Symposium: Management of Failed ACL Reconstruction ISAKOS – Wed May 18th 2011

14:30 – 15:30 Rio de Janeiro, Brazil

Christopher D. Harner, MD - Medical Director, Center of Sports Medicine Professor, Department of Orthopedic Surgery

University of Pittsburgh Medical Center

Gustavo A. Rincon, MD - Sports Medicine Research Fellow University of Pittsburgh Medical Center

Practice profile:

o Location: academic medical center (44 residents and 6 fellows) o Research: Clinical, Basic Science o Years in practice: 23 o Number of primary ACL’s /yr: 120-150 o Number of Revision ACL’s /yr: 25-30 o When there are tunnel/hardware issues I prefer a two stage revision

(~80% of cases) o One stage revision: “exchange graft” (~20% cases) o Graft Preference depends on:

• Etiology of failure • Patient preference • Surgeon’s comfort / experience

o I use ~66% auto (BTB, QT, Hamstrings), ~33% allo (100% BTB) o I do not use a tourniquet or leg holder o I use intraop fluoroscopy in all cases to confirm tunnel position

Revision Technique: 2 stage (~80% cases)

o 1st stage:

• Metal and graft removal • Bone graft tunnels (usually expanded) with freeze dried allograft

dowels or “clups” • Address meniscal tears: repair if possible

o 2nd stage (4-6 months later): • Revision with BTB (Auto 66%, Allo 33%) • Single Bundle: 100% • I address all secondary restraint laxity problems:

- MCL/POL - Loss of medial meniscus - Posterolateral corner (rare)

• Post op. Rehab is “slower” than primary ACL cases

Single stage revision: “exchange graft” (~20% cases)

Case Examples

1. 2 stage revision:

o 17 y/o female o 15 months after ACLR right knee (Hamstrings) o Twisted her same knee playing soccer o Etiology of failure: Traumatic o X ray: expanded tunnels: 16.2 mm femoral, 17.6 mm tibial o MRI: ACL graft tear & medial meniscus tear

o 1st stage: Removal graft, metal, “bioabsorbible” screws, and sutures Bone graft (allo) expanded tunnels Medial Meniscus repair

Material removed Bone graft tunnels

o 2nd stage: (4-6 months later) ACL BTB autograft Femoral tunnel: AM portal

2. Single stage revision:

o 25 year old male ski instructor o 4 years S/P BTB auto o March 2010: Traumatic injury to his knee o Acute traumatic failure of ACL graft and lateral meniscus root tear o No tunnel expansion allowed single stage revision o Offered contralateral BTB but patient preferred BTB allograft o Lateral meniscus root repair

Lateral meniscus root tear Graft failure

Set Up Same femoral Tunnel

o Fluoroscopic views of tunnels o Always check intraop position of endobutton

REFERENCES

1. Ahn JH, Lee YS, Ha HC. Comparison of revison surgery with primary anterior cruciate ligament

reconstruction and outcome of revision surgery between different graft materials. Am J Sports Med. 2008;36(10):1889-1895

2. Allen C, Wong EK, Livesay GA, Sakane M, Fu FH, Woo S. Importance of the medial meniscos in the anterior cruciate ligament-deficient knee. Journal of Orthopaedic Research. 18(1):109-15, 2000

3. Allen C, Giffin JR, Harner CD. Revision ACL reconstruction. Orthopaedic Clinics in North America, 2002

4. Baer GS, Harner CD. Clinical Outcomes of allograft versus autograft in anterior cruciate ligament reconstruction. Clin Sports Med. 2007;26(4):661-681

5. Barret GR, Brown TD. Femoral tunnel defect filled with a synthetic dowel graft for a single-staged revision anterior cruciate ligament reconstruction. Arthroscopy. 2007;23(7): e791-794

6. Battaglia TC, Miller MD, Management of bony deficiency in revision anterior cruciate ligament reconstruction using allograft bone dowels: surgical technique. Arthroscopy. 2005;21(6):767

7. Carson EW, Anisko EM, Restrepo C, Panariello RA, O’Brien SJ, Warren RF. Revision anterior cruciate ligament reconstruction: etiology of failures and clinical results. J Knee Surg. 2004;17(3):127-132

8. Denti M, Lo Vetere D, Bait C, Schonhuber H, Melegati G, Volip P. Revision anterior cruciate ligament reconstruction: causes of failure, surgical technique and clinical results. Am J Sports Med. 2008;36(10):1896-1902

9. Diamantopoulos AP, Lorbach O, Paessler HH. Anterior cruciate ligament revision reconstruction: results in 107 patients. Am J Sports Med. 2008;36(5):851-860

10. Garofalo R, Djahangiri A, Siegrist O. Revision anterior cruciate ligament reconstruction with quadriceps tendon-patellar bone autograft. Arthroscopy. 2006;22(2):205-214

11. George MS, Dunn WR, Spindler KP. Current Concepts review: revision anterior cruciate ligament reconstruction. Am J Sports Med. 2006;34(12):2026-2037

12. Harner CD. Editorial comment. Failed ACL reconstruction surgery. Clin Orthop Relat Res. 1996;325:2-3

13. 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;463-474

14. Harner CD, Honkamp NJ, Ranawat AS. Anteromedial portal technique for creating the anterior cruciate ligament tunnel. Arthroscopy. 2008;24(1):113-115

15. Johnson DL, Swenson TM, Irrgang JJ, Fu FH, Harner CD. Revision anterior cruciate ligament surgery: experience from Pittsburgh. Clin Orthop Relat Res. 1996;325:100-109

16. Kamath G, Redfern J, Greis P, Burks R. Revision Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2010;:1-19

17. Noyes FR, Barber-Westin SD. Anterior cruciate ligament revision reconstruction: results using a quadriceps tendon-patellar bone autograft. Am J Sports Med. 2006;34(4):553-564

18. Noyes FR, Barber-Westin SD. Revision anterior cruciate ligament reconstruction using a 2-stage technique with bone grafting of the tibial tunnel. Am J Sports Med. 2006;34(4):678-680

19. O’Neill DB. Revision arthroscopically assisted anterior cruciate ligament reconstruction with previously unharvested ipsilateral autografts. Am J Sports Med. 2004;32(8):1833-1841

20. Ohly NE, Murray IR, Keating JF. Revision anterior cruciate ligament reconstruction: timing of surgery and the incidence of meniscal tears and degenerative change. J Bone Joint Surg Br. 2007;89(8):1051-1054

21. Said HG, Baloch K, Green M. A new technique for femoral and tibial tunnel bone grafting using the OATS harvesters in revision anterior cruciate ligament reconstruction. Arthroscopy. 2006;22(7):e791-791

22. Shelbourne KD, O’Shea JJ. Revision anterior cruciate ligament reconstruction using the contralateral bone-patellar tendon-bone graft. Instr Course Lect. 2002;51:343-346

23. Thomas NP, Kankate R, Wandless F, Pandit H. Revision anterior cruciate ligament reconstruction using a 2-stage technique with bone grafting of the tibial tunnel. Am J Sports Med. 2005;33(11):1701-1709