Surgical Predictors of Clinical Outcomes after Revision Anterior Cruciate Ligament Reconstruction

Christina R. Allen, Allen F. Anderson, Daniel E. Cooper, Thomas M. Deberardino, Warren R. Dunn, Amanda K. Haas, Laura J. Huston, Brett A. Lantz, Barton Mann, Sam K. Nwosu, Kurt P. Spindler, Michael J. Stuart, Rick W. Wright, John P. Albright, Annunziato Amendola, Jack T. Andrish, Christopher C. Annunziata, Robert A. Arciero, Bernard R. Bach, Champ L. BakerArthur R. Bartolozzi, Keith M. Baumgarten, Jeffery R. Bechler, Jeffrey H. Berg, Geoffrey A. Bernas, Stephen F. Brockmeier, Robert H. Brophy, Charles A. Bush-Joseph, J. Brad Butler, John D. Campbell, James L. Carey, James E. Carpenter, Brian J. Cole, Jonathan M. Cooper, Charles L. Cox, R. Alexander Creighton, Diane L. Dahm, Tal S. David, David C. Flanigan, Robert W. Frederick, Theodore J. Ganley, Elizabeth A. Garofoli, Charles J. Gatt, Steven R. Gecha, James Robert Giffin, Sharon L. Hame, Jo A. Hannafin, Christopher D. Harner, Norman Lindsay Harris, Keith S. Hechtman, Elliott B. Hershman, Rudolf G. Hoellrich, Timothy M. Hosea, David C. Johnson, Timothy S. Johnson, Morgan H. Jones, Christopher C. Kaeding, Ganesh V. Kamath, Thomas E. Klootwyk, Bruce A. Levy, C. Benjamin Ma, G. Peter Maiers, Robert G. Marx, Matthew J. Matava, Gregory M. Mathien, David R. McAllister, Eric C. McCarty, Robert G. McCormack, Bruce S. Miller, Carl W. Nissen, Daniel F. O'Neill, Brett D. Owens, Richard D. Parker, Mark L. Purnell, Arun J. Ramappa, Michael A. Rauh, Arthur C. Rettig, Jon K. Sekiya, Kevin G. Shea, Orrin H. Sherman, James R. Slauterbeck, Matthew V. Smith, Jeffrey T. Spang, Steven J. Svoboda, Timothy N. Taft, Joachim J. Tenuta, Edwin M. Tingstad, Armando F. Vidal, Darius G. Viskontas, Richard A. White, James S. Williams, Michelle L. Wolcott, Brian R. Wolf, James J. York

Research output: Contribution to journalArticle

9 Citations (Scopus)

Abstract

Background: Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes compared with primary ACL reconstruction. Hypothesis: Certain factors under the control of the surgeon at the time of revision surgery can both negatively and positively affect outcomes. Study Design: Case-control study; Level of evidence, 3. Methods: Patients undergoing revision ACL reconstruction were identified and prospectively enrolled between 2006 and 2011. Data collected included baseline demographics, intraoperative surgical technique and joint disorders, and a series of validated patient-reported outcome instruments (International Knee Documentation Committee [IKDC] subjective form, Knee Injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Marx activity rating scale) completed before surgery. Patients were followed up for 2 years and asked to complete an identical set of outcome instruments. Regression analysis was used to control for age, sex, body mass index (BMI), activity level, baseline outcome scores, revision number, time since last ACL reconstruction, and a variety of previous and current surgical variables to assess the surgical risk factors for clinical outcomes 2 years after revision ACL reconstruction. Results: A total of 1205 patients (697 male [58%]) met the inclusion criteria and were successfully enrolled. The median age was 26 years, and the median time since their last ACL reconstruction was 3.4 years. Two-year follow-up was obtained on 82% (989/1205). Both previous and current surgical factors were found to be significant contributors toward poorer clinical outcomes at 2 years. Having undergone previous arthrotomy (nonarthroscopic open approach) for ACL reconstruction compared with the 1-incision technique resulted in significantly poorer outcomes for the 2-year IKDC (P =.037; odds ratio [OR], 2.43; 95% CI, 1.05-5.88) and KOOS pain, sports/recreation, and quality of life (QOL) subscales (P ≤.05; OR range, 2.38-4.35; 95% CI, 1.03-10.00). The use of a metal interference screw for current femoral fixation resulted in significantly better outcomes for the 2-year KOOS symptoms, pain, and QOL subscales (P ≤.05; OR range, 1.70-1.96; 95% CI, 1.00-3.33) as well as WOMAC stiffness subscale (P =.041; OR, 1.75; 95% CI, 1.02-3.03). Not performing notchplasty at revision significantly improved 2-year outcomes for the IKDC (P =.013; OR, 1.47; 95% CI, 1.08-1.99), KOOS activities of daily living (ADL) and QOL subscales (P ≤.04; OR range, 1.40-1.41; 95% CI, 1.03-1.93), and WOMAC stiffness and ADL subscales (P ≤.04; OR range, 1.41-1.49; 95% CI, 1.03-2.05). Factors before revision ACL reconstruction that increased the risk of poorer clinical outcomes at 2 years included lower baseline outcome scores, a lower Marx activity score at the time of revision, a higher BMI, female sex, and a shorter time since the patient's last ACL reconstruction. Prior femoral fixation, prior femoral tunnel aperture position, and knee flexion angle at the time of revision graft fixation were not found to affect 2-year outcomes in this revision cohort. Conclusion: There are certain surgical variables that the physician can control at the time of revision ACL reconstruction that can modify clinical outcomes at 2 years. Whenever possible, opting for an anteromedial portal or transtibial surgical exposure, choosing a metal interference screw for femoral fixation, and not performing notchplasty are associated with significantly better 2-year clinical outcomes.

Original languageEnglish (US)
Pages (from-to)2586-2594
Number of pages9
JournalAmerican Journal of Sports Medicine
Volume45
Issue number11
DOIs
StatePublished - Sep 1 2017
Externally publishedYes

Fingerprint

Anterior Cruciate Ligament Reconstruction
Odds Ratio
Knee Injuries
Knee Osteoarthritis
Thigh
Knee
Documentation
Quality of Life
Activities of Daily Living
Body Mass Index
Metals
Pain
Recreation
Ontario
Reoperation
Osteoarthritis
Sports
Case-Control Studies
Joints
Regression Analysis

Keywords

  • ACL fixation
  • anterior cruciate ligament
  • outcomes
  • revision ACL reconstruction
  • surgical approach
  • surgical factors
  • tunnel position

ASJC Scopus subject areas

  • Orthopedics and Sports Medicine
  • Physical Therapy, Sports Therapy and Rehabilitation

Cite this

Allen, C. R., Anderson, A. F., Cooper, D. E., Deberardino, T. M., Dunn, W. R., Haas, A. K., ... York, J. J. (2017). Surgical Predictors of Clinical Outcomes after Revision Anterior Cruciate Ligament Reconstruction. American Journal of Sports Medicine, 45(11), 2586-2594. https://doi.org/10.1177/0363546517712952

Surgical Predictors of Clinical Outcomes after Revision Anterior Cruciate Ligament Reconstruction. / Allen, Christina R.; Anderson, Allen F.; Cooper, Daniel E.; Deberardino, Thomas M.; Dunn, Warren R.; Haas, Amanda K.; Huston, Laura J.; Lantz, Brett A.; Mann, Barton; Nwosu, Sam K.; Spindler, Kurt P.; Stuart, Michael J.; Wright, Rick W.; Albright, John P.; Amendola, Annunziato; Andrish, Jack T.; Annunziata, Christopher C.; Arciero, Robert A.; Bach, Bernard R.; Baker, Champ L.; Bartolozzi, Arthur R.; Baumgarten, Keith M.; Bechler, Jeffery R.; Berg, Jeffrey H.; Bernas, Geoffrey A.; Brockmeier, Stephen F.; Brophy, Robert H.; Bush-Joseph, Charles A.; Butler, J. Brad; Campbell, John D.; Carey, James L.; Carpenter, James E.; Cole, Brian J.; Cooper, Jonathan M.; Cox, Charles L.; Creighton, R. Alexander; Dahm, Diane L.; David, Tal S.; Flanigan, David C.; Frederick, Robert W.; Ganley, Theodore J.; Garofoli, Elizabeth A.; Gatt, Charles J.; Gecha, Steven R.; Giffin, James Robert; Hame, Sharon L.; Hannafin, Jo A.; Harner, Christopher D.; Harris, Norman Lindsay; Hechtman, Keith S.; Hershman, Elliott B.; Hoellrich, Rudolf G.; Hosea, Timothy M.; Johnson, David C.; Johnson, Timothy S.; Jones, Morgan H.; Kaeding, Christopher C.; Kamath, Ganesh V.; Klootwyk, Thomas E.; Levy, Bruce A.; Ma, C. Benjamin; Maiers, G. Peter; Marx, Robert G.; Matava, Matthew J.; Mathien, Gregory M.; McAllister, David R.; McCarty, Eric C.; McCormack, Robert G.; Miller, Bruce S.; Nissen, Carl W.; O'Neill, Daniel F.; Owens, Brett D.; Parker, Richard D.; Purnell, Mark L.; Ramappa, Arun J.; Rauh, Michael A.; Rettig, Arthur C.; Sekiya, Jon K.; Shea, Kevin G.; Sherman, Orrin H.; Slauterbeck, James R.; Smith, Matthew V.; Spang, Jeffrey T.; Svoboda, Steven J.; Taft, Timothy N.; Tenuta, Joachim J.; Tingstad, Edwin M.; Vidal, Armando F.; Viskontas, Darius G.; White, Richard A.; Williams, James S.; Wolcott, Michelle L.; Wolf, Brian R.; York, James J.

In: American Journal of Sports Medicine, Vol. 45, No. 11, 01.09.2017, p. 2586-2594.

Research output: Contribution to journalArticle

Allen, CR, Anderson, AF, Cooper, DE, Deberardino, TM, Dunn, WR, Haas, AK, Huston, LJ, Lantz, BA, Mann, B, Nwosu, SK, Spindler, KP, Stuart, MJ, Wright, RW, Albright, JP, Amendola, A, Andrish, JT, Annunziata, CC, Arciero, RA, Bach, BR, Baker, CL, Bartolozzi, AR, Baumgarten, KM, Bechler, JR, Berg, JH, Bernas, GA, Brockmeier, SF, Brophy, RH, Bush-Joseph, CA, Butler, JB, Campbell, JD, Carey, JL, Carpenter, JE, Cole, BJ, Cooper, JM, Cox, CL, Creighton, RA, Dahm, DL, David, TS, Flanigan, DC, Frederick, RW, Ganley, TJ, Garofoli, EA, Gatt, CJ, Gecha, SR, Giffin, JR, Hame, SL, Hannafin, JA, Harner, CD, Harris, NL, Hechtman, KS, Hershman, EB, Hoellrich, RG, Hosea, TM, Johnson, DC, Johnson, TS, Jones, MH, Kaeding, CC, Kamath, GV, Klootwyk, TE, Levy, BA, Ma, CB, Maiers, GP, Marx, RG, Matava, MJ, Mathien, GM, McAllister, DR, McCarty, EC, McCormack, RG, Miller, BS, Nissen, CW, O'Neill, DF, Owens, BD, Parker, RD, Purnell, ML, Ramappa, AJ, Rauh, MA, Rettig, AC, Sekiya, JK, Shea, KG, Sherman, OH, Slauterbeck, JR, Smith, MV, Spang, JT, Svoboda, SJ, Taft, TN, Tenuta, JJ, Tingstad, EM, Vidal, AF, Viskontas, DG, White, RA, Williams, JS, Wolcott, ML, Wolf, BR & York, JJ 2017, 'Surgical Predictors of Clinical Outcomes after Revision Anterior Cruciate Ligament Reconstruction', American Journal of Sports Medicine, vol. 45, no. 11, pp. 2586-2594. https://doi.org/10.1177/0363546517712952
Allen, Christina R. ; Anderson, Allen F. ; Cooper, Daniel E. ; Deberardino, Thomas M. ; Dunn, Warren R. ; Haas, Amanda K. ; Huston, Laura J. ; Lantz, Brett A. ; Mann, Barton ; Nwosu, Sam K. ; Spindler, Kurt P. ; Stuart, Michael J. ; Wright, Rick W. ; Albright, John P. ; Amendola, Annunziato ; Andrish, Jack T. ; Annunziata, Christopher C. ; Arciero, Robert A. ; Bach, Bernard R. ; Baker, Champ L. ; Bartolozzi, Arthur R. ; Baumgarten, Keith M. ; Bechler, Jeffery R. ; Berg, Jeffrey H. ; Bernas, Geoffrey A. ; Brockmeier, Stephen F. ; Brophy, Robert H. ; Bush-Joseph, Charles A. ; Butler, J. Brad ; Campbell, John D. ; Carey, James L. ; Carpenter, James E. ; Cole, Brian J. ; Cooper, Jonathan M. ; Cox, Charles L. ; Creighton, R. Alexander ; Dahm, Diane L. ; David, Tal S. ; Flanigan, David C. ; Frederick, Robert W. ; Ganley, Theodore J. ; Garofoli, Elizabeth A. ; Gatt, Charles J. ; Gecha, Steven R. ; Giffin, James Robert ; Hame, Sharon L. ; Hannafin, Jo A. ; Harner, Christopher D. ; Harris, Norman Lindsay ; Hechtman, Keith S. ; Hershman, Elliott B. ; Hoellrich, Rudolf G. ; Hosea, Timothy M. ; Johnson, David C. ; Johnson, Timothy S. ; Jones, Morgan H. ; Kaeding, Christopher C. ; Kamath, Ganesh V. ; Klootwyk, Thomas E. ; Levy, Bruce A. ; Ma, C. Benjamin ; Maiers, G. Peter ; Marx, Robert G. ; Matava, Matthew J. ; Mathien, Gregory M. ; McAllister, David R. ; McCarty, Eric C. ; McCormack, Robert G. ; Miller, Bruce S. ; Nissen, Carl W. ; O'Neill, Daniel F. ; Owens, Brett D. ; Parker, Richard D. ; Purnell, Mark L. ; Ramappa, Arun J. ; Rauh, Michael A. ; Rettig, Arthur C. ; Sekiya, Jon K. ; Shea, Kevin G. ; Sherman, Orrin H. ; Slauterbeck, James R. ; Smith, Matthew V. ; Spang, Jeffrey T. ; Svoboda, Steven J. ; Taft, Timothy N. ; Tenuta, Joachim J. ; Tingstad, Edwin M. ; Vidal, Armando F. ; Viskontas, Darius G. ; White, Richard A. ; Williams, James S. ; Wolcott, Michelle L. ; Wolf, Brian R. ; York, James J. / Surgical Predictors of Clinical Outcomes after Revision Anterior Cruciate Ligament Reconstruction. In: American Journal of Sports Medicine. 2017 ; Vol. 45, No. 11. pp. 2586-2594.
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title = "Surgical Predictors of Clinical Outcomes after Revision Anterior Cruciate Ligament Reconstruction",
abstract = "Background: Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes compared with primary ACL reconstruction. Hypothesis: Certain factors under the control of the surgeon at the time of revision surgery can both negatively and positively affect outcomes. Study Design: Case-control study; Level of evidence, 3. Methods: Patients undergoing revision ACL reconstruction were identified and prospectively enrolled between 2006 and 2011. Data collected included baseline demographics, intraoperative surgical technique and joint disorders, and a series of validated patient-reported outcome instruments (International Knee Documentation Committee [IKDC] subjective form, Knee Injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Marx activity rating scale) completed before surgery. Patients were followed up for 2 years and asked to complete an identical set of outcome instruments. Regression analysis was used to control for age, sex, body mass index (BMI), activity level, baseline outcome scores, revision number, time since last ACL reconstruction, and a variety of previous and current surgical variables to assess the surgical risk factors for clinical outcomes 2 years after revision ACL reconstruction. Results: A total of 1205 patients (697 male [58{\%}]) met the inclusion criteria and were successfully enrolled. The median age was 26 years, and the median time since their last ACL reconstruction was 3.4 years. Two-year follow-up was obtained on 82{\%} (989/1205). Both previous and current surgical factors were found to be significant contributors toward poorer clinical outcomes at 2 years. Having undergone previous arthrotomy (nonarthroscopic open approach) for ACL reconstruction compared with the 1-incision technique resulted in significantly poorer outcomes for the 2-year IKDC (P =.037; odds ratio [OR], 2.43; 95{\%} CI, 1.05-5.88) and KOOS pain, sports/recreation, and quality of life (QOL) subscales (P ≤.05; OR range, 2.38-4.35; 95{\%} CI, 1.03-10.00). The use of a metal interference screw for current femoral fixation resulted in significantly better outcomes for the 2-year KOOS symptoms, pain, and QOL subscales (P ≤.05; OR range, 1.70-1.96; 95{\%} CI, 1.00-3.33) as well as WOMAC stiffness subscale (P =.041; OR, 1.75; 95{\%} CI, 1.02-3.03). Not performing notchplasty at revision significantly improved 2-year outcomes for the IKDC (P =.013; OR, 1.47; 95{\%} CI, 1.08-1.99), KOOS activities of daily living (ADL) and QOL subscales (P ≤.04; OR range, 1.40-1.41; 95{\%} CI, 1.03-1.93), and WOMAC stiffness and ADL subscales (P ≤.04; OR range, 1.41-1.49; 95{\%} CI, 1.03-2.05). Factors before revision ACL reconstruction that increased the risk of poorer clinical outcomes at 2 years included lower baseline outcome scores, a lower Marx activity score at the time of revision, a higher BMI, female sex, and a shorter time since the patient's last ACL reconstruction. Prior femoral fixation, prior femoral tunnel aperture position, and knee flexion angle at the time of revision graft fixation were not found to affect 2-year outcomes in this revision cohort. Conclusion: There are certain surgical variables that the physician can control at the time of revision ACL reconstruction that can modify clinical outcomes at 2 years. Whenever possible, opting for an anteromedial portal or transtibial surgical exposure, choosing a metal interference screw for femoral fixation, and not performing notchplasty are associated with significantly better 2-year clinical outcomes.",
keywords = "ACL fixation, anterior cruciate ligament, outcomes, revision ACL reconstruction, surgical approach, surgical factors, tunnel position",
author = "Allen, {Christina R.} and Anderson, {Allen F.} and Cooper, {Daniel E.} and Deberardino, {Thomas M.} and Dunn, {Warren R.} and Haas, {Amanda K.} and Huston, {Laura J.} and Lantz, {Brett A.} and Barton Mann and Nwosu, {Sam K.} and Spindler, {Kurt P.} and Stuart, {Michael J.} and Wright, {Rick W.} and Albright, {John P.} and Annunziato Amendola and Andrish, {Jack T.} and Annunziata, {Christopher C.} and Arciero, {Robert A.} and Bach, {Bernard R.} and Baker, {Champ L.} and Bartolozzi, {Arthur R.} and Baumgarten, {Keith M.} and Bechler, {Jeffery R.} and Berg, {Jeffrey H.} and Bernas, {Geoffrey A.} and Brockmeier, {Stephen F.} and Brophy, {Robert H.} and Bush-Joseph, {Charles A.} and Butler, {J. Brad} and Campbell, {John D.} and Carey, {James L.} and Carpenter, {James E.} and Cole, {Brian J.} and Cooper, {Jonathan M.} and Cox, {Charles L.} and Creighton, {R. Alexander} and Dahm, {Diane L.} and David, {Tal S.} and Flanigan, {David C.} and Frederick, {Robert W.} and Ganley, {Theodore J.} and Garofoli, {Elizabeth A.} and Gatt, {Charles J.} and Gecha, {Steven R.} and Giffin, {James Robert} and Hame, {Sharon L.} and Hannafin, {Jo A.} and Harner, {Christopher D.} and Harris, {Norman Lindsay} and Hechtman, {Keith S.} and Hershman, {Elliott B.} and Hoellrich, {Rudolf G.} and Hosea, {Timothy M.} and Johnson, {David C.} and Johnson, {Timothy S.} and Jones, {Morgan H.} and Kaeding, {Christopher C.} and Kamath, {Ganesh V.} and Klootwyk, {Thomas E.} and Levy, {Bruce A.} and Ma, {C. Benjamin} and Maiers, {G. Peter} and Marx, {Robert G.} and Matava, {Matthew J.} and Mathien, {Gregory M.} and McAllister, {David R.} and McCarty, {Eric C.} and McCormack, {Robert G.} and Miller, {Bruce S.} and Nissen, {Carl W.} and O'Neill, {Daniel F.} and Owens, {Brett D.} and Parker, {Richard D.} and Purnell, {Mark L.} and Ramappa, {Arun J.} and Rauh, {Michael A.} and Rettig, {Arthur C.} and Sekiya, {Jon K.} and Shea, {Kevin G.} and Sherman, {Orrin H.} and Slauterbeck, {James R.} and Smith, {Matthew V.} and Spang, {Jeffrey T.} and Svoboda, {Steven J.} and Taft, {Timothy N.} and Tenuta, {Joachim J.} and Tingstad, {Edwin M.} and Vidal, {Armando F.} and Viskontas, {Darius G.} and White, {Richard A.} and Williams, {James S.} and Wolcott, {Michelle L.} and Wolf, {Brian R.} and York, {James J.}",
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language = "English (US)",
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pages = "2586--2594",
journal = "American Journal of Sports Medicine",
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TY - JOUR

T1 - Surgical Predictors of Clinical Outcomes after Revision Anterior Cruciate Ligament Reconstruction

AU - Allen, Christina R.

AU - Anderson, Allen F.

AU - Cooper, Daniel E.

AU - Deberardino, Thomas M.

AU - Dunn, Warren R.

AU - Haas, Amanda K.

AU - Huston, Laura J.

AU - Lantz, Brett A.

AU - Mann, Barton

AU - Nwosu, Sam K.

AU - Spindler, Kurt P.

AU - Stuart, Michael J.

AU - Wright, Rick W.

AU - Albright, John P.

AU - Amendola, Annunziato

AU - Andrish, Jack T.

AU - Annunziata, Christopher C.

AU - Arciero, Robert A.

AU - Bach, Bernard R.

AU - Baker, Champ L.

AU - Bartolozzi, Arthur R.

AU - Baumgarten, Keith M.

AU - Bechler, Jeffery R.

AU - Berg, Jeffrey H.

AU - Bernas, Geoffrey A.

AU - Brockmeier, Stephen F.

AU - Brophy, Robert H.

AU - Bush-Joseph, Charles A.

AU - Butler, J. Brad

AU - Campbell, John D.

AU - Carey, James L.

AU - Carpenter, James E.

AU - Cole, Brian J.

AU - Cooper, Jonathan M.

AU - Cox, Charles L.

AU - Creighton, R. Alexander

AU - Dahm, Diane L.

AU - David, Tal S.

AU - Flanigan, David C.

AU - Frederick, Robert W.

AU - Ganley, Theodore J.

AU - Garofoli, Elizabeth A.

AU - Gatt, Charles J.

AU - Gecha, Steven R.

AU - Giffin, James Robert

AU - Hame, Sharon L.

AU - Hannafin, Jo A.

AU - Harner, Christopher D.

AU - Harris, Norman Lindsay

AU - Hechtman, Keith S.

AU - Hershman, Elliott B.

AU - Hoellrich, Rudolf G.

AU - Hosea, Timothy M.

AU - Johnson, David C.

AU - Johnson, Timothy S.

AU - Jones, Morgan H.

AU - Kaeding, Christopher C.

AU - Kamath, Ganesh V.

AU - Klootwyk, Thomas E.

AU - Levy, Bruce A.

AU - Ma, C. Benjamin

AU - Maiers, G. Peter

AU - Marx, Robert G.

AU - Matava, Matthew J.

AU - Mathien, Gregory M.

AU - McAllister, David R.

AU - McCarty, Eric C.

AU - McCormack, Robert G.

AU - Miller, Bruce S.

AU - Nissen, Carl W.

AU - O'Neill, Daniel F.

AU - Owens, Brett D.

AU - Parker, Richard D.

AU - Purnell, Mark L.

AU - Ramappa, Arun J.

AU - Rauh, Michael A.

AU - Rettig, Arthur C.

AU - Sekiya, Jon K.

AU - Shea, Kevin G.

AU - Sherman, Orrin H.

AU - Slauterbeck, James R.

AU - Smith, Matthew V.

AU - Spang, Jeffrey T.

AU - Svoboda, Steven J.

AU - Taft, Timothy N.

AU - Tenuta, Joachim J.

AU - Tingstad, Edwin M.

AU - Vidal, Armando F.

AU - Viskontas, Darius G.

AU - White, Richard A.

AU - Williams, James S.

AU - Wolcott, Michelle L.

AU - Wolf, Brian R.

AU - York, James J.

PY - 2017/9/1

Y1 - 2017/9/1

N2 - Background: Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes compared with primary ACL reconstruction. Hypothesis: Certain factors under the control of the surgeon at the time of revision surgery can both negatively and positively affect outcomes. Study Design: Case-control study; Level of evidence, 3. Methods: Patients undergoing revision ACL reconstruction were identified and prospectively enrolled between 2006 and 2011. Data collected included baseline demographics, intraoperative surgical technique and joint disorders, and a series of validated patient-reported outcome instruments (International Knee Documentation Committee [IKDC] subjective form, Knee Injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Marx activity rating scale) completed before surgery. Patients were followed up for 2 years and asked to complete an identical set of outcome instruments. Regression analysis was used to control for age, sex, body mass index (BMI), activity level, baseline outcome scores, revision number, time since last ACL reconstruction, and a variety of previous and current surgical variables to assess the surgical risk factors for clinical outcomes 2 years after revision ACL reconstruction. Results: A total of 1205 patients (697 male [58%]) met the inclusion criteria and were successfully enrolled. The median age was 26 years, and the median time since their last ACL reconstruction was 3.4 years. Two-year follow-up was obtained on 82% (989/1205). Both previous and current surgical factors were found to be significant contributors toward poorer clinical outcomes at 2 years. Having undergone previous arthrotomy (nonarthroscopic open approach) for ACL reconstruction compared with the 1-incision technique resulted in significantly poorer outcomes for the 2-year IKDC (P =.037; odds ratio [OR], 2.43; 95% CI, 1.05-5.88) and KOOS pain, sports/recreation, and quality of life (QOL) subscales (P ≤.05; OR range, 2.38-4.35; 95% CI, 1.03-10.00). The use of a metal interference screw for current femoral fixation resulted in significantly better outcomes for the 2-year KOOS symptoms, pain, and QOL subscales (P ≤.05; OR range, 1.70-1.96; 95% CI, 1.00-3.33) as well as WOMAC stiffness subscale (P =.041; OR, 1.75; 95% CI, 1.02-3.03). Not performing notchplasty at revision significantly improved 2-year outcomes for the IKDC (P =.013; OR, 1.47; 95% CI, 1.08-1.99), KOOS activities of daily living (ADL) and QOL subscales (P ≤.04; OR range, 1.40-1.41; 95% CI, 1.03-1.93), and WOMAC stiffness and ADL subscales (P ≤.04; OR range, 1.41-1.49; 95% CI, 1.03-2.05). Factors before revision ACL reconstruction that increased the risk of poorer clinical outcomes at 2 years included lower baseline outcome scores, a lower Marx activity score at the time of revision, a higher BMI, female sex, and a shorter time since the patient's last ACL reconstruction. Prior femoral fixation, prior femoral tunnel aperture position, and knee flexion angle at the time of revision graft fixation were not found to affect 2-year outcomes in this revision cohort. Conclusion: There are certain surgical variables that the physician can control at the time of revision ACL reconstruction that can modify clinical outcomes at 2 years. Whenever possible, opting for an anteromedial portal or transtibial surgical exposure, choosing a metal interference screw for femoral fixation, and not performing notchplasty are associated with significantly better 2-year clinical outcomes.

AB - Background: Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes compared with primary ACL reconstruction. Hypothesis: Certain factors under the control of the surgeon at the time of revision surgery can both negatively and positively affect outcomes. Study Design: Case-control study; Level of evidence, 3. Methods: Patients undergoing revision ACL reconstruction were identified and prospectively enrolled between 2006 and 2011. Data collected included baseline demographics, intraoperative surgical technique and joint disorders, and a series of validated patient-reported outcome instruments (International Knee Documentation Committee [IKDC] subjective form, Knee Injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Marx activity rating scale) completed before surgery. Patients were followed up for 2 years and asked to complete an identical set of outcome instruments. Regression analysis was used to control for age, sex, body mass index (BMI), activity level, baseline outcome scores, revision number, time since last ACL reconstruction, and a variety of previous and current surgical variables to assess the surgical risk factors for clinical outcomes 2 years after revision ACL reconstruction. Results: A total of 1205 patients (697 male [58%]) met the inclusion criteria and were successfully enrolled. The median age was 26 years, and the median time since their last ACL reconstruction was 3.4 years. Two-year follow-up was obtained on 82% (989/1205). Both previous and current surgical factors were found to be significant contributors toward poorer clinical outcomes at 2 years. Having undergone previous arthrotomy (nonarthroscopic open approach) for ACL reconstruction compared with the 1-incision technique resulted in significantly poorer outcomes for the 2-year IKDC (P =.037; odds ratio [OR], 2.43; 95% CI, 1.05-5.88) and KOOS pain, sports/recreation, and quality of life (QOL) subscales (P ≤.05; OR range, 2.38-4.35; 95% CI, 1.03-10.00). The use of a metal interference screw for current femoral fixation resulted in significantly better outcomes for the 2-year KOOS symptoms, pain, and QOL subscales (P ≤.05; OR range, 1.70-1.96; 95% CI, 1.00-3.33) as well as WOMAC stiffness subscale (P =.041; OR, 1.75; 95% CI, 1.02-3.03). Not performing notchplasty at revision significantly improved 2-year outcomes for the IKDC (P =.013; OR, 1.47; 95% CI, 1.08-1.99), KOOS activities of daily living (ADL) and QOL subscales (P ≤.04; OR range, 1.40-1.41; 95% CI, 1.03-1.93), and WOMAC stiffness and ADL subscales (P ≤.04; OR range, 1.41-1.49; 95% CI, 1.03-2.05). Factors before revision ACL reconstruction that increased the risk of poorer clinical outcomes at 2 years included lower baseline outcome scores, a lower Marx activity score at the time of revision, a higher BMI, female sex, and a shorter time since the patient's last ACL reconstruction. Prior femoral fixation, prior femoral tunnel aperture position, and knee flexion angle at the time of revision graft fixation were not found to affect 2-year outcomes in this revision cohort. Conclusion: There are certain surgical variables that the physician can control at the time of revision ACL reconstruction that can modify clinical outcomes at 2 years. Whenever possible, opting for an anteromedial portal or transtibial surgical exposure, choosing a metal interference screw for femoral fixation, and not performing notchplasty are associated with significantly better 2-year clinical outcomes.

KW - ACL fixation

KW - anterior cruciate ligament

KW - outcomes

KW - revision ACL reconstruction

KW - surgical approach

KW - surgical factors

KW - tunnel position

UR - http://www.scopus.com/inward/record.url?scp=85028728803&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85028728803&partnerID=8YFLogxK

U2 - 10.1177/0363546517712952

DO - 10.1177/0363546517712952

M3 - Article

C2 - 28696164

AN - SCOPUS:85028728803

VL - 45

SP - 2586

EP - 2594

JO - American Journal of Sports Medicine

JF - American Journal of Sports Medicine

SN - 0363-5465

IS - 11

ER -