Abstract
Background:
Anterior cruciate ligament (ACL) reconstruction is a common orthopedic surgery, and due to the increased number of primary reconstructions being performed, the number of revision ACL reconstructions is also increasing.
Indications:
Two-stage revision ACL reconstruction has lower failure rates compared to 1-stage and is indicated when significant tunnel expansion has occurred or malpositioned tunnels prohibit an adequate reconstruction. In this presentation, 2-stage revision ACL reconstruction was performed with an arthroscopic bone grafting technique of both the femoral and tibial tunnels secondary to tunnel osteolysis.
Technique Description:
Standard diagnostic arthroscopy is performed, and any chondral or meniscal pathology is addressed. The remnant ACL graft and all hardware are removed. The tunnels are debrided thoroughly. Using a modified syringe, the tunnels are packed with a mixture of cancellous bone chips and cortical fibers that have been hydrated with whole blood and platelet-rich plasma (PRP). The patient is placed into a brace postoperatively, and a computed tomography (CT) is obtained approximately 4 to 6 months postoperatively to assess for bone healing. Revision ACL reconstruction is performed once indicated with standard rehabilitation and return to play protocol.
Results:
Both 1-stage and 2-stage revision ACL reconstructions have been demonstrated to have significant improvement in outcomes scores preoperatively to postoperatively. However, 2-stage has lower failure rates compared to single-stage and has a high return to level of play.
Discussion/Conclusion:
Revision ACL reconstruction is becoming more commonly performed, and 2-stage revision is frequently required due to multiple factors. In this video, we demonstrate bone grafting for revision ACL reconstruction for tunnel osteolysis.
Patient Consent Disclosure Statement:
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
This is a visual representation of the abstract.
Video Transcript
This presentation will focus on revision anterior cruciate ligament (ACL) reconstruction, specifically 2-stage revision ACL reconstruction with arthroscopic tunnel bone grafting, with a review of our preoperative planning, a description of our surgical technique, and outcomes, presented by doctors Ryan H. Barnes, Christopher C. Kaeding, Robert A. Magnussen, and David C. Flanigan from the Sports Medicine Institute within the Department of Orthopedic Surgery at The Ohio State University. Our disclosures can be found on the AAOS (American Academy of Orthopaedic Surgeons) website. Here is a brief outline for the presentation.
ACL reconstructions continue to increase annually in the United States, with an estimated 175 000 to 200 000 performed each year. 5 With this increase in primary reconstructions, the number of revision reconstructions has also increased, with an estimated graft rupture rate ranging from 1.8% to 10.4% at 5 years. At 6-year follow-up, 18.9% of patients who had undergone ACL reconstruction underwent subsequent surgeries, with younger age at index surgery and the use of allografts being risk factors for requiring a second surgery.
Risk factors for ACL reconstruction failure is multifactorial, but 75% of failures are attributable to technical factors. 4 The remaining are secondary to trauma. Female sex, younger age, and graft type are also risk factors for ACL reconstruction failure.
When seeing these patients in the clinic, it is crucial to elicit a thorough history including their initial injury, details from their index surgery including when, what type of graft and hardware that was used, if there were any other concomitant surgery performed, if there were any postoperative complications, and details regarding rehabilitation and return to sport. If possible, it is important to obtain an operative report and intraoperative arthroscopic pictures. It is then key to ask the patient about their most recent symptoms, if there was an injury, if they are having any mechanical symptoms, and what are their athletic goals.
Along with a thorough history, it is important to perform a comprehensive physical exam. This includes evaluating the skin and looking at scars from prior incisions, assessing the patient’s overall lower extremity alignment for varus or valgus angulation, the knee’s range of motion, and a ligamentous examination, performing anterior and posterior drawer, Lachman test, pivot shift, and assessing for a possible posterolateral corner injury which could lead to primary ACL reconstruction failure. It is then important to evaluate the patient’s neurovascular exam, assess the patient’s gait, and consider other possible causes of failure including ligamentous laxity.
Preoperative assessment should include plain radiographs, computed tomography (CT) to assess for tunnel expansion, and magnetic resonance imaging (MRI) to assess the integrity of the graft and if there was an injury that was not addressed at the index surgery that could potentially contribute to continued instability. It is also important to rule out a latent infection, so obtaining basic infection labs with complete blood count (CBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) should be obtained. You can also consider aspiration of the knee and sending the aspirated fluid for cell count, cultures, and possible Synovasure to rule out infection. Computed tomography remains the gold standard for evaluating for tunnel widening and osteolysis, as it provides the best bony detail to characterize the precise tunnel position and size. 7 However, 3D MRIs have been reported to have similar accuracy as CT scans with the additional benefits of reducing exposure and potentially eliminating the cost of obtaining a CT scan. 3
Indications for 2-stage revision ACL reconstruction includes malpositioned bone tunnels that will interfere with revision reconstruction tunnel placement and the presence of tunnel osteolysis, active infection, and arthrofibrosis with loss of motion.2,7 Bone grafting as the first stage has been shown to improve the success of revision ACL reconstruction. Various techniques exist for bone grafting the tunnels including allograft chips, struts, autografting, and using bone dowels. 1
This case is of a 44-year-old female who initially presented to our clinic 2 years following a right ACL reconstruction complaining of continued right knee pain and instability without a specific injury. On examination, she had a positive anterior drawer, Lachman, and pivot shift. Radiographs, MRI, and CT scans show significant tunnel dilation, and the MRI shows re-tear of the graft.
The patient is placed in a supine position, and a tourniquet is placed on the operative thigh but is typically not inflated. A foot holder and lateral thigh post are placed to aid in positioning intraoperatively. Depending on the hardware from the index surgery, fluoroscopy should be available. Prior to starting, an examination under anesthesia should be performed.
A standard diagnostic arthroscopy is performed to evaluate the integrity of the cartilage and menisci. The remnant ACL graft is then assessed in the notch. It is important to evaluate the tunnel placement on the femoral and tibial sides. The ACL should then be debrided using a combination of a shaver and biter. Biopsy of the ACL and synovium can be obtained if there is concern for infection. Hardware should be removed. Next, the femoral tunnel should be thoroughly debrided with a combination of shaver and curettes until a bleeding bony bed is obtained. An accessory medial portal can be used to obtain the appropriate trajectory to the femoral tunnel if required.
Once satisfied with femoral tunnel debridement, attention is turned to bone grafting the femoral tunnel. The tip of a 3-cc syringe is cut off and filled with a mixture of cancellous bone chips and cortical fibers that have been hydrated with whole blood and platelet-rich plasma (PRP). Using an extended accessory anterior medial portal, the syringe is placed into the tunnel and the mixture is injected into the tunnel. Bone tamps are then used to compress the graft, and the tunnel is filled and tamped until filled.
Next, the tibial tunnel is addressed. Using the prior incision for the tibial tunnel, the process of hardware removal, biopsy, and tunnel debridement is repeated in a similar fashion to the femoral tunnel. When bone grafting the tibial tunnel, the knee is extended, and a key elevator is inserted through the anteromedial portal and placed over the tibial tunnel to block graft from extruding into the joint. The bone graft mixture is then inserted up the tibial tunnel and impacted with a tamp until filled. By keeping the knee in extension, the key elevator is held in place over the tibial tunnel aperture while filling the tunnel with bone graft. Once the graft has been sufficiently packed, the key elevator is removed, and the scope is inserted to ensure no extrusion of the graft into the joint. The incisions are then closed in layers, with careful attention to the tibial tunnel outlet closure to prevent any graft extrusion, and a sterile dressing is placed along with a hinged knee brace.
Postoperatively, the patient is weight-bearing as tolerated with the hinged knee brace locked in extension for 2 weeks but allowed to start range of motion. Following the 2 weeks, the patient is transitioned into an ACL brace. The patient is followed postoperatively with radiographs at the 2-week, 6-week, and 3-month postoperative appointment. A CT scan is obtained at approximately the 6-month postoperative appointment to assess for consolidation and allow progression to the second stage; however, the duration can change depending upon the amount of preoperative tunnel expansion. Once there is adequate bony healing, the second stage with revision ACL reconstruction can be performed, with the surgeon’s graft choice depending on patient factors.
Outcomes of 1-stage versus 2-stage revision ACL reconstruction have both been shown to have significant improvements preoperatively to postoperatively. 6 Although it did not reach statistical significance, Mitchell et al 6 reported a 10.3% failure rate following 1-stage revision ACL reconstruction versus 6.1% failure rate for 2-stage revision ACL reconstruction. Two-stage revision ACL reconstruction has been reported to have good long-term follow-up data with significant improvement in IKDC (International Knee Documentation Committee) and Lysholm scores as well as return to preoperative sport activity level.
Here is a list of our references. We hope you have found this presentation to be helpful, and we appreciate your time and attention. Thank you.
Footnotes
Submitted December 13, 2023; accepted September 25, 2023.
One or more of the authors has declared the following potential conflict of interest or source of funding: C.C.K. received consulting fees from Zimmer Biomet, Arthrex, Bioventus; education payments from CDC Medical; grant support from DJO; fees for services other than consulting from Arthrex and Smith & Nephew; and honoraria from NovoPedics. R.A.M. received education payments from CDC Medical and a grant from DJO LLC. D.C.F. received consulting fees from Ceterix, DePuy/Medical Device Business Services, Linvatec, Smith & Nephew, Vericel, Bioventus LLC, and Zimmer Biomet; nonconsulting fees from Pacira Pharmaceuticals, Karl Storz Endoscopy-America; and honoraria from Vericel. 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.
