Anterior Cruciate Ligament Reconstruction Failure Research Articles

Extra-articular procedures for the ACL-deficient knee: a state of the art review

Some patients have continued rotatory instability following intra-articular anterior cruciate ligament (ACL) reconstruction, which limits their functional abilities. Advanced surgical techniques, such as double-bundle reconstruction and anteromedial portal drilling, have not solved this problem. This has led many surgeons to revisit the use of extra-articular procedures to control rotatory laxity. Multiple anatomic studies have confirmed the presence of an anterolateral ligament (ALL) that attaches to the tibia at the site of the Segond fracture. The biomechanical importance of this ligament is still being debated. Extra-articular reconstructions decrease the forces produced by intra-articular ACL grafts. Patients likely to benefit from additional extra-articular reconstruction are: (1) those with high-grade pivot shifts; (2) patients with previous failed ACL reconstructions without an obvious cause; (3) participants in contact sports and (4) patients in subgroups that have a high risk of failure (eg, generalised laxity). A variety of extra-articular reconstructions have been developed. Those techniques that have long-term follow-up data were described before most current orthopaedic surgeons were in practice. The available evidence suggests that performing an additional extra-articular reconstruction can improve rotational stability in patients undergoing intra-articular ACL reconstructions. Newer ‘anatomic’ reconstructions of the ALL have recently been proposed but there are limited data on their effectiveness. Currently, there are no studies comparing different extra-articular procedures.

Two-Stage Revision Anterior Cruciate Ligament Reconstruction.

The number of primary anterior cruciate ligament (ACL) tears is rapidly increasing. In patients who wish to return to their preoperative level of function, specifically as it pertains to participation in sports, the gold standard of treatment following an ACL tear remains an anterior cruciate ligament (ACL) reconstruction. Despite a majority of good/excellent results following primary ACL reconstruction, there is a growing subset of patients with persistent or recurrent functional instability who require revision ACL reconstruction. Preoperative planning for revision ACL reconstruction requires a careful understanding of the root cause of ACL failure, including possible technical causes of primary ACL failure and the presence of combined knee pathology that was not addressed at the index ACL reconstruction. The decision to perform 2-stage revision ACL reconstruction is multifactorial and is reached by technical considerations that may make a 1-stage revision less optimal, including tunnel widening, arthrofibrosis, active infection, and others. Concomitant knee pathology such as meniscal deficiency, malalignment (including an increase in posterior tibial slope), chondral lesions, and other ligamentous laxity may also require a staged approach to treatment. This evidence-based review covers the indications for 2-stage revision ACL reconstruction, surgical techniques, evidence for and technique of bone grafting prior ACL tunnels, and outcomes of 2-stage revision stratified by initial cause of ACL reconstruction failure. With proper preoperative planning and an understanding of the cause of failure following the primary ACL reconstruction, revision ACL reconstruction can offer excellent outcomes in the motivated patient. [Orthopedics. 2016; 39(3):e456-e464.].

Analysis of different causes and risk factors of anterior cruciate ligament reconstruction failure

BackgroundAnterior cruciate ligament (ACL) reconstruction failure is characterized by recurrent knee instability, stiffness, or pain that prevents a patient from participating in his or her chosen activities. The etiology of ACL reconstruction failure is multifactorial; surgical errors, infection, trauma, and/or associated pathology are blamed.AimThe purpose of this retrospective study was to define and analyze the causes of failure of ACL reconstruction.Patients and methodsThis study reviewed 300 patients who underwent ACL reconstructions, which were performed at Mansoura knee Surgery and Arthroscopy Unit over a 5-year period from 2005 to 2010. Untreated laxity, angular deformity, femoral and tibial tunnel malposition, method of fixation, and meniscus surgery were assessed; new trauma and infection were recorded. Assessment included knee stability tests, range of motion, and International Knee Documenting Committee scoring system evaluation.ResultsIn our study, the rate of ACL reconstruction failure was 7%. The main causes of failure were malpositioned tunnels (66.5%) and new trauma (24%). However, 15% of malpositioned tunnels caused failure and 50% of trauma caused failure. Moreover, 33% of infection, 5% of extracortical fixation, 2.2% of partial menisectomy, and 6% of preoperative varus knee were associated with failure.ConclusionMalpositioned tunnels and new trauma are the dominant causes of ACL reconstruction failure. Infection, extracortical fixation, partial menisectomy, and varus knee are risk factors for ACL reconstruction failure; thus, the failure is multifactorial.

Combined posterolateral corner and acute anterior cruciate ligament injuries in an adolescent cohort: a magnetic resonance imaging analysis.

Failure of a reconstructed anterior cruciate ligament (ACL) has significant morbidity in the paediatric and adolescent patient population. Untreated concomitant posterolateral corner (PLC) injury is an identified cause of failed ACL reconstruction; however, the injury pattern has yet to be defined for the paediatric population. Magnetic resonance imaging (MRI) studies of the knee performed between 1 January 2009 and 1 January 2013 were retrospectively reviewed. Imaging reports indicating an intra-substance injury of the ACL were reviewed, and all associated injured structures were recorded. Injury patterns were categorised by age, gender, physis status and associated injuries. Logistic regression and chi-square analyses compared ACL disruptions with and without concomitant PLC injuries. One hundred and twenty-eight patients (74 boys and 54 girls, average age 15.27 years) sustained an ACL disruption. Concomitant injury to the PLC was seen in 13.3% of injuries. Associated PLC injuries were significantly associated with lateral meniscus injury and Segond fractures. Lateral meniscus injury was predictive of PLC injury (p = 0.05) upon logistic regression analysis. Concomitant PLC injuries were found in 13.3% of all ACL disruptions on MRI analysis. Lateral meniscus injuries associated with an ACL disruption were predictive of concomitant PLC injury. Combined injury of the ACL and lateral meniscus should prompt close scrutiny to PLC structures.

Presence of bacteria in failed anterior cruciate ligament reconstructions.

BackgroundNovel microbial detection technologies have revealed that chronic bacterial biofilms, which are recalcitrant to antibiotic treatment, are common in failed orthopedic procedures.QuestionsAre bacteria present on failed anterior cruciate ligament (ACL) reconstructions? Is there a difference in the presence or nature of bacteria in failed ACL reconstructions relative to a control set of healthy ACL’s?MethodsWe used a case–control study design, where we analyzed the bacterial composition of 10 failed ACL reconstructions and compared it to 10 native ACL’s harvested during total knee arthroplasty. The IBIS Universal Biosensor was used to determine the nature of bacteria on ACL specimens, and fluorescent in situ hybridization (FISH) was used to visualize bacteria in a subset of cases.ResultsBacteria are present in failed ACL reconstructions. Bacteria are present in ACL’s harvested during total knee arthroplasty, but the nature of the species differs significantly between experimental and control sets. Twelve genera were detected in the experimental set (in both allografts and autografts), and in four samples multiple species were detected. In contrast, the control group was characterized by presence of Propionibacterium acnes.ConclusionsWe demonstrate the presence of bacteria on failed ACLs surgeries, and open the door to investigate whether and how bacteria and the associated immune responses could possibly contribute to graft failure.Clinical relevanceIf microbial pathogens can be linked to failed grafts, it could provide: (1) markers for early diagnosis of abnormal healing in ACL surgeries, and (2) targets for early treatment to prevent additional reconstruction surgeries.

Lateral Tibial Posterior Slope Is Increased in Patients With Early Graft Failure After Anterior Cruciate Ligament Reconstruction

Background: The lateral tibial posterior slope (LTPS) has been reported in multiple studies to correlate with an increased risk for native anterior cruciate ligament (ACL) tearing. To date, no study has examined the effect of an increased LTPS as measured on magnetic resonance imaging (MRI) on the likelihood of ACL graft failure. Hypothesis: An increased LTPS as measured on MRI would correlate with an increased risk for ACL graft failure. Study Design: Case-control study; Level of evidence, 3. Methods: Fifty-eight patients were initially identified who experienced graft failure after primary ACL reconstruction and underwent revision between 1998 and 2009. Exclusion criteria were clinical follow-up of less than 4 years, graft failure occurring greater than 2 years after primary surgery, skeletal immaturity, deep infection, lack of available preoperative MRI, and history of trauma to the proximal tibia. This left 35 patients with early (within 2 years) failure of primary ACL reconstruction. These patients were matched to 35 control participants who had undergone ACL reconstruction with a minimum of 4 years of clinical follow-up and no evidence of graft failure. Patients were matched by age, sex, date of primary surgery, and graft type. The LTPS was then determined on MRI in a blinded fashion. Results: The mean time to failure in patients in the study group was 1 year (range, 0.6-1.4 years). The mean follow-up of those in the matched control group was 6.9 years (range, 4.0-13.9 years). The mean LTPS in the early ACL failure group was found to be 8.4°, which was significantly larger than that in the control group at 6.5° (P = .012). The odds ratio for graft failure considering a 2° increase in the LTPS was 1.6 (95% CI, 1.1-2.2) and continued to increase to 2.4 (95% CI, 1.2-5.0) and 3.8 (95% CI, 1.3-11.3) with 4° and 6° increases in the LTPS, respectively. No significant association was identified between graft type and graft failure. Conclusion: An increased LTPS is associated with an increased risk for early ACL graft failure, regardless of graft type. Orthopaedic surgeons should consider measuring the LTPS as part of the preoperative assessment of ACL-injured patients.

The role of high tibial osteotomy in the treatment of knee laxity: a comprehensive review.

The purpose of this study is to review the indications for and outcomes of high tibial osteotomy in the treatment of patients with chronic knee laxity. A comprehensive literature review was performed to identify surgical indications and results of high tibial osteotomy for the treatment of chronic knee laxity. Four distinct situations were identified in which a high tibial osteotomy may be advantageous: (1) anterior laxity with varus osteoarthritis, (2) chronic anterior laxity in the setting of varus with lateral ligamentous laxity, (3) chronic anterior laxity in the setting of a high tibial slope, and (4) chronic posterior laxity or posterolateral corner injury. A total of 24 studies were included in this report, including reports of the treatment of 410 knees as well as several review articles. The most frequently reported indication for that addition of HTO was anterior laxity in the setting of varus OA, which was noted to have good results, minimizing anterior knee laxity and allowing return to sports, while reducing the progression of osteoarthritis. More advanced cases in which lateral structures have also become stretched and incompetent are an excellent indication for HTO, with the need for subsequent lateral procedures dependent on the degree of varus laxity and especially hyperextension that is present. Excessive tibial slope has been identified as a cause of ACL reconstruction failure, and some authors have recommended addressing very high slope in revision cases. In knees with chronic posterior or posterolateral instability, correction of alignment first is generally recommended, with subsequent ligamentous procedures performed when instability persists. Knees with chronic instability pose a difficult treatment challenge. In all cases, the contribution of coronal plane alignment to varus-valgus knee stability must be carefully considered and addressed prior to ligament surgery. Sagittal plane alignment is also key and must not be overlooked. Such considerations drive the indication for osteotomy as well as the type of osteotomy that is chosen. Level of evidence IV.

The role of computer assisted navigation in revision surgery for failed anterior cruciate ligament reconstruction of the knee: A continuous series of 52 cases

IntroductionThe causes of failure of anterior cruciate ligament (ACL) reconstruction mainly involve incorrect tunnel positioning. There is no intraoperative tool allowing the surgeon to test graft biomechanics and to confirm that the new graft is in an optimal position. HypothesisControl is improved with computer assisted navigation. Material and methodsIn this retrospective study, revision ACL reconstruction was performed with a new autologous graft in a continuous series of 52 failed ACL reconstructions. A computer assisted navigation system was used intraoperatively in all knees. Evaluation with this system confirmed the position of old and new tunnels as well as intraoperative laxity. ResultsEvaluation of tunnel position based on traditional radiological criteria found in the literature significantly underestimated graft biomechanics: 69% of the cases presented with unfavorable graft ansiometry (mean: 13±2.2mm) while the correct position of the tibial tunnel was identified in 64% of cases on radiography and the femoral tunnel in 48%. All new grafts were optimally positioned by the computer assisted navigation system with a mean isometery of 3.2 (±0.7) mm. Comparative pre- and postoperative evaluation of laxity showed a statistically significant improvement (P<0.001): preoperative and postoperative Lachman test: 10.5±2mm and 3±0.5, respectively; global rotational laxity: 24±5° and 37±7° respectively. ConclusionThe use of a computer assisted navigation system allows optimal positioning of the graft as well as a predictive assessment of laxity. Type of studyLevel IV, retrospective cohort study.

Anterior Closing Wedge Tibial Osteotomy for Failed Anterior Cruciate Ligament Reconstruction

The success rate for achieving knee stability in primary anterior cruciate ligament (ACL) reconstruction is high; however, the results of revision reconstruction are less satisfactory. Sagittal plane malalignment is an uncommon predisposing factor for failure because excessive posterior tibial slope increases stress on the ACL graft. In carefully selected patients, tibial slope correction is an essential adjunctive procedure to achieve a stable knee. We present a case report outlining the surgical technique for correction of sagittal plane imbalance by a slope-decreasing anterior closing wedge tibial osteotomy combined with a second-stage revision ACL reconstruction. At 2 years following surgery, our patient had a stable knee and returned to low-impact athletic activity without symptoms. Further investigation is needed to refine the indications for this procedure in the setting of failed ACL reconstruction.

Knee stability, athletic performance and sport-specific tasks in non-professional soccer players after ACL reconstruction: comparing trans-tibial and antero-medial portal techniques.

a wrong position of bone tunnels, in particular on the femur, is one of the most frequent causes of a failed anterior cruciate ligament (ACL) reconstruction. Several studies demonstrated that drilling the femoral tunnel through the antero-medial portal (AMP) allows a more anatomical placement on the lateral femoral condyle and higher knee stability, compared to trans-tibial (TT) technique. The aim of this study was to retrospectively evaluate two groups of soccer players operated on for ACL reconstruction according to either one of these two techniques. two groups of non-professional soccer players operated on for a single bundle ACL reconstruction with hamstrings autograft using either a TT (20 patients) or an AMP (23 patients) technique were retrospectively evaluated with KT-1000 arthrometer, manual pivot shift test, isokinetic test, the incremental treadmill-running test, athletic and sport specific tasks, and knee scores (IKDC, Lysholm and KOOS). the AMP group showed better results at pivot shift test and KOOS, but lower flexion angles at single leg squat test. There were no differences in all the other considered outcomes. the better rotational stability of the knee achieved in AMP group did not lead to significantly better clinical and functional results in our patients. Case-control study.

Multirater Agreement of the Causes of Anterior Cruciate Ligament Reconstruction Failure

Background: Anterior cruciate ligament (ACL) reconstruction failure occurs in up to 10% of cases. Technical errors are considered the most common cause of graft failure despite the absence of validated studies. Limited data are available regarding the agreement among orthopaedic surgeons regarding the causes of primary ACL reconstruction failure and accuracy of graft tunnel placement. Hypothesis: Experienced knee surgeons have a high level of interobserver reliability in the agreement about the causes of primary ACL reconstruction failure, anatomic graft characteristics, and tunnel placement. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Twenty cases of revision ACL reconstruction were randomly selected from the Multicenter ACL Revision Study (MARS) database. Each case included the patient’s history, standardized radiographs, and a concise 30-second arthroscopic video taken at the time of revision demonstrating the graft remnant and location of the tunnel apertures. All 20 cases were reviewed by 10 MARS surgeons not involved with the primary surgery. Each surgeon completed a 2-part questionnaire dealing with each surgeon’s training and practice, as well as the placement of the femoral and tibial tunnels, condition of the primary graft, and the surgeon’s opinion as to the causes of graft failure. Interrater agreement was determined for each question with the kappa coefficient and the prevalence-adjusted, bias-adjusted kappa (PABAK). Results: The 10 reviewers have been in practice an average of 14 years and have performed at least 25 ACL reconstructions per year, and 9 were fellowship trained in sports medicine. There was wide variability in agreement among knee experts as to the specific causes of ACL graft failure. When participants were specifically asked about technical error as the cause for failure, interobserver agreement was only slight (PABAK = 0.26). There was fair overall agreement on ideal femoral tunnel placement (PABAK = 0.55) but only slight agreement on whether a femoral tunnel was too anterior (PABAK = 0.24) and fair agreement on whether it was too vertical (PABAK = 0.46). There was poor overall agreement for ideal tibial tunnel placement (PABAK = 0.17). Conclusion: This study suggests that more objective criteria are needed to accurately determine the causes of primary ACL graft failure as well as the ideal femoral and tibial tunnel placement in patients undergoing revision ACL reconstruction.

Transphyseal Anterior Cruciate Ligament Reconstruction in Patients With Open Physes

Background: The treatment of anterior cruciate ligament (ACL) injuries in skeletally immature patients is controversial. Current evidence supports the view that surgical techniques restore knee stability and prevent progressive articular damage. However, most of the studies on this topic are small case series or they have short- or medium-term follow-up times. Purpose: To determine the long-term functional outcomes and secondary complications of transphyseal intra-articular ACL reconstruction with hamstring graft in skeletally immature patients. Study Design: Case series; Level of evidence, 4. Methods: Transphyseal ACL reconstruction with autograft hamstrings was performed in 27 skeletally immature patients. The average age at surgery was 13 years (range, 12-16 years), and the average follow-up time was 10.6 years (range, 10-13 years). Clinical outcomes were assessed with preoperative and final follow-up Tegner, International Knee Documentation Committee (IKDC) subjective, and Lysholm scores. Surgery details, return to sports, and ACL reconstruction failures were collected. The anteroposterior knee laxity was assessed by arthrometry, and the presence of deformities and lower limb length discrepancies were evaluated by radiographs. The presence of degenerative signs on anteroposterior and lateral knee radiographs at final follow-up was also evaluated. Results: Transphyseal ACL reconstruction was performed with vertically oriented tunnels, 7 to 10 mm in diameter, using semitendinosus-gracilis autograft. The average preoperative Tegner, IKDC, and Lysholm scores were 7, 55, and 40, respectively. Significant differences in these scores were observed at the time of the final assessment (Tegner, 6 [P = .026]; IKDC, 94 [P < .001]; Lysholm, 92 [P < .001]). Two patients reported instability during sports activity. Three patients had a rupture of the ACL graft. No leg length discrepancy, axis malalignment, or degenerative changes were observed. Conclusion: The transphyseal ACL reconstruction in skeletally immature patients is a safe option, with high functional and satisfaction results, without significant growth plate damage in this series of patients.

Revision of failed anterior cruciate ligament reconstruction with quadrupled semitendinosus allograft: intermediate-term outcome

The aim of the present study is to present intermediate-term clinical outcome after revision anterior cruciate ligament (ACL) reconstruction using semitendinosus allograft from donor less than 65 years old. A retrospective study of patients treated with ACL revision from 2003 to 2011 at a District General Hospital. A Study follow-up took place in 2014; clinical outcomes were measured by IKDC, Tegner, Lysholm, and Pain scores and KT-1000 arthrometry laxity measurements. We also registered reoperations and complications. Nineteen patients were available for follow-up, and one had telephonic interview. Mean follow-up time was 6 (3-9) years and mean age was 33.68 years, and 14 were men and six women. One patient required staged procedures, 5% were re-revised for early graft failure and clinical instability, and 15% had reoperations for other pathologies. The data analysis reveals statistically significant differences between preoperative and postoperative scores. Lysholm score improved from preoperatively 55.5±11 points (range 35-71 points) to postoperatively 89.7±10 points (range 55-100 points), Tegner activity scale score improved from 2.7±1.3 points (range 1-5 points) to 7.1±2.2 points (range 1-10). Pain score improved from 7.7±1.5 (range 4-10 points) to 1.1±1.9 (range 0-8 points). Level of Activity score improved from 3.6±1.1 (range 2-6 points) to 8.8±1.6 (range 3-10 points). In our patient series, revision ACL reconstruction showed a statistically significant improvement in postoperative subjective and objective scores. Five percent failure after mean 6 years (3-9 years) is less compared to other studies; surgical technique and donor age could have played a significant role in lower failure rate. In our series 50% patients had meniscal and 55% had Gr I/II chondral injury, this could also explain lower failure rate. Revision of a failed ACL reconstruction using semitendinosus allograft is a safe procedure that improves the function of the patient as demonstrated by clinical scores. Retrospective case series, Level IV.

Notchplasty in anterior cruciate ligament reconstruction in the setting of passive anterior tibial subluxation.

In an effort to minimize graft impingement among various ACL deficient states, we sought to quantitatively determine requirements for bone resection during notchplasty with respect to both volumetric amount and location. A validated method was used to evaluate Magnetic Resonance Imaging scans. We measured the ATT of the medial and lateral compartments in the following four states: intact ACL (27 patients), acute ACL disruption; <2 months post-injury (76 patients), chronic ACL disruption; 12 months post-injury (42 patients) and failed ACL reconstruction (75 patients). Subsequently, 11 cadaveric knees underwent Computed Tomography (CT) scanning. Specialized software allowed virtual anterior translation of the tibia according to the average ATT measured on MRI. Impingement volume was analyzed by performing virtual ACLRs onto the various associated CT scans. Location was analyzed by overlaying an on-screen protractor. The center of the notch was defined as 0°. Average impingement volume changed significantly in the various groups compared to the intact ACL group (acute 577 ± 200 mm(3), chronic 615 ± 199 mm(3), failed ACLR 678 ± 210 mm(3), p=0.0001). The location of the required notchplasty of the distal femoral wall border did not change significantly. The proximal femoral border moved significantly towards the center of the notch (acute 8.6° ± 4.8°, chronic 7.8° ± 4.2° (p=0.013), failed ACLR 5.1° ± 5.9° (p=0.002)). Our data suggests that attention should be paid peri-operatively to the required volume and location of notchplasty among the various ACL deficient states to minimize graft impingement.

Restriction in hip internal rotation is associated with an increased risk of ACL injury.

Evidence suggests that femoroacetabular impingement (FAI) in athletes may increase the risk of anterior cruciate ligament (ACL) injury. This study correlates ACL injury with hip range of motion in a consecutive series of elite, contact athletes and tests the hypothesis that a restriction in the available hip axial rotation in a dynamic in silico model of a simulated pivot landing would increase ACL strain and the risk of ACL rupture. Three hundred and twenty-four football athletes attending the 2012 NFL National Invitational Camp were examined. Hip range of internal rotation was measured and correlated with a history of ACL injury and surgical repair. An in silico biomechanical model was used to study the effect of FAI on the peak relative ACL strain developed during a simulated pivot landing. The in vivo results demonstrated that a reduction in internal rotation of the left hip was associated with a statistically significant increased odds of ACL injury in the ipsilateral or contralateral knee (OR 0.95, p=0.0001 and p<0.0001, respectively). A post-estimation calculation of odds ratio for ACL injury based on deficiency in hip internal rotation demonstrated that a 30-degree reduction in left hip internal rotation was associated with 4.06 and 5.29 times greater odds of ACL injury in the ipsilateral and contralateral limbs, respectively. The in silico model demonstrated that FAI systematically increased the peak ACL strain predicted during the pivot landing. FAI may be associated with ACL injury because of the increased resistance to femoral internal axial rotation during a dynamic maneuver such as a pivot landing. This insight may lead to better interventions to prevent ACL injury and improved understanding of ACL reconstruction failure. Cohort study, Level IV.

Lateral Tibial Slope is Increased with Patients with Early Graft Failure Following ACL Reconstruction

Objectives:To determine the relationship between lateral tibial slope and probability of early graft failure in patients who have undergone anterior cruciate ligament (ACL) reconstruction.Methods:Fifty-eight patients were initially identified who experienced graft failure following primary ACL reconstruction and were revised between 1989 and 2009. Exclusion criteria were: clinical follow-up of less than four years, graft failure occurring greater than two years from primary surgery, skeletal immaturity, deep infection, lack of availability of preoperative MRI imaging, and history of previous trauma to the proximal tibia. This left 35 cases of early (within 2 years) failure of primary ACL reconstruction. These cases were matched to 35 controls that had undergone ACL reconstruction with a minimum of 4 years of clinical follow-up and no evidence of graft failure. Patients were matched by age, gender, date of primary surgery, and graft type. Lateral tibial slope was then determined on MRI imaging in blinded fashion.Results:All 35 cases failed within 2 years of primary ACL reconstruction. Mean time to failure in this group was 1 year (range 0.6-1.4 years). Mean follow-up of the matched control group was 6.9 years (range 4.0-13.9 years). Mean lateral tibial slope in the early ACL failure group was found to be 8.4 degrees, which was significantly larger than the control group at 6.5 degrees (p=0.02). The odds ratio for failure considering a 2 degree increase in tibial slope was 1.5 (95% CI 1.02-2.2), and continued to increase to 2.2 (95% CI 1.1-4.6) and 3.3 (95% CI 1.1-10) with 4 degree and 6 degree increases in tibial slope, respectively (Fig 1). No significant association was identified between graft type and primary ACL reconstruction failure.Conclusion:Increased lateral tibial slope is associated with an increased risk for early ACL graft failure, regardless of graft type. Orthopaedic surgeons should consider measuring lateral tibial slope as part of the preoperative assessment of ACL-injured patients.

Revision surgery for failed anterior cruciate ligament reconstruction in the knee

Abstract Anterior cruciate ligament (ACL) reconstruction is a commonly performed surgical procedure in the knee. Revision following failed ACL reconstruction surgery is an increasingly common procedure. Revision surgery can be complicated due to the large variability of methods of primary ACL reconstruction, and the presence of bony defects and hardware. The cause of failure of the original ACL graft must be identified. The surgeon must have a strategy to deal with various problems and be flexible when operating on these patients. Outcomes following revision ACL surgery should not be expected to be as good as following primary ACL surgery, and patients should be counselled regarding this. Even if a stable knee is achieved objectively, subjective patient related outcomes are not as good as following primary ACL reconstruction. There is also a higher rate of re-rupture after revision ACL surgery, and thus return to sport is less likely. Damage to the chondral surfaces has a significant effect on the outcome following revision ACL surgery. An unstable ACL-deficient knee has a higher incidence of chondral damage and there may be a role for revision ACL surgery for its protective effect against further chondral damage, even if subjective outcomes are not as good.

Revision Surgery After Primary Double-Bundle ACL Reconstruction

The scientific debate regarding whether double-bundle ACL (anterior cruciate ligament) reconstruction is superior to single-bundle ACL reconstruction continues. Although this topic has been studied extensively1-3, relatively little is known about how to perform revision surgery after a failed primary double-bundle ACL reconstruction. The addition of a second pair of tibial and femoral tunnels in double-bundle ACL reconstruction can pose technical challenges for the revision procedure. It is for this reason that double-bundle ACL reconstruction has historically been referred to as “double-bundle—double-trouble.”4 However, the current literature reveals a lack of clinical experience regarding the surgical management and outcomes of revision surgery for failed primary double-bundle ACL reconstruction. This article focuses on revision surgery after failure of a primary double-bundle ACL reconstruction procedure. The diagnostic modalities employed in the evaluation and grading of various primary femoral and tibial tunnel scenarios will be reviewed. Using current literature and the authors’ experience, representative cases and revision strategies for possible primary tunnel scenarios are discussed. Finally, a detailed surgical treatment algorithm will be proposed as a guide for surgical decision-making (Video 1 [online]). Video 1 Video demonstrating revision ACL surgery after primary double-bundle ACL reconstruction. AM = anteromedial, PL = posterolateral, AP = anteroposterior, and PA = posteroanterior. We define failure of ACL reconstruction with use of both objective and subjective parameters. Objectively, failure can be defined as a deficit of 10° of knee extension or 10° of knee flexion compared with the contralateral, uninjured side; demonstration of knee instability as assessed by the Lachman test (≥ +2), pivot-shift test (≥ +2), or arthrometer (>3 mm side-to-side difference); and/or absence of an intact graft on magnetic resonance imaging (MRI) or during arthroscopy. In addition to these strictly objective criteria, subjective outcome measures are also important. A patient presenting with pain, subtle instability, …

Femoral marrow cavity bone harvesting used for arthroscopic refilling of misplaced or enlarged bone tunnels in revision ACL surgery

In anterior cruciate ligament (ACL) revision surgery, refilling of misplaced or enlarged tunnels frequently requires bone harvesting from the iliac crest. Unfortunately, donor-site pain displays a relevant complication. In order to optimize patients' comfort, we developed a procedure combining minimally invasive intramedullary bone harvesting from the femur with arthroscopic tunnel refilling. Patients with ACL reconstruction failure that were not eligible for one-step revision surgery but required tunnel refilling prior to the next ACL reconstruction were enrolled prospectively. Cancellous bone was harvested intramedullarily from the ipsilateral femur using the reamer-irrigator-aspirator system in a minimally invasive manner. Afterwards, the femoral and tibial tunnels were arthroscopically refilled using cones and push rods. Computer tomography (CT) analyses were carried out before and after the filling procedure. Pain levels were assessed during the entire follow-up. Patients undergoing iliac crest bone harvesting for other reasons served as a control group. Finally, the quality of the newly formed bone stock was evaluated in the subsequent ACL reconstruction procedure. Five patients were included during a 6-month period. Prior to refilling, tunnel analysis revealed a mean tunnel volume of 7.9 cm(3) at the femur [SD ± 5.3 cm(3)] and of 6.7 cm(3) [SD ± 5.1 cm(3)] at the tibia. The CT analyses further revealed that graft failure was predominantly caused by tunnel misplacement. Post-operatively, pain levels due to intramedullary bone harvesting were significantly lower compared to iliac crest bone harvesting at every analysed time point. Three to five months after tunnel filling, CT analyses showed sufficiently incorporated bone stocks with filling rates of 75 % femoral and 94 % tibial. ACL revision surgery was performed 4-5 months after tunnel filling without any complication. Intramedullary bone harvesting from the ipsilateral femur combined with arthroscopic refilling of the bone tunnels ensures a high-quality bone stock for further ACL reconstruction. The clinical relevance is shown by the feasibility of this technique and the significantly reduced pain levels during post-operative recovery.

HYPERMOBILITY: A RISK FACTOR FOR FAILURE FOLLOWING ACL RECONSTRUCTION

Hypermobility is associated with increased risk of sporting injuries. This study was performed to assess the risk of failure following primary ACL reconstruction in patients with hypermobility. Prospective data were...