Between 2020 and 2022, 15 patients with graft failure after primary ACLR and high-grade anterior knee instability who underwent revision ACLR and modified Lemaire extra-articular tenodesis with soft anchors were included in the retrospective study.
Demographic data are shown in Table 1.
All primary ACLR procedures were performed in different hospitals using autografts (10 hamstring and 5 bone-patellar tendon-bone grafts). Four patients underwent meniscectomy or partial meniscectomy at the time of primary procedure, and one patient had chondral damage treated with shaving. No lower-limb malalignment was observed.
Patient selection
Between 2020 and 2022, fifteen consecutive patients underwent revision ACLR of a previously reconstructed ACL with a concomitant modified Lemaire tenodesis with soft anchors.
All primary ACLRs were performed in other hospitals.
The inclusion criteria were as follows: (1) failed primary ACLR, confirmed by recurrence of giving way episodes as revealed by a side-to-side difference of more than seven millimetres in the Rolimeter® test and a pivot shift graded as 2+ or 3+; and (2) complete or almost complete range of motion (ROM, with only a minimum flexion loss being accepted). The exclusion criteria were as follows: (1) concomitant posterior cruciate ligament injury; (2) contralateral instability or previous ACL reconstruction; (3) severe chondral damage (grade 3 or 4 according to the Outerbridge classification system); and (4) degenerative arthritis (Fairbank grade 3 or 4).[1]
All patients underwent a preoperative evaluation at least 18 months after primary ACL reconstruction. Clinical examination included functional scoring systems by
Tegner and Lysholm [20], functional knee scores and International Knee Documentation Committee (IKDC) subjective and objective scores.
For accurate preoperative planning, all patients underwent a standing radiographic examination to determine tunnel position and orientation, tunnel expansion and early degenerative changes in the knee.
The study conformed to the ethical guidelines outlined in the 1996 Declaration of Helsinki and was approved by Comitato Etico ASL Lecce.
Surgical technique
An arthroscopically assisted two-incision procedure with ipsilateral or contralateral doubled semitendinosus and gracilis tendon grafts was used in all patients. The graft was fixed on the femur
with an adjustable loop suspensory fixation device (Arthrex, Naples, FL) and on the tibia with a bioscrew device (Arthrex, Naples, FL).
As described by the outside-in technique, the femoral tunnel was selected as the entry point in the center of the anatomic femoral footprint of the ACL. With a second incision and a RetroDrill reamer, a new femoral tunnel with a different orientation was created in a previously undrilled area of the femoral condyle. With this technique, any conflict with the existing femoral tunnel or previously used fixation devices was avoided. In ten patients, the tibial tunnel from the primary ACLR procedure was correctly placed and could therefore be reused in the revision surgery after accurate redrilling. In five other cases, a new tunnel was drilled with no or only partial convergence with the previous tunnel. It was not necessary to remove any previously used tibial fixation devices from any patients.
A modified Lemaire procedure was performed in all cases. A six centimeter skin incision was made over the lateral epicondyle. Then, a six- to eight-centimeter-long and 1-cm-wide strip of the distal tractus of the iliotibial band (ITB) was dissected and connected with the Gerdy tubercle. The proximal end of the strip was sutured with a nonresorbable 0 Ethibond suture and passed under the lateral collateral ligament.
The insertion point proximal and posterior to the lateral epicondyle was identified, and a 2.6 mm knotless suture anchor (2.6 FiberTak, Arthrex) was used. Importantly, the drilling angle was altered to avoid tunnel convergence, more commonly anteriorly and proximally. The prepared strip was then passed through the loop from the suture anchor and fixed at 20° of flexion, while avoiding fixation of the tibia in external rotation. In all cases, the fixation device of the modified Lemaire provided secure, strong and stiff mechanical fixation.
Rehabilitation protocol
Postoperative rehabilitation consisted of brace-free, immediate full weight bearing and progressive ROM exercises. Early rehabilitation focused on maintaining full extension and performing quadriceps activation exercises. Jumping and treadmill running was allowed at 3 months. Return to sports was allowed at 6 months for nonpivoting sports, 8 months for pivoting noncontact sports, and a minimum of 9 months for pivoting contact sports.
Follow-up
All 15 patients were available for review at a minimum follow-up of 2 years (mean 2.4). The activity level was assessed with reference to the Tegner scale. The subjective functional status was evaluated using the Lysholm score [20] and the IKDC 2000 score [4].
All patients underwent a standard bilateral knee examination. Knee stability was assessed with a Lachman test, a pivot-shift test and a Rolimeter® arthrometric test. Knee examination was classified according to the IKDC 2000 objective evaluation scale.
Standing radiographs were obtained from all patients (AP, PA view at 45 degrees weight bearing and lateral view with monopodalic support). Radiographs were evaluated using the IKDC [4], Fairbank, and Kellgren and Lawrence [10] scales to determine the grade of osteoarthritis and to evaluate the presence of tunnel convergence.[2]
Statistical analysis
A descriptive analysis of all variables of interest was performed.
All data were analyzed using a paired t test and a v2 test to determine significant differences between preoperative and follow-up data. The level of significance was set at p< 0.05.
[3] To evaluate the primary study outcomes (laxity, subjective scores), the power to detect a difference between mean preoperative and follow-up scores was determined. With 15 knees in this study, it was found that this investigation had sufficient power (90%) to detect differences of 4.7 mm 6between the mean preoperative and follow-up values for the Rolimeter® arthrometric test and 28 points between the mean preoperative and follow-up values for patient satisfaction at a significance level of < 0.05.
Statistical analysis was performed using SPSS 9.0 software.