Revision anterior cruciate ligament surgery: state of the art

With the increase in number of anterior cruciate ligament (ACL) reconstructions being performed, and with patients’ desire to return to high-level sports activities, the prevalence of ACL revision has been rising despite recent improvements in ACL reconstruction technique. ACL reconstruction failures can be classified into 3 general categories: recurrent instability, postoperative complications and patient comorbidities. Of these 3 categories, recurrent instability is the most common cause for revision surgery. Cases of recurrent instability can be further subdivided into 2 groups: traumatic and atraumatic. Causes of atraumatic failure include technical errors, missed associated injuries, biological factors and infection. Careful preoperative evaluation and planning, sophisticated surgical technique (including individualised graft selection, anatomical tunnel placement and secure fixation), careful evaluation and treatment of all associated injuries, and individualised rehabilitation are all essential for successful revision ACL surgery. There have been very few high-level studies in the field of revision ACL surgery; therefore, accumulating more evidence for clinical outcomes and prognostic factors to improve revision surgery procedure will be necessary. Both primary ACL injury prevention and reinjury prevention, as well as individualised anatomic primary ACL reconstruction, are critical to reduce the incidence of revision ACL surgery. INTRODUCTION Revision anterior cruciate ligament surgery: prevalence and societal impact Anterior cruciate ligament (ACL) injury is one of the most frequent sports-related injuries that require surgery. An estimated 200 000 ACL injuries occur annually in the USA alone, and the incidence of ACL reconstruction has increased, particularly in females as well as in those younger than 20 and older than 40. Conventional single-bundle techniques for ACL reconstruction had been considered successful, as anterior stability was restored and the majority of athletes were able to return to sports. However, both biomechanical and clinical studies have revealed that conventional nonanatomic single-bundle reconstruction fails to restore normal knee kinematics, especially in terms of rotational stability. Therefore, recent ACL reconstruction strategies have been shifting towards anatomic reconstruction, aiming to reproduce the native anatomy and normal kinematics of the knee. On the other hand, with the increase in number of ACL reconstructions being performed and with patients’ desire to return to high-level sports activities, the prevalence of ACL revision has been rising despite the recent improvement in ACL reconstruction technique. The reported rate of revision ACL reconstruction is between 4% and 25%, depending on the criteria for revision and the graft used for primary reconstruction. Most revisions occur between 1 and 2 years after the primary surgery. Consequently, surgeons and researchers should take a great interest in preventing the original ACL injury as well as reinjury after ACL reconstruction. Reviews and state of the art or current concept articles Systematic reviews of the literature on ACL revision surgery have mostly focused on causes/risks of failure in primary ACL reconstruction, indications/ strategies of revision, technical considerations and clinical outcomes. Eleven review articles were identified from the past 10 years on the topic of revision ACL surgery and related subjects. Five reviews focused on risks and causes of primary ACL reconstruction failure, 10–13 four on indications/strategies and techniques of revision surgeries, 10 14 15 and four on clinical outcomes; two of them focused on return to sports. 18 In addition, one recent article described strategies for revision surgery after primary double-bundle (DB) ACL reconstruction. Moreover, it should be noted that the Multicenter ACL Revision Study (MARS) was developed in 2006 to create a multisurgeon, multicentre prospective longitudinal study. The goal of MARS was to obtain sufficient participants to allow multivariable analysis and determine predictors of clinical outcome after revision ACL reconstruction. The MARS group has already published 13 articles regarding revision ACL reconstruction. Although most of the articles have thus far focused on preoperative/intraoperative factors, one article has recently been published focusing on meniscal and articular cartilage predictors of clinical outcome after revision ACL reconstruction. More articles regarding clinical outcomes are expected in the near future (box 1). CURRENT STATE OF THE ART Causes of primary ACL reconstruction failure In spite of recent improvements in surgical technique, ACL reconstructions are still susceptible to fail for a variety of reasons. The definitions of the ACL reconstruction failures can be (1) knees that require revision ACL reconstruction, and (2) knees with low quality of life, represented by a low score on the Knee Injury and Osteoarthritis Outcome Score (KOOS) activities of daily living (ADL) subscale. These failures can be classified into three general categories: recurrent instability, State of the Art To cite: Koga H, Engebretsen L, Fu FH, et al. JISAKOS 2017;2:36–46. 1Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan 2Department of Orthopaedic Surgery, Oslo University Hospital and Faculty of Medicine, University of Oslo, and Oslo Sports Trauma Research Center, Oslo, Norway 3Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA Correspondence to Dr Takeshi Muneta, Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan; [email protected] Received 12 September 2016 Revised 27 November 2016 Accepted 29 November 2016 Published Online First 16 December 2016 36 Koga H, et al. JISAKOS 2017;2:36–46. doi:10.1136/jisakos-2016-000071. Copyright © 2017 ISAKOS group.bmj.com on August 27, 2017 Published by http://jisakos.bmj.com/ Downloaded from