Copyright © 2006 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Nicholas J. Honkamp, MD, and Freddie H. Fu, MD, DSc(Hon), DPs(Hon)*,
Center for Sports Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
Posted November 2006
The purpose of the study by Ferretti et al. was to evaluate
the results of revision anterior cruciate ligament reconstruction with the use
of an autogenous doubled semitendinosus and gracilis graft in association with
an extra-articular iliotibial band tenodesis. The authors retrospectively
followed thirty patients who had previously undergone a primary anterior cruciate
ligament reconstruction at other institutions with the use of an autogenous
bone-patellar tendon-bone graft (twenty-six patients) or a prosthetic ligament
(four patients). Functional outcomes, graft survival, and radiographic outcomes
were evaluated at a mean of five years. One patient went on to revision graft
failure, and two patients had a grade 2+ on pivot shift testing and a
side-to-side difference of >5 mm on KT-1000 anterior drawer testing. One
patient was lost to follow up; therefore, the authors report that their failure
rate was 10% (three of twenty-nine patients). All but one patient were
satisfied with the result. The strengths of this study include the objective
definition of primary anterior cruciate ligament reconstruction failure
(positive Lachman test, positive pivot shift test, a side-to-side difference of
>5 mm on KT-1000 anterior drawer testing, and recurrent episodes of giving-way),
the five-year medium-term mean follow-up, and the excellent follow-up
assessment data (radiographs, physical examination, functional outcome scores, and
KT-1000 results).
An interesting finding of the study was the cause of failure
of the primary reconstruction. The authors demonstrated an error in tunnel
placement in ten patients, new trauma in fourteen patients, failure of a
prosthetic ligament in four patients, and unknown cause in two patients. Many
authors have proposed how to evaluate a failed anterior cruciate ligament
reconstruction1. We have found the major causes of failure to be surgical
technique, failure of graft incorporation, and new trauma2.
The position of an anterior cruciate ligament reconstruction
graft continues to be the most important surgical variable because of its
direct effect on knee biomechanics and subsequent functional outcome. Malpositioned
bone tunnels, particularly on the femoral side, lead to increased stresses
within the graft and on the articular surfaces of the joint3,4. The
high prevalence of tunnel malposition in the current study is thus not
surprising and reinforces the need for continued vigilance on the part of
surgeons in their tunnel placement.
Failure of graft incorporation is another consideration. Autograft
anterior cruciate ligament bone-patellar tendon-bone grafts have shown favorable
graft revascularization properties, and bone-plug incorporation resembles a
normal anterior cruciate ligament insertion5,6. Although the authors
do not comment directly on the time frame from primary reconstruction to
traumatic re-injury, they do state that the average time from primary
reconstruction to revision was five years. Thus, failure of graft incorporation
seems an unlikely source of failure in this study group, in which twenty-six of
thirty patients had autogenous bone-patellar tendon-bone as the primary
reconstructive graft. A new traumatic event, as the authors state, is then the
primary mode of recurrent failure in this study group. In this case, the use of
an autogenous hamstring graft, as opposed to allograft, for revision
reconstruction is very appropriate.
Another potential cause of recurrent anterior cruciate
ligament failure is the loss of secondary stabilizers of the knee. The authors
do not comment, in the physical examination subsection, on any potential loss
of secondary stabilizers such as the posterolateral corner, medial collateral
ligament, or the meniscus. Furthermore, they do not comment on the status of
the meniscus and cartilage surfaces at the time of the initial operation (all of
which were performed at other institutions). It is well known that loss of these
secondary stabilizers can lead to premature anterior cruciate ligament graft
failure, even in well-done anterior cruciate ligament reconstructions2.
It is interesting that the authors use a lateral tenodesis
to treat severe rotatory instability in patients undergoing primary anterior
cruciate ligament reconstruction, and added the procedure to the management of patients
in the current study in an effort to protect the revision anterior cruciate
ligament graft from undesired stresses during the early postoperative period. The
goal of most extra-articular lateral tenodesis procedures is to provide a checkrein
effect on the lateral plateau to prevent anterior subluxation as the knee
approaches terminal extension7. Although many retrospective studies
have confirmed that this technique produces satisfactory results at the time of
intermediate follow-up8,9, two studies that directly compared
standard intra-articular reconstructions with and without lateral
extra-articular augmentation did not show any statistical difference between
the two groups10,11. Additionally, human cadaveric investigations
have shown that lateral tenodeses may overconstrain lateral tibial motion and
prevent the normal "screw-home" mechanism of the knee12,13.
These abnormal biomechanical conditions, particularly in the
context of knees with possible chondral and/or meniscal disorders in addition
to an anterior cruciate ligament injury, may have an important effect on the
long-term risk of degenerative joint disease. No data on the status of the knee
at the initial reconstruction were given; however, the authors note that,
during the revision anterior cruciate ligament operations, they performed six
partial lateral meniscectomies and three partial medial meniscectomies and observed
that three patients had grade-III chondromalacia of a femoral condyle. At a
mean radiographic follow-up of forty-seven months, the authors state that eleven
patients had mild, five had moderate, and two had severe degenerative knee
signs in accordance with the criteria of Fairbank. This is important, as
multiple studies have concluded that meniscal and chondral injuries often do
not manifest an increased prevalence of arthrosis until at least five years
after injury or surgery14,15. Therefore, it is quite possible that
these radiographic changes will progress in this study group.
While no study, to our knowledge, confirms that anterior cruciate ligament reconstruction improves
knee stability and thereby helps avoid further meniscal and articular cartilage
damage and subsequent arthrosis, most orthopaedic surgeons would agree that
this makes some intuitive anatomic sense. However, there is mounting evidence
that our current method of single-bundle anterior cruciate ligament
reconstruction does not restore proper rotational and varus-valgus stability to
the knee16,17. A more anatomic double-bundle anterior cruciate
ligament reconstruction that more closely replicates the anatomical two-bundle
arrangement of a native anterior cruciate ligament has been shown biomechanically
to help restore this stability. We currently perform double-bundle anterior
cruciate ligament reconstruction, which has been our standard anterior cruciate
ligament reconstructive procedure since 2003 in primary and revision operations.
Additionally, in the current study, fourteen patients had traumatic anterior
cruciate ligament re-tears. Whether rotational instability from a single-bundle
reconstruction contributed to re-tear, and whether a double-bundle
reconstruction would have helped in preventing this, remains unanswered. In our
personal experience, we have performed posterolateral bundle anterior cruciate
ligament augmentation surgery on nineteen patients who previously had undergone
single-bundle anterior cruciate ligament reconstruction and experienced
persistent rotatory instability18. Prospective follow-up studies on
double-bundle anterior cruciate ligament reconstruction are currently under way
at our institution.
The study has some limitations. Its retrospective nature,
the lack of data on the intra-articular status of the knee at the time of primary
surgery, the lack of a precise timetable from primary reconstruction to injury
to revision reconstruction, the nonanatomic augmentation, and the use of
fixation devices with which the authors had limited previous experience make it
difficult to draw precise conclusions. Nonetheless, with the number of primary anterior
cruciate ligament reconstructions increasing, revision anterior cruciate
ligament surgery will increase. Studies such as this are important first steps
if we are to provide our patients with evidence-based treatments. The challenge
is to design prospective studies that make use of multivariate analysis so that
we can determine which clinical and operative variables are most important.
*The authors did not receive any outside funding or grants
in support of their research for or preparation of this work. Neither they nor
a member of their immediate families received payments or other benefits or a
commitment or agreement to provide such benefits from a commercial entity. No
commercial entity paid or directed, or agreed to pay or direct, any benefits to
any research fund, foundation, division, center, clinical practice, or other
charitable or nonprofit organization with which the authors, or a member of their
immediate families, are affiliated or associated.
References
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2. Harner CD, Giffin JR, Dunteman RC, Annunziata CC, Friedman MJ. Evaluation and treatment of recurrent instability after anterior cruciate ligament reconstruction. Instr Course Lect. 2001;50:463-74.
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4. Khalfayan EE, Sharkey PF, Alexander AH, Bruckner JD, Bynum EB. The relationship between tunnel placement and clinical results after anterior cruciate ligament reconstruction. Am J Sports Med. 1996;24:335-41.
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13. Engebretsen L, Lew WD, Lewis JL, Hunter RE. The effect of an iliotibial tenodesis on intraarticular graft forces and knee joint motion. Am J Sports Med. 1990;18:169-76.
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17. Sakane M, Fox RJ, Woo SL, Livesay GA, Li G, Fu FH. In situ forces in the anterior cruciate ligament and its bundles in response to anterior tibial loads. J Orthop Res. 1997;15:285-93.
18. Tjoumakaris FP, Starman JS, Buoncristiani A, Honkamp NJ, Fu FH. The double bundle paradigm: applications for revision ACL surgery. Read at the ISAKOS Congress Biennial Meeting. 2007 May 30; Florence, Italy.
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