Underwent Revision Anterior Cruciate Ligament Research Articles

Hamstring autografts demonstrate either similar or inferior outcomes to quadriceps or bone-patellar tendon-bone autografts in revision anterior cruciate ligament reconstruction: A systematic review of comparative studies.

To evaluate the clinical outcomes in patients undergoing revision anterior cruciate ligament reconstruction (r-ACLR) using hamstring tendon (HT) autografts with those using either quadriceps tendon (QT) or bone-patellar tendon-bone (BPTB) autografts or allografts. Three databases were searched on 8 August 2023. The authors adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Revised Assessment of Multiple Systematic Reviews (R-AMSTAR) guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. Data on demographics, surgical details, patient-reported outcome measures (PROMs), rates of instability, failure and return to sport (RTS) were extracted. Eleven studies comprising 859 patients were included in this review. Five studies compared HT and QT autografts. One study each reported greater IKDC scores (p = 0.04) and Tegner scores (p = 0.04) in the QT group, while one study each reported higher anterior translation (p = 0.04), rates of positive pivot shift (p = 0.03) and rates of failure (p = 0.03) in the HT group. Six studies compared HT and BPTB autografts with one study each reporting greater Lysholm scores (p = 0.02) and less side-to-side anterior laxity (p < 0.01) in the BPTB group. Two studies compared HT autografts with allografts with only one study reporting a faster time to RTS in the HT group than the allograft group (p < 0.001). All other comparisons were not significant. HT autografts result in either similar or inferior outcomes in r-ACLR when compared to QT or BPTB autograft options. Allografts resulted in similar outcomes to HT autografts apart from greater time to RTS for r-ACLR. Level III.

Combined Anterolateral Ligament Reconstruction Results in Better Knee Stability and More Satisfactory Subjective Outcomes in Non-Athlete Patients Undergoing Revision Anterior Cruciate Ligament Reconstruction.

Background: Consensus has not yet been reached regarding combined anterior cruciate ligament reconstruction (ALLR) with revisional anterior cruciate ligament reconstruction (RACLR). We aimed to compare the clinical outcomes between patients who underwent isolated RACLR and those who underwent RACLR combined with ALLR. Methods: Between June 2010 and June 2021, 49 patients who underwent RACLR were retrospectively reviewed over a 24-month follow-up. Patients were categorized into the isolated RACLR (n = 37, group 1) or combined ALLR group (n = 12, group 2). Clinical outcomes were evaluated with several patient-reported outcome measures (PROMs) and minimal clinically important differences (MCIDs) for each PROM. The side-to-side difference (SSD) of the anterior instability was measured. The pivot-shift test was performed. Results: Baseline characteristics showed no differences between the groups. PROMs showed no significant differences between the groups at the 2-year follow-up. Group 2 was superior to group 1 in the MCID achievement rate for Lysholm knee and International Knee Documentation Committee (IKDC) subjective scores at 24 months postoperatively. At the final follow-up, the proportion of IKDC grade A in SSD for anterior laxity was higher in group 2 than in group 1 (58.3% versus [vs.] 18.3%, p = 0.009), and the proportion of pivot-shift grade 0 was also higher in group 2 (66.7% vs. 27.0%, p = 0.013). The "near return to activity" rate was also higher in group 2 than in group 1 (83.3% vs. 45.9%, p = 0.043). Conclusions: Combining ALLR with RACLR in non-athletes results in a higher proportion of patients with less mechanical graft failure and satisfactory clinical outcomes.

Concomitant Popliteomeniscal Fascicles Tears Are Found in 21% of Professional Soccer Players With Acute Anterior Cruciate Ligament Injuries

PurposeTo investigate the incidence of popliteomeniscal fascicles (PMF) tears in anterior cruciate ligament (ACL) rupture in professional soccer players, to describe arthroscopic and MRI findings and treatment of these lesions with clinical outcomes, and to evaluate the incidence of subsequent lateral meniscus tears and ACL reinjury. MethodsACL reconstructions on soccer players were retrospectively analyzed, and among them, a cohort of patients with PMFs tears was reviewed. The cohort was assessed with magnetic resonance imaging (MRI) examination, arthrometric testing, Lysholm score and IKDC score. The occurrence of subsequent lateral meniscus tears and ACL reinjury were evaluated. ResultsA total of 208 ACL reconstructions were identified. From these, 43 males and 3 females with a mean age of 24 ± 4.2 years were included. Median time from injury to surgery was 5 days. Pre-operative MRI showed a tear of posterior PMFs in 24 out of 47 knees (51.1%). The mean pre-op arthrometric measured laxity was 4.3 ± 1.65 mm, and post-op 0.1 ± 1.1 mm. Pre-op Lysholm score and IKDC score were respectively 50.4 ± 25.4 and 39.6 ± 5, post-op was 98 ± 2.4 and 73.6 ± 1.2. Mean time to return to play, at the same pr-op level for all patients, was 184 ± 41.7 days. One patient underwent ACL revision due to a reinjury 9 months after surgery, while no lateral meniscus tears occurred in the follow-up period. ConclusionsPopliteomeniscal fascicles tears are found in approximately 20% of professional soccer players with acute ACL injuries. After ACL reconstruction and PFT repair, outcomes including return to play are good, ACL retear is low, and recurrent lateral meniscus tears were not observed. Level of EvidenceLevel IV, Therapeutic case series.

Mid-term Results of a Single-Stage Revision Anterior Cruciate Ligament Reconstruction: A Retrospective Analysis of 36 Cases

Background. Revision anterior cruciate ligament reconstruction is becoming more and more common in the knee surgery due to the annual increase in the number of primary anterior cruciate ligament reconstructions. Choosing the most suitable graft and determining the staging of the surgical treatment by preoperative assessment of the possibility of performing the most anatomical revision canals and their interposition with the primary canals are the main factors that influence treatment results.&#x0D; Aim of the study — comparative assessment of the results of using hamstring tendon and peroneus longus tendon autografts in a one-stage revision reconstruction of the anterior cruciate ligament.&#x0D; Methods. A retrospective analysis of the medical records of 36 patients who underwent revision anterior cruciate ligament reconstruction was performed. The patients were divided into two groups: in the patients of the study group (n = 19) a peroneus longus tendon (PLT) autograft was used, in the comparison group (n = 17) a hamstring tendon autograft (HT) was applied. Subjective and objective evaluation using the KOOS, IKDC, and Lysholm scales was performed, and position of the central entry points of the primary and revision canals was determined.&#x0D; There were no statistically significant differences in the objective assessment of the knee joint stability. Significantly better results of subjective assessment of the knee function according to the Lysholm and KOOS scales were obtained in the PLT group (p = 0.042 and p0.001, respectively). Position of revision canals corresponded to the standard values, but position of the femoral canal had a slight cranial and anterior displacement. It was also found that the PLT graft diameter was statistically significantly larger than the HT graft diameter (p0.001).&#x0D; Results. There were no statistically significant differences in the objective assessment of the knee joint stability. Significantly better results of subjective assessment of the knee function according to the Lysholm and KOOS scales were obtained in the PLT group (p = 0.042 and p0.001, respectively). Position of revision canals corresponded to the standard values, but position of the femoral canal had a slight cranial and anterior displacement. It was also found that the PLT graft diameter was statistically significantly larger than the HT graft diameter (p0.001).&#x0D; Conclusion. One-stage revision anterior cruciate ligament reconstruction is a safe and effective surgical procedure providing satisfactory objective and subjective clinical results. Use of peroneus longus tendon autograft allows to obtain better results in comparison with the hamstring tendon autograft.

A Lateral Extra-articular Procedure Reduces the Failure Rate of Revision Anterior Cruciate Ligament Reconstruction Surgery Without Increasing Complications: A Systematic Review and Meta-analysis

Background: Lateral extra-articular procedures are becoming increasingly popular in association with anterior cruciate ligament (ACL) reconstruction, especially in patients with persistent rotatory instability and in a high-risk population. However, few studies have investigated the outcomes of the lateral extra-articular procedure as an associated procedure in an ACL revision (R-ACLR) setting and its benefit with respect to isolated intra-articular reconstruction. Hypothesis: Lateral extra-articular procedures reduce the failure rate of revision ACL reconstruction (R-ACLR). Purpose: To compare subjective outcomes, knee stability, and failure and complication rates between patients who underwent ACL revision with and without an associated lateral extra-articular procedure. Study Design: Systematic review and meta-analysis; Level of evidence, 3. Methods: A systematic search of the PubMed, Cochrane, and OVID databases was performed on September 2022 in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Eligible studies were trials directly comparing patients who had isolated ACL revision with patients who had ACL revision associated with lateral extra-articular procedures at a minimum follow-up of 2 years. A meta-analysis was performed, and bias and the quality of the evidence were rated according to the Newcastle-Ottawa Scale. The meta-analysis was conducted according to the PRISMA guidelines. Results: Eight studies were included: a total of 334 patients were treated with isolated revision (isolated (R-ACLR)) and 342 treated with combined revision and a lateral extra-articular procedure (combined (R-ACLR)). For the failure rate, the meta-analysis showed a significantly decreased relative risk reduction of 54% (P = .004) in patients with combined (R-ACLR) with respect to isolated R-ACL, whereas no difference in complication rate was observed. The combined (R-ACLR) group demonstrated a decreased risk ratio of 50% (P = .002) for having a positive pivot-shift test result and a relative risk reduction of 68% (P = .003) for having a grade 2-3 pivot shift when compared with the isolated (R-ACLR) group. Finally, no significant differences were observed among the lateral extra-articular procedures. Conclusion: The addition of a lateral extra-articular procedure to revision ACL significantly reduced the failure rate and postoperative pivot shift without increasing the complication rate. Anterolateral ligament reconstruction and a lateral extra-articular procedure with iliotibial band were effective in improving the outcomes of revision ACL reconstruction. Further high-level studies could help to clarify which subgroup of patients could particularly benefit from an anterolateral procedure in the context of ACL revision.

One-stage anterior cruciate ligament revision surgery after primary failed double-bundle reconstruction: a systematic review.

Anterior cruciate ligament (ACL) revision surgery after failed double-bundle (DB) reconstruction is a challenging procedure. This study aimed to systematically review the research on ACL revision surgery following failed DB reconstruction, providing an overview on indications, surgical techniques, clinical outcomes and potential pitfalls occurring while performing this therapeutic approach. Literature published from exception to February 2023 was searched in the Pubmed/MEDLINE, Embase and CINAHL databases. Studies in English reporting on patients who underwent ACL revision surgery after prior failed DB reconstruction were considered. Review articles and expert opinion or editorial pieces were excluded. Outcomes of interest included indications and pre-operative planning, surgical technique and associated procedures, type of revision surgery (either one- or two-stage), graft choice, clinical and functional outcomes, rate of complications, failure rate. Overall, 4 studies met all the inclusion criteria for this review. All were published between 2007 and 2020. The search resulted in two retrospective comparative studies, one case series, and one case report. Average follow-up periods ranged from 24 to 45months. From these studies, 66 patients (66 knees) were identified. One-stage revision surgery was performed in 64 on 66 patients (97%) with pathologic laxity following DB ACL reconstruction. Most frequently reported outcome was Lysholm score in five studies: average postoperative Lysholm score ranged from 90.5 to 91.0 while Tegner activity level ranged from 5.6 to 7.0. In 4 patients (6%) re-revision surgery was performed due to graft re-rupture. One-stage ACL revision surgery following DB ACL reconstruction appears feasible providing satisfying outcomes and limited complications. The literature on this subject is limited and further comparative studies reporting long-term outcomes are needed, as high-level studies on this topic are still lacking.

Ramp Tear among Patients Undergoing Arthroscopic Anterior Cruciate Ligament Reconstruction in a Tertiary Care Centre.

Ramp tear is a specific injury that affects the posterior horn of the medial meniscus and its meniscosynovial or meniscocapsular attachments. The actual prevalence of ramp lesion is unknown due to the high probability of misdiagnosis or underdiagnosis caused by the low sensitivity of imaging modalities and poor visualization during arthroscopy. This study aimed to find out the prevalence of ramp tear among patients undergoing arthroscopic anterior cruciate ligament reconstruction in a tertiary care centre. A descriptive cross-sectional study was conducted among patients undergoing arthroscopic anterior cruciate ligament reconstruction after getting ethical approval from the Institutional Review Committee. Data from 1 March 2019 to 31 December 2022 was collected between 1 May 2023 to 30 May 2023 from medical records. The study included all patients who underwent arthroscopic anterior cruciate ligament reconstruction. Patients with a previous history of medial meniscus injury or repair and undergoing revision anterior cruciate ligament reconstruction were excluded. Convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval. Out of 412 patients who underwent arthroscopic anterior cruciate ligament reconstruction, 53 (12.86%) (9.63-16.09, 95% Confidence Interval) had ramp tears. The mean age of patients with ramp tears was 28.64±7.57 years. Among 53 patients, 42 (79.24%) were male and 11 (20.75%) were female. The prevalence of ramp tears in patients undergoing arthroscopic anterior cruciate ligament reconstruction in a tertiary care centre was found to be lower than other studies done in other international studies. anterior cruciate ligament injuries; anterior cruciate ligament reconstruction; arthroscopy.

Effect of Anterior Tibial Closing Wedge Osteotomy on Coronal Tibial Alignment in Relation to Preoperative Medial Proximal Tibial Angle and Wedge Height.

The posterior tibial slope has been identified as an anatomic risk factor for anterior cruciate ligament insufficiency and reruptures after anterior cruciate ligament reconstruction. Anterior tibial closing wedge osteotomy for correction of sagittal plane deformities has the potential to cause an unintended change in coronal plane alignment. To evaluate the effects of anterior tibial closing wedge osteotomies for correction of posterior tibial slope on coronal plane alignment using an infratuberosity surgical approach and to identify predictive factors for a change in medial proximal tibial angle (MPTA). Case series; Level of evidence, 4. This study reports on retrospectively obtained data from radiographic measurements of 38 anterior tibial closing wedge osteotomies. All patients underwent revision anterior cruciate ligament reconstruction and had undergone ≥1 previous anterior cruciate ligament reconstruction. In all patients, an infratuberosity approach was used with angular stable plate fixation. Pre- and postoperative radiographs were examined retrospectively to detect changes in the sagittal and coronal plane alignment (posterior tibial slope and MPTA). A multivariate regression analysis was used to identify predictors for a change in MPTA. The study group consisted of 14 women and 24 men whose mean ± SD age at the index procedure was 31.6 ± 8.7 years (range, 17-51 years). Posterior tibial slope decreased significantly (by 7.2° ± 2.3°; P < .001) from 14.6° ± 2.0° preoperatively to 7.4° ± 2.1° postoperatively. MPTA decreased significantly by 1.3° ± 1.5° (P = .005) from pre- to postoperative measurement. Mean wedge height was 9.3 ± 1.1 mm. A lower preoperative MPTA (coefficient = 0.32; P = .017; 95% CI, 0.06-0.59) and larger wedge height (coefficient = 0.48; P = .029; 95% CI, 0.05-0.9) were significant predictive factors for a decrease in MPTA. Anterior tibial closing wedge osteotomy for posterior tibial slope reduction resulted in a slight but significant decrease of the MPTA in the coronal plane. These changes were dependent on the preoperative MPTA and the wedge height.

Association of Tibial Tubercle–Trochlear Groove Distance With Risk of ACL Graft Failure

Background: Limited evidence suggests a positive correlation between tibial tubercle–trochlear groove (TT-TG) distance and the risk of native anterior cruciate ligament (ACL) tear. The relationship between TT-TG distance and the risk of ACL graft failure is unknown. Hypothesis: TT-TG distance is independently associated with risk of ACL graft failure. Study Design: Cohort study; Level of evidence, 3. Methods: All patients who underwent ACL revision surgery between 2010 and 2018 at a single institution were identified. A control cohort underwent primary ACL reconstruction (ACLR) between 2006 and 2015, with no evidence of graft failure at 8.1 ± 2.5 years postoperatively. Record review included anthropometrics, graft type, and estimated Tegner activity score at ≥6 months after primary ACLR. Magnetic resonance imaging (MRI) scans after native ACL tear (controls) or graft failure (revision cohort) were assessed for (1) TT-TG distance, (2) proximal tibial slopes, (3) depth of tibial plateau concavity, and (4) tunnel position (revision cohort). Associations between ACL graft failure and MRI measurements, surgical variables, and patient characteristics were evaluated with logistic regression analyses. Sensitivity analyses, excluding patients with tunnel malposition, were performed to confirm multivariable results in patients with “ideal” tunnel placement. Results: Participants included 153 patients who underwent revisions and 144 controls. Controls were older than the patients who underwent revision (26.6 ± 8.8 vs 20.6 ± 7.3 years; P &lt; .001). The mean TT-TG distance and lateral posterior tibial slope (PTS) were smaller for the control group than for the revision group (TT-TG: 9.3 ± 3.9 vs 11.2 ± 4.2 mm; P &lt; .001; lateral PTS: 6.2° ± 3.3° vs 7.2° ± 3.6°; P = .01). TT-TG distance, lateral PTS, and age were associated with risk of ACL graft failure by multivariable analysis (OR, 1.15; 95% CI, 1.07-1.23; P &lt; .001; OR, 1.13; 95% CI, 1.04-1.22; P = .004; and OR, 0.90; 95% CI, 0.87-0.94; P &lt; .001, respectively). With sensitivity analyses, TT-TG distance, lateral PTS, and age at index surgery remained significantly and independently associated with ACL graft failure. Conclusion: Increased TT-TG distance, increased lateral PTS, and younger age are independently associated with increased odds of ACL graft failure. Patients with these characteristics may require a more comprehensive strategy to reduce the risk of ACL reinjury.

Comparison of Onlay Anchor Fixation Versus Transosseous Fixation for Lateral Extra-articular Tenodesis During Revision ACL Reconstruction.

There is evidence on the clinical effectiveness of the Lemaire technique for lateral extra-articular tenodesis (LET) in patients undergoing revision anterior cruciate ligament reconstruction (ACLR), but the best fixation technique is unknown. To compare the clinical outcomes of 2 fixation techniques after revision ACLR: (1) onlay anchor fixation, which would avoid tunnel conflict and physis injury, and (2) transosseous tightening and interference screw fixation. Pain at the area of LET fixation was also assessed. Cohort study; Level of evidence, 3. This was a retrospective 2-center study of patients with first-time revision ACLR and either LET with anchor fixation (aLET) with a 2.4-mm suture anchor or LET with transosseous fixation (tLET). Outcomes at minimum 12-month follow-up were assessed with the International Knee Documentation Committee score, Knee injury and Osteoarthritis Outcome Score, visual analog scale for pain at the LET fixation area, Tegner score, and anterior tibial translation (ATT). A subgroup analysis within the aLET group investigated passing the graft over or under the lateral collateral ligament (LCL). In total, 52 patients were included (26 patients in each group); the mean ± SD follow-up was 13.7 ± 3.4 months. No statistically significant differences were detected between the groups with respect to patient-reported outcome scores, clinical examination, or instrumented testing (side-to-side difference in ATT at 30° of flexion; aLET, 1.5 ± 2.5 mm; tLET, 1.6 ± 1.7 mm). Clinical failure was detected in 1 patient with aLET and none with tLET. Subgroup analysis revealed a small, nonsignificant flexion deficit in knees in which the iliotibial band strand was passed under (n = 42) or over (n = 10) the LCL. No clinically relevant tenderness was detected at the area of LET fixation in any group (aLET, 0.6 ± 1.3; tLET, 0.9 ± 1.7; over the LCL, 0.2 ± 0.6; under the LCL, 0.9 ± 1.6). Onlay anchor fixation and transosseous fixation of the LET were equivalent with respect to outcome scores and instrumented ATT testing. Clinically, there were minor differences in passage of the LET graft over or under the LCL.

Efficacy comparison between a new generation of artificial ligaments and bone-patellar tendon-bone autograft for anterior cruciate ligament revision

Objective: To compare the clinical efficacy of a new generation of ligaments (LARS artificial ligament) and bone-patellar tendon-bone (BPTB) autograft as grafts in anterior cruciate ligament (ACL) revision. Methods: A retrospective cohort study. The clinical data of 54 patients who underwent ACL revision from January 2018 to June 2020 in the First Hospital Affiliated to Army Medical University were retrospectively analyzed. There were 44 males and 10 females with a mean age of (28.5±7.7) years (15-45 years). Among them, 24 cases underwent ACL revision with LARS artificial ligament (LARS group), the other 30 cases underwent ACL revision with BPTB (BPTB group). The subjective and objective knee joint evaluation indexes were compared between the two groups to evaluate the clinical efficacy. The subjective evaluation indexes included Tegner score, Lysholm score and the International Knee Documentation Committee (IKDC) score. The objective evaluation indexes included the Lachman test, pivot-shift test, the anterior tibial translation (ATT) measurement at the weight-bearing position and the rate of patients returned to pre-injury sports. Results: The follow-up period was (32.8±5.3) months (24-42 months). At the last follow-up, the IKDC score, Tegner score and Lysholm score in the two groups significantly increased when compared with those before surgery (all P<0.05), and there was no significant difference in those indexes between the two groups (all P>0.05). The ATT measurement in the weight-bearing position was (3.1±0.7) mm in the LARS group and it was (4.1±0.9) mm in the BPTB group, which were significantly improved when compared with those before surgery (both P<0.05), and it was better in the LARS group than in the BPTB group (P<0.05). Postoperative Lachman test and pivot-shift test results in the LARS group were better than those in the BPTB group with statistically significant difference (both P<0.05). The rate of patients returned to pre-injury sports one year after surgery was 79.2%(19/24) in the LARS group and it was 50.0%(15/30) in the BPTB group, and the difference was statistically significant (P=0.029). Conclusions: Both LARS artificial ligament and BPTB autograft can achieve good short-term clinical efficacy in ACL revision, but LARS artificial ligament group has more advantages than BPTB autograft group in knee stability and early return to sports.

Autograft Demonstrates Superior Outcomes for Revision Anterior Cruciate Ligament Reconstruction When Compared With Allograft: A Systematic Review

Background: Multiple studies have compared outcomes among patients undergoing revision anterior cruciate ligament reconstruction (ACLR) with autograft versus allograft, but these data are inconsistently reported and long-term outcomes depending on graft type are yet to be determined. Purpose: To perform a systematic review of clinical outcomes after revision ACLR (rACLR) with autograft versus allograft. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of the literature was performed by searching PubMed, the Cochrane Library, and Embase to identify studies that compared the outcomes of patients undergoing rACLR with autograft versus allograft. The search phrase used was autograft allograft revision anterior cruciate ligament reconstruction. Graft rerupture rates, return-to-sports rates, anteroposterior laxity, and patient-reported outcome scores (subjective International Knee Documentation Committee, Tegner, Lysholm, and Knee injury and Osteoarthritis Outcome Score) were evaluated. Results: Eleven studies met inclusion criteria, including 3011 patients undergoing rACLR with autograft (mean age, 28.9 years) and 1238 patients undergoing rACLR with allograft (mean age, 28.0 years). Mean follow-up was 57.3 months. The most common autograft and allograft types were bone–patellar tendon–bone grafts. Overall, 6.2% of patients undergoing rACLR experienced graft retear, including 4.7% in the autograft group and 10.2% in the allograft group (P < .0001). Among studies that reported return-to-sports rates, 66.2% of patients with an autograft returned to sports as opposed to 45.3% of patients with an allograft (P = .01). Two studies found significantly greater postoperative knee laxity in the allograft group as compared with the autograft group (P < .05). Among all patient-reported outcomes, 1 study found 1 significant difference between groups: patients with an autograft had a significantly higher postoperative Lysholm score when compared with patients with an allograft. Conclusion: Patients undergoing revision ACLR with an autograft can be expected to experience lower rates of graft retear, higher rates of return to sports, and less postoperative anteroposterior knee laxity when compared with patients undergoing revision ACLR with an allograft.

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

Background: Meniscal and chondral damage is common in the patient undergoing revision anterior cruciate ligament (ACL) reconstruction. Purpose: To determine if meniscal and/or articular cartilage pathology at the time of revision ACL surgery significantly influences a patient’s outcome at 6-year follow-up. Study Design: Cohort study; Level of evidence, 3. Methods: Patients undergoing revision ACL reconstruction were prospectively enrolled between 2006 and 2011. Data collection included baseline demographics, surgical technique, pathology, treatment, and scores from 4 validated patient-reported outcome instruments: International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Marx Activity Rating Scale. Patients were followed up at 6 years and asked to complete the identical set of outcome instruments. Regression analysis assessed the meniscal and articular cartilage pathology risk factors for clinical outcomes 6 years after revision ACL reconstruction. Results: An overall 1234 patients were enrolled (716 males, 58%; median age, 26 years). Surgeons reported the pathology at the time of revision surgery in the medial meniscus (45%), lateral meniscus (36%), medial femoral condyle (43%), lateral femoral condyle (29%), medial tibial plateau (11%), lateral tibial plateau (17%), patella (30%), and trochlea (21%). Six-year follow-up was obtained on 79% of the sample (980/1234). Meniscal pathology and articular cartilage pathology (medial femoral condyle, lateral femoral condyle, lateral tibial plateau, trochlea, and patella) were significant drivers of poorer patient-reported outcomes at 6 years (IKDC, KOOS, WOMAC, and Marx). The most consistent factors driving outcomes were having a medial meniscal excision (either before or at the time of revision surgery) and patellofemoral articular cartilage pathology. Six-year Marx activity levels were negatively affected by having either a repair/excision of the medial meniscus (odds ratio range, 1.45-1.72; P≤ .04) or grade 3-4 patellar chondrosis (odds ratio, 1.72; P = .04). Meniscal pathology occurring before the index revision surgery negatively affected scores on all KOOS subscales except for sports/recreation (P < .05). Articular cartilage pathology significantly impaired all KOOS subscale scores (P < .05). Lower baseline outcome scores, higher body mass index, being a smoker, and incurring subsequent surgery all significantly increased the odds of reporting poorer clinical outcomes at 6 years. Conclusion: Meniscal and chondral pathology at the time of revision ACL reconstruction has continued significant detrimental effects on patient-reported outcomes at 6 years after revision surgery.

Comparison of the Clinical Outcomes of Revision and Primary ACL Reconstruction: A Matched-Pair Analysis With 3-5 Years of Follow-up

Background: There are limited studies designed by matching related factors to compare clinical outcomes and return to sport (RTS) between patients undergoing revision anterior cruciate ligament reconstruction (R-ACLR) and primary ACLR (P-ACLR). Purpose: (1) To compare the outcomes between R-ACLR and P-ACLR in a matched-pair analysis with 3- to 5-year follow-up and (2) to evaluate patient-reported factors for not returning to preinjury-level sport. Study Design: Cohort study; Level of evidence, 4. Methods: Patients who underwent R-ACLR between September 2016 and November 2018 were propensity matched by age, sex, body mass index, passive anterior tibial subluxation, and generalized hypermobility in a 1:1 ratio to patients who underwent P-ACLR during the same period. By combining in person follow-up at 2 years postoperatively and telemedicine interview at the final follow-up (January 2022), knee stability and clinical scores were compared, including International Knee Documentation Committee (IKDC), Lysholm, and Tegner. Status of RTS was requested, specifically whether the patient returned to preinjury level of sport. Patient-reported reasons for not returning were analyzed. Results: There were 63 matched pairs in the present study. Knee stability was similar in terms of KT-2000 arthrometer, Lachman test, and pivot-shift test results between the groups at 2 years of follow-up. At the final follow-up, no significant difference was found between groups for postoperative clinical scores (IKDC, Tegner, and Lysholm) (P > .05). There was a significant difference in total RTS: 53 (84.1%) in the P-ACLR cohort and 41 (65.1%) in the R-ACLR cohort (P = .014). No significant difference was shown in terms of RTS at the same level: 35 (55.6%) in P-ACLR and 31 (49.2%) in R-ACLR (P = .476). Significantly more patients showed fear of reinjury: 26 of 32 (81.3%) in the R-ACLR group as compared with 15 of 28 (53.5%) in the P-ACLR group (P < .021). Conclusion: R-ACLR resulted in similar clinical scores (IKDC, Tegner, and Lysholm) but significantly lower RTS versus P-ACLR at 3 to 5 years of follow-up. Fear of reinjury was the most common factor that caused sport changes in patients with R-ACLR.

The Addition of Either an Anterolateral Ligament Reconstruction or an Iliotibial Band Tenodesis Is Associated With a Lower Failure Rate After Revision Anterior Cruciate Ligament Reconstruction: A Retrospective Comparative Trial

To compare the failure rate in patients who underwent revision anterior cruciate ligament (ACL) reconstruction alone or associated with an extra-articular procedure. Secondary objectives were to compare ACL laxity, patient-reported outcome measures, and complication rates in these patients and, subsequently, to compare the outcomes of patients who underwent revision ACL reconstruction associated with anatomical anterolateral ligament (ALL) reconstruction or lateral extra-articular tenodesis (LET). This was a retrospective comparative study. Patients were classified into 2 groups, according to whether (group 2) or not (group 1) an extra-articular reconstruction was performed. Patients who underwent an extra-articular procedure were further divided into ALL reconstruction (group 2A) and LET (group 2B). Baseline demographic variables, operative data and postoperative data were evaluated. The groups with (86 patients) and without (88 patients) an associated extra-articular reconstruction had similar preoperative data. Group 2 had a lower failure rate (4.6% vs 14.7%; P= .038), better KT-1000, better pivot-shift, and better Lysholm. There was no difference regarding complications, except more lateral pain in group 2. Regarding the groups who underwent ALL reconstruction (41 patients) and LET (46 patients), group 2A showed better Lysholm scores. Both groups had similar failure rates and complications. Patients who underwent revision ACL reconstruction with a laterally based augmentation procedure had a lower failure rate than patients who underwent isolated revision ACL reconstruction. KT-1000 and pivot-shift examination were also significantly better when a lateral augmentation was performed. Complications were similar except for an increase in lateral pain in the augmented group. No clinically important differences were found when comparing the LET group to the ALL group other than a statistical improvement in the Lysholm functional scale, likely not clinically meaningful, favoring the ALL group and an increased duration of post-operative lateral pain in the LET group. III, retrospective comparative therapeutic trial.

Descriptive Characteristics and Outcomes of Patients Undergoing Revision Anterior Cruciate Ligament Reconstruction With and Without Tunnel Bone Grafting

Background: Lytic or malpositioned tunnels may require bone grafting during revision anterior cruciate ligament reconstruction (rACLR) surgery. Patient characteristics and effects of grafting on outcomes after rACLR are not well described. Purpose: To describe preoperative characteristics, intraoperative findings, and 2-year outcomes for patients with rACLR undergoing bone grafting procedures compared with patients with rACLR without grafting. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 1234 patients who underwent rACLR were prospectively enrolled between 2006 and 2011. Baseline revision and 2-year characteristics, surgical technique, pathology, treatment, and patient-reported outcome instruments (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index, and Marx Activity Rating Scale [Marx]) were collected, as well as subsequent surgery information, if applicable. The chi-square and analysis of variance tests were used to compare group characteristics. Results: A total of 159 patients (13%) underwent tunnel grafting—64 (5%) patients underwent 1-stage and 95 (8%) underwent 2-stage grafting. Grafting was isolated to the femur in 31 (2.5%) patients, the tibia in 40 (3%) patients, and combined in 88 patients (7%). Baseline KOOS Quality of Life (QoL) and Marx activity scores were significantly lower in the 2-stage group compared with the no bone grafting group (P≤ .001). Patients who required 2-stage grafting had more previous ACLRs (P < .001) and were less likely to have received a bone–patellar tendon–bone or a soft tissue autograft at primary ACLR procedure (P≤ .021) compared with the no bone grafting group. For current rACLR, patients undergoing either 1-stage or 2-stage bone grafting were more likely to receive a bone–patellar tendon–bone allograft (P≤ .008) and less likely to receive a soft tissue autograft (P≤ .003) compared with the no bone grafting group. At 2-year follow-up of 1052 (85%) patients, we found inferior outcomes in the 2-stage bone grafting group (IKDC score = 68; KOOS QoL score = 44; KOOS Sport/Recreation score = 65; and Marx activity score = 3) compared with the no bone grafting group (IKDC score = 77; KOOS QoL score = 63; KOOS Sport/Recreation score = 75; and Marx activity score = 7) (P≤ .01). The 1-stage bone graft group did not significantly differ compared with the no bone grafting group. Conclusion: Tunnel bone grafting was performed in 13% of our rACLR cohort, with 8% undergoing 2-stage surgery. Patients treated with 2-stage grafting had inferior baseline and 2-year patient-reported outcomes and activity levels compared with patients not undergoing bone grafting. Patients treated with 1-stage grafting had similar baseline and 2-year patient-reported outcomes and activity levels compared with patients not undergoing bone grafting.

Poster 261: Increased TT-TG and Tibial Slope are Independent Predictors of ACLR Failure

Objectives:Tibial tubercle-trochlear groove (TT-TG) distance is a surrogate measure of valgus and rotational stress on the anterior cruciate ligament (ACL) and may predict ACL injury. Increased posterior tibial slope has been associated with risk of ACL re-tear but no studies have evaluated TT-TG as a predictor of ACL re-tear. We hypothesized TT-TG distance and posterior tibial slope would be independent predictors of ACL graft re-tear.Methods:All patients who underwent ACL revision surgery between 2010-2018 at a single institution were identified. A control cohort underwent primary ACL reconstruction (ACLR) between 2006-2015, with no evidence of graft failure at 8.1 ± 2.5 yrs post-op. Record review included anthropometrics, graft type, and estimated highest Tegner activity score at ≥ 6 months post primary ACLR. Magnetic resonance images (MRI) following native ACL tear (controls) or graft failure (revision cohort) were assessed for the following: 1) medial, lateral, and coronal tibial slope, 2) depth of tibial plateau concavity, 3) TT-TG distance, and 4) tunnel position. Logistic regression analyses were used to associate ACL graft failure with radiographic parameters, surgical variables, and demographics. Sensitivity analyses, excluding patients in the revision group with tunnel malposition, were performed to confirm multivariable results.Results:Participants included 153 revisions and 146 controls. Controls were older than revisions (26.6 ± 8.8 yrs vs. 20.6 ± 7.3 yrs). Mean TT-TG distance and lateral tibial slope values were smaller for the control vs. revision group (TT-TG = 9.4 ± 3.9 mm vs. 11.2 ± 4.2 mm; lateral tibial slope = 6.2o ± 3.4° vs. 7.2o ± 3.6°). TT-TG distance and lateral tibial slope were associated with increased risk of ACL graft failure by multivariable analysis (OR: 1.14, CI: 1.07, 1.22, p < 0.001 and OR: 1.11, CI: 1.02, 1.20, p = 0.007, respectively). With sensitivity analyses, age at index surgery, TT-TG distance, and lateral tibial slope remained significant predictors of ACL revision.Conclusions:Increased TT-TG distance, increased lateral tibial slope, and younger age are associated with increased odds of ACL graft failure. These patients may require a more comprehensive strategy to reduce the risk of ACL re-tear.Table 1.Demographic and Clinical Characteristics of Study Population by Revision Status

Integration of polyurethane meniscus scaffold during ACL revision is not reliable at 5years despite favourable clinical outcome.

The aim of this study was to evaluate the clinical outcome at 5-year follow-up of a one-step procedure combining anterior cruciate ligament (ACL) reconstruction and partial meniscus replacement using a polyurethane scaffold for the treatment of symptomatic patients with previously failed ACL reconstruction and partial medial meniscectomy. Moreover, the implanted scaffolds have been evaluated by MRI protocol in terms of morphology, volume, and signal intensity. Twenty patients with symptomatic knee laxity after failed ACL reconstruction and partial medial meniscectomy underwent ACL revision combined with polyurethane-based meniscal scaffold implant. Clinical assessment at 2- and 5-year follow-ups included VAS, Tegner Activity Score, International Knee Documentation Committee (IKDC), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Lysholm Score. MRI evaluation of the scaffold was performed according to the Genovese scale with quantification of the scaffold's volume at 1- and 5-year follow-ups. All scores revealed clinical improvement as compared with the preoperative values at the 2- and 5-year follow-ups. However, a slight, but significant reduction of scores was observed between 2 and 5years. Concerning the MRI assessment, a significant reduction of the scaffold's volume was observed between 1 and 5years. Genovese Morphology classification at 5years included two complete resorptions (Type 3) and all the remaining patients had irregular morphology (Type 2). With regard to the Genovese Signal at the 5-year follow-up, three were classified as markedly hyperintense (Type 1), 15 as slightly hyperintense (Type 2), and two as isointense (Type 1). Simultaneous ACL reconstruction and partial meniscus replacement using a polyurethane scaffold provides favourable clinical outcomes in the treatment of symptomatic patients with previously failed ACL reconstruction and partial medial meniscectomy at 5years. However, MRI evaluation suggests that integration of the scaffold is not consistent. Level IV.

Adolescents Have Twice the Revision Rate of Young Adults After ACL Reconstruction With Hamstring Tendon Autograft: A Study From the Swedish National Knee Ligament Registry.

Background:Previous studies have identified young age as a risk factor for anterior cruciate ligament (ACL) revision. However, few studies have looked separately at pediatric patients and adolescents with regard to outcomes after ACL reconstruction.Purpose:To determine whether patient age at ACL reconstruction affects the risk of undergoing revision surgery in young patients.Study Design:Cohort study; Level of evidence, 3.Methods:This study was based on data from the Swedish National Knee Ligament Registry. Patients aged 5 to 35 years who underwent a primary ACL reconstruction with a hamstring tendon autograft between January 1, 2005, and December 31, 2015, were included. The cohort was stratified into different age groups of pediatric patients, adolescents, and young adults to estimate patients with open, recently closed, and closed epiphyses, respectively. The primary endpoint was ACL revision. A multivariable Cox regression model was used to assess the ACL revision rate. The results were expressed as hazard ratios (HRs) and 95% CIs.Results:A total of 36,274 ACL reconstructions were registered during the study period. Of these, 2848 patients were included in the study: 47 pediatric patients (mean age, 13.6 years; range, 9-15 years), 522 adolescents (mean age, 17.4; range, 14-19 years), and 2279 young adults (mean age, 27.0; range, 20-35 years). A total of 31 patients (1.1%) underwent ACL revision within 2 years (0 pediatric patients, 9 adolescents [1.7%], and 22 young adults [1.0%]) and a total of 53 patients (2.6%) underwent ACL revision within 5 years (2 pediatric patients [6.9%], 15 adolescents [3.9%], and 36 young adults [2.2%]). The adolescent age group had a 1.91 times higher rate of ACL revision compared with the young adults (HR = 1.91 [95% CI, 1.13-3.21]; P = .015). There were no differences in revision rates between the pediatric age group and the young adults (HR = 2.93 [95% CI, 0.88-9.79]; P = .081).Conclusion:Adolescents had almost twice the rate of revision ACL reconstruction compared with young adults.

Anterior Cruciate Ligament Reconstruction and Lateral Plasty in High-Risk Young Adolescents: Revisions, Subjective Evaluation, and the Role of Surgical Timing on Meniscal Preservation.

In adolescents, the rate of meniscal injury at the time of anterior cruciate ligament (ACL) reconstruction, the rate of ACL graft revision, and clinical outcomes has not yet been investigated. In patients younger than 16 years, the rate of meniscal injuries at the time of ACL reconstruction increases with time from injury. The mid-term revision rate and reoperation rate after ACL reconstruction with hamstrings and lateral tenodesis are lower than those reported in literature for isolate ACL reconstruction. Case series. Level 4. Patients younger than 16 years who underwent ACL reconstruction with hamstring and lateral tenodesis, with a follow-up ≥2 years were included. The number of meniscal lesions was stratified according to the delay between injury-to-surgery (<3, 3-12, >12 months). All reoperations, Lysholm score, Knee Injury and Osteoarthritis Outcome Score subscales for pain (at rest and during activity), and return to sport were collected. A total of 151 patients (mean age 14.8 ± 1.2 years) were included. Patients undergoing surgery at <3 months after injury had a lower meniscal injury rate (36%) than those treated at 3 to 12 months (55%) and >12 months (63%) after injury (P = 0.04). Medial meniscal lesions were more likely to be repaired when surgery was performed <3 months after injury (91%). Subjective follow-up data were available for 132 patients, and 19 were lost to follow-up. At 6.0 ± 2.6 years, 6% of patients underwent ACL revision; 1 of 20 (5%) patients with posterior tibial slope ≥12° and 4 of 45 (9%) patients with Tegner level ≥8. Nine new meniscal procedures were performed; 19% of repaired menisci underwent meniscectomy. Good or excellent Lysholm score was reported by 88% of patients; 56% of patients with concurrent lateral meniscectomy had pain during activity, 91% returned to sport, and 79% were still participating at final follow-up. Patients younger than 16 years undergoing ACL reconstruction within 3 months from injury had the lowest rate of meniscal injuries. ACL reconstruction with lateral tenodesis had low revision rate (6%) and good or excellent clinical outcomes in 88% of young adolescents. Sport physicians should be aware that adolescent patients undergoing ACL reconstruction within 3 months after injury have the lowest rate of meniscal injuries; the mid-term revision rate of ACL reconstruction with lateral plasty is lower than 10% and the patients' perceived outcomes are good with almost all patients returning to sport activity.