Strategies for revision surgery after primary double-bundle anterior cruciate ligament (ACL) reconstruction

Purpose

The purpose of this article was to discuss pre- and intra-operative considerations as well as surgical strategies for different femoral and tibial tunnel scenarios in revision surgery following primary double-bundle anterior cruciate ligament (ACL) reconstruction.

Methods

Based on the current literature of ACL revision surgery and surgical experience, an algorithm for revision surgery after primary double-bundle ACL reconstruction was created.

Results

A guideline and flowchart were created using a case-based approached for revision surgery after primary double-bundle ACL reconstruction.

Conclusion

Revision surgery after primary double-bundle ACL reconstruction can be a challenging procedure that requires flexibility and a repertoire of surgical techniques. The combination of pre-operative planning with 3D-CT reconstruction, in addition to careful intra-operative assessment, and the use of this flowchart can simplify the ACL revision procedure.

Level of evidence

V.     

The concept of individualized anatomic anterior cruciate ligament (ACL) reconstruction

Purpose

To describe the concept of individualized anatomic anterior cruciate ligament (ACL) reconstruction.

Methods

The PubMed/Medline database was searched using keywords pertaining to ACL reconstruction. Relevant articles were reviewed in order to summarize important concepts of individualized surgery in ACL reconstruction. Surgical experiences with case examples are also highlighted.

Results

Individualized ACL surgery allows for the customization of surgery to each individual patient. Accounting for graft selection and other characteristics such as anatomy, lifestyle and activity preferences may provide the patient with the best potential for a successful outcome. The surgeon should be comfortable with a variety of graft harvests and surgical techniques when practicing individualized surgery.

Conclusion

Individualized anatomic ACL reconstruction is founded on the objective evaluation of functional anatomy and individual characteristics, thereby restoring the ACL as closely as possible to the native anatomy and function. The adoption and subsequent use of individualized surgery may facilitate improved clinical as well as objective outcomes, particularly in the long term.

Level of evidence

V.     

Variability in rehabilitation protocols following pediatric anterior cruciate ligament (ACL) reconstruction

ABSTRACT

Objectives: The objective of this study was to assess the variability of publicly available pediatric anterior cruciate ligament (ACL) reconstruction rehabilitation protocols produced by academic orthopedic surgery departments and children’s hospitals.

Methods: A web-based search was performed to identify rehabilitation protocols. Protocol and literature review guided the development of a comprehensive scoring rubric that was used to assess protocols for the presence and timing of postoperative adjunctive therapy and physical therapy recommendations.

Results: A search of 180 academic orthopedic surgery programs and 250 children’s hospitals identified 21 rehabilitation protocols. A majority of these protocols (90%) recommended postoperative adjunctive therapies such as bracing (81%), cryotherapy (43%), electrical muscle stimulation (24%), and/or continuous passive motion (14%). Several protocols (57%) recommended a specific weight-bearing status in the immediate postoperative period, but there was minimal consensus on that status. Conversely, there was more agreement amongst protocols that recommended strength exercises (52%); a majority of protocols suggested quad sets (91%), ankle pumps (73%), leg press (64%), and/or double-leg squats (55%). Ten protocols (48%) recommended initiation of stretches in the first week following surgery, and most commonly suggested patella mobilizations start at an average of 1.9 weeks postop (range 0–8 weeks). Twelve protocols (57%) discussed return to play, with an average recommended return to play at 7.5 months (range 3–11 months) postoperatively. However, few protocols recommended that patients get approval from their surgeon (19%) or pass specific tests (24%) prior to return to play.

Conclusion: Few academic departments of orthopedic surgery or children’s hospitals publish pediatric ACL reconstruction protocols online. Given the substantial variability observed amongst these protocols and recent findings that patients increasingly turn to the internet for medical information, this study suggests that standardization of pediatric ACL reconstruction rehabilitation has the potential to further optimize patient care.     

Symmetry restoration and functional recovery before and after anterior cruciate ligament reconstruction

Purpose

The aims of this study were to evaluate the functional recovery before and after ACL reconstruction and to evaluate the sensitivity to change in performance-based and self-reported outcomes prior to and after ACL reconstruction and to determine whether these changes represent clinically relevant improvement.

Methods

Eighty-three athletes participated in this study. Athletes were tested after an ACL injury, after preoperative training, and 6 and 12 months after ACL reconstruction. Athletes completed quadriceps strength testing, hop testing, and self-reported questionnaires for knee function (International Knee Documentation Committee subjective knee form, Knee Outcome Survey-Activities of Daily Living Scale, and the Global Rating Scale of Perceived Function) at each testing period.

Results

A significant interaction of limb by time was seen in normalized quadriceps strength, and single, triple, and 6-m timed hop, where the involved limb improved more than the uninvolved limb over time. A main effect of time was noted for performance-based limb symmetry indexes and self-reported measures.

Conclusion

Limb-to-limb asymmetries are reduced, and normal limb symmetry is restored after perturbation training and aggressive quadriceps strengthening and returned to similar levels 6 months after reconstruction. Performance-based values on the involved limb and self-reported outcomes are sensitive to change over time, and these were clinically relevant improvements.

Level of evidence

Prognostic study, Level II.     

TransLateral ACL reconstruction: a technique for anatomic anterior cruciate ligament reconstruction

Anatomic placement of the femoral tunnel in anterior cruciate ligament (ACL) reconstruction confers biomechanical advantages over the traditional tunnel position. The anteromedial portal technique for anatomic ACL reconstruction has many well-described technical challenges. This paper describes the TransLateral technique. The technique produces anatomic femoral tunnel placement using direct measurement of the medial wall of the lateral femoral condyle and out to in drilling. All work is carried out through the lateral portal with all viewing via the medial portal. There is no need for an accessory medial portal or hyperflexion of the knee. Level of evidence Expert opinion, Level V.     

Comparison of double-bundle anterior cruciate ligament (ACL) reconstruction and single-bundle reconstruction with remnant pull-out suture

Purpose

The purpose of this study was to evaluate the stability and functional outcomes of anterior cruciate ligament (ACL) reconstruction by tensioning of the ACL remnant using pull-out sutures compared with ACL double-bundle reconstruction.

Methods

Forty-four patients were included in single-bundle reconstruction with remnant tensioning group (Group 1), and 56 patients were included in the double-bundle reconstruction group (Group 2). The remnant tissue was tensioned to the direction of posterolateral bundle, which unrelated to the type of remnant bundle. Objective knee stability was evaluated by anterior stress radiography, KT-1000 and lateral pivot shift tests. The Tegner activity scale, International Knee Documentation Committee and OrthopädischeArbeitsgruppeKnie scoring systems were used for clinical evaluation.

Results

No statistically significant intergroup differences were observed in mechanical stability and clinical results (n.s). However, surgical time of remnant tensioning group is shorter than double-bundle reconstruction group (P = 0.005).

Conclusion

Remnant tensioning suture with single-bundle reconstruction could be used with positive results as good as double-bundle technique if a good ACL remnant was found bridging the femur and tibia, rather than debride or damage to the remnant tissue during operation.

Level of evidence

Retrospective, comparative cohort study, Level IV.     

Anatomic anterior cruciate ligament (ACL) reconstruction: a global perspective. Part 1

Purpose

In August 2011, orthopaedic surgeons from more than 20 countries attended a summit on anatomic anterior cruciate ligament (ACL) reconstruction. The summit offered a unique opportunity to discuss current concepts, approaches, and techniques in the field of ACL reconstruction among leading surgeons in the field.

Methods

Five panels (with 36 panellists) were conducted on key issues in ACL surgery: anatomic ACL reconstruction, rehabilitation and return to activity following anatomic ACL reconstruction, failure after ACL reconstruction, revision anatomic ACL reconstruction, and partial ACL injuries and ACL augmentation. Panellists’ responses were secondarily collected using an online survey.

Results

Thirty-six panellists (35 surgeons and 1 physical therapist) sat on at least one panel. Of the 35 surgeons surveyed, 22 reported performing “anatomic” ACL reconstructions. The preferred graft choice was hamstring tendon autograft (53.1 %) followed by bone-patellar tendon-bone autograft (22.8 %), allograft (13.5 %), and quadriceps tendon autograft (10.6 %). Patients generally returned to play after an average of 6 months, with return to full competition after an average of 8 months. ACL reconstruction “failure” was defined by 12 surgeons as instability and pathological laxity on examination, a need for revision, and/or evidence of tear on magnetic resonance imaging. The average percentage of patients meeting the criteria for “failure” was 8.2 %.

Conclusions

These data summarize the results of five panels on anatomic ACL reconstruction. The most popular graft choice among surgeons for primary ACL reconstructions is hamstring tendon autograft, with allograft being used most frequently employed in revision cases. Nearly half of the surgeons surveyed performed both single- and double-bundle ACL reconstructions depending on certain criteria. Regardless of the technique regularly employed, there was unanimous support among surgeons for the use of “anatomic” reconstructions using bony and soft tissue remnant landmarks.

Level of evidence

V.     

Graft size after anterior cruciate ligament reconstruction

Purpose

The native anterior cruciate ligament (ACL) is composed of two distinct bundles, the anteromedial (AM) and posterolateral (PL), and both have been shown to be reliably measured on magnetic resonance imaging (MRI). The purpose of this study was to measure the size of the AM and PL bundles after ACL double-bundle reconstructions on MRI and compare this to the relative graft size at the time of surgery.

Methods

Between January 2007 and April 2010, 85 knees were identified after allograft double-bundle ACL reconstruction with post-operative MRI (1.5 T) and met inclusion criteria. On standard sagittal, coronal and oblique coronal MRIs, the AM and PL bundles were delineated and the midsubstance width of the ACL graft was measured. The images were independently measured in a blinded fashion by two observers. Linear and curvilinear regression analysis was used to analyse the relationship between graft size and time after reconstruction.

Results

The mean age of the patients was 24.6 years (SD 10.4). Mean time from surgery to post-operative MRI was 271.5 days (SD 183.4). The mean percentage of the original size of the AM bundle was 86.9 % (SD 9.9) and of the PL bundle was 88.6 % (SD 9.9). There was no correlation between the relative size of the AM graft and the time from surgery (r = 0.3, n.s.) and no significant relationship for the PL graft (r = 0.1, n.s).

Conclusion

On average, there was no graft enlargement of the AM and PL grafts 275.1 days after allograft ACL double-bundle reconstruction, as the mean relative graft size was less than 100 % on MRI. This study suggests that surgeons, who use allografts, should measure the ACL and replace it with a similar size, as there is a low risk of hypertrophy of the graft within one year post-operative.

Level of evidence

IV.     

Gait patterns after anterior cruciate ligament reconstruction

The aim of this study is to analyse the changes in select gait parameters following anterior cruciate ligament (ACL) reconstruction. The study was performed on 15 subjects who underwent ACL reconstruction by the bone-patellar tendon-bone technique. Gait analysis was performed using the Elite three-dimensional (3D) optoelectronic system (BTS), a Kistler force platform and the Telemg telemetric electromyograph (BTS). Kinematic data were recorded for the principal lower limb joints (hip, knee and ankle). The examined muscles include vastus lateralis, rectus femoris, biceps femoris and semitendinosus. The results obtained from the operated subjects were compared with those of 10 untreated subjects and 5 subjects without ACL damage. In the operated subjects the knee joint angular values regained a normal flexion pattern for the injured limb during the stance phase. The analysis of joint moments shows: (a) sagittal plane: recovery of the knee flexion moment at loading response and during preswing; (b) frontal plane: recovery of the normal patterns for both hip and knee adduction-abduction moments during the entire stance phase. The examination of ground reaction forces reveals the recovery of frontal component features. The EMG traces show the normal biphasic pattern for the operated subjects as compared to the untreated subjects. The results suggest that the gait parameters shift towards normal value patterns.     

Accelerated rehabilitation after anterior cruciate ligament reconstruction

To overcome many of the complications after ACL reconstruction (prolonged knee stiffness, limitation of complete extension, delay in strength recovery, anterior knee pain), yet still maintain knee stability, we developed a rehabilitation protocol that emphasizes full knee extension on the first postoperative day and immediate weightbearing according to the patient's tolerance. Of 800 patients who underwent intraarticular ACL patellar tendon-bone graft reconstruction, performed by the same surgeon, the last 450 patients have followed the accelerated rehabilitation schedule as outlined in the protocol. A longer than 2 year followup is recorded for 73 of the patients in the accelerated rehabilitation group. On the 1st postoperative day, we encouraged these patients to walk with full weightbearing and full knee extension. By the 2nd postoperative week, the patients with a 100 degree range of motion participated in a guided exercise and strengthening program. By the 4th week, patients were permitted unlimited activities of daily living and were allowed to return to light sports activities as early as the 8th week if the Cybex strength scores of the involved extremity exceeded 70% of the scores of the noninvolved extremity and the patient had completed a sport-specific functional/agility program. The patient database was compiled from frequent clinical examinations, periodic knee questionnaires, and objective information, such as range of motion measurements, KT-1000 values, and Cybex strength scores. A series of graft biopsies obtained at various times have revealed no adverse histologic reaction.(ABSTRACT TRUNCATED AT 250 WORDS)     

Patellofemoral problems after anterior cruciate ligament reconstruction

Between 1982 and 1986, 126 patients who had undergone ACL reconstruction were followed in a prospective manner. One year follow-up statistics were reviewed for the presence of 13 different complications. The most prevalent complications were quadriceps weakness, flexion contracture, and patellofemoral pain. Quadriceps weakness (strength less than 80% of the normal side) was present in 65% of patients and correlated positively with flexion contracture, patellar irritabibilty, and ACL reconstructions using patellar tendon grafts. Flexion contracture of 5 degrees or more was present in 24% of patients and correlated positively with increased age and patellar irritability. Patellofemoral pain was present in 19% of patients and correlated positively with flexion contracture. Clinical relevance: The three most common complications of knee ligament surgery are shown to be strongly interrelated. It is likely that a causal relationship is present in which flexion contracture causes patellofemoral irritability, and that both of these factors, alone or in combination, result in quadriceps weakness. If this theory is correct, then it is crucial that postoperative rehabilitation programs place a major emphasis on the avoidance of flexion contracture.     

Restoration of anterior cruciate ligament-hamstring reflex arc after anterior cruciate ligament reconstruction

It has recently been emphasized that restoration of neuromuscular function contributes to dynamic stability of the anterior cruciate ligament (ACL) reconstructed knee. The existence of an ACL-hamstring reflex arc, one of the protective ligament-muscular pathways, has been revealed in normal human knees. Although reinnervation to the reconstructed ACL has been observed histologically, it remains unclear whether the ACL-hamstring reflex arc is reestablished. This study examined the existence of the ACL-hamstring reflex arc in ACL-reconstructed knees by analyzing the changes in the hamstring EMG elicited by electrical stimulation to the reconstructed ACL. The patellar tendon grafts transplanted as an ACL substitute in three patients were electrically stimulated via a bipolar wire electrode inserted arthroscopically. The surface EMG was monitored from the ipsilateral biceps femoris and semitendinosus. In two of the three patients the significantly increased EMG value of the biceps femoris was detected between 120 and 140 ms after the onset of electrical ACL stimulation. The increased EMG activity detected in the biceps femoris after the stimulation to the patellar tendon graft indicated reestablishment of the ACL-hamstring reflex arc in the ACL-reconstructed knee.     

Type of measurement used influences central and peripheral contributions to quadriceps weakness after anterior cruciate ligament (ACL) reconstruction

ObjectiveThe relative contribution of muscle size and voluntary activation (VA) on quadriceps strength after anterior cruciate ligament (ACL) reconstruction remains inconclusive. Here, we aimed to determine the contributions of muscle size and VA on quadriceps strength in ACL-reconstructed patients and determine if contributions were similar if unilateral outcomes (i.e. ACL-reconstructed limb) or the LSI was used. Design: A cross-sectional study.SettingA university research laboratory.ParticipantsSixteen individuals 6–12 months after ACL reconstruction (Age: 22.3 ± 6.0yr, Height: 1.7 ± 0.1 m, Mass: 68.7 ± 11.5 kg) were recruited.Main outcome measuresQuadriceps isometric strength and VA, via the interpolated triplet technique, were assessed bilaterally. Ultrasound images were acquired of the vastus lateralis to calculate cross-sectional area (CSA) in both legs. LSI’s were computed for all variables by expressing values of the reconstructed leg as a percent of the non-reconstructed leg. Separate stepwise linear regressions were performed to examine the contribution of VA and CSA on quadriceps strength. Model 1 used LSI for all outcomes and model 2 used outcomes from the reconstructed leg.ResultsWe observed between limb deficits of 27.78% in quadriceps strength, 13.61% in vastus lateralis CSA, and 13.18% in VA (P < 0.05). Strength LSI was significantly predicted by VA LSI (R² = 0.45, P < 0.01), but not by CSA LSI (R² = 0.01, P =0.87). Reconstructed leg strength was significantly predicted by VL CSA (R² = 0.50, P < 0.01) but not quadriceps VA (R² = 0.08, P =0.11).ConclusionsThe contributions of VA and CSA on quadriceps PT differed greatly if LSI or reconstructed leg outcomes were used. Evaluation of VA and CSA in unison may be provide a more holistic understanding of the sources of muscle weakness after ACL reconstruction.     

Recurrent acute hemarthrosis after anterior cruciate ligament reconstruction

Arthroscopic-assisted and endoscopic operative techniques have allowed for less and less restrictive postoperative rehabilitation programs after cruciate ligament reconstruction. Accelerated rehabilitation programs may, however, also provoke mechanical problems at the transplant-bone interface, as reports in the literature of loosened fixation devices and loosened or even fractured bone pegs with subsequent hemarthrosis and recurrent instability have shown. We describe the case of a patient who presented with recurrent acute hemarthrosis after anterior cruciate ligament reconstruction without additional trauma and without instability. However, the symptoms and signs were clearly related to the fixation method employed.     

Isokinetic muscle strength after anterior cruciate ligament reconstruction

The purpose of the present study was to investigate the isokinetic muscle strength 6 months after reconstruction of the anterior cruciate ligament (ACL). In order to recommend full-load come-back in sport, sufficient muscle strength may be important. Ninety female elite team handball players (mean 24.1 years) were postoperatively tested with Biodex. The operated limb was compared with the contralateral limb: 82.2% had a hamstring strength of a minimum of 49.6 Nm, corresponding to at least 90% of the non-operated limb, while only 12.2% fulfilled the recommended strength of 117.7 Nm for quadriceps femoris. Patients over 26 years showed significantly lower muscle strength in the operated limb than their younger counterparts. Increased focus on quadriceps femoris muscle strength during rehabilitation may improve the knee function faster after ACL reconstruction.     

Infrapatellar heterotopic ossification after anterior cruciate ligament reconstruction

Reconstruction of the anterior cruciate ligament (ACL) is currently a common procedure. We report a case of ACL reconstruction using an autologous patellar tendon graft, where great infrapatellar heterotopic ossification occurred post-operatively. We found no similar cases in the literature. We discuss about the probable origin.