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Graft Failures and Results of ACL Revision Surgery

With the increased number of athletes of all ages, there has been a steady rise in the number of anterior cruciate ligament (ACL) injuries. Surgery to repair the damage involves the use of graft materials to replace the ligament. Despite improved surgical technique, 25 per cent of the grafts fail.

In this study, surgeons from Germany investigate the reasons for graft failure. They present the mid- to long-term results of ACL revision surgery using autografts. An autograft refers to tissue taken from some other part of the patient's body. The harvested tissue is used to replace the torn ligament. The most common autografts for ACL repair are from the patellar tendon or the hamstrings tendon.

The authors describe their graft technique. Holes are drilled in the bone to create a tunnel through which the graft is inserted. Graft fixation was done using sutures but without any hardware (screws, wires, or metal plates).

Simple to more complex revision methods are discussed. The extent of surgery depended on the condition of the cartilage and meniscus. Malposition of the tunnel from the first surgery was a major reason for graft failure requiring correction.

Outcomes were measured using physical and radiographic examinations. Several tests of function, range of motion, and strength were also used. The surgeons made note of the timing of the revision surgery (e.g., within first 12 months after ACL repair). Any signs of joint degeneration or arthritic changes were also recorded. Everyone was followed for at least three years.

The authors report ACL revision surgery was able to provide function and stability to most of the patients in the study. The most common causes of failure included tunnel malposition, reinjury, and use of a synthetic graft.

Most of the patients reported improved quality of life after ACL revision surgery. Even so, two-thirds did not return to their preinjury level of activity. This was due in part to the fact that many of the patients were older (30 to 50 years old). They chose not to return to a higher level of activity.

X-ray results also showed signs of progressive osteoarthritis for nearly 80 per cent of the patients. This was compared to 40 per cent before the revision operation. The rate of osteoarthritis was less in patients who had early revision surgery. Early revision has better results because the knee cartilage is in better shape with less meniscus damage.

References: Andreas P. Diamantopoulos, MD, et al. Anterior Cruciate Ligament Revision Reconstruction. In The American Journal of Sports Medicine. May 2008. Vol. 36. No. 5. Pp. 851-860.

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