Original Article
Revision Single-Stage Anterior Cruciate Ligament Reconstruction Using an Anterolateral Tibial Tunnel Sohrab Keyhani, MD1 Behzad Hanafizadeh, MD2 René Verdonk, MD, PhD3 Mohammadreza Minator Sajjadi, MD4 Mehran Soleymanha, MD5 1 Department of Knee Surgery and Sports Medicine, Akhtar
Orthopedic Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2 Department of Orthopaedic Surgery, Akhtar Orthopedic Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran 3 Department of Orthopedics and Traumatology, Ghent University, Ghent, Belgium 4 Research Development Unit, Department of Orthopaedic Surgery, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran 5 Department of Orthopedic Surgery, Orthopaedic Research Center, Poursina Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
Address for correspondence Mehran Soleymanha, MD, Department of Orthopedic Surgery, Orthopaedic Research Center, Poursina Medical and Educational Center, Rasht 0098, Gilan Province, Iran (e-mail:
[email protected]).
J Knee Surg
Abstract
Keywords
► anterior cruciate ligament ► revision anterior cruciate ligament reconstruction ► anterolateral tibial tunnel ► single-stage
received September 12, 2018 accepted after revision December 16, 2018
Revision anterior cruciate ligament (ACL) reconstruction is a technically demanding enterprise. Management of widened or previously malpositioned tunnels is challenging and often requires innovative approaches. The purpose of this study was to evaluate the function and clinical results of revision single-stage ACL surgery using an anterolateral tibial tunnel (ALTT). A consecutive series of knees with arthroscopic ACL revision surgery were analyzed prospectively between April 2012 and September 2015. Among the 93 patients presented with revision ACL reconstruction, 25 patients met the study inclusion criteria for the ALTT technique and were followed up for a minimum of 2 years (range: 24–51 months). The clinical results were evaluated by means of the Lysholm score, International Knee Documentation Committee (IKDC) score, and Tegner activity level scale, and the knee stability was assessed by the Lachman test, pivot shift test, and anterior drawer test. Magnetic resonance imaging (MRI) of the index knee before the surgery and 2 years after revision surgery was assessed. The mean IKDC subjective score, mean Tegner activity level scale, and mean Lysholm score significantly improved in all study participants. This study showed that ACL revision surgery with ALTT can reliably restore stability and provide fair functional outcomes in patients with ACL retear. One could expect acceptable lateral tibial tunnel length compared with medial tibial tunnel in classic ACL revision, intact bony surround, and good graft fixation. This technique is clinically relevant in that making an anterolateral tunnel in one-stage ACL revision surgery had a good subjective result with low complication rate in midterm follow-up.
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DOI https://doi.org/ 10.1055/s-0039-1677812. ISSN 1538-8506.
Revision Single-Stage ACL Reconstruction Using ALTT
Keyhani et al.
Although long-term functional stability and symptom relief can be achieved following anterior cruciate ligament (ACL) reconstruction, approximately 2 to 10% of patients will eventually require revision ACL reconstruction surgery.1 The ACL reconstruction can fail for a variety of reasons. New trauma is the most common reason for ACL reconstruction failure, but additional factors including higher posterior tibial slope and technical failures (such the nonanatomic tunnels or undiagnosed concomitant ligament injuries) should be investigated.2 The revision procedure is more challenging than primary reconstruction and often results in inferior outcomes compared with primary ACL surgery due to technical difficulties such as previously malpositioned tunnel or widened tunnel and graft choices.3 Epidemiologic data from the Multicenter ACL Revision Study (MARS) demonstrated that 80% of ACL reconstruction failures were at least partially due to femoral tunnel malposition and 37% due to incorrect tibial tunnel placement.4 The etiology of tunnel widening is not fully understood but it is believed that biomechanical and biological factors are involved.5–8 Bone tunnel enlargement or previously malpositioned tunnels in revision ACL reconstruction often requires innovative approaches and different strategies for bony defect management.8–10 A new femoral tunnel in an anatomic position through the anteromedial portal is feasible,11 but dealing with the tibial tunnel is more complex. Tibial tunnels can be described based on the intra-articular aperture of the tunnel and dilation of the tunnel.12 When the aperture is in the correct position and there is no tunnel dilation, the surgeon can use the previous tunnel in revision surgery; in conditions such as huge tunnel widening, surgeons face a challenge in deciding one-stage or two-stage revision. Achieving stable graft fixation is extremely difficult in the setting of tunnel convergence with the expansion or overlapping of revision tunnels into previous tunnels and with massive osteolysis with weak bone stock.13 Generally, twostage revision surgery using bone grafting is performed for such cases, but some surgeons favor single-stage surgery due to the long therapeutic period and financial matters in the two-stage operation.14,15 The aim of this study was to report the functional and clinical outcomes of lateral tibial tunnel technique in revision ACL reconstruction in a midterm follow-up period. It was hypothesized that single-stage revision ACL reconstruction using a lateral tibial tunnel can restore stability and improve functional outcomes compared with the preoperative state.
Materials and Methods Patient Selection A consecutive series of knees with arthroscopic ACL revision surgery were analyzed prospectively between April 2012 and September 2015. Among the 93 patients presented with revision ACL reconstruction, 25 patients met the study inclusion criteria for the anterolateral tibial tunnel (ALTT) technique and were followed up for a minimum of 2 years (range: 24–51 months; ►Table 1). Inclusion criteria were ACL reconstruction failure with tibia tunnel malposition or The Journal of Knee Surgery
Table 1 Patient selection Correct position
Incorrect position
Total
No dilation
71
10
81
Dilation
9
3
12
Total
80
13
93
widening more than 14 mm. Exclusion criteria were age < 18 or > 60, infection, chondral damage > grade III (International Cartilage Repair Society, ICRS; candidate for osteotomy), untreated associated ligament injury, uncorrected lower limb malalignment, and previous meniscectomy.16,17 ACL graft rerupture was diagnosed by means of clinical examination (Lachman’s test in 20-degree knee flexion, positive pivot shift test, and positive anterior drawer) and confirmed by magnetic resonance imaging (MRI). Three-dimensional computed tomography (CT) imaging was obtained for all patients to assess the femoral and tibial tunnels. Patients’ radiographs and intraoperative arthroscopic photos were obtained from hospital records. Data, including associated procedures performed at the time of revision reconstruction, type of graft utilized, type of graft fixation, use of bone grafting, tibial tunnel length, and meniscal and cartilage status of the knee were extracted from our ACL reconstruction registry. ACL stability in follow-up was assessed by the Lachman test, pivot shift test, and anterior drawer test. Patients were requested to complete the Tegner activity level scale, International Knee Documentation Committee (IKDC) Subjective Knee Evaluation form, and Lysholm scoring forms. MRI of the index knee before surgery and 1 year after revision surgery was assessed. All surgeries and postoperative clinical testing included in this study were performed by the same consultant surgeon (K.S). All patients were informed about their condition and the modification in their revision surgery by written consent.
Surgical Technique During the procedure, patients were placed supine on the operating table, with a tourniquet placed high on the thigh. The knee was flexed 90 degrees by draping the leg over the edge of the operating table. The surgical technique involved a standard knee arthroscopic evaluation and treatment for any concomitant intraarticular pathology, as indicated. The remaining soft tissue and the failed graft were debrided by arthroscopic shaver and biter, and notchplasty was performed when necessary (if the notch index was less than 0.2 mm).18 The intra-articular location and condition of the tibial and femoral tunnels were evaluated. The prior femoral tunnel was identified. If it was in a good position the soft tissue and hardware were removed and the tunnel reamed up to the diameter of the new graft, and otherwise a new tunnel in anatomic location was made. A small incision was made over the anterior–superior insertion of the tibialis anterior muscle. As it planned preoperatively, the new tibial tunnel was created along the down-slope of the medial tibial spine at the level of the
Revision Single-Stage ACL Reconstruction Using ALTT
Keyhani et al.
Fig. 3 Final appearance of the graft (right knee).
Fig. 1 The entry point of the tunnel (right knee).
posterior border of the anterior horn of the lateral meniscus but rotating the tibial aimer so that the starting point was on the lateral tibial cortex, approximately half-way between the tibial tubercle and the posterolateral border of the tibia. The entry point was determined to be approximately 20 mm lateral to tibial tubercle and 30 mm below the joint line (►Fig. 1). Gentle release of the muscle at the entry point of the tunnel was done by a periosteal elevator and the tibial aimer angle was set at 55 degrees. The new lateral tunnel was created after insertion of the guide pin. Because of the oblique direction of the lateral tunnel with respect to plateau, the aperture would be oval-shaped. The appropriate reaming diameter was determined to be 1 mm less than the allograft size to avoid oversizing of the oval-shaped articular aperture. At this stage, the arthroscope was entered into the tunnel from the distal entry point to evaluate bony surrounding of the tunnel, articular aperture, and probable overlapping of two tunnels. The tunnel length was measured by depth gauges. The graft that was used was a tibialis posterior tendon allograft (Tissue Regeneration Corporation, Kish, Iran) in all 25 cases. The allograft was passed through the tunnels from distal to proximal. Due to the rightangle direction, graft passage was guided by a small curved periosteal elevator intra-articularly to avoid cutting from the surrounding chondral tissue by passing suture (►Fig. 2). The knee was cycled repetitively to evaluate the isometric behavior of the revised graft and to achieve desired tension of
the graft; by full extension and flexion of the joint, graftnotch impingement and malpositioning of the graft were ruled out respectively (►Fig. 3). Loop and endo-button (suspensory fixation) or screw fixation (in case of the too short tunnel) was used on the femoral side, whereas a bioabsorbable interference screw was used on the tibial side. The knee stability was judged again by Lachman test before wound closure.
Postoperative Rehabilitation Low-molecular-weight heparin (LMWH) was used for 2 weeks. If the meniscal repair was performed with ACL revision surgery, the rehabilitation program was organized with respect to the associated procedure. If not, rehabilitation of the knee joint was performed according to the following program: weeks 0 to 2: immobilized in full extension in a brace and nonweight bearing; with isometric quadriceps exercises, weeks 2 to 4: 0 to 45 degree range of motion and tolerable weight bearing; weeks 4 to 6: gradual increase up to 90 degrees and full weight bearing; weeks 6– 12: full range of motion.
Statistical Analysis Statistical analyses were performed with SPSS software version 21 (IBM; Armonk, NY). The frequency, mean, and standard deviation were used to describe the data. Data were analyzed using the Wilcoxon test for comparing the preoperative and postoperative Lysholm score, IKDC score, and Tegner activity level scale. Statistical significance was considered to be p < 0.05.
Results
Fig. 2 Suture passage (right knee).
All patients in this study were male. The mean age of the patients was 36 years (range: 20–49 years) and the average body mass index (BMI) was 27.4 kg/m2 (range: 22–31 kg/m2). Mean length of the lateral tibial tunnel was 35.8 mm (32–43 mm). MRI was not performed in asymptomatic patients. The mean Lysholm score, the mean IKDC subjective score, and the mean Tegner activity level scale were improved significantly postoperatively (►Table 2). Lachman, anterior drawer, and pivot shift tests were performed every 6 months to evaluate the anteroposterior The Journal of Knee Surgery
Revision Single-Stage ACL Reconstruction Using ALTT
Keyhani et al.
Table 2 Preoperative and postoperative evaluations Preoperative
Postoperative
p-value
Lysholm score
63.4 8.23
80.86 6.41
p < 0.001
IKDC score
60.45 6.92
72.29 4.71
p < 0.001
Tegner scores
5.09 1.89
7.69 1.25
p < 0.001
Abbreviation: IKDC, International Knee Documentation Committee.
and rotatory stability of the knee. Any grade II or III, more instability in sagittal plane, or positive pivot shift test was defined as a failure. None of 25 cases had the anteroposterior laxity or pivot shift test in follow-up visit 6 months after the operation but two cases had a subsequent failure of revision due to new trauma; however, these cases had normal stability tests before their repeated trauma.
Discussion In this study, one-stage ACL revision surgery using ALTT restored the stability and contributed to satisfactory functional outcomes. Regular follow-up physical examinations in the case series showed that desired anteroposterior and rotational stability of the knee joint could be reached using a lateral tibial tunnel technique. There is also a remarkable improvement in knee function based on subjective scoring records; significant improvements in Tegner activity level scale, IKDC score, and Lysholm score were found. Bone tunnel widening is a frequently encountered phenomenon following ACL revision reconstruction.5,6 This complication can alter the result of the revision surgery because of poor graft to bone incorporation and weakly fixed graft. An anatomic position in good-quality bone regardless of any previously drilled tunnel is very important. Accepted techniques to address tunnel problems in the single-stage revision surgery include the funnel technique,19 stacking
interference screw,20,21 instant bone allograft technique,21 and dilatation technique.22 If tunnel dilation more than 14 to 15 mm is encountered, especially in the distal or middle part of the tunnel that compromises the fixation, reconstruction using lateral tibial tunnel technique may be an appropriate solution. The lateral tibial tunnel provides good bone for graft fixation without any bone weakness in the medial part and decreases the risk of the medial proximal tibia fracture in future. If tunnel dilation is in proximal part and less than 20 mm, the lateral tibial tunnel with bone grafting of the tunnel would be a good option, but if the diameter is more than 20 mm other strategies such as two-stage revision should be considered.23 In cases of entirely incorrect position of the aperture of the tibial tunnel without any tunnel dilation, single-stage revision reconstruction is performed by creating a new medial tunnel,23 but if the previous tunnel is excessively dilated, creating a lateral tunnel is a feasible strategy. In this study, the lateral tibial tunnel technique of ACL revision surgery provides three clear benefits. First, there is no need for second-stage operation. Second, patients could return to their work and sports activities faster than twostage revision. Third, graft fixation through the new tibial tunnel with good-quality surrounding native bone could be stronger than previous dilated tunnel which has been filled with allograft. Graft fixation is critical after revision ACL reconstruction, and often backup cortical fixation is used on the tibial side. Graft incorporation would be better with a new ALTT that has a healthy bone. The mean length of the ALTT in this study was 35.8 mm (32–43 mm); this means that the lateral tibial tunnel technique provides acceptable tunnel length to achieve proper and strong fixation of the allograft in revision reconstruction of ACL (►Fig. 4), this result was comparable with the cadaveric study of Van Der Bracht et al.3
Fig. 4 Postoperative MRI evaluation (left knee). MRI, magnetic resonance imaging. The Journal of Knee Surgery
Revision Single-Stage ACL Reconstruction Using ALTT Two of the 25 cases had rerupture of their grafts in the follow-up period. The first one was a 31-year-old man who had a motor-car accident in the 11 months postsurgery and his revised graft failed due to this trauma. His knee was the good subjective and objective outcome postprimary operation. The second rerupture case was an athlete who sustained trauma to his index knee during taekwondo exercises 14 months postrevision. Therefore, the failure rate of this technique was 8%. Overall, using the ALTT in ACL revision surgery to overcome the widening issue has not been emphasized enough in previous clinical studies. The clinical outcomes of this initial case series are very encouraging in the midterm follow-up period, particularly remarkable improvement in Tegner scores, IKDC score, and Pivot shift test which support the results of Van Der Bracht et al’s studies.3 Further studies are needed to describe the long-term outcomes of this technique. There are several limitations that should be considered when interpreting the results of this study. In the current study, lateral tibial tunnel technique was not directly compared with a classic revision ACL reconstruction, but postoperative outcomes validate previous biomechanical studies of Van Der Bracht that have noted that lateral tunnel ACL reconstruction can restore nearly normal knee stability to an ACL-deficient knee.24 Another limitation of this study is the relatively small sample size.
Funding None. Conflict of Interest None.
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Conclusion ACL revision surgery with ALTT can reliably restore stability and provide fair functional outcomes in patients with ACL retear. One could expect acceptable lateral tibial tunnel length compared with medial tibial tunnel in classic ACL revision, intact bony surround, and good graft fixation. This technique is clinically relevant in that making an anterolateral tunnel in one-stage ACL revision surgery had the good subjective result with low complication rate in midterm follow-up. Ethical Approval This study was approved by the Akhtar Hospital Research Ethic Committee in Tehran, Iran (No: 759). Authors' Contributions Developing the original idea and the protocol: Sohrab Keyhani. Definition of intellectual content: Sohrab Keyhani. Contribution to the development of the protocol: Behzad Hanafizadeh, Mohammadreza Minator Sajjadi. Study supervision and preparation of the manuscript: René Verdonk. Preparation and drafting of the manuscript: Mehran Soleymanha. Note Informed consent was obtained from all individual participants included in the study.
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