Anterior cruciate ligament (ACL) graft failure from rupture, attenuation, or malposition may cause recurrent subjective instability and objective laxity, and occurs in 3% to 22% of ACL reconstruction (ACLr) procedures. Revision ACLr is often indicated to restore knee stability, improve knee function, and facilitate return to cutting and pivoting activities. Prior to reconstruction, a thorough clinical and diagnostic evaluation is required to identify factors that may have predisposed an individual to recurrent ACL injury, appreciate concurrent intra-articular pathology, and select the optimal graft for revision reconstruction. Single-stage revision can be successful, although a staged approach may be used when optimal tunnel placement is not possible due to the position and/or widening of previous tunnels. Revision ACLr often involves concomitant procedures such as meniscal/chondral treatment, lateral extra-articular augmentation, and/or osteotomy. Although revision ACLr reliably restores knee stability and function, clinical outcomes and reoperation rates are worse than for primary ACLr.

Cite this article: Bone Joint J 2023;105-B(5):474–480.

Aims

Orthopaedic surgery requires grafts with sufficient mechanical strength. For this purpose, decellularized tissue is an available option that lacks the complications of autologous tissue. However, it is not widely used in orthopaedic surgeries. This study investigated clinical trials of the use of decellularized tissue grafts in orthopaedic surgery.

Bone-patellar tendon-bone autografts, hamstring autografts or allografts are widely used grafts for ACL revision surgeries. Also use of quadriceps autograft for both primary and revision ACL surgeries is in an increasing popularity due to its biomechanical superior properties and less donor site morbidity. However, although several fixation techniques and devices for quadriceps tendon graft fixation on femoral side have been reported, literature lacks about biomechanical studies comparing properties of these different fixation techniques and devices. We aimed to investigate whether there is a difference between the fixation techniques of quadriceps tendon graft by using different fixation techniques and devices on the femoral side in terms of stiffness and amount of slippage in the tunnel. Full-thickness central parts of quadriceps tendons from paired knees of twenty five calf knees were fixed through a 10mm x 25mm tunnel in twenty five paired sheep femurs. Quadriceps tendon patellar side with soft tissue ending fixed with four different fixation devices (adjustable suspensory system (group 1), absorbable interference screw (group 2), titanium interference screw (group 3) and adjustable suspensory system + absorbable interference screw (group 4)) and quadriceps tendon with a patellar bone plug fixed with a titanium interference screw (group 5) were tested in a servohydraulic materials testing machine. 10 samples were included in each group. After applying a preload of 10 N, a cyclic force was applied for 20 cycles from 10N to 110N at a 1 hertz frequency. Amount of slippage in the tunnel was calculated as the difference measured in millimeters between length at 10 N after 20 cycles and starting length at 10 N (Graph 1). To determine the stiffness, a single load-to-failure cycle was performed at a strain rate of 20 mm/min as the last step (Figure 1). Rupture of the graft was not seen in any of the samples. Median values of amount of slippage in the tunnel were 6,41mm, 5,99mm, 3,01mm, 4,83mm, and 3,94mm respectively. Median values of maximum load at failure were 464N, 160N, 350N, 350N and 389N respectively. Amount of slippage in the tunnel was highest in the group 1 and was lowest in the group 3 (p<0.001). Group 1 was found to be most resistant group against load-to-failure test and group 2 was the weakest (p<0.001). However inter-group analyses between group 3 and 5 revealed that, although group 3 had the least slippage in the tunnel, group 5 was better in terms of stiffness, but there was no statistically significant difference (p=0,124 and 0,119 respectively). There was a significant difference between group 2 and 3 in both amount of slippage in the tunnel and stiffness (p=0,001 and 0.028 respectively)(Table 1). Our study revealed that, although quadriceps graft with a bone plug fixed with metal interference screws is widely presumed to be a stable fixation technique, there was no significant difference in terms of stiffness when compared with quadriceps graft with soft tissue ending fixed with a metal interference screw. Although adjustable suspensory device group was the best in the terms of resistance against load-to-failure, it was the worst in terms of amount of slippage from the tunnel. Thus, if a suspensory device is to be used, it must be kept in mind that a strong 20 cycles of intra-operative tension force must be applied to prevent further slippage of the graft in the tunnel which can result in failure of reconstruction. For any figures or tables, please contact the authors directly

Aims

Although knee osteoarthritis (OA) is diagnosed and monitored radiologically, actual full-thickness cartilage loss (FTCL) has rarely been correlated with radiological classification. This study aims to analyze which classification system correlates best with FTCL and to assess their reliability.

Aims

Anterior cruciate ligament (ACL) surgery in children and the adolescent population has increased steadily over recent years. We used a national database to look at trends in ACL reconstruction and rates of serious complications, growth disturbance, and revision surgery, over 20 years.

Aims

To investigate the risk factors for progression of articular cartilage damage after anatomical anterior cruciate ligament (ACL) reconstruction.

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Our aim was to perform a meta-analysis of the outcomes of revision anterior cruciate ligament (ACL) reconstruction, comparing the use of different types of graft.

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The aim of this study was to investigate the long-term clinical and radiological outcome of patients who suffer recurrent injuries to the anterior cruciate ligament (ACL) after reconstruction and require revision surgery.

Aims. To examine the rates of hamstring graft salvage with arthroscopic debridement of infected anterior cruciate ligament (ACL) reconstruction as reported in the literature and discuss functional outcomes. Materials and Methods. A search was performed without language restriction on PubMed, EMBASE, Ovid, CINAHL and Cochrane Register of Controlled Trials (CENTRAL) databases from their inception to April 2015. We identified 147 infected hamstring grafts across 16 included studies. Meta-analysis was performed using a random-effects model to estimate the overall graft salvage rate, incorporating two different definitions of graft salvage. Results. The graft salvage rate was 86% (95% confidence intervals (CI) 73% to 93%; heterogeneity: tau. 2. = 1.047, I. 2. = 40.51%, Q = 25.2, df = 15, p < 0.001), excluding ACL re-ruptures. Including re-ruptures as failures, the graft salvage rate was 85% (95% CI 76% to 91%; heterogeneity: tau. 2.  = 0.099, I. 2. = 8.15%, Q = 14.15, df = 13, p = 0.36). Conclusions. Arthroscopic debridement combined with antibiotic treatment can lead to successful eradication of infection and graft salvage, with satisfactory functional outcomes in many cases of septic arthritis following ACL reconstruction. Persistent infection despite repeat arthroscopic debridements requires graft removal with the intention of revision ACL surgery at a later stage. Take home message: Arthroscopic debridement combined with antibiotic therapy is an appropriate initial approach in most cases of septic arthritis following ACL reconstruction, achieving graft salvage rates of about 85%. Cite this article: Bone Joint J 2016;98-B:608–15

The use of platelet-rich plasma (PRP) as an adjuvant to tissue repair is gaining favour in orthopaedic surgery. Tunnel widening after anterior cruciate ligament (ACL) reconstruction is a recognised phenomenon that could compromise revision surgery. The purpose of this study was to determine whether PRP might prevent tunnel widening in ACL reconstruction.

Patients undergoing ACL reconstruction using a hamstring graft were randomly allocated either to have PRP introduced into the tunnels peri-operatively or not. CT scanning of the knees was carried out on the day after surgery and at three months post-operatively and the width of the tunnels was measured. Patients were also evaluated clinically at three months, when laxity was also measured.

Each group comprised 25 patients, and at three months post-operatively all were pain-free with stable knees, a negative Lachman test and a good range of movement. Arthrometric results had improved significantly in both groups (p < 0.001). Despite slightly less tunnel widening in the PRP group, there was no significant difference between the groups at the femoral opening or the mid-tunnel (p = 0.370 and p = 0.363, respectively) nor at the tibial opening or mid-tunnel (p = 0.333 and p = 0.177, respectively).

We conclude that PRP has no significant effect in preventing tunnel widening after ACL reconstruction.

Cite this article: Bone Joint J 2013;95-B:65–9.

Introduction. Numerous types of graft can be used for revision of anterior cruciate ligament (ACL) reconstruction. The goal of our studies was to analyze mid term outcomes of revision of anterior cruciate ligament reconstructions conducted by means of ipsilateral bone -patellar tendon -bone (B-PT-B) transplant. Materials and methods. We conducted a retrospective study on a consecutive series of 44 patients. All patients were operated on by the same senior surgeon in our institution between 2003 and 2009. All patients had undergone a first ACL reconstruction with B-PT-B transplant. They all had ACL revision under arthroscopic assistance and by means of ipsilateral B-PT-B transplant after a minimum of 18 months after primary surgery. At time of ACL revision, the mean patients age was 28 years (range, 17–49 years). The average postoperative follow up after revision was 55 months (range, 12–88 months). We had no patient lost to follow up. All patients were evaluated by an independent observer using IKDC scoring system and KT 2000. Results. The postoperative IKDC score averaged 78.2 (range, 41,4–97,7). 10 patients (22.7%) had their knee graded A, 25 patients (56.8%) grade B, 8 patients (18.2%) grade C and one patient (2.3%) grade D. The post operative maxi manual differential KT 2000 averaged 1,52 mm (range, −1mm/12mm). The identified aetiologies for poor clinical outcomes were menisectomy in the first ACL reconstruction (p<0.01) and articular cartilage lesions (ICRS grade III and IV) found during ACL revision. In most cases, return to sport activities was achieved but not at the same level. We had no specific complication after second harvesting of the patellar tendon. Discussion. The type of graft used in revision of ACL reconstructions is a controversy. In the literature, many studies reported the results of revision of ACL reconstructions but with poor methodology and few data for every type of graft. In our study, we found clinical results comparable to those classically reported in the literature. Clinical evaluation showed good control of the laxity and no specific patellar tendon complication. Conclusion. The clinical results of revision of ACL reconstructions is lower than in primary surgery. We did not noticed specific patellar tendon complication after second harvesting of BPTB transplant. The revision of ACL reconstruction with ipsilateral BPTB transplant showed good clinical results and good control of the anteroposterior laxity

Introduction. Multiple ACL revisions represent an extremely demanding surgery, due to the presence of enlarged or malpositioned tunnels, hardware, injuries to the secondary stabilizers and difficulties in retrieving autologous tendons. An anatomical ACL reconstruction is not always possible. We analyzed the results in a series of patients operated with over the top reconstruction (OTTR) and lateral extra-articular plasty to the Gerdy's tubercle (LP) using Achilles (AT) or tibialis posterior tendon (TPT) allografts. Methods. From 2002 to 2008, twenty-four male athletes with a mean age of 30.8 years were operated. 20 of the patients had two, while four patients had three previous reconstructions. IKDC score and KT evaluation were used at a mean 3.3 years follow-up (2–7 years). Results. The mean IKDC subjective score at follow-up was 81.3. The IKDC objective score rated A or B in 84% of the patients. Of the 20 good results, 17 patients resumed sport activity at the pre-injury level. KT side-to-side difference averaged 3.5 mm in the TPT, versus 3.2 mm in the AT group. No significant differences were noted between the AT and TPT group. Conclusions. Multiple ACL revision surgery is a salvage procedure, with average good results, but not equivalent to primary ACL reconstruction. Patients should be advised that a return to sports may not be feasible. OTTR+LP is an established technique that permits to overcome difficult anatomical situations, with cortical fixation providing good immediate stability and avoiding tunnel fixation and bone grafting. Long tendon grafts as AT and TPT are needed

Purpose. The aim of the present study was to investigate the relationship between generalised ligament laxity and requirement for revision ACL reconstruction. Materials and methods. 126 patients undergoing primary ACL reconstruction were included in the study along with 35 patients undergoing revision ACL surgery. 62 patients without any knee ligament injury formed an age and sex matched the control group. The Beighton score was used to quantify the ligamentous laxity in all cases with a score more than 4 classified as having generalised ligamentous laxity. The revision ACL patients were evaluated to identify technical errors at the time of the primary procedure or subsequent traumatic injury that could have contributed to primary graft failure. Results. The primary ACL surgery group was associated with an increased generalised ligamentous laxity compared to the control group and this was statistically significant (p < 0.05). Similarly the revision surgery group was also associated with increased generalised ligamentous laxity compared to the control group (p < 0.05). The revision ACL surgery group was also associated with increased generalised ligamentous laxity when compared to the primary ACL surgery group but this did not quite achieve statistical significance (p = 0.058). There was a subgroup within the revision cohort, who had a failure of the original surgery due to biological failure of the primary graft. The incidence of generalised ligament laxity in this group was significantly higher than the primary surgery group (p < 0.05). Conclusion. The findings of the study suggest a clear relationship between generalised ligamentous laxity and ACL injury. The study also highlights a link between generalised ligamentous laxity and requirement for revision ACL surgery. Based on the results of our study we feel that in the presence of GLL an autogenous graft may not be the best mode of reconstruction for either primary of revision ACL reconstruction. A case could be made for preferring allografts over autografts for these patients to reduce the rate of graft failure. Further prospective studies comparing allograft and autorgraft failure rates in patients undergoing primary and revision ACL are required to confirm our observations

Aim: In order to monitor the developments in anterior cruciate ligament (ACL) reconstruction and clinical outcome, a national clinical database for knee ligament surgery (Danish ACL Registry) was established in 2005. This study presents data for 2 years national production of ACL reconstructions from the Danish ACL registry. Methods: All clinics performing ACL reconstructions in Denmark reports to the database. The database is divided into surgeon data and patient data. The surgeon reports anamnestic, objective knee laxity and operative data including graft and implant choices. At one year control, complications, reoperations and objective knee laxity are recorded. The patient registers the KOOS knee score and Tegner function score preoperatively and at 1, 5 and 10 years follow-up. A specific set of indicators that define good diagnostic procedures and clinical outcome have been specified. Results: During the first 24months, more than 5000 knee-ligament reconstructions were registered. 84 % were primary ACL recontruction, 7,7 % were ACL revisions 8,4 %were multiligament reconstructions. 90 % of all departments reported to the database. 71 % of primary ACL reconstruction used hamstring tendon grafts and 21 % used patella tendon graft. Meniscus injuries were treated in 35 % of all patients. 17 % had significant cartilage lesions. Follow-up KOOS scores demonstrated specific differences between primary ACL, revision ACL and multiligament reconstructions. Conclusion: This study presents epidiomiology and follow-up data a national ACL reconstruction registry. These data will become new international reference materials for outcome measures before and after ACL surgery. The database will enable future monitoring of developments in ACL reconstruction techniques and outcome

Introduction: Loss of the meniscus frequently leads to progressive arthritic changes in the involved compartment. Replacement of the lost meniscus with a resorbable collagen scaffold has been proved to allow regeneration of meniscal tissue. MATERIAL AND Methods: Between June 2001 and September 2004, 42 patients, 38 male and 4 female, underwent arthroscopic placement of a collagen meniscus implant (CMI) to reconstruct the damaged medial meniscus. Their age ranged between 22 and 50 years. All patients had an associated ACL insufficiency, 39 secondary to acute ACL tear and 3 ACL graft failures. ACL reconstruction with hamstrings grafts (39) and ACL revision with allograft (3) was performed at the time of CMI implantation. The interval between ACL injury and surgery ranged between 3 weeks and 6 months. Ten patients also had a lateral meniscus tear. All patients were followed with clinical, weight-bearing radiographs, KT-1000 and magnetic resonance examinations for at least 18 months (range, 18– 84 months). The IKDC form was used to record and evaluate the Results:. Results: The length of the implanted CMI ranged between 3 and 5.5 cm and required 4 to 8 stiches. The IKDC subjective evaluation was normal in 18 patients, nearly normal in 18, abnormal in 5 and severely abnormal in 1. Range of motion was normal in 28 patients and nearly normal in 14. KT 1000 examination was normal in 32 patients, nearly normal in 7, abnormal in 1 and severely abnormal in 2. The X ray findings were normal in 28 patients, nearly normal in 6 and abnormal in 8. Complications included 2 saphenous nerve neuritis, 1 ACL graft tear with CMI implant breakage and 2 knee stiffness that required mobilization. 40 patients returned to work. The average time to resume work was 5.5 months. Conclusion: Simultaneous ACL reconstruction and collagen meniscal implantation is a viable and effective option in young active patients with ACL insufficiency and associated meniscal injuries

Revision ACL reconstruction is becoming more frequent especially in specialized centers, due to the large numbers of primary ACL procedures performed. In two stage revisions, bone grafting of the tunnels may be undertaken if the primary position was inaccurate or if osteolysis has caused widening of the tunnels. This will allow the desired placement of the new tunnels without the risk of loss of structural integrity. It is technically difficult to deliver and impact bone graft into the femoral tunnel with the standard surgical and arthroscopic instruments. We describe a new technique for femoral and tibial tunnels impaction grafting in two stage ACL revisions, utilizing the OATS grafting instruments. The appropriately sized OATS harvester is chosen 1 mm larger than the tunnel size and is used to harvest bone graft from the iliac crest through a percutaneous approach. This provides a cylindrical graft, which is delivered to the femoral tunnel through the arthroscopic portal. The inside punch of the harvester is tapped, this allows delivery of the graft in a controlled manner, and allows impaction into the tunnel. The same is repeated for the tibial tunnel while providing support for the proximal end of the tunnel

Purpose: To describe functional results following revision ACL reconstruction surgery. Methods: Patients more than 2 years post-operative from revision ACL surgery by the same surgeon were asked to participate. Patient-based evaluation was determined by ACL Quality of Life(QOL) and Lysholm scores while clinical evaluation was based on IKDC and KT1000 Arthrometer scoring. Surgical information and radiographs were reviewed to identify associated pathologies and surgical technique. Results: Of 18 eligible patients, 15 were available for review(10 male, 5 female). Average age was 29 years(24–52); average follow-up time was 45.6 months(24–120). Primary ACL reconstructions failed due to surgical technique in 3 patients(20%), while trauma led to failure in 11 patients (73%). One patient failed due to previously unrecognized posterolateral instability and required an osteotomy at revision surgery. During revision surgery, 12 patients received a hamstring graft (10 contralateral, 2 ipsilateral) and 3 patients received a tibial posterior allograft. The most frequent concomitant procedures were a partial medial meniscectomy(3) and chondroplasty (5). Based on latest follow-ups, 7 patients had +2 grade on Lachman’s test, 4 patients had +1 grade and 4 patients had a negative grade. IKDC evaluation classified 3 patients as ‘normal’, 4 as ‘nearly normal’, 3 as ‘abnormal’ and 1 as ‘severely abnormal’. Autograft patients had a mean side-to-side difference of 2.8mm while allograft patients had a mean difference of 4.5 mm. Patient-rated Lysholm scores indicated that 4 patients received a ‘good’ score (84–94), 5 patients a ‘fair’ score (65–83) and 3 patients a ‘poor’ score (0–64). The average QOL score was 58.2%(12–96%). Patients characterized as having poor clinical and patient-rated results also had significant articular lesions identified during surgery. Conclusions: Results of revision surgery do not appear to be as good as previously published reports of primary reconstructions. Consideration must be given to the status of the articular cartilage, as it appears to be an important factor in determining the overall functional result