The ITB fascia is closed to the lateral femoral epicondyle with a running heavy suture, and all incisions are then irrigated and closed (Figures 10, 11). Standard sterile surgical dressing, Cryo/Cuff (Aircast, Vista, California), and brace are applied with the knee locked at 20°. Patients are generally discharged home the same day and followed up in clinic 1 week after surgery.
Complications
The peroneal nerve must be identified and protected during the open lateral procedure. In addition, the need for the extra lateral incision poses a slightly higher risk for infection compared with the traditional arthroscopic revision ACL procedure. Last, the additional tunnels required for the tenodesis can increase the theoretical potential for distal femur fracture and ACL graft fixation failure on the femoral side.
Postoperative Management
The operative knee is kept in extension in a brace locked at 20° for week 1 after surgery. Isometric quadriceps exercises are started immediately after surgery. Flexion to 90° is allowed starting week 2 after surgery, when the patient begins supervised active/passive flexion and progressive ROM exercises. In most cases, full ROM should be achieved by 6 to 8 weeks after surgery. Patients are progressed in their weight-bearing status by about 25% of their body weight per week, and use of crutches should be discontinued by week 4 after surgery. The brace should be discontinued by week 6 after surgery, when use of stationary bicycle and closed chain exercises begin. The patient may begin jogging when the operative leg regains 80% of contralateral quadriceps strength via Cybex strength testing. Functional drills begin in month 6, but patients should be counseled against returning to sport any earlier than 9 months after surgery.
Discussion
Achieving a successful outcome in revision ACL surgery (vs primary ACL surgery) is a significant challenge. Any of numerous factors can make the revision surgery more challenging, including existing poorly placed tunnels, tunnel expansion, lack of ideal graft choice, loss of secondary stabilizers, and deviations of the weight-bearing axis. Therefore, outcomes of revision surgery tend to be more moderate than outcomes of primary procedures.4,8-12
Revision ACL reconstruction techniques are varied and can involve use of autograft or allograft tissue as well as extra-articular augmentation techniques. Diamantopoulos and colleagues8 reported the outcomes of revision ACL reconstruction using bone–tendon–bone, hamstring, or quadriceps autografts in 107 patients. The majority of patients had improved outcome measures (mean Lysholm score improved from 51.5 to 88.5) and side-to-side laxity measurements. However, only 36.4% returned to preinjury activity level. Similarly, Noyes and Barber-Westin9 reported the outcomes of revision ACL reconstruction using quadriceps tendon–patellar bone autograft in 21 patients. Although there was significant improvement in terms of symptoms and activity level, 4 of the 21 knees were graded abnormal or severely abnormal on the IKDC (International Knee Documentation Committee) ligament rating. In a systematic review, pooled results of revision ACL reconstructions reiterated the above results.10 Eight hundred sixty-three patients from 21 studies were included in the analysis, which found significantly worse subjective outcomes than for primary procedures and a dramatically higher failure rate for the re-reconstructed ACL.
Several authors have directly compared primary cohorts with revision cohorts. Ahn and colleagues11 compared the outcomes of 59 revision ACL reconstructions with those of 117 primary reconstructions at a single institution. Although statistical comparison of stability between primary and revision ACL reconstructions showed no difference, revision reconstructions fared more poorly in terms of quality of life and return to activity compared with primary reconstructions. In a large cohort study of the Danish registry, revisions were found to have worse subjective outcomes than primary reconstructions as well.12 The study also found that the rerupture risk was significantly higher (relative risk, 2.05) when allograft was used.
Given the inferior results of revision surgery, our technique is recommended to augment the stability of reconstructed knees in the setting of revision ACL reconstruction. Adding the extra-articular procedure may augment the revised graft and protect it from excessive stress.13 A cadaver study compared double-bundle ACL reconstruction with single-bundle hamstring reconstruction plus extra-articular lateral tenodesis and found improved internal rotation control at 30° of flexion in the latter.14 Using contralateral 4-strand hamstring autograft in combination with an extra-articular lateral augment can have encouraging outcomes. Ferretti and colleagues15 reported an average Lysholm score of 95 in 12 patients who underwent this revision procedure and good anterior-to-posterior stability in 11 of the 12 patients. Trojani and colleagues16 reported on a cohort of 163 patients who underwent ACL revision surgery over a 10-year period. The authors found that 80% of patients with a lateral extra-articular tenodesis performed to augment their revision reconstruction had a negative pivot shift at long-term follow-up—versus only 63% of patients who underwent isolated revision ACL reconstruction. This finding was statistically significant, but the authors did not find any differences in IKDC scores between groups. These results support the initial biomechanical findings of Engebretsen and colleagues,17 who found that adding a lateral tenodesis decreased the forces on the reconstructed graft by 15%.