J Knee Surg 2021; 34(08): 801-809
DOI: 10.1055/s-0039-3400741
Original Article

Multiple ACL Revision: Failure Analysis and Clinical Outcomes

Francesco Dini
1   Department of Orthopaedic and Trauma Surgery, Città di Parma Clinic, Parma, Italy
,
Andrea Tecame
1   Department of Orthopaedic and Trauma Surgery, Città di Parma Clinic, Parma, Italy
,
Aldo Ampollini
1   Department of Orthopaedic and Trauma Surgery, Città di Parma Clinic, Parma, Italy
,
Paolo Adravanti
1   Department of Orthopaedic and Trauma Surgery, Città di Parma Clinic, Parma, Italy
› Author Affiliations

Abstract

Anterior cruciate ligament (ACL) reconstruction represents one of the most successful orthopedic surgical procedures. Nevertheless, ACL revisions are still very frequent, with a small but relevant number of failures. The purpose of this study is to analyze the failure causes and the clinical outcomes of patients who underwent a re-revision ACL reconstruction. Between January 2009 and December 2017, 263 ACL revisions were performed by a single senior surgeon. Seventeen patients (12 males and 5 females) underwent re-revision ACL reconstruction meeting the inclusion criteria. The mean age was 28.4 years (range, 19–41 years). Before the re-revision, the patients were evaluated preoperatively and after a mean follow-up of 29 months (range, 13–58 months). Assessment included subjective and objective evaluations (Lysholm and International Knee Documentation Committee [IKDC]), KT-2000 arthrometer, radiographic study, and preoperative computed tomography scan. Five patients showed a too anterior previous femoral tunnel and seven a too vertical and posterior tibial tunnel; eight meniscal tears were found. Five patients had grade III–IV according to Outerbridge cartilage lesions. IKDC showed a statistically significant improvement (A + B 35%, C + D 65% preop, A + B 82%, C + D 18% postop, odds ratio: 0.1169; p = 0.0083). The mean Lysholm score ranged from 43 ± 9 to 87 ± 7 (p < 0.001). The KT-2000 arthrometer showed a statistically significant improvement from a mean of 5.8 ± 1.4 to 1.5 ± 1.1 (p < 0.001) at last follow-up. Out of 17 patients, only 4 returned to sports activity at the same preinjury levels. Postoperatively at the last follow-up after last revision surgery, no osteoarthritis evolution was observed. This study showed good clinical and radiological results after the last revision ACL surgery in patients with multiple failures of ACL reconstruction but only one-fourth of the patients returned to the same preoperative sport level. Traumatic events, technical errors, and untreated peripheral lesions are the main causes of multiple previous failures; the worst clinical outcomes were found in the patients with high grade of chondral lesions.



Publication History

Received: 19 March 2019

Accepted: 14 October 2019

Article published online:
27 November 2019

© 2019. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 
  • References

  • 1 Gianotti SM, Marshall SW, Hume PA, Bunt L. Incidence of anterior cruciate ligament injury and other knee ligament injuries: a national population-based study. J Sci Med Sport 2009; 12 (06) 622-627
  • 2 Keller RA, Mehran N, Austin W, Marshall NE, Bastin K, Moutzouros V. Athletic performance at the NFL Scouting Combine after anterior cruciate ligament reconstruction. Am J Sports Med 2015; 43 (12) 3022-3026
  • 3 Samuelsson K, Magnussen RA, Alentorn-Geli E. et al. Equivalent knee injury and osteoarthritis outcome scores 12 and 24 months after anterior cruciate ligament reconstruction: results from the Swedish National Knee Ligament Register. Am J Sports Med 2017; 45 (09) 2085-2091
  • 4 Cristiani R, Engström B, Edman G, Forssblad M, Stålman A. Revision anterior cruciate ligament reconstruction restores knee laxity but shows inferior functional knee outcome compared with primary reconstruction. Knee Surg Sports Traumatol Arthrosc 2019; 27 (01) 137-145
  • 5 Lind M, Menhert F, Pedersen AB. Incidence and outcome after revision anterior cruciate ligament reconstruction: results from the Danish registry for knee ligament reconstructions. Am J Sports Med 2012; 40 (07) 1551-1557
  • 6 Wright RW, Huston LJ, Spindler KP. et al; MARS Group. Descriptive epidemiology of the Multicenter ACL Revision Study (MARS) cohort. Am J Sports Med 2010; 38 (10) 1979-1986
  • 7 Liechti DJ, Chahla J, Dean CS. et al. Outcomes and risk factors of rerevision anterior cruciate ligament reconstruction: a systematic review. Arthroscopy 2016; 32 (10) 2151-2159
  • 8 Mayr R, Rosenberger R, Agraharam D, Smekal V, El Attal R. Revision anterior cruciate ligament reconstruction: an update. Arch Orthop Trauma Surg 2012; 132 (09) 1299-1313
  • 9 Fanelli GC, Edson CJ, Maish DR. Revision anterior cruciate ligament reconstruction: associated patholaxity, tibiofemoral malalignment, rehabilitation, and results. Am J Knee Surg 2001; 14 (03) 201-204
  • 10 Arianjam A, Inacio MCS, Funahashi TT, Maletis GB. Analysis of 2019 patients undergoing revision anterior cruciate ligament reconstruction from a community-based registry. Am J Sports Med 2017; 45 (07) 1574-1580
  • 11 Irrgang JJ, Anderson AF, Boland AL. et al. Development and validation of the International Knee Documentation Committee subjective knee form. Am J Sports Med 2001; 29 (05) 600-613
  • 12 Lysholm J, Gillquist J. Evaluation of knee ligament surgery results with special emphasis on use of a scoring scale. Am J Sports Med 1982; 10 (03) 150-154
  • 13 Swami VG, Cheng-Baron J, Hui C, Thompson RB, Jaremko JL. Reliability of 3D localisation of ACL attachments on MRI: comparison using multi-planar 2D versus high-resolution 3D base sequences. Knee Surg Sports Traumatol Arthrosc 2015; 23 (04) 1206-1214
  • 14 Meuffels DE, Potters JW, Koning AH, Brown Jr CH, Verhaar JA, Reijman M. Visualization of postoperative anterior cruciate ligament reconstruction bone tunnels: reliability of standard radiographs, CT scans, and 3D virtual reality images. Acta Orthop 2011; 82 (06) 699-703
  • 15 Sommer C, Friederich NF, Müller W. Improperly placed anterior cruciate ligament grafts: correlation between radiological parameters and clinical results. Knee Surg Sports Traumatol Arthrosc 2000; 8 (04) 207-213
  • 16 Amis AA, Jakob RP. Anterior cruciate ligament graft positioning, tensioning and twisting. Knee Surg Sports Traumatol Arthrosc 1998; 6 (Suppl. 01) S2-S12
  • 17 Parkinson B, Gogna R, Robb C, Thompson P, Spalding T. Anatomic ACL reconstruction: the normal central tibial footprint position and a standardised technique for measuring tibial tunnel location on 3D CT. Knee Surg Sports Traumatol Arthrosc 2017; 25 (05) 1568-1575
  • 18 van Eck CF, van den Bekerom MP, Fu FH, Poolman RW, Kerkhoffs GM. Methods to diagnose acute anterior cruciate ligament rupture: a meta-analysis of physical examinations with and without anaesthesia. Knee Surg Sports Traumatol Arthrosc 2013; 21 (08) 1895-1903
  • 19 Kellgren JH, Lawrence JS. Radiological assessment of osteo-arthrosis. Ann Rheum Dis 1957; 16 (04) 494-502
  • 20 Allen CR, Giffin JR, Harner CD. Revision anterior cruciate ligament reconstruction. Orthop Clin North Am 2003; 34 (01) 79-98
  • 21 Erickson BJ, Cvetanovich G, Waliullah K. et al. Two-stage revision anterior cruciate ligament reconstruction. Orthopedics 2016; 39 (03) e456-e464
  • 22 Slette EL, Mikula JD, Schon JM. et al. Biomechanical results of lateral extra-articular tenodesis procedures of the knee: a systematic review. Arthroscopy 2016; 32 (12) 2592-2611
  • 23 Outerbridge RE. The etiology of chondromalacia patellae. J Bone Joint Surg Br 1961; 43-B: 752-757
  • 24 Hamilton RT, Shultz SJ, Schmitz RJ, Perrin DH. Triple-hop distance as a valid predictor of lower limb strength and power. J Athl Train 2008; 43 (02) 144-151
  • 25 Barber SD, Noyes FR, Mangine RE, McCloskey JW, Hartman W. Quantitative assessment of functional limitations in normal and anterior cruciate ligament-deficient knees. Clin Orthop Relat Res 1990; (255) 204-214
  • 26 Noyes FR, Barber SD, Mangine RE. Abnormal lower limb symmetry determined by function hop tests after anterior cruciate ligament rupture. Am J Sports Med 1991; 19 (05) 513-518
  • 27 Wegrzyn J, Chouteau J, Philippot R, Fessy MH, Moyen B. Repeat revision of anterior cruciate ligament reconstruction: a retrospective review of management and outcome of 10 patients with an average 3-year follow-up. Am J Sports Med 2009; 37 (04) 776-785
  • 28 Griffith TB, Allen BJ, Levy BA, Stuart MJ, Dahm DL. Outcomes of repeat revision anterior cruciate ligament reconstruction. Am J Sports Med 2013; 41 (06) 1296-1301
  • 29 Wright RW, Gill CS, Chen L. et al. Outcome of revision anterior cruciate ligament reconstruction: a systematic review. J Bone Joint Surg Am 2012; 94 (06) 531-536
  • 30 Siebold R, Dejour D, Zaffagnini S. Anterior Cruciate Ligament Reconstruction. A Practical Surgical Guide. Berlin: Springer Science & Business; 2014
  • 31 Buda R, Ruffilli A, Di Caprio F. et al. Allograft salvage procedure in multiple-revision anterior cruciate ligament reconstruction. Am J Sports Med 2013; 41 (02) 402-410
  • 32 Akhtar MA, Bhattacharya R, Keating JF. Generalised ligamentous laxity and revision ACL surgery: Is there a relation?. Knee 2016; 23 (06) 1148-1153
  • 33 Robb C, Kempshall P, Getgood A. et al. Meniscal integrity predicts laxity of anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2015; 23 (12) 3683-3690
  • 34 Uchio Y, Ochi M, Adachi N, Kawasaki K, Kuriwaka M. Determination of time of biologic fixation after anterior cruciate ligament reconstruction with hamstring tendons. Am J Sports Med 2003; 31 (03) 345-352
  • 35 Pascual-Garrido C, Carbo L, Makino A. Revision of anterior cruciate ligament reconstruction with allografts in patients younger than 40 years old: a 2 to 4 year results. Knee Surg Sports Traumatol Arthrosc 2014; 22 (05) 1106-1111
  • 36 Bait C, Randelli P, Compagnoni R. et al. Italian consensus statement for the use of allografts in ACL reconstructive surgery. Knee Surg Sports Traumatol Arthrosc 2019; 27 (06) 1873-1881
  • 37 Barrett AM, Craft JA, Replogle WH, Hydrick JM, Barrett GR. Anterior cruciate ligament graft failure: a comparison of graft type based on age and Tegner activity level. Am J Sports Med 2011; 39 (10) 2194-2198
  • 38 Kaeding CC, Aros B, Pedroza A. et al. Allograft versus autograft anterior cruciate ligament reconstruction: predictors of failure from a MOON prospective longitudinal cohort. Sports Health 2011; 3 (01) 73-81
  • 39 Getelman MH, Friedman MJ. Revision anterior cruciate ligament reconstruction surgery. J Am Acad Orthop Surg 1999; 7 (03) 189-198
  • 40 Machotka Z, Scarborough I, Duncan W, Kumar S, Perraton L. Anterior cruciate ligament repair with LARS (Ligament Advanced Reinforcement System): a systematic review. Sports Med Arthrosc Rehabil Ther Technol 2010; 2: 29
  • 41 Franceschi F, Papalia R, Del Buono A. et al. Two-stage procedure in anterior cruciate ligament revision surgery: a five-year follow-up prospective study. Int Orthop 2013; 37 (07) 1369-1374
  • 42 Thomas NP, Kankate R, Wandless F, Pandit H. Revision anterior cruciate ligament reconstruction using a 2-stage technique with bone grafting of the tibial tunnel. Am J Sports Med 2005; 33 (11) 1701-1709
  • 43 Adravanti P, Dini F, de Girolamo L, Cattani M, Rosa MA. Single-bundle versus double-bundle anterior cruciate ligament reconstruction: a prospective randomized controlled trial with 6-year follow-up. J Knee Surg 2017; 30 (09) 898-904
  • 44 Trojani C, Beaufils P, Burdin G. et al. Revision ACL reconstruction: influence of a lateral tenodesis. Knee Surg Sports Traumatol Arthrosc 2012; 20 (08) 1565-1570
  • 45 Thaunat M, Clowez G, Saithna A. et al. Reoperation rates after combined anterior cruciate ligament and anterolateral ligament reconstruction: a series of 548 patients from the SANTI Study Group with a minimum follow-up of 2 years. Am J Sports Med 2017; 45 (11) 2569-2577
  • 46 Ahmed I, Salmon L, Roe J, Pinczewski L. The long-term clinical and radiological outcomes in patients who suffer recurrent injuries to the anterior cruciate ligament after reconstruction. Bone Joint J 2017; 99-B (03) 337-343
  • 47 Grassi A, Macchiarola L, Urrizola Barrientos F. et al. Steep posterior tibial slope, anterior tibial subluxation, deep posterior lateral femoral condyle, and meniscal deficiency are common findings in multiple anterior cruciate ligament failures: an MRI case-control study. Am J Sports Med 2019; 47 (02) 285-295