AANA Fellowship Education - ACL Tear.…Again! Now What?-Presentation (PDF)

Presentation (PDF)
Pdf Summary
The document summarizes a comprehensive webinar titled "ACL Tear…Again! Now What?" held on April 27, 2021, featuring multiple orthopedic experts discussing failed primary anterior cruciate ligament reconstruction (ACLR), evaluation, alternative surgical options, and cartilage restoration.

Key points include: 

1. <strong>Failed Primary ACL Reconstruction</strong> has worse outcomes than initial surgery, including a 4-fold higher failure rate, reduced return-to-sport rates (43% vs. 87%), and prevalent meniscal and cartilage injuries. Failure causes include technical surgical errors (especially femoral tunnel malposition), malalignment, biological factors, and trauma. Assessment involves detailed history, physical examination, and imaging (X-ray, MRI, CT) focusing on tunnel position, alignment, meniscal/cartilage status, and infection contribution.

2. <strong>Revision ACL Reconstruction</strong> requires root cause analysis, considering graft choice, tunnel positions, and patient-specific factors. Single-stage revision is standard when bone stock allows, whereas two-stage surgery is needed for large tunnel widening, infection, or loss of motion. Bone grafting and osteotomy are considered in malalignment or slope abnormalities.

3. <strong>Posterior Tibial Slope (PTS)</strong> is crucial, with increased slope linked to higher graft failure risk. Surgical correction via anterior closing wedge osteotomy can reduce PTS and improve outcomes. Combined coronal and sagittal plane osteotomies address varus malalignment and slope issues.

4. <strong>Lateral Extra-Articular Tenodesis (LET) and Anterolateral Ligament (ALL) reconstruction</strong> may augment rotational stability in select revision cases but do not address meniscal deficiency or malalignment and should be used judiciously.

5. <strong>Cartilage Defect Management</strong> involves a "three-legged stool" approach of ligament competency, cartilage health, and alignment. Surgical options range from marrow stimulation and osteochondral autografts to advanced techniques like Autologous Chondrocyte Implantation (ACI) and Matrix-induced ACI (MACI), with patient selection critical for success. Outcomes show MACI having better pain and function scores than microfracture, particularly in larger lesions, though prior marrow stimulation may negatively impact ACI success.

6. <strong>Case discussions</strong> highlight multi-factorial nature of failed ACLRs with meniscal deficiency, malalignment, and chondral damage. Treatments combine osteotomy, revision ACLR, meniscal transplantation, and cartilage restoration through ACI/MACI tailored to each patient's pathology.

7. <strong>Rehabilitation protocols</strong> after cartilage restoration emphasize protected weight-bearing and gradual range of motion and strengthening to optimize healing.

In conclusion, successful management of ACL revision requires careful evaluation of failure etiology, correction of alignment and slope abnormalities, consideration of graft and fixation options, judicious use of extra-articular procedures, and addressing concomitant meniscal and cartilage pathology with both biological and mechanical solutions. Patient-specific factors and tailored surgical staging are keys to improved outcomes in this complex patient population.
Keywords
ACL tear
Anterior cruciate ligament reconstruction
Revision ACL surgery
Failed primary ACLR
Posterior tibial slope
Osteotomy
Lateral extra-articular tenodesis
Cartilage restoration
Autologous chondrocyte implantation
Meniscal deficiency