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Editorial Commentary: Anterior Cruciate Ligament Tunnel Aperture Overlap Determines Need for 1- Versus 2-Stage Revision: Setting the Stage

      Abstract

      Despite general agreement that tunnel widening ≥14 mm necessitates a 2-stage approach for revision anterior cruciate ligament (ACL) reconstruction, there is very little literature describing the effect of tunnel overlap between the previous tunnel and new tunnel with 1-stage ACL revisions. Tunnel overlap, particularly at the aperture, should be minimized without compromising anatomic tunnel location(s). This can often be accomplished with a 1-stage revision, but 2-stage revisions are sometimes required. Revision ACL reconstruction can be challenging and it is helpful for the surgeon to carefully plan preoperatively and have several options available to him/her intraoperatively, including the possibility of a 2-stage revision.
      Although it is reasonably well accepted that tunnel widening ≥14 mm necessitates a 2-stage approach for revision anterior cruciate ligament (ACL) reconstruction.
      • Mitchell J.J.
      • Chahia J.
      • Dean C.S.
      • Cinque M.
      • Matheny L.M.
      • LaPrade R.F.
      Outcomes after 1-stage versus 2-stage revision anterior cruciate ligament reconstruction.
      ,
      • Richter D.L.
      • Werner B.C.
      • Miller M.D.
      Surgical pearls in revision anterior cruciate ligament surgery. When must I stage?.
      there is very little published guidance regarding overlap of the previous ACL tunnel(s) and the planned new tunnel(s). “One-Stage Anatomical Revision Anterior Cruciate Ligament Reconstruction: Results According to Tunnel Overlaps” by Ahn, Son, Jeong, Park, and Lee
      • Ahn J.-H.
      • Son D.-W.
      • Jeong H.-J.
      • Park D.-W.
      • Lee I.-G.
      One-stage anatomical revision anterior cruciate ligament reconstruction: Results according to tunnel overlaps.
      attempts to provide such guidance, at least for the femoral side. The authors found that revision ACL reconstruction with femoral tunnel overlap had equivalent results with cases in which there was no femoral tunnel overlap. Although the authors described 3 different types of femoral tunnel overlap, they did not stratify their results based on type, and the overlap and the aperture of the new tunnel was minimal for all 3 types. I believe that the size of the tunnel aperture is the key in deciding whether a single- versus a 2-stage procedure is required. Yoon et al.
      • Yoon K.H.
      • Kim J.S.
      • Park S.Y.
      • Park S.E.
      One-stage revision anterior cruciate ligament reconstruction: Results according to preoperative bone tunnel diameter: Five to fifteen-year follow-up.
      evaluated 88 patients who underwent 1-stage revision ACL reconstruction. The patients were divided into 2 groups based on the tunnel diameter (group A, <12 mm; group B, >12 mm). At a mean follow-up of 7.9 years, clinical scores following revision ACL reconstruction did not differ significantly according to the tunnel size. However, the results of the postoperative side-to-side differences of the Lachman test as well as the pivot-shift test were significantly superior in group A (<12 mm). Note also that allografts were used in the majority of cases by Ahn, Son, Jeong, Park, and Lee
      • Ahn J.-H.
      • Son D.-W.
      • Jeong H.-J.
      • Park D.-W.
      • Lee I.-G.
      One-stage anatomical revision anterior cruciate ligament reconstruction: Results according to tunnel overlaps.
      The MARS (Multicenter ACL Revision Study) group has shown inferior results with allograft use in the setting of revision ACL reconstruction,
      MARS Group
      Effect of graft choice on the outcome of revision anterior cruciate ligament reconstruction in the Multicenter ACL Revision Study (MARS) cohort.
      so we do not recommend routine use of these grafts.
      If you will allow me, I would like to offer some recommendations on when staging of ACL revisions is appropriate—consider me your stage-coach:
      • 1.
        All patients (and most surgeons) prefer a 1-stage approach. However, it is better to have a successful 2-stage revision ACL reconstruction than a failed 1-stage procedure.
      • 2.
        Obtain a noncontrast computed tomography scan for every planned ACL revision. Tunnel widening (osteolysis) is best characterized with this study.
        • Marchant Jr., M.H.
        • Willimon S.C.
        • Vinson E.
        • Pietrobon R.
        • Garrett W.E.
        • Higgins L.D.
        Comparison of plain radiography, computed tomography, and magnetic resonance imaging in the evaluation of bone tunnel widening after anterior cruciate ligament reconstruction.
        Study the sagittal and coronal images for both the femoral and tibial tunnels.
      • 3.
        If the previous tunnel diameter on either the femoral or tibial side is ≥14 mm, then plan for a 2-stage approach.
      • 4.
        If your planned tunnel will result in a greatly expanded or oval tunnel aperture, then fill the previously drilled tunnel before reaming the new tunnel. Sometimes you can fill the previous tunnel (I prefer bone dowels
        • Battaglia T.C.
        • Miller M.D.
        Management of bony deficiency in revision anterior cruciate ligament reconstruction using allograft bone dowels: Surgical technique.
        ,
        • Kew M.E.
        • Miller M.D.
        • Werner B.C.
        Techniques for ACL revision reconstruction.
        ) and ream a new tunnel with a single-stage approach.
        • Werner B.C.
        • Gilmore D.J.
        • Hamann J.C.
        • Miller M.D.
        Revision ACL reconstruction: Results of a single-stage approach using allograft dowel bone grafting for femoral defects.
        Substantial overlap at the aperture may require a 2-stage approach.
      • 5.
        It is a good idea to plan for your new tunnel to diverge from the previous tunnel(s). This may require a different technique than what was done with the index surgery (e.g., outside-in or independent femoral tunnel drilling).
      • 6.
        You can also fill voids with a retrograde approach—this may help avoid injury to the medial femoral condyle.
      • 7.
        Plan on back-up fixation for all revision ACL reconstructions—you can never trust the bony integrity. This includes using extended buttons for cortical fixation.
      • 8.
        Never compromise on tunnel location to do a single-stage revision. Anatomical tunnel position is more important than having to stage the revision.
      • 9.
        Always be prepared for plan B (and sometimes plan C) with revision ACL reconstruction. I believe that it is better to prepare the patient for a 2-stage procedure preoperatively. If you are then able to do it in 1 stage, it is a pleasant surprise.
      • 10.
        Address all risk factors at the time of surgery—correct excessive tibial slope, double (or triple) check for missed collateral ligament injuries, consider lateral extra-articular tenodesis augmentation, preserve or replace significant meniscal deficiency, etc.
      Revision ACL reconstruction can be both a challenging and rewarding procedure—do it right the second (or third) time—results deteriorate with each revision.
      MARS Group
      Effect of graft choice on the outcome of revision anterior cruciate ligament reconstruction in the Multicenter ACL Revision Study (MARS) cohort.

      Supplementary Data

      References

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        Outcomes after 1-stage versus 2-stage revision anterior cruciate ligament reconstruction.
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        Surgical pearls in revision anterior cruciate ligament surgery. When must I stage?.
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        One-stage anatomical revision anterior cruciate ligament reconstruction: Results according to tunnel overlaps.
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