Revision ACL Surgery

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Charles H. Brown Jr.,M.D,

Director International Knee & Joint Centre Abu Dhabi, United Arab Emirates

Revision

ACL

Surgery

Introduction

 Incidence of ACL reconstruction in an active population reported to be 30 per 100,000  Estimated that there are around 300,000 ACL reconstructions performed per year in the

USA

 Reported success rate of primary ACL reconstruction: 75 ‐ 97%

 Therefore, a significant number of patients who undergo ACL reconstruction may have a less than satisfactory outcome Categories of Failure There is no strict or universally accepted definition of failure after ACL reconstruction. Patient dissatisfaction following primary ACL reconstruction can be divided into 3 general catagories: recurrent instability (graft failure), postoperative complications (infection, loss of motion, patella fracture), and comorbidities related to concomitant pathologic abnormalities (lower extremity malalignment, extensor mechanism dysfunction, donor site pain, meniscus loss, arthritis). Complications Comorbidites Instability

Patient dissatisfaction after ACL reconstruction Patient dissatisfaction after ACL reconstruction Patient dissatisfaction after ACL reconstruction

Although graft failure is the most common cause for failed ACL surgery, it is important to remember that other non‐graft related problems can lead to an unsatisfactory outcome after ACL surgery.  Loss of motion Non‐anatomic graft placement Impingement Infection

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Capsulitis Cyclops lesion Concomitant ligament surgery Immobilization  Extensor mechanism dysfunction Anterior knee pain Donor site pain Quadriceps muscle weakness Patellar tendinitis Patellar fracture Patellar tendon rupture  Degenerative Arthritis Initial traumatic event (bone bruise) Meniscectomy Damage secondary to recurrent giving way

Etiology of ACL Graft Failure

The etiology of ACL graft failure is varied and often more than one cause exists. In general, the etiology of ACL graft failure can be dividing into 3 categories: (1) surgical technique, (2) trauma, (3) poor graft incorporation and healing(failure of ACL graft to undergo the ligamentization process), and arthrofibrosis and rehabilitation. Early failures (< 3 months) are usually related to loss of fixation and infection. Mid‐term failures (3 – 12 months) are often due to errors in surgical technique, aggressive physical therapy and unrecognized loss of secondary restraints. Late failures (> 12 months) are usually related to trauma. Surgical Technique Trauma Poor graft incorporation and healing Arthrofibrosis and rehabilitation

University of Pittsburgh Classification

Etiology of ACL Graft Failure

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 Etiology of ACL graft failure in published revision studies 0 10 20 30 40 50 60 70 80 90 100

Technical Errors Traumatic Cases Biological Causes Unknown/Other

Noyes and Barber-Westin (2001) O’Neill (2004) Carson (2004)

Grossman (2005) Ferretti (2006) Garafalo (2006)

Salmon (2006) Ahn (2008) Denti (2008)

Diamantopoulos (2008) MARS Group (2010) Trojani (2011)

Danish ACL Registry (2012)

49 49 42 42 68 68 48 48₄₇₄₇ 79 79 22 22 66 66 52 52 64 64 24 24 50 50 29 29 44 44 79 79 24 24 34 34 47 47 21 21 58 58 18 18 35 35 24 24 32 32 30 30 38 38 0 000 8 8 17 17 7 7 0 0 11 11 16 16 3 344 7744 2 2 24 24 15 15 3 3 16 16 0 00000000000000000

Etiology of ACL Graft Failure

 Technical errors in published revision studies 0 10 20 30 40 50 60 70 80 90 100 Nonanatomic Tunnel Placement Associated laxity/Malalignment

Inadequate graft Fixation failure Other

Noyes and Barber-Westin (2001) O’Neill (2004) Carson (2004)

Ferretti (2006) Garafalo (2006) Salmon (2006)

Ahn (2008) Diamantopoulos (2008) MARS Group (2010)

Trojani (2011) Danish ACL Registry (2012)

Technical Errors in ACL Surgery

100 78 77 71 100 9193 96 58 68 90 63 0 0 0 7 0 0 0 0 0 13 29 4 7 7 10 5 8 5 9 7 7 17 0 0 0 0 0 0 0 0 0 0 0 0 0 5 00 0

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Nonanatomic tunnel placement

Nonanatomic

Graft Placement

Failed ACL Reconstruction

Excessive graft Excessive graft length changes length changes Rotational Rotational Instability Instability Loss of Loss of motion motion Graft Graft Impingement Impingement

Technical Errors in ACL Surgery

Failure to address associated ligamentous laxity or secondary restraints at the time of the primary reconstruction Graft impingement Inadequate strength of the primary ACL graft 1. hamstring tendon grafts < 8 mm 2. irradiated allografts Graft tension 1. undertensioning = patholaxity 2. overtensioning = overconstraint of the joint Lower extremity malalignment  Trauma Early failure before graft incorporation and completion of rehabilitation (< 6 months) 1. Overaggressive rehabilitation 2. Premature return to athletics Late failure after resumption of full activities (> 6 months) 1. Inadequate rehabilitation 2. Significant reinjury 5 – 7%  Biological failure (failure of the ACL graft to complete the ligamentization process, resulting in a atonic, disorganized, nonviable ACL graft). Biological failure of the ACL graft should be

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suspected in patients who present with symptoms of recurrent instability without a history of trauma and no identifiable error in surgical technique or abnormal biomechanical factors.

Preoperative Evaluation

 Must first determine if the cause of the patient's complaints are truly due to a failed ACL graft

 Patient dissatisfaction following primary ACL reconstruction generally falls into the following categories: Recurrent instability Postoperative complications Preexisting comorbidities  Indications for revision ACL surgery

The primary goal of a revision ACL reconstruction is to reconstruct a ruptured or incompetent ACL graft with the goal to stabilize the knee and prevent further meniscal and articular cartilage injuries, while simultaneously maximizing the patient’s function and activity level  History Cause of primary injury History of reinjuries Symptoms (pain vs instability) Primary graft type Operative technique (one‐incision vs two incision) Type of graft fixation Postoperative rehabilitation program used Ability and time patient returned to preinjury level  Physical examination Lower extremity alignment Gait (varus thrust, hyperextension) Range of motion Extensor mechanism 1. Donor site pain 2. Patellofemoral pain 3. Patellar tendinitis 4. Infrapatellar contracture

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Ligament examination (important to check for associated ligamentous laxity)

Previous incisions

 Radiographic examination. Preoperative imaging should be assessed for 3 major issues regarding the primary ACL reconstruction: (1) the presence of hardware that will interfere with the revision procedure, (2) tunnel position, and (3) tunnel expansion.

AP view (femoral tunnel angle)

True lateral view in maximum hyperextension (tibial tunnel placement) Merchant’s view both knee

Standing AP and PA 45 flexion views AP view both knees (joint space narrowing Standing long films of both lower extremities (lower extremity alignment) CT scan (bone tunnel placement, tunnel enlargement) MRI scan (evaluation of the ACL graft, articular cartilage, collateral ligaments) CT scan (helpful to evaluate bone tunnel enlargement) Bone scan (OA, infection) Preoperative Planning  Patient must be given realistic expectation of the outcome of revision surgery  Revision surgery favorable in terms of restoring stability  Revision surgery unpredictable in terms of returning patient to preinjury activity levels  Revision surgery cannot relieve pain secondary to extensor mechanism dysfunction or pain secondary to articular cartilage injury  Success of revision surgery influenced by: 1. Etiology of the primary failure 2. Preoperative laxity of the knee (secondary restraints) 3. Status of the menisci, articular cartilage, and secondary restraints  Important preoperative factors: 1. Range of motion 2. Placement of previous incisions 3. Type of graft used in the primary reconstruction 4. Type and location of fixation hardware 5. Size and location of bone tunnels 6. Presence of associated ligamentous laxities  Staged procedure performed when there is: 1. Loss of motion (must address loss of motion prior to revision surgery) 2. Bone tunnel enlargement (bone grafting)

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3. Potential for overlapping bone tunnels (bone grafting) Graft selection Controversial!Autograft tissue has a higher success rate but has the issue of donor site morbidity. In cases of tunnel enlargement, it is often desirable to use a replacement graft with a large cross‐ sectional area (quadriceps tendon autograft) as this allows the bone tunnels to be filled. Allograft tissue has the advantages of unlimited tissue and bone block size. However, allograft tissue has the associated risks of disease transmission, possible alteration of initial tensile properties due to the effects of secondary sterilization, and a higher failure rate.

•Limited soft tissue and bone block size

•Better objective stability results and lower failure rate compared to allografts

•Greater surgical exposure required

•No risks of disease transmission

•Donor site morbidity

• No added costs

•Autograft tissue may not be available

• Faster and more complete biological incorporation

Disadvantages Advantages

What Graft for Revision ACL Surgery: Autografts What Graft for Revision ACL Surgery:

What Graft for Revision ACL Surgery: AutograftsAutografts

• Inferior objective results and higher failure rate compared to autografts

•Decreased operative time (no autograft harvest required)

•Risk of disease transmission

• No donor site morbidity

•Slower graft incorporation

•No limitation of soft tissue or bone block size

•Cost

•Wide variety of tissue options

Disadvantages Advantages

What Graft for Revision ACL Surgery: Allografts What Graft for Revision ACL Surgery:

What Graft for Revision ACL Surgery: AllograftsAllografts

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Technical considerations in ACL revision surgery

 Use a skin incision that will allow simultaneous graft harvest, drilling of the tibial tunnel and tibial graft fixation  Hardware removal, don't underestimate have appropriate instrumentation available  Leave secure hardware in place if it does not interfere with drilling new bone tunnels  Bone tunnels most technically challenging part of the procedure Overlap Overlap Anatomic

Anatomic NonanatomicNonanatomic

ACL graft with a

large bone block

or bone graft or bone graft tunnel tunnel New anatomic New anatomic bone tunnel bone tunnel

Bone Tunnel Placement

No Overlap

Non

Non--ExpandedExpanded

Expanded

Preoperative Bone Tunnel Assessment

Bone graft tunnel

Use existing Use existing bone tunnel bone tunnel

 Graft fixation (the surgeon must be knowledgeable and proficient with all fixation options for bone and soft tissue grafts)  Associated surgical procedures: 1.Posterolateral reconstruction 2.MCL/POL reconstruction 3.Meniscal repair/replacement (MM allograft can help restore AP translation) 4.Articular cartilage surgery 5.Osteotomy (malalignment)

Role of extra‐articular reconstruction

 Extra‐articular reconstruction has a longer lever arm which is more effective at controlling tibial rotation

 Extra‐articular reconstruction has been shown to reduce the forces on an intra‐articular ACL graft

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 Extra‐articular reconstruction has been shown to lower the failure rate and increase the percentage of patients with a negative pivot shift test

Rehabilitation

 Avoid accelerated rehabilitation

 Rehab program dictated by graft size/length, bone quality, and type of fixation and associated surgery

 Soft tissue grafts with suspensory fixation require more and longer postoperative protection

 Minimum 9 month return to sports

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References

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