Preoperative planning, imaging
Ideally, Sgaglione likes to obtain and review the notes of the surgeon who performed the initial ACL reconstruction. He uses KT-1000 testing to assess the amount of patients’ anteroposterior translation. For salvage cases, he thinks about skin incisions and associated meniscal and articular cartilage pathology. He also uses MRI and 3-D CT to analyze the tunnels in difficult revision cases. Surgeons should look for previous injuries and potential technical errors in tunnel positioning.Most importantly, Sgaglione said, surgeons should be aware of athletes who re-injure themselves after return to play. Surgeons should also consider whether the patient had returned to play too early, and may have had a deficient graft that along along with trauma results in failure.
During revision cases, surgeons can encounter malpositioned tunnels that may have caused impingement. When templating tunnels, Sgaglione said that 3-D CTs can help avoid tunnel confluence, or “owl’s eyes” and to template out divergent tunnels. In patients with osteolysis, Sgaglione suggests addressing bone loss before revision.
 This lateral radiograph of failed ACL reconstruction shows a technically malpositioned “floating” femoral interference screw and anterior tibial tunnel. |  This AP radiograph of a failed ACL reconstruction with allograft tissue reveals vertical femoral tunnel orientation and tibial tunnel osteolysis requiring bone graft at revision surgery.” Images: Sgaglione NA |
Bone grafting and allografts
“I have a low threshold for bone grafting. I have become a little more conservative in that I tend to stage more now, and I do not primarily shim as much,” Sgaglione said.But if Sgaglione encounters problems with the femoral tunnel, he uses iliac crest bone graft. Then, 4 months to 6 months postoperatively, he performs a definitive reconstruction.
Indications for use of allograft tissue for primary reconstruction must be precise and orthopedists must screen and question the bone banks used, Sgaglione said. Allografts do however give options, especially in revision cases.
“They can give you the bone block advantages, as well as the limitation of harvest morbidity,” Sgaglione said.
Sgaglione also examines for concomitant pathologies including combined ligament pathologies. Some patients may need meniscal allograft transplantation, or posterolateral or posteromedial corner reconstruction.
“When you start doing revision work, you are invariably going to be dealing with meniscal attrition and articular cartilage lesions,” he said.
Patients who have meniscal loss or chondral injuries, usually will have a less favorable outcome after revision reconstruction making them, in essence, salvage cases. Sgaglione recommends counseling patients to have realistic goals and that surgeons be prepared for a variety of situations.
“You have to know how to reposition tunnels, when to remove hardware and when to leave the hardware in,” he said. “You need to possibly have revision trays to allow you to get out screws that are stripped and obviously have various options. Keep your options open as far as fixation grafts and associated reconstruction.” – by Renee Blisard
Revision ACL surgery is a common procedure performed at the Dubai Bone and Joint Center. We fortunately have all the revisions acl equipment available to remove all of the old hardware if needed, plus multiple fixation methods if required. We prefer a different technique than this author, we tend to make allograft cylinders from freeze dried femoral heads for both tibial and femoral defects, usually perform the definitive operation 8 weeks after grafting, after we have checked to ensure the bone graft has healed. We really try our best to perform single stage revision, however as with some of the revisions we are seeing.....although very few...failed double bundle reconstruction, single stage revision is very difficult.
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