Outcomes After 1-Stage Versus 2-Stage Revision Anterior Cruciate Ligament Reconstruction

Mitchell, Justin J.; Chahla, Jorge; Dean, Chase S.; Cinque, Mark E.; Matheny, Lauren M.; LaPrade, Robert F.

doi:10.1177/0363546517698684

Cited by 52 publications

(86 citation statements)

References 35 publications

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“…One interesting point to mention is that in 4 patients, new cartilage and/or meniscus lesions developed that required treatment between the firstand second-stage procedures. This finding is consistent with the observations of Mitchell et al 32,33 and confirms the indication of revision ACLR in patients who are young and engage in sports. The choice of a 1-or 2-stage procedure depends on several different factors.…”

Section: Discussionsupporting

confidence: 92%

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Autologous Bone Graft Versus Silicate-Substituted Calcium Phosphate in the Treatment of Tunnel Defects in 2-Stage Revision Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized Controlled Study With a Minimum Follow-up of 2 Years

Recum

Gehm

Guehring³

et al. 2020

Arthroscopy: The Journal of Arthroscopic & Related Surgery

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Purpose: To compare and evaluate knee laxity and functional outcomes between autologous bone graft and silicatesubstituted calcium phosphate (Si-CaP) in the treatment of tunnel defects in 2-stage revision anterior cruciate ligament reconstruction (ACLR). Methods: This prospective, randomized controlled trial was conducted between 2012 and 2015 with a total of 40 patients who underwent 2-stage revision ACLR. The tunnels were filled with autologous iliac crest cancellous bone graft in 20 patients (control group) and with Si-CaP in the other 20 patients (intervention group). After a minimum follow-up period of 2 years, functional outcomes were assessed by KT-1000 arthrometry (side-to-side [STS] difference), the Tegner score, the Lysholm score, and the International Knee Documentation Committee score. Results: A total of 37 patients (follow-up rate, 92.5%) with an average age of 31 years were followed up for 3.4 years (range, 2.2-5.5 years). The KT-1000 measurement did not show any STS difference between the bone graft group (0.9 AE 1.5 mm) and the Si-CaP group (0.7 AE 2.0 mm) (P ¼ .731). One patient in the intervention group (5%) had an STS difference greater than 5 mm. Both groups showed significant improvements in the Tegner score, Lysholm score, and International Knee Documentation Committee score from preoperative assessment to final follow-up (P .002), without any difference between the 2 groups (P ! .396). Complications requiring revision occurred in 4 control patients (22%) and in 2 patients in the intervention group (11%) (P ¼ .660). No complications in relation to Si-CaP were observed. Conclusions: Equivalent knee laxity and clinical function outcomes were noted 3 years after surgery in both groups of patients. Si-CaP bone substitute is therefore a safe alternative to autologous bone graft for 2-stage ACLR. Level of Evidence: Level I, prospective, randomized controlled clinical trial. See commentary on page 186 R upture of the anterior cruciate ligament (ACL) is one of the most common knee injuries, and a marked increase in anterior cruciate ligament reconstructions (ACLRs) has occurred over the past 20 years. 1,2 Because of the rise in operations, the number of revision procedures is also increasing

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Section: Discussionsupporting

confidence: 92%

“…It also needs to be taken into account that the outcomes of 2-stage revision ACLR are inferior to those of 1-stage revision ACLR. Mitchell et al 32 compared the outcomes after 1-and 2-stage ACL revision surgery. They were able to show that the outcomes of 2-stage ACL revision surgery are inferior to those of 1-stage revision.…”

Section: Discussionmentioning

confidence: 99%

Autologous Bone Graft Versus Silicate-Substituted Calcium Phosphate in the Treatment of Tunnel Defects in 2-Stage Revision Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized Controlled Study With a Minimum Follow-up of 2 Years

Recum

Gehm

Guehring³

et al. 2020

Arthroscopy: The Journal of Arthroscopic & Related Surgery

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“…6,27 A recent study by Mitchell et al, however, showed no difference in subjective outcomes between patients treated with a one or a two-stage revision ACL reconstruction. 28 The fact that in this study, no difference was observed in chondral status in between the two stages, also advocates against chondral lesions as a potential driver for inferior subjective results in two-stage revision ACL reconstruction.…”

Section: Discussionmentioning

confidence: 55%

The Occurrence of Meniscal and Chondral Injury in Two-Stage Revision Anterior Cruciate Ligament Reconstruction: A Consecutive Case Series

et al. 2019

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Two-stage revision anterior cruciate ligament (ACL) reconstruction is an effective way to revise suboptimal tunnel-placement allowing for proper graft fixation. However, prolonged increased laxity of the knee may increase the risk of meniscal or chondral injury. It was hypothesized that no additional meniscal or chondral lesions occur in between the two stages of the two-stage revision ACL reconstruction. In this retrospective study, 42 patients undergoing a two-stage revision ACL reconstruction were included. Surgical notes for both stages were screened for meniscal and chondral status, interventions to any concurrent injury, surgery dates, along with basic patient characteristics. In 4 of the 42 patients, a new meniscal tear occurred in between the two stages, of which three required partial meniscectomy during the second stage of the ACL revision. One patient experienced a new small degenerative tear that did not require intervention. Two out of the four menisci that were repaired during the first stage had failed and required partial meniscectomy. No significant difference was found in the time between the two stages with respect to the occurrence of meniscal tears. No significant differences in chondral status were found. In conclusion, approximately 10% of patients developed a new meniscal tear and no difference in macroscopic chondral injury was observed between the first and second stages.

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“…35 However, no differences exist between one-and two-stage revision ACL procedures across the 12-Item Short Form Health Survey, Mental and Physical Component Summaries, Western Ontario and McMaster Universities Arthritis Index (WOMAC), Lysholm and Tegner active scale scores, or failure rates. 39 Although onestage approaches are presumably the result of a shared decision-making approach with the patient to limit operative time, and both the rehabilitation interval and risks of two surgical procedures, the fact that no difference exists between the staged approaches questions whether the risks of two separate procedures are more theoretical rather than a real clinical concern. Thus, in the absence of a "gold standard" revision operation, REVISE respects this variability while still guiding practice.…”

Section: Discussionmentioning

confidence: 99%

The REVision Using Imaging to Guide Staging and Evaluation (REVISE) in ACL Reconstruction Classification

Crum

Rabuck

et al. 2019

J Knee Surg

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Revision anterior cruciate ligament (ACL) procedures are increasing in incidence and possess markedly inferior clinical outcomes (76% satisfaction) and return-to-sports (57%) rates than their primary counterparts. Given their complexity, a universal language is required to identify and communicate the technical challenges faced with revision procedures and guide treatment strategies. The proposed REVision using Imaging to guide Staging and Evaluation (REVISE) ACL (anterior cruciate ligament) Classification can serve as a foundation for this universal language that is feasible and practical with acceptable inter-rater agreement. A focus group of sports medicine fellowship-trained orthopaedic surgeons was assembled to develop a classification to assess femoral/tibial tunnel “usability” (placement, widening, overlap) and guide the revision reconstruction strategy (one-stage vs. two-stage) post–failed ACL reconstruction. Twelve board-certified sports medicine orthopaedic surgeons independently applied the classification to the de-identified computed tomographic (CT) scan data of 10 patients, randomly selected, who failed ACL reconstruction. An interclass correlation coefficient (ICC) was calculated (with 95% confidence intervals) to assess agreement among reviewers concerning the three major classifications of the proposed system. Across surgeons, and on an individual patient basis, there was high internal validity and observed agreement on treatment strategy (one-stage vs. two-stage revision). Reliability testing of the classification using CT scan data demonstrated an ICC (95% confidence interval) of 0.92 (0.80–0.98) suggesting “substantial” agreement between the surgeons across all patients for all elements of the classification. The proposed REVISE ACL Classification, which employs CT scan analysis to both identify technical issues and guide revision ACL treatment strategy (one- or two-stage), constitutes a feasible and practical system with high internal validity, high observed agreement, and substantial inter-rater agreement. Adoption of this classification, both clinically and in research, will help provide a universal language for orthopaedic surgeons to discuss these complex clinical presentations and help standardize an approach to diagnosis and treatment to improve patient outcomes. The Level of Evidence for this study is 3.

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Outcomes After 1-Stage Versus 2-Stage Revision Anterior Cruciate Ligament Reconstruction

Cited by 52 publications

References 35 publications

Autologous Bone Graft Versus Silicate-Substituted Calcium Phosphate in the Treatment of Tunnel Defects in 2-Stage Revision Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized Controlled Study With a Minimum Follow-up of 2 Years

Autologous Bone Graft Versus Silicate-Substituted Calcium Phosphate in the Treatment of Tunnel Defects in 2-Stage Revision Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized Controlled Study With a Minimum Follow-up of 2 Years

The Occurrence of Meniscal and Chondral Injury in Two-Stage Revision Anterior Cruciate Ligament Reconstruction: A Consecutive Case Series

The REVision Using Imaging to Guide Staging and Evaluation (REVISE) in ACL Reconstruction Classification

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