Revision ACL Surgery Stage it!!!!!!! Darren L. Johnson, M.D. Professor and Chairman Medical Director of Sports Medicine University of Kentucky School of Medicine
Disclosure Consultant: Smith-Nephew Endoscopy Institution: Research/Education Smith-Nephew Endoscopy DJ Orthopaedics
Staging Indications:< 10% Motion lossparticularly extension Tunnel placement prevents anatomic new tunnel Tunnel lysis(15mm) prevents secure fixation and biology healing of graft
Radiographs/CT/MRI Operative Reports/Pictures Tunnel Placement/Location: 3D Secondary Restraints P L A M
CT Scan Obtained Tibial Tunnel 18mm Femoral Tunnel
Motion Loss
FAILED DB ACL/BONE GRAFT
RACL after Bone graft
Revision ACL& Medial Meniscal Allograft
ACL Allograft failure 3X Bone graft
L. C. 23 y/o former collegiate softball player Underwent ACL reconstruction (BPTB) Had total lateral menisectomy Drive through sign laterally!!!!!
My Approach Staged procedure: 1. a. Hardware removal, bonegraft b. Posterolateral corner recon Semi-T: Larson technique c. Lateral meniscus transplant:slot
Outside-In on Femur:All Revisions Drill Outside In!!!! Find a virgin femoral tunnel Avoid previous hardware
EF/32F Failed acl with BHMM
Case EF
Case EF
RACL/EF 021395959
Thank You
Pearls Determine Why the Graft Failed Treat other involved Structures Stage if Necessary!!!! Have a contract with patient to follow post op regimen(9-12 months) Use a large GRAFT! Auto if possible
Be Prepared Decide on the type of Graft Autograft if possible, Other Leg?? Hardware Removal Sets Have X-ray available Do revision last case, Don t Rush Bone dowels to avoid staging
Pt Eval: Physical Exam Patient Size/Bone/BMI Gait Alignment Secondary Restraints Quantify Anterior laxity Quantify Rotatory Laxity
Tools Required Kitchen Sink!!! ½ size Drills/Fluted Drills Dilators Flexible Drills Rear-Entry Guide Image
ACL Technique Perhaps the most important factor for ACL Reconstruction in 2015 is surgical technique! Anatomic ACL Reconstruction! Forsythe B, Kopf S, Wong A, Martins C, Anderst W, Tashman S, Fu F. J Bone Joint Surg Am. 2010;92:1418-1426.
Why I use Large autografts! Lower failure rate in young patients Early incorporation of graft Reduced cost No issues with availability
Anatomic ACL Reconstruction 90 Zantop T, Wellman M, Fu FH, Petersen W. Tunnel Positioning of Anteromedial and Posterolateral Bundles in Anatomic Anterior Cruciate Ligament Reconstruction: Anatomic and Radiographic Findings. Am J Sports Med. 2008; 36:65-72.
Why Medial Portal drilling Outside-IN Anatomy: 100% fill of tunnel within native footprint Independent tibial tunnel placement Size of opening is accurate: not oval A M P SB L SB
Pitfalls of MP drilling Damage to MFC Short femoral tunnel Posterior blow-out
Short femoral tunnel
5 years PO Late Failure ACL: Too Vertical
Revision Surgery
Treat Other Involved Structures Absent medial meniscus lost important stabilizer. Do Medial Meniscal Allograft Arthritis and Mal-alignment: HTO Collateral Capsuloligamentous Involvement: Arthroscopic drive through sign Gait Analysis Varus/Valgus Thrust
Medial Gap Test/MCL and POL
Medial drive through arthroscopy video
Gapped lateral compartment
Positive Lateral Drive-Through
One Stage Tibial Tunnel Stainless Steel is Harder than Titanium Miller MD. Revision Cruciate Ligament Surgery with Retention of Hardware. Arthroscopy 1998; 14(1): 111-114
NP/RACL/Outside -In
Revision ACL Opening Wedge HTO
Revision ACL 1 Stage
Outside-In on Femur Drill Outside In!!!! Find a virgin femoral tunnel Avoid previous hardware
DR/RACL/MM allograft
Grand Canyon Size Tunnel Tunnel Lysis TA Allograft High School Female Soccer
Staging surgery: Indications Motion problems Anatomic graft placement Secure fixation for immediate rehab
Conclusions Etiology of Failure Obtain previous records Large Graft Other Structures Outside in Femur Stage if necessary Anatomic Counsel Patient