ACL revision surgery: Don’t make unrealistic promises

While revisions are a viable option for some patients, not everyone stands to benefit from the procedure.

Issue: Issue 5 2003

Sweden flag HELSINKI — As more men and women are electing to undergo anterior cruciate ligament reconstruction surgery, the number of revisions required for failed reconstructions is also escalating worldwide.

“In the United States, surgeons are performing approximately 10,000 ACL revisions a year. Probably in the entirety of Europe, we have the same numbers,” said Ejnar Eriksson, MD, of Stockholm.

In a special Revision ACL Symposium held during the European Society of Knee Surgery, Sports Traumatology and Arthroscopy (ESSKA) Specialty Day meeting, orthopaedic surgeons skilled in the procedure generally agreed that the most common reason primary ACL surgeries fail is due to technical errors. For example, in some cases, the graft has been placed too anteriorly on the femur, causing impingement.

Other etiologies may also be the reason for failure, he said. Dutch researchers from Nijmegen recently reported in Knee Surgery, Sports Traumatology, Arthroscopy (the ESSKA journal) that in only one or two cases out of 10, the femoral canal ended up in the proper anatomical position if the femoral canal was drilled through the tibial drill hole. “But instead, if you go through the anterior-medial arthroscopic portal, you end up in the proper position in almost every case,” he said, adding that a German group in Heidelberg recently confirmed this finding.

Other causes

EFORT 2003 Helsinki Should all failed ACL reconstructions have a revision? “I don’t think so,” Eriksson said. Perhaps 20% of all patients who have a primary ACL surgery and continue to experience problems should undergo a revision, he said. “There is no doubt that people can live a relatively healthy life without a functioning ACL. If you avoid certain sports and movements, such as rapid acceleration, rapid deceleration and rapid change of direction, you can live well without revising the ACL. We should remember that when we discuss revisions with patients.”

Eriksson told attendees that there are no age limits for ACL revisions. “If a 60-year-old gym teacher has a failed ACL and he [frequently] gets tripped up when he tries to show his students a movement, he should get a revision. But on the other hand, there are lots of 30-year-olds who don’t need a revision because they don’t do those types of activities,” he said.

Eriksson also discouraged orthopaedic surgeons from using synthetic grafts in ACL revision surgery. “I think we should fight [their use]. They’re like a shoelace; they are [essentially] made of the same material.

“Have you ever had a shoelace last five years? If you haven’t had a shoelace last for five years, why should you expect a shoelace inside the knee to last five years?” he joked.

Counseling patients

Surgeons should be honest with their patients about what to expect from an ACL revision. “Revision ACL surgery results are not as good as the results from the primary ACL surgery. We cannot promise that all the pain will be reduced,” Eriksson said. “There is a good chance it will be reduced, but we cannot promise it. Can we promise them a return to sports? They may be able to get back to playing, but we can’t promise them a full 100% return.

“Quite honestly, I don’t think [the success of the revision] depends as much on whether you use a one-stage or two-stage procedure or whether you use patellar tendon or hamstrings; it depends on the fact that you’re a good surgeon,” he said.

Eriksson added: “Should every orthopaedic or trauma surgeon perform ACL reconstructions, or should they be performed by surgeons and centers who do 50 procedures or more a year? That’s something to think about.”

For your information:

Eriksson E. Conclusions. Presented at the European Society of Knee Surgery, Sports Traumatology and Arthroscopy Specialty Day Meeting. June 8, 2003. Helsinki.