Document Title: Noyes-JBJS-Aug01.shtml
Article Title: Revision Anterior Cruciate Surgery with Use of Bone-Patellar Tendon-Bone Autogenous Grafts
Authors: Frank R. Noyes, MD and Sue D. Barber-Westin, BS
Publication: The Journal of Bone and Joint Surgery
Date: August 2001
Volume 83, pages 1131-1143
Keywords: ACL revision reconstruction, patellar-tendon autograft.

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Comments (provided by Sue Barber-Westin): This investigation followed 52 knees that received a patellar tendon autograft for revision reconstruction from 24 to 74 months postoperatively. KT-1000 testing found that 24% of the grafts failed. However, the failure rate differed according to additional procedures required. In knees in which only an ACL reconstruction was done, the failure rate was 16%; in those that also required a high tibial osteotomy, it was 22%. At follow-up, 63% had returned to mostly light sports without problems, and 94% believed their knee condition had improved compared to the preoperative status. Additionally, in 11 knees the patellar tendon was re-harvested for the revision procedure. Six of these 11 grafts subsequently failed, and the authors warned against using a PT which had previously been harvested, regardless of the time interval between the original and revision operations.

Abstract

Background: A prospective study was done to determine the functional results, patient satisfaction, and graft failure rate after fifty-seven consecutive revision replacements of the anterior cruciate ligament with use of a bone-patellar tendon-bone autogenous graft.

Methods: Fifty-four patients (fifty-five operations) were followed in this study. Concurrent operative procedures were performed during the revision procedure in thirty-seven knees (67%). These procedures included repair of a meniscal tear in twenty knees (36%) and reconstruction of deficient posterolateral or medial ligament structures in seventeen knees (31%). Nine knees (16%) had a high tibial osteotomy to correct varus malalignment before the revision operation. The results were evaluated with the Cincinnati Knee Rating System.

Results: There were significant improvements in the scores for pain (p < 0.0001), activities of daily living (p < 0.01), sports participation (p < 0.001), patient satisfaction (p < 0.0001), and overall rating of the knee (p < 0.0001). Thirty-three (60%) of the replaced ligaments were functional, nine (16%) were partially functional, and thirteen (24%) had failed.

Conclusions: Many knees (93%) had compounding problems, including articular cartilage damage, prior meniscectomy, loss of secondary ligament restraints, varus malalignment, and concomitant ligament replacement or meniscal repair. Therefore, the results were generally less favorable than those following primary operations. The rate of graft failure was three times higher than our previously reported failure rate after primary replacements of the anterior cruciate ligament with a bone-patellar tendon-bone autogenous graft. Even so, symptoms and functional limitations with regard to daily and sports activities were found to have decreased and patient satisfaction improved. We advocate correction of varus malalignment prior to anterior cruciate procedures. Associated posterolateral ligament deficiencies should be surgically corrected during anterior cruciate procedures to prevent excessive loading on the graft from abnormal lateral tibiofemoral joint opening. Meniscal tears, including complex tears that extend into the avascular zone, can be concurrently repaired successfully during the revision.

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