Eur J Orthop Surg Traumatol DOI 10.1007/s00590-014-1549-2
ORIGINAL ARTICLE
Revision of failed anterior cruciate ligament reconstruction with quadrupled semitendinosus allograft: intermediate-term outcome S. Chougule • G. Tselentakis • Stefania Stefan Georgeos Stefanakis
•
Received: 2 July 2014 / Accepted: 17 September 2014 Ó Springer-Verlag France 2014
Abstract Purpose The aim of the present study is to present intermediate-term clinical outcome after revision anterior cruciate ligament (ACL) reconstruction using semitendinosus allograft from donor less than 65 years old. Methods A retrospective study of patients treated with ACL revision from 2003 to 2011 at a District General Hospital. A Study follow-up took place in 2014; clinical outcomes were measured by IKDC, Tegner, Lysholm, and Pain scores and KT-1000 arthrometry laxity measurements. We also registered reoperations and complications. Results Nineteen patients were available for follow-up, and one had telephonic interview. Mean follow-up time was 6 (3–9) years and mean age was 33.68 years, and 14 were men and six women. One patient required staged procedures, 5 % were re-revised for early graft failure and clinical instability, and 15 % had reoperations for other pathologies. The data analysis reveals statistically significant differences between preoperative and postoperative scores. Lysholm score improved from preoperatively 55.5 ± 11 points (range 35–71 points) to postoperatively 89.7 ± 10 points (range 55–100 points), Tegner activity scale score improved from 2.7 ± 1.3 points (range 1–5 points) to 7.1 ± 2.2 points (range 1–10). Pain score S. Chougule (&) G. Tselentakis S. Stefan G. Stefanakis Department of Orthopaedics, East Surrey Hospital, Redhill RH16EL, UK e-mail: [email protected] G. Tselentakis e-mail: [email protected] S. Stefan e-mail: [email protected] G. Stefanakis e-mail: [email protected]
improved from 7.7 ± 1.5 (range 4–10 points) to 1.1 ± 1.9 (range 0–8 points). Level of Activity score improved from 3.6 ± 1.1 (range 2–6 points) to 8.8 ± 1.6 (range 3–10 points). Conclusion In our patient series, revision ACL reconstruction showed a statistically significant improvement in postoperative subjective and objective scores. Five percent failure after mean 6 years (3–9 years) is less compared to other studies; surgical technique and donor age could have played a significant role in lower failure rate. In our series 50 % patients had meniscal and 55 % had Gr I/II chondral injury, this could also explain lower failure rate. Revision of a failed ACL reconstruction using semitendinosus allograft is a safe procedure that improves the function of the patient as demonstrated by clinical scores. Level of evidence Retrospective case series, Level IV. Keywords Revision ACL reconstruction Allograft Outcome measures
Introduction Primary anterior cruciate ligament (ACL) reconstruction is sixth most commonly performed procedure in orthopedic and sports medical practice, and rate of success ranges from 75 to 95 % [1, 2]. ACL reconstruction is the preferred treatment option for clinical instability. Revision of failed prosthetic ACL reconstructions will continue to be necessary as previously placed grafts will fail with time [3]. These patients often present with recurrent instability, pain, swelling or effusion. Graft rupture and the generation of particulate debris are common causes of these symptoms. Management of those patients is complex, Operative treatment includes removing the prosthesis and fixation
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devices and evaluation of femoral and tibial bone stock and determining adequacy of previous tunnel positions [4], and staged surgery may be necessary if there is significant bone loss on either side. Reconstruction can be performed with the use of either autograft or allograft tissue [5–7]. Reconstruction with allograft has the major advantage of eliminating donor site morbidity [8, 9] and faster rehabilitation. However, allograft has the major disadvantages of the potential for disease transmission [10] and limited availability. In addition, concerns were about slower incorporation, inadequate ligamentization, possible immunogenicity, and increased cost [10–13]. Preoperative evaluation This starts with a careful history and physical examination. History will include recurrent instability, pain, swelling, previous other intra-articular pathology, e.g., meniscal or chondral injury. Physical examination includes laxity assessment and range of movement in the knee joint [14]. Plain radiographs are performed to see joint space narrowing. MRI and CT scan are useful to find out tunnel positions and size [4] and if these are of concern. Many studies have reported results of revision surgery of bone patellar tendon bone allograft [5, 15–18], and there are few studies, which report about semitendinosus allograft. The purpose of this paper is to report our experience and intermediate-term functional outcome of revision ACL reconstruction surgery with a quadrupled semitendinosus allograft up to 9 years after surgery in District General Hospital.
examination was performed for effusion, range of motion and crepitations, as well as Tegner, Lysholm, and IKDC knee scores. Before the revision, all patients had recurrent knee laxity (a positive Lachman test) [19], a positive pivot shift test, and KT-1000 anterior drawer testing in sagittal Table 1 Outerbridge scale Properties 1
Superficial lesion, fissures, cracks, and indentations.
2
Fraying, lesions extending down \50 % of cartilage depth
3
Partial loss of cartilage thickness, cartilage defects extending down [50 % of cartilage depth
4
Complete loss of cartilage thickness, bone exposed
Table 2 KT-1000 measurements in patients undergoing revision ACL reconstruction using semitendinosus allograft assessed at 8 weeks preoperatively and 6 years following revision surgery Grade
0
80
Partially functional 3–5.5 mm
10
15
Failure [5 mm
90
5
Table 3 Pivot shift/Lachman test in patients undergoing revision ACL reconstruction using semitendinosus allograft assessed at 8 weeks preoperatively and 6 years following revision surgery Pivot shift (%)
Materials and methods
Preoperative assessment A comprehensive evaluation of the knee was undergone in which detailed history was taken, and the physical
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Post operative (%)
Functional \3 mm
Preoperative
We performed twenty revision ACL reconstructions using quadrupled semitendinosus allograft from 2003 to 2011. There were fourteen men, and six women aged between 20 and 53 (mean age of 33.68 years). We excluded patients who had multiligament injury and reconstructive surgery, patients over 55 years old, previous open knee surgery, bilateral ACL ruptures, and those with previous revision procedure. All patients had a preoperative evaluation consisting of a through history, a physical examination, and calculation of the Tegner and Lysholm functional knee scores. The follow-up evaluation also included calculation of Tegner, Lysholm, and IKDC scores.
Preoperative (%)
Postoperative
Lachman test (%)
Absent—00
Gr I—00
Minor—20
Gr II—10
Moderate—80 Absent—75
Gr III—90 Gr I—70
Minor—20
Gr II—20
Moderate—5
Gr III—10
Table 4 Patient-reported outcome measures Preoperative
Postoperative
1–5
5–10
Pain score (rest)
4 (0–8)
2 (1–8)
Pain score (15 min walk)
6n (1–8)
2 (1–10)
Tegner score (range)
Patient satisfaction Very satisfied (%)
35
Satisfied (%)
30
Fair (%)
28
Unsatisfied (%) Would have procedure again
7 Yes—80 % No—20 %
Eur J Orthop Surg Traumatol
plane and episodes of giving way with daily or sports activities. All patients had knee radiographs including anterior posterior and lateral views and MRI scan to evaluate the extent of degenerative changes, previous fixation devices, tunnel positions, and associated injuries. Arthroscopically assisted anterior cruciate ligament revisions were performed in two hospitals but by the same surgeon (senior author). Quadrupled semitendinosus allograft from donor less than 65 years was used in all the patients. Endo-button was used for femoral fixation, and
Table 5 Number of operative procedures undertaken with primary and revision anterior cruciate ligament reconstruction surgery Procedure
During primary surgery
During revision surgery
Partial menisectomy
25 % (5)
10 % (2)
Meniscal repair
1
0
Excision of buckethandle tear
1
0
Osteoarthritis
30 %
55 %
biodegradable screw and spiked staple were used on tibial side. We used transtibial approach for femoral tunnel drilling in all our patients. All patients were followed up at 6 weeks, 3, 6, 12, 24, and 36 months and assessed by the team. At each consultation, KT-1000 and clinical laxity testing were performed. Primary reconstruction was performed by bone patellar tendon bone in six patients; Dacron graft in two, allograft in one, and 11 patients had ipsilateral gracilis and semitendinosus grafts. The primary ACL reconstruction had been performed by senior author in 10 cases and other surgeons in remaining cases. During primary surgery, five of them had meniscal injuries (Table 3). One had bucket-handle lateral meniscal tear which was repaired, one had grade II medial collateral ligament injury treated with trepanization, and grade I injuries were treated conservatively. MCL injuries are classified as Grade I—Tears involve a few fibers of the MCL with localized tenderness (opening 0–5 mm). Grade II—Injuries include disruption of more fibers with generalized tenderness (valgus opening 5–10 mm).
Fig. 1 Lysholm score preoperative versus Lysholm score postoperative (scatter plot of the preoperative Lysholm score versus postoperative Lysholm score with a linear regression line). The size of the plot marker (circle) indicates the number of patients. The horizontal and vertical histograms show the distribution of the Lysholm scores preoperative and postoperative, respectively
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Eur J Orthop Surg Traumatol Fig. 2 Tegner score preoperative versus Tegner score postoperative (scatter plot of the preoperative Tegner score versus postoperative Tegner score with a linear regression line). The size of the plot marker (circle) indicates the number of patients. The horizontal and vertical histograms show the distribution of the Tegner scores preoperative and postoperative, respectively
Grade III—Injuries are complete MCL tears with resultant medial joint laxity to valgus stress ([10-mm opening). During primary surgery, Gr I/II osteoarthritic changes were seen in 30 % of patients and one had microfracture (see Table 1). During revision surgery, 10 % patients had new meniscal injury and 55 % had Gr I/II osteoarthritis; one patient who had repair of meniscus showed good healing of meniscus; one patient had Dacron-induced synovitis with tibial bone defect who had two-stage procedure: first stage was debridement and bone graft of tibial defect. Other patient who had microfracture showed good healing. One patient had common peroneal injury following initial injury. The average time from primary surgery to the revision was 6.8 years (range 3–17 years). One patient had re-revision for failed graft and symptomatic instability. Postoperative assessment All patients were retrospectively evaluated by senior author and his team at a mean of 6 years following surgery apart
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from regular follow-up (range 3–9 years). At the time of follow-up, nineteen patients returned for an evaluation that included a through history, a physical examination, and KT-1000 arthrometric testing and one had telephonic interview. The follow-up evaluation also included calculation of Tegner, Lysholm, and IKDC knee scores. Operative summaries of the revision ACL reconstructions were also reviewed to determine other associated surgery performed and status of knee intraoperatively. Rehabilitation Similar protocol as used for primary ACL reconstruction was used for revision surgery. Range of motion exercises was started as soon as patient is comfortable on the same day. Initially, patients were mobilized with crutches and partial weight bearing moving gradually to full weight bearing within 2–3 days; as they become more comfortable, crutches were discarded. In all patients, range of motion was allowed up to 90° immediately postoperatively, which was slowly increased till they achieve full flexion. Muscle strengthening and proprioceptive exercises were begun on second postoperative day,
Eur J Orthop Surg Traumatol Fig. 3 Pain score preoperative versus Pain score postoperative (scatter plot of the preoperative Pain score versus postoperative Pain score with a linear regression line). The size of the plot marker (circle) indicates the number of patients. The horizontal and vertical histograms show the distribution of the Pain scores preoperative and postoperative, respectively
which includes isometric, closed chain exercises. Running cutting maneuvers were delayed till 6 months following surgery, after 6 months sports-specific drills commenced and strengthening and endurance excecises continued. Full sporting activity resumed after 9 months.
Our patients showed significant improvement in subjective and objective outcome scores. The end point indicating failure is re-revision of the reconstructed ACL. One patient (5 %) required re-ACL revision for symptomatic instability. This patient had graft rupture within 10 weeks of surgery following another twisting injury, and he had stable knee following re-ACL revision.
Results Objective knee stability outcome (Tables 2 and 3) Nineteen patients were available for follow-up, and one had telephonic interview. Average time at follow-up was 6 years (range 3–9 years). Our patients showed significant improvement in objective knee stability scores, and patient-reported outcome measures demonstrated significant improvement for the sub-score of sports, recreation, and quality of life. Statistical analysis was used to determine the effect that ACL revision surgery had on Pain scores, Level of Activity, Lysholm scores, and Tegner score. Data analysis revealed statistically significant differences between preoperative and postoperative scores that there was strong evidence of mean increase in Activity scores, Lysholm scores, and Tegner scores and mean decrease in Pain score following revision surgery.
At 6-year follow-up, sagittal knee laxity measured by means of the KT-1000 improved significantly from 5.5 mm preoperatively to less than 3 mm in 80 % patients, and 15 % had laxity between 3 and 5.5 mm, while no improvement in sagittal knee laxity was seen in only 5 % of patients. Pivot shift was absent in 75 % of patients, minor in 20 % of patients, and moderate in 5 % of patients (Table 3). Patient-reported outcome measures (Table 4) These scores demonstrated significant improvement for the sub-score of sports and recreation and quality of life.
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Eur J Orthop Surg Traumatol Fig. 4 Level of Activity preoperative versus Level of Activity postoperative (scatter plot of the preoperative Level of Activity versus postoperative Level of Activity with a linear regression line). The size of the plot marker (circle) indicates the number of patients. The horizontal and vertical histograms show the distribution of the activity scores preoperative and postoperative, respectively
Overall, 65 % of patients reported that they were satisfied or very satisfied with the outcome of the ACL revision and 80 % stated that they would have the procedure again. Pain score improved from 4 to 2 at rest and from 6 to 2 after 15 min of walking. Statistical analysis Statistical analysis was used to determine the effect that ACL revision surgery had on Pain scores, Level of Activity, Lysholm scores, and Tegner score. Linear regression analysis of the data was performed to determine variables statistically associated with changes in Pain score, Level of Activity, and Lysholm and Tegner scores. Statistical analysis of changes in functional knee (Lysholm and Tegner) scores, Pain scores, and Activity scores preoperatively and postoperatively was made using paired t test within groups. Significance was established at p \ 0.001 (functional assessment: Lysholm and Tegner scores, Level of Activity, Pain scores). The data analysis reveals statistically significant differences between preoperative and postoperative scores.
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Lysholm score improved from preoperatively mean and standard deviation 55.5 ± 11 points (range 35–71 points) to postoperatively mean and standard deviation 89.7 ± 10 points (range 55–100 points) (Fig. 1). Tegner activity scale score improved from preoperatively mean and standard deviation 2.7 ± 1.3 points (range 1–5 points) to postoperatively mean and standard deviation 7.1 ± 2.2 points (range 1–10) (Fig. 2). Pain score improved from preoperatively mean and standard deviation 7.7 ± 1.5 (range 4–10 points) to postoperatively mean and standard deviation 1.1 ± 1.9 (range 0–8 points) (Fig. 3). The Level of Activity score improved from preoperatively mean and standard deviation 3.6 ± 1.1 (range 2–6 points) to postoperatively mean and standard deviation 8.8 ± 1.6 (range 3–10 points) (Fig. 4). The differences in the Pain scores [t (19) = 12.9437, p = 3.57e-11], Level of Activity [t (19) = 12.7508, p = 4.617e-11], Lysholm scores [t (19) = 8.9303, p = 1.576e-08], and Tegner scores [t (19) = 9.5677, p = 5.337e-09] before and after the ACL surgery were significant.
Eur J Orthop Surg Traumatol
Complications and failures One patient required re-ACL revision for symptomatic instability. This patient had graft rupture within 10 weeks of surgery. The interval between ACL revision and re-ACL revision was 6 months (Fig. 6a–d). Same patient had painful cystic swelling over tibial staple site 4 years following re-revision ACL; MRI confirmed cyst but graft was intact; he underwent excision of cyst and removal of tibial staple in July 2014; he had negative pivot and Lachman was Gr I; and his knee remains stable (Fig. 5a–f). Other causes for reoperation were as follows: meniscus injury and ongoing knee pain. One patient had surgery for new medial meniscal tear 3 years following revision surgery, and one patient had arthroscopy for ongoing knee pain due to Gr III degeneration in medial compartment; none of our patients had infection or DVT.
Discussion
Fig. 5 A 47-year-old man who developed cystic swelling at tibial portal site following re-revision of ACL reconstruction (MRI and X ray findings of patient who had re-revision of ACL). a MRI showing failed primary (ACL reconstruction). b Radiograph following failed revision (ACL reconstruction showing widened femoral tunnel). c MRI showing revision graft rupture. d MRI showing revision graft rupture. e MRI sagittal view following re-revision, intact graft. f MRI post re-revision for tibial portal site swelling (Benign cyst on MRI)
There is a strong evidence of a mean increase in Activity scores, Lysholm scores, and Tegner scores postoperatively and a mean decrease in postoperative Pain scores. Significant changes in values were observed at the time of the postoperative follow-up, all four tests having very low p values (p \ 0.001).
Most studies on ACL revision are focused on a specific surgical technique and different grafts [6, 20, 21]. Some examine results of ACL revision seen at a specialized center [22, 23]. A recent review presented outcome data from the published retrospective studies where the patient numbers ranged from 21 to 107 with failure rates from 6 to 24 % after 5- to 6-year follow-up [24], and mixed-effect model meta-analysis of 21 studies showed failure rate of 15 % at 2 years. Our series of 20 patients showed failure of graft in one patient (5 %) requiring re-revision and 10 % of patients had Gr III Lachman following surgery without symptomatic instability. The majority of the studies used specific techniques and mixed graft choices [25] and as such did not investigate outcome following use of single graft type. We used semitendinosus allograft in all our patients with 5 % failure at mean 6 years. Another study derived from a national registry for knee ligament reconstruction [26] also demonstrated less favorable results after 30 months of follow-up in 443 revision ACL reconstruction patients based on KOOS and Tegner function score compared with primary ACL reconstruction. This registry showed meniscal injury in 35 % of all patients, and 17 % showed cartilage injury. At 2 years, 3 % of primary reconstructions were revised. Follow-up KOOS demonstrated difference between primary ACL, revision ACL, and multiligament reconstructions. Sports/recreation score was 40, 32, and 28, and quality-of-life score was 40, 32, and 33 for the respective groups. The same study showed graft failure rate of 6 % in revision ACL reconstruction at 5 years, and in their series,
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Eur J Orthop Surg Traumatol Fig. 6 a Primary ACL reconstruction using hamstring graft. b Revision ACL reconstruction using allograft. c Re-revision ACL reconstruction using allograft. d Re-revision ACL reconstruction using allograft
30 % of patients had surgery using allograft [26]. However, our patients were followed up longer than those reported by these authors. A recent French multicenter study [27] investigating descriptive data of ACL revision in 293 patients demonstrated that the main causes for ACL graft failure were femoral tunnel position (36 %), new trauma (30 %), and unknown cause (15 %); our patient who had graft rupture had another twisting injury, and other 10 % of patients who had Gr III Lachman did not have clinical instability. This study reported a cumulative meniscus lesion incidence of 70 % after 2.5 years following ACL revision and demonstrated that meniscectomy during revision surgery negatively influenced both functional outcome and knee stability. Meniscal and cartilage injuries in ACL revision patients are a likely cause of poorer clinical outcome as compared to primary ACL reconstruction. Kamath and Burks in their study concluded that good results can be obtained in terms of functional stability after revision reconstruction, but chondral and meniscal injury as well as unrecognized associated pathologic instability may play a role in diminished outcomes [24], and in our study, group of 55 % had Gr I/II chondral injury at the time of revision surgery.
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Fifty percent of our patients had meniscal injury at 9 years, six had meniscal resection and one had repair of bucket-handle tear during primary surgery and two had meniscal resection at revision surgery and one had meniscal resection following revision surgery (see Table 5). The re-revision in our patients was 5 % after a mean 6-year follow-up. This is a higher risk compared with the revision risk after primary ACL reconstruction. We used quadrupled semitendinosus allograft from donor less than 65 years old. Hampton studied effect of donor age on allograft patellar tendon in 75 revision ACL reconstructions at 24 months and has demonstrated statistically significant improvement in patient-related outcome measures using donor age as a contributing variable [28]. The exact age of donor was not available in our series, however all the allografts were from donor less than 65 years of age, that seems to be in agreement with Hampton’s work. The present study is primarily limited by its design as a retrospective study and small sample size. We did, however, managed to follow-up almost all patients in our series, and one had telephonic interview to obtain functional outcome scores. Our patients showed statistically
Eur J Orthop Surg Traumatol
significant improvement in mean Activity scores, Lysholm scores, and Tegner scores and a mean decrease in postoperative Pain score. Despite improvement in these outcome measures and achieving acceptable knee stability, all patients undergoing revision ACL reconstruction should be carefully counseled before undergoing revision ACL surgery. Conclusion This study demonstrates statistically significant intermediate-term improvement in patient-related outcome scores. The total re-revision rate of 5 % is relatively less compared to other studies, but conclusion cannot be drawn due to small number of cases in our study. Factors that influence final outcome are tunnel placement, surgical technique, and donor age and could be contributing to lower failure rate in our case series. In our series 50 % patients had meniscal and 55 % had Gr I/II chondral injury, this could also explain lower failure rate. Revision of a failed ACL reconstruction using semitendinosus allograft is a safe procedure that improves the function of the patient as demonstrated by the clinical scores. Acknowledgments We wish to express our warm thanks to all the authors who contributed to the study. Conflict of interest peting interests.
The authors declare that they have no com-
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11. Barber FA, McGuire DA, Johnson DH (2003) Point counterpoint: should allografts be used for routine anterior cruciate ligament reconstructions? Arthroscopy 19:421–425 12. Frank CB, Jackson DW (1997) Current concepts review; the science of reconstruction of the anterior cruciate ligament. J Bone Jt Surg Am 79:1556–1576 13. Moller E, Weidenhielm L, Werner S (2009) Outcome and kneerelated quality of life after anterior cruciate ligament reconstruction: a long-term follow-up. Knee Surg Sports Traumatol Arthrosc 17:786–794 14. Harner CD, Giffin JR, Dunteman RC, Annunziata CC, Friedman MJ (2001) Evaluation and treatment of recurrent instability after anterior cruciate ligament reconstruction. Instr Course Lect 50:463–474 15. Gorschewsky O, Browa A, Vogel U, Stauffer E (2002) Clinico histologic comparison of allogenic and autologous bone tendon bone using one third of the patellar tendon in reconstruction of the anterior cruciate ligament. Unfallchirurg 105:703–714 (German) 16. Collette M, Dupont B, Peters M (1991) Reconstruction of anterior cruciate ligament with a free graft of the patellar tendon; allograft versus autograft. Acta Prthop Beig 57(Suppl 2):54–60 (French) 17. Lephart SM, Kocher MS, Harner CD, Fu FH (1993) Quadriceps strength and functional capacity after anterior cruciate ligament reconstruction patellar tendon autograft versus allograft. Am J Sports Med 21:267–269 (Chinese) 18. Stringham DR, Pelmas CJ, Burks RT, Newman AP, Marcus RL (1996) Comparison of anterior cruciate ligament reconstructions using patellar tendon allograft or autograft. Arthroscopy 12:414–421 19. Briggs KK, Lysholm J, Tegner Y, Rodkey WG, Kocher MS, Steadman JR (2009) The reliability, validity, and responsiveness of the Lysholm score and Tegner activity scale for anterior cruciate ligament injuries of the knee: 25 years later. Am J Sports Med 37:890–897 20. Ferretti A, Conteduca F, Monaco E, De Carli A, D’Arrigo C (2006). Revision anterior cruciate ligament reconstruction with doubled semitendinosus and gracilis tendons and lateral extraarticular reconstruction. J Bone Jt Surg Am 88:2373–2379 21. Fox JA, Pierce M, Bojchuk J, Hayden J, Bush-Joseph CA, Bach BR Jr (2004) Revision anterior cruciate ligament reconstruction with nonirradiated fresh-frozen patellar tendon allograft. Arthroscopy 20:787–794 22. Johnson DL, Coen MJ (1995) Revision ACL surgery: etiology, indications, techniques, and results. Am J Knee Surg 8:155–167 23. Tambe AD, Godsiff SP, Mulay S, Joshi M (2006) Anterior cruciate ligament insufficiency: does delay in index surgery affect outcome in recreational athletes. Int Orthop 30(2):104–109 24. Kamath GV, Redfern JC, Greiswww PE, Burks RT (2011) Revision anterior cruciate ligament reconstruction. Am ente reconstructions. Knee Surg Sports Traumatol Arthrosc 17:117–124 25. Harner CD, Olson E, Irrgang JJ, Silverstein S, Fu FH, Silbey M (1996) Allograft versus autograft anterior cruciate ligament reconstruction: 3- to 5-year outcome. Clin Orthop Relat Res 324:134–144 26. Lind M, Menhert F, Pedersen AB (2009) The first results from the Danish ACL reconstruction registry: epidemiologic and 2 year follow-up results from 5,818 knee ligament reconstructions. Knee Surg Sports Traumatol Arthrosc 17:117–124 27. Trojani C, Sbihi A, Djian P, Potel JF, Hulet C, Jouve F, Bussiere C, Ehkirch FP, Burdin G, Dubrana F, Beaufils P, Franceschi JP, Chassaing V, Colombet P, Neyret P (2011) Causes for failure of ACL reconstruction and influence of meniscectomies after revision. Knee Surg Sports Traumatol Arthrosc 19:196–201 28. Hampton DM, Lamb J, Klimkiewicz JJ (2012) Effect of donor age on patellar tendon allograft ACL reconstruction. Orthopedics 35(8):e1173–e1176, 0147–7447
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ORIGINAL ARTICLE
Revision of failed anterior cruciate ligament reconstruction with quadrupled semitendinosus allograft: intermediate-term outcome S. Chougule • G. Tselentakis • Stefania Stefan Georgeos Stefanakis
•
Received: 2 July 2014 / Accepted: 17 September 2014 Ó Springer-Verlag France 2014
Abstract Purpose The aim of the present study is to present intermediate-term clinical outcome after revision anterior cruciate ligament (ACL) reconstruction using semitendinosus allograft from donor less than 65 years old. Methods A retrospective study of patients treated with ACL revision from 2003 to 2011 at a District General Hospital. A Study follow-up took place in 2014; clinical outcomes were measured by IKDC, Tegner, Lysholm, and Pain scores and KT-1000 arthrometry laxity measurements. We also registered reoperations and complications. Results Nineteen patients were available for follow-up, and one had telephonic interview. Mean follow-up time was 6 (3–9) years and mean age was 33.68 years, and 14 were men and six women. One patient required staged procedures, 5 % were re-revised for early graft failure and clinical instability, and 15 % had reoperations for other pathologies. The data analysis reveals statistically significant differences between preoperative and postoperative scores. Lysholm score improved from preoperatively 55.5 ± 11 points (range 35–71 points) to postoperatively 89.7 ± 10 points (range 55–100 points), Tegner activity scale score improved from 2.7 ± 1.3 points (range 1–5 points) to 7.1 ± 2.2 points (range 1–10). Pain score S. Chougule (&) G. Tselentakis S. Stefan G. Stefanakis Department of Orthopaedics, East Surrey Hospital, Redhill RH16EL, UK e-mail: [email protected] G. Tselentakis e-mail: [email protected] S. Stefan e-mail: [email protected] G. Stefanakis e-mail: [email protected]
improved from 7.7 ± 1.5 (range 4–10 points) to 1.1 ± 1.9 (range 0–8 points). Level of Activity score improved from 3.6 ± 1.1 (range 2–6 points) to 8.8 ± 1.6 (range 3–10 points). Conclusion In our patient series, revision ACL reconstruction showed a statistically significant improvement in postoperative subjective and objective scores. Five percent failure after mean 6 years (3–9 years) is less compared to other studies; surgical technique and donor age could have played a significant role in lower failure rate. In our series 50 % patients had meniscal and 55 % had Gr I/II chondral injury, this could also explain lower failure rate. Revision of a failed ACL reconstruction using semitendinosus allograft is a safe procedure that improves the function of the patient as demonstrated by clinical scores. Level of evidence Retrospective case series, Level IV. Keywords Revision ACL reconstruction Allograft Outcome measures
Introduction Primary anterior cruciate ligament (ACL) reconstruction is sixth most commonly performed procedure in orthopedic and sports medical practice, and rate of success ranges from 75 to 95 % [1, 2]. ACL reconstruction is the preferred treatment option for clinical instability. Revision of failed prosthetic ACL reconstructions will continue to be necessary as previously placed grafts will fail with time [3]. These patients often present with recurrent instability, pain, swelling or effusion. Graft rupture and the generation of particulate debris are common causes of these symptoms. Management of those patients is complex, Operative treatment includes removing the prosthesis and fixation
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devices and evaluation of femoral and tibial bone stock and determining adequacy of previous tunnel positions [4], and staged surgery may be necessary if there is significant bone loss on either side. Reconstruction can be performed with the use of either autograft or allograft tissue [5–7]. Reconstruction with allograft has the major advantage of eliminating donor site morbidity [8, 9] and faster rehabilitation. However, allograft has the major disadvantages of the potential for disease transmission [10] and limited availability. In addition, concerns were about slower incorporation, inadequate ligamentization, possible immunogenicity, and increased cost [10–13]. Preoperative evaluation This starts with a careful history and physical examination. History will include recurrent instability, pain, swelling, previous other intra-articular pathology, e.g., meniscal or chondral injury. Physical examination includes laxity assessment and range of movement in the knee joint [14]. Plain radiographs are performed to see joint space narrowing. MRI and CT scan are useful to find out tunnel positions and size [4] and if these are of concern. Many studies have reported results of revision surgery of bone patellar tendon bone allograft [5, 15–18], and there are few studies, which report about semitendinosus allograft. The purpose of this paper is to report our experience and intermediate-term functional outcome of revision ACL reconstruction surgery with a quadrupled semitendinosus allograft up to 9 years after surgery in District General Hospital.
examination was performed for effusion, range of motion and crepitations, as well as Tegner, Lysholm, and IKDC knee scores. Before the revision, all patients had recurrent knee laxity (a positive Lachman test) [19], a positive pivot shift test, and KT-1000 anterior drawer testing in sagittal Table 1 Outerbridge scale Properties 1
Superficial lesion, fissures, cracks, and indentations.
2
Fraying, lesions extending down \50 % of cartilage depth
3
Partial loss of cartilage thickness, cartilage defects extending down [50 % of cartilage depth
4
Complete loss of cartilage thickness, bone exposed
Table 2 KT-1000 measurements in patients undergoing revision ACL reconstruction using semitendinosus allograft assessed at 8 weeks preoperatively and 6 years following revision surgery Grade
0
80
Partially functional 3–5.5 mm
10
15
Failure [5 mm
90
5
Table 3 Pivot shift/Lachman test in patients undergoing revision ACL reconstruction using semitendinosus allograft assessed at 8 weeks preoperatively and 6 years following revision surgery Pivot shift (%)
Materials and methods
Preoperative assessment A comprehensive evaluation of the knee was undergone in which detailed history was taken, and the physical
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Post operative (%)
Functional \3 mm
Preoperative
We performed twenty revision ACL reconstructions using quadrupled semitendinosus allograft from 2003 to 2011. There were fourteen men, and six women aged between 20 and 53 (mean age of 33.68 years). We excluded patients who had multiligament injury and reconstructive surgery, patients over 55 years old, previous open knee surgery, bilateral ACL ruptures, and those with previous revision procedure. All patients had a preoperative evaluation consisting of a through history, a physical examination, and calculation of the Tegner and Lysholm functional knee scores. The follow-up evaluation also included calculation of Tegner, Lysholm, and IKDC scores.
Preoperative (%)
Postoperative
Lachman test (%)
Absent—00
Gr I—00
Minor—20
Gr II—10
Moderate—80 Absent—75
Gr III—90 Gr I—70
Minor—20
Gr II—20
Moderate—5
Gr III—10
Table 4 Patient-reported outcome measures Preoperative
Postoperative
1–5
5–10
Pain score (rest)
4 (0–8)
2 (1–8)
Pain score (15 min walk)
6n (1–8)
2 (1–10)
Tegner score (range)
Patient satisfaction Very satisfied (%)
35
Satisfied (%)
30
Fair (%)
28
Unsatisfied (%) Would have procedure again
7 Yes—80 % No—20 %
Eur J Orthop Surg Traumatol
plane and episodes of giving way with daily or sports activities. All patients had knee radiographs including anterior posterior and lateral views and MRI scan to evaluate the extent of degenerative changes, previous fixation devices, tunnel positions, and associated injuries. Arthroscopically assisted anterior cruciate ligament revisions were performed in two hospitals but by the same surgeon (senior author). Quadrupled semitendinosus allograft from donor less than 65 years was used in all the patients. Endo-button was used for femoral fixation, and
Table 5 Number of operative procedures undertaken with primary and revision anterior cruciate ligament reconstruction surgery Procedure
During primary surgery
During revision surgery
Partial menisectomy
25 % (5)
10 % (2)
Meniscal repair
1
0
Excision of buckethandle tear
1
0
Osteoarthritis
30 %
55 %
biodegradable screw and spiked staple were used on tibial side. We used transtibial approach for femoral tunnel drilling in all our patients. All patients were followed up at 6 weeks, 3, 6, 12, 24, and 36 months and assessed by the team. At each consultation, KT-1000 and clinical laxity testing were performed. Primary reconstruction was performed by bone patellar tendon bone in six patients; Dacron graft in two, allograft in one, and 11 patients had ipsilateral gracilis and semitendinosus grafts. The primary ACL reconstruction had been performed by senior author in 10 cases and other surgeons in remaining cases. During primary surgery, five of them had meniscal injuries (Table 3). One had bucket-handle lateral meniscal tear which was repaired, one had grade II medial collateral ligament injury treated with trepanization, and grade I injuries were treated conservatively. MCL injuries are classified as Grade I—Tears involve a few fibers of the MCL with localized tenderness (opening 0–5 mm). Grade II—Injuries include disruption of more fibers with generalized tenderness (valgus opening 5–10 mm).
Fig. 1 Lysholm score preoperative versus Lysholm score postoperative (scatter plot of the preoperative Lysholm score versus postoperative Lysholm score with a linear regression line). The size of the plot marker (circle) indicates the number of patients. The horizontal and vertical histograms show the distribution of the Lysholm scores preoperative and postoperative, respectively
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Eur J Orthop Surg Traumatol Fig. 2 Tegner score preoperative versus Tegner score postoperative (scatter plot of the preoperative Tegner score versus postoperative Tegner score with a linear regression line). The size of the plot marker (circle) indicates the number of patients. The horizontal and vertical histograms show the distribution of the Tegner scores preoperative and postoperative, respectively
Grade III—Injuries are complete MCL tears with resultant medial joint laxity to valgus stress ([10-mm opening). During primary surgery, Gr I/II osteoarthritic changes were seen in 30 % of patients and one had microfracture (see Table 1). During revision surgery, 10 % patients had new meniscal injury and 55 % had Gr I/II osteoarthritis; one patient who had repair of meniscus showed good healing of meniscus; one patient had Dacron-induced synovitis with tibial bone defect who had two-stage procedure: first stage was debridement and bone graft of tibial defect. Other patient who had microfracture showed good healing. One patient had common peroneal injury following initial injury. The average time from primary surgery to the revision was 6.8 years (range 3–17 years). One patient had re-revision for failed graft and symptomatic instability. Postoperative assessment All patients were retrospectively evaluated by senior author and his team at a mean of 6 years following surgery apart
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from regular follow-up (range 3–9 years). At the time of follow-up, nineteen patients returned for an evaluation that included a through history, a physical examination, and KT-1000 arthrometric testing and one had telephonic interview. The follow-up evaluation also included calculation of Tegner, Lysholm, and IKDC knee scores. Operative summaries of the revision ACL reconstructions were also reviewed to determine other associated surgery performed and status of knee intraoperatively. Rehabilitation Similar protocol as used for primary ACL reconstruction was used for revision surgery. Range of motion exercises was started as soon as patient is comfortable on the same day. Initially, patients were mobilized with crutches and partial weight bearing moving gradually to full weight bearing within 2–3 days; as they become more comfortable, crutches were discarded. In all patients, range of motion was allowed up to 90° immediately postoperatively, which was slowly increased till they achieve full flexion. Muscle strengthening and proprioceptive exercises were begun on second postoperative day,
Eur J Orthop Surg Traumatol Fig. 3 Pain score preoperative versus Pain score postoperative (scatter plot of the preoperative Pain score versus postoperative Pain score with a linear regression line). The size of the plot marker (circle) indicates the number of patients. The horizontal and vertical histograms show the distribution of the Pain scores preoperative and postoperative, respectively
which includes isometric, closed chain exercises. Running cutting maneuvers were delayed till 6 months following surgery, after 6 months sports-specific drills commenced and strengthening and endurance excecises continued. Full sporting activity resumed after 9 months.
Our patients showed significant improvement in subjective and objective outcome scores. The end point indicating failure is re-revision of the reconstructed ACL. One patient (5 %) required re-ACL revision for symptomatic instability. This patient had graft rupture within 10 weeks of surgery following another twisting injury, and he had stable knee following re-ACL revision.
Results Objective knee stability outcome (Tables 2 and 3) Nineteen patients were available for follow-up, and one had telephonic interview. Average time at follow-up was 6 years (range 3–9 years). Our patients showed significant improvement in objective knee stability scores, and patient-reported outcome measures demonstrated significant improvement for the sub-score of sports, recreation, and quality of life. Statistical analysis was used to determine the effect that ACL revision surgery had on Pain scores, Level of Activity, Lysholm scores, and Tegner score. Data analysis revealed statistically significant differences between preoperative and postoperative scores that there was strong evidence of mean increase in Activity scores, Lysholm scores, and Tegner scores and mean decrease in Pain score following revision surgery.
At 6-year follow-up, sagittal knee laxity measured by means of the KT-1000 improved significantly from 5.5 mm preoperatively to less than 3 mm in 80 % patients, and 15 % had laxity between 3 and 5.5 mm, while no improvement in sagittal knee laxity was seen in only 5 % of patients. Pivot shift was absent in 75 % of patients, minor in 20 % of patients, and moderate in 5 % of patients (Table 3). Patient-reported outcome measures (Table 4) These scores demonstrated significant improvement for the sub-score of sports and recreation and quality of life.
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Eur J Orthop Surg Traumatol Fig. 4 Level of Activity preoperative versus Level of Activity postoperative (scatter plot of the preoperative Level of Activity versus postoperative Level of Activity with a linear regression line). The size of the plot marker (circle) indicates the number of patients. The horizontal and vertical histograms show the distribution of the activity scores preoperative and postoperative, respectively
Overall, 65 % of patients reported that they were satisfied or very satisfied with the outcome of the ACL revision and 80 % stated that they would have the procedure again. Pain score improved from 4 to 2 at rest and from 6 to 2 after 15 min of walking. Statistical analysis Statistical analysis was used to determine the effect that ACL revision surgery had on Pain scores, Level of Activity, Lysholm scores, and Tegner score. Linear regression analysis of the data was performed to determine variables statistically associated with changes in Pain score, Level of Activity, and Lysholm and Tegner scores. Statistical analysis of changes in functional knee (Lysholm and Tegner) scores, Pain scores, and Activity scores preoperatively and postoperatively was made using paired t test within groups. Significance was established at p \ 0.001 (functional assessment: Lysholm and Tegner scores, Level of Activity, Pain scores). The data analysis reveals statistically significant differences between preoperative and postoperative scores.
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Lysholm score improved from preoperatively mean and standard deviation 55.5 ± 11 points (range 35–71 points) to postoperatively mean and standard deviation 89.7 ± 10 points (range 55–100 points) (Fig. 1). Tegner activity scale score improved from preoperatively mean and standard deviation 2.7 ± 1.3 points (range 1–5 points) to postoperatively mean and standard deviation 7.1 ± 2.2 points (range 1–10) (Fig. 2). Pain score improved from preoperatively mean and standard deviation 7.7 ± 1.5 (range 4–10 points) to postoperatively mean and standard deviation 1.1 ± 1.9 (range 0–8 points) (Fig. 3). The Level of Activity score improved from preoperatively mean and standard deviation 3.6 ± 1.1 (range 2–6 points) to postoperatively mean and standard deviation 8.8 ± 1.6 (range 3–10 points) (Fig. 4). The differences in the Pain scores [t (19) = 12.9437, p = 3.57e-11], Level of Activity [t (19) = 12.7508, p = 4.617e-11], Lysholm scores [t (19) = 8.9303, p = 1.576e-08], and Tegner scores [t (19) = 9.5677, p = 5.337e-09] before and after the ACL surgery were significant.
Eur J Orthop Surg Traumatol
Complications and failures One patient required re-ACL revision for symptomatic instability. This patient had graft rupture within 10 weeks of surgery. The interval between ACL revision and re-ACL revision was 6 months (Fig. 6a–d). Same patient had painful cystic swelling over tibial staple site 4 years following re-revision ACL; MRI confirmed cyst but graft was intact; he underwent excision of cyst and removal of tibial staple in July 2014; he had negative pivot and Lachman was Gr I; and his knee remains stable (Fig. 5a–f). Other causes for reoperation were as follows: meniscus injury and ongoing knee pain. One patient had surgery for new medial meniscal tear 3 years following revision surgery, and one patient had arthroscopy for ongoing knee pain due to Gr III degeneration in medial compartment; none of our patients had infection or DVT.
Discussion
Fig. 5 A 47-year-old man who developed cystic swelling at tibial portal site following re-revision of ACL reconstruction (MRI and X ray findings of patient who had re-revision of ACL). a MRI showing failed primary (ACL reconstruction). b Radiograph following failed revision (ACL reconstruction showing widened femoral tunnel). c MRI showing revision graft rupture. d MRI showing revision graft rupture. e MRI sagittal view following re-revision, intact graft. f MRI post re-revision for tibial portal site swelling (Benign cyst on MRI)
There is a strong evidence of a mean increase in Activity scores, Lysholm scores, and Tegner scores postoperatively and a mean decrease in postoperative Pain scores. Significant changes in values were observed at the time of the postoperative follow-up, all four tests having very low p values (p \ 0.001).
Most studies on ACL revision are focused on a specific surgical technique and different grafts [6, 20, 21]. Some examine results of ACL revision seen at a specialized center [22, 23]. A recent review presented outcome data from the published retrospective studies where the patient numbers ranged from 21 to 107 with failure rates from 6 to 24 % after 5- to 6-year follow-up [24], and mixed-effect model meta-analysis of 21 studies showed failure rate of 15 % at 2 years. Our series of 20 patients showed failure of graft in one patient (5 %) requiring re-revision and 10 % of patients had Gr III Lachman following surgery without symptomatic instability. The majority of the studies used specific techniques and mixed graft choices [25] and as such did not investigate outcome following use of single graft type. We used semitendinosus allograft in all our patients with 5 % failure at mean 6 years. Another study derived from a national registry for knee ligament reconstruction [26] also demonstrated less favorable results after 30 months of follow-up in 443 revision ACL reconstruction patients based on KOOS and Tegner function score compared with primary ACL reconstruction. This registry showed meniscal injury in 35 % of all patients, and 17 % showed cartilage injury. At 2 years, 3 % of primary reconstructions were revised. Follow-up KOOS demonstrated difference between primary ACL, revision ACL, and multiligament reconstructions. Sports/recreation score was 40, 32, and 28, and quality-of-life score was 40, 32, and 33 for the respective groups. The same study showed graft failure rate of 6 % in revision ACL reconstruction at 5 years, and in their series,
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Eur J Orthop Surg Traumatol Fig. 6 a Primary ACL reconstruction using hamstring graft. b Revision ACL reconstruction using allograft. c Re-revision ACL reconstruction using allograft. d Re-revision ACL reconstruction using allograft
30 % of patients had surgery using allograft [26]. However, our patients were followed up longer than those reported by these authors. A recent French multicenter study [27] investigating descriptive data of ACL revision in 293 patients demonstrated that the main causes for ACL graft failure were femoral tunnel position (36 %), new trauma (30 %), and unknown cause (15 %); our patient who had graft rupture had another twisting injury, and other 10 % of patients who had Gr III Lachman did not have clinical instability. This study reported a cumulative meniscus lesion incidence of 70 % after 2.5 years following ACL revision and demonstrated that meniscectomy during revision surgery negatively influenced both functional outcome and knee stability. Meniscal and cartilage injuries in ACL revision patients are a likely cause of poorer clinical outcome as compared to primary ACL reconstruction. Kamath and Burks in their study concluded that good results can be obtained in terms of functional stability after revision reconstruction, but chondral and meniscal injury as well as unrecognized associated pathologic instability may play a role in diminished outcomes [24], and in our study, group of 55 % had Gr I/II chondral injury at the time of revision surgery.
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Fifty percent of our patients had meniscal injury at 9 years, six had meniscal resection and one had repair of bucket-handle tear during primary surgery and two had meniscal resection at revision surgery and one had meniscal resection following revision surgery (see Table 5). The re-revision in our patients was 5 % after a mean 6-year follow-up. This is a higher risk compared with the revision risk after primary ACL reconstruction. We used quadrupled semitendinosus allograft from donor less than 65 years old. Hampton studied effect of donor age on allograft patellar tendon in 75 revision ACL reconstructions at 24 months and has demonstrated statistically significant improvement in patient-related outcome measures using donor age as a contributing variable [28]. The exact age of donor was not available in our series, however all the allografts were from donor less than 65 years of age, that seems to be in agreement with Hampton’s work. The present study is primarily limited by its design as a retrospective study and small sample size. We did, however, managed to follow-up almost all patients in our series, and one had telephonic interview to obtain functional outcome scores. Our patients showed statistically
Eur J Orthop Surg Traumatol
significant improvement in mean Activity scores, Lysholm scores, and Tegner scores and a mean decrease in postoperative Pain score. Despite improvement in these outcome measures and achieving acceptable knee stability, all patients undergoing revision ACL reconstruction should be carefully counseled before undergoing revision ACL surgery. Conclusion This study demonstrates statistically significant intermediate-term improvement in patient-related outcome scores. The total re-revision rate of 5 % is relatively less compared to other studies, but conclusion cannot be drawn due to small number of cases in our study. Factors that influence final outcome are tunnel placement, surgical technique, and donor age and could be contributing to lower failure rate in our case series. In our series 50 % patients had meniscal and 55 % had Gr I/II chondral injury, this could also explain lower failure rate. Revision of a failed ACL reconstruction using semitendinosus allograft is a safe procedure that improves the function of the patient as demonstrated by the clinical scores. Acknowledgments We wish to express our warm thanks to all the authors who contributed to the study. Conflict of interest peting interests.
The authors declare that they have no com-
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