Initial Evaluation
The patient to be selected for a revision anterior cruciate ligament
reconstruction must be carefully assessed subjectively and objectively. A
detailed description of previous operation(s) should be obtained along with
the clinical data as reported in the previous operative report. Only patients
with previously unharvested semitendinosus and gracilis tendons can be
selected for this procedure. The postoperative course of the failed operation
should also be investigated. In some instances, the inability of the patient
to strictly follow the prescriptions of the surgeon in the postoperative
period can contribute to the failure of either the primary or the revision
reconstruction, or both. However, the main issues to be investigated are the
symptoms reported by the patient at the time of clinical presentation.
Patients who express dissatisfaction after anterior cruciate ligament
reconstruction are often actually dissatisfied because they have pain,
swelling, and/or stiffness and not because they have true instability. For
these patients, a revision would be inappropriate. Only patients with
recurrent instability and episodes of giving-way in daily life or during
sports activity should be considered as candidates for a revision
reconstruction.
The instability must be confirmed by physical examination. A positive
Lachman test and a grade of moderate (2+) to severe (3+) on the pivot shift
test are the most frequent objective data encountered when a revision is
indicated. A mild pivot shift (+) should be regarded as a possible indication
for initial conservative treatment, including strengthening of the quadriceps
and hamstrings and proprioceptive rehabilitation, prior to consideration of
revision surgery.
Physical examination should also exclude associated ligamentous lesions,
such as posterior cruciate ligament instability as well as severe valgus or
varus instability, which are a relative contraindication for isolated anterior
cruciate ligament revision surgery.
Radiographs are mandatory in the preoperative assessment of the patient.
Standard anteroposterior and lateral radiographs are usually sufficient to
determine the presence, site, type, and size of fixation devices, as well as
the direction, position, and dimension of the bone tunnels
(Fig. 1). Knowledge of these
features is essential to preoperative planning. A three-dimensional computed
tomography scan can be useful in gaining better visualization of the
orientation of the tunnels as well as in measuring possible tunnel
enlargement. Magnetic resonance imaging is acquired to document the status of
the menisci and the articular cartilage, both of which can severely affect the
clinical outcome (Fig. 2).
Patients with previous meniscectomies or wide and irreparable meniscal tears
and patients with severe chondral damage should be advised of possible
unsatisfactory results, including the possibility of persistent pain or
swelling.
For most patients, with the occasional exception, a thorough history,
physical examination, and review of imaging studies will allow the surgeon to
understand the cause of failure of the primary reconstruction.
Preoperative Planning
Fixation devices must be clearly localized and identified in order to plan
removal or determine that retention would not interfere with the drilling of
new tunnels for the revision procedure. If large retained metallic implants
interfere with the anticipated path of the new tunnels to be drilled, the
possibility of a two-stage procedure should be considered and the patient
should be informed accordingly.
Severe tunnel widening that precludes adequate graft fixation should be
considered to be another indication for a two-stage procedure. In four of our
patients, a two-stage revision was necessary 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, we filled minor defects with autogenous bone graft harvested from
the proximal part of the tibia and then performed the revision, all in one
stage (Fig. 3, A through
D). 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 tibial side and two transcondylar screws on the
femoral side) left in situ (Fig.
4).
No matter which procedure is chosen, a complete set of screwdrivers or
other specific instrumentation appropriate for removal of the fixation devices
should be available before performing revision surgery.
The direction of the previously drilled tunnels should be carefully
evaluated and compared with the direction of the new tunnels to be drilled,
with consideration given to the outside-in technique that will be used after
creation of the femoral tunnel. In the circumstance of divergent tunnels,
serious potential problems should be anticipated
(Fig. 4 and
Figs. 5-A and 5-B); in the
event of correct positioning of the tibial and/or femoral tunnel, the tunnels
can be simply redrilled to freshen the bone walls in order to obtain secure
fixation with the appropriate
devices8-10.
The extension and direction of the previous incision from the primary
reconstruction must be considered so that the incision that is chosen for the
revision surgery will optimally facilitate the removal of the fixation device,
the exposure and harvesting of the pes anserinus, and the performance of the
lateral reconstruction procedure but minimize the risk of skin necrosis.
Antibiotic Prophylaxis and Choice of Anesthesia
Antibiotic prophylaxis is instituted two hours before the operation. The
choice of the anesthesia is made in conjunction with the anesthesiologist and
the patient and depends on several factors, including age, comorbid medical
problems, history of previous procedures, and, ultimately, the wishes of the
patient. Most commonly, general anesthesia or an epidural anesthetic with
concomitant intravenous sedation is chosen. Preoperative femoral and/or
sciatic nerve blocks can be performed as an adjunct for postoperative pain
relief.
Positioning and Examination of the Anesthetized Patient
After the administration of anesthesia and before final positioning of the
patient on the operating table, the knee is examined for a final assessment of
the preoperative status; the Lachman test and pivot shift test, the posterior
drawer test, and valgus and varus stress tests in flexion are performed.
The patient is placed in the supine position on the operating table with
the involved limb placed in a non-captured (u-shaped) leg holder, allowing the
leg to be maintained with the hip externally rotated and the knee flexed at
90°. The heel is set to rest on a sandbag that is taped to the bed,
allowing the knee to be maintained in 90° of flexion without manual
assistance; however, a full free range of motion of the knee throughout the
entire procedure must be ensured (Fig.
6). The extremity is prepared with an alcohol and Betadine
(povidone-iodine) solution and is draped in a meticulous fashion. A
fluoroscope should be draped and made ready, as it is occasionally used to
help localize fixation devices that need to be removed.
Diagnostic Arthroscopy and Intra-articular Preparation
The tourniquet is inflated to 350 mm Hg, and the exact time is recorded. A
30° arthroscope is introduced and maintained for the entire procedure
through the central transtendinous portal with continuous gravity inflow
irrigation. The central portal is located about 1 cm superior to the lateral
joint line and just in the center of the knee joint (not the center of the
patellar tendon) (Fig. 7). This
approach allows the best visualization of the entire intercondylar notch,
including the most posterior part of the medial aspect of the lateral femoral
condyle, without the need to change portals for the scope. An accurate
diagnostic arthroscopy is conducted to assess the cruciate ligaments, menisci,
and articular cartilage. Once the intra-articular disorder is confirmed,
including the status of the previously reconstructed anterior cruciate
ligament, any concomitant articular cartilage or meniscal injury is addressed.
Every effort is made to preserve the meniscal tissue; peripheral meniscal
tears are repaired by means of the outside-in technique, whereas central or
irreparable meniscal tears are débrided to a stable rim. In the case of
a meniscal repair, the sutures are tied down at the conclusion of the
procedure. Unstable articular cartilage defects are débrided. The
entire intra-articular portion of the previously reconstructed graft is
completely removed with a shaver in order to identify both the tibial and the
femoral attachments. For a primary reconstruction that makes use of a
prosthetic ligament, all of the ligament must be carefully removed on both the
femoral and the tibial side. A notchplasty is usually unnecessary unless the
notch is severely narrowed. Intra-articular fixation devices are localized and
removed with use of an appropriate screwdriver and arthroscopic grasper (Figs.
8 and
9). The use of a burr is
sometimes needed in order to localize interference screws that are deeply
positioned in the lateral femoral condyle.
Skin Incisions and Extra-articular Procedures
The tibial incision is chosen with consideration given to the scar of the
primary reconstruction, the anatomical site of the pes anserinus tendons, and
the fixation devices to be removed. A 4 to 5-cm oblique incision centered over
the pes anserinus is usually sufficient to enable the surgeon to perform all
of the medial-side procedures. In some instances, the same incision that was
used in the primary reconstruction can be used. The removal of the tibial
fixation device is performed first in order to minimize bone disruption; the
use of fluoroscopy may be required to precisely localize the hardware
(Fig. 10). In the event that
excessive bone loss occurs during the removal of the femoral or tibial
devices, the procedure is aborted and the reconstruction is performed at the
time of a second-stage operation.
The pes anserinus is exposed and the sartorius fascia is incised along its
fibers, thus exposing the underlying tendons. The gracilis tendon is isolated
and pulled distally with a curved hook as the adhesions with the surrounding
structures are dissected. Once the tendon is mobilized, an open tendon
stripper is positioned and advanced retrograde up to the musculotendinous
junction in order to harvest the entire length
(Fig. 11). The same procedure
is used to fully harvest the semitendinosus tendon. The residual muscle tissue
is removed from the harvested tendons with use of the blade of a smoothed
scissor. Each tendon is then released from its insertion with use of a
scalpel.
On the lateral side, a 10 to 12-cm hockey-stick incision is made, extending
from Gerdy's tubercle proximally to just inferior to the lateral epicondyle
while the knee is flexed to 90°. The proximal extent of this incision
parallels the midportion of the iliotibial tract
(Fig. 12). The fascia lata is
exposed and incised along its fibers about 3 cm from the posterior border. The
vastus lateralis is then retracted anteriorly, and the femoral condyle is
exposed (Fig. 13, A and
B). Retained fixation devices are removed with the same
care that was used for the tibial devices. If preoperative planning suggests
possible trouble in removal of the femoral implants, tendon harvest should be
deferred until the surgeon is confident that a two-stage procedure will not be
necessary.
Preparation and Pre-Tensioning of the Graft
The graft preparation is performed by an assistant while the senior surgeon
is drilling the cruciate tunnels. The tendons are mounted on a workstation
that maintains the proper tension, and a Bunnell-style suture is then placed
in the free ends of each tendon, with a different color suture used for each
tendon (Fig. 14). The tendons
are then doubled and sized with use of calibrated metal cylinders.
Preparation of the Cruciate Tunnel
The arthroscope remains in the central portal; we typically prefer to
address the tibial tunnel first. A commercially available anterior cruciate
ligament tibial guide (Citieffe, Bologna, Italy) is set at approximately
60° and is introduced through the anteromedial portal. The probe of the
guide is placed in the center of the joint, about 7 mm anterior to the
posterior cruciate ligament. A Kirschner wire is used for predrilling; the
entry point of the Kirschner wire on the anteromedial tibial surface is
identified with use of the preoperative plan in order to avoid overlap with
the previous tunnel (unless the tunnel of the primary reconstruction was
properly positioned). After acceptable placement of the guidewire in the
tibial tunnel, the tunnel is drilled with use of an 8 to 9-mm cannulated
drill, depending on the size of the two doubled gracilis and semitendinosus
tendon grafts. All of the bone reamings from the drill are collected
(Fig. 15); in order to avoid
excessive outflow of fluid from the joint, a plug is placed in the drill
hole.
The femoral tunnel is created with use of an outside-in technique. A
femoral guide is introduced through the anteromedial portal so that the tip
faces the desired point of intra-articular entry for the femoral tunnel. This
point is usually located 5 mm anterior to the posterior edge of the medial
surface of the lateral femoral condyle (at the ten to eleven o'clock position
in a right knee). This position, usually far posterior to most of the entries
performed with use of an "inside out" technique, enables the
surgeon to perform a divergent drilling
(Fig. 16, A and
B).
A Kirschner wire is then drilled through the posterolateral corner of the
femoral condyle to the desired intra-articular entry point. After acceptable
placement of the guidewire, the femoral tunnel is drilled with a cannulated
drill-bit that is between 8 and 9 mm in diameter, depending on the size of the
tendons. Bone from the reaming is once again collected.
Preparation for the Tibial Fixation and Final Positioning of the
Graft
The arthroscope is removed from the joint, and the external aspect of the
tibial tunnel is exposed. The soft tissue surrounding the entry is removed,
and the bone edges are adequately exposed. The
Evolgate9,10
(Citieffe) device is used to secure the graft in the tibial tunnel. This
device is composed of three components, all made of a titanium alloy: a coil
(a spiral 21 mm in length and 10 mm in diameter) with a spike positioned at
one extremity, a 9 × 20-mm screw, and a washer
(Fig. 17). A Kirschner wire is
used to drill a hole just adjacent and parallel to the tibial tunnel in order
to provide housing for the hook of the Evolgate. Before the tendons are pulled
through the tibial tunnel, the spiral is inserted into the tibial tunnel with
a special impactor, which also provides penetration of the spike in the
predrilled tibial cortex (Fig. 18, A,
B, and C). The
Swing-Bridge8
(Citieffe) device consists of a titanium-alloy cylinder (diameter, 10 mm) with
a smooth metal half-ring (diameter, 10 mm) at one end and a shelf with grooves
at the other (Fig. 19). The
free tendon ends are dragged through the ring of the device and then pulled
into the joint with use of an outside-in technique from femur to tibia by
means of a shuttle wire. When the ends are pulled out from the tibial side,
the Swing-Bridge is completely inserted into the femoral tunnel with an
impactor until the shelf reaches the femoral cortical bone. After the tendons
are pulled through the bone tunnels and secured at the femoral side, the four
tendon strands, whose ends are easily recognized by the different colored
sutures, are then equally tensioned by hand on the tibial side. All of the
bone collected from tunnel-drilling is placed in a syringe and injected into
the tibial tunnel among the four tendon strands to fill the empty spaces and
promote healing. A cannulated core reamer can be used to collect a greater
amount of bone in situations in which moderate bone loss has been
sustained.
The screw and the washer of the Evolgate are then inserted into the tibial
tunnel, interfering with the tendon ends and the spiral, until the washer
presses against the tibial cortex (Fig.
20). The spike prevents rotation of the spiral as the screw
tightens.
In situations in which loss or improper tension of the graft has occurred
after tibial fixation, the Swing-Bridge allows a second and final tensioning
of the graft, which can be accomplished by twisting the graft bundles from the
femoral side.
Reinforcement of the walls of the tibial tunnel can be beneficial even in
primary reconstructions, but this step is even more important in revision
anterior cruciate ligament surgery, during which the bone density is often
substantially reduced from the removal of preexisting fixation devices. The
Evolgate fixation device offers secure initial mechanical fixation even in a
compromised bone situation (Fig.
3).
After final fixation of the graft, the arthroscope is reinserted and the
position, alignment, and tensioning of the graft are checked with use of a
probe. If impingement is present, a mild notchplasty or roofplasty is
performed; in the case of improper tension, the Swing-Bridge allows fine
adjustment of the tension by twisting the graft bundles from the femoral
side.
Extra-Articular Reconstruction
An extra-articular procedure (the Coker-Arnold modification of the
MacIntosh procedure) is then
performed7,11.
With 1 cm of the iliotibial tract left intact posteriorly, a 1-cm-wide and
13-cm-long strip of the iliotibial tract is detached proximally, leaving
intact its distal attachment on Gerdy's tubercle. The lateral collateral
ligament is identified, and the proximal part of the strip is passed under the
ligament; the band is then reflected on itself and sutured under tension with
periosteal stitches to Gerdy's tubercle while the tibia is held in maximal
external rotation (Figs. 21-A through
21-E).
Final Steps
The tourniquet is deflated and hemostasis is achieved. To avoid placing
excessive pressure on the patellofemoral joint, only the proximal part of the
fascia lata is closed. Two suction drains, one intra-articular and one medial
and subcutaneous, are placed. Meticulous suturing of the deep layers and the
skin is performed. A standard sterile surgical dressing and a moderately
compressive elastic bandage are applied to the knee, to include the foot and
the leg. A brace is applied with the knee locked in full extension.
Prophylaxis against deep venous thrombosis is instituted with use of
low-molecular-weight heparin and mechanical foot pumps.
Postoperative Rehabilitation
The knee is kept in full extension in the brace for two to three weeks,
according to the strength of the fixation obtained at surgery. Following the
removal of the drains at forty-eight hours after the operation, weight-bearing
is allowed, as tolerated, with the aid of crutches. Immediately following
surgery, isometric quadriceps exercises are started with the knee in full
extension. At two to three weeks postoperatively, the patient begins
supervised active and passive flexion, which is limited to 90° until the
fourth week, at which time progressive range-of-motion exercises are
encouraged. The brace is discontinued after six weeks, at which time full
weight-bearing without crutches is allowed. At two months after surgery, a
quadriceps-strengthening program as well as pro-prioceptive rehabilitation is
prescribed. Strengthening of the hamstrings is not begun until three months
postoperatively. Running is permitted after four months if 80% of the
contralateral quadriceps strength has been achieved. A return to specific
athletic training is allowed between four and six months postoperatively.
CRITICAL CONCEPTSINDICATIONS:Recurrent instability with a moderate-to-severe grade on the pivot shift
test and a positive Lachman test after primary anterior cruciate ligament
reconstruction with use of bone-patellar tendon-bone graft, allograft, or
prosthetic ligamentsCONTRAINDICATIONS:Failure of a primary reconstruction due to reasons other than recurrent
instability (pain, stiffness, swelling, or unresolved infection)Previously harvested ipsilateral semitendinosus and gracilis tendonsSevere intra-articular degenerative changesAssociated severe ligamentous injuries affecting the posterior cruciate
ligament, the posterolateral corner, or the medial compartmentPITFALLS:A complete set of instruments should be available for the removal of
retained fixation devicesTo assure adequate fixation while enlarging the new tunnel, overlapping of
the old tunnel should be avoidedIf the walls of the tunnels are redrilled in the same position as in the
primary reconstruction, they should be refreshed and reinforcedMaximum external tibial rotation should be maintained while performing the
lateral extra-articular reconstructionAUTHOR UPDATE:The described surgical technique has not changed substantially since the
publication of the original paper.
CRITICAL CONCEPTS
INDICATIONS:
Recurrent instability with a moderate-to-severe grade on the pivot shift
test and a positive Lachman test after primary anterior cruciate ligament
reconstruction with use of bone-patellar tendon-bone graft, allograft, or
prosthetic ligaments
Recurrent instability with a moderate-to-severe grade on the pivot shift
test and a positive Lachman test after primary anterior cruciate ligament
reconstruction with use of bone-patellar tendon-bone graft, allograft, or
prosthetic ligaments
CONTRAINDICATIONS:
Failure of a primary reconstruction due to reasons other than recurrent
instability (pain, stiffness, swelling, or unresolved infection)Previously harvested ipsilateral semitendinosus and gracilis tendonsSevere intra-articular degenerative changesAssociated severe ligamentous injuries affecting the posterior cruciate
ligament, the posterolateral corner, or the medial compartment
Failure of a primary reconstruction due to reasons other than recurrent
instability (pain, stiffness, swelling, or unresolved infection)
Previously harvested ipsilateral semitendinosus and gracilis tendons
Severe intra-articular degenerative changes
Associated severe ligamentous injuries affecting the posterior cruciate
ligament, the posterolateral corner, or the medial compartment
PITFALLS:
A complete set of instruments should be available for the removal of
retained fixation devicesTo assure adequate fixation while enlarging the new tunnel, overlapping of
the old tunnel should be avoidedIf the walls of the tunnels are redrilled in the same position as in the
primary reconstruction, they should be refreshed and reinforcedMaximum external tibial rotation should be maintained while performing the
lateral extra-articular reconstruction
A complete set of instruments should be available for the removal of
retained fixation devices
To assure adequate fixation while enlarging the new tunnel, overlapping of
the old tunnel should be avoided
If the walls of the tunnels are redrilled in the same position as in the
primary reconstruction, they should be refreshed and reinforced
Maximum external tibial rotation should be maintained while performing the
lateral extra-articular reconstruction
AUTHOR UPDATE:
The described surgical technique has not changed substantially since the
publication of the original paper.