Revision ACL Surgery Research Articles

Meniscal and Articular Cartilage Predictors of Outcome following Revision ACL Reconstruction: A 6-Year Follow-up Study

Objectives:Previous work has shown that having a lateral meniscectomy prior to revision ACL surgery, as well as grade 3-4 chondral damage to the trochlea at the time of revision ACL surgery results in poorer outcomes at 2 years. Alternatively, meniscal or articular cartilage (AC) pathology documented at the time of a revision surgery were not found to be significant risk factors for 2-year activity levels. The purpose of this study was to follow this cohort for a longer time period, to determine if either meniscal and/or articular cartilage pathology noted at the time of revision ACL surgery significantly affects a patient’s activity level, sports function, and OA symptoms at 6-year follow-up.Methods:Revision ACL reconstruction patients were identified and prospectively enrolled between 2006 and 2011. Data collected included baseline demographics, surgical technique and pathology, and a series of validated patient reported outcome instruments (IKDC, KOOS, WOMAC, and Marx activity rating score). Patients were followed up for 6 years and asked to complete the identical set of outcome instruments.Regression analysis was used to control for age, gender, BMI, smoking status, activity level, baseline outcome scores, revision number, time since their last ACL reconstruction, graft choice, and previous and current meniscal and articular cartilage pathology, in order to assess the meniscal and AC pathology risk factors for clinical outcomes 6 years after revision ACL reconstruction.Results:1234 patients met the inclusion criteria and were successfully enrolled, with 716 (58%) males and a median cohort age of 26 years. The median time since their last ACL reconstruction was 3.4 years. Surgeons noted previous pathology in the medial meniscus (39%), lateral meniscus (20%), and articular surfaces (12%) at the time of revision surgery. Surgeons reported current pathology at the time of revision surgery in the medial meniscus (45%), lateral meniscus (36%), medial femoral condyle (MFC; 43%), lateral femoral condyle (LFC; 29%), medial tibial plateau (MTP; 11%), lateral tibial plateau (LTP; 17%), patella (30%), and trochlea (21%). At 6 years, follow-up was obtained on 77% (949/1234). Previous and current meniscal pathology (both medial and lateral), as well as current AC pathology (in the MFC, LTP, trochlea, and patella) were found to be significant drivers of poorer outcomes at 6 years. The most consistent cartilage-related factors driving outcome in revision patients were either a previous or current repair or excision of the medial meniscus and patellofemoral AC pathology. Six-year Marx activity levels were negatively impacted by having either a repair or an excision of the medial meniscus (odds ratio range =0.58-66; 95% CI=0.38-0.91; p=0.01) or having grade 3-4 patellar chondrosis (OR=0.57; 95% CI= 0.35-0.95; p=0.03). Conversely, 6-year activity levels significantly improved by having either a lateral meniscus repair or excision (OR=1.49-2.22; 95% CI=1.07-4.04; p=0.005). Previous medial or lateral meniscal pathology negatively affected all KOOS subscales except for sports/recreation (p<0.05). Articular pathology significantly impaired KOOS symptoms, sports/recreation and the quality of life subscales (p<0.05). The KOOS sports/recreation subscale was significantly affected by articular cartilage pathology (LTP, patella, trochlea; p<0.03). Lower baseline outcome scores, lower baseline activity level, and being a smoker all significantly increased the odds of reporting poorer clinical outcomes at 6 years.Conclusion:Meniscal and articular cartilage pathology was found to have a larger impact at 6 years following revision ACL surgery, as compared to 2-year follow-up. In contrast to 2-year follow-up, incidence of medial meniscal and AC pathology at the time of a patient’s revision surgery were found to significantly diminish a patient’s activity level at 6 years, whereas the incidence of lateral meniscal repair or excision was found to improve a patient’s activity level. Having a previous medial meniscal repair or excision or exhibiting grade 2-4 chondral damage noted at the time of ACL revision reconstruction results in poorer IKDC and KOOS scores and worse WOMAC pain and ADL scores at 6 years following revision surgery.

Moderately Increased Post-Operative Anterior Knee Laxity does not Predict Decreases in Patient-Reported Outcome Scores or Subsequent Knee Surgery between 2 and 6 Years after ACL reconstruction

Objectives:A primary goal of anterior cruciate ligament reconstruction is to reduce pathologically increased anterior and rotational laxity of the knee. The impact of residual anterior laxity on patient-reported outcomes and the risk of subsequent ipsilateral knee surgery has not been clearly elucidated. The goal of this study is to determine the influence of residual anterior knee laxity on changes in patient-reported outcomes from 2 to 6 years following ACL reconstruction and risk of subsequent ipsilateral knee surgery during that period.Methods:From a prospective multi-center cohort of patients, 429 patients under age 35 years injured in sports with no history of concomitant ligament surgery, revision ACL surgery, or surgery of the contralateral knee were identified at a minimum 2 years following primary ACL reconstruction. These patients underwent a KT-1000 assessment of anterior knee laxity examination relative to the contralateral normal knee by an independent examiner and completed patient-reported outcome assessments with KOOS and IKDC scores. Patients were followed until the 6-year mark following ACL reconstruction and any ipsilateral knee surgeries performed during this period were noted. Patients completed the same patient-reported outcome assessments at 6 years post-operative. Subsequent surgery risk was calculated and compared between those patients with side-to-side KT-1000 differences between -1 and 2 mm and those with a side-to-side KT-1000 differences between 2 and 6mm. Multiple linear regression models were built to determine the relationship between KT-1000 and 2 to 6 year change in patient-reported outcome score while controlling for age, sex, BMI, smoking status, meniscus and cartilage status, and graft type.Results:Thee hundred seventy-seven patients (87.9%) were available for follow-up at the six year mark post-operative. There were 36 patients with a side to side KT-1000 difference less than -1 mm (tighter than contralateral) that were excluded from the analysis. Side-to-side KT-1000 difference was between -1 and 2 mm (IKDC A) in 153 patients, between 2 and 6 mm (IKDC B) in 162 patients, and greater than 6 mm in 26 patients. Subsequent knee surgery was performed significantly more patients in the IKDC A group (23 of 153 patients, 15%) than in the IKDC B group (13 of 162 patients, 8%) (p = 0.05). Increased side-to-side KT-1000 differences at 2-year post-operative were correlated with decreases in subjective IKDC score (β = -0.67, p = 0.038) and KOOS-sport subscale (β = -0.90, p = 0.029) but not with other KOOS subscales. A 5mm increase in anterior laxity at 2 years would predict a 3.4 point decrease in IKDC subjective score and a 4.5 point decrease in the KOOS sport subscale at 6 years post-operative.Conclusion:Three presence of 2 to 6 mm of residual side-to-side KT-1000 difference is not associated with an increased risk of subsequent ipsilateral knee surgery or clinically relevant decrease in patient-reported outcome score up to 6 years following ACL reconstruction.

Functional outcomes following contralateral hamstring tendon autografts with extra-articular tenodesis for ACL revision surgery.

Lateral extra-articular procedure in association with ACL reconstruction can act as a protection against undesired load occurring during early postoperative phases, thus making it useful in revision ACL surgery. The purpose of the present study is to retrospectively review the clinical outcome of contralateral hamstring tendon autografts with extra-articular tenodesis for ACL revision surgery, specifically with regard to patient satisfaction, return to preinjury activity level, and postoperative functional outcomes. The hypothesis was that this combined procedure leads to improved stability and functional outcome in patients affected by ACL re-tear. Twelve patients who underwent ACL revision surgery using contralateral hamstring tendon autografts and extra-articular tenodesis were retrospectively reviewed at an average follow-up of 4.1 years (range, 2 to 7 years). All the operations were performed by a single senior surgeon. The Tegner, Lysholm, International Knee Documentation Committee (IKDC) Subjective Knee Form were used. Objective evaluation included range of motion, Lachmann test, pivot-shift test and KT-1000 instrumented laxity testing. Wilcoxon test was utilized to compare the preoperative and follow-up status. Differences with a P value <0.05 were considered statistically significant. Lysholm knee score as well as IKDC score significantly improved at follow-up (P<0.05). No significant differences concerning Tegner activity level were reported (P=0.9). In terms of knee stability, anterior tibial translation according to manual laxity testing and as measured with KT-1000 arthrometer significantly improved after surgery (P<0.05). The present study shows favorable results for revision ACL reconstruction with contralateral hamstrings and associated extra-articular tenodesis concerning subjective knee function and knee stability as well as ability to resume sport activities.

Does hamstring tendon graft diameter affect the outcome of anterior cruciate ligament surgery?

Summary Introduction Aim of this study was to see the effect of quadruple hamstring tendon graft diameter on knee stability, functional outcome, and graft rupture risk after ACL reconstruction. Method This study had two parts retrospective part and prospective part. In retrospective part, 18 athletes who underwent revision ACL reconstruction surgery between years 2008 and 2015 were identified from the computerized database. In prospective part, 103 athletes who underwent primary ACL reconstruction were enrolled in the study and divided into two groups depending upon their quadruple hamstring tendon graft diameter – group A (graft diameter Results In retrospective study, l6/18 athletes who underwent revision ACL surgery had graft size 0.05). Conclusion Graft size of

Single-stage revision anterior cruciate ligament reconstruction using bone grafting for posterior or widening tibial tunnels restores stability of the knee and improves clinical outcomes.

Revision ACL surgery may be complicated by tunnel malposition and/or tunnel widening and often requires a staged treatment approach that includes bone grafting, a period of several months to allow bone graft incorporation and then definitive revision ACL reconstruction. The purpose of this study was to evaluate the results of a single-staged ACL revision reconstruction technique using a cylindrical dowel bone graft for patients who have existing posteriorly placed and/or widened tibial tunnels in the tibia at a minimum of 2years follow-up. Between 2010 and 2014, patients undergoing single-stage revision ACL reconstruction with the described technique were prospectively enrolled and evaluated. At a minimum of 24months, patients were evaluated by physical examination, multiple clinical outcome instruments including KOOS, Tegner and Lysholm, and preoperative and postoperative MRIs. At a mean of 35.1months, 18 consecutive patients had no revision surgery and no subjective knee instability. There were statistically significant improvements in the Tegner (median 2, interquartile range 2.25; p < 0.01), Lysholm (20.0 ± 15.0; p < 0.01), KOOS symptoms scale (12.9 ± 11.8; p < 0.01), KOOS pain scale (15.4 ± 18.7; p < 0.01), KOOS ADL scale (13.5 ± 19.0; p < 0.01), KOOS sports scale (32.8 ± 26.4; p < 0.01), and KOOS QoL scale (18.1 ± 16.9; p < 0.01). Postoperative MRI demonstrated statistically significant anteriorization of the tibial tunnel and a statistically significant decrease in tunnel widening. Revision ACL reconstruction utilizing a single-staged tibial tunnel grafting technique resulted in improved knee pain, function, and stability at a minimum of 24-month follow-up. IV.

Age over 50years is not a contraindication for anterior cruciate ligament reconstruction.

To report clinical and functional results of ACL reconstruction in patients over 50years old and investigate the influence of surgery on osteoarthritis progression in this cohort of patients. A systematic review was performed on PubMed, Scopus, Google scholar, Cochrane library and EMBASE, using a strategy search design to collect clinical studies reporting outcomes of ACL reconstruction in patients aged 50years or older. The primary outcome measure was clinical and functional results, including failure rate defined as reoperation for revision ACL surgery or conversion to total knee arthroplasty; secondary outcomes included radiological findings, expressed according to the validated grading score. A total of 16 studies were found suitable and included. Overall, 470 arthroscopic ACL reconstructions were performed in 468 patients (278 males, 190 females), with a mean age of 53.6years (50-75years). The total failure rate, described as reoperation for revision ACL surgery was 2.7% (10 knees), ranging from 0 to 14.3% in the selected studies. All papers reviewed showed a statistically significant improvement of clinical and functional scores at final follow-up, comparable to younger control group, when reported. Post-operative objective stability testing with KT-1000 arthrometer device or equivalent was performed in seven studies, with a mean side-to-side difference of 2.2mm (0.2-2.7mm). Radiographic signs of progression of osteoarthritis were reported in six studies, where severe signs of degeneration (grade 3 or 4 according Kellgren-Lawrence or Ahlbäck classification) shifted from 4 out of 216 knees (1.9%) before surgery to 28 out of 187 knees (15%) following ACL reconstruction, after a mean period of follow-up ranging from 32 to 64months. ACL reconstruction in patients older than 50years is a safe procedure with good results that are comparable to those of younger patients previously reported. Age itself is not a contraindication to ACL surgery because physiological age, clinical symptoms and functional requests are more important than chronological age in decision process. Since cohort size in the present study is not large enough, and taking into account the high occurrence of concomitant meniscal and chondral lesions, more high-quality studies are necessary to draw definitive conclusions about development of osteoarthritis of the knee after ACL surgery in these patients. IV.

Revision ACL reconstruction using quadriceps or hamstring autografts leads to similar results after 4 years: good objective stability but low rate of return to pre-injury sport level.

Due to the increased importance of revision ACL reconstruction, this study aims to evaluate the outcome 4years after the surgery, compare two revision strategies and identify factors that influence the results. Seventy-nine patients who received a revision ACL reconstruction were retrospectively evaluated. All patients were assessed with an average follow-up of 4.4years (range 3.3-5.5years). The results of patients treated with a quadriceps autograft were compared with those treated with a hamstring autograft. Ninety-seven percent of patients had a KT-1000 side-to-side difference of ≤ 5mm (mean 1.7 ± 2.0mm). Pivot-shift test was absent or minor in 95%. In the SLTH-test, 70% of patients reached 90% of the contralateral side. The mean Lysholm score on follow-up was 83 ± 12 (56% excellent/good). The mean IKDC 2000 subjective evaluation score was 81 ± 14 (58% normal/almost normal). The median Tegner activity score was 6 (range 3-10), a median of 2 levels worse than before the first injury. Return to sport rate was 89% but only 34% of patients reached their pre-injury sport level. Most common cause for this reduction was fear of another injury. Three patients suffered a re-rupture. Patients with a hamstring autograft performed pivoting sports more often, but had worse pivot-shift results compared to those with a quadriceps autograft. No significant influence was seen for other parameters. Young, male patients with a high activity level and no chondral damage had the best results. Through revision ACL reconstruction, the goal of stabilizing the knee can be achieved in the majority of patients. However, a good function and a high activity level are significantly less common in these patients. The main reason for this is fear of a renewed ACL-injury. Both quadriceps and hamstring autografts were able to achieve a good outcome. Young, male, patients with a normal BMI, a high activity level and without cartilage damage seem to benefit the most from revision ACL surgery. The discrepancy between the good laxity restoration and the lower activity rate should therefore be a main point in clinical counseling when deciding for or against revision ACL-Reconstruction. III.

No effect of graft size or body mass index on risk of revision after ACL reconstruction using hamstrings autograft.

The current study investigated the distribution of hamstrings graft size and body mass index and any potential effect on the risk of revision surgery in a large prospective cohort of patients undergoing ACL reconstruction. More specifically, the aim of the study was to investigate whether larger graft size or smaller BMI would decrease the risk of revision after ACL reconstruction. A total of 4029 patients, prospectively registered in the Norwegian Knee Ligament Registry, were included in the study. Univariate Kaplan-Meier survival analyses (with log-rank tests) and the Cox proportional hazard (PH) regression model were applied to compare risk of revision between groups of patients. Mutual adjustment for gender, age, activity at the time of injury and fixation method of the graft was performed. Graft sizes spanned from 5.5 to 11.0mm and the median of 8.0mm was reported in 42% of patients in the cohort. BMI was reported from 15 to 57 with a median of 25. 46% of patients were classified as overweight (WHO standards), while 23% of patients were obese. At a median of 2.5years after surgery, 150 patients had undergone revision surgery. Although certain effects were seen in the unadjusted analyses, neither graft size (diameter) nor patient BMI did affect the risk of undergoing revision surgery in the adjusted analyses. Graft size and BMI was not found to be independent risk factors for undergoing ACL revision surgery. In contrast to other studies, graft size of 8mm or larger did not have a better outcome than smaller graft sizes. A relatively large group of overweight patients undergoing ACL surgery reflects the general increase in weight seen in Western societies. Although the current study differs from previous findings, it might indicate that graft diameter is less important than previously stated. Cohort study, II.

Survivorship of allograft ACL reconstruction in adolescent patients

PurposeThe overall benefits of ACL reconstructive surgery in young athletes has been previously established. Graft selection for ACL reconstruction, specifically in this population however, remains controversial. The literature is limited and long-term survival rate of allograft ACL reconstruction in the adolescent population remains poorly defined. Current evidence, none level I, appears to demonstrate increased failure and subsequent revision rates in allograft reconstruction of complete ACL tears compared to autograft; 7–35% compared to 3–13% respectively. The purpose of the present study was to evaluate revision rate and functional outcomes of allograft ACL reconstruction in the adolescent population at extended follow-up. MethodsA retrospective chart review was performed. Forty patients who underwent transphyseal ACL reconstruction with either bone patellar tendon bone (BTB) or Achilles tendon bone (ATB) allograft performed by a single surgeon over a 12-year period were identified. Demographic and surgical details were analyzed. Enrolled patients completed a Lysholm Knee Scoring Scale and a Tegner Activity Level Scale during phone interviews. All secondary surgeries performed on the ipsilateral knee were recorded. ResultsTwenty-five patients were enrolled; fifteen were lost to follow-up. There were ten male and fifteen female patients included for analysis. Average age at index surgery was 16 years (range 13–18 years). BTB allograft was used for seven patients, and ATB allograft was used for the remaining eighteen patients. Average follow-up was 54 months (range 13–136 months). The average Lysholm score at follow-up was 87 (range 57–100). The average Tegner score at follow-up was 6.8 (range 3–10). Three patients underwent revision ACL surgery (12% study group, 7.5% all) for traumatic re-rupture. Re-rupture occurred 12, 13 and 38 months after index surgery. ConclusionsAutograft remains the standard for ACL reconstruction in the general pediatric population. In the adolescent population, however, the use of BTB or ATB allograft is a reasonable alternative with satisfactory outcomes, decreased harvest site morbidity, decreased post-operative pain and faster rehabilitation. The traumatic re-rupture rate in this series was similar to previously published traumatic failure rates in young adult athletes after reconstruction with autologous tissue (11–13%). Further prospective studies are needed to determine any true difference in the use of either allograft or autograft in the adolescent population.

A novel technique for bone marrow concentrate aspiration from the intercondylar notch during arthroscopic ACL reconstruction

Objectives:Anterior cruciate ligament Reconstruction (ACL-R) is a frequent surgery with a failure rate of 8-10%, being a cause the lack of integration of the graft. Methods of biological augmentation have been developed, such as the extraction of human mesenchymal cells by aspiration of BMC.Objective:describe and demonstrate the safety of a new arthroscopic technique of BMC aspiration from the femoral intercondylar notch.Methods:Prospective non-randomized clinical study of 45 consecutive patients undergoing anatomic ACL-R with hamstring autograft. Patients with Multiligamentary injuries or revision ACL surgery were excluded. Control group was composed by 19 patients that underwent isolated ACL-R. Intervention group was composed by 29 patients who underwent ACL-R, BMC aspiration and subsequent instillation of the BMC.Variables assessed to compare both groups were: Demographics, Surgical Time and Complications (hemarthrosis, rate of infection and risk of fracture).BMC Aspiration Technique was performed before tunnel drilling and shutting-off the water pump. Through the medial portal, the 14-gauge trocar/needle aspiration device was introduced and positioned into the upper and central region of the intercondylar notch. With a clockwise-like twisting motion, the trocar was used to pierce the cortex 25 mm into the distal femur, obtaining 60 ml of BM which was processed with the Angel system (ArthrexR). Finally, under dry arthroscopic vision, the BMC was instilled in both bone tunnels and into the graft.Statistical analysis was performed in stata 11, considering a statistical significance of 5%.Results:No demographic differences were reported. The surgical time of the control group was 50.57 min (SD 8.44) and intervention group 65.69 min (SD 10.98) (p <0.011). 0% of complications associated with the procedure were reported.Conclusion:The aspiration of BMC through the femoral intercondylar notch during the arthroscopic ACL-R, is a safe, reproducible technique without associated complications, however, it significantly increases the surgical time.

ACL Revision Surgery with Autografts and Allografts: A Comparative Study

ACL Revision Surgery with Autografts and Allografts: A Comparative Study

Increased incidence of anterior cruciate ligament revision surgery in paediatric verses adult population.

To evaluate the anterior cruciate ligament graft failure rate in a population of 1376 patients submitted to single-bundle anterior cruciate ligament reconstruction procedure. It was hypothesized that the younger the patient, the greater the chance of a new anterior cruciate ligament graft ligament injury. A retrospective chart review was performed on patients who had SB anterior cruciate ligament reconstruction between the years, 2001 and 2016, with a minimum post-operative follow-up period of 6months. The patient population was divided into three groups, according to age: group 1-under 16years old; group 2-between 16 and 18years old; and group 3-older than 18years old. Data collected included sex, laterality and graft choice data. In group 1 (under 16years old), there were 61 primary ACL surgeries performed and 15 (24.6%) revision ACL surgeries. In group 2 (between 16 and 18years old), there was 57 primary ACL procedures, of which 10 (17.5%) were revisions. In the group 3 (older than 18years of age), 1258 surgeries were done with 116 (9.2%) revisions. The rate of ACL revision surgery in patients under 16years of age was significantly higher than that found in patients older than 18years old. When compared to the population between 16 and 18years old, there were a higher number of failure cases, however, statistically non-significant. IV.

The diameter of single bundle, hamstring autograft does not significantly influence revision rate or clinical outcomes after anterior cruciate ligament reconstruction

BackgroundAnterior cruciate ligament (ACL) graft failure is a complication of ACL reconstruction (ALCR). Smaller autograft diameter may be a contributing factor. Our aim was to determine if hamstring autograft diameter influences graft rupture and patient-reported outcome scores. MethodsThis study included 786 consecutive patients undergoing primary, single bundle, autograft hamstring ACLR. The primary outcome was revision ACLR surgery. Secondary outcomes were patient reported International Knee Documentation Committee (IKDC) score, Knee Injury & Osteoarthritis Outcome Score (KOOS) and Tegner Activity score. Multiple logistic regression and Fischer Exact tests were employed for statistical analysis. ResultsIncreasing autograft diameter did not lead to a reduction in revision ACLR surgery (odds ratio [OR], 1.093; 95% confidence interval [CI], 0.612 to 1.954; P=0.76). Revision ACLR positively correlated with male gender (OR, 3.971; 95% CI 1.109 to 14.214; P=0.03) and negatively correlated with increasing age (OR, 0.919; 95% CI 0.882–0.958, P<0.0001). There was no association between graft rupture rate and dichotomized graft size. At latest follow-up, there was no correlation between graft diameter and IKDC (Pearson's adjusted R2=0.058; P=0.75), Tegner Activity score (Pearson's adjusted R2=0.244; P=0.53), or any component of the KOOS (Pearson's adjusted R2 range: 0.008 to 0.141; P-value range: 0.21 to 0.76). ConclusionIncreased hamstring autograft diameter did not significantly reduce revision ACLR surgery or improve clinical outcomes. Other factors such as gender and age do influence the rate of revision ACL surgery. Study designLevel IV, retrospective case series.

High non-anatomic tunnel position rates in ACL reconstruction failure using both transtibial and anteromedial tunnel drilling techniques.

Although it is well known from cadaveric and biomechanical studies that transtibial femoral tunnel (TT) positioning techniques are associated with non-anatomic tunnel positions, controversial data exist as so far no clinical differences could have been found, comparing transtibial with anteromedial techniques (AM). The purpose of the study was to analyze if graft failure following TT ACL reconstruction was more commonly associated with non-anatomic tunnel position in comparison with the AM technique. We hypothesized that, compared to AM techniques, non-anatomic tunnel positions correlate with TT tunnel positioning techniques. A total of 147 cases of ACL revision surgery were analyzed retrospectively. Primary ACL reconstructions were analyzed regarding the femoral tunnel drilling technique. Femoral and tibial tunnel positions were determined on CT scans using validated radiographic measurement methods. Correlation analysis was performed to determine differences between TT and AM techniques. A total of 101 cases were included, of whom 64 (63.4%) underwent the TT technique and 37 (36.6%) the AM technique for primary ACL reconstruction. Non-anatomic femoral tunnel positions were found in 77.2% and non-anatomical tibial tunnel positions in 40.1%. No correlations were found comparing tunnel positions in TT and AM techniques, revealing non-anatomic femoral tunnel positions in 79.7 and 73% and non-anatomic tibial tunnel positions in 43.7 and 35.1%, respectively (p>0.05). Considerable rates of non-anatomic femoral and tibial tunnel positions were found in ACL revisions with both transtibial and anteromedial femoral drilling techniques. Despite the potential of placing tunnels more anatomically using an additional AM portal, this technique does not ensure anatomic tunnel positioning. Consequently, the data highlight the importance of anatomic tunnel positioning in primary ACL reconstruction, regardless of the applied drilling technique.

Radiographic analysis of Re-Ruptures of reconstructed ACLs - Evaluation of tunnel position as a possible cause of Failure

Objectives:Previous studies detected femoral and / or tibial tunnel malpositioning as possible causes for the failure of an anterior cruciate ligament reconstruction. We investigated various radiological angles and criterias for ACL revision surgery to find possible causes for the failure of the primary reconstructed ACLs based on digital X-ray images.Materials and Methods:529 ACL revisions after previous reconstruction were carried out between 1993 and 2013, of which we were able to include 100 patients with digital radiographs in our study. We investigated the angles of the femoral and tibial tunnel position in the coronal and sagittal plane. Furthermore we analyzed the entry point on the femur in accordance with the quadrant method described by Bernard and Hertel. We divided into: A) adequate trauma (n = 87) and non-trauma group (n = 13); B) Hamstring (n = 76) and Patella-BTB group (n = 24); C) transtibial (n = 83) and anteromedial group (n = 17). In addition we built subgroups B1/C1 adequate re-trauma or B2/C2 no adequate trauma to analyze whether there were differences in these groups.Results:The trauma group differed significantly from the non-trauma group in the measured angle of the tibial tunnel in the ap radiograph (trauma group 28.4°, non-trauma group 22.67°; p = 0.013). The Hamstring group differed significantly from the BTB group in the measured inclination angle of the femoral tunnel in the ap radiograph (HS group 54.86°, BTB group 62.78°; p = 0.015). There was also a significant difference concerning the tibial tunnel in the ap radiograph (HS group 29.56°, BTB group 21.63°; p = 0.0001). Comparing the two groups for the femoral tunnel placement-techniques we could find significant differences in the femoral ap-radiographs (inclination angle: TT = 59.04°, AM = 45.64°; p = 0.0001). The analysis of the 4 subgroups revealed differences in the tibial ap images: The BTB trauma group had an average of 23.56° relative to the BTB non-trauma group of 16.91° (p=0.013). The HS groups among themselves did not differ significantly, but the HS non-trauma group had a significantly higher angle with 29.38° to 16.91° in the BTB non-trauma group (p = 0.0003). In addition there was a significant difference when comparing the transtibial trauma group with the transtibial non trauma group (TT trauma = 27.66°, TT non trauma = 21.15°; p = 0.017)Conclusion:Overall we could only find a few significant differences in the measured angles and only a few deviations from the values described within the literature. Therefore a real trauma was necessary to rupture the reconstructed ACL in 87%. In 13% we could find a possible cause within the tibial tunnel: the steeper the tibial tunnel was, less trauma was necessary for failure, especially when using the transtibial drilling method or Patella-BTB grafts. However the small sample size limits the results therefore further studies are necessary.

Revision surgery in anterior cruciate ligament reconstruction: a cohort study of 17,682 patients from the Swedish National Knee Ligament Register

PurposeTo investigate the association between surgical variables and the risk of revision surgery after ACL reconstruction in the Swedish National Knee Ligament Register.MethodsThis cohort study was based on data from the Swedish National Knee Ligament Register. Patients who underwent primary single-bundle ACL reconstruction with hamstring tendon were included. Follow-up started with primary ACL reconstruction and ended with ACL revision surgery or on 31 December, 2014, whichever occurred first. Details on surgical technique were collected using an online questionnaire. All group comparisons were made in relation to an “anatomic” reference group, comprised of essential AARSC items, defined as utilization of accessory medial portal drilling, anatomic tunnel placement, visualization of insertion sites and pertinent landmarks. Study end-point was revision surgery.ResultsA total of 108 surgeons (61.7%) replied to the questionnaire. A total of 17,682 patients were included [n = 10,013 males (56.6%) and 7669 females (43.4%)]. The overall revision rate was 3.1%. Older age as well as cartilage injury evident at index surgery was associated with a decreased risk of revision surgery. The group using transtibial drilling and non-anatomic bone tunnel placement was associated with a lower risk of revision surgery [HR 0.694 (95% CI 0.490–0.984); P = 0.041] compared with the anatomic reference group. The anatomic reference group showed no difference in risk of revision surgery compared with the transtibial drilling groups with partial anatomic [HR 0.759 (95% CI 0.548–1.051), n.s.] and anatomic tunnel placement [HR 0.944 (95% CI 0.718–1.241), n.s.]. The anatomic reference group showed a decreased risk of revision surgery compared with the transportal drilling group with anatomic placement [HR 1.310 (95% CI 1.047–1.640); P = 0.018].ConclusionNon-anatomic bone tunnel placement via transtibial drilling resulted in the lowest risk of revision surgery after ACL reconstruction. The risk of revision surgery increased when using transportal drilling. Performing anatomic ACL reconstruction utilizing eight selected essential items from the AARSC lowered the risk of revision surgery associated with transportal drilling and anatomic bone tunnel placement. Detailed knowledge of surgical technique using the AARSC predicts the risk of ACL revision surgery.Level of evidenceIII.

Revision ACL Reconstruction in Children and Adolescents

Results of revision ACL reconstruction in pediatric patients has not been well studied. The purpose of this study was to assess the demographics, technique, and results of ACL revision in children and adolescents. This was a retrospective case series and outcomes assessment of all pediatric/adolescent patients (<18 years) who underwent revision ACL surgery at a single institution. Charts were reviewed for patient demographics, injury characteristics, operative details, surgical complications, and patient outcome. Patient-oriented outcome measures were also sent to all patients and included the Pedi-IKDC, Tegner Activity Scale, Lysholm Knee Score, and a self-designed Physical Activity Survey to assess return to sport. Ninety revision ACL reconstructions were performed in 88 patients. Average patient age at the time of revision was 16.6 years (SD 1.69), and 28.8% were skeletally immature. Time to failure after primary ACL reconstruction was 1.28 years (SD 1.06), and the most common mechanism of failure was noncontact sports injuries. 74.4% had additional intraarticular injuries that required surgical intervention at the time of revision. Revision graft type included allograft (61.1%), patellar tendon (21.1%), hamstring (16.7%), and iliotibial band (1.1%). There was a 20% graft reinjury rate. Additional procedures after revision were required in 25.5% of knees, and 20% of revision reconstructions had contralateral ACL injuries. 50% of patients completed outcome measures with an average time since revision of 5.1 years. The mean outcome scores were: Pedi-IKDC 71.7 (SD 12.6), Lysholm 79 (SD 13.2), Tegner 6.6 (range 6-10). 69% of patients reported returning to sports at an average of 8.9 months (3-36), however, only 55.2% of these reported being able to return to the same level of play. Revision ACL reconstruction in pediatric patients was associated with worse functional outcome, lower activity level, higher rates of graft retearing, and lower return to sports rates than primary ACL reconstruction.

Anterior Cruciate Ligament Revision Surgery: Ipsilateral Quadriceps Versus Contralateral Semitendinosus-Gracilis Autografts

To evaluate the subjective outcomes, knee stability, and donor-site morbidity after revision ACL reconstruction using either autologous ipsilateral quadriceps tendon or contralateral semitendinosus-gracilis tendon. A sample size calculation suggested that we needed 25 patients in each group to detect equality between both groups. Therefore, we evaluated 30 consecutive patients who underwent an ACL revision surgery with ipsilateral bone-quadriceps tendon grafts and 30 consecutive patients with the contralateral semitendinosus-gracilis grafts between January 2010 and December 2012. Because of follow-up and exclusion criteria, finally 51 patients were evaluated. All patients were followed prospectively for at least 2years with KT1000 arthrometer testing and the International Knee Documentation Committee (IKDC) objective grading. At the 24-month follow-up, additional clinical scores were evaluated: the Knee Injury Osteoarthritis Outcome Score (KOOS), the Lysholm score, assessing pain during kneeling, and anterior knee pain. The KT1000 postoperative arthrometer side-to-side difference was 2.0 ± 1.2mm for the quadriceps group and 3.0 ± 2.9mm for the semitendinosus-gracilis group. The difference was not statistically significant (P= .461). There was also no difference in the rate of positive pivot-shift tests between groups (P= .661). The Lysholm score was 82.5 ± 18 in the quadriceps group and 73.8 ± 19 in the semitendinosus-gracilis group. The difference was not statistically significant (P= .060). There was also no significant difference in the single KOOS subscores, assessing pain while kneeling and anterior knee pain (included in the KOOS score). No rerupture occurred during follow-up. Revision ACL reconstruction using the quadriceps tendon graft showed clinical outcomes similar to those of the contralateral semitendinosus-gracilis graft in terms of knee stability and function. Thus, the bone-quadriceps tendon graft may be a good alternative to the contralateral semitendinosus-gracilis tendon graft for revision ACL reconstruction. Level II, prospective comparative study.

Long Term Follow Up of Pediatric ACL Reconstruction in New York State

Objectives:The primary aim of this study was to determine the rate of subsequent ACL reconstruction and additional non-ACL knee surgery in children that had previously undergone ACL reconstruction in New York State. The secondary aim was to assess factors associated with additional ACL and non-ACL knee surgery.Methods:Pediatric patients (age < 21) who underwent ACL reconstruction between 1997 and 2010 in New York State were identified using the Statewide Planning and Research Cooperative System (SPARCS) database. Patients were tracked for subsequent ACL reconstruction and additional non-ACL knee surgery. Each case had a minimum of one year follow up. A Cox proportional hazards model was used to assess time to subsequent surgery, adjusting for age, sex, race, comorbidity index, insurance type, surgeon and hospital ACL volume, and poverty prevalence.Results:23,912 primary pediatric ACL reconstructions were identified. 1955 patients (8.2%) underwent subsequent ACL reconstruction. 7.4% had one additional ACL reconstruction and 0.7% had two or more additional ACL reconstructions. 3341 patients (14%) had subsequent non-ACL knee surgery with 11.1% having one subsequent surgery and 2.9% having two or more additional knee surgeries. Risk factors for revision ACL surgery were younger age at time of primary ACL surgery (p<0.001), male gender (p<0.001), white race (p=0.003), private insurance (p<0.001), higher hospital ACL volume (>20 per year; p=0.002), and higher surgeon ACL volume (>10 per year; p=0.003). Risk factors for return to the OR for other non-ACL knee surgeries were younger age at the time of primary ACL reconstruction (p<0.001), white race (p<0.001), private insurance (p=0.016), and higher hospital ACL volume (>20 per year; p=0.007).Conclusion:This study aims to provide information on the rate of return to the operating room and rate of secondary ACL reconstruction in an adolescent population over the past 20 years in New York State. Males and younger patients had a higher rate of subsequent ACL reconstruction. Higher rates of ACL reconstruction in younger children may be due to greater at-risk activities in younger children, longer follow up, or inherently less reliable reconstructions given the non-anatomic reconstructions that are frequently required in the skeletally immature. The association between socioeconomic factors and increased subsequent knee surgeries likely represents a disparity in access to care for low socioeconomic status patients.

Meniscal Repair with Concurrent Anterior Cruciate Ligament Reconstruction: Operative Success and Patient Outcomes at 6-Year Follow-up

Objectives:Meniscus repairs are commonly performed concurrently with anterior cruciate ligament reconstruction (ACLR) in the acutely injured knee. Properly functioning menisci coupled with knee stability are thought to be critical factors in achieving optimal outcomes. While meniscal repair in conjunction with ACLR has demonstrated good success at 2 years, no large-scale, prospective, multicenter studies have evaluated long-term patient-oriented outcomes after combined ACLR and meniscus repair. We hypothesize that patient-centered outcome scores will deteriorate and ipsilateral reoperations will increase at 6 years following combined ACLR and meniscus repair.Methods:All unilateral primary ACL reconstructions from the Multicenter Orthopaedic Outcomes Network (MOON) between 2002 and 2004 were evaluated, and patients who underwent concurrent meniscus repair were selected. Validated patient-oriented outcome data [Knee Injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities (WOMAC) scores, Marx activity scores and International Knee Documentation Committee (IKDC) scores] was gathered at 2 and 6 years following the index procedure. Subsequent ipsilateral knee re-operation was confirmed by operative reports to evaluate for failure of meniscal repairs.Results:In total, 1440 primary ACLR’s were performed between 2002 and 2004 as part of the study cohort. Of these, 286 subjects underwent concurrent meniscus repair (298 meniscal repairs). 235/286 (82.2%) were available for follow up at 6 years (154 medial meniscus repairs, 72 lateral meniscal repairs, and 9 patients who underwent both lateral and medial meniscal repairs). Overall, the success rate of meniscal repair at the time of ACLR was 86% (202/235) at 6 years. We found an 86.4% six year success rate with combined ACLR and medial meniscal repair, 86.1% for lateral meniscal repairs and 77.8% when both medial and lateral menisci were repaired. 27.3% (9/33) of the failures were associated revision ACL surgery. Medial meniscal repairs failed earlier (mean 2.1 years) than lateral meniscal repairs (mean 3.7 years) (p=0.01). All-inside techniques were performed in 88.5% of cases. There were 31 failures with this technique representing a 14.9% failure rate. There was one failure in the inside-out technique group (1/19, 5.2%), and one failure noted in the outside-in technique group (1/6, 16.6%). Significant improvements were observed in patient reported outcomes [KOOS Symptoms, KOOS Pain, KOOS KRQOL, WOMAC Pain, and IKDC scores] when baseline scores were compared to 6-year follow-up. No significant clinical differences were observed between 2 and 6 year follow up indicating there was no clinical deterioration over this time period. Marx Activity levels gradually declined from time of injury to 6-year follow-up.Conclusion:Concurrent meniscal repair with ACLR is associated with success rates approximating 86% at 6-year follow-up. Patient-oriented outcome measures were generally similar between 2 and 6 years follow up. Surgeons may expect good clinical outcomes 6 years after combined ACLR and meniscus repairs.