Summary

Multiple revision ACL surgery can be successful with proper patient selection and surgical approach.

Abstract

Background

As participation in youth sports has increased, the number of injuries to the anterior cruciate ligament and subsequent reconstruction have increased as well. Patients continue to return to sport following their reconstruction, with increasing numbers sustaining recurrent tears. While outcome studies exist for revision ACL reconstruction, little has been reported of patients who have failed revision anterior cruciate ligament (ACL) reconstruction requiring multiple revisions. Our study aimed to determine patient outcomes following a revision ACL reconstruction following a previously revised ACL reconstruction and determine whether there are any particular factors that determine superior subjective outcomes.

Purpose

The purpose of this study was to evaluate the outcomes of patients undergoing repeat revision ACL reconstruction surgery. We aimed to assess the failure rate of this surgery, the risk factors for failure, surgical technique pearls, as well as the functional outcomes of patients following this procedure.

Methods

All patients who underwent a repeat revision ACL reconstruction surgery following a failed previous revision reconstruction between 1999 and 2012 were identified. Failures were defined as a feeling of subjective instability with Lachman grade of 2B or greater on exam. All procedures were performed by a single sports medicine fellowship-trained orthopaedic surgeon. Patients were asked to complete the Tegner Activity Level Scale, International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, and IKDC Current Health Assessment Form. Data, including associated procedures performed at time of revision reconstruction, type of graft utilized, type of graft fixation, use of bone grafting, and meniscal and cartilage status of the knee were obtained from patient records. Other variables, including body-mass index, date of revision ACL reconstruction, type of revision reconstruction graft, and circumstances of injury leading to failure of previous revision reconstruction were analyzed.

Results

14 patients were available for follow-up. Twelve of these patients underwent a secondary revision procedure and two underwent a tertiary revision procedure. Three patients had subsequent failure of the revision graft with mean time to failure of 20 months. For the remaining patients, average time from revision procedure to final follow-up was 37.5 months (Range 15-68 months). Mean Tegner activity score was 6.3 at follow-up and mean subjective International Knee Documentation Committee (IKDC) score was 69.5. There were no statistically significant differences in outcome scores when comparing revision graft type, body mass index (BMI), gender, need for bone grafting, and time from failure to revision.

Conclusions

Revision ACL reconstruction can be technically difficult and the multiple-revision can be even more challenging due to bone loss, previous fixation devices, and associated cartilage damage. Outcome data following multiple-revision ACL reconstructions are currently limited. Three out of fourteen patients undergoing multiple revision reconstructions failed in our cohort. Even so, validated outcome scores suggest that this procedure can successfully return patients to recreational sports. There were no differences in outcome scores when comparing revision graft type, body mass index (BMI), gender, need for bone grafting, and time from failure to revision. These data may be useful when counseling a patient regarding the decision to undergo a multiple revision ACL reconstruction.