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PEARLS & PITFALLS – SURGICAL TECHNIQUE
Tips in ACL Revision Surgery
Gonzalo Samitier, MD, PhD, FEBOT1
Eduard Alentorn-Geli, MD, MSc, PhD, FEBOT 2 Ramon Cugat, MD, PhD 3
Kevin W. Farmer, MD 4
Alejandro I. Marcano, MD 4
Michael W. Moser, MD 4
1 Sports Medicine and Shoulder Division. Hospital General de Villalba (Comunidad de Madrid–SPAIN). Grupo Idcsalud
2 Sports Medicine Division, Duke University Medical Center, Durham, NC, USA
3 Orthopaedic Surgery Department, Hospital Quirón Barcelona. García-Cugat Foundation, Barcelona, SPAIN
4 Sports Medicine Division, Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
INTRODUCTION
Anterior Cruciate Ligament (ACL) rupture is one of the most common orthopaedic surgical conditions in active population; ACL reconstruction has satisfactory outcomes in 75% to 97% of patients, however, with the number of primary procedures increasing each year, the absolute number of graft failures after ACL repair is also rising and so revision surgeries. In a very recent study using two large US databases, the incidence rate of ACL rupture rose from 32.9 per 100,000 person-years in 1994 to 43.5 per 100,000 person-years in 2006, particularly in females as well as those younger than 20 years and those 40 years or older.
No universally accepted definition for failure of an ACL reconstruction exists; objectively Hofbauer et al. recently redefined it as a deficit of 10° of knee extension or 10° of knee flexion compared with the contralateral, uninjured side and / or demonstration of knee instability as assessed by the Lachman test (>= 2), pivot-shift test (>= 2), or arthrometer (>3 mm side-to-side difference).
In this article we would like to review the multifactorial causes of ACL surgery failure, focusing on preventing and solving such situations, particularly those due to primary graft insufficiency or rupture and recurrent instability.
1. KNOWING WHAT FAILED
Patient Evaluation
A meticulous evaluation of the patient will help us to better understand the cause of primary failure as well as to plan ahead the revision surgery if needed. Most of the factors that should be considered during the initial approach to a patient with ACL graft failure are shown in Table 1. Laboratory tests are not included in our table but may be also helpful in some cases to detect infectious or inflammatory processes.
Table 1. Relevant History Data for Preoperative Planning.
Primary Procedure
Injury: date, mechanism of injury, symptoms
Surgery: date, surgical technique, graft choice, fixation methods, associated injuries, other surgical procedures
Postoperative: complications, rehabilitation, return to sports
Recurrence: date, mechanism of injury, signs and symptoms (instability/pain/stiffness/knee effusion)
Physical Exam
Inspection: scars, swelling, muscle atrophy, lower limb alignment, gait
Palpation: temperature, knee effusion, trigger points, catching, locking, crepitation
Function: range of motion, knee strength
Special tests: anteroposterior stability (Lachman test, anterior- posterior drawer), rotational stability (pivot shift sign test, dial test), and mediolateral stability (valgus-varus test), meniscal tests
Imaging Studies
Plain radiographs (standing anteroposterior view, lateral view at 30o of knee flexion, axial view at 45o of knee flexion [Merchant’s view], standing posteroanterior view at 45o of knee flexion [Fick’s view], with Long leg weightbearing , functional radiographs): assess lower limb alignment, position of tunnels, tunnel widening, fixation methods, degree of knee osteoarthritis and associated instabilities
MRI: assess knee effusion, graft preservation, tunnel preservation, cartilage damage, and meniscal injuries
Bone scintigraphy Tc99: degree of knee arthropathy, complex regional pain syndrome, infection
CT and 3-D CT scan: bone abnormalities, previous tunnels size and exact assessment of the previous tunnel location.
Technical Considerations
Graft choice: autograft vs allograft, soft tissue vs bone-tendon grafts, ipsilateral versus contralateral graft
Surgical technique: non-anatomic transtibial vs anatomic, single- bundle vs double-bundle, all-in side vs outside-in,
Removal of hardware: fluoroscopy, universal set of instruments
Other procedures: high tibial osteotomy, treatment of cartilage, meniscectomy vs meniscal repair, meniscal transplant, associated ligament injuries reconstruction
12 ISAKOS NEWSLETTER 2015: Volume I