Revision ACL Surgery

Transcription

1 Charles H. Brown Jr.,M.D, Director International Knee & Joint Centre Abu Dhabi, United Arab Emirates Introduction Revision ACL Surgery 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). Patient dissatisfaction after ACL reconstruction Instability Complications Comorbidites 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

2 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. Etiology of ACL Graft Failure University of Pittsburgh Classification Surgical Technique Arthrofibrosis and rehabilitation Poor graft incorporation and healing Trauma

3 Etiology of ACL graft failure in published revision studies Etiology of ACL Graft Failure 100 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) Technical Errors Traumatic Cases Biological Causes Unknown/Other Technical errors in published revision studies Technical Errors in ACL Surgery Noyes and Barber-Westin (2001) O Neill (2004) Carson (2004) Ferretti (2006) Garafalo (2006) Salmon (2006) Ahn (2008) Diamantopoulos (2008) MARS Group (2010) 78 Trojani (2011) Danish ACL Registry (2012) Nonanatomic Tunnel Placement Associated laxity/malalignment 29 Inadequate graft Fixation failure Other

4 Nonanatomic tunnel placement Technical Errors in ACL Surgery Nonanatomic Graft Placement Rotational Instability Excessive graft length changes Graft Impingement Loss of motion Failed ACL Reconstruction 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

5 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

6 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)

7 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 crosssectional 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. What Graft for Revision ACL Surgery: Autografts Advantages Faster and more complete biological incorporation No added costs No risks of disease transmission Better objective stability results and lower failure rate compared to allografts Disadvantages Autograft tissue may not be available Donor site morbidity Greater surgical exposure required Limited soft tissue and bone block size What Graft for Revision ACL Surgery: Allografts Advantages Wide variety of tissue options No limitation of soft tissue or bone block size No donor site morbidity Decreased operative time (no autograft harvest required) Cost Disadvantages Slower graft incorporation Risk of disease transmission Inferior objective results and higher failure rate compared to autografts

8 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 Preoperative Bone Tunnel Assessment Bone Tunnel Placement Anatomic Nonanatomic Expanded Non-Expanded Overlap No Overlap ACL graft with a large bone block or bone graft tunnel Use existing bone tunnel Bone graft tunnel New anatomic 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 Both of these characteristics are advantageous in revision ACL surgery

9 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

10 References 1. Sports Medicine and Arthroscopy Review, Volume 13, Number 1. Revision ACL Issues, Part 1. Guest Editor: Bernard R. Bach Jr.,MD 2. Sports Medicine and Arthroscopy Review, Volume 13, Number 2. Revision ACL Issues, Part 2. Guest Editor: Bernard R. Bach Jr.,MD 3. Bach BR, Wojtys EM, Lindenfeld TN: Reflex sympathetic dystrophy, patellar infera contracture syndrome, and loss of motion following anterior cruciate ligament surgery. Inst Course Lect 46: , Bach BR, Provender, MT (eds): ACL surgery: How to get it right the first time and what to do if it fails. Slack Incorporated, Brown CH, Carson EW. Revision anterior cruciate ligament surgery. Clinics in Sports Medicine 1999;18: Corsetti JR, Jackson DW: Failure of anterior cruciate ligament reconstruction. The biologic basis. Clin Orthop 323:42 49, Harner CD, Irrgang JJ, Paul JJ, et al: Loss of motion after anterior cruciate ligament reconstruction. Am J Sports Med 20: , Howell SM, Clark JA, Farley TE: A rationale for predicting anterior cruciate graft impingement by the intercondylar roof: An MRI study. Am J Sports Med 19: , Howell SM, Clark JA: Tibial tunnel placement in anterior cruciate ligament reconstructions and graft impingement. Clin Orthop 283: , Irrgang JJ, Harner CD: Loss of motion following knee ligament reconstruction. Sports Med 19: , Jaureguito JW, Paulos LE: Why grafts fail? Clin Orthop 323:25 41, Johnson DL, Fu FH: Anterior cruciate ligament reconstruction: Why do failures occur? Instruct Course Lect 44: , Johnson DL, Fu FH: Revision ACL surgery: etiology, indications, techniques, and results. Amer J Knee Surg 8: , Johnson DL, Swenson TM, Irrgang JL, et al: Revision anterior cruciate ligament surgery: experience from Pittsburgh. Clin Orthop 323: , Kamath GV, Redfern JC, Greis PE, Burks RT: Revision anterior cruciate ligament reconstruction. Am J Sports Med 39: , Marchant BG, Noyes FR, Barber Westin SD, Fleckenstein C: Prevalence of nonanatomical graft placement in a series of failed anterior cruciate ligament reconstruction. Am J Sports Med 38: , 2010

11 17. MARS Group, Effect of graft choice on the outcome of revision anterior cruciate ligament reconstruction in the multicenter ACL revision study (MARS) cohort. Am J Sports Med 42: , Marx RG (ed): Revision ACL reconstruction. Springer, Menetrey J, Duthon VB, Laumonier T, Fritschy D: Biological failure of the anterior cruciate ligament graft. Knee Surg Sports Traumatol Arthrosc 16: , Miller MD: Revision cruciate ligament surgery with retention of femoral interference screws. Arthroscopy 14: , Morgan JA, Dahm D, Levy B, Stuart MJ: Femoral tunnel malposition in ACL revision reconstruction. J Knee Surg 25: , Noyes FR, Wojtys EM, Marshall MT: The early diagnosis and treatment of developmental patella infera syndrome. Clin Orthop 265: , Noyes FR, Mangine, RE, Barber SD: The early treatment of motion complications after reconstruction of the anterior cruciate ligament. Clin Orthop 227: , Noyes FR, Barber Westin SD, Roberts CS: Use of allografts after failed treatment of the anterior cruciate ligament. J Bone Joint Surg 76 A: , Noyes FR, Barber Westin SD: Revision anterior cruciate ligament surgery: experience from Cincinnati. Clin Orthop 323: , Noyes FR, Barber Westin SD: Anterior cruciate ligament revision reconstruction:results using a quadriceps tendon patellar bone autograft. Am J Sports Med 34: , Paulos LE, Rosenberg TD, Drawbert J, et al: Infrapatellar contracture syndrome: an unrecognized cause of knee stiffness with patellar infera. Am J Sports Med 15: , Paulos LE, Wnorowski DC, Greenwald AE: Infrapatellar contracture syndrome. Diagnosis, treatment, and long term follow up. Am J Sports Med 22: , Safran MR: Graft selection in knee surgery. Am J Knee Surg 8: , Safran MR, Harner CD: Technical considerations of revision anterior cruciate ligament surgery. Clin Orthop 323:50 64, Siebold, Dejour, Zaffagnini (eds): Anterior cruciate ligament reconstruction: A practical surgical guide. Springer, Stäubli H U: The quadriceps tendon patellar bone construct for ACL reconstruction. Sports Medicine Arthroscopy Review 5:59 67, Trojani C, Beaufils P, Burdin G, et al. Revision ACL reconstruction: influence of a lateral

12 tenodesis. Knee Surg Sports Traumatol Arthrosc 20: , Uribe JW, Hechtman KS, Zvijac JE, et al: Revision anterior cruciate ligament surgery: experience from Miami. Clin Orthop 323:91 99, Vergis A, Gillquist J: Current concepts: Graft failure in intra articular anterior cruciate ligament reconstructions: A review of the literature. Arthroscopy 11: , Wetzler MJ, Bartolozzi AR, Gillespie MJ, et al: Revision anterior cruciate ligament reconstruction. Oper Tech Orthop 6: , Wilde J, Bedi A, Altchek DW: Revision anterior cruciate ligament reconstruction. Sports Health 6: , 2014