Abstract
Background:
The number of multiply revised anterior cruciate ligament reconstructions (rrACLRs) performed each year continues to increase. The most reliable graft type and surgical technique in the young, active patient remains to be determined.
Purpose:
To determine the outcomes of rrACLR using quadriceps tendon (QT) autograft with lateral extra-articular tenodesis (LET).
Study Design:
Case series; Level of evidence, 4.
Methods:
A retrospective review was performed of all competitive athletes undergoing rrACLR with QT autograft and LET at a single institution with a minimum follow-up of 2 years. Patient demographics, physical examination, and radiological findings, and previous surgical details were documented. Patient outcomes were noted, including the International Knee Documentation Committee (IKDC) and Lysholm scores, ability to return to sport and return at the same level of play, retear rate, and other complications.
Results:
A total of 19 rrACLRs were performed and met inclusion criteria in the 10-year study period. All participants were high school, collegiate, or professional athletes with a mean age of 22 years, and 63.2% were female. The mean follow-up was 42.3 months, and IKDC scores increased from 51.6 preoperatively to 74.7 at the final follow-up (P < .001). Likewise, the Lysholm score increased significantly from a preoperative value of 53.6 to 76.8 at the final follow-up (P < .001). Return to play was possible in 52.6% of the patients at a mean of 11.5 months, with 31.6% returning to the same or higher level of play. One (5.3%) patient experienced a recurrent ACL tear, and 2 (10.5%) experienced a contralateral tear. Arthrofibrosis requiring surgical intervention occurred in 26.3% of the athletes.
Conclusion:
Short- to midterm results demonstrated that competitive athletes who received an rrACLR using a QT autograft with LET had statistically significant improvements in both IKDC and Lysholm scores, with more than half of patients being able to return to sport and nearly a third returning at the same or higher level of play. In the setting of a third ACL reconstruction, quadriceps tendon autograft with LET is a reasonable option even in high-risk patients.
Keywords
Competitive athletes are at an elevated risk for anterior cruciate ligament (ACL) injuries given the involvement of cutting and pivoting movements. When these injuries increase, so do the number of ACL reconstructions (ACLRs), as this procedure is now one of the most frequently performed orthopaedic surgeries in the United States.5,29 While advancements in surgical techniques and rehabilitation protocols have improved outcomes, revision ACLR (rACLR) and multiply revised ACLR (rrACLR) due to graft failure hold significant challenges, particularly in high-risk populations such as competitive athletes. 8
Although there has been notable improvement in technique, failure rates after a single rACLR have been noted in up to 30% of patients. 8 It has been well established that the outcomes after rACLR and rrACLR are clinically inferior to those after the primary ACLR, with guarded return-to-sport rates and knee function.8,10,11,16 Furthermore, there are unique technical and clinical factors that complicate this surgery. Knee malalignment, poor previous tunnel placement, concomitant injuries, and limited graft choices are among the frequently encountered considerations in this patient cohort that must be addressed to optimize outcomes.8,10,11,16
Regarding graft selection, surgeons are often confronted with limited options in the setting of rrACLR. For example, traditional ipsilateral autografts may not be available, and contralateral graft harvest is not without notable morbidity in the competitive athlete. 25 In this context, despite the known increase in failure rate, the majority of rrACLRs in previous literature have been performed with allograft.7,8 Given its accessibility, tensile properties, and functional 6 and clinical 4 outcomes, the quadriceps tendon (QT) autograft has become an increasingly popular option, especially in the setting of rrACLR. 27 Furthermore, lateral extra-articular tenodesis (LET) has also gained traction as an adjunct to ACLR to lower the risk of graft retear in high-risk populations and in the revision setting.1,8,12 For example, in the primary rACLR, Alm et al 1 noted a significant decrease in failure after augmentation with LET when evaluating hamstring, bone–patellar tendon–bone, and QT autografts. In this challenging patient population, QT autograft with LET augmentation is increasingly becoming a more common combination of graft choice with an adjunct procedure. 31
In the case of failure of a revision surgery, the repeat revision (rrACLR) is a challenging clinical problem with limited evidence in the setting of use of QT autograft with LET augmentation. The purpose of this study was to report the clinical and functional outcomes of rrACLRs utilizing a QT autograft with LET augmentation in the high-risk competitive athletic population at a minimum follow-up of 2 years. Given the known outcomes from the existing literature on LET and QT autograft, we hypothesized that this patient cohort would have similar patient-reported outcome (PRO) measures at the final follow-up and similar return-to-sport rates to those who underwent single-revision ACL surgery.
Methods
Patient Selection and Outcomes
Analysis of the records of patients undergoing rrACLR by a single fellowship-trained sports medicine surgeon (K.J.E.) between June 2012 and November 2019 was retrospectively performed. Patients were included in the study if they underwent reconstruction with a QT autograft with LET augmentation; were at least 18 years of age; were actively involved in high school, collegiate, or professional sports; and had at least 2 years of follow-up. Exclusion criteria included multiligamentous knee injuries, those with a posterior tibial slope ≥13°, and those who underwent concomitant procedures outside of meniscal debridement or repair.
Included patients underwent chart review to evaluate demographics, operative dates, initial and revision graft selection, level of sport, return to sport and level returned to, and complications. PROs, including the International Knee Documentation Committee (IKDC) and Lysholm scores, were collected preoperatively and at 6 months, 1 year, and 2 years after surgery. Patients with incomplete PRO scores were contacted by telephone to complete the forms remotely.
Surgical Indications
The graft choice was made after a detailed discussion with the patient. If the patient had previous reconstruction with either bone–patellar tendon–bone or hamstring tendon, then the ipsilateral QT was offered as a repeat revision graft choice. During the study period, it was the surgeon’s standard practice to add an LET to any repeat revision reconstruction, and thus this represents a continuous series. Slope-correcting procedures were offered in cases with a posterior tibial slope >12°, but these cases were excluded. Tibial slope was measured on a lateral knee radiograph after drawing 2 circles along the tibial metaphysis and diaphyseal region to define the longitudinal axis. The posterior slope was then measured along the medial tibial plateau. Bone grafting and staging were performed in cases with tunnel widening >13 mm or tunnel malposition as determined by the senior author (K.J.E.) on preoperative advanced imaging.
Surgical Procedure
Standard supine patient positioning, nonsterile tourniquet application, and general anesthesia with a femoral nerve block were utilized in all cases. Diagnostic arthroscopy was performed to confirm graft rupture and evaluate for concomitant pathology. QT graft harvest was performed through an approximately 3 cm–long transverse incision just proximal to the superior patellar pole. The QT was identified and cleared off before a 9-mm double-bladed knife (Arthrex) was used to make 2 incisions outlining the central portion of the tendon. Sharp dissection was used to remove the tendon from the proximal patella and subsequently whipstitched. The proximal aspect of the graft was transected with a cigar cutter (Arthrex). The length of graft harvested was based on the patient’s height (60-mm graft for patients ≤5 feet 5 inches, 65-mm graft for patients 5 feet 6 inches to 6 feet 1 inch, 70-mm graft for patients 6 feet 2 inch to 6 feet 6 inches, and 75-mm graft for patients ≥6 feet 6 inches). A tightrope (Arthrex) was sutured to the proximal graft end, and an Attachable Button System (Arthrex) was sutured to the distal end.
An all-inside technique was performed in all cases. A 7-mm over-the-top guide was used for femoral tunnel placement before overreaming to create a 25-mm femoral socket. Anterior tibial hardware was removed as necessary before a 55° tibial guide and FlipCutter (Arthrex) were used to create a 25-mm tibial socket. A 4.75-mm SwiveLock (Arthrex) was used to back up the tibial side of the graft in all cases.
A modified Lemaire LET was performed after the ACLR. An approximately 5-cm incision was made on the lateral aspect of the knee posterior to the femoral condyle. After dissection, a 1 × 8-cm central slip of the iliotibial band was sharply cut while maintaining the distal insertion onto the tubercle of Gerdy. After the proximal end was whipstitched with a No. 1 absorbable suture, the graft was placed deep to the lateral collateral ligament. A Beath pin was used to place the graft through the center of the anterolateral ligament insertion, with care taken to maintain an anterior-superior trajectory to avoid tunnel convergence. The location of this was roughly 5 mm posterior and proximal to the insertion of the femoral LCL attachment as described by Kennedy et al. 20 After reaming a 6-mm tunnel, a 7-mm biocomposite screw was used to fix the graft in the tibia with the knee in 60° of flexion and neutral foot position.
Postoperative Protocol
All patients were placed in a hinged knee brace locked in extension and were allowed 50% weightbearing for the first 2 weeks. After 2 weeks, patients were able to bear weight as tolerated. At 6 weeks, the brace was discontinued. Physical therapy focused on range of motion and quadriceps strengthening and was initiated at 2 weeks. In those who underwent meniscal repair, patients were 50% weightbearing with the brace locked in extension for 4 weeks. The brace was unlocked at 4 weeks with gradual progression of weightbearing. Return to sport was determined after the patient demonstrated lack of effusion, strength 90% of the contralateral side, and single-hop and triple-crossover-hop tests within 10% of the contralateral side. Arthrofibrosis requiring intervention in this study was considered a lack of 110° of knee flexion by the eighth postoperative week. The athlete was also required to complete the lower extremity functional test with physical therapy. After these benchmarks were met, the athlete progressed through sport-specific activities before final clearance was granted from the senior surgeon.
Manipulation Under Anesthesia
Range of motion was carefully measured at each postoperative visit. If the patient did not reach at least 110° of flexion at 8 weeks postoperatively, they were consented for manipulation under anesthesia (MUA) with or without lysis of adhesions (LOA). Patients who underwent manipulation had physical therapy for 5 days after the procedure. Once the patient demonstrated full range of motion, they were returned to the above ACL postoperative protocol.
Statistical Analysis
Descriptive statistics are used for patient demographics, return-to-sport timeline, and return-to-sport level (Table 1). A Student t test with a P value set to .05 was used to compare preoperative with postoperative PRO scores. Statistical analysis was performed with Microsoft Excel (Microsoft).
Characteristics of the Study Population (N = 19) a
Data are reported as n (%) or mean ± SD. ACL, anterior cruciate ligament; BMI, body mass index; BTB, bone–patellar tendon–bone; LFC, lateral femoral condyle; MFC, medial femoral condyle; PF, patellofemoral.
Results
Patient Characteristics
A total of 29 patients underwent rrACLR with LET. Nineteen of these patients met inclusion criteria and were included, and 10 patients were excluded due to loss to follow-up (n = 1), <2 years of follow-up (n = 4), or inactivity in competitive sports at the time of re-revision (n = 5). A summary of the patient demographics is shown in Table 1. The mean follow-up percentage of the included patients was 96.6%. The mean age of the patients was 22 years, and 63.2% of the patients were female. All participants were competitive athletes, with 10.5% of the participants playing at the high school level, 68.4% playing at the college level, and 21.1% playing at the professional level. Thirteen (68.4%) athletes played soccer, 4 (21.1%) played football, and 2 (10.5%) played lacrosse.
For their first ACLR, 10 (52.6%) patients received a bone–patellar tendon–bone autograft, 8 (42.1%) received a hamstring tendon autograft, and 1 (5.3%) received an allograft. For their second ACLR, 8 (42.1%) patients received a bone–patellar tendon–bone autograft, 6 (31.6%) received a hamstring tendon autograft, and 5 (26.3%) received an allograft. During the third ACLR with LET, 4 (21.1%) patients underwent a medial, lateral, or bilateral meniscectomy, and 6 (31.6%) underwent a medial, lateral, or bilateral meniscal repair. Furthermore, a majority of the patients (n = 14, 73.4%) underwent chondroplasty at the time of the third surgery, including 10 (52.3%) patients at the patellofemoral joint, 3 at the medial femoral condyle, and 1 at the lateral femoral condyle. The posterior tibial slope was measured at a mean of 8.6° (range, 6°-12°).
Postoperative Outcome Scores
IKDC and Lysholm outcome scores were obtained preoperatively to a mean follow-up of 42.3 months (Table 2, Figure 1). The IKDC score increased significantly from 51.6 preoperatively to 74.7 at the final follow-up (P < .001). Similarly, the preoperative Lysholm score was 53.6 and the score at the final follow-up was 74.3 (P < .001).
Outcomes of LET and Multirevision ACL Reconstruction (N = 19) a
Data are reported as n (%) or mean ± SD. Bold P values indicate a statistically significant difference between the final follow-up and the preoperative score (P < .05). ACL, anterior cruciate ligament; IKDC, International Knee Documentation Committee; LET, lateral extra-articular tenodesis.
International Knee Documentation Committee (IKDC) and Lysholm outcome measures at the preoperative and 6-month, 1-year, 2-year, and final follow-up time points. *Statistically significant difference compared with the preoperative time point. LET, lateral extra-articular tenodesis; QT, quadriceps tendon autograft; rrACLR, third revision anterior cruciate ligament reconstruction.
Clinical Outcomes
At the final follow-up, the knee flexion was measured to be a mean of 135.5° between all patients, and a positive pivot-shift test was exhibited in 4 (21.1%) patients. The mean posterior tibial slope of those who had a positive pivot-shift test was 8° (7°, 8°, 8°, and 10°). Within the patient population, 52.6% were able to return to play at a mean of 11.5 months. Specifically, 6 (31.6%) athletes returned to their same or higher level of play.
Complications
One (5.3%) patient of the 19 sustained a recurrent ipsilateral ACL tear (Table 3). This patient had a posterior tibial slope of 11°. Two (10.5%) patients had a contralateral ACL tear. Other complications included arthrofibrosis requiring surgery, which occurred in 26.3% (n = 5) of the athletes, and hematoma, which occurred in 10.5% (n = 2) of the athletes. Four of the 5 patients with arthrofibrosis required MUA. None of the patients with a hematoma required surgical intervention.
Complications of LET and Multirevision ACL Reconstruction (N = 19) a
ACL, anterior cruciate ligament; IKDC, International Knee Documentation Committee; LET, lateral extra-articular tenodesis.
Discussion
This study evaluated the 2-year clinical and surgical outcomes of high-level competitive athletes undergoing a third rACLR (rrACLR) utilizing a QT autograft with LET over a 10-year clinical period. In this challenging and rare clinical cohort, the main findings of this study were that patients had statistically significant improvements in both IKDC and Lysholm scores, with more than half of the patients being able to return to sport and nearly a third returning at the same or higher level of play. These results should be viewed in the context of a notably high overall complication rate, with >50% of patients experiencing postoperative complications and >25% requiring subsequent intervention for arthrofibrosis. Our findings suggest that rrACLR utilizing a QT autograft and LET is an acceptable option with fair clinical outcomes and modest return-to-sport rates compared with the literature noted below.
In their systematic review evaluating the third rACLR, D’Ambrosi et al 8 noted similar outcomes in a combined cohort of 295 patients with a mean age of 29.9 years with heterogeneous graft choices and inclusion of extra-articular augmentation (15.9% of patients). Notably, in terms of clinical outcomes, this review found a range of fair postoperative Lysholm scores from 68 to 90 and subjective IKDC scores from 58.9 to 84 at the final follow-up. These are similar to the mean postoperative Lysholm and IKDC scores at the final follow-up in our cohort (74.3 and 74.7, respectively) and notably lower than those with primary ACL revision (rACLR). 13 However, we found a significantly higher return-to-sport rate (52.6%) and, more importantly, return to same level of sport (31.6%) than the 10.5% of patients returning to the same level of sport in the review by D’Ambrosi et al. 8 This is especially important given the younger and higher-demand patients evaluated in our study and may be explained by the improved rotational stability afforded with the consistent use of LET augmentation.21,30
Despite the promising outcomes in this study after rrACLR, there is a consistent trend of worsening clinical and functional results as the number of revision surgeries increases, likely secondary to an increased cumulative burden of injury to the knee.8,13,14,22 In our cohort, 52.6% of patients had associated meniscal surgery performed, and 73.4% had evidence of chondral injury. This appears to be a trend in rrACLR, with previous reviews noting 62.6% of patients with meniscal injury and 85.4% with chondral injury. 8 Notably, chondral injury burden has previously been identified to be most strongly associated with inferior outcomes in the setting of ACLR.9,17 Our patient cohort also had a high rate of patellofemoral lesions (52.3%), which are known to be especially symptomatic in active patients and likely contributed to lower outcome scores. 28 These findings suggest that poorer outcomes in patients with multiple revisions are strongly influenced by osteoarthritic progression.
Another important finding in this study was that 53% of patients experienced a complication after rrACLR, with the most common being arthrofibrosis (n = 5, 26.3%) and rupture of the contralateral (n = 2, 10.5%) or ipsilateral (n = 1, 5.3%) ACL. Arthrofibrosis, especially anteriorly, has been noted as a complication after utilization of QT autograft, thought to be secondary to inherent graft stiffness, collagen density, and tensile strength.18,19 In their review of risk factors for MUA or LOA after ACLR, Huleatt et al 19 found that 8.3% of patients required this intervention with a 2.68 times elevated risk when utilizing a QT autograft compared with other graft types. Other notable risk factors included concurrent meniscal repair (OR, 2.83), age <18 years (OR, 2.39), multiple concomitant procedures (OR, 1.69), and female sex (OR, 1.6). 19 In the context of these reports, the elevated risk of arthrofibrosis in our study was likely reflective of (1) the contribution of multiple risk factors for arthrofibrosis and (2) the low threshold by the operating surgeon to return to the surgery for MUA/LOA. As noted in the Methods section, patients were indicated for intervention if they did not reach 110° of flexion by 8 weeks postoperatively, and the majority of these (80%) only required an MUA without arthroscopic LOA. This practice is in line with previous literature suggesting that earlier intervention for knee arthrofibrosis may lead to improved outcomes when present.2,3
Regarding the risk of subsequent ACL rupture, the risk reported in the current study is slightly better than those previously reported in the literature. For example, Engler et al 11 noted a 21% rate of recurrent graft failure and Griffith et al 16 noted a 13% rerupture risk in their cohorts of rrACLRs, which are higher than the 5.3% in our cohort. Both of these studies evaluated older patients and were heterogeneous in the graft type used, and importantly, they did not note LET augmentation. At the final follow-up, 21.1% of our patients were noted to have a residual pivot shift, which could be indicative of additional capsuloligamentous injury in the setting of multiple ACL tears not completely resolved with LET augmentation. In general, literature on the use of LET augmentation in rrACLR is limited, but our findings suggest that the additional rotational stability may reduce graft stress and be protective from subsequent rerupture in this challenging population.24,30 Our low retear rate with 2-year follow-up is especially important because we only evaluated high-risk competitive athletes with a mean age of 22 years, with the majority being female (63.2%) and playing soccer (68.4%). Furthermore, these patients undergoing rrACLR were likely selected because they were more motivated to return to sport, given their continued play after the initial injury.
Regarding contralateral ACL tears, the 10.5% tear rate in our cohort is consistent with those previously reported in high-risk populations 23 but lower than that reported in the revision setting. For example, Green et al 15 noted a 10% rate of contralateral ACLR in a pediatric population undergoing primary ACLR with QT autograft and LET augmentation, whereas Rayes et al 26 found that up to 27.8% of patients experienced an injury with bone–patellar tendon–bone autograft with LET augmentation in the revision setting. It can be postulated that patients with multiple ACL tears likely have additional inherent risk factors for ACL tear, such as pathological biomechanical movement patterns, ligamentous laxity, or elevated posterior tibial slope, which place them at a baseline elevated risk of injury to the contralateral limb.
This study is not without limitations. As a retrospective and observational study of high-level athletes undergoing a rrACLR, this is a rare cohort without a control group for comparison. Given the inherently small sample size, some complications and outcomes may have been missed or overestimated. No postoperative magnetic resonance imaging was performed to assess graft integrity. Furthermore, the procedures were performed by a single surgeon at a tertiary orthopaedic center, which may limit the generalizability of these findings to alternate practice settings.
Conclusion
Short- to midterm results demonstrated that competitive athletes who received an rrACLR using QT autograft with LET had statistically significant improvements in both IKDC and Lysholm scores, with more than half of patients being able to return to sport and nearly a third returning at the same or higher level of play. In the setting of a third ACLR, QT autograft with LET is a reasonable option even in high-risk patients.
Footnotes
Final revision submitted December 30, 2024; accepted January 27, 2025.
One or more of the authors has declared the following potential conflict of interest or source of funding: S.V.T. has received support for education from ImpactOrtho and hospitality payments from Stryker Corp. J.C.B. has received support for education from ImpactOrtho and hospitality payments from Stryker Corp. J.H. has received support for education from ImpactOrtho and hospitality payments from Stryker Corp. A.H. has received hospitality payments from Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
Ethical approval for this study was obtained from WCG IRB (IRB tracking No. 20216101).
