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Surgeons have great latitude with revision ACL reconstruction
Realistic discussions with patients about outcomes are important.
When contemplating revision ACL reconstruction, the problem needs to be accurately defined and several treatment plans in place that cover all pathologies. Surgeons should also consider tunnel repositioning, as well as counseling patients for realistic outcomes.
“You want to do these cases with your ‘A team’ and you want to have every choice available to you for tunnel repositioning and removal of hardware – when to remove and when not to remove hardware for space consideration,” said Nicholas A. Sgaglione, MD, chairman of the Department of Orthopedic Surgery at North Shore Long Island Jewish Medical Center. In addition, surgeons should be prepared to perform additional ligament reconstruction such as posterolateral corner reconstruction if needed.
“I think the significance of addressing and treating anterior cruciate ligament revision is that with the increase number of primary ACL surgeries being performed, there are a larger number of revisions that need to be done,” Sgaglione told Orthopedics Today. “We continue to be challenged by trying to achieve optimal results with revision surgery. But our results – even in the best of hands – at times can be less than optimal in 10% to 25% of cases.”
Why did it fail?
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Image: Beadling L, Orthopedics Today |
The etiology for ACL surgical failure also needs to be precisely defined. Among the etiologies that could be responsible for failure include technical nonanatomic graft and tunnel placement, traumatic re-injury and concomitant pathology, such as associated patholaxity.
“True re-injury needs to be looked at very carefully from a temporal standpoint,” said Sgaglione. “However, most ACL revision failures in my community and in my hands are technical, and less associated with missed pathology or trauma.”
Diagnosis for revision ACL reconstruction begins with a thorough history, analysis of prior treatment — including operative records — a comprehensive physical exam, weight-bearing radiographs, arthrometric measurements and MRI or CT scan.
Surgical management
“Management starts with appropriate counseling, defining indications for surgery, devising surgical plans — a plan A, plan B, even plan C — addressing concomitant pathologies, achieving anatomic tunnel repositioning and secure fixation,” said Sgaglione, in a presentation to Orthopedics Today Hawaii 2011. “Staging is key; when in doubt, stage the procedure, at least for bone grafting.”
Bone grafting, either in a combined procedure or staged, is only one surgical technique for revision ACL reconstruction. The use of allograft tissue, both to reduce the risks of harvest morbidity and to incorporate the advantage of allograft bone, is another option.
“My preferred technique is single-staged with bone grafting, as needed, along with the use of allograft tissue, including a bone-tendon-bone allograft, and bioabsorbable fixation,” Sgaglione said. Surgeons may also consider a contralateral extremity autograft tissue in select cases.
Outcomes in most studies of revision surgery “do not approach the success of primary ACL reconstruction,” Sgaglione said. “Revision ACL reconstruction is more commonly associated with significant meniscal attrition and associated articular cartilage pathology. These concomitant pathologies affect prognosis and reduce the overall return to pre-injury functional activity levels.”
Still, a number of these patients can be helped, as long as there is a “realistic discussion of outcomes,” said Sgaglione, noting that 50% to 75% of patients may accept return to pre-injury functional activity attain an improvement. “In many of these cases, the surgical revision reconstruction can be reconsidered a salvage procedure.”
Sgaglione also stressed that meniscal attrition has a significant impact on ultimate outcomes. – by Bob Kronemyer
Reference:
- Sgaglione NA. Revision ACL reconstruction. Presented at Orthopedics Today Hawaii 2011. Jan 16-19, 2011. Koloa, Hawaii.
- Nicholas A. Sgaglione, MD, chairman of the Department of Orthopedic Surgery, North Shore Long Island Jewish Medical Center, can be reached at 600 Northern Blvd., Great Neck, New York, 11021; 516-627–7047; e-mail: nas@optonline.net.
- Disclosure: Sgaglione has no relevant disclosure related to this presentation.
