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Editorial Commentary: Remember the Risk Factors During Individualized, Anatomic, Value-Based Anterior Cruciate Ligament Reconstruction

      Abstract

      Understanding the etiology behind anterior cruciate ligament (ACL) reconstruction failure is a complex topic still being investigated heavily. The 3 classes of failure are technical, traumatic, and biologic. Technical errors are most common and most frequently reflect tunnel malposition. In addition, tibial slope has long been understood to be a risk factor for failed ACL reconstruction. Although not routinely performed at time of primary ACL reconstruction, osteotomy may be considered in the setting of failed ACL reconstruction. Relative quadriceps weakness is a risk factor, and we recommend sport-specific return-to-play testing as well as benchmarks for relative quadriceps strength before full return to activity. Revision ACL reconstruction is associated with both increased costs and worse patient outcomes, so every effort should be made to give patients the best chance of success after the index surgery. Whereas this begins with understanding the patient’s history and risk factors for failure, it crescendos with careful attention to the individually variable factors that make each case unique, tailoring one’s management to ensure that each patient receives an anatomic, individualized, and value-based ACL reconstruction.
      We commend the authors Ziegler, DePhillipo, Kennedy, Dekker, Dornan, and LaPrade on their recent study investigating risk factors for revision anterior cruciate ligament (ACL) reconstruction, titled, “Beighton Score, Tibial Slope, Tibial Subluxation, Quadriceps Circumference Difference and Family History Are Risk Factors for Anterior Cruciate Ligament Graft Failure: A Retrospective Comparison of Primary and Revision Anterior Cruciate Ligament Reconstructions.” In their retrospective cross-sectional study, the authors identify several risk factors associated with revision, including factors that may be identified preoperatively as well as those pertaining to surgical technique. Family history of ACL injury, higher Beighton score, and increased lateral tibial slope were all associated with having revision ACL reconstruction. Additionally, anteromedial tibial subluxation and side-to-side quadriceps circumference were greater in the revision group. Based on 3-dimensional computed tomography (3D CT) reformatted images, the femoral and tibial tunnel were more likely to be malpositioned in the revision group.
      • Ziegler C.
      • DePhillipo N.
      • Kennedy M.
      • Dekker T.
      • Dornan G.
      • LaPrade R.
      Beighton score, tibial slope, tibial subluxation, quadriceps circumference difference and family history are risk factors for anterior cruciate ligament graft failure: A retrospective comparison of primary and revision anterior cruciate ligament reconstructions.
      The etiology for failed ACL reconstructions is a complex, multifaceted issue, and understanding the associated risk factors may give us a better idea of the underlying mechanisms. In addition to increased financial burden, revision ACL reconstruction is also associated with worse outcomes and lower rates of return to play.
      • Herzog M.M.
      • Marshall S.W.
      • Lund J.L.
      • Pate V.
      • Spang J.T.
      Cost of outpatient arthroscopic anterior cruciate ligament reconstruction among commercially insured patients in the United States, 2005-2013.
      • Lefevre N.
      • Klouche S.
      • Mirouse G.
      • Herman S.
      • Gerometta A.
      • Bohu Y.
      Return to sport after primary and revision anterior cruciate ligament reconstruction: A prospective comparative study of 552 patients from the FAST cohort.
      • Battaglia M.J.
      • Cordasco F.A.
      • Hannafin J.A.
      • et al.
      Results of revision anterior cruciate ligament surgery.
      Maximizing value for patients means giving them the best chance of success after primary ACL reconstruction, while avoiding treatments that are less likely to provide benefit. This begins with fully understanding what makes each patient’s case unique, as well as identifying the risk factors for failure. We recommend tailoring surgical management to the patient’s individually unique morphology, as well as the rehabilitation to their sport-specific need.
      • Hussein M.
      • Van Eck C.F.
      • Cretnik A.
      • Dinevski D.
      • Fu F.H.
      Individualized anterior cruciate ligament surgery: A prospective study comparing anatomic single- and double-bundle reconstruction.
      ,
      • Yabroudi M.A.
      • Irrgang J.J.
      Rehabilitation and return to play after anatomic anterior cruciate ligament reconstruction.
      The Multicenter ACL Revision Study (MARS), which analyzed revision ACL reconstruction in 460 patients, broadly defined 3 classes of failure; technical, traumatic, and biologic.
      • Wright R.W.
      • Huston L.J.
      • et al.
      MARS Group
      Descriptive epidemiology of the Multicenter ACL Revision Study (MARS) cohort.
      Technical error was found to be the most commonly cited etiology, reflecting the authors’ reported frequency of tunnel malposition among the revision group.
      • Ziegler C.
      • DePhillipo N.
      • Kennedy M.
      • Dekker T.
      • Dornan G.
      • LaPrade R.
      Beighton score, tibial slope, tibial subluxation, quadriceps circumference difference and family history are risk factors for anterior cruciate ligament graft failure: A retrospective comparison of primary and revision anterior cruciate ligament reconstructions.
      ,
      • Morgan J.A.
      • Dahm D.
      • Levy B.
      • Stuart M.J.
      MARS Study Group
      Femoral tunnel malposition in ACL revision reconstruction.
      Using 3D CT reformatted images for all 90 revision patients, the authors found that all but 1 patient had tunnel malposition. Through our biomechanical studies, we have found that grafts placed within the anatomic footprint experience improved knee kinematics compared with grafts placed outside the anatomic footprint.
      • Yamamoto Y.
      • Hsu W.-H.
      • Woo S.L.-Y.
      • Van Scyoc A.H.
      • Takakura Y.
      • Debski R.E.
      Knee stability and graft function after anterior cruciate ligament reconstruction: A comparison of a lateral and an anatomical femoral tunnel placement.
      ,
      • Musahl V.
      • Plakseychuk A.
      • VanScyoc A.
      • et al.
      Varying femoral tunnels between the anatomical footprint and isometric positions: Effect on kinematics of the anterior cruciate ligament-reconstructed knee.
      Clinically, we have found similar results. In a prospective, randomized control trial comparing conventional single-bundle to anatomic single- and double-bundle ACL reconstruction, anatomic reconstruction resulted in improved kinematics.
      • Hussein M.
      • van Eck C.F.
      • Cretnik A.
      • Dinevski D.
      • Fu F.H.
      Prospective randomized clinical evaluation of conventional single-bundle, anatomic single-bundle, and anatomic double-bundle anterior cruciate ligament reconstruction: 281 cases with 3- to 5-year follow-up.
      In addition to placing tunnels within the native ACL insertion sites on both the femur and tibia, we believe that anatomic ACL reconstruction includes the functional restoration of the ACL to its native dimensions and collagen orientation.
      • van Eck C.F.
      • Gravare-Silbernagel K.
      • Samuelsson K.
      • et al.
      Evidence to support the interpretation and use of the anatomic anterior cruciate ligament reconstruction checklist.
      The ACL is a dynamic structure that varies in shape along its length, as well as under different loading conditions.
      • Fujimaki Y.
      • Thorhauer E.
      • Sasaki Y.
      • Smolinski P.
      • Tashman S.
      • Fu F.H.
      Quantitative in situ analysis of the anterior cruciate ligament.
      The cross-section of the native ACL is typically largest at the tibial insertion, narrowest in the midbody, and larger again at the femoral insertion site.
      • Fujimaki Y.
      • Thorhauer E.
      • Sasaki Y.
      • Smolinski P.
      • Tashman S.
      • Fu F.H.
      Quantitative in situ analysis of the anterior cruciate ligament.
      ,
      • Iriuchishima T.
      • Yorifuji H.
      • Aizawa S.
      • Tajika Y.
      • Murakami T.
      • Fu F.H.
      Evaluation of ACL mid-substance cross-sectional area for reconstructed autograft selection.
      Additionally, the relative size of the ACL varies considerably, with the area of the tibial insertion site varying as much as 3-fold between patients.
      • Kopf S.
      • Pombo M.W.
      • Szczodry M.
      • Irrgang J.J.
      • Fu F.H.
      Size variability of the human anterior cruciate ligament insertion sites.
      ,
      • Guenther D.
      • Irarrázaval S.
      • Albers M.
      • Vernacchia C.
      • Irrgang J.J.
      • Musahl V.
      • Fu F.H.
      Area of the tibial insertion site of the anterior cruciate ligament as a predictor for graft size.
      In a prospective study, we have found that individualizing surgery with respect to the size of the ACL’s tibial insertion site provides superior outcomes, irrespective of technique.
      • Hussein M.
      • Van Eck C.F.
      • Cretnik A.
      • Dinevski D.
      • Fu F.H.
      Individualized anterior cruciate ligament surgery: A prospective study comparing anatomic single- and double-bundle reconstruction.
      Based on our experience, we recommend reconstructing 50% to 80% of the patient’s individually unique tibial insertion area to best respect the patient’s native anatomy.
      Given that it is modifiable, surgical methodology remains an attractive risk factor for study. As other risk factors for failure are identified, the question remains how, or if, they should be addressed. As the authors identify, tibial slope has long been understood to be a risk factor for failed ACL reconstruction.
      • Ziegler C.
      • DePhillipo N.
      • Kennedy M.
      • Dekker T.
      • Dornan G.
      • LaPrade R.
      Beighton score, tibial slope, tibial subluxation, quadriceps circumference difference and family history are risk factors for anterior cruciate ligament graft failure: A retrospective comparison of primary and revision anterior cruciate ligament reconstructions.
      ,
      • Yoon K.H.
      • Park S.Y.
      • Park J.-
      • Kim E.J.
      • Kim S.J.
      • Kwon Y.B.
      • Kim S.-
      Influence of posterior tibial slope on clinical outcomes and survivorship after anterior cruciate ligament reconstruction using hamstring autografts: A minimum of 10-year follow-up.
      Osteotomy is not routinely performed at time of primary ACL reconstruction but may be considered in the setting of multiple failed ACL reconstructions. Although some studies also recommend routine lateral sided extra-articular tenodesis for certain patients to reduce failure rates, we have found similarly low levels of failure following isolated individualized anatomic ACL reconstruction in our prospective randomized trials.
      • Hussein M.
      • Van Eck C.F.
      • Cretnik A.
      • Dinevski D.
      • Fu F.H.
      Individualized anterior cruciate ligament surgery: A prospective study comparing anatomic single- and double-bundle reconstruction.
      ,
      • Hussein M.
      • van Eck C.F.
      • Cretnik A.
      • Dinevski D.
      • Fu F.H.
      Prospective randomized clinical evaluation of conventional single-bundle, anatomic single-bundle, and anatomic double-bundle anterior cruciate ligament reconstruction: 281 cases with 3- to 5-year follow-up.
      ,
      • Sonnery-Cottet B.
      • Saithna A.
      • Cavalier M.
      • et al.
      Anterolateral ligament reconstruction is associated with significantly reduced ACL graft rupture rates at a minimum follow-up of 2 years: A prospective comparative study of 502 patients from the SANTI Study Group.
      ,
      • Getgood A.M.J.
      • Bryant D.M.
      • Litchfield R.
      • et al.
      Lateral extra-articular tenodesis reduces failure of hamstring tendon autograft anterior cruciate ligament reconstruction: 2-Year outcomes from the STABILITY Study randomized clinical trial.
      In the postoperative setting, side-to-side differences in quadriceps size and strength can be addressed throughout the rehabilitation process. We recommend sport-specific return-to-play testing as well as benchmarks for relative quadriceps strength before full return to activity.
      • Yabroudi M.A.
      • Irrgang J.J.
      Rehabilitation and return to play after anatomic anterior cruciate ligament reconstruction.
      In summary, every effort should be made to give patients the highest chance of success after primary ACL reconstruction. This involves being cognizant of the risk factors for failure and understanding when to intervene. In this study, Zeigler et al.
      • Musahl V.
      • Plakseychuk A.
      • VanScyoc A.
      • et al.
      Varying femoral tunnels between the anatomical footprint and isometric positions: Effect on kinematics of the anterior cruciate ligament-reconstructed knee.
      identified several risk factors associated with revision ACL reconstruction, with tunnel malposition being particularly common. In our experience, we can maximize the chance of success after primary surgery by giving every patient an individualized, anatomic, and value-based ACL reconstruction.

      Supplementary Data

      References

        • Ziegler C.
        • DePhillipo N.
        • Kennedy M.
        • Dekker T.
        • Dornan G.
        • LaPrade R.
        Beighton score, tibial slope, tibial subluxation, quadriceps circumference difference and family history are risk factors for anterior cruciate ligament graft failure: A retrospective comparison of primary and revision anterior cruciate ligament reconstructions.
        Arthroscopy. 2020; 37: 195-205
        • Herzog M.M.
        • Marshall S.W.
        • Lund J.L.
        • Pate V.
        • Spang J.T.
        Cost of outpatient arthroscopic anterior cruciate ligament reconstruction among commercially insured patients in the United States, 2005-2013.
        Orthop J Sports Med. 2017; 5 (2325967116684776)
        • Lefevre N.
        • Klouche S.
        • Mirouse G.
        • Herman S.
        • Gerometta A.
        • Bohu Y.
        Return to sport after primary and revision anterior cruciate ligament reconstruction: A prospective comparative study of 552 patients from the FAST cohort.
        Am J Sports Med. 2017; 45: 34-41
        • Battaglia M.J.
        • Cordasco F.A.
        • Hannafin J.A.
        • et al.
        Results of revision anterior cruciate ligament surgery.
        Am J Sports Med. 2007; 35: 2057-2066
        • Hussein M.
        • Van Eck C.F.
        • Cretnik A.
        • Dinevski D.
        • Fu F.H.
        Individualized anterior cruciate ligament surgery: A prospective study comparing anatomic single- and double-bundle reconstruction.
        Am J Sports Med. 2012; 40: 1781-1788
        • Yabroudi M.A.
        • Irrgang J.J.
        Rehabilitation and return to play after anatomic anterior cruciate ligament reconstruction.
        Clin Sports Med. 2013; 32: 165-175
        • Wright R.W.
        • Huston L.J.
        • et al.
        • MARS Group
        Descriptive epidemiology of the Multicenter ACL Revision Study (MARS) cohort.
        Am J Sports Med. 2010; 38: 1979-1986
        • Morgan J.A.
        • Dahm D.
        • Levy B.
        • Stuart M.J.
        • MARS Study Group
        Femoral tunnel malposition in ACL revision reconstruction.
        J Knee Surg. 2012; 25: 361-368
        • Yamamoto Y.
        • Hsu W.-H.
        • Woo S.L.-Y.
        • Van Scyoc A.H.
        • Takakura Y.
        • Debski R.E.
        Knee stability and graft function after anterior cruciate ligament reconstruction: A comparison of a lateral and an anatomical femoral tunnel placement.
        Am J Sports Med. 2004; 32: 1825-1832
        • Musahl V.
        • Plakseychuk A.
        • VanScyoc A.
        • et al.
        Varying femoral tunnels between the anatomical footprint and isometric positions: Effect on kinematics of the anterior cruciate ligament-reconstructed knee.
        Am J Sports Med. 2005; 33: 712-718
        • Hussein M.
        • van Eck C.F.
        • Cretnik A.
        • Dinevski D.
        • Fu F.H.
        Prospective randomized clinical evaluation of conventional single-bundle, anatomic single-bundle, and anatomic double-bundle anterior cruciate ligament reconstruction: 281 cases with 3- to 5-year follow-up.
        Am J Sports Med. 2012; 40: 512-520
        • van Eck C.F.
        • Gravare-Silbernagel K.
        • Samuelsson K.
        • et al.
        Evidence to support the interpretation and use of the anatomic anterior cruciate ligament reconstruction checklist.
        J Bone Joint Surg Am. 2013; 95: e153
        • Fujimaki Y.
        • Thorhauer E.
        • Sasaki Y.
        • Smolinski P.
        • Tashman S.
        • Fu F.H.
        Quantitative in situ analysis of the anterior cruciate ligament.
        Am J Sports Med. 2016; 44: 118-125
        • Iriuchishima T.
        • Yorifuji H.
        • Aizawa S.
        • Tajika Y.
        • Murakami T.
        • Fu F.H.
        Evaluation of ACL mid-substance cross-sectional area for reconstructed autograft selection.
        Knee Surg Sports Traumatol Arthrosc. 2014; 22: 207-213
        • Kopf S.
        • Pombo M.W.
        • Szczodry M.
        • Irrgang J.J.
        • Fu F.H.
        Size variability of the human anterior cruciate ligament insertion sites.
        Am J Sports Med. 2011; 39: 108-113
        • Guenther D.
        • Irarrázaval S.
        • Albers M.
        • Vernacchia C.
        • Irrgang J.J.
        • Musahl V.
        • Fu F.H.
        Area of the tibial insertion site of the anterior cruciate ligament as a predictor for graft size.
        Knee Surg Sports Traumatol Arthrosc. 2017; 25: 1576-1582
        • Yoon K.H.
        • Park S.Y.
        • Park J.-
        • Kim E.J.
        • Kim S.J.
        • Kwon Y.B.
        • Kim S.-
        Influence of posterior tibial slope on clinical outcomes and survivorship after anterior cruciate ligament reconstruction using hamstring autografts: A minimum of 10-year follow-up.
        Arthroscopy. 2020; 36: 2718-2727
        • Sonnery-Cottet B.
        • Saithna A.
        • Cavalier M.
        • et al.
        Anterolateral ligament reconstruction is associated with significantly reduced ACL graft rupture rates at a minimum follow-up of 2 years: A prospective comparative study of 502 patients from the SANTI Study Group.
        Am J Sports Med. 2017; 45: 1547-1557
        • Getgood A.M.J.
        • Bryant D.M.
        • Litchfield R.
        • et al.
        Lateral extra-articular tenodesis reduces failure of hamstring tendon autograft anterior cruciate ligament reconstruction: 2-Year outcomes from the STABILITY Study randomized clinical trial.
        Am J Sports Med. 2020; 48: 285-297