Arthroscopy: The Journal of Arthroscopic and Related Surgery 10(2): 148-151 Published by Raven Press, Ltd. @ 1994 Arthroscopy Association of North America

What Would You Do?

Case Report: Revision Anterior Cruciate Ligament Reconstruction

Daniel J. Karns, M.D., Robert S. Heidt, Jr., M.D., Bruce R. Holladay, M.D., and Angelo J. Colosimo, M.D.

Summary: A case report is presented in which a professional football player, who was 4 years status post anterior cruciate ligament (ACL) reconstruction with autogenous patellar tendon, ruptured his graft. The contralateral pateUar tendon was not available as a graft because of a more recent ACL reconstruc- tion using that autogenous pateUar tendon. This case reports the use of a previous donor site for supplying a pateUar tendon autograft. Biopsy of the donor graft was consistent with normal tendon. The use of a healed patellar tendon donor site is a viable option for revision anterior cruciate reconstructive surgery. This option prevents the possibility of disease transmission with use of an allograft. We have shown grossly and histologically that the donor site has the potential to regenerate to tissue that has the appearance of normal tendon. This option could be available for revision surgery, but would not be recommended if the initial surgery was <18 months-2 years in the past. Key Words: Anterior cruciate ligament--Revision ACL surgery--Autograft.

Autografts are the currently recommended tissue of choice for reconstructing chronic ruptures of the anterior cruciate ligament (ACL) (1). The central one-third bone-patellar tendon-bone autograft has been shown to be the strongest tissue available (2). What does the orthopaedic surgeon do when revi- sion surgery is required and autogenous patellar tendon is not available? The following report de- scribes the use of ipsilateral patellar tendon, from a previous donor site, for reconstruction of a rupture of the ACL.

CASE REPORT

A 26-year-old professional football player injured his left knee playing football. Physical examination

From Wellington Orthopaedics and Sports Medicine (D.J.K., R.S.H., B.R.H.) and the Department of Orthopaedic Surgery (A.J.C.), University of Cincinnati, Cincinnati, Ohio.

Address correspondence and reprint requests to Daniel J. Karns, M.D., The Bone and Joint Institute, The Christ Hospital, 2139 Auburn Avenue, Cincinnati, OH 45219, U.S.A.

revealed a positive Lachman test with a soft end- point and a positive pivot shift, consistent with a complete tear of the ACL. This was confirmed with a magnetic resonance (MR) scan.

He was 4 years status post reconstructive surgery for that ACL, which was reconstructed with autog- enous patellar tendon, from the same knee. He was 2 years status post reconstruction of his left ACL, also reconstructed with autogenous patellar tendon.

The patient elected to undergo a third ligament reconstruction, the second reconstruction for the left knee. Several options were available. Ham- string tendon, allograft tendon, or use of the prior donor site were the options discussed. Preoperative radiographs and a MR scan of the knee revealed healing of the patellar tendon defect, along with healing of the defect in the bony patella (Figs. 1 and 2). After discussion with the patient, it was decided he should undergo reconstruction using the healed donor site of the ipsilateral knee.

The patient was taken to the operating room, where he underwent endoscopic reconstruction of

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REVISION ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION 149

FIG. 1. Preoperative sunrise view of the patella shows filling in of the bony defect from initial surgery.

the ACL. At surgery, the patellar tendon defect was fully healed with what appeared to be normal ten- don (Fig. 3). The bony defect in the patella had also healed. A 10-mm graft was harvested in the usual fashion with bone blocks at both ends. The graft was then placed endoscopically through two new tunnels in the tibia and femur without complica- tions. Postoperatively, he was placed in a brace with unlimited motion and 50% weight-bearing for 3 weeks. He has progressed to full weight-bearing and is undergoing progressive rehabilitation at present.

Surgical biopsy of the central region of the autog- enous graft revealed light microscopic and electron microscopic findings consistent with normal tendon

FIG. 2. Preoperative magnetic resonance scan shows regenera- tion of pateUar tendon defect.

FIG. 3. Autogenous graft shown to be grossly of normal appear- ance.

(Figs. 4 and 5). The electron microscopic view shows collagen fibers aligned in a parallel manner, consistent with normal tendon.

DISCUSSION

The dilemma presented in this case is one of treatment options for a patient who had a ruptured ACL and who had already undergone bilateral re- constructions using the ipsilateral patellar tendon.

The current options available for reconstruction of the ACL include the following: autogenous grafts consisting of patellar tendon, hamstring tendons, il- iotibial band, or fascia lata; allograft; or synthetic prosthesis.

Autogenous patellar tendon has become the fa- vored graft and has had a good outcome clinically (3). Engebretsen et al., in a prospective study com- paring primary repair of the ACL with augmenta- tion using either autogenous pateUar tendon or the Kennedy Ligament Augmentation device, found that repair with patellar tendon augmentation was significantly more stable and showed a greater func- tional level when compared with primary repair or the Kennedy Ligament Augmentation device (4). It has also been shown that the autogenous patellar tendon can withstand a greater maximum load when compared with other autogenous graft tissues (2).

Although allografts offer less morbidity without having a graft donor site, they have fallen out of favor recently. A prospective study showed that the use of bone-patellar tendon-bone allografts, with or without the use of a ligament augmentation device, did not reduce the amount of anterior-posterior sta- bility satisfactorily, for reconstruction of chronic ruptures of the ACL (1). The authors recommended

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150 D. J. KARNS ET AL.

FIG. 4. Light microscopic view with elastin stain shows the normal-appearing tendon.

the use of autogenous patellar ligament grafts in pa- tients who do not have contraindications to recon- struction with an autogenous graft.

The risk of disease transmission has also de- creased the use of allografts. The estimated risk of disease transmission from an allograft is <1 per 1,000,000 (5). The human immunodeficiency virus can survive freezing and freeze drying in bone. Sterilization of allografts is not a solution, because radiation is effective in killing the viruses, but de- creases the tensile strength of the graft (5). The use of freeze-dried, ethylene oxide-sterilized allografts resulted in a high failure rate in another study (6).

The other valid alternative is use of a synthetic

ligament such as GORE-TEX. Paulos et al. showed a high rate of complications when a GORE-TEX ACL prosthesis was used. In a review of 268 pa- tients, 12% had fair and poor results secondary to recurrent effusions. Rupture of the prosthesis oc- curred in 12% of the patients. Loosening >3 mm occurred in 34% of the patients, with loosening >5 mm resulting in a higher number of unacceptable results. Finally, there was an infection rate of 2.7%. Although subjectively 89% had acceptable results, the authors believed there were limited indications for using a GORE-TEX prosthesis (7).

A search of the literature revealed two studies documenting the potential for healing of the patellar

FIG. 5. Electron micrograph shows near-parallel orientation of collagen bundles.

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tendon donor site. One report showed histological evidence of healing of the donor defect with hyper- trophic tendinous tissue 8 months after surgery (8). A MR imaging study evaluating patellar tendon har- vest sites during the postoperative period demon- strated signal intensity consistent with normal ten- don 18 months after surgery (9).

CONCLUSIONS

The use of a healed patellar tendon donor site is a viable option for revision ACL reconstructive sur- gery. This option prevents the possibility of disease transmission with use of an allograft. Use of the old donor site also gives the patient the most stable construct as seen in the literature. We have shown grossly and histologically that the donor site has the potential to regenerate to tissue that has the appear- ance of normal tendon. This option could be avail- able for revision surgery, but would not be recom- mended if the initial surgery was <18 months-2 years in the past. This conclusion is based on the results of the MR imaging study that reported nor- mal MR findings at 18 months status post harvesting of the graft (9).

REFERENCES

1. Noyes FR, Barber SD. The effect of a ligament-augmenta- tion device on allograft reconstructions for chronic ruptures of the anterior cruciate ligament. J Bone Joint Surg [Am] 1992;74:960-73.

2. Noyes FR, Butler DL, Grood ES, Zernicke RF, Hefzy MS. Biomechanical analysis of human ligament grafts used in knee ligament repairs and reconstructions. J Bone Joint Surg [Am] 1984;66:344-52.

3. Garth WP. Current concepts regarding the anterior cruciate ligament. Orthop Rev 1992;21:565-75.

4. Engebretsen L, Benum P, Fasting O, Molster A, Strand T. A prospective, randomized study of three surgical techniques for treatment of acute ruptures of the anterior cruciate liga- ment. Am J Sports Med 1990;18:585-90.

5. Meyers JF. Allograft reconstruction of the anterior cruciate ligament. Ctin Sports IVied 1991;10:487-98.

6. Roberts TS, Drez D, McCarthy W, Paine R. Anterior cru- ciate ligament reconstruction using freeze-dried, ethylene oxide-sterilized, bone-patellar tendon-bone allografts. Am J Sports Med 1991;19:35-41.

7. Paulos LE, Rosenberg TD, Grewe SR, Tearse DS, Beck CL. The GORE-TEX anterior cruciate ligament prosthesis. Am J Sports Med 1992;20:246-52.

8. Berg EE. Intrinsic healing of a patellar tendon donor site defect after anterior cruciate ligament reconstruction. Clin Orthop 1992;278:160-3.

9. Coupens SD, Yates CK, Sheldon C, Ward C. Magnetic res- onance imaging evaluation of the pateUar tendon after use of its central one-third for anterior cruciate ligament recon- struction. Am J Sports Med 1992;20:332-5.

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