Revision Anterior Cruciate Ligament Reconstruction Research Articles

Anterior cruciate ligament reconstruction with suture tape augmentation in the high-risk, young population.

This study evaluated patient-reported outcome measures and reinjury rates in higher-risk adolescents and young adults aged 14-25years old following Anterior Cruciate Ligament reconstruction using autograft with suture tape augmentation (SA ACLR). We performed a retrospective case series of patients aged 14-25 who underwent SA ACLR by a single surgeon between 2016 and 2020. After a minimum of 2years of follow-up, data was collected on reinjury and patient reported outcome measures, including Knee Injury and Osteoarthritis Outcome Score (KOOS), Marx Activity Rating Scale (MARS), Single Assessment Numeric Evaluation (SANE), and Visual Analog Pain Scale (VAPS). 27 patients were identified. 4 were lost to follow-up, and 23 met inclusion criteria (11 male, 12 female). Average age was 20, and average follow-up was 2.5years. Failure rate was 8.7%, with two patients requiring revision ACL reconstruction. One patient required two additional meniscal operations with intraoperative findings demonstrating maintenance of an intact ACL. Postoperative patient-reported outcomes measures (PROMs) were obtained for the patients who did not require additional surgery (n = 20), and preoperative PROMs were available for 16 of these patients. Postoperatively, patients reported a mean VAPS of 0.74 ± 1.27, MARS of 8.05 ± 5.58, and SANE of 83.05 ± 16.47. Mean KOOS was 86.92 ± 11.77 with subscores Pain of 86.94 ± 12.94, Symptoms of 82.16 ± 14.96, ADL of 95.81 ± 8.10, Sport of 75.61 ± 21.52, and QOL of 70.64 ± 22.04. Paired t-tests demonstrated significant improvements in VAPS, SANE, and KOOS outcomes following surgery. Patients were significantly less active postoperatively as reported by the MARS. A multivariable regression analysis showed that increased age predicted poorer postoperative KOOS Pain outcomes, and female sex predicted inferior KOOS Pain and Sport outcomes. SA ACLR is a safe and effective surgical technique in the high failure risk young adult demographic, with a low reinjury rate and acceptable KOOS scores. Patients were active with minimal pain at minimum two years of follow-up. Female sex was a risk factor for poorer outcomes in this population.

Surgical Predictors of Clinical Outcome 6 Years After Revision ACL Reconstruction

Background: Revision anterior cruciate ligament (ACL) reconstruction has been documented to have inferior outcomes compared with primary ACL reconstruction. The reasons why remain unknown. Purpose: To determine whether surgical factors performed at the time of revision ACL reconstruction can influence a patient’s outcome at 6-year follow-up. Study Design: Cohort study; Level of evidence, 2. Methods: Patients who underwent revision ACL reconstruction were identified and prospectively enrolled between 2006 and 2011. Data collected included baseline patient characteristics, surgical technique and pathology, and a series of validated patient-reported outcome instruments: Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) subjective form, Western Ontario and McMaster Universities Osteoarthritis Index (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 baseline patient characteristics and surgical variables to assess the surgical risk factors for clinical outcomes 6 years after surgery. Results: A total of 1234 patients were enrolled (716 men, 58%; median age, 26 years), and 6-year follow-up was obtained on 79% of patients (980/1234). Using an interference screw for femoral fixation compared with a cross-pin resulted in significantly better outcomes in 6-year IKDC scores (odds ratio [OR], 2.2; 95% CI, 1.2-3.9; P = .008) and KOOS sports/recreation and quality of life subscale scores (OR range, 2.2-2.7; 95% CI, 1.2-4.8; P < .01). Use of an interference screw compared with a cross-pin resulted in a 2.6 times less likely chance of having a subsequent surgery within 6 years. Use of an interference screw for tibial fixation compared with any combination of tibial fixation techniques resulted in significantly improved scores for IKDC (OR, 1.96; 95% CI, 1.3-2.9; P = .001); KOOS pain, activities of daily living, and sports/recreation subscales (OR range, 1.5-1.6; 95% CI, 1.0-2.4; P < .05); and WOMAC pain and activities of daily living subscales (OR range, 1.5-1.8; 95% CI, 1.0-2.7; P < .05). Use of a transtibial surgical approach compared with an anteromedial portal approach resulted in significantly improved KOOS pain and quality of life subscale scores at 6 years (OR, 1.5; 95% CI, 1.02-2.2; P≤ .04). Conclusion: There are surgical variables at the time of ACL revision that can modify clinical outcomes at 6 years. Opting for a transtibial surgical approach and choosing an interference screw for femoral and tibial fixation improved patients’ odds of having a significantly better 6-year clinical outcome in this cohort.

MCL augmentation using a peroneus longus split tendon autograft satisfactorily restores knee stability with no impairment in foot function and with a low failure rate for concurrent ACL reconstruction.

Addressing grade 2 and 3 medial-sided instabilities during anterior cruciate ligament (ACL) reconstruction is crucial to reduce the risk of ACL graft failure. This study introduced a minimally invasive, medial collateral ligament (MCL) augmentation technique using a peroneus longus split tendon autograft, which was fixed to the femoral deep MCL insertion and tibial superficial MCL insertion. This prospective, longitudinal, single-centre case series included patients who underwent MCL augmentation concurrent with primary or revision ACL reconstruction due to anteromedial instability. Preoperatively and at 1-year follow-up, clinical examinations, such as rolimeter test of anterior tibial translation and medial instability, knee (International Knee Documentation Committee subjective knee form [IKDC], Lsyholm, Knee Injury and Osteoarthritis Outcome Score [KOOS]) and foot function scores (American Orthopaedic Foot and Ankle Society score [AOFAS]) and complications, were analyzed. Thirty-one patients with a mean follow-up of 13.5 ± 2.6 months and a mean age of 27.8 ± 9.6 years were included. The side-to-side difference for anterior tibial translation significantly improved from preoperative to 1-year follow-up with an ACL reconstruction failure rate of 6.5%. No patient retained a grade 2 or 3 medial instability on valgus stress testing with 30° flexion. Significant improvements from preoperative to 1-year postoperative follow-up were observed in knee function scores: IKDC (48.9 ± 26.9- 71.3 ± 11.5, p < 0.001) and Lysholm (59.9 ± 28.5-80.5 ± 11.2, p = 0.002) as well as KOOS pain, ADL, sport and QoL, each reaching the respective minimal clinically important difference values. The foot function score AOFAS showed no significant impairment (100 ± 0-99.3 ± 2.5, p = 0.250). Complications included cyclops lesions of ACL reconstruction in three patients. At 1-year follow-up, MCL augmentation using a peroneus longus split tendon autograft for patients simultaneously undergoing ACL reconstruction satisfactorily restores knee stability, has a low ACL reconstruction failure rate and does not significantly impair foot function. Level IV therapeutic study; case series.

Physiologic Preoperative Knee Hyperextension Is Not Associated With Postoperative Laxity, Subjective Knee Function, or Revision Surgery After ACL Reconstruction With Hamstring Tendon Autografts.

There is concern that physiologic knee hyperextension may be associated with inferior outcomes after anterior cruciate ligament reconstruction (ACLR) using hamstring tendon (HT) autografts. To assess whether there is an association between contralateral passive preoperative knee hyperextension (≤-5°) and postoperative anterior knee laxity, subjective knee function, or revision surgery after ACLR using HT autografts. Cohort study; Level of evidence, 3. Patients without concomitant ligament injuries who underwent primary ACLR using an HT autograft at Capio Artro Clinic, Stockholm, Sweden, between January 1, 2005, and December 31, 2018, were identified. The cohort was dichotomized into the hyperextension group (≤-5°) and the no hyperextension group (>-5°) depending on preoperative contralateral passive knee extension degree. Anterior knee laxity (KT-1000 arthrometer; 134 N) was assessed preoperatively and at 6 months postoperatively. The Knee injury and Osteoarthritis Outcome Score (KOOS) was collected preoperatively and at 1, 2, and 5 years postoperatively. Patients who underwent revision ACLR at any institution in Sweden within 5 years of the primary surgery were identified in the Swedish National Knee Ligament Registry. A total of 6104 patients (53.5% male) for whom knee range of motion measurements were available were identified (hyperextension group [≤-5°]: 2350 [38.5%]; mean extension, -6.1°± 2.3° [range, -20° to -5°]; no hyperextension group [>-5°]: 3754 [61.5%]; mean extension, 0°± 1.4° [range, -4° to 15°]). There were no intergroup differences in anterior knee laxity preoperatively (hyperextension group, 3.6 ± 2.8 mm; no hyperextension group, 3.7 ± 2.7 mm; P = .24) or postoperatively (hyperextension group, 1.8 ± 2.3 mm; no hyperextension group, 1.8 ± 2.2 mm; P = .41). The only significant but nonclinically relevant intergroup differences were seen in the KOOS Symptoms subscale at the 1-year follow-up (hyperextension group, 81.4 ± 16.0; no hyperextension group, 80.3 ± 16.5; P = .03) and in the Sport and Recreation subscale at the 5-year follow-up (hyperextension group, 73.0 ± 25.6; no hyperextension group, 75.7 ± 24.3; P = .02). No other significant intergroup differences were noted preoperatively or at 1, 2, or 5 years postoperatively in any of the KOOS subscales. The overall revision ACLR rate at ≤5 years after the primary surgery was 4.9% (302 of 6104 patients). The hazard for revision ACLR in the no hyperextension group (4.5%; 170 of 3754 patients) was not significantly different from that in the hyperextension group (5.6%; 132 of 2350 patients) (hazard ratio, 0.89; 95% CI, 0.71 to -1.12; P = .34). A subsequent subanalysis showed that the hazard of revision ACLR in patients with no hyperextension was not significantly different from that of patients with ≤-10° of extension (5.8%; 27 of 467 patients) (hazard ratio, 0.91; 95% CI, 0.61 to 1.36; P = .65). Preoperative passive contralateral knee hyperextension (≤-5°) was not associated with postoperative anterior knee laxity, subjective knee function, or revision surgery ≤5 years after ACLR using HT autografts. Therefore, the presence of knee hyperextension alone should not be considered a contraindication per se for the use of HT autografts in ACLR.

Never Assume Successful Treatment of Septic Arthritis: Bacteria Isolated at Revision ACL Reconstruction 3 Years After Primary ACL Reconstruction "Successfully" Treated for Infection.

Level IV.

Preservation of the MMPH and Status of the Notch Configurations Are Important Factors for Successful Revision ACL Reconstruction.

The aim of this study was to identify the differences in anatomical factors between the patients who underwent revision and primary anterior cruciate ligament reconstructions (ACLR) and compare the outcomes between the 2 surgeries. Retrospective cohort study. Single institution tertiary academic center between 2014 and 2020. A total of 84 matched patients who underwent revision (group I) or primary ACLR (group II). Radiological evaluations were performed using side-to-side differences (SS-D), femorotibial angle, and posterior tibial slope. The medial meniscus posterior horn status as width (MMPHW), medial tibial plateau width (MTPW), notch configurations, tunnel positions, and sagittal graft angle were measured using 3D-CT and magnetic resonance imaging (MRI). Graft signals were assessed using MRI. The clinical outcomes were assessed. Group I showed larger SS-D and higher mean Howell grade of anterior cruciate ligament (ACL) graft than group II (P = 0.002 and P = 0.004, respectively). Multivariate regression analyses showed that the decreased MMPHW/MTPW ratio (P = 0.010) and notch width index (P < 0.007) were significantly independent factors associated with the higher Howell grade of ACL grafts. The decreased MMPHW/MTPW ratio (P < 0.001) was a significantly independent factor associated with larger SS-D. In the subgroup analysis, all patients in the notchplasty group showed wider notches postoperatively (P < 0.001). Revision ACLRs resulted in worse ACL signal intensity and stability outcome. The results of this study suggest that it may be important to preserve the MMPHW as much as possible and check notch configurations, especially during a revision ACLR.

Revision ACL reconstruction, but not bilateral ACL reconstruction, is associated with clinically relevant inferior subjective knee function compared with primary ACL reconstruction: A comparative analysis of 6831 patients.

To evaluate and compare the subjective knee function in patients undergoing revision and bilateral anterior cruciate ligament (ACL) reconstruction (ACLR) with those undergoing primary ACLR in a large cohort. Patients without concomitant ligament injuries who underwent primary, revision or bilateral ACLR at the Capio Artro Clinic, Stockholm, Sweden, between 2005 and 2018 were identified. The Knee injury and Osteoarthritis Outcome Score (KOOS) was collected preoperatively and at 1, 2 and 5 years postoperatively from the Swedish National Knee Ligament Registry. Patients who underwent revision and bilateral ACLR were compared with those who underwent primary ACLR (control group) using Student's t test. A total of 6831 patients (6102 with primary ACLRs, 343 with revision ACLRs and 386 with bilateral ACLRs) were included. Preoperatively, there were significant but nonclinically relevant differences in favour of the revision ACLR group for KOOS Symptoms, Pain, Activities of Daily Living (ADL) and Sport/Rec subscale scores compared with the primary ACLR group. Postoperatively, except for the 1-year Symptoms and ADL subscales, the revision ACLR group reported significantly lower scores on all KOOS subscales than the primary ACLR group, with clinically relevant differences (>8-10 points) for the 1-, 2- and 5-year Sport/Rec and Quality of Life (QOL) subscales. The bilateral ACLR group reported significantly, but not clinically relevant, inferior scores on the 1-year Symptoms and QOL subscales and the 5-year Sport/Rec and QOL subscales compared with the primary ACLR group. Revision ACLR, but not bilateral ACLR, was associated with clinically relevant inferior subjective knee function compared with primary ACLR. It is important to counsel patients regarding their future subjective knee function after repeated ACLR. Compared to primary ACLR, inferior subjective results should be expected after revision ACLR, but not after bilateral ACLR. Level III.

The role of anterolateral complex surgery and slope-reducing osteotomies in revision ACL reconstructions: a narrative review.

Anterior cruciate ligament reconstruction (ACLR) failures occur for various reasons including residual laxity, untreated concomitant injuries, poor graft quality, and high tibial slope. Various additional procedures can help to decrease revision ACLR failures including anterolateral complex (ALC) procedures and slope-reducing osteotomies for patients with high tibial slopes. This narrative review aims to review the literature on the roles of ALC augmentation procedures and slope-reducing osteotomies in the setting of patients undergoing revision ACLRs. A narrative review of relevant literature was performed in July 2024. Studies about anterolateral complex reconstructions and slope-reducing osteotomies in revision ACLRs were included. The literature reported that lateral extra-articular tenodesis (LET) and anterolateral ligament reconstructions (ALLR) can be used in revision ACLR cases to significantly reduce clinical knee laxity and the risk of repeated graft failure. There is not currently a strong opinion on which ALC procedure is superior. There are reported slight differences in lateral knee pain and knee stiffness, but both similarly significantly improve clinical and functional outcomes. In revision ACLR cases that also have a high posterior tibial slope (PTS), a slope-reducing tibial osteotomy is warranted. An anterior closing wedge proximal tibial osteotomy (ACW-PTO) significantly reduces anterior tibial translation and graft failure. There is concern about the changes to patellar height, but the literature has found that such changes are either slight or absent by 6 months postoperatively. The risk of ACLR failure is increased by risk factors like high tibial slope, preoperative knee laxity, and prior ACLR rupture. Anterolateral complex procedures and slope-reducing osteotomies may be used to address these specific concerns and reduce the risk of graft rupture. For revision ACLR cases with lower PTS, augmentation with a LET or an ALLR to reduce the risk of graft failure and improve rotational stability may be warranted. In the setting of a revision ACLR in patients with a high PTS of ≥12°, a concomitant ACW-PTO and ALC procedure should be considered to decrease the risk of an ACLR graft failure.

Trends in Anterior Cruciate Ligament Reconstruction Techniques and Postoperative Care Among Leaders in the Field: A Survey of the Herodicus Society.

Despite a growing body of literature regarding anterior cruciate ligament reconstruction (ACLR), there remains a wide diversity in surgical technique and clinical practice across providers. To (1) describe current ACLR practice preferences among members of the Herodicus society and (2) determine whether these preferences are influenced by years in practice and overall surgical volume. Cross-sectional study. A 24-question survey investigating surgeons' practices and preferred ACLR surgical techniques was sent via email to all active Herodicus Society members. Survey responses were subdivided by years of experience and overall ACLR annual case volume. Descriptive statistics were compiled and chi-square testing was utilized to determine the significance of experience and case volume on survey responses. Of the 113 invited Herodicus Society members who perform ACLR, 69 (61%) completed the survey. Respondents had a mean ± SD of 30.9 ± 9.8 years of experience in clinical practice and performed a mean of 96.0 ± 50.7 primary and 21.6 ± 16.9 revision ACLR annually. Of revision cases, 72.1% were performed using a single-stage technique. Mean frequency of graft usage by surgeon was bone-patellar tendon-bone autograft (58.6%), quadriceps autograft (14.6%), hamstring tendon autograft (14.0%), and allograft (11.8%). The plurality of surgeons responded that they used anterolateral augmentation "rarely" in primary ACLR (39.1%) and "sometimes" in revision ACLR (31.9%), with the majority performing lateral extra-articular tenodesis (66.7%) rather than anterolateral ligament reconstruction (14.5%). Most surgeons would not allow a 20-year-old football player to return before 7 months after ACLR (71.0%) but highly valued return-to-sports testing to determine readiness (94.2%). Higher volume surgeons performed single-stage revision ACLR at a significantly higher rate (79.8% vs 62.9%, P = .02) and significantly differed in return-to-sports criteria, with a greater proportion relying primarily on biometric testing (P = .01). The survey demonstrated that, in the Herodicus Society, a wide range of preferences exist regarding ACLR surgical technique. Bone-patellar tendon-bone autograft is the most frequent primary ACLR graft choice. Most participants have not embraced newer techniques such as anterolateral or suture tape augmentation. Return to sports is generally not allowed before 7 months and heavily factors-in return-to-sports testing metrics, suggesting that purely time-based criteria for return to sports is not modern practice among elite sports medicine surgeons.

Posterior Lateral Meniscal Root Repair Through Lateral Tunnel and Anterior Cruciate Ligament Revision: How to Avoid Tunnel Overlapping

Posterior lateral meniscal root (PLMR) tears are commonly observed in conjunction with anterior cruciate ligament (ACL) injuries. The presence of PLMR tears exacerbates knee instability, increasing stress on ACL grafts and accelerating joint degeneration if left untreated. Anatomical repair of PLMR tears is therefore crucial for restoring native knee kinematics and reducing tibiofemoral contact pressures, thereby safeguarding the ACL graft. However, the standard use of a single medial tunnel approach for concomitant PLMR and revision ACL reconstruction may require reconsideration to prevent the potential risks of tunnel overlapping, which could undermine graft anatomical integrity. This article, to prevent the risk of tunnel overlapping, introduces a surgical approach that employs an additional lateral tibial tunnel for PLMR repair, instead of the typically used single medial one, for PLMR repair during simultaneous revision ACL reconstruction.

Reviewing Revision Anterior Cruciate Ligament Reconstruction: Why and How?

Reviewing Revision Anterior Cruciate Ligament Reconstruction: Why and How?

Rate and Timing of Revision and Contralateral Anterior Cruciate Ligament Reconstruction Relative to Index Surgery.

After anterior cruciate ligament (ACL) reconstruction (ACLR), ipsilateral ACL graft reinjury or contralateral ACL injury has been reported. The rate and predictors of such subsequent ACL injuries have not been reported in recent years and in large patient cohorts. The current study utilized a large, national, multi-insurance, administrative database to assess subsequent ACLR and factors associated with its occurrence. Cross-sectional study; Level of evidence, 3. Using the PearlDiver M151 database, patients who underwent ACLR within the United States between 2015 and 2021 were abstracted. All included patients had ≥3 years of evaluation after initial ACLR. Patients who underwent a subsequent reconstruction (ipsilateral or contralateral) within 3 years were determined and the timing assessed. Using univariable and multivariable logistic regression, the factors associated with having a subsequent ACLR and the factors associated with returning for ipsilateral versus contralateral ACLR were examined. In total, 40,151 patients who underwent initial ACLR during the study period were identified. Of these, subsequent ACLR was performed for 1689 patients (4.2%). These included ipsilateral revision for 1018 (60.3%) and contralateral reconstruction for 671 (39.7%) patients. Patients returning for ipsilateral reconstruction did so sooner than patients needing a contralateral reconstruction. On multivariable analysis, the only factor independently associated with subsequent ACLR was younger age (odds ratio [OR] = 4.17 for 10-14 years relative to 25-29 years; P < .0001). Factors associated with returning for an ipsilateral revision ACLR as opposed to contralateral ACLR were earlier revision (OR = 1.49 within 1.5 years relative to after 1.5 years; P = .0001) and female sex (OR = 0.62 relative to male sex; P < .0001). The overall rate of requiring a subsequent ACLR was found to be 4.2%, with 60.3% of these being to the ipsilateral ACL. This information may be helpful for evolving injury-prevention programs and patient counseling.

Management of Bone Loss in a Revised and Infected Anterior Cruciate Ligament Reconstruction

Case: We present the case of a 21-year-old male patient who underwent primary anterior cruciate ligament (ACL) reconstruction, which was later complicated by retear, deep infection, and massive bone loss. We adopted a multidisciplinary approach to address each facet of this rare complication. Conclusion: Salvage options for revision ACL reconstruction pose significant challenges. We applied a novel technique involving suture button suspension of bone graft and addressed secondary modes of failure to achieve a satisfactory and functional outcome.

Trends in lateral extra-articular augmentation use and surgical technique with anterior cruciate ligament reconstruction from 2016-2023, an ACL Study Group Survey

PurposeTo survey the ACL study group (ACLSG) members to determine the current practice patterns surrounding the use and methodology of lateral extra-articular procedures (LEAPs), including anterolateral ligament reconstruction (ALLR) or lateral extra-articular tenodesis (LET) during ACL reconstruction (ACLR). MethodsA web-based questionnaire was distributed to members of the ACLSG during the 2016, 2018, 2020, and 2023 biennial meetings. Questions explored the indications and techniques when incorporating LEAPs in ACLR. ResultsAnalysis of survey responses found that the reported use of LEAPs in both primary and revision ACLR significantly increased between 2016 and 2023 and that surgeons were using lateral augmentation more frequently over time. Surgical techniques were stable across survey years, with most surgeons using iliotibial band (ITB) autograft attached at Gerdy's tubercle, passed under the lateral collateral ligament (LCL), and anchored proximal/posterior to the lateral femoral epicondyle. ConclusionSurvey responses demonstrate that LEAPs are becoming more common among ACL surgeons in the ACL SG, with the modified Lemaire LET being the predominant technique. This aligns with recent clinical studies showing improved outcomes and reduced risk of failure in ACLR with lateral augmentation compared to ACLR alone. Level of evidenceLevel V, Expert Opinion

Posterior Tibial Slope Measured on Plain Radiograph Versus MRI and Its Association With Revision Anterior Cruciate Ligament Reconstruction: A Matched Case-Control Study.

Posterior tibial slope (PTS) has been identified as a possible modifiable risk factor for anterior cruciate ligament (ACL) injury and ACL reconstruction (ACLR) failure. However, the findings in the literature are inconsistent. This may be explained by several different reasons, including different measurement methods, differing definitions of ACLR failure, and possible inclusion of suboptimal films. To compare PTS values obtained using plain radiographs (XR-PTS) in a young (≤21 years of age), skeletally mature patient population with those obtained using magnetic resonance imaging (MRI), as well as to quantify the number of suboptimal lateral knee radiographs obtained across an integrated health care system and determine the potential effect of including these radiographs on summary statistics of XR-PTS. Case-control study; Level of evidence, 3. Skeletally mature adolescent and young adult patients ≤21 years of age were identified from the ACLR registry of Kaiser Permanente. The cases of concern were patients requiring revision ACLR. The controls were patients who had an ACLR and did not require a revision procedure. The XR-PTS measurements were made on plain radiographs by a single blinded reviewer. These results were compared with measurements obtained using MRI. The quality of each plain radiograph was evaluated by measuring posterior/distal femoral condylar overlap and length of tibial diaphysis captured on the radiograph. Summary statistics with and without inclusion of measurements made on suboptimal radiographs were calculated. Of the initial 634 patients with ACLR (317 case-control pairs), 561 (88.5%) had radiographs available and were included for the analysis comparing radiograph to MRI slope measurements. For the evaluation of slope between case and control pairs with radiograph information available, there were 257 case-control pairs; there were 124 pairs when those with suboptimal radiographs were excluded. There was no difference in MRI-measured lateral tibial posterior slope or medial tibial posterior slope for the 257 case-control pairs with XR-PTS information and for the 124 pairs with optimal radiographs. XR-PTS in the revision cohort was significantly steeper than in the control group when suboptimal radiographs were included in the analysis. There was no difference when patients with suboptimal radiographs were excluded. PTS measurements made on plain radiographs were larger than those made on MRI. There was a poor correlation between measurements made using these 2 modalities (r = 0.22 for radiograph and medial PTS). This study did not find a significantly steeper XR-PTS in patients who had to undergo revision ACLR when suboptimal radiographs were not included in the analysis. The present study's results confirmed the findings from a previous study of the same patient population that used MRI. However, there was poor correlation between PTS measurements made using plain radiograph and MRI.

Use of Fast-Setting Bone Graft Substitute to Allow Single-Stage Revision Anterior Cruciate Ligament Reconstruction

Background: The overall revision rate for primary anterior cruciate ligament reconstruction (ACLR) has increased over the past decade, with the commonest mode of failure being a combination of traumatic, technical, and biological factors. The challenge in revision ACLR is the need to address malpositioned or widened tunnels with the ideal scenario being single-stage revision, with widened and type 2 tunnels being the most difficult scenarios to deal with. Tunnels can be filled using autograft, allograft, and more recently described bone graft substitute (BGS). In this video, we describe a technique using fast-setting BGS to fill the problem of malpositioned tunnel or tunnels to allow single-stage revision ACLR. Indications: This technique is indicated in patients undergoing revision ACLR where tunnels are nearly right (type 2) with no widening at the joint surface aperture. Technique Description: Following preparation of the notch, the femoral tunnels are prepared in the normal fashion to remove all the previous graft and to create fresh bleeding surfaces. The fluid in the knee is completely drained, and the femoral tunnel is repeatedly dried with ribbon gauze that is left in place until ready to inject. The BGS, genex (Biocomposites Ltd), is mixed and loaded into the delivery syringe before injecting arthroscopically. After 15 minutes, the new anatomic femoral tunnel is then prepared in routine fashion. The same steps are repeated for the tibial tunnel. Results: Twenty patients underwent single-stage revision ACLR using this technique. There have been no reruptures in this series. All eligible patients at the 12-month follow-up had grade 0 or 1 laxity on clinical examination and full incorporation of the BGS on radiographs. There were no complications related to the BGS during the intra- or postoperative period. Discussion/Conclusion: We describe a technique that allows revision ACLR to be performed as single stage in a subset of patients with type 2 tunnels with successful short- to mid-term results. We have found this to be a safe and effective way to avoid 2-stage surgery in a subgroup of cases who have a challenging problem for surgeons to manage. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Risk for Revision ACLR After Primary All-Inside Quadrupled Semitendinosus Hamstring Tendon Autograft ACLR With Independent Suture Tape Augmentation: A Retrospective Cohort Study.

The rate of failed anterior cruciate ligament reconstruction (ACLR) remains high in the younger and more active patient populations. Suture tape augmentation (STA) in addition to ACLR may reduce the risk for revision surgery. The purpose of this study was to compare patient outcomes between patients who underwent primary all-inside quadrupled semitendinosus hamstring tendon autograft (QST-HTA) ACLR with and without STA. It was hypothesized that the STA cohort would demonstrate a lower incidence of subsequent revision ACLR while maintaining comparable patient-reported outcomes. Cohort study; Level of evidence, 3. All patients ≤40 years of age who received primary all-inside QST-HTA ACLR with and without independent STA augmentation were identified. The following validated patient-reported outcome measures (PROMs) were collected: visual analog scale for pain, Single Assessment Numeric Evaluation, Knee injury and Osteoarthritis Outcome Score subscales, and Tegner activity scale. KT-1000 arthrometer measurements were collected pre- and postoperatively. Cox proportional hazards model and nominal logistic regression analysis were used to assess additional variables associated with revision ACLR. A total of 104 patients with a mean age of <22 years were included in the final data analysis (STA: 36 patients; control: 68 patients). Significantly fewer patients in the STA group sustained a graft failure necessitating revision surgery at the final follow-up (5.6% vs 24%; relative risk, 0.24 [95% CI, 0.06-0.97]; P = .017). Four-year graft survival was significantly higher in the STA group (97.2% vs 82.4%; P = .031). All PROMs significantly improved postoperatively except for Tegner levels, which decreased in both groups compared with their preinjury levels (P < .001). Return to sports was similar in both groups with >70% of patients returning to their previous level of competition. Regression analysis demonstrated increased risk for revision ACLR in younger patients, high school athletes, and those with higher postoperative activity levels. QST-HTA ACLR with STA was associated with reduced risk for revision ACLR compared with nonaugmented QST-HTA ACLR in this young patient population. Furthermore, the addition of suture tape did not appear to affect postoperative patient-reported and return-to-sports outcomes.

It is challenging to reproduce both anatomical and functional aspects of anterolateral reconstruction: postoperative 3D-CT analysis of the femoral tunnel position

BackgroundThis study aimed to evaluate the femoral tunnel position and fiber length of the anterolateral ligament (ALL) reconstruction compared with the natural anatomy of the ALL. We also evaluated whether the femoral tunnel position would affect residual pivot shift.MethodsThis study was a retrospective review of 55 knees that underwent ALL reconstruction considering the anatomical and functional aspects, during primary anterior cruciate ligament (ACL) reconstruction in the presence of a high-grade pivot shift or revisional ACL reconstruction. We determined the position of the femoral tunnel and the length of graft using a three-dimensional (3D)-computed tomography (CT) model after ALL reconstruction. We also measured graft excursion during surgery and examined pivot shift 2 years after surgery. We conducted a subgroup analysis of femoral tunnel position, fiber length, isometricity, and residual pivot shift depending on whether the tunnel was anterior or posterior to the lateral epicondyle (LE). We also performed a subgroup analysis depending on whether the ACL reconstruction was primary or revisional.ResultsThe mean femoral tunnel position was 2.04 mm posterior and 14.5 mm proximal from the center of the LE. The mean lengths of the anterior and posterior fibers were 66.6 and 63.4 mm, respectively. The femoral tunnel was positioned more proximally than the anatomical position, and both anterior and posterior ALL fibers were longer than the natural anatomy. The anteroposterior femoral tunnel position was significantly correlated with anterior (p = 0.045) and posterior (p = 0.037) fiber excursion. In the subgroup analysis, there was no significant difference in the residual pivot shift between the posterior and anterior tunnel positions. However, there were significant differences for proximal position (p < 0.001) and fiber length (p = 0.006). There was no significant difference between primary and revisional ACL regarding femoral tunnel position and fiber lengths.ConclusionIt is challenging to reproduce both anatomical and functional aspects of ALL reconstruction in both primary and revision ACL reconstruction. Especially for functional reconstruction, the femoral tunnel tended to be positioned more proximally than the anatomical position. However, the femoral tunnel position did not affect functional clinical outcomes at the 2-year follow-up.Level of evidenceLevel IV Case series.

Graft choice to decrease the revision rate of anterior cruciate ligament reconstruction: a nationwide retrospective cohort study

There are many graft choices for anterior cruciate ligament (ACL) reconstruction, including autografts and allografts. The choice of graft has been identified as a significant factor affecting the outcome of ACL reconstruction. This study aimed to determine whether allograft or autograft is better for avoiding revisional ACL reconstruction. The National Health Insurance Service-Health screening database analyzed 146,122 patients who underwent ACL reconstruction surgery from Jan. 1, 2002, to Dec. 31, 2021. The study was conducted in two groups, autograft or allograft, and the rates of revision ACL reconstruction between the two groups were compared. Propensity score matching and multivariable Cox Proportional Hazard model analysis were used. The significant predictors for complications (p < 0.05) were as follows. The total of patients with ACL reconstruction was 146,122. Allograft was used in 121,148 patients, and autograft was used in 24,974 patients. 9.2% of the allograft group and 8.7% of the autograft group underwent revision ACL reconstruction. (P < .0001) 70.0% & 63.6% of patients underwent revision surgery within 1 year in the allograft & autograft groups, respectively. In summary, using autograft in primary ACL reconstruction is helpful in lowering the rate of revision surgery.

Increased rate of surgery for loss of motion following anterior cruciate ligament reconstruction during COVID-19

ObjectivesTo investigate the incidence and risk factors associated with loss of motion after anterior cruciate ligament reconstruction (ACLR) during the coronavirus disease 2019 pandemic (COVID-19). MethodsA retrospective review of patients undergoing primary ACLR between March 2017 and November 2022 by a senior high-volume orthopaedic surgeon was performed. Exclusion criteria included revision ACLR, multiligamentous knee surgery, and age <14 years. The COVID-19 group was categorized according to the United States Centers for Disease Control Public Health Emergency declaration dates (January 31, 2020–May 11, 2023). To minimize confounding variables associated with the early stages of COVID-19, patients who underwent ACLR between December 1, 2019 and February 29, 2020 were excluded. Loss of motion was defined using the International Knee Documentation Committee criteria for loss of motion of the knee (i.e. an extension deficit >5° or flexion deficit >15° compared to the contralateral knee) 3–12 months after ACLR or as requiring surgery to restore motion within 12 months of ACLR. ResultsA total of 336 individuals who underwent 352 primary ACLRs (164 pre-COVID-19, 188 during COVID-19) were included (mean age: 25.2 ​± ​10.6 years, 44% female). The overall rate of postoperative loss of motion was 15% (n = 53), and 9% (n = 31) required surgery to restore motion within 12 months of ACLR. More patients underwent surgery for loss of motion during COVID-19 compared to pre-COVID-19, which was statistically significant (12% (n = 23) vs 5% (n = 8), respectively, P = 0.02). However, a statistically significant difference in the rate of loss of motion was not detected (18% (n = 33) vs 12% (n = 20), respectively, P = 0.16). A statistically significant increased median time from injury to ACLR was observed during COVID-19 compared to pre-COVID-19 (55 vs 37 days, P <0.01). More patients were unable to achieve terminal extension (0°) at minimum 9 months postoperatively during COVID-19 compared to pre-COVID-19 (10% vs 3%, P = 0.04) and motion was worse at this interval (0°–136° vs −2°–138°, P <0.01). ConclusionSurgery for loss of motion following ACLR was more common during COVID-19. Decreased access to elective medical care, changed activity level, psychological effects, or COVID-19 itself may explain the increased rate of surgery for loss of motion during COVID-19. Level of evidenceCase series; level IV.