KNEE

Medium to long-term follow-up after ACL revision

Martin Lind

Bent Lund

Peter Faun

Sinan Said

Lene Lindberg Miller

Svend Erik Christiansen
Received: 12 March 2011 / Accepted: 14 July 2011 / Published online: 29 July 2011
Springer-Verlag 2011
Abstract
Purpose The aim of the present study is to present epi-
demiology and clinical outcome after revision anterior
cruciate ligament (ACL) reconstruction with an interme-
diate follow-up time of up to 9 years.
Methods A retrospective study of patients treated with
ACL revision from 2001 to 2007 at a university referral
clinic was conducted. Study follow-up was performed in
2010; this follow-up included objective IKDC scores,
KOOS, Tegner and SANE subjective scores, KT-1000
knee laxity measurements and registration of reoperations
and complications.
Results One hundred and twenty-eight patients were
available for follow-up. Median follow-up time was 6
(29) years. Mean age was 32 years, 50% were men.
Eleven percent required staged procedures, 30% were
reconstructed with allograft tendons and 23% had collateral
ligament reconstruction in combination with the ACL
revision. SANE knee global score (0100) was 74 at fol-
low-up, KOOS sub-scores were preoperatively 66, 69, 77,
42 and 39 for pain, symptoms, activity of daily living,
sports and quality of life, respectively. At follow-up, scores
were 70, 76, 81, 50 and 50, respectively. Sport and quality
of life scores increased signicantly. KT-1000 was 6.2 mm
preoperatively and 2.5 at follow-up (P\0.05). Six percent
were re-revised and 2 patients had total knee replacements.
Conclusion Despite objective ndings of acceptable
sagittal knee stability at follow-up, subjective outcome
scores indicate signicant knee impairment with low scores
in sport and quality of life. A re-revision rate of 6% after
6 years is acceptable. It is imperative that patients eligible
for ACL revision receive proper counseling in terms of
outcome expectancies.
Level of evidence Retrospective case series, Level IV.
Keywords Revision ACL Retrospective case study
KOOS ACL failure
Introduction
Reconstruction of the anterior cruciate ligament in order
to restore knee stability in young active patients is
increasingly performed. Incidence of surgery in the age
group most prone to ACL injuries (1540 years) is
85/100,000 [6]. Overall incidence in Western nations is
approximately 40/100,000, resulting in more than 250,000
ACL reconstructions performed yearly in Europe and the
United States alone. As established denitions of failure
have not yet been determined, outcome of ACL recon-
struction is at present not extensively described. Failed
ACL reconstruction can ultimately necessitate ACL
revision reconstruction. However, indications for ACL
revision are not clearly dened, and certainly not all
patients with poor outcome after ACL reconstruction will
require an ACL revision nor will they benet from such a
procedure.
While the exact incidence of ACL reconstruction failure
leading to ACL revision is unknown, data from national
registries has demonstrated both that 10% of all ACL
reconstruction procedures are revision procedures and that
ACL revision is performed in less than 5% of all knee
ligament reconstructions within the rst 2 postoperative
M. Lind (&) B. Lund P. Faun S. Said
L. L. Miller S. E. Christiansen
Division of Sports Trauma, Orthopedic Department,
Aarhus University Hospital, Tage Hansensgade 2,
8000 Aarhus C, Denmark
e-mail: Martinlind@dadlnet.dk
1 3
Knee Surg Sports Traumatol Arthrosc (2012) 20:166172
DOI 10.1007/s00167-011-1629-3
years [15]. Therefore, opportunities to perform high-evi-
dence level studies are severely limited. Current knowledge
concerning outcome after ACL revision is based on level 3
and 4 studies, typically with fewer than 50 patients [5, 11].
Because these studies use varying objective and subjective
outcome measures and present different operative tech-
nique principles, inter-study comparison is difcult.
In Scandinavia, national registries have now been
established. These registries can generate demographic and
outcome data for ACL revision for entire nations and
thereby provide more reliable data describing the true
outcome after both ACL reconstruction and ACL revision,
but because these registries have been established only
very recently, published data describing ACL revision
outcome is correspondingly sparse [7, 15]. In the United
States, multicenter cohort studies, the multicenter ortho-
pedic outcome network (MOON), have established cohorts
of ACL reconstruction and ACL revision-operated patients
with high levels of follow-up and established outcome
parameters that will enable the generation of valid data for
the outcome of these procedures [23, 24]. Results from
these studies have established that clinical outcome after
ACL revision is poorer than after primary ACL recon-
struction and that repeated graft failure is a potential
problem.
ACL revisions are typically performed on young and
active individuals who will possibly face impaired knee
function resulting from a failed procedure and it is there-
fore vitally important to improve current knowledge con-
cerning outcome after ACL revision. Since, at the present
time, there is a lack of knowledge surrounding failure of
ACL revision, predictors of repeat graft failure and poor
clinical outcome need to be established.
The aim of the present study is to investigate the epi-
demiology and clinical outcome of ACL revision after an
intermediate follow-up period of 29 years in a large
patient cohort treated at a university referral clinic.
Materials and methods
In the period from 2001 to 2007, a total of 168 patients
were treated with ACL revision surgery at Aarhus Uni-
versity Hospital, Division of Sports Trauma, which is a
university referral clinic. Inclusion criteria were: rst-
time ACL revision surgery with and without concomitant
collateral ligament reconstructions. Exclusion criteria
were: repeat ACL revision or concomitant PCL knee
ligament reconstruction. Due to lack of follow-up
opportunity, deceased patients and patients who had
migrated out of the country were also excluded from the
study.
Evaluation
All included patients were admitted for study follow-up in
the rst 6 months of 2010. At follow-up, patients were
clinically evaluated by an independent physiotherapist;
evaluation included objective and instrumented knee laxity
measurement.
Patients were evaluated by means of follow-up objective
IKDC scores [8]. Pivot shift was graded as either absent,
minor, moderate or gross. Anterior sagittal instability at
25 of knee exion was objectively assessed by means of
instrumented KT-1000 measurements, with the index side
to normal side difference at maximum anterior load as the
primary parameter.
Patient-related outcome measures were performed by
means of preoperative and follow-up KOOS subjective
scores [19]. KOOS quality of life subscale below 44 points
has been suggested as an indicator for failure after ACL
reconstruction surgery [3]. Using the single assessment
numeric evaluation (SANE) method, patients were also
asked to rate their overall knee function on the operated
side on a scale from 1 to 100, with 100 being normal [22].
Ability to perform sports and working ability were assessed
by means of Tegner functional score (010) [20]. Pain at
rest and after 15 min of walking was evaluated using a
010 Likert scale. Follow-up patient satisfaction with the
outcome was graded: very satised with the outcome,
satised with the outcome, slightly unsatised with the
outcome and unsatised. Patients were also asked whether
or not they would have the procedure performed again.
All complications and reoperations during the follow-up
period were registered.
Generally, in cases with acceptable tunnel positioning
and limited tunnel widening, an autograft tendon either
semitendinosus/gracilis (ST/G) or patella-bone-tendon-
bone (BTB) was used so that if the primary procedure was
performed with ST/G and BTB, graft was used for the
revision procedure and vice versa. If tunnel widening was
extensive ([12 mm), a staged procedure with allogenic
bone transplantation in both femoral and tibial tunnels was
performed. Tunnel widening was assessed in accordance
with the method described by LInsalata et al. [13].
Poor femoral tunnel position at primary surgery was
dened as vertical if the hole angle was less than 25 to the
vertical axis, and anterior if the center of the tunnel was
anterior to the posterior one-third of the Blumensaat line
(our own denition). Allograft tendons were used in cases
where the patients occupation contraindicated the use of
BTB graft, or if the patient had a strong aversion toward
autograft harvest and the surgeon considered the use of
allograft to be benecial. The latter could be applicable in
cases of moderate tunnel widening and tunnel malposition
Knee Surg Sports Traumatol Arthrosc (2012) 20:166172 167
1 3
where an allograft with bone blocks could compensate for
these insufciencies and enable a single stage procedure.
Collateral ligament insufciency was treated with rele-
vant ligament reconstruction according to previously pub-
lished methods [9, 14].
Rehabilitation
Patients were allowed unloaded free range of motion
immediate postoperatively. Full-weight bearing was
allowed after 2 weeks. Controlled sports activities after
34 months and contact sports after 12 months were
allowed. However, patients were advised to discontinue
contact sports if the cause for revision was new trauma
during contact sports.
Statistical analysis
KOOS score, pain score, SANE score and KT-1000 data
are expressed as mean values with standard deviation in
brackets. Tegner scores are expressed as median values
with range values in brackets. Comparison of preoperative
and follow-up KT-1000 and KOOS data was performed
with Students t test. A P value of \0.05 was considered
signicant.
Results
One hundred and twenty-eight patients (76%) were avail-
able for follow-up. Ninety-eight patients were seen at a
project follow-up visit and, for all subjective scores, 30
patients were followed up by means of telephone interview
and mail contact. Average follow-up was 5.9 years (range
29 years). Fifty percent were women. Median age was
31 years with a range from 16 to 58.
Primary ACL reconstruction
At primary ACL reconstruction, graft choice for the cohort
was patella tendon in 50% of patients and semitendinosus/
gracilis in 41%. Of the 9% of other graft types, 6% were
various synthetic graft materials. Thirty-three percent had
meniscus injury; of these, 27% were isolated medial, 4%
isolated lateral and 2% combined medial and lateral.
Revision ACL reconstruction
Median time from primary ACL reconstruction to ACL
revision was 58 months (range 0311). The surgeon-eval-
uated primary cause of ACL graft failure is shown in
Table 1. The three most common causes were: new trauma
(30%), unknown cause (24%) and femoral tunnel placement
(20%). Staged procedures with initial tunnel bone grafting
with allograft bone was performed in 11% of patients. Graft
choice at ACL revision was PTB graft in 28%, semitendi-
nosus/gracilis graft in 41% and allograft in 31% of patients.
A collateral ligament reconstruction was performed at the
time of ACL revision in 23% of cases. In 3% of cases, MCL
was performed and in 20% of cases a combination of LCL
and posterolateral corner reconstruction was performed.
Meniscus injury was seen in 45% of patients with 30%
medial and 15% lateral lesions. Cartilage lesions (ICRS
grade 3 or 4) were seen in 59% of patients. In 17% of cases,
the cartilage lesions were isolated to one compartment and
in 32%, multiple compartments were affected. In all cases,
cartilage lesions were treated solely with debridement, with
no cartilage repair procedures performed.
Objective knee stability outcome
Sagittal knee laxity measured by means of the KT-1000
knee stability test improved signicantly from 6.5 mm
preoperatively to 2.5 mm at follow-up. No improvement in
sagittal knee laxity was seen in only 3% of patients and a
follow-up side-to-side difference of [5 mm (IKDC group
C and D for anterior laxity) was seen in 6% of patients.
Pivot shift was absent in 41%, minor in 48% and moderate
in 18% of patients.
Overall, objective IKDC score at follow-up was 5%
group A, 59% group B, 29% group C and 5% group D.
Subjective outcome
Patient-related outcome measures are presented in Table 2
and Fig. 1. KOOS scores demonstrated signicant improve-
ment for the sub-score of sports and recreation and quality
of life, which improved 8 and 11 points, respectively.
When dividing the patient material into two groups of
patients who had either isolated ACL revision or in com-
bination with collateral ligament reconstruction, the fol-
lowing was found: In terms of preoperative status, patients
with collateral insufciency had a lower KOOS sports/
Table 1 Surgeon-evaluated causes for revision ACL surgery
Cause for revision ACL surgery %
New trauma 30
Unknown cause 24
Femoral tunnel placement 20
Collateral ligament laxity 7
Combined femoral and tibial tunnel placement 6
Tibia tunnel placement 6
Tunnel widening 3
Other cause 5
168 Knee Surg Sports Traumatol Arthrosc (2012) 20:166172
1 3
recreation sub-score than patients with isolated sagittal
laxity. At follow-up, a tendency toward higher KOOS
scores but no signicant differences in the various sub-
scores was found for patients with isolated ACL revision.
Overall, 2/3 of the patients (63%) stated that they were
satised or very satised with the outcome of the ACL
revision and 74% stated that they would have the procedure
again now that they knew the outcome. Pain score mean
values are seen in Table 2. The mean values are relatively
low, between 2 and 3. Fifty percent of patients were at rest
and 43% completely pain free after 15 min of walking.
Complications and failures
The primary event indicating failure is re-revision of the
ACL. Seven patients (6%) required re-ACL revision. The
interval between ACL revision and re-ACL revision was
between 2.3 and 8.4 years. Including re-ACL revision, a
total of 30% of patients had one or more reoperations.
Other causes for reoperation were: meniscus injury
(13 patients/10%), arthrobrosis (2 patients/1.6%), deep
infection (2 patients/1.6%), and supercial infection
(1 patient/0.8%); 2 patients had total knee arthroplasty due
to severe chronic pain. Another cause for reoperation was
hardware removal in 12% of patients. A severely low score
(below 44 points) in the KOOS quality of life subscale was
found in 31% of patients.
Discussion
The most important nding of the present study was that
outcome after ACL revision is less favorable than after
primary ACL, based on less improvement in patient-related
outcome scores, and higher reoperation rates. These key
ndings emphasize the need for proper counseling of
patients before consenting to undergo an ACL revision
procedure.
Table 2 Patient-related
outcome results
Tegner score, SANE score and
pain scores is presented as
median and range in brackets
All cases
N = 128
Isolated ACL revision
N = 99
ACL revision ? collateral
N = 29
Follow-up Follow-up Follow-up
SANE score 75 (40100) 75 (40100) 80 (4590)
Tegner score 4 (18) 4 (110) 4 (18)
Pain score (rest) 2 (18) 2 (18) 2 (16)
Pain score
(15 min walk)
2 (110) 2 (110) 2 (110)
Patient satisfaction
Very satised (%) 33 35 33
Satised (%) 31 30 38
Fair (%) 26 28 19
Unsatised (%) 10 7 10
Would have
procedure
again (%)
74 74 73
Fig. 1 KOOS proles of preoperative and follow-up conditions. a All
patients. b Patients with isolated ACL revision. c Patients with ACL
revision in combination with collateral ligament reconstruction. The
different sub-scores are PAIN, SYMPtoms, activities of daily living,
SPORTs and recreation and quality Of life. Asterisk indicated
P\0.05 for comparison within sub-score
Knee Surg Sports Traumatol Arthrosc (2012) 20:166172 169
1 3
Due to the scarcity of literature encompassing larger
clinical studies, a comparison of outcome data from the
present study to other studies is difcult. Most studies on
ACL revision are focused on a specic surgical technique
or graft choice [1, 2, 4, 5, 12, 18]. Few studies examine
results after the normal spectrum of ACL revision seen at a
specialized center. A recent review presented outcome data
from published retrospective studies where the patient
numbers ranged from 21 to 107 with failure rates from 6 to
24% after 56 years follow-up [11]. The majority of the
studies used specic techniques and graft choices and as
such did not investigate the typical array of surgical tech-
niques needed for ACL revision. The value of the present
study lies in its substantial patient cohort of 128 and the
typical spectrum of ACL reconstruction failure cases seen
at a specialized center combined with a midterm follow-up
median 6 years.
In contrast to the retrospective data mentioned above,
a cohort of prospectively followed patients with ACL
reconstruction and ACL revision procedures has been
established in a multicenter orthopedic outcome network in
the USA. Preliminary results from this network present a
cohort of 47 ACL revision patients followed for 2 years.
They demonstrate that reoperations were seen in 15% of
patients and of these, 5% were re-ACL revision. Subjective
outcome investigated by means of SF36 demonstrated
improvement only in the physical activity score and not in
mental health and vitality [23]. Another study derived from
a national registry for knee ligament reconstruction also
demonstrated less favorable results after 1 year follow-up
in 222 patients based on KOOS scores after ACL revision
compared to primary ACL reconstruction [15]. A case
series from a major university clinic in the USA with 25
ACL revision patients operated with allografts presented
data on patient satisfaction: In this study, 76% of patients
declared that they would have the ACL revision procedure
performed again compared to 74% in the present study
[10].
We performed a subgroup analysis by dividing the
patients into groups of either isolated ACL revision or in
combination with collateral ligament reconstructions. The
only difference between the two groups was a lower pre-
operative KOOS sports and recreation sub-score, which is
understandable against the background of a combined lig-
ament insufciency. The various follow-up outcome scores
between the two groups did not differ.
The KOOS score has recently gained increasing popu-
larity for the evaluation of patient-related outcome after
ACL reconstruction [3, 6, 15]. However, of the ve sub-
scales in the KOOS score, the subscale for activity of daily
living is particularly unresponsive in terms of ACL
reconstruction treatment. This has necessitated modica-
tions of the score in order to adapt a measure specically
for ACL reconstruction patients. A recent study investi-
gating conservative treatment after ACL injury devised a
measure called KOOS
4
that is calculated as the average
score of KOOS pain, symptoms, sports and quality of life
subscales [3]. Another problem with patient-related out-
come measures in ACL patients is a poor correlation to
functional parameters such leg strength, hop test and
objective knee laxity [17].
An inter-study comparison of subjective outcome
measures is always challenging. By using the overall
improvement in responsive KOOS sub-scores (KOOS
4
),
the following impact of primary ACL reconstruction and
ACL revision has been demonstrated: In the Danish ACL
registry, the KOOS
4
improved 25 points for primary
ACL reconstruction and 13 points for ACL revision [15];
in the recent ACL level 1 study by Frobell et al. [3],
KOOS
4
improved 39 points for the ACL reconstruction
group. These data must be compared to a KOOS
4
improvement of only 8 points in the present study. These
data indicate that the impact on subjective outcome of
ACL revision is only about half that of primary ACL
reconstruction.
A recent French multicenter study investigating
descriptive data of ACL revision in 293 patients demon-
strated that the main causes for ACL graft failure were
femoral tunnel position (36%), new trauma (30%), and
unknown cause (15%). The present study found the same
three main revision causes [21]. The same study showed a
cumulative meniscus lesion incidence of 70% after
2.5 years follow-up after ACL revision. They demonstrated
that meniscectomy negatively inuenced both functional
outcome and knee stability. This accumulated incidence of
meniscus and cartilage injuries in ACL revision patients is
a likely cause of poorer clinical outcome after ACL revi-
sion as compared to primary ACL reconstruction. The use
of allografts for primary ACL reconstruction has been
demonstrated as a risk factor for revision. In a study by
Mehta et al. [16], the use of allograft resulted in a tenfold
increase in revision rates within the rst 4 postoperative
years.
The risk of re-revision in the present study was found to
be 6% after a median 6 years follow-up. This is a higher
risk compared to the revision risk after primary ACL
reconstruction. The 5-year incidence following primary
ACL reconstruction has recently been shown to be in the
range of 34% in national register studies (unpublished
data). Preliminary data from the MOON cohort at 2 years
follow-up demonstrated a reoperation risk of 15%, of
which 2.5% were re-revisions [23]. However, the latter
prospective cohort was limited to 39 patients making the
statistical background for re-revision rate potentially weak.
In the present study, no patients had ACL revision before
the 2 years follow-up.
170 Knee Surg Sports Traumatol Arthrosc (2012) 20:166172
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The present study is primarily limited by its design as a
retrospective study. Another weakness is the follow-up
completeness, which is limited by the fact that patients
typically were referred to our clinic from the entire country
and therefore living so far away that traveling to a follow-
up visit was unacceptable. We did, however, gather follow-
up data on some of these patients by means of telephone
interview and mail correspondence in order to obtain
patient-related outcome scores. The patients included in
this study were surgically treated by four different sur-
geons, which could potentially add bias due to different
surgical strategies choices on the part of the individual
surgeon. However, the results are more likely to represent
the general outcome after ACL revision performed by
multiple surgeons. Similarly, patients with a wide age
range were included, which can also introduce bias but at
the same time, this wide age range also represents the
typical clinical scenario for ACL revision cases. Our sub-
group analysis results in smaller study groups thus limiting
the power of analysis. The results from the subgroup
analysis should therefore be evaluated cautiously. For a
single institution study, our case series, with follow-up data
from 128 patients, is large, which increases the validity and
interest of the presented data. Even though the present
study is a single-center study, ACL revision was performed
by means of a variety of techniques and multiple graft
choices, all chosen by several surgeons. We therefore
consider that our material represents the ACL revision
patient population to an acceptable degree.
As improvements in subjective clinical outcome fol-
lowing revision ACL reconstruction are limited despite
achievement of acceptable knee stability, patients should
be carefully counseled before undergoing revision ACL
surgery.
Conclusion
Results from this study on ACL revision demonstrate
limited improvement in patient-related outcome scores
compared to studies on primary ACL reconstruction. The
total reoperation rate of 30%, 6% of which was re-ACL
revision, is relatively high. It is imperative that patients
eligible for ACL revision receive proper counseling in
terms of outcome expectancies.
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