Surgical Treatment of Combined ACL Medial and Lateral Side Injuries: Acute and Chronic
12.14 Conclusion
The principles of surgical management of the multiple-ligament-injured knee include identi fi cation and treatment of all pathology, including meniscal and articular surface injuries, as well as the collateral, capsular, and cruciate ligaments involved. Anatomic graft insertion, combined with secure graft fi xation and an individualized postoperative rehabilitation program, provides for the most stable postoperative function. Preoperative planning, including the timing of surgery, vascu- lar status of the involved limb, soft tissue viability, and injuries to other organ systems must be considered during an indi- vidual’s treatment algorithm.
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Injuries to the anterior cruciate ligament (ACL) are common in the athletically active population. This population of patients has increased dramatically in the last 30 years. Since the enactment of Title IX, male participation at the high school level has remained constant, while female participation has increased approximately tenfold (from 0.3 to 3.2 million) [ 1 ] . High school and collegiate athletics contributes to >50,000 ACL injuries in female athletes each year. Studies have shown that adolescents are participating in competitive sports at a much younger age with constant year-round competitive practice, game sessions, and tournament events which signi fi cantly increase the exposure risk of that knee. Our baby boomer popula- tion continues to remain quite athletically active into their sixties and seventies. In fact, ACL reconstruction has become one of the most common procedures performed by orthopedic surgeons today. Over the past several decades the number of ACL reconstructions performed every year has steadily increased. It is estimated that over 250,000 ACL injuries occur every year in the USA with a correspondingly high number of reconstructions performed. Data from the American Board of Orthopaedic Surgery part II oral exam seems to suggest that the majority of these surgeries are performed by surgeons who perform <20 per year. Of additional concern is that less than 20% of patients undergoing ACL reconstruction have a meniscus repair performed when we know that the incidence of meniscal pathology approaches 60%. It is clearly possible that menisci are being excised that have the potential to be saved with current meniscal repair techniques.
Primary ACL reconstruction has been shown to be quite successful in restoring knee stability and function in the majority of patients. Although our ability to diagnose, reconstruct, and rehab these patients has led to a better understanding of the natural history and functional consequences of an ACL-de fi cient knee, there still remains considerable room for improvement if we look critically at our outcomes. While we have greatly improved with our ability for the ACL-injured athlete to return to the fi eld after primary ACL reconstruction in the majority of cases, unfortunately only a minority of them truly return to their previous level of performance. Evidence indicates that normal function of the knee, as de fi ned by the IKDC guidelines, may only be restored in approximately 40% of patients. Of more concern is that, in some studies, up to 90% of individuals undergoing primary ACL reconstruction have radiographic evidence of osteoarthritis within 7 years of primary surgery. The current way we evaluate our results may be outdated and not nearly sensitive enough to determine if a reconstruction is truly a success long term.
One must question our short-term versus long-term goals of treatment: early return to the playing fi eld versus long-term devel- opment of irreversible osteoarthritis. Our physical exam skills that enable us to objectively evaluate anterolateral rotational laxity in the of fi ce are nonsensitive, nonspeci fi c, unreliable, and not validated as an objective measurement tool. While the majority of ACL reconstructions may have a good endpoint on a Lachman or anterior drawer, there is no reliable way to measure rotational stability in the of fi ce/laboratory with any reproducible objectivity. If a “success” is determined only by a good end- point on a Lachman or drawer testing, we are not being honest with ourselves or our patients. The primary reason to reconstruct the ACL is to eliminate the pivot shift or anterolateral patholaxity.
A failed ACL reconstruction needs to be clearly de fi ned. Not all ACL failures present with the same symptoms or complaints to the of fi ce. Most would agree that a reconstructed knee that demonstrates recurrent instability or a stable knee with signi fi cant loss of motion after surgery limiting functional activity may be considered an objective clinical failure [ 2 ] .
Revision ACL-Based Multiple Ligament Knee Surgery
Seth A. Cheatham and Darren L. Johnson
S. A. Cheatham , M.D.
Orthopaedic Surgery , Virginia Commonwealth University Medical Center , 1800 W. Borad Street , Richmond , VA 23284 , USA e-mail: scheatham@mcvh-vcu.edu
D. L. Johnson , M.D. (*)
Orthopaedic Surgery , University of Kentucky , 740 S. Limestone, Suite K415 , Lexington , KY 40536 , USA e-mail: dljohns@email.uky.edu
G.C. Fanelli (ed.), The Multiple Ligament Injured Knee: A Practical Guide to Management, DOI 10.1007/978-0-387-49289-6_13, © Springer Science+Business Media New York 2013
Some may also argue that persistent, chronic pain that prevents return to activities following reconstruction may also be classi fi ed as a failure. On the other hand, there can also be a subjective sense of surgical failure by the patient. The highly competitive athlete who competes at an elite level that does not return to competitive sports at the same level in terms of intensity, frequency, and performance may be unhappy with their surgical result. Although the physical exam performed in the of fi ce may not detect any obvious objective failure signs or symptoms, it is a subjective failure to the patient because their knee does not perform at the level they were at prior to their injury. The absence of a universally accepted de fi nition of ACL reconstruction failure makes it dif fi cult to calculate the true number or incidence of failures. Unsuccessful results from ACL reconstruction have ranged from 3 to 52% in the literature depending on the criteria used to de fi ne failure [ 2– 4 ] . There are numerous reasons why ACL reconstructions fail but are generally placed into one of four categories: (1) recurrent patho- laxity or instability, (2) loss of motion or arthro fi brosis, (3) persistent pain, and (4) extensor mechanism dysfunction. We will focus our discussion to ACL failure due to recurrent patholaxity secondary to missed capsular and ligamentous injuries and how to best address these surgically.
ACL injuries frequently occur concurrently with other capsular and ligamentous injuries. A truly isolated ACL injury is extremely uncommon. Failure to recognize and appropriately address associated injuries to the secondary and tertiary restraints to anterior tibial translation as well as pathologic rotatory laxity may subject the primary ACL graft to excessive tensile forces and result in early failure. This usually occurs relatively early after primary ACL reconstruction because of the large nonphysiologic forces the graft must absorb. The pathologic forces that the graft experiences early in the incorporation phase have a detrimental effect on collagen incorporation and ultimate strength of the graft. Posterolateral instability is the most commonly unrecognized concurrent de fi ciency and has been reported to be present in 10% to 15% of chronically ACL-de fi cient knees [ 5 ] . The medial collateral ligament (MCL), posterior horn of the medial meniscus, and posterior capsule/posterior oblique ligament (POL) also provide secondary stability in the ACL-de fi cient knee and must be carefully assessed for injury [ 6 ] . This only emphasizes the importance of a thorough exam under anesthesia. One must correct these concurrent instability patterns at the time of revision surgery for another failure not to occur.