Revision Anterior Cruciate Ligament Surgery Research Articles

Graft choice has no significant influence on the rate of return to sport at the preinjury level after revision anterior cruciate ligament reconstruction: a systematic review and meta-analysis

ImportanceFor an athlete undergoing anterior cruciate ligament (ACL) reconstruction, regardless of the level of play, often the most patient-important outcome is the ability to return to sport. Various graft types are currently being used in revision ACL reconstruction; however, it remains unclear how graft choice affects the ability of athletes to return to sporting activities.ObjectiveTo evaluate the rate at which patients return to sport after revision ACL reconstruction based on the graft choice.Evidence reviewThe databases PubMed (MEDLINE), Ovid (MEDLINE) and EMBASE were searched from database inception until 18 March 2016 by 2 reviewers independently. The systematic electronic search yielded 2666 studies. Inclusion criteria were English-language studies investigating revision ACL surgery on humans of all ages participating in sports of all levels with reported return to sport outcomes for patients stratified by graft choice. Conference papers, book chapters, review articles and technical reports were excluded.Findings16 studies (n=944 patients) met the inclusion criteria for our analyses with a mean follow-up of 60.7 months (range: 12–1008 months). 1 study was of level II evidence, 2 were level III and 13 were level IV. A meta-analysis of proportions was used to combine the rate of return to preinjury level for each graft type using a random effects model. The pooled rate of return to preinjury sporting level was 67% (95% CI 62% to 72%; I2=14.64%) for patients with a bone-patellar-tendon bone autograft, 55% (95% CI 39% to 71%; I2=76.71%) for patients with a hamstring tendon autograft and 64% (95% CI 56% to 74%; I2=82.12%) for patients with allografts.Conclusions and relevancePooled estimates suggest no significant influence of graft choice on the rate of return to sport at the preinjury level after revision ACL reconstruction. However, there is a lack of high quality, prospective, comparative studies evaluating the rate of return to sport from which to derive definitive conclusions on the efficacy of different graft choices.Level of evidenceLevel IV, systematic review of level II to IV studies.

Causes of Failure of Anterior Cruciate Ligament Reconstruction and Revision Surgical Strategies.

PurposeLong-term outcomes of anterior cruciate ligament (ACL) reconstruction are good or excellent; however, 0.7%–20% of patients suffer from recurrent instability due to graft failure. The purpose of this paper was to analyse failure aetiology and the possibilities of revision surgical strategies, with a description of our experience. We obtained optimal and good results in most of our patients.Materials and MethodsWe retrospectively reviewed 42 patients who underwent revision surgery (43 revisions) due to relapsing instability after ACL reconstruction between 2006 and 2015. We used allografts in 39 cases and autografts in 4 cases.ResultsThe 85.7% of the patients obtained optimal results (normal knee; group A) and the 7.2% obtained good results (nearly normal knee; group B) according to the International Knee Documentation Committee score. The most frequent failure causes were traumatic events, non-anatomic tunnel placement, and lack of graft incorporation.ConclusionsA correct revision surgery requires accurate patient evaluation and knee imaging. Preoperative planning starts with the identification of the cause of failure of the primary reconstruction. Then, the most suitable procedure should be determined for each case. It is also important to accurately inform the patient of all the complexity of an ACL revision surgery even if it is a procedure with high rates of excellent and good outcomes.

Variables Associated with Chondral and Meniscal Injuries in Anterior Cruciate Ligament Surgery.

This article aims to evaluate factors associated with chondral and meniscal lesions in primary and revision anterior cruciate ligament (ACL) reconstructions. ACL reconstructions from 2001 to 2008 at a single institution were retrospectively analyzed. Logistic regression was used to estimate the association between chondral and meniscal injuries and age, gender, tear chronicity, additional ligamentous injuries, sport type, and participation level. Of the 3,040 ACL reconstructions analyzed, 90.4% were primary reconstructions and 9.6% were revisions. Meniscal injuries were significantly lower in the revision group (44.0 vs. 51.9%; p = 0.01), while chondral injuries were significantly higher in the revision group (39.9 vs. 24.0%; p < 0.0001). Inspection of the small subgroup (n = 85) receiving both primary and revision ACL surgery at our center indicated that meniscal injuries at revision were evenly split between menisci with and without previous repairs, whereas the vast majority of Grade III and IV chondral lesions were new. More patients presented for surgery later in the revision group than in the primary group (56.5 vs. 35.3%; p < 0.0001). Male gender, primary reconstruction, and short interval (less than 2 weeks) between injury and surgery were associated with increased likelihood of meniscus tear. Age (greater than 22 years) and long interval (greater than 6 weeks) between injury to surgery and higher sport activity level were associated with chondral lesions. Revision ACL reconstructions are associated with a higher proportion of chondral lesions and a lower proportion of meniscal tears. Early primary and revision ACL construction is recommended to reduce the probability of chondral lesions.

Hospital for Special Surgery ACL Registry: 2-Year Outcomes Suggest Low Revision and Return to OR Rates.

Anterior cruciate ligament (ACL) injuries are among the most common knee injuries. Patient outcomes, rate of subsequent operations, and rate of subsequent ACL reconstruction following primary ACL reconstruction need to be evaluated. This study was designed to answer the following questions: (1) What is the return to surgery (OR) rate following primary ACL reconstruction and (2) what is the revision ACL reconstruction rate? Data was drawn from the Hospital for Special Surgery (HSS) ACL Registry. International Knee Documentation Committee (IKDC) Subjective Knee Evaluation, Lysholm-Tegner Scales, Marx Activity Scale, and SF12 were completed by patients at baseline, 1-, and 2-year follow-up. Clinical data and intraoperative data were registered by surgeons on an intraoperative form. Subsequent surgery rates were determined by evaluating the medical records for subsequent surgery, laterality, surgeon, procedure description, and type of anesthesia. The majority of the ACL reconstructions performed were autograft (76.6%) with the most common graft being bone-patellar tendon-bone (BTB) autograft (47.2%), hamstring autograft (21.9%), and Achilles allograft (18.2%). Average IKDC score improved from 51.9 (SD 16.1) at baseline to 83.5 (SD 14.2) at 2-year follow-up. Females had a 2.5-point lower IKDC and 1.4-point Marx scores compared to males. Of the enrolled patients, 7.3% had revision ACL surgery with 70.4% being ipsilateral ACL surgery. Of the enrolled patients, 10.3% had subsequent knee surgery with 72.3% being ipsilateral knee surgery. Multivariable logistic regression analysis showed that patients less than 18years of age at the time of their index surgery were over three times more likely to undergo a revision ACL reconstruction compared to older patients and were at four times higher risk than older patients for any subsequent knee surgery. Understanding ACL surgery, patient outcomes, and risk factors for revision ACL surgery and subsequent knee surgery after primary ACL reconstruction is essential. Patients less than 18years of age have a higher risk of subsequent knee surgery and subsequent ACL surgery than older patients.

Double-Bundle and Single-Bundle ACL Reconstruction Techniques Did Not Differ in Terms of Clinical Outcomes at 2 or 5 Years.

Sasaki S, Tsuda E, Hiraga Y, Yamamoto Y, Maeda S, Sasaki E, Ishibashi Y. Prospective randomized study of objective and subjective clinical results between double-bundle and single-bundle anterior cruciate ligament reconstruction. Am J Sports Med. 2016 Apr;44(4):855-64. ### Question: What is the relative effectiveness of double-bundle anterior cruciate ligament (ACL) reconstruction with hamstring tendon graft (DB-HT) and rectangular-tunnel single-bundle ACL reconstruction with patellar tendon graft (RTSB-PT) at 2 years? ### Design: Randomized (unclear allocation concealment), unblinded, controlled trial with a mean of 3.2 years of follow-up. ### Setting: 1 clinical center at Hirosaki University, Hirosaki, Japan. ### Patients: 150 patients (mean age, 26 years; 58% women) who needed ACL reconstruction. Exclusion criteria were skeletal immaturity with an open physis of the femur or tibia, bilateral ACL injury or multiple knee ligament injury, revision ACL surgery, knee osteoarthritis, knee surgery with high tibial osteotomy or medial patellofemoral ligament reconstruction, or failure to complete the study questionnaire. 91% of patients completed follow-up. ### Intervention: DB-HT (n = 76) or RTSB-PT (n = 74). For the DB-HT technique, the semitendinosus tendon was used in 94% of patients. The graft was split and used for the anteromedial bundle (AMB) and posterolateral bundle (PLB). The femoral and tibial tunnel positions were created according to accepted anatomical guidelines. The femoral tunnel for the AMB was made with use of either a transtibial or outside-in technique. Fixation on the femur and tibia was done with a cortical-button suspension technique. For the RTSB-PT technique, the bone blocks of the bone-patellar tendon-bone grafts …

Generalised ligamentous laxity and revision ACL surgery: Is there a relation?

BackgroundThe aim of the present study was to investigate the relationship between generalised ligamentous laxity (GLL) and requirement for revision anterior cruciate ligament (ACL) reconstruction. MethodsThe study cohort consisted of 139 patients undergoing primary ACL reconstruction, 44 patients undergoing revision ACL surgery and a control group of 70 patients without any knee ligament injury. A Beighton score of four or more was classified as generalised ligamentous laxity. ResultsThe primary and revision ACL surgery groups had an increased incidence of GLL compared to the control group (p<0.05). The revision ACL surgery group also had higher incidence of GLL as compared to primary ACL surgery group (p<0.05). There was a sub group within the revision cohort, who had failure of the original surgery without an identifiable cause (biological failure). The incidence of GLL in this group was significantly higher than the primary surgery group (p<0.05). ConclusionsThe findings of this study suggest that GLL may be associated with a higher risk of ACL injury and an increased risk of graft failure after primary ACL reconstruction. Based on the results of our study we feel that in the presence of GLL an autogenous graft may not be the best option for either primary or revision ACL reconstruction. Level of Evidence3 (III).

Return to sports and functional results after revision anterior cruciate ligament reconstruction by fascia lata autograft

IntroductionThe surgical revision rate following anterior cruciate ligament (ACL) surgery is 3% at 2 years and 4% at 5 years. Revision ACL surgery raises the question of the type of graft to be used. The present study assessed return to sports and functional results after revision ACL reconstruction by fascia lata graft. The hypothesis was that fascia lata provides a reliable graft in revision ACL surgery. Material and methodsA single-center retrospective continuous study included 30 sports players with a mean age of 26.8±8 years undergoing surgical revision for iterative ACL tear between 2004 and 2013. Multi-ligament lesions were excluded. Type and level of sports activity were assessed preoperatively, after primary surgery and at end of follow-up. Clinical assessment used subjective IKDC, Lysholm and KOOS scores. ResultsAt a mean 4.6±1.6 years’ follow-up, all patients had resumed sport activity, but only 12 with the same sport at the same level. Median subjective IKDC score increased from 57 [54.3; 58.5] preoperatively to 82 [68.3; 90] at last follow-up, and Lysholm score from 46 [42.3; 51] to 90.5 [80.8; 96.8]; KOOS score at last follow-up was 94.7 [83; 100]. ConclusionFunctional results in revision ACL reconstruction by fascia lata graft were satisfactory, with similar return-to-sports rates as with other techniques. Fascia lata provides a reliable graft in revision ACL surgery. Level of evidenceIV, retrospective study.

Predictors of Revision Surgery After Primary Anterior Cruciate Ligament Reconstruction.

Background:Revision anterior cruciate ligament (ACL) reconstruction surgery occurs in 5% to 15% of individuals undergoing ACL reconstruction. Identifying predictors for revision ACL surgery is of essence in the pursuit of creating adequate prevention programs and to identify individuals at risk for reinjury and revision.Purpose:To determine predictors of revision ACL surgery after failed primary ACL reconstruction.Study Design:Case-control study; Level of evidence, 3.Methods:A total of 251 participants (mean age ± SD, 26.1 ± 9.9 years) who had undergone primary ACL reconstruction 1 to 5 years earlier completed a comprehensive survey to determine predictors of revision ACL surgery at a mean 3.4 ± 1.3 years after the primary ACL reconstruction. Potential predictors that were assessed included subject characteristics (age at the time of surgery, time from injury to surgery, sex, body mass index, preinjury activity level, return to sport status), details of the initial injury (mechanism; concomitant injury to other ligaments, menisci, and cartilage), surgical details of the primary reconstruction (Lachman and pivot shift tests under anesthesia, graft type, femoral drilling technique, reconstruction technique), and postoperative course (length of rehabilitation, complications). Univariate and multivariate logistic regression analyses were performed to identify factors that predicted the need for revision ACL surgery.Results:Overall, 21 (8.4%) subjects underwent revision ACL surgery. Univariate analysis showed that younger age at the time of surgery (P = .003), participation in sports at a competitive level (P = .023), and double-bundle ACL reconstruction (P = .024) predicted increased risk of revision ACL surgery. Allograft reconstructions also demonstrated a trend toward greater risk of revision ACL surgery (P = .076). No other variables were significantly associated with revision ACL surgery. Multivariate analysis revealed that revision ACL surgery was only predicted by age at the time of surgery and graft type (autograft vs allograft).Conclusion:The overall revision ACL surgery rate after primary unilateral ACL reconstruction was 8.4%. Univariate predictors of revision ACL reconstruction included younger age at the time of surgery, competitive baseline activity level, and double-bundle ACL reconstruction. However, multivariable logistic regression analysis indicated that age and reconstruction performed with allograft were the only independent predictors of revision ACL reconstruction.

Effect of High-Grade Preoperative Knee Laxity on Anterior Cruciate Ligament Reconstruction Outcomes

Background: Knee laxity in the setting of suspected anterior cruciate ligament (ACL) injury is frequently assessed through physical examination using the Lachman, pivot-shift, and anterior drawer tests. The degree of laxity noted on these examinations may influence treatment decisions and prognosis. Hypothesis: Increased preoperative knee laxity would be associated with increased risk of subsequent revision ACL reconstruction and worse patient-reported outcomes 2 years postoperatively. Study Design: Cohort study; Level of evidence, 2. Methods: From an ongoing prospective cohort study, 2333 patients who underwent primary isolated ACL reconstruction without collateral or posterior cruciate ligament injury were identified. Patients reported by the operating surgeons as having an International Knee Documentation Committee (IKDC) grade D for Lachman, anterior drawer, or pivot-shift examination were classified as having high-grade laxity. Multiple logistic regression modeling was used to evaluate whether having high-grade preoperative laxity was associated with increased odds of undergoing revision ACL reconstruction within 2 years of the index procedure, controlling for patient age, sex, Marx activity level, level of competition, and graft type. Multiple linear regression modeling was used to evaluate whether having high-grade preoperative laxity was associated with worse IKDC score or Knee injury and Osteoarthritis Outcome Score Knee-Related Quality of Life subscale (KOOS-QOL) scores at a minimum 2 years postoperatively, controlling for baseline score, patient age, ethnicity, sex, body mass index, marital status, smoking status, sport participation, competition level, Marx activity rating score, graft type, and articular cartilage and meniscus status. Results: Pre-reconstruction laxity data were available for 2325 patients (99.7%). Two-year revision data were available for 2259 patients (96.8%), and patient-reported outcomes were available for 1979 patients (84.8%). High-grade preoperative laxity was noted in 743 patients (31.9%). The mean postoperative IKDC score was 81.8 ± 15.9, and the mean KOOS-QOL score was 72.0 ± 22.0. The presence of high-grade pre-reconstruction laxity was associated with significantly increased odds of ACL graft revision (odds ratio [OR] = 1.87 [95% CI, 1.19-2.95]; P = .007). The presence of high-grade pre-reconstruction laxity was not associated with any difference in postoperative IKDC (β = −0.56, P = .44) or KOOS-QOL (β = 0.04, P = .97). Conclusion: The presence of high-grade pre-reconstruction knee laxity as assessed by manual physical examination under anesthesia is associated with significantly increased odds of revision ACL surgery but has no association with patient-reported outcome scores at 2 years after ACL reconstruction.

Delayed Anterior Cruciate Ligament Reconstruction in Young Patients With Previous Anterior Tibial Spine Fractures

Background: Avulsion fractures of the anterior tibial spine in young athletes are injuries similar to anterior cruciate ligament (ACL) injuries in adults. Sparse data exist on the association between anterior tibial spine fractures (ATSFs) and later ligamentous laxity or injuries leading to ACL reconstruction. Purpose: To better delineate the incidence of delayed instability or ACL ruptures requiring delayed ACL reconstruction in young patients with prior fractures of the tibial eminence. Study Design: Case series; Level of evidence, 4. Methods: We identified 101 patients between January 1993 and January 2012 who sustained an ATSF and who met inclusion criteria for this study. All patients had been followed for at least 2 years after the initial injury and were included for analysis after completion of a questionnaire via direct contact, mail, and/or telephone. If patients underwent further surgical intervention and/or underwent later ACL reconstruction, clinical records and operative reports pertaining to these secondary interventions were obtained and reviewed. Differences between categorical variables were assessed using the Fisher exact test. The association between time to revision ACL surgery and fracture type was assessed by Kaplan-Meier plots. The association between need for revision ACL surgery and age, sex, and mechanism of surgery was assessed using logistic regression. Results: Nineteen percent of all patients evaluated underwent delayed ACL reconstruction after a previous tibial spine fracture on the ipsilateral side. While there were a higher proportion of ACL reconstructions in type II fractures, there was not a statistically significant difference in the number of patients within each fracture group who went on to undergo later surgery (P = .29). Further, there was not a significant association between fracture type, sex, or mechanism of injury as it related to the progression to later ACL reconstruction. However, there was a significant association between age at the time of injury and progression to later ACL reconstruction (P = .02). For every year increase in age at the time of injury, the odds of going on to undergo delayed ACL reconstruction were greater by a factor of 1.3 (95% CI, 1.1-1.6). Conclusion: Although an ATSF is a relatively rare injury, our cohort of patients suggests that a subset of young patients with all types of tibial spine fractures will require later ACL reconstruction. There is a need to counsel patients that a delayed ACL rupture is a potential risk after an ATSF, especially as children approach skeletal maturity. Further patient follow-up and prospective studies are required.

Anterior Cruciate Ligament Injuries in Baseball Players

To determine common mechanisms of anterior cruciate ligament (ACL) injury in baseball players and to quantify the rate of return to play after primary surgical reconstruction and review intermediate clinical outcomes. Surgical injuries involving the ACL in youth, high school, collegiate, and professional baseball players were queried for an 11-year period (2001 to 2011). Over the study period, 42 baseball players were identified who had undergone arthroscopically assisted primary ACL reconstruction by 1 of 3 attending surgeons. Retrospective chart review was performed for all 42 patients to evaluate variables of age, level of competition, position, mechanism of injury, graft choice, and associated meniscal injuries. Twenty-six patients were reached for telephone survey and International Knee Documentation Committee questionnaire and they answered questions about their original injury and playing history. The most common mechanism of injury was fielding, followed by base running. Infielders and outfielders (32% each) were the most commonly injured position, followed by pitchers (29%). Among the 32 players for whom it could be determined, 30 (94%) were able to return to playing baseball at a mean follow-up of 4.2years (range 1.0 to 9.9years). The mean International Knee Documentation Committee score was 84.0 (range 63 to 91). Among the 26 patients contacted for telephone interview, no one required revision ACL surgery, but 3 required a subsequent procedure for meniscal tear. Twenty-five patients (96%) denied any episodes of instability in the knee after reconstruction. The overwhelming majority of baseball players that sustain ACL injuries do so while fielding or base running. Outfielders are significantly more likely than infielders to suffer ACL injuries while fielding versus base running. The results with respect to return to play are promising, as nearly all patients were able to return to baseball and none required a revision ACL surgery at a mean follow-up of 4.2years. Level IV, therapeutic case series.

Reconstrucción mínimamente invasiva del ligamento anterolateral

IntroductionAnteroposterior instability and rotatory laxity demonstrated by severe pivot-shift test may be caused by combined lesions of the anterior cruciate ligament (ACL) and lateral structures of the knee, particularly the anterolateral ligament (ALL). This ligament acts as a secondary stabiliser that restrains internal rotation and supplements the primary stabilising role of the ACL. Materials and methodsTo describe a minimally invasive ALL reconstruction technique following anterior cruciate ligament revision surgery. Brief description of surgical indications, outcomes, and complications. DiscussionPersistent rotatory instability after ACL reconstruction suggests that intra-articular reconstruction may not be sufficient to restore rotational stability in a subgroup of patients. Numerous extra-articular reconstruction techniques have been described with long incisions and cosmetic issues. A description is presented of a simple, minimally invasive ALL reconstruction technique performed after anatomical ACL revision in a single procedure. This technique is indicated in patients with acute ACL injuries and revision ACL associated with a severe pivot-shift, chronic ACL injuries, and joint hyper-laxity. Although this technique has not proven to be superior to any other extra-articular anterolateral ligament reconstructions, it uses simple, reliable and cosmetic surgery, with good early results in a small series of patients.

Graft salvage following infected anterior cruciate ligament reconstruction: a systematic review and meta-analysis.

To examine the rates of hamstring graft salvage with arthroscopic debridement of infected anterior cruciate ligament (ACL) reconstruction as reported in the literature and discuss functional outcomes. A search was performed without language restriction on PubMed, EMBASE, Ovid, CINAHL and Cochrane Register of Controlled Trials (CENTRAL) databases from their inception to April 2015. We identified 147 infected hamstring grafts across 16 included studies. Meta-analysis was performed using a random-effects model to estimate the overall graft salvage rate, incorporating two different definitions of graft salvage. The graft salvage rate was 86% (95% confidence intervals (CI) 73% to 93%; heterogeneity: tau(2) = 1.047, I(2) = 40.51%, Q = 25.2, df = 15, p < 0.001), excluding ACL re-ruptures. Including re-ruptures as failures, the graft salvage rate was 85% (95% CI 76% to 91%; heterogeneity: tau(2)= 0.099, I(2) = 8.15%, Q = 14.15, df = 13, p = 0.36). Arthroscopic debridement combined with antibiotic treatment can lead to successful eradication of infection and graft salvage, with satisfactory functional outcomes in many cases of septic arthritis following ACL reconstruction. Persistent infection despite repeat arthroscopic debridements requires graft removal with the intention of revision ACL surgery at a later stage. Arthroscopic debridement combined with antibiotic therapy is an appropriate initial approach in most cases of septic arthritis following ACL reconstruction, achieving graft salvage rates of about 85%. Cite this article: Bone Joint J 2016;98-B:608-15.

Avoidance of Reamer Breakage During ACL Reconstruction With Flexible Reamer System: Response.

Authors’ Response: We greatly appreciate the viewpoints of Dr Jaiman concerning the timing/use of the 4.5-mm reamer when utilizing a flexible reamer for establishing a femoral tunnel. Using a flexible reamer system is very advantageous in creating a low femoral tunnel especially in the current context of concomitant anterolateral ligament (ALL) reconstruction or posterolateral corner reconstruction, as can often be needed with revision anterior cruciate ligament (ACL) surgery. Furthermore, avoiding knee hyperflexion facilitates placement of the femoral guide pin, as visualization and graft passage is almost never compromised as is often seen with straight pins/reamers placed using the necessary hyperflexion to avoid a short femoral tunnel. Furthermore, with modern flexible reamers and experience, the ACL tunnel length is maximized, with most condylar distances 35 to 40 mm with use of standard offset guides. As the reader suggests, utilizing the appropriate graft size reamer first is quite acceptable as it does seat the femoral tunnel/socket when the pin is placed ideally. We often utilize this first step. However, in those situations when the nitinol pin is too posterior or low on the lateral wall, using the 4.5-mm reamer first across the intercondylar distance allows adjustability of the femoral tunnel anteriorly or superiorly without having to replace the flexible pin. In our experience, redirecting a slightly low or posterior nitinol wire can be difficult as the nitinol pin often drops into the same track. Furthermore, there are advantages to knowing the condylar width (especially if too short or in the case of a less experienced surgeon) before seating the femoral tunnel. If the surgeon does elect to ream first with the 4.5-mm reamer, the femoral tunnel can still be seated in an accurate position, despite the mobility. One advantage of reaming with the 4.5-mm first, in our experience, is that it allows the flexible final-sized reamer to seat itself within the condyle in the scenario where the pin is too posterior. We agree that placement of the final socket centered on the bifurcate ridge is most critical, and we often ream with the final-sized reamer first then follow with the 4.5-mm reamer. We discussed in the article reaming with the 4.5-mm reamer first as it is a very nice technical trick to adjust the final socket without having to replace the nitinol pin when the initial attempt/placement could be adjusted slightly anteriorly or superiorly, which is often the case. When using a bone-tendon-bone autograft, this technique modification helps avoid posterior wall blow out from a posteriorly placed nitinol wire. Although using the final-sized reamer first works extremely well when the pin is placed accurately, we find that reaming with the 4.5-mm reamer first prevents the larger, final-sized reamer from kinking on the nitinol wire and is often easier to ream. With our change to the Stryker flexible system we have not had reamer or wire breakage regardless of the order of reaming. As to the use of the tibial guide, the proper selection of tibial angle we agree can be variable and is best adjusted to replicating the ACL tibial footprint. We find the 55° setting very useful when performing hamstrings autografts but have utilized other angles of approach, when appropriate, as suggested by the readers’ comment.

Micheli Anterior Cruciate Ligament Reconstruction in Skeletally Immature Youths

Background: The management of anterior cruciate ligament (ACL) tears in the skeletally immature patient remains controversial. Outcomes on a physeal-sparing technique using the iliotibial band for combined intra-articular and extra-articular ACL reconstruction, called the Micheli technique, have been described and reported by the original authors. Purpose: To evaluate the clinical outcomes of a physeal-sparing technique using the iliotibial band for combined intra-articular and extra-articular ACL reconstruction. Study Design: Case series; Level of evidence, 4. Methods: Between 2005 and 2011, all patients who underwent Micheli ACL reconstruction performed by a single surgeon were identified. A minimum of 3 years’ growth remaining was a prerequisite for Micheli reconstruction. Patients were excluded if postoperative follow-up was less than 1 year. Patients were evaluated for functional outcomes, satisfaction, graft survival, radiographic and clinical evidence of growth disturbance, and the need for additional procedures. Results: Twenty-one patients (22 knees) met the inclusion criteria for this study. The mean age at the time of surgery was 11.8 years (range, 9.9-14.0 years). All patients were male. There were 4 concomitant meniscal repairs and 5 partial meniscectomies performed. All patients (100%) completed follow-up at a mean duration of 3.0 years (range, 1.0-6.9 years). Overall, 6 knees (27%) underwent reoperation. Of these, 3 knees (14%) underwent revision ACL surgery: 2 revision reconstructions at 2.8 and 4.0 years postoperatively and 1 graft shrinkage at 4.7 months postoperatively. Three knees (14%) underwent subsequent meniscal procedures, including 2 partial meniscectomies and 1 meniscal repair. Of the 19 knees that did not require revision ACL surgery, the median patient satisfaction score was 10 (range, 9-10). The mean Pediatric International Knee Documentation Committee score was 96.5 ± 2.9, and the mean Lysholm score was 95.0 ± 6.1. The median preinjury Tegner activity level was 8 (range, 6-10), and the median postoperative Tegner activity level was 8 (range, 6-10). Of the 19 knees that did not require revision ACL surgery, all had a normal Lachman test result, with a firm endpoint and normal pivot shift. At follow-up, 53% of knees had closed physes. There were no angular deformities or limb-length discrepancies. Conclusion: At a mean 3-year follow-up, the study findings confirmed excellent functional outcomes, a low ACL revision rate, and no growth disturbances. Patients returned to their preoperative activity level after reconstruction. This procedure offers a safe and effective ACL reconstruction option in children with several years of growth remaining.

Failure of Anterior Cruciate Ligament Reconstruction.

The present review classifies and describes the multifactorial causes of anterior cruciate ligament (ACL) surgery failure, concentrating on preventing and resolving such situations. The article particularly focuses on those causes that require ACL revision due to recurrent instability, without neglecting those that affect function or produce persistent pain. Although primary ACL reconstruction has satisfactory outcome rates as high as 97%, it is important to identify the causes of failure, because satisfactory outcomes in revision surgery can drop to as much as 76%. It is often possible to identify a primary or secondary cause of ACL surgery failure; even the most meticulous planning can give rise to unexpected findings during the intervention. The adopted protocol should therefore be sufficiently flexible to adapt to the course of surgery. Preoperative patient counseling is essential. The surgeon should limit the patient's expectations for the outcome by explaining the complexity of this kind of procedure. With adequate preoperative planning, close attention to details and realistic patient expectations, ACL revision surgery may offer beneficial and satisfactory results for the patient.

Effect of High-Grade Pre-operative Knee Laxity on Outcomes of Anterior Cruciate Ligament Reconstruction

Objectives:Knee laxity in the setting of suspected anterior cruciate ligament (ACL) injury is frequently assessed through physical examination using the Lachman, pivot-shift, and anterior drawer tests. The degree of laxity noted on these examinations may influence treatment decisions and prognosis. We hypothesized that increased pre-operative knee laxity (Grade 3+ pivot-shift, Lachman > 10mm, or anterior drawer greater than 10mm) are associated with increased risk of revision ACL reconstruction and poorer patient-reported outcomes at two years post-operative.Methods:From an ongoing prospective cohort study, 1394 patients that underwent primary isolated ACL reconstruction within 3 months of injury with autograft tissue without medial collateral, lateral collateral, or posterior cruciate injury requiring treatment or prior contralateral ACL injury were identified. Demographic data, physical examination findings under anesthesia at the time of ACL reconstruction, information regarding meniscus status and treatment, and pre-operative and 2 year post-operative International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Outcome Score Knee Related Quality of Life subscale (KOOS-QOL), and Marx activity scores were collected. Patients reported by the operating surgeons as having a Lachman or anterior drawer examination at least 10mm greater than the contralateral side were classified as having a high grade Lachman or anterior drawer respectively. Patients reported by the operating surgeon as having a 3+ pivot-shift were classified as having a high-grade pivot-shift. Patients demonstrating high-grade laxity on any of these examinations were classified as having high-grade pre-operative knee laxity. Multiple logistic regression modeling was used to evaluate whether having high-grade pre-operative laxity was associated with increased odds of undergoing revision ACL reconstruction within 2 years of the index procedure, controlling for patient age, sex, activity level, and graft type. Multiple linear regression modeling was used to evaluate whether having high-grade pre-operative laxity was associated with poorer IKDC or KOOS-QOL scores at 2 years post-operative, controlling for patient age, sex, BMI, and smoking status, baseline score, activity level, graft type, and the presence and treatment of meniscal tears.Results:Two year revision data were available for 1333 patients (95.4%) and patient-reported outcomes were available for 1205 patients (86.4%). High-grade pre-operative laxity was noted in 395 patients (29.6%), including high grade pivot-shift in 24.9%, high-grade Lachman in 11.5%, and high-grade anterior drawer in 8.1%. ACL graft revision was performed in 59 patients (4.4%). The mean post-operative IKDC score was 84.1 ± 14.4 and the mean KOOS-QOL score was 75.1 ± 20.4. The presence of high grade pre-laxity was not associated with increased odds of ACL graft revision (OR=1.47, 95% CI: 0.85 - 2.55, p = 0.17). Similarly, the presence of high-grade pre-laxity was not associated with any difference in post-operative IKDC (β = -0.33, p = 0.71) or KOOS-QOL (β = -0.51, p = 0.70).Conclusion:The presence of high-grade pre-operative knee laxity as assessed by physical examination under anesthesia (Grade 3+ pivot-shift, Lachman > 10mm, or anterior drawer greater than 10mm) is not associated increased odds of revision ACL surgery or poorer patient-reported outcome scores at 2 years following ACL reconstruction.

Length Change Patterns in the Lateral Extra-articular Structures of the Knee and Related Reconstructions

Background: Lateral extra-articular soft tissue reconstructions in the knee may be used as a combined procedure in revision anterior cruciate ligament surgery as well as in primary treatment for patients who demonstrate excessive anterolateral rotatory instability. Only a few studies examining length change patterns and isometry in lateral extra-articular reconstructions have been published. Purpose: To determine a recommended femoral insertion area and graft path for lateral extra-articular reconstructions by measuring length change patterns through a range of knee flexion angles of several combinations of tibial and femoral insertion points on the lateral side of the knee. Study Design: Controlled laboratory study. Methods: Eight fresh-frozen cadaveric knees were freed of skin and subcutaneous fat. The knee was then mounted in a kinematics rig that loaded the quadriceps muscles and simulated open-chain knee flexion. The length changes of several combinations of tibiofemoral points were measured at knee flexion angles between 0° and 90° by use of linear variable displacement transducers. The changes in length relative to the 0° measurement were recorded. Results: The anterior fiber region of the iliotibial tract displayed a significantly different (P < .001) length change pattern compared with the posterior fiber region. The reconstructions that had a femoral insertion site located proximal to the lateral epicondyle and with the grafts passed deep to the lateral collateral ligament displayed similar length change patterns to each other, with small length increases during knee extension. These reconstructions also showed a significantly lower total strain range compared with the reconstruction located anterior to the epicondyle (P < .001). Conclusion: These findings show that the selection of graft attachment points and graft course affects length change pattern during knee flexion. A graft attached proximal to the lateral femoral epicondyle and running deep to the lateral collateral ligament will provide desirable graft behavior, such that it will not suffer excessive tightening or slackening during knee motion. Clinical Relevance: These results provide a surgical rationale for lateral extra-articular soft tissue reconstruction in terms of femoral graft fixation site and graft route.

The Prevalence of Meniscal Tears in Young Athletes Undergoing Revision Anterior Cruciate Ligament Reconstruction

The purpose of this study was to determine the incidence of meniscal injury, specifically medial meniscal injury, in US Army soldiers undergoing revision anterior cruciate ligament (ACL) reconstruction. A retrospective review was performed of all patients who underwent revision ACL reconstruction from 2002 to 2011 at our institution. A complete chart review was performed to identify the prevalence of meniscal pathology identified at the time of revision ACL surgery. Patient demographic data and meniscal injury patterns were analyzed. Sixty-seven patients were identified, with a mean age of 28 years. The mean time to revision reconstruction was 67 months. Most patients (64.1%) reported a distinct reinjury. Reinjury was reported as the cause for revision ACL reconstruction in 43 patients. In this subgroup the mean time from reinjury to revision surgery was 13.9 months. Meniscal pathology was identified in 50 patients (74.6%). Medial meniscal tears were noted in 38 patients (56.7%), a rate significantly greater than that previously described (P= .008). Lateral meniscal tears were noted in 26 patients (38.8%), which was similar to previously published data (P= .52). The prevalence of meniscal injury at the time of revision ACL reconstruction in active-duty US Army soldiers is nearly identical to that of previously published data looking at a civilian population (74.6% v 74%) in the Multicenter ACL Revision Study (MARS) cohort. However, the incidence of medial meniscal injury was greater in the active-duty population than in the civilian population (56.7% v 40%). The observed increase in the prevalence of medial meniscal pathology is likely multifactorial, relating to the unique demands on young military athletes in both combat and training environments, rate of reinjury, and various delays to treatment after reinjury. Level IV, therapeutic case series.

Minimally Invasive Harvest of a Quadriceps Tendon Graft With or Without a Bone Block

The quadriceps tendon (QT) as a graft source for anterior cruciate ligament (ACL) and posterior cruciate ligament reconstruction has recently achieved increased attention. Although many knee surgeons have been using the QT as a graft for ACL revision surgery, it has never gained universal acceptance for primary ACL reconstruction. The QT is a very versatile graft that can be harvested in different widths, thicknesses, and lengths. Conventionally, the QT graft is harvested by an open technique, requiring a 6 to 8 cm longitudinal incision, which often leads to unpleasant scars. We describe a new, minimally invasive, standardized approach in which the QT graft can be harvested through a 2- to 3-cm skin incision and a new option of using the graft without a bone block.