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Document Title: Noyes-AJSM-Apr06.shtml
Article Title: Anterior Cruciate Ligament Revision Reconstruction -- Results Using a Quadriceps Tendon–Patellar Bone Autograft
Authors: Frank R. Noyes, MD and Sue D. Barber-Westin
Publication: American Journal of Sports Medicine, Baltimore, Maryland
Date: April 2006
Volume 34, pages 553-564
Keywords: Revision ACL reconstruction, quadriceps patellar-tendon-bone autograft, failure of first-time graft, bone grafing, dealing with osteopenic (softened) bone.
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Comments: Surgeon error is the #1 cause of ACL-graft failure, and despite the commonness of ACL injuries and reconstructions, this surgery remains technically demanding for even the most experienced of surgeons. Noyes and Barber-Westin describe a viable autograft source for revision-reconstruction cases, in particular in cases where the patient's patellar tendon has already been harvested and where the patient would prefer not to harvest the patellar tendon from the contralateral knee. The authors note that, prior to pursuing revision ACL reconstruction, full knee motion should be achieved. They note that in cases where a full extension may not be obtainable because the first graft was placed too far forwards, or because of the presence of a cyclops lesion, or because the posterior capsular structures may have undergone unbidden shortening, a staged arthroscopic debridement procedure (entailing removal of the original ACL graft as well as notchplasty [i.e. widening of the femoral notch where the ACL resides]) is needed. The authors note that the correction of badly misplaced bone tunnels often requires bone grafting in advance.
ABSTRACT
Background: The quadriceps tendon is a viable graft source for revision anterior cruciate ligament reconstruction.
Purpose: To determine the functional results and graft failure rates in knees in which the patellar tendon had been previously harvested or was unavailable, expanded tunnels precluded the use of a semitendinosus-gracilis graft, or patients requested autogenous tissues instead of allografts for revision reconstruction.
Study Design: Case series; Level of evidence, 4.
Methods: The authors observed 21 patients for a mean of 49 months postoperatively after revision anterior cruciate ligament reconstruction with a quadriceps tendon graft. The results were determined by KT-2000 arthrometer testing, the Cincinnati Knee Rating System, and the International Knee Documentation Committee Rating System. Fifteen knees required a concurrent procedure, including reconstruction of posterolateral structures in 5 knees, meniscal repairs in 5 knees, and high tibial osteotomy in 2 knees.
Results: Significant improvements occurred in symptoms (P < .0001), daily activities (P < .05), sports activities (P < .01), and the overall rating scores (P < .0001). Eighteen patients rated their knee condition as improved. Total mean anterior-posterior displacements decreased from 8.4 +mn; 3.1 mm preoperatively to 2.0 +mn; 2.3 mm at follow-up (P < .001). On the International Knee Documentation Committee knee ligament rating, 17 knees were graded as normal or nearly normal, 3 were graded as abnormal, and 1 was graded as severely abnormal.
Conclusion: The revision operation provided reasonable results in this group of complex knees. However, the functional and overall results were inferior to those reported for primary anterior cruciate ligament reconstruction. Many knees (90%) had compounding problems of articular cartilage damage, meniscectomy, varus malalignment, or additional ligamentous injury that most likely affected the results.
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