Second-Stage Revision Anterior Cruciate Ligament Reconstruction After Three Failures With Anterolateral Ligament Reconstruction,Medial Meniscal Root Repair With Centralization Suture,and Inside-Out Lateral Meniscal Repair

Abstract

Background:

Anterior cruciate ligament (ACL) graft failure is a relatively common occurrence and is even more likely in the presence of medial meniscal deficiency. ACL tears cause significant knee instability, particularly anterolaterally, and are commonly treated with a surgical reconstruction.

Indications:

During a revision ACL reconstruction (ACLR), clinical studies have demonstrated that correcting medial meniscus pathologies and reconstructing the anterolateral ligament (ALL) improve outcomes. This is the patient's fourth ACLR, complicated by a concomitant extruded medial meniscal root tear, and confirmed on clinical examination and imaging. An ALL reconstruction (ALLR) and medial meniscal root repair with a centralization suture were therefore indicated during the revision ACLR.

Technique Description:

The technique described was used for a revision ACLR after 3 failed reconstructions with a concomitant ALLR and lateral meniscal peripheral and medial meniscal root repair as part of the second stage of a 2-stage surgery. The first stage of surgery included ACL tunnel debridement and bone grafting. The second stage procedure described here included a revision ACLR with bone-patellar tendon-bone autograft and an ALLR using the inferior portion of the iliotibial band, fixated with suture anchors to recreate the anatomic proximal and distal attachment sites. For the menisci, a lateral meniscal posterolateral peripheral tear was repaired using an inside-out technique, and the medial meniscal root tear was repaired with a double transtibial tunnel root repair with a centralization suture to reduce extrusion.

Results:

Recent literature has demonstrated that rerevision ACLR improved functional outcomes and overall knee stability. Despite these improvements, the overall rate of return to preinjury activity levels was poor, with high inter-study variability.

Discussion:

A complex revision ACLR with an ALLR and multiple meniscal repairs is described, along with technical considerations to improve long-term outcomes and minimize complication risks.

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.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

This is a video presentation depicting a second-stage revision of anterior cruciate ligament reconstruction (ACLR) after 3 failures with an anterolateral ligament reconstruction (ALLR), medial meniscal root repair with a centralization suture, and an inside-out lateral meniscal repair.

Background

The role of the ACL is to stabilize the knee by preventing excessive anterior tibial translation on the femur and by limiting rotational knee movements. ACL tears cause significant anterolateral knee instability and are commonly treated with a surgical reconstruction using bone-patellar tendon-bone (BPTB), hamstring, or quadriceps tendon autografts. ⁶ In revision cases, an adjunctive ALLR may be warranted to enhance graft stability.^10,12 The incidence of medial meniscal root tears in revision ACLRs is reported to be 5.6%, with medial meniscal root tears occurring about 4 times less frequently than lateral meniscal root tears. ² Given the propensity for root tears to increase contact pressures, this may lead to early-onset symptomatic cartilage damage over time.^4,8 Medial meniscal root tears, defined as avulsions or radial tears within 1 cm of the tibial attachment, may present with medial extrusion. ⁸ In such cases, a centralization suture should be considered alongside a transtibial tunnel repair to restore the dispersion of hoop stress and restore meniscal function, as it has demonstrated improved clinical outcome scores.^5,13

The patient presented is a 35-year-old man who has recurrent right knee pain and instability after 3 previous right knee ACLRs with 2 Achilles tendon allografts and, most recently, a contralateral hamstring autograft. The patient sustained a noncontact reinjury while planting during a basketball game 8 months before presenting to the clinic.

Indications

On initial physical examination, the right knee revealed a symmetric range of motion to the contralateral side with 3 cm of heel height to 140° of flexion. He had a positive Lachman test, a high-grade pivot shift test, and pseudo-laxity with valgus stress consistent with disruption of the revision ACLR graft and possible medial meniscal root pathology.

Standing lateral radiographs of the right knee demonstrated a posterior tibial slope (PTS) of 12.4° and an anteriorly translated tibia consistent with a failed ACLR. The Rosenberg view demonstrated mild degenerative changes of the right medial compartment, and the long leg standing anteroposterior view demonstrated neutral mechanical alignment. Magnetic resonance imaging of the right knee demonstrated an ACLR graft tear, with a possible medial meniscal root tear. Right knee computed tomography (CT) demonstrated tunnel widening with 2 diverging femoral tunnels measuring approximately 14 mm in diameter on sagittal CT and a large tibial tunnel measuring 17 × 18 mm on axial CT.

Technique Description

Due to recurrent ACLR failure and significant tunnel widening, a staged revision ACLR was recommended. ⁹ Stage 1 proceeded as a debridement and bone grafting of the tibial and femoral tunnels. Intraoperatively, a peripheral tear of the lateral meniscus and a posterior horn medial meniscal type 2 root tear with significant extrusion were identified. These were planned to be repaired during stage 2 to avoid recurrent periods of immobility, allow weightbearing to facilitate bone graft incorporation, and prevent damage to the repair in the setting of persistent ligament instability.

Six months were allowed for the healing of the bone-grafted tunnels. Then, a right knee revision ACLR with BPTB autograft and an anatomic ALLR using the inferior iliotibial band (ITB), along with a concomitant medial meniscal root repair and a lateral meniscal peripheral tear repair, proceeded.^9,12 The ALLR was ultimately chosen over a lateral extra-articular tenodesis due to the preference of the surgeon in providing a robust reconstruction graft in the face of 3 previous failed ACLRs. A slope-reducing osteotomy was considered, given the borderline PTS, but ultimately decided against, given the decreased failure rates with the preferable BPTB autograft availability and the stability added from an ALLR. The patient's examination under anesthesia confirmed the previous clinical findings and surgical plan, with a high-grade pivot shift and a positive Lachman test.

First, the central third of the patellar tendon was harvested, including 10 × 20 mm patellar and 10 × 25 mm tibial tubercle bone plugs to create the ACL BPTB autograft. The autograft was then prepared at a separate table, sized to pass through 10-mm tunnels with 2 passing sutures fixed to each bone plug.

Next, the ALLR was approached by creating a 10-cm incision centered over the ITB, terminating at Gerdy's tubercle. Once isolated, an 8 cm long by 1 cm wide inferior strip of the ITB was harvested to serve as an autograft for the ALLR, amputating the proximal portion while leaving the distal attachment intact at Gerdy's tubercle. To best approximate the anatomic tibial attachment of the ALL, a spinal needle was inserted into the lateral joint line. Using this needle as a landmark, a Q-Fix anchor (Smith & Nephew) was placed 1 cm distal to the joint line midway between Gerdy's tubercle and the anterior margin of the fibular head, and the graft was sewn in at the tibial attachment site of the ALL. On the femur, the fibular collateral ligament was utilized to help identify the lateral epicondyle and the femoral ALL attachment. Another Q-Fix anchor (Smith & Nephew) was placed 5 mm posterior and proximal to the lateral epicondyle to serve as the femoral attachment of the reconstructed ALL. The distal portion of the graft was then fixed using a modified Mason-Allen stitch technique, while the proximal end of the graft was approximated over the anatomic femoral ALL attachment anchor.

Medial and lateral parapatellar arthroscopic portals were created next. Arthroscopy of the joint demonstrated grade 2 chondromalacia of the medial femoral condyle and trochlear groove. A gentle trochlear groove chondroplasty was then performed. The posterior medial meniscal root was detached, and the meniscus was significantly extruded, which was consistent with the previous arthroscopic examination. The lateral meniscal peripheral tear was visualized and appeared repairable without signs of bucketing.

Next, attention was turned to creating the femoral ACLR tunnel. A debridement notchplasty was performed initially to restore the normal notch contour and minimize the chance of graft impingement. The back wall of the lateral femoral condyle was then viewed from an accessory far anteromedial portal, and a bur hole was placed at the midpoint of the normal attachment sites of the anteromedial and posterolateral bundles. The knee was then maximally flexed, and a beath pin was drilled anterolaterally out of the patient's thigh. Once the beath pin was placed, the tunnel was then over-reamed with a 10-mm low-profile reamer to a depth of 25 mm, ensuring a 2-mm back wall was maintained. A passing stitch was then placed to later facilitate graft insertion.

Next, the lateral meniscal peripheral tear was addressed. First, dissection was performed anterior to the lateral gastrocnemius tendon and superior to the biceps femoris tendon to insert a retractor to maintain visualization as well as provide protection for the posterior knee neurovasculature from the inside-out needles. A ball rasp was then used on the edges of the patient's lateral meniscal tear to stimulate healing. The lateral meniscus was repaired with 4 vertical mattress inside-out sutures placed and then tied externally.

Then, the patient's posterior medial meniscal root tear was addressed with a transtibial root repair and a centralization suture. First, a curette was used to localize tunnel placement for the meniscal root attachment. Next, a scissor biter was used to release the extruded medial meniscus from the capsule, to allow anatomic reduction of the medial meniscus. An aiming device and a guide pin were used to create 2 transtibial tunnels to the previously decorticated meniscal root footprint. First, the posterior tunnel for the root footprint was created, and a 5 mm parallel offset guide was used to then drill the more anterior tunnel in the footprint. The tunnels were placed to ensure they are preserved during the upcoming ACLR tibial drilling, and 2 cannulas were inserted into the tunnels to mark their locations and assist with suture passage. A right curved mini FirstPass (Smith & Nephew) was used to place 2 vertical mattress UltraTape sutures (Smith & Nephew) into the medial meniscal root tear that were subsequently shuttled down the cannulas. This reduced the medial meniscus to its anatomic attachment, but for full reduction and optimal contact area, a centralization suture was required.

The position of the centralization suture tunnel was localized by making a small nick in the far posteromedial aspect of the medial tibial plateau cartilage with a curette to identify the target of the tibial guide. The tunnel was created with the tibial guide and a guide pin, then an UltraTape horizontal mattress suture (Smith & Nephew) was placed before being shuttled down the cannula. This eliminated medial meniscus extrusion when traction was applied to the stitch.

After this, the ACL tibial attachment was visualized both medially and laterally, using the anterior horn of the lateral meniscus as a guide, given the known 41% overlap with the ACL footprint. ¹¹ The ACL tibial tunnel was then planned, accounting for the previous trajectories of the 3 transtibial root repair tunnels and staying in proximity to the tibial tubercle. The tibial tunnel pin was placed and overreamed to 10 mm, while the other sutures were held to prevent capture. The tunnel was subsequently visualized to confirm that adequate bleeding bone from the previous bone grafting was present, indicating good bony healing.

The ACL graft was then pulled into the femoral tunnel and fixed in the femur with a 7 × 20– mm titanium screw. The root repair sutures were then tied over an Endobutton (Smith & Nephew) while the centralization suture was held to maintain the reduction of the meniscus. The centralization suture was then tied over an Endobutton. Then a 9 × 20–mm screw was fixed in the tibial tunnel with the knee in full extension while aiming the screw laterally to avoid contact with the root repair sutures.

Lastly, the ALLR was completed by fixating the graft to the femoral anatomic attachment site with the previously placed Q-Fix anchor (Smith & Nephew) while the knee was flexed to 20° and the foot in a neutral position.

Repeat examination demonstrated elimination of the Lachman test and no internal rotation on the pivoting simulation.

Results and Discussion

Given the complexity of this surgery, multiple technical considerations should be taken into account to avoid complications. Graft optimization is an important first step. Achilles tendon allografts have been used frequently in the past, but recent evidence indicates that autografts are superior, particularly in young and active patients.^1,10 Another complication is the risk for tibial tunnel convergence due to the 4 tunnels being created within the tibia. Minimizing the risk of tunnel convergence necessitates meticulous planning of the tunnel trajectories and careful marking of tunnel locations. The medial meniscal root repair tunnels should be drilled in parallel to the ACL tibial tunnel in the sagittal plane to reduce convergence risk. ³ The medial meniscus centralization suture tunnel may then be placed more anterior and slightly lateral with a decreased angle from the axial plane. An additional potential complication is ACL graft impingement at the roof of the intercondylar notch due to osteophytes. To address this, a notchplasty should be considered. The knee should be cycled several times after graft fixation to ensure that no residual impingement remains.

The patient began physical therapy on postoperative day 1, emphasizing quadriceps activation, edema control, and range of motion. He will be nonweightbearing on the right lower extremity for 6 weeks, with knee flexion limited to 90° for the first 2 weeks, after which he can increase as tolerated. Then, 6 weeks after surgery, he may initiate a partial protected weightbearing program in his ACL brace while slowly weaning off crutches as he is able to walk without a limp. Rehabilitation will primarily focus on motion initially to ensure biologic healing in light of this very complex reconstruction.

A systematic review by Olson et al ⁷ included 399 patients who underwent rerevision ACLR. The rerevision ACLR was demonstrated to improve functional outcomes and overall knee stability. Despite these improvements, there was an overall poor rate of return to preinjury activity level with high variability within the studies reviewed, ranging from 12.5% to 80%, with the majority of the studies reviewed showing a return to previous activity levels of <50%. Consequently, it is essential to optimize the surgical procedure and recovery adequately to maximize the potential for return to full activity.

Plain films were obtained on postoperative day 1. They demonstrated anatomic ACLR hardware placement.