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Prepare for a variety of situations when performing ACL revision surgery

Issue: April 2012

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At Orthopedics Today Hawaii 2012, Nicholas A. Sgaglione, MD, reviewed strategies for revision ACL reconstruction that included thorough preoperative planning, preparing for meniscal attrition and articular cartilage lesions, and tunnel repositioning.

“There are certainly a large number of ACLs being done,” Sgaglione said. “I think ACL surgery has become an ESPN operation as we say, and because of that perception, many patients currently undergoing ACL reconstruction have great goals and expectations. I think if we are thoughtful about it, we recognize that — even in the best of hands — if you look at your data, you are getting about an 85% successful outcome.”

Preoperative planning, imaging

Ideally, Sgaglione likes to obtain and review the notes of the surgeon who performed the initial ACL reconstruction. He uses KT-1000 testing to assess the amount of patients’ anteroposterior translation. For salvage cases, he thinks about skin incisions and associated meniscal and articular cartilage pathology. He also uses MRI and 3-D CT to analyze the tunnels in difficult revision cases. Surgeons should look for previous injuries and potential technical errors in tunnel positioning.

Most importantly, Sgaglione said, surgeons should be aware of athletes who re-injure themselves after return to play. Surgeons should also consider whether the patient had returned to play too early, and may have had a deficient graft that along along with trauma results in failure.

During revision cases, surgeons can encounter malpositioned tunnels that may have caused impingement. When templating tunnels, Sgaglione said that 3-D CTs can help avoid tunnel confluence, or “owl’s eyes” and to template out divergent tunnels. In patients with osteolysis, Sgaglione suggests addressing bone loss before revision.

Bone grafting and allografts

“I have a low threshold for bone grafting. I have become a little more conservative in that I tend to stage more now, and I do not primarily shim as much,” Sgaglione said.

But if Sgaglione encounters problems with the femoral tunnel, he uses iliac crest bone graft. Then, 4 months to 6 months postoperatively, he performs a definitive reconstruction.

Indications for use of allograft tissue for primary reconstruction must be precise and orthopedists must screen and question the bone banks used, Sgaglione said. Allografts do however give options, especially in revision cases.

“They can give you the bone block advantages, as well as the limitation of harvest morbidity,” Sgaglione said.

Sgaglione also examines for concomitant pathologies including combined ligament pathologies. Some patients may need meniscal allograft transplantation, or posterolateral or posteromedial corner reconstruction.

“When you start doing revision work, you are invariably going to be dealing with meniscal attrition and articular cartilage lesions,” he said.

Patients who have meniscal loss or chondral injuries, usually will have a less favorable outcome after revision reconstruction making them, in essence, salvage cases. Sgaglione recommends counseling patients to have realistic goals and that surgeons be prepared for a variety of situations.

“You have to know how to reposition tunnels, when to remove hardware and when to leave the hardware in,” he said. “You need to possibly have revision trays to allow you to get out screws that are stripped and obviously have various options. Keep your options open as far as fixation grafts and associated reconstruction.” – by Renee Blisard

Reference:

• Sgaglione NA. ACL revision reconstruction: Strategies and management. Presented at Orthopedics Today Hawaii 2012, Jan. 15-18. Wailea, Hawaii.

For more information:

• Nicholas A. Sgaglione, MD, can be reached at the Department of Orthopedic Surgery, North Shore Long Island Jewish Medical Center, 611 Northern Blvd., Great Neck, NY 11021; 516-723- 2663; email: nas@optonline.net.
• Disclosure: Sgaglione receives royalties from Biomet and is a board member of the Arthroscopy Association of North America.