Outcomes of 1- Versus 2-Stage Revision Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

Abstract

Background: Anterior cruciate ligament reconstruction (ACLR) is a common orthopaedic sports medicine procedure, but graft failure is not uncommon and often leads to revision ACLR. Revision surgery can be performed in a 1- or 2-stage fashion. Hypothesis: Graft failure risk, patient-reported outcomes, and anterior knee laxity are similar after 1- and 2-stage revision ACLR. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of the literature was performed to evaluate patient outcomes after 1- versus 2-stage revision ACLR. A search was performed with the phrase “revision anterior cruciate ligament reconstruction” across Embase, PubMed, Scopus, and SportDiscus from the beginning of their archives through July 12, 2019. Results: Thirteen studies met inclusion criteria and included 524 patients: 319 patients who underwent 1-stage revision ACLR and 205 patients who underwent 2-stage revision ACLR. Two studies compared outcomes of 1- versus 2-stage revision ACLR; 4 studies reported outcomes after 2-stage revision ACLR; and the remaining 7 studies documented outcomes after 1-stage ACLR. The mean follow-up was 4.1 years. The 2 studies that compared 1- versus 2-stage ACLR reported no differences in functional, radiologic, or patient-reported outcomes or failure risk. Overall, 9 studies reported subjective International Knee Documentation Committee (IKDC) scores; 4 studies, Knee injury and Osteoarthritis Outcome Score values; 8 studies, Lysholm scores; and 7 studies, Tegner scores; 8 studies measured anterior laxity with a KT-1000 arthrometer. The mean weighted subjective IKDC score for all studies including this outcome at final follow-up was 66.6 for 1-stage revisions and 65.9 for 2-stage revisions. Conclusion: The available evidence comparing 1- versus 2-stage revision ACLR is retrospective and limited. The results of each approach are similar in appropriately selected patients.

Influence of Preoperative Tunnel Widening On the Outcomes of a Single Stage–Only Approach to Every Revision Anterior Cruciate Ligament Reconstruction: An Analysis of 409 Consecutive Patients From the SANTI Study Group

“…These findings are consistent with a recent meta-analysis that demonstrated no difference in outcomes between 1- and 2-stage R-ACLR. 5 The authors reported that indications for 2-stage surgery based on tunnel size were debatable and that they may be influenced by graft choice and surgical technique.…”

“…A particular strength of the current study is the inclusion of a large series of consecutive patients treated with a single stage–only approach to every R-ACLR, regardless of the presence of tunnel widening. In the meta-analysis from Colatruglio et al, 5 the second graft rupture rate after R-ACLR varied in the included studies from 2% to 10.3%. However, 13 of the 15 studies included ≤50 patients, and follow-up ranged from 1 to 7.9 years.…”

“…Despite that, the authors of 2 recent systematic reviews (including only case series and no comparative studies) reported that clinical outcomes of both approaches are comparable and that there was no significant difference in subsequent revision rates. 5,21 This is an important finding because if there is no major difference in outcomes, then it seems logical to avoid the associated increased morbidity (2 procedures), longer period of knee instability before definitive reconstruction (risking further meniscal and cartilage injuries), longer overall rehabilitation, and greater economic and societal costs associated with 2-stage surgery. 7,9,32,36 The main purpose of this study was to evaluate the clinical outcomes of a single stage-only approach to R-ACLR using an outside-in technique.…”

Outside-In Drilling Allows Avoidance of Two-Stage Surgery in Revision Anterior Cruciate Ligament Reconstruction

“…Clinical outcomes of 1- and 2-stage R-ACLR are not significantly different with respect to subsequent revision rates according to 2 recent systematic reviews. 5 , 6 It therefore seems logical to avoid a 2-stage procedure whenever possible so that the associated increased morbidity of 2 procedures, a prolonged period of knee instability (before definitive surgery), multiple periods of rehabilitation, and increased health care and societal cost also can be avoided.…”

Revision Anterior Cruciate Ligament Reconstruction: Tibial Tunnel-First Graft-Sizing Technique

“…This decision is contingent on the degree of malalignment, graft size, and surrounding pathology of the original tunnel. [20][21][22] Since outcomes are not significantly different between single-and 2-staged procedures, a single-stage approach is preferable due to the faster recovery and fewer operations. 17,23 In cases in which tunnel positioning is satisfactory, reusing the same tunnel is sufficient if patent and sized correctly for the new graft.…”