A high tibial slope, allograft use, and poor patient-reported outcome scores are associated with multiple ACL graft failures

Abstract

Purpose To compare clinical outcomes, radiographic characteristics, and surgical factors between patients with single and multiple anterior cruciate ligament (ACL) graft failures. It was hypothesized that patients experiencing multiple ACL graft failures exhibit lower patient-reported outcome scores (PROs) and a higher (steeper) posterior tibial slope (PTS) than patients with single ACL graft failure. Methods Patients undergoing revision ACL reconstruction with a minimum follow-up of 12 months were included in this retrospective cohort study. Based on the number of ACL graft failures, patients were assigned either to the group “single ACL graft failure “or” multiple ACL graft failures “. The PTS was measured on strict lateral radiographs. Validated PROs including the International Knee Documentation Committee (IKDC) subjective knee form, Knee Injury and Osteoarthritis Outcome Score, Lysholm Score, Tegner Activity Scale, ACL-Return to Sport after Injury Scale, and Visual Analogue Scale for pain were collected. Results Overall, 102 patients were included with 58 patients assigned to the single ACL graft failure group and 44 patients to the multiple ACL graft failures group. Quadriceps tendon autograft was used significantly more often (55% vs. 11%, p < 0.001) and allografts were used significantly less often (31% vs. 66%, p < 0.001) as the graft for first revision ACL reconstruction in patients with single versus multiple ACL graft failures. Patients with multiple ACL graft failures were associated with statistically significantly worse PROs (IKDC: 61.7 ± 19.3 vs. 77.4 ± 16.8, p < 0.05; Tegner Activity Scale: 4 (range, 0–7) vs. 6 (range 2–10), p < 0.05), higher PTS (12 ± 3° vs. 9 ± 3°, p < 0.001), and higher rates of subsequent surgery (73% vs. 14%, p < 0.001) and complications (45% vs. 17%, p < 0.05) than patients with single ACL graft failure. Conclusion Compared to single ACL graft failure in this study multiple ACL graft failures were associated with worse PROs, higher PTS, and allograft use. During the first revision ACL reconstruction, it is recommended to avoid the use of allografts and to consider slope-reducing osteotomies to avoid multiple ACL graft failures and improve PROs. Level of evidence Level 3.

Practice Patterns for Revision Anterior Cruciate Ligament Reconstruction in an Integrated Health Care System

“…Prior studies have consistently demonstrated better outcome scores and lower graft failure rates with autografts compared with allografts for revision ACLR. 14 – 17 , 23 , 24 The MARS group showed that the use of autografts for revision ACLR resulted in improved International Knee Documentation Committee scores, Knee injury and Osteoarthritis Outcome Score values in the Sport and Recreation and Quality of Life subscales, and 2-year Marx scores compared with use of allografts. 15 The authors also found that patients undergoing revision ACLR with an autograft were 2.8 times less likely to sustain a subsequent graft rupture compared with those with an allograft.…”

“…14 This was supported by one study that showed that recurrent graft failures requiring multiple revision ACLR procedures are associated with the use of allografts for the first revision compared to single graft failures in which autografts are predominant. 23 …”

“…14 This was supported by one study that showed that recurrent graft failures requiring multiple revision ACLR procedures are associated with the use of allografts for the first revision compared to single graft failures in which autografts are predominant. 23 A recent study evaluating factors that influence graft choice concluded that the revising surgeon had the largest effect on graft choice. The authors showed that if the prior graft type was an autograft, then an allograft was 3.6 times more likely to be chosen for revision.…”

“…Surgeons were categorized by the number of annual ACLR procedures performed as low (17), medium (18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34), or high (35) volume. This cutoff has been previously described to determine clinically meaningful annual volume thresholds based on the risk of subsequent knee surgery after ACLR as opposed to an arbitrarily defined volume cutoff point.…”

A review of role of osteotomy in knee ligament injuries

“…21,28,36 In a study looking at single revision ACL versus multiple revision ACL reconstruction patients, Winkler and colleagues noted, that a higher medial PTS is observed in patients with multiple compared to single ACL graft failures (12þ À3 versus 9þ À3 ). 46 A cadeveric study by Petrigliano and colleagues looked at the effect of sectioning PCL and PLC on static and dynamic testing, assessing for any change produced by altering the native tibial slope. They found that increasing PTS by 5 deg in a PCL/PLC deficient knee can reduce the posterior drawer but has no effect on dial test.…”