UK Sports Medicine Conference

Revision Anterior Cruciate Ligament (ACL) Reconstruction

Case Presentation

Jeremy M. Burnham, MDUK Orthopaedic Surgery and Sports Medicine

History:

• CC: trouble with right knee• HPI: 23 yo WM, college student• c/o sharp/stabbing intermittent pain,

mostly on medial side of knee• Occasional feelings of instability• Unable to stop, cut, or change

direction• 2 year history of pain and swelling,

recent progression of symptoms• No recent injury

History:

• PMH/PSH: Non-contact ACL tear sometime in 2009, subsequently developed symptomatic medial meniscus tear

• ACL Recon with soft tissue allograft 2/2010• Partial medial menisectomy• 9x35 Stryker bioabsorbable screw

proximally, distal fixation was 9x20mm retro Arthrex bioabsorbable inside-out• Describes femoral tunnel at 11

o’clock• MRI read 8/2012 shows intact

graft with increased intra-substance signal

Physical Exam:

• No effusion, knee ROM 0-135, positive Lachman, positive anterior drawer, positive pivot shift

• TTP medial jointline• Stable to v/v at 0/30, no patellar

maltracking

Preop XR’s:

Surgical Findings:

• Previous ACL remnant with very few fibers left• Tibial side noted to be posterior• Bucket handle medial meniscus

tear• Radial tear of lateral meniscus

Surgical Procedures 8/22/13:

• Revision right ACL-R• 80% partial medial menisectomy• 15% partial lateral menisectomy

Surgical Findings – Old ACL Graft Remnants:

Surgical Findings – Medial Meniscus:

Surgical Findings – Old Femoral Tunnel:

Surgical Findings – Old Femoral Tunnel:

Surgical Findings – New Graft:

Recent Postop Visit:

• Pain controlled• Expected effusion• Drain was pulled POD#1• Advanced per protocol• No postoperative complications

Postop XR’s:

Morgan, J. A., Dahm, D., Levy, B., Stuart, M. J., & Group, M. S. (2012). Femoral tunnel malposition in ACL revision reconstruction. J Knee Surg, 25(5), 361-368. doi: 10.1055/s-0031-1299662

Of the 460 revisions included for study, 276 (60%) cases cited a specific "technical cause of failure." Femoral tunnel malposition was cited in 219 (47.6%) of 460 cases. Femoral tunnel malposition was cited as the only cause of failure in 117 cases (25.4%). Surgeons judged the femoral tunnel too vertical in 42 cases (35.9%), too anterior in 35 cases (29.9%), and too vertical and anterior in 31 cases (26.5%). Revision reconstruction involved the drilling of an entirely new femoral tunnel in 91 cases (82.1%). For primary reconstruction, autograft tissue was used in 82 cases (70.1%). For revision reconstruction, autograft tissue was used in 61 cases (52.1%) and allograft tissue in 56 cases (47.9%). Femoral tunnel malposition in primary ACL reconstruction was the most commonly cited reason for graft failure in this cohort. Graft selection is widely variable among surgeons.

Getgood, A., & Spalding, T. (2012). The evolution of anatomic anterior cruciate ligament reconstruction. Open Orthop J, 6, 287-294. doi: 10.2174/1874325001206010287

MoChen, J. L., Allen, C. R., Stephens, T. E., Haas, A. K., Huston, L. J., Wright, R. W., . . . Multicenter, A. C. L. R. S. G. (2013). Differences in mechanisms of failure, intraoperative findings, and surgical characteristics between single- and multiple-revision ACL reconstructions: a MARS cohort study. Am J Sports Med, 41(7), 1571-1578. doi: 10.1177/0363546513487980

• RESULTS: A total of 1200 patients

• The most common cause of reruptures was a traumatic, noncontact ACL graft injury in 55%

• 25% of patients had a nontraumatic, gradual-onset recurrent injury, and

• 11% had a traumatic, contact injury.

Getgood, A., & Spalding, T. (2012). The evolution of anatomic anterior cruciate ligament reconstruction. Open Orthop J, 6, 287-294. doi: 10.2174/1874325001206010287

Getgood, A., & Spalding, T. (2012). The evolution of anatomic anterior cruciate ligament reconstruction. Open Orthop J, 6, 287-294. doi: 10.2174/1874325001206010287

Illingworth, KD, et. Al., Fu, “A Simple Evaluation of Anterior Cruciate Ligament Femoral Tunnel Position: The Inclination Angle and Femoral Tunnel Angle,” Am. J. Sports Med 39:12 (December, 2011), pp. 2611-2618.

Ahn, J. H., et al (2013). 3-D reconstruction computed tomography evaluation of tunnel location during single-bundle anterior cruciate ligament reconstruction: a comparison of TT and 2-incision TTI techniques. Clin Orthop Surg, 5(1), 26-35.