Primary revision with replasty of the anterior cruciate ligament

Abstract

Restoration of knee stability after rerupture of an anterior cruciate ligament (ACL) graft. Acute and chronic functional instability with rerupture of an ACL graft with subjective instability with anatomical or non-anatomical bone tunnel without tunnel widening. Partial anatomical bone tunnels of the previous operation, significant tunnel widening of anatomical bone tunnels, local infection of the knee joint, local soft tissue damage. Graft choices are hamstring tendons (semitendinosus muscle, gracilis muscle), the quadriceps tendon, patellar tendon and aperoneus tendon split graft. In cases with anatomical tunnels, careful debridement is performed down to the tunnel wall.In non-anatomical tunnels, anew femoral tunnel is drilled over adeep anteromedial portal with the knee flexed more than 110° in the insertion area of the ACL.Using drills and dilators, atunnel is prepared.At the tibia, the anterior horn of the lateral meniscus serves as alandmark in the absence of an ACL stump.The cortical tibial tunnel aperture is probed with aguide wire and the tunnel is drilled stepwise until the tunnel wall is reached, which is debrided with aspoon or synovial resector to remove graft residues and implants from the tunnel.The femoral fixation can either be done with aflip button, an interference screw or in the case of abone block graft implant-free. At the tibial side, the graft is fixed with aresorbable interference screw and fixation button. The rehabilitation program comprises 4-5phases. Inflammatory phase (weeks1-2): control of pain and swelling (cooling, isometric tension exercises, 20 kg partial load). Phase2 (weeks 2-6): increasing load and range of motion with closed chain exercises (target: extension/flexion 0-0-120°). Phase3 (from week6): strength and coordination exercises. Phase4: balance, strength and jump exercises. Return to competitive sport not before postoperative month 6-10. Included were 51patients with recurrent instability after ACL surgery where primary ACL replacement was performed with ipsilateral bone quadriceps tendon graft or contralateral semitendinosus-gracilis graft. All patients had anatomical or non-anatomical tunnel locations without significant widening (>11 mm). After 2years, the side-to-side difference for anterior tibial translation measured with the KT 1000 arthrometer was 2.0 ± 1.2 mm for the quadriceps group and 3.0 ± 2.9 mm for the semitendinosus-gracilis group (P = 0.461). No difference in the rate of positive pivot shift tests (P = 0.661); no significant difference in the individual Knee Injury and Osteoarthritis Outcome Score (KOOS) subscores or in the frequency of anterior knee pain.