Surgical Treatment of Combined ACL Medial and Lateral Side Injuries: Acute and Chronic
13.17 Summary
As the number of primary ACL reconstructions continue to increase, so too does the number of failures. Failure of an ACL reconstruction may be attributed to a multitude of factors. Recurrent patholaxity, loss of motion, graft failures, persistent pain, and extensor mechanism dysfunction are all reasons why patients return to the of fi ce unsatis fi ed with their reconstruc- tion. Understanding the exact etiology of failure is the fi rst and most important step if a successful revision surgery is to be attempted.
Fig. 13.5 Reconstruction of a chronic PMC injury with the use of two allografts to recreate the POL and MCL
The current literature suggests that only approximately 60% of patients are able to return to sports following single-bundle ACL revision surgery [ 37 ] . Many of these patients that do return are not able to perform at the same level, frequency, or duration they were at before their injury. Of even greater concern is that >50% of patients have early radiographic signs of degenerative arthritis as early as 5 years after primary ACL surgery. We believe that use of nonanatomic principles combined with unrecognized laxity of secondary restraints is the primary reason that this occurs. Not all medial-sided knee injuries heal with nonoperative management. Furthermore, unrecognized PLC injuries remain one of the more common reasons why ACL reconstructions fail. Failure to address the PMC or a missed PLC injury may be a cause of residual laxity or failure of an associated ACL reconstruction.
While addressing missed injuries to secondary restraints, it is our contention that use of the anatomic double-bundle ACL techniques and principles in revision surgery will improve knee kinematics and therefore improve overall outcome. It is also possible that by restoring native ACL anatomy the incidence of post-ACL reconstruction degenerative changes may decrease although long-term data is needed to support this claim. During the past 3 years, the senior author has revised over 100 ACLs in the manner described here, with no functional failures due to stiffness, no episodes of fracture or fi xation loss, and only two requiring a staged procedure. Our short-term functional results using anatomic double-bundle techniques in revision situations have been encouraging in terms of patient satisfaction and ability to return to preinjury level of activity while formal evaluation is in progress.
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