Abstract
Background: The outcome of revision anterior cruciate ligament
reconstruction has only rarely been reported. The purpose of this study was to
evaluate the results of revision anterior cruciate ligament surgery with use
of an autogenous doubled semitendinosus and gracilis graft in association with
an extra-articular procedure.
Methods: Between 1997 and 2003, thirty patients underwent a repeat
reconstruction of a previously reconstructed torn anterior cruciate ligament
with use of a doubled semitendinosus and gracilis graft combined with an
extra-articular reconstruction. Primary reconstruction had been done with an
autogenous patellar tendon graft in twenty-six patients and with a prosthetic
ligament in four patients; the average time from the primary reconstruction to
the revision was five years. Functional outcomes, graft survival, and
radiographic outcomes were evaluated at a mean of five years. A graft was
considered to have failed when a revision was done or when the side-to-side
difference on KT-1000 arthrometer testing was >5 mm and/or the pivot-shift
test grade was greater than a trace.
Results: One patient underwent another revision reconstruction
because of graft failure at three years postoperatively. The mean
International Knee Documentation Committee (IKDC) subjective knee score for
the remaining twenty-nine patients was 84 ± 12 points, and the mean
Lysholm knee score was 90 ± 10 points. The side-to-side difference as
measured with the KT-1000 arthrometer with maximum manual force was <3 mm
in twenty patients (of the twenty-eight who returned for follow-up), between 3
and 5 mm in six patients, and >5 mm in two patients. The result of the
pivot shift examination was normal in fifteen patients, slightly positive in
eleven patients, and positive in two patients. Twenty-five percent of the
patients showed no radiographic signs of degenerative joint disease.
Conclusions: Revision anterior cruciate ligament reconstruction with
use of an autogenous doubled semitendinosus and gracilis graft combined with
an extra-articular procedure provided satisfactory functional outcomes, with a
failure rate of 10%.
Level of Evidence: Therapeutic Level IV. See Instructions
to Authors for a complete description of levels of evidence.
The rate of success of anterior cruciate ligament reconstruction ranges
from 75% to
95%1,2,
with most patients able to return to their desired daily or sport activities
and regaining knee stability. Although techniques and options for suitable
graft substitutes for use in anterior cruciate ligament reconstruction
continue to improve, failures can occur for many
reasons3,4.
The prevalence of failure is difficult to determine because of a lack of
uniformity in the definition of a failure. When failure has been defined as
recurrent laxity (side-to-side laxity in excess of 5 mm or a grade 2+ or
greater on pivot shift testing), the reported prevalence has ranged from 10%
to 25%5. Very few
reports deal with revision anterior cruciate ligament surgery. While some
investigators have reported the results of revision of a failed anterior
cruciate ligament reconstruction continue to improve, failures can occur for
many
reasons3,4.
The prevalence of failure is difficult to determine because of a lack of
uniformity in the definition of a failure. When failure has been defined as
recurrent laxity (side-to-side laxity in excess of 5 mm or a grade 2+ or
greater on pivot shift testing), the reported prevalence has ranged from 10%
to 25%5. Very few
reports deal with revision anterior cruciate ligament surgery. While some
investigators have reported the results of revision of a failed anterior
cruciate ligament reconstruction with use of a bone-patellar tendon-bone graft
from the contralateral side, an allograft, or a prosthetic
ligament6-10,
fewer have dealt with the outcomes of revision surgery with use of hamstring
tendons11,12.
The purpose of this study was to report our results of revision anterior
cruciate ligament surgery with a doubled gracilis and semitendinosus tendon
graft combined with an extra-articular stabilizing procedure.
Between 1997 and 2003, revision of an anterior cruciate ligament
reconstruction was performed with use of a doubled gracilis and semitendinosus
tendon graft in thirty consecutive patients in our hospital, and all were
included in this study. There were twenty-two men and eight women with a mean
age of thirty-four years (range, twenty-one to thirty-nine years). All
patients were retrospectively evaluated at a mean of five years (range, two to
eight years) after the revision anterior cruciate ligament reconstruction.
The primary anterior cruciate ligament reconstruction had been done in
other hospitals with use of either a bone-patellar tendon-bone graft
(twenty-six patients) or a prosthetic ligament (four patients). The average
time from the primary reconstruction to the revision was five years (range,
one to eleven years).
All patients had a preoperative evaluation consisting of a thorough
history, a physical examination, and calculation of the
Tegner13 and
Lysholm14
functional knee scores. Before the revision, all patients had recurrent knee
laxity (a positive Lachman test, a positive pivot shift test, and a
side-to-side difference of >5.5 mm on KT-1000 anterior drawer testing) and
episodes of giving-way with daily or sports activities.
All patients also had a standard standing radiographic examination to
evaluate the extent of degenerative changes, the orientation of the tunnels
and their possible enlargement, and the presence of fixation devices.
At the time of follow-up, twenty-eight patients returned for an evaluation
that included a thorough history, a physical examination, a radiographic
examination, and KT-1000 arthrometric testing. The follow-up evaluation also
included calculation of subjective functional
Tegner13 and
Lysholm14 scores
and subjective and objective International Knee Documentation Committee
(IKDC)15 scores.
One patient was evaluated only with the use of the rating scales, during a
telephone interview, and one patient had a repeat revision in another hospital
and was included with the result defined as a failure. Operative summaries of
the revision anterior cruciate ligament reconstructions were also reviewed to
determine cartilage and meniscal status. All postoperative evaluations,
including the radiographic scoring, were performed by an experienced
independent examiner (E.M.).
Revision Surgery
The same surgical technique—an arthroscopically assisted two-incision
procedure with autogenous ipsilateral doubled semitendinosus and gracilis
tendon grafts—was used by the same surgeon in all patients. The graft
was fixed on the femur with the Swing-Bridge (Citieffe, Bologna, Italy) in all
patients and on the tibia with two staples in eleven patients and with the
Evolgate device (Citieffe) in nineteen patients. The Swing-Bridge is a femoral
fixation device that can be used in double-incision anterior cruciate ligament
surgery; it offers very strong and stiff fixation, by means of its cortical
grip16,17
(Fig. 1). The Evolgate is a
tibial fixation device for soft tissues that is composed of three components:
a screw, a coil that is inserted inside the bone tunnel to reinforce the walls
of the tunnel, and a washer for cortical
fixation18,19
(Fig. 2).
In all patients, an extra-articular procedure (the Coker-Arnold
modification of the MacIntosh procedure) was also
performed20. In
this procedure, a portion of the iliotibial band is detached proximally,
reflected and passed under the lateral collateral ligament, and sutured under
tension with periosteal stitches to Gerdy's tubercle while the tibia is kept
in maximum external rotation (Fig.
3).
Rehabilitation Protocol
The knee was placed in a full extension brace for two to three weeks
postoperatively with weight-bearing allowed as tolerated with crutches.
Progressive range-of-motion exercises were then encouraged. At six weeks,
weight-bearing without crutches was permitted. From two to four months after
the surgery, a muscle-strengthening program was prescribed and a gradual
return to specific athletic training was allowed between four and six months
postoperatively.
Assessment
The final physical examination included evaluation of the range of motion,
measurement of the thigh circumference (10 cm proximal to the patella), and
stability tests. Ligamentous stability was assessed with the Lachman test and
was graded as +, 2+, or 3+. It was also evaluated with the pivot shift test
and was graded as + (slip), 2+ (jump), or 3+ (transient lock).
A detailed final follow-up questionnaire that included the IKDC 2000,
Lysholm, and Tegner scales was developed. The questionnaire was completed by
the patient to eliminate interviewer bias. The type and level of return to
sport activities were also recorded.
Standing posteroanterior and lateral radiographs were made for twenty-four
of the thirty patients at the time of final follow-up and were evaluated for
the signs described by
Fairbank21 and
according to the IKDC
200015 criteria.
Each knee was tested preoperatively and postoperatively with the KT-1000
arthrometer by an experienced independent examiner (E.M.). The side-to-side
differences at maximum manual force in anterior displacement were calculated,
and a failure was defined as a side-to-side difference exceeding 5 mm.
All data were analyzed with the chi-square, Kruskal-Wallis, and Wilcoxon
signed-rank tests. Statistical analysis was performed with use of the
Stata-9.2 software package (Stata-Corp, College Station, Texas) at the
Regional Agency of Public Health. Significance was established at p <
0.05.
The cause of failure of the primary reconstruction was a well-documented
error in surgical technique (improper tunnel placement) in ten patients, a new
knee injury sustained during sports activity in fourteen patients, failure of
a prosthetic ligament in four patients, and unknown but without a specific
injury in two patients.
In four patients, a two-stage revision was done because difficulty with the
removal of a preexisting fixation device had resulted in excessive bone-tunnel
enlargement that precluded secure fixation of the graft. In two other
patients, minor defects were filled with autogenous bone graft harvested from
the proximal part of the tibia and revision was performed in one stage. In
three other patients, preexisting devices were difficult to remove and the
revision was done in one stage with the devices (one interference screw on the
tibical side and two transcondylar screws on the femoral side) left in situ
(Fig. 4).
In addition to the anterior cruciate ligament revision, six partial lateral
meniscectomies and three partial medial meniscectomies were performed. Only
severe (grade-III [deep fissures] or grade-IV [subchondral bone exposed])
degenerative changes were recorded and treated with débridement. One
patient had grade-III chondromalacia of the medial femoral condyle, and two
patients had grade-III chondromalacia of the lateral femoral condyle. In one
patient, a loose body was found and removed.
Physical Examination
At the time of the preoperative evaluation, all patients had a markedly
positive Lachman test (anterior subluxation of the tibia without a firm end
point) and the pivot shift test was + in four patients, 2+ in nine patients,
and 3+ in seventeen patients. At the follow-up evaluation, twenty-two of the
twenty-eight patients who returned for testing had a negative Lachman test and
six had a grade + with a firm end point. The pivot shift test was negative in
fifteen patients, + in eleven, and 2+ in two. A significant reduction in the
grades demonstrated by both the Lachman test (p = 0.00001) and the pivot shift
test (p = 0.0013) was observed at the time of final follow-up.
Full extension was achieved in all patients, with a mean flexion deficit of
7° (range, 0° to 17°). No patient was unable to squat. There was a
mean difference of 1 cm between the thigh circumferences of the involved and
uninvolved limbs.
Arthrometric Evaluation
The mean side-to-side difference on KT-1000 testing with manual maximum
force was 7.2 ± 1.8 mm (range, 5 to 10 mm) preoperatively and 2.5
± 1.8 mm (range, 0 to 6 mm) postoperatively. The difference between the
preoperative and postoperative values was significant (p = 0.003). The
postoperative side-to-side difference was 0 to <3 mm in twenty of the
twenty-eight patients, between 3 and 5 mm in six, and >5 mm in two.
Radiographic Examination
Radiographs were made for twenty-four of the twenty-nine patients at a mean
of forty-seven months (range, twenty-six to eighty-two months)
postoperatively. According to the criteria of
Fairbank21, there
were no degenerative signs in six patients, mild signs in eleven, moderate
signs in five, and severe signs in two. According to the IKDC 2000 criteria
for radiographic evaluation, the medial compartment was normal in ten
patients, had mild changes in seven, had moderate changes in six, and had
severe changes in one. The lateral compartment was normal in sixteen patients
and had mild changes in eight patients. The patellofemoral articulation was
normal in seventeen patients, had mild changes in six patients, and had
moderate changes in one patient.
Functional Assessment
Preoperatively, the mean Lysholm score (and standard deviation) was 65.4
± 20 points (range, 35 to 94 points) and the mean Tegner activity scale
score was 3.5 ± 2.7 points (range, 0 to 9 points). According to the
IKDC objective evaluation, none of the thirty patients were in group A or B,
twelve were in group C, and eighteen were in group D.
Postoperatively, the mean Lysholm score was 90 ± 10 points (range,
72 to 100 points) and the mean Tegner activity scale score was 6.2 ±
2.1 points (range, 4 to 9 points). The mean score according to the IKDC
subjective evaluation was 84 ± 12 points (range, 55 to 100 points).
According to the IKDC objective evaluation, fifteen of the twenty-eight
patients were in group A (normal), eleven were in group B (nearly normal), two
were in group C (abnormal), and none were in group D (severely abnormal). The
differences in the Lysholm scores (p = 0.0009), Tegner scores (p = 0.0013),
and IKDC grades (p = 0.00001) before and after surgery were significant.
All but one patient were completely or very satisfied with the result of
the surgical procedure.
At the time of follow-up, 30% (nine) of the thirty patients had returned to
the same sport but at a lesser level, 20% (six) had returned to the same sport
(volleyball, football, and professional basketball) and level, and 50%
(fifteen) had begun to participate in a much less dangerous sport
(bodybuilding, jogging, and swimming).
Failure was defined as a grade 2+ or 3+ pivot shift test and/or a KT-1000
test at maximum manual force showing a side-to-side difference of >5 mm.
Only two patients had a side-to-side difference of >5 mm with a 2+ pivot
shift. There was another failure of the revision, which was treated with a
repeat revision elsewhere. Thus, our failure rate was three of twenty-nine, or
10%. There were no infections, no additional operations for the treatment of
arthrofibrosis, and only one subsequent operation for removal of an Evolgate
screw on the tibial side because of local pain.
The number of patients with recurrent instability after a failure of an
anterior cruciate ligament reconstruction has risen during the last ten to
fifteen years because of the considerable increase in the number of primary
reconstructions6-10.
It is accepted that not all patients with a failed anterior cruciate ligament
reconstruction are candidates for revision surgery. Patients who have
recurrent symptoms of instability during sports activities or activities of
daily living as well as objective findings of laxity (positive Lachman and
pivot shift tests) are candidates for revision surgery. However, patients with
pain and swelling alone, without laxity, could have a meniscal tear or
cartilage degeneration and probably are not suitable for anterior cruciate
ligament revision surgery. All of the patients in our study had knee pain and
instability during sports and daily activities and instability on objective
evaluation.
The most common etiologic factor in failures of anterior cruciate ligament
reconstructions is considered to be an error in surgical technique—i.e.,
improper intra-articular placement of the graft with impingement of the graft
in the intercondylar notch, improper tensioning of the graft, or inadequate
graft fixation. However, such errors are not always recognized during revision
surgery. In our study, the failure was caused by a well-documented error in
surgical technique during the primary reconstruction in ten patients, a new
knee injury in fourteen patients, and rupture of a prosthetic ligament in four
patients.
Surgical revision of a failed anterior cruciate ligament reconstruction
requires thorough preoperative planning and evaluation of the factors that may
have caused the failure so that these problems can be addressed during the
revision operation. The evaluation should include a radiographic examination
to evaluate the orientation of the tunnels (and any possible enlargement of
them) and the type of preexisting fixation devices. Other factors that could
result in a two-stage procedure, such as the type of graft used in the primary
reconstruction and the site and type of fixation devices utilized, should also
be assessed.
In our experience, the most common reasons for performing a two-stage
procedure were bone-tunnel enlargement, problems encountered with removal of
preexisting devices, and osteolysis around the tunnels. Specifically, in three
patients the removal of preexisting devices would have resulted in bone
disruption of either the tibial or the femoral condyle and the revision was
performed in a single stage with these devices left in situ
(Fig. 4).
In the literature, the grafts most commonly used for revision anterior
cruciate ligament reconstruction have been reported to be a bone-patellar
tendon-bone graft taken from the contralateral side or a fresh-frozen
bone-patellar tendon-bone allograft for patients who had failure of an
autogenous bone-patellar tendon-bone
graft7-10
and an autogenous ipsilateral bone-patellar tendon-bone graft for those in
whom a prosthetic ligament
failed7. Yoshiya et
al.12 proposed that
anterior cruciate ligament revision surgery be done with regenerated
semitendinosus tendon following a failure of a reconstruction with hamstring
tendons. The use of allograft tissue for a revision anterior cruciate ligament
reconstruction has been criticized. The cost of the tissue, the efficiency of
the procedure in patients with chronic instability, and disease transmission
should all be
considered10. Use
of a bone-patellar tendon-bone graft from the contralateral side necessitates
harvesting of the graft from the contralateral, healthy leg and often patients
are reluctant to pursue this
approach9.
Our first choice for revision anterior cruciate ligament reconstruction is
the use of ipsilateral hamstring tendons. Some authors have criticized the use
of hamstring tendons for revision of a primary reconstruction that had been
performed with a bone-patellar tendon-bone graft because the hamstring tendons
are generally several millimeters smaller in diameter than the patellar tendon
bone plugs. Thus, many of these patients have expanded tunnels, and one of the
keys for a successful hamstring reconstruction is appropriate "fit and
fill" of the graft in its host
tunnel22.
Therefore, the problem with revision anterior cruciate ligament surgery with a
doubled gracilis and semitendinosus tendon graft seems to be secure fixation
of the graft in the tunnels employed.
The two-incision technique that we used seems to be a good choice,
especially when a half-tunnel technique was used in the primary reconstruction
or when a blow-out of the posterior cortical wall was encountered. In fact,
the outside-in technique allows the surgeon to orient the femoral tunnel in
such a way that the new graft can be fixed in a previously un-drilled area of
the lateral femoral condyle.
The role and effectiveness of a lateral extra-articular procedure performed
in association with the anterior cruciate ligament reconstruction have not
been defined23.
While some authors have expressed the belief that postoperative stability
cannot be improved by any additional
procedure24, others
have reported better results when an extra-articular iliotibial band tenodesis
was performed in association with an intra-articular anterior cruciate
ligament reconstruction, especially if a semitendinosus and gracilis graft was
used25. When we
perform a primary anterior cruciate ligament
reconstruction26,
we use a modified MacIntosh lateral tenodesis with an intra-articular doubled
gracilis and semitendinosus tendon graft reconstruction only to treat severe
chronic rotatory instability (a 3+ pivot shift test). However, we agree with
Draganich et al.27,
who stated that they believed that the extra-articular reconstruction can
protect the graft from excessive, undesired stresses during the early
postoperative period and thus it would be useful in revision anterior cruciate
ligament surgery.
In the last few years, the use of an accelerated rehabilitation program
after anterior cruciate ligament reconstruction has become widely accepted.
However, it is well known that secure tendon-to-bone healing requires at least
twelve weeks. Therefore, accelerated rehabilitation, and the related
micro-motion of the graft in the tunnels, could compromise the bone-tendon
interface, resulting in poor biological
fixation28. When
hamstring grafts are used, especially in revision surgery and even when strong
and stiff fixation devices are utilized, we believe that a slower
rehabilitation program such as the one employed in the present study should be
followed.
The criteria for failure, if defined, have been variable in the published
articles on revision anterior cruciate ligament reconstruction. If we consider
failure in this series to be additional revision surgery, a side-to-side
difference of >5 mm on KT-1000 testing with maximum manual force, or a
grade of 2+ or higher on pivot shift testing, our failure rate would be three
(10%) of twenty-nine.
Revision anterior cruciate ligament surgery is often not expected to yield
the same results as primary reconstruction and may be considered as a salvage
procedure7 with
limited goals, such as restoring stability to allow work, activities of daily
living, and light recreational sports. The results in our study compare well
with those reported after the use of various grafts for revision anterior
cruciate ligament surgery and demonstrate that satisfactory outcomes can be
achieved with the use of previously unharvested ipsilateral
tendons9,10,29-32.
When we compared the results of our revision anterior cruciate ligament
reconstructions with those of our primary anterior cruciate ligament
reconstructions done with the same technique and rehabilitation program, we
did not find any difference in the arthrometric findings; the mean
side-to-side difference with maximum manual force was 2.2 ± 2.2 mm
after the primary reconstructions and 2.5 ± 1.8 mm after the revisions
(p > 0.05). However, we found significant differences in the patients'
subjective evaluations. According to the subjective IKDC evaluation, 87% of
the results were grade A (normal) and 13% were grade B (nearly normal)
following the primary reconstructions, whereas 54% were grade A, 39% were
grade B, and 7% were grade C following the revisions (p < 0.05). These less
favorable subjective results may be attributed to many factors, including the
number of previous operations, meniscal damage, and osteoarthritic changes in
the knee.
Only 20% of our patients returned to the same sport activities at the same
level as was possible before the first injury, which is often the patient's
main goal; 50% of the patients preferred a less stressful activity for reasons
other than the result of the operation (work, family responsibilities, or fear
of a new injury), and 30% returned to the same activity but at a lesser level
after the revision surgery. However, all but one patient were satisfied with
the result of the revision anterior cruciate ligament reconstruction and
stated that they would have the surgery again under similar circumstances.
Therefore, the emotional status of patients, their goals, and their degree of
motivation with regard to rehabilitation are other issues to be considered
when planning revision surgery.
Several studies have demonstrated a correlation between cartilage damage
and meniscal tears and the clinical and radiographic outcomes of both primary
and revision anterior cruciate ligament
surgery8,10.
Only 25% of our patients had no signs of degenerative joint disease at the
time of follow-up. When a patient has substantial articular cartilage damage,
the goal of the operation perhaps should be to decrease instability with
activities of daily living and possibly allow a return to light recreational
activity.
In conclusion, despite the limitations of this retrospective study (the
lack of a control group, the introduction of a relatively innovative fixation
device, and the adjunctive use of an extra-articular procedure), the results
suggest that the use of a doubled semitendinosus and gracilis autograft
combined with an extra-articular reconstruction is a reasonable alternative
for revision anterior cruciate ligament reconstruction. However, patients
should be informed that, despite the achievement of a stable knee following
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