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A 16-year-old football player presents with knee pain after two ACL reconstructions with hamstring autograft
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An otherwise healthy 16-year-old high school football player presented to the clinic with right knee pain following a blow to the anteromedial side of the knee in a football game. He could walk off the field and in clinic did not have significant pain, but his knee was stiff and swollen. The patient had a history of ACL reconstruction, which was performed twice on the affected right knee. The primary reconstruction was with an ipsilateral hamstring tendon autograft and the revision surgery was with the contralateral hamstring autograft. At the time of both ACL surgeries, the patient’s meniscus was normal with no evidence of tears and did not require treatment. However, the patient’s initial ACL reconstruction failed after 4 months following a non-contact twisting injury sustained during physical therapy.
Physical examination and imaging
On physical exam, the patient’s right knee was noted to have moderate effusion with pain to palpation over the medial joint line, as well as over the femoral attachment of the fibular collateral ligament (FCL). He had significantly reduced range of motion (ROM), from 5° to 100°. His exam was notable for a positive Lachman’s test (3+) with no firm endpoint, a 3+ pivot shift and increased gapping in response to varus stress (2+ at full extension; 3+ at 30° flexion). His dial test was symmetric to the contralateral side. He was neurovascularly intact throughout.
His radiographs included full-length standing, anteroposterior (AP), lateral and bilateral varus stress views. A CT was also obtained. An MRI from an outside institution was available (Figures 1 to 5).
Images: LaPrade RF
What is your diagnosis?
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Re-tear of ACL, FCL tear, medial meniscal ramp lesion, femoral condyle impaction fracture and chondromalacia
This was a complex injury that needed to be fully examined and worked up to develop the proper treatment protocol. Given a history of ACL graft tear following two prior hamstring (HS) autograft ACL reconstructions (ACLRs), the patient’s presentation and his mechanism of injury, it was fairly evident the patient re-tore his ACL. In addition, his previous tunnels had widened significantly and were malpositioned, and he had an undiagnosed injury to his FCL. Many factors can lead to failure of ACLR, including native anatomy (such as increased sagittal plane tibial slope), reconstruction tunnel malpositioning and other undiagnosed associated injuries. An example of associated injuries that lead to increased ACLR failure are injuries to the posterolateral corner of the knee, particularly injuries to the FCL. Studies have shown failure to address instability of the FCL leads to increased forces on the ACL graft in response to clinical movements. Injuries to this area of the knee can be difficult to assess, especially in an acute setting of complex injuries. Patients often have a lot of pain, which makes it difficult to examine them. Furthermore, FCL tears can be missed on MRI. For this reason, the authors recommend varus stress radiographs to obtain objective information supporting FCL tear when lateral compartment gapping greater than 2.7 mm is found on the varus stress radiographs. In this instance, the patient had significantly increased varus gapping of the affected knee compared to the contralateral knee.
Other injuries to look for that are commonly associated with ACL tears are medial collateral ligament tears and meniscal pathology, particularly ramp lesions of the posterior aspect of the medial meniscus. These are difficult to diagnose, as well, because these are often missed on MRI. However, the literature includes reports on new diagnostic protocols for how to find and diagnose these injuries on MRI. It is also important to reassess for this injury intraoperatively.
Treatment
Our evaluation under anesthesia confirmed our exam finding in the clinic and found a 3+ Lachman and pivot shift, 2+ varus gapping at full extension and 3+ varus gapping at 30° flexion. There was no valgus gapping and the patient’s posterior drawer test was normal.
A two-stage procedure was performed because significant ACL tunnel widening was detected on CT scan (14.2 mm). The patient’s alignment was normal. Removal of deep hardware and tunnel bone grafting was performed in the first stage of surgery. For this purpose, allograft demineralized bone matrix was prepared and placed into a cannula. All arthroscopic fluid was then evacuated from the joint. The femoral tunnel bone graft was placed first. The allograft bone was then pushed into the femoral tunnel defect and then into the tibial tunnel making sure no bone graft was left in the joint. To prevent breaching the exit hole of the tibial tunnel, a large curette was inserted through the anteromedial portal to provide a “roof” while the graft was impacted. After the bone graft procedure, the patient was allowed to bear weight as tolerated and was advised to use crutches for 2 weeks. After the first 2 weeks, the patient remained in a CTi ACL brace (Ossur) until the second-stage of the operation took place.
Eight months after the first-stage surgery and after the patient had radiographic evidence of incorporation of his bone graft, we proceeded with the second stage, which included FCL reconstruction with HS allograft, inside-out medial meniscus repair, lateral meniscus root repair (with a two-tunnel transtibial technique), revision ACLR with bone-tendon-bone (BTB) autograft and lateral femoral condyle osteochondral autograft (Figures 6 to 12). The rehabilitation for the second stage was almost identical to what is done for single-stage ACLR. The main difference between rehabilitation in the case of a standard ACLR vs. a staged revision ACLR is the lack of progression to high-load muscular strength development and an increased time for return to sports activities, which allows more time for biologic incorporation of the revision ACL graft. Briefly, upon discharge, the patient was non-weight-bearing for 6 weeks. Physical therapy commenced 24 hours after surgery to gain early ROM, aid muscle reactivation and control edema. The patient’s rehabilitation included straight leg raises in an immobilizer until he could perform them without any extension sag. It was anticipated that he would not return to full activities until a minimum of 9 months postoperatively.
Outcome
At his most recent follow up appointment, the patient reported he was doing well. His range of motion was 0° to 130°, he had no pain, was not using his crutches and was weight-bearing as tolerated.
A study by J.J. Mitchell and colleagues compared outcomes, patient satisfaction and failure rates of single-stage vs. two-stage revision ACLR. There were 39 patients in the single-stage group and 49 patients in the two-stage group who underwent tunnel bone grafting in the first-stage. In both groups, the SF-12 PCS, the WOMAC score, the Lysholm score and the Tegner activity scale significantly improved from preoperative to postoperative status. However, there was no significant difference in the SF-12 MCS score before and after surgery in either group. There were no significant differences between single-stage and two-stage ACL revisions for any objective or subjective data point In addition, there was no significant difference in failure rates or other demographic data between the groups, although there were four failures in the single-stage group (10.3%) and three failures in the staged group (6.1%).
- References:
- Chahla J, et al. Arthrosc Tech. 2016;doi:10.1016/j.eats.2015.10.021.
- Dejour D, et al. Knee Surg Sports Traumatol Arthrosc. 2015;doi:10.1007/s00167-015-3758-6.
- DePhillipo NN, et al. Am J Sports Med. 2017;doi:10.1177/0363546517704426.
- LaPrade RF, et al. Am J Sports Med. 1999;doi:10.1177/03635465990270041101.
- LaPrade RF, et al. J Bone Joint Surg Am. 2008;doi:10.2106/JBJS.G.00979.
- Matava MJ, et al. Am J Sports Med. 2015;doi:10.1177/0363546514560880.
- Mitchell JJ, et al. Am J Sports Med. 2017;doi:10.1177/0363546517698684.
- Zeng C, et al. Knee Surg Sports Traumatol Arthrosc. 2014;doi:10.1007/s00167-012-2277-y.
- For more information:
- Jorge Chahla, MD, PhD, can be reached at Santa Monica Orthopaedic Group - Kerlan Jobe Institute, 2020 Santa Monica Blvd., Suite 400, Santa Monica, CA 90404; email: jchahla@msn.com.
- Patrick M. Kane, MD, can be reached at Premier Orthopaedic Bone and Joint Care, PO Box 607, Georgetown, DE 19947; email: patrick.w.kane@gmail.com.
- Nicholas I. Kennedy, MD, can be reached at Mayo Clinic Orthopedic Surgery and Sports Medicine, Rochester, MN 55902; email: nickkennedy2202@gmail.com.
- Robert F. LaPrade, MD, can be reached at Steadman Clinic, 181 West Meadow Dr., Suite 400, Vail, CO 81657; email: amanda@thesteadmanclinic.com.
- Edited by Gregory L. Cvetanovich, MD, and Benedict U. Nwachukwu, MD, MBA. Cvetanovich is in the Division of Sports Medicine at Rush University Medical Center. Nwachukwu is an orthopedic surgery chief resident at Hospital for Special Surgery. For information on submitting Orthopedics Today Grand Rounds cases, please email: orthopedics@healio.com.
Disclosures: LaPrade reports he receives royalties from and is a paid consultant for Arthrex, Ossur and Smith & Nephew. Chahla, Kane and Kennedy report no relevant financial disclosures.