Abstract
Revision anterior cruciate ligament reconstruction (ACLR) is a challenging procedure. Results are less satisfactory than those of primary ACLR owing to bone defects, altered anatomic landmarks, and concomitant injuries. Modifiable factors such as autograft, early surgery, 2-stage surgery for 1 cm of tunnel widening or greater, and anterolateral ligament reconstruction or lateral extra-articular tenodesis may improve outcomes of anterior cruciate ligament revision surgery. Finally, it is important to consider patients’ expectations after revision ACLR when counseling patients and making surgical decisions.
Revision anterior cruciate ligament reconstruction (ACLR) is a challenging procedure. Its results are less satisfactory than those of primary ACLR owing to bone defects, altered anatomic landmarks, and severe concomitant injuries induced by additional injuries and prolonged instability.
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Sylvia, Toppo, Perrone, Miltenberg, Power, Richmond, and Salzler,6
in their study “Revision Soft-Tissue Allograft Anterior Cruciate Ligament Reconstruction Is Associated With Lower Patient-Reported Outcomes Compared With Primary Anterior Cruciate Ligament Reconstruction in Patients Aged 40 and Older,” also highlight poor patient-reported outcomes (PROs) after revision ACLR in middle-aged patients. They found that revision allograft ACLRs in patients aged 40 years or older were associated with lower PROs compared with primary ACLRs. Patients who underwent revision ACLR failed to meet the patient acceptable symptom state (PASS) threshold for the International Knee Documentation Committee (IKDC) score more often and were dissatisfied with the results of the procedure more than twice as often as patients who underwent primary ACLR.The number of revision ACLRs has increased in recent years, with as many as 13,000 patients undergoing revision ACLR annually in the United States alone.
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Nevertheless, whether revision ACLR can achieve comparable clinical outcomes to those of primary ACLR remains an open question. However, this study may provide some clues to solving this problem.This study used soft-tissue allografts in both primary and revision ACLRs. A Multicenter Orthopaedic Outcomes Network (MOON) cohort study reported that the rate of graft rupture with allograft reconstruction is 4 times higher than that with autograft reconstruction.
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It also showed that the difference in the risk of graft rerupture between autograft and allograft in young patients was greater than that in older patients. However, the results of this study do not imply that the use of allografts guarantees satisfactory outcomes in older patients. A Multicenter ACL Revision Study (MARS) cohort study evaluated the effect of graft choice on the outcomes of revision ACLR.10
It found that improved sports function, improved PROs, and a decreased risk of graft rerupture were obtained at 2 years’ follow-up when autograft was used. Moreover, Grossman11
et al. reported that allograft showed more laxity than autograft at 3 to 9 years’ follow-up after revision ACLR (3.21 mm vs 1.33 mm). The findings of these studies suggested that autograft should be used in primary or revision ACLR when possible to improve clinical outcomes and graft survivorship.Degenerative chondral and meniscal lesions are common in middle-aged patients during ACLR.
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Moreover, a recent study reported that patients who underwent revision ACLR had more chondral lesions and higher-grade chondral lesions than those who underwent primary ACLR.13
In the current study by Sylvia et al.,6
revision ACLR patients showed a longer duration between injury and surgery and the rate of concomitant meniscal repair was higher in the revision ACLR group (21.9% vs 6%, P = .007). Stone et al.14
similarly reported that delayed ACLR in patients aged 40 years or older is associated with an increased risk of medial meniscal injury at 1 year. Therefore, immediate reconstruction for a failed ACLR may help decrease the possibility of arthritis developing as it has been associated with the duration between failure and revision ACLR.Published studies
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,15
have shown that proper management of tunnel widening is crucial for successful revision ACLR. Although there is still controversy about the amount of tunnel widening indicated for 2-stage revision ACLR, there seems to be a consensus that a large amount of tunnel widening can affect graft fixation and healing in revision ACLR. It has previously been reported in the literature that 2-stage surgery should be performed if the tunnel size exceeds 10 to 15 mm.4
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In addition, recent clinical studies have reported that anterolateral ligament reconstruction or lateral extra-articular tenodesis can improve the clinical outcomes and survivorship of revision ACLR.16
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, 18
The study by Sylvia et al.
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has several limitations. Because this study was retrospective, recall bias could have influenced the results. The revision surgical procedures were performed by 4 different surgeons. In addition, the population, from a single center, may not be fully representative of all populations, and longer follow-up may better represent postoperative outcomes. The 2 groups in this study also differed regarding mean follow-up time and concomitant meniscal repair, which could influence the results. Finally, data from patients managed nonoperatively and preoperative PROs were unavailable for comparison between groups. However, these limitations do not outweigh the study’s benefit to the scientific literature. This study highlights poor PROs after revision ACLR in middle-aged patients, who have been shown to have lower expectations than younger patients.19
As Sylvia et al. mentioned in the “Discussion” section, patients’ expectations should be considered when counseling patients before revision ACLR. In addition, future research and efforts are needed to improve the clinical outcomes of revision ACLR.Supplementary Data
- ICMJE author disclosure forms
References
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Footnotes
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The author reports no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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