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

The aim of this study was to compare the preinjury functional scores with the postinjury preoperative score and postoperative outcome scores following anterior cruciate ligament (ACL) reconstruction surgery (ACLR).

Abstract. Introduction. The outcome of revision anterior cruciate ligament reconstruction (ACL-R) is guarded, particularly their return to sports activities. It is important to know the factors affecting the functional outcomes following a revision ACL-R. Methods. We analysed results from 39 patients, who underwent a revision ACL reconstruction by a single surgeon and was followed up over a year. Some of them were treated in 2-stage revision while the rest were single-stage revision, depending upon their size of bone tunnel or osteolysis as assessed by pre-operative CT scan. Result. We analysed data from 39 patients with a mean age of 31 (17–52) and an average follow-up of 3.6 years (2–5 years). The average KOOS quality of life score was 58.94 (±23.02) and the mean Lysholm score was 89.48 (±10.1). Medial meniscal tear was significantly correlated with Lysholm score (p<0.005), but not with KOOS-QOL. Tear in lateral meniscus was not related significantly. Patients having Grade II or above cartilage damage showed inferior outcomes in terms of Lysholm score and poor return to sports, and it was statistically significant (p<0.02). There was no significant differences in outcomes between single stage revision and 2-stage revision (p=0.336). 15 patients (42.5%) returned to their pre-injury sports activities after revision surgery with the mean return to sports score of 58.65 (±16.1). Conclusions. The long-term functional outcome after revision ACL reconstruction is satisfactory, but not the return to sports. Expectations on outcome should be carefully managed particularly those having concomitant medial meniscal injury or cartilage damage

Abstract

Aims

There is limited information on outcomes of revision ACL reconstruction (rACLR) in soccer (association football) athletes, particularly on return to sport and the rate of additional knee surgery. The purpose of this study was to report return to soccer after rACLR, and to test the hypothesis that patient sex and graft choice are associated with return to play and the likelihood of future knee surgery in soccer players undergoing rACLR.

Revision anterior cruciate ligament (ACL) reconstruction is a technically demanding procedure, reporting poorer outcomes compared to the primary procedure. Identification of the cause of primary failure and a thorough pre-operative evaluation is required to plan the most appropriate surgical approach. 3D printing technology has become increasingly commonplace in the surgical setting. In particular, patient-specific anatomical models can be used to aid pre-operative planning of complicated procedures. We have conducted a qualitative study to gauge the interest amongst orthopaedic knee surgeons in using a 3D-printed model to plan revision ACL reconstructions.

A tibia and femur model was printed from one patient who is a candidate for the procedure. The binder jetting printing technique was performed, using Visijet PXL Core powder. 12 orthopaedic knee surgeons assessed the usefulness of the 3D-printed model compared to conventional CT images on a likert scale. 6 key steps of preoperative planning were assessed, including the size and location of the tunnel defects, the need for notchplasty, and whether a staged revision was required.

We found that surgeons preferred the 3D-printed model to conventional CT images only, and 83% of them would use such a model for both pre-operative simulation, and as an intra-operative reference. However, there were some variation in the perceived usefulness of the model in several areas assessed. This may reflect differences in individual approach towards planning of the procedure.

Our findings suggest that 3D-printed models could be a versatile pre-operative and intra-operative tool for complicated arthroscopic knee surgery. While 3D printing technology is becoming increasingly accessible and affordable, in-depth cost-effectiveness studies need to be conducted before it can be integrated into clinical. Further study would be needed to determine the clinical utility and economic cost-effectiveness of the 3D-printed model in revision ACL reconstruction.

The purpose of this study was to compare intra-operative, clinical, functional, and patient-reported outcomes following revision anterior cruciate ligament reconstruction (ACL-R) with a matched cohort of primary isolated ACL-R. A secondary purpose was to compare patient-reported outcomes within revision ACL-R based on intra-operative cartilage pathology. Between January 2010 and August 2017, 396 patients underwent revision ACL-R, and were matched to primary isolated ACL-R patients using sex, age, body mass index (BMI), and Beighton score. Intra-operative assessments including meniscal and chondral pathology, and graft diameter were recorded. Lachman and pivot shift tests were completed independently on each patient at two-years post-operative by a physiotherapist and orthopaedic surgeon. A battery of functional tests was assssed including single-leg Bosu balance, and four single-leg hop tests. The Anterior Cruciate Ligament-Quality of Life Questionnaire (ACL-QOL) was completed pre-operatively and two-years post-operatively. Descriptive statistics including means (M) and standard deviations (SD), and as appropriate paired t-tests were used to compare between-groups demographics, the degree and frequency of meniscal and chondral pathology, graft diameter, rate of post-operative ACL graft laxity, the surgical failure rate, and ACL-QOL scores. Comparative assessment of operative to non-operative limb performance on the functional tests was used to assess limb symmetry indices (LSI). Revision ACL-R patients were 52.3% male, mean age 30.7 years (SD=10.2), mean BMI 25.3 kg/m2 (SD=3.79), and mean Beighton score 3.52 (SD=2.51). In the revision group, meniscal (83%) and chondral pathology (57.5%) was significantly more frequent than in the primary group (68.2% and 32.1%) respectively, (p < 0 .05). Mean graft diameter (mm) in the revision ACL-R group for hamstring (M=7.89, SD=0.99), allograft (M=8.42, SD=0.82), and patellar or quadriceps tendon (M=9.56, SD=0.69) was larger than in the primary ACL-R group (M=7.54, SD=0.76, M=8.06, SD=0.55, M=9, SD=1) respectively. The presence of combined positive Lachman and pivot shift tests was significantly more frequent in the revision (21.5%) than primary group (4.89%), (p < 0 .05). Surgical failure rate was higher in the revision (10.3%) than primary group (5.9%). Seventy-three percent of revision patients completed functional testing. No significant LSI differences were demonstrated between the revision and primary ACL-R groups on any of the functional tests. No statistically significant differences were demonstrated in mean preoperative ACL-QOL scores between the revision (M=28.5/100, SD=13.5) and primary groups (M=28.5/100, SD=14.4). Mean two-year scores demonstrated statistically significant and minimally clinically important differences between the revision (M=61.1/100, SD=20.4) and primary groups (M=76.0/100, SD=18.9), (p < 0 .05). Mean two-year scores for revision patients with repair of the medial (M=59.4/100, SD=21.7) or lateral meniscus (M=59.4/100, SD=23.6), partial medial meniscectomy (M=59.7/100, SD=20), grade three or four osteoarthritis (M=55.9/100, SD=19.5), and medial femoral condyle osteoarthritis (M=59.1/100, SD=18) were lower compared with partial lateral meniscectomy (M=67.1/100, SD=19.1), grade one or two osteoarthritis (M=63.8/100, SD=18.9), and lateral femoral condyle osteoarthritis (M=62, SD=21). Revision ACL-R patients demonstrated a greater amount of meniscal and chondral pathology at the time of surgery. Two-years post-operative these patients demonstrated higher rates of graft laxity and lower ACL-QOL scores compared with the primary ACL-R group. Higher grade and medial sided osteoarthritis was associated with inferior ACL-QOL scores in revision ACL-R

Aims

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.

Aims

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.

Purpose

Elective ACLR is indicated for symptomatic instability of the knee. Despite being a common procedure, there are numerous surgical techniques, graft and fixation choices. Many have been directly compared in randomized trials and meta-analyses. The typical operation is arthroscopic-assisted, uses autograft tendon and screw fixation. Research in elective joint replacement surgery has demonstrated an inverse relationship between surgeon volume and revision and complication rates. How patient demographics, provider characteristics and graft/fixation choices influence ACLR revision rates has not been reported on a population level. We hypothesized that ACLR using tendon autograft and screw fixation performed by high volume surgeons will have the lowest rate of revision. In contrast, the risk of contralateral ACLR in the same cohort will be influenced only by patient factors.

Introduction

Tunnelwidening in failed anterior cruciate ligament reconstruction (ACLR) can result in the staged revision procedures with a need for bone transplantation prior to revision reconstruction. Limited knowledge exist regarding to quality of different transplantation methods. The present study used CT-scanning to evaluate tunnel bone density after allogenic bone chips and bone cylinder transplantation.

We hypothesized that bone chips transplantation resulted in higher bone density than bone cylinder transplantation due to possible voids between individual cylinders in the tunnels.

We reviewed 87 patients who underwent revision anterior cruciate ligament (ACL) reconstruction. The incidence of meniscal tears and degenerative change was assessed and related to the timing from primary ACL graft failure to revision ACL reconstruction. Patients were divided into either an early group (revision surgery within 6 months of graft failure) or a delayed group. Degenerative change was scored using the French Society of Arthroscopy system. There was a significantly higher incidence of articular cartilage degeneration in the delayed group compared to the early group (53.2% vs 24%, p < 0.01, Mann- Whitney U test). No patients in the early group had advanced degenerative change (SFA grades 3 or 4), compared with 12.9% of patients in the delayed group. There was no significant difference in the incidence of meniscal tears between the two groups. In conclusion, the findings of the study support the view that patients with a failed ACL reconstruction and symptomatic instability should have an early revision reconstruction procedure carried out to minimise the risk of articular degenerative change.

Aim: The purpose of this study was to evaluate the results of transphyseal ACL reconstruction technique in skeletally immature patients. Material & Methods: Between 2002 and 2008, twenty knees in twenty skeletally immature patients with a mean chronological age of 13.2 years (range, 7 to 16.2 years) underwent transphyseal reconstruction of the anterior cruciate ligament with use of an autogenous quadrupled hamstrings-tendon graft with metaphyseal fixation. Ten knees had additional meniscal surgery. The functional outcome, graft survival, radiographic outcome, and any growth disturbance were evaluated at a mean of 2.2 years (range, 1.0 to 5.9 years) after the surgery. Results: No patient underwent revision anterior cruciate ligament reconstruction. The mean International Knee Documentation Committee subjective knee score (SD) was 90.5 (10.0) points and the mean Lysholm knee score was 92.2 (10.0) points. The result of the Lachman examination was normal in 18 knees and nearly normal in two; it was not abnormal or severely abnormal in any knee. The mean increase in total height was 7.2 cm (range, 1.2 to 20.4 cm) from the time of surgery to the time of final follow-up. No angular deformities of the lower extremity were measured radiographically, and no lower-extremity length discrepancies were measured clinically. Complications included one case of knee stiffness requiring physiotherapy, one case of persistent pain leading to medial menisectomy for tear and one case of re-injury five months post ACL reconstruction requiring medial meniscus repair. Conclusion: Excellent functional outcome was noted in skeletally immature patients after transphyseal reconstruction of the anterior cruciate ligament with use of an autogenous quadrupled hamstrings-tendon graft with metaphyseal fixation. There were very few complications and no growth disturbance

Purpose of the study: Failure of anterior cruciate ligament (ACL) ligamentoplasty is a major surgical challenge. Over the last decade, failures have been related to the use of synthetic material, but at the present time, most of the failures observed are related to an inappropriate position for the graft. The purpose of this work was to report a prospective cohort of 44 consecutive patients where the objective and subjective results of revision surgery were recorded.

Material and methods: Between January 2000 and January 2004, 44 patients with a healthy contralateral knee were included in this study: 26 males and 18 females, mean age 30 years (range 20–53 years). The majority of the initial grafts were patellar (57%), hamstring tendons had been used for 26%. The time from the first ligamentoplasty to revision reconstruction was 38.7±28.3 months. This was a first revision for 38 patients and six patients had had multiple revisions. The preoperative IKDC scores were: subjective 51.7±16.2; overall: 1B, 19C, 24D. The maximal manual differential laxity measured with KT1000 was 8.6±3.1 mm. In 70% of cases, the cause of failure was related to an inadapted position of the graft. At revision, grade 2 or 3 cartilage lesions were observed in 50% of knees. Reconstructions were performed with autografts: patellar tendon (39%), hamstring tendons (31%), or quadricipital tendon (29%), combined with lateral ligamentoplasty in 78% of the cases.

Results: Mean follow-up in this series was 14.7 months, minimum 12 months. At last follow-up, the IKDC scores were: 73.8±13.9 for the subjective assessment and 9A, 12B, 17C, 6D for the overall assessment. 67.7% of patients were satisfied or very satisfied. The maximal manual differential laxity measured with KT1000 was 4.3±3.5 mm. All variables exhibited statistically significant improvement. Grade B or C radiologial modifications were noted in 32% of cases.

Discussion and conclusion: Complete analysis of the clinical findings searching for combined laxity as well as a precise preoperative radiological work-up is the key to a successful operative strategy. Data provided by this series confirmed that outcome is less satisfactory after revision reconstruction of the ACL than first-intention ligamentoplasty. Most of the knees involved however present cartilaginous and meniscal lesions with associated peripheral injuries. Short-term cartilage degradation is a worrisome problem and emphasizes the importance of correctly positioning the ACL graft at the primary surgery.

We reviewed 87 patients who underwent revision reconstruction of the anterior cruciate ligament. The incidence of meniscal tears and degenerative change was assessed and related to the interval between failure of the primary graft and revision reconstruction. Patients were divided into two groups: early revision surgery within six months of graft failure, and delayed revision. Degenerative change was scored using the French Society of Arthroscopy system.

There was a significantly higher incidence of articular cartilage degeneration in the delayed group (Mann-Whitney U-test, 53.2% vs 24%, p < 0.01). No patient in the early group had advanced degenerative change, compared to 9.2% of patients in the delayed group. There was no significant difference (Mann-Whitney U-test, p = 0.3) in the incidence of meniscal tears between the two groups.

We conclude that revision reconstruction should be carried out within six months of primary graft failure, in order to minimise the risk of degenerative change.

Aim: The aim of our study was to evaluate the results of the Soffix Mark I and Mark II hamstring fixation devices, placed transtibially with an “over the top” femoral route when applied to revision anterior cruciate ligament (ACL) surgery secondary to synthetic ligament failure.

Patients and Methods: 29 ACL revisions performed between 1992 and 2000 were evaluated. Twenty six failed prosthetic ligaments, 2 failed semitendinosus/gracilis (STG) and one BTB autografts were revised using hamstring grafts in 26, quadriceps in 2, and patella bone tendon bone (BTB) in 1 patient. Mark I and II fixation devices were employed. Follow up included clinical examination, KT 2000 arthrometric assessment, Lysholm, Tegner and IKDC scoring. The average follow up time was 50 months ±22.4.

Results: Arthrometric examination showed a mean side to side difference (SSD) of 2.98 mm ±1.5. The mean Lysholm score was 86.5 ±10.5 and 21 patients had a B rating (nearly normal) on IKDC scoring, while 3 score A (normal). The mean Lysholm score was 86.5 ±10.5. The lowest clinical scores were noted in 4 multiply operated knees.

Conclusions: We concluded that a revision technique using the STG Soffix fixation device can restore stability with good functional outcomes following failed primary ACL reconstruction. Multiply re-operated knees had the worst functional results despite restoration of stability.

Aim: The aim of our study was to evaluate the results of the Soffix Mark 1 and Mark 11 hamstring fixation device, placed transtibially with an “over the top” femoral route when applied to revision anterior cruciate ligament (ACL) surgery.

Method and results: Twenty nine ACL revisions performed between 1992 – 2000 were evaluated. Twenty six failed prosthetic ligaments, two failed semitendinosus/ gracilis (STG) and one BTB autografts were revised using hamstring grafts in 26, quadriceps in two, and patella bone tendon bone (BTB) in one patient. Mark 1 and 11 fixation devices were employed. Follow up included clinical examination, KT 2000 arthrometric assessment, Lysholm, Tegner and IKDC scoring. The average follow up time was 50 months ±22.4.

Arthrometric examination showed a mean side to side difference (SSD) of 1.66 mm ±1.5. The mean Lysholm score was 87.2 ±12.5 and 22 patients had a B rating (nearly normal) on IKDC scoring.

The Mark II Soffix group had a mean SSD of 1.23 mm ±1.3, a mean Lysholm score of 85.8 ±14.6 and IKDC B rating in 11/15. The lowest clinical scores were in 4 multiply operated knees but the SSDs were comparable with other groups. The Mark 1 Soffix group had a mean SSD of 2.0 mm ±1.6, Lysholm score of 84.6 ±14.3 and 13/16 had a B rating (IKDC). The smaller SSD in the Mark I Soffix was statistically significant (p< 0.05) when compared with the Mark I device. Multiply operated knees had worse IKDC and Lysholm scores (not statistically significant).

Conclusions: We concluded that a revision technique using the STG Soffix fixation device can restore stability with good functional outcomes following failed primary ACL reconstruction. Multiply re-operated knees had the worst functional results despite restoration of stability.