multiple ACL graft failures group. Quadriceps tendon autograft was used significantly more often (55% vs. 11%, p < 0.001) and allografts were used significantly less often (31% vs. 66%, p < 0.001) as the graft for first revision ACL reconstruction in patients with single versus multiple ACL graft failures. Patients with multiple ACL graft failures were associated with statistically significantly worse PROs (IKDC: 61.7 ± 19.3 vs. 77.4 ± 16.8, p < 0.05; Tegner Activity Scale: 4 (range, 0–7) vs. 6 (range 2–10), p < 0.05), higher PTS (12 ± 3° vs. 9 ± 3°, p < 0.001), and higher rates of subsequent surgery (73% vs. 14%, p < 0.001) and complications (45% vs. 17%, p < 0.05) than patients with single ACL graft failure.ConclusionCompared to single ACL graft failure in this study multiple ACL graft failures were associated with worse PROs, higher PTS, and allograft use. During the first revision ACL reconstruction, it is recommended to avoid the use of allografts and to consider slope-reducing osteotomies to avoid multiple ACL graft failures and improve PROs.Level of evidenceLevel 3.
Highlights
Group comparison revealed that statistically significantly more patients underwent first revision anterior cruciate ligament (ACL)-R using quadriceps tendon autograft in the single ACL graft failure group compared to the multiple ACL graft failures group (32 (55%) vs. 5 (11%), p < 0.001)
The most important finding of this study was that compared to patients with single ACL graft failure patients with multiple ACL graft failures were associated with worse patient-reported outcomes (PROs), higher medial posterior tibial slope (PTS) (12° vs. 9°), less quadriceps tendon autograft use (11% vs. 55%), and more allograft use (66% vs. 31%)
The present study showed that in patients with a single ACL graft failure, quadriceps tendon autografts were significantly more often used in first revision anterior cruciate ligament reconstruction (ACL-R) than in patients with multiple ACL graft failures, where allografts were predominant
Summary
The failure rate after revision anterior cruciate ligament reconstruction (ACL-R) has been reported to be 3–21% [1,2,3,4,5] compared to 3–10% after primary ACL-R [6,7,8,9,10,11].1 3 Vol.:(0123456789)Knee Surgery, Sports Traumatology, ArthroscopyAnatomical and patient-related risk factors, technical and biological failures, unappreciated concomitant capsuloligamentous or meniscal injuries, as well as aggravated surgical conditions due to previous interventions have been identified as underlying causes for the increased failure rate [1, 12,13,14,15].Despite a large body of the literature regarding single anterior cruciate ligament (ACL) graft failures, only a few studies emphasizing multiple ACL graft failures have been published [1, 5, 12, 13, 15, 16]. The failure rate after revision anterior cruciate ligament reconstruction (ACL-R) has been reported to be 3–21% [1,2,3,4,5] compared to 3–10% after primary ACL-R [6,7,8,9,10,11]. Prior studies have shown that undergoing more than one revision ACL-R is a predictor for worse patient-reported outcomes (PROs) and subsequent graft failures [2, 17]. The majority of patients that have sustained multiple ACL graft failures present with meniscal tears and cartilage lesions [5, 12, 13, 15, 16], which are well-known negative predictors for long-term knee function. Surgery- and patient-related predictors of multiple ACL graft failures may aid in surgical decision-making and patient counseling for revision ACL reconstruction
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