Elsevier

Clinics in Sports Medicine

Volume 18, Issue 1, 1 January 1999, Pages 109-171
Clinics in Sports Medicine

REVISION ANTERIOR CRUCIATE LIGAMENT SURGERY

https://doi.org/10.1016/S0278-5919(05)70133-2Get rights and content

The importance of the anterior cruciate ligament (ACL) to the maintenance of normal knee function is now well accepted.94 An untreated ACL tear can lead to recurrent giving-way episodes, damage to the menisci and articular cartilage, with progression to osteoarthritis in some patients.9, 38, 41, 42, 91, 94, 106, 141 The poor long-term results of nonoperative treatment, primary repair, and extra-articular reconstruction have led to intra-articular ACL reconstruction becoming the surgical procedure of choice for an athletically active patient with a functionally unstable knee.* Reconstruction of the ACL is one of the most commonly performed orthopedic operations. According to the National Center of Health Statistics, in 1991 approximately 63,000 ACL reconstructions were performed in the United States. By current industry estimates, over 100,000 ACL reconstructions are performed annually in the United States.

The success rate of primary ACL reconstruction has been reported to range from 75% to 93%, good or excellent results with respect to relief of giving-way symptoms, restoration of functional stability, and return to normal or near normal activity levels Given the reported success rates, a significant number of patients who undergo ACL reconstruction may have a less than satisfactory outcome. What qualifies as a unsatisfactory result or “failure” after ACL reconstruction, however, has not been well defined or agreed on. Johnson and Fu69 have defined a failed ACL reconstruction as a knee that demonstrates recurrent pathologic laxity that was present prior to surgery, or a stable knee that has a range of motion from 10 to 120 degrees of flexion that is stiff and painful even with activities of daily living. Although graft failure is the most common cause of failed ACL surgery, it is important to keep in mind that non–graft-related conditions may also result in persistent complaints and an unsatisfactory outcome. Failed ACL surgery can be classified into one of the following four categories with the potential for overlap among the categories in some cases69:

  • 1

    Loss of motion or arthrofibrosis

  • 2

    Extensor mechanism dysfunction

  • 3

    Arthritis

  • 4

    Recurrent patholaxity (graft failure)

It is important to characterize and categorize properly the residual complaints following the original ACL reconstruction in order to prevent a second ligament operation directed at improving anterior laxity of the knee from being performed, only to result in the patient continuing to experience the original non–graft-related complaints.

Given today's emphasis on maintaining fitness and the participation of all age groups in physical activities that place the ACL at risk for injury, the number of primary ACL reconstructions performed can be expected to continue to increase. Although surgical and rehabilitation advancements have improved the success rate of primary ACL reconstruction, the increasing number of primary reconstructions being performed can be expected to lead to an increasing number of patients with the potential need for revision ACL surgery.44, 47, 59, 60, 120, 132, 134, 136

In general, the results of revision ACL reconstruction do not appear to be as favorable as those of primary reconstructions.* The success rate of revision ACL reconstruction is determined by many factors including the origin of the primary failure, the preoperative laxity of the knee, the status of the secondary restraints, menisci and articular cartilage, and patient motivation and compliance. In order to maximize the success of revision ACL surgery, a methodic and organized approach is required. This article reviews the etiology of failed ACL surgery, discusses preoperative evaluation and planning, and reviews some of the technical considerations of revision ACL surgery.

Section snippets

Loss of Motion

Loss of motion is one of the most common complications following knee ligament surgery.‡ The incidence of loss of motion following ACL surgery has been reported to range from 5.5% to 24%.52, 64, 122 The large variation in the reported incidence reflects differences in the criteria used to define the problem, differences between studies in the timing of surgery, and differences in surgical technique and postoperative rehabilitation. Delaying

Errors in Surgical Technique

Errors in surgical technique are the most frequent cause of graft failure.68, 69, 70, 72, 126, 151, 155, 157, 158 Nonanatomic graft placement is the most common surgical error responsible for failure of the primary ACL graft. * An improperly positioned femoral or tibial tunnel results in excessive length changes of the ACL graft as the knee moves through a range of motion.44, 47, 55, 94, 138 Because biologic ACL grafts can

PREOPERATIVE EVALUATION

Preoperative evaluation is one of the most important aspects of revision ACL surgery. First and foremost, it must be determined if the previous surgery has truly failed. Because of the different categories of failure and overlap between them, determining whether the patient's residual complaints are primarily caused by graft failure can at times be very difficult. Current indications for revision ACL surgery include instability with activities of daily living or athletic activities, and the

PREOPERATIVE PLANNING

Once the preoperative evaluation has been completed, the surgeon should have determined the origins of the primary failure and determined whether the patient is a candidate for revision ligament surgery. Patient compliance and motivation are important factors that are critical to the success of revision ACL surgery. If revision ACL surgery is recommended, the patient must be given a realistic expectation of the expected outcome, and not be promised too much. In general, the results of revision

Skin Incisions

Careful planning of skin incisions around the knee is needed to avoid wound healing problems. Meticulous surgical technique and handling of the soft tissues is critical. In general, previous incisions should be used or extended if they allow simultaneous hardware removal, graft harvest, and proper placement and fixation of the new graft.

Old vertical incisions can be extended proximally or distally to harvest either a patellar tendon or hamstring tendon graft for the revision procedure (Fig. 16)

SUMMARY

An increasing number of revision ACL reconstructions are being performed each year. Revision ACL surgery is challenging and cannot be approached in the same manner as primary ACL surgery. Successful revision ACL surgery requires a detailed history, a comprehensive physical examination, appropriate radiologic studies, and careful preoperative planning. The results of revision ACL surgery do not equal the results of primary ACL surgery, and this should be explained to the patient prior to surgery.

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      The authors noted further incorporation at 24 weeks and suggested that autogenous grafts increased bone formation in the tunnels. They performed a 2-stage revision for tibial tunnels with an aperture greater than 20 mm, taking into consideration that a bone tunnel of 15 mm diameter with 45° of inclination resulted in a tibial tunnel aperture of >20 mm.31 We compared our findings with the previously published study, since the prior study used a similar graft diameter.

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    Address reprint requests to Charles H. Brown, Jr, MD, Brigham and Women's Hospital, Department of Orthopaedic Surgery, 75 Francis Street, Boston, MA 02115

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