[Arthroscopy-assisted revision in failed reconstruction of anterior cruciate ligament: 32 cases]

The aim of this retrospective study was to analyze mid-term outcome after anterior cruciate ligament (ACL) revision performed arthroscopically with a patellar tendon graft.

The series included 32 revision arthroscopies for ligamentoplasties of the ACL performed after primary intraarticular plasty. Outcome was assessed using the IKDC score at least 2 years after revision surgery. A free patellar autograft was used in all cases in association with an anterolateral plasty in 9 cases using the Marshal-MacIntosh technique. There were 25 men, mean age 28.5 years. Mean follow-up was 4 years. The initial plasty was done with a synthetic ligament in 15 cases and an autograft in 17, including 12 patellar tendons. In 3 cases, the revision was needed for synovitis involving the synthetic ligament. In all the other cases, revision was indicated for instability, most of the failures resulting from a defective femoral position (particularly for autografts) or renewed trauma.

Among the 23 patients who were initially competition-level athletes, 18 recovered their sports activity, 8 at an equivalent level. At last follow-up, the IKDC global scores were: A 5 patients (15.6%), B 16 patients (50%), C 8 patients (25%), D 3 patients (9.4%). Certain residual laxity was present in 3 cases (C and D laxity score for 2 of them). A tibiofemoral narrowing was present in the medial compartment in one patient alone. Factors of poor prognosis for the IKDC score were: long delay from accident to initial treatment (p=0.04), associated medial meniscectomy (p=0.02). Presence of an initial femoral tunnel had no effect on revision due to its very anterior situation.

The technical difficulty of revision of an intra-articular ligamentoplasty of the ACL is to position the new transplant so it will satisfy the same requirements as the initial plasty. This position depends particularly on the femoral component due to the importance of the position of the initial femoral tunnel and the degree of bone loss (osetolysis, ablation of an interfering screw.). The homolateral patellar tendon was used for the graft in all cases except one and iterative use of the patellar tendon for grafting did not cause supplementary morbidity. The patellar tendon remains the transplant of choice for ligament reconstruction. Meniscectomy had a deleterious effect on the final outcome. As for first intention plasty, the therapeutic strategy should preserve as much meniscal stock as possible, depending on the type and degree of damage.

Revision ACL plasty can provide good anatomic results although functional outcome is less satisfactory than after primary intention ligamentoplasty. A precise clinical and radiographic analysis of the cause of failure of the primary plasty must be obtained in order to establish a surgical strategy allowing the most clinically effective plasty with well positioned bone tunnels.