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Return to sports and functional results after revision anterior cruciate ligament reconstruction by fascia lata autograft
G Model OTSR-1571; No. of Pages 4
ARTICLE IN PRESS Orthopaedics & Traumatology: Surgery & Research xxx (2016) xxx–xxx
Available online at
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Original article
Return to sports and functional results after revision anterior cruciate ligament reconstruction by fascia lata autograft G. Mirouse a,∗ , R. Rousseau a , L. Casabianca a , M.A. Ettori a , B. Granger b , H. Pascal-Moussellard a , F. Khiami a a Département de Chirurgie Orthopédique et Traumatologie du Sport, Groupe Hospitalier Pitié-Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France b Département de Biostatistiques, de Santé Publique et d’Information Médicale, Groupe Hospitalier Pitié-Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
a r t i c l e
i n f o
Article history: Received 9 January 2016 Accepted 17 June 2016 Keywords: Anterior cruciate ligament Ligament reconstruction Revision surgery Fascia lata Return to sports
a b s t r a c t Introduction: The surgical revision rate following anterior cruciate ligament (ACL) surgery is 3% at 2 years and 4% at 5 years. Revision ACL surgery raises the question of the type of graft to be used. The present study assessed return to sports and functional results after revision ACL reconstruction by fascia lata graft. The hypothesis was that fascia lata provides a reliable graft in revision ACL surgery. Material and methods: A single-center retrospective continuous study included 30 sports players with a mean age of 26.8 ± 8 years undergoing surgical revision for iterative ACL tear between 2004 and 2013. Multi-ligament lesions were excluded. Type and level of sports activity were assessed preoperatively, after primary surgery and at end of follow-up. Clinical assessment used subjective IKDC, Lysholm and KOOS scores. Results: At a mean 4.6 ± 1.6 years’ follow-up, all patients had resumed sport activity, but only 12 with the same sport at the same level. Median subjective IKDC score increased from 57 [54.3; 58.5] preoperatively to 82 [68.3; 90] at last follow-up, and Lysholm score from 46 [42.3; 51] to 90.5 [80.8; 96.8]; KOOS score at last follow-up was 94.7 [83; 100]. Conclusion: Functional results in revision ACL reconstruction by fascia lata graft were satisfactory, with similar return-to-sports rates as with other techniques. Fascia lata provides a reliable graft in revision ACL surgery. Level of evidence: IV, retrospective study. © 2016 Elsevier Masson SAS. All rights reserved.
1. Introduction Anterior cruciate ligament (ACL) tear is frequent in sports players. First-line treatment most often uses hamstring or patellar tendon graft, with good functional results but an iterative tear rate of 3% at 2 years and 4% at 5 years [1,2]. Complications of reconstruction comprise recurrent instability, postoperative stiffness and pain that may prevent resumption of sport [3,4]. Return-to-sports rates following primary reconstruction range from 50% to 70% [5], and are even lower after revision reconstruction [6–14]. Revision ACL surgery may raise several problems, which should be analyzed preoperatively to avoid reproducing the causes of failure: management of existing material, bone-tunnels, cartilage and meniscal capital.
∗ Corresponding author. E-mail address: [email protected] (G. Mirouse).
There is no consensus on type of graft or surgical technique: hamstring, patella or quadriceps tendon or allograft may all be used [3–11]. Fascia lata autograft is an old technique, but which has been improved [15]; there have been several studies of its use in primary surgery but, to our knowledge, none in revision surgery. The present study assessed return to sports and functional results after revision ACL reconstruction by fascia lata autograft. The hypothesis was that fascia lata provides a reliable graft in revision ACL surgery.
2. Material and methods A single-center retrospective continuous series included all sport-playing patients aged 18–50 years operated on for isolated revision ACL reconstruction by fascia lata graft between 2004 and 2013.
http://dx.doi.org/10.1016/j.otsr.2016.06.017 1877-0568/© 2016 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Mirouse G, et al. Return to sports and functional results after revision anterior cruciate ligament reconstruction by fascia lata autograft. Orthop Traumatol Surg Res (2016), http://dx.doi.org/10.1016/j.otsr.2016.06.017
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Table 1 Clinical and pre-injury sports characteristics. Patient
Age
Gender
Graft
Reasons for revision
Sport
Pre-injury level
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
20 22 27 17 17 27 21 18 28 20 31 17 36 25 27 33 34 35 19 29 36 29 45 20 18 24 30 25 46 18
M M M M M M M F F M F F M F F F F F M F F F F F F F F F M F
ST-G ST-G ST-G ST-G ST-G + lat tenodesis Patella tendon ST-G ST-G Patella tendon ST-G ST-G ST-G ST-G Patella tendon Patella tendon Patella tendon ST-G Synthetic ligament cv ST-G Patella tendon ST-G ST-G ST-G ST-G ST-G + Lat Tenodesis Patella tendon ST-G ST-G ST-G ST-G+ Lat Tenodesis
Instability Repeat trauma Repeat trauma Repeat trauma Instability Pain Pain Instability Repeat trauma Repeat trauma Repeat trauma Repeat trauma Pain Instability Instability Repeat trauma Repeat trauma Repeat trauma Repeat trauma Repeat trauma Repeat trauma Instability Instability Repeat trauma Repeat trauma Pain Repeat trauma Repeat trauma Instability Instability
Soccer Soccer Soccer Soccer Handball Soccer Soccer Handball Basketball Handball Soccer Soccer Kite-surfing Volleyball Skiing Handball Tennis Tennis Volley Fencing Fencing Skiing Handball Handball Rugby Running Skiing Running Running Running
Competition Competition Competition Professional Professional Competition Competition Competition Competition Competition Regular recreational Competition Competition Competition Competition Competition Professional Occasional recreational Professional Regular recreational Competition Regular recreational Regular recreational Competition Competition Occasional recreational Regular recreational Occasional recreational Occasional recreational Competition
ST-G: semitendinosus-gracilis.
Exclusion criteria comprised: multi-ligament tears, non-sportsplayers, contralateral ACL tear or surgery, and septic complications. All patients were operated on by a single senior surgeon, using the modified MacIntosh fascia lata technique [15]. Assessment was performed independently, on subjective IKDC and Lysholm scores ahead of primary ACL surgery and at last follow-up, and on KOOS score at last follow-up. The ACL-RSI scale, a psychological scale correlating with Return to Sport after Injury in ACL reconstruction, was administered at last follow-up [16]. Assessment included type of sport and level, before injury, after primary surgery and at last follow-up. Sports were classified as pivot-contact, pivot, and line. Levels were classified as professional, competition, regular recreational (same sport more than twice weekly) and occasional recreational (less than twice weekly). All patients were seen at last follow-up and filled out a questionnaire assessing sports activity and functional scores. The series comprised 30 patients, at a mean 4.6 ± 1.6 years’ follow-up; there was no loss to follow-up. Clinical and sport-related characteristics are shown in Table 1. 2.1. Statistical analysis Quantitative variables were expressed as median [1st quartile; 3rd quartile]. Qualitative variables were expressed in absolute values. The Wilcoxon test for matched data analyzed significant change in IKDC and Lysholm scores. The significance threshold was set at 0.05. All analyses were performed on R software, version 3.1.3. 3. Results At last follow-up, all patients had returned to sport after revision surgery: 12 to the same sport at the same level, 15 to the same sport
at a lower level, and 3 to a different sport. Fig. 1 presents return to sport according to primary versus revision surgery. Median subjective IKDC rose from 57 [54.3; 58.5] preoperatively to 83 [68.3; 90] at last follow-up (: 26 [8.3; 32.5]; P < 0.0001) and Lysholm score from 46 [42.3; 51] to 90.5 [80.8; 96.8] (: 41 [36.3; 48.8]; P < 0.0001). At last follow-up, global KOOS score was 94.7 [83; 100]: 97.2 [90.9; 100] for stiffness, 98.6 [95.8; 100] for pain, 80 [62.5; 93.8] for daily activity, and 75 [43.4; 93.8] for sports activity. Mean ACL-RSI score was 59 ± 24. There were 4 postoperative complications: 3 harvesting site hematomas not requiring surgical drainage, and 1 small asymptomatic muscle hernia. At last follow-up, there were no cases of surgical revision for meniscus or cartilage lesion.
4. Discussion All patients returned to sport. Twelve returned to the same sport, at pre-injury level, after revision surgery; this is one of the objectives of ACL reconstruction. Functional scores (subjective IKDC and Lysholm) improved systematically. Autograft biomechanics in ACL reconstruction should approximate native ACL, while showing low morbidity [17]. Fascia lata is biomechanically suitable. According to Chan et al. [18], initial traction resistance (3266 N) and rigidity are equal to or greater than those of several other ACL graft candidate tissues, including patella tendon. Meta-analyses of iterative ACL surgery report that grafts are autografts in 85% of cases (50% patella, 29% hamstring and 6% quadriceps tendon), with allograft in the remaining 15% [19]. Our own preference is for fascia lata, associating mixed intraarticular reconstruction and above all lateral tenodesis, very often used in revision ACL surgery to improve control of knee rotation [20]. Performing an out-in femoral tunnel facilitates the creation of the new tunnel, controls the intra- and extra-articular exit point, and reduces the risk of posterior cortical collapse.
Please cite this article in press as: Mirouse G, et al. Return to sports and functional results after revision anterior cruciate ligament reconstruction by fascia lata autograft. Orthop Traumatol Surg Res (2016), http://dx.doi.org/10.1016/j.otsr.2016.06.017
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Fig. 1. Sports level before ACL tear, after primary surgery and after revision surgery.
One objective of ACL surgery is return to sports, with the same sport at the same level. There is a vast literature on return to sport after revision surgery [9,10,19,21–23]. A 2015 meta-analysis [19] reported 84% return to sport, whatever the sport and level, 52% for return to previous level, and 51% for return to competition sport. Our results are similar to those of the literature (Table 2). The literature reports mean subjective IKDC scores of 75.8 and Lysholm scores of 82.1 [19,25]. Return to sport after primary ligament reconstruction has been widely studied, with divergent findings; return to the previous level of sport, however, has never been clearly defined, despite being a prime objective of ACL surgery. Rodríguez-Roiz et al. [5] reported 91.9% return to recreational sports, but only 51.2% at the
previous level. Ardern, in a meta-analysis [26], reported that the rate of return to sport after primary surgery had increased over the previous 10 years: 78% before 2000, and 85% in 2011; return to competition level rose from 44% to 56%. Return to sport after primary or revision surgery seems not to differ in the literature. There have been no studies of return to sport after primary ACL reconstruction using fascia lata. Return to sport after ACL surgery involves several factors, some of which are difficult to assess. The patient has to be able to overcome the fear of further injury if he or she is to return to the same level, and there are close correlations between self-confidence, optimism, motivation and return to sport [27–29]. These psychological factors may explain why some patients fail to resume sport
Table 2 Return to sport after revision ACL surgery in the literature. Shelbourne et al. (2014) [22]
Gifstad et al. (2013) [24]
Franceschi et al. (2013) [23]
Muneta et al. (2010) [21]
Noyes et al. (2006) [11]
Grossman et al. (2005) [4]
Grassi et al. (2015) [19]
Our series
Number of patients Population
259
56
30
21
21
29
1090
30
Competition
Mixed
Mixed
Mixed
Mixed
Mixed
Mixed
Mixed
Mean age (yrs)
22.4
26.5
29.1
27
33
30.2
27.7
26
Follow-up (yrs)
7.2
7.5
6.8
3.3
4.1
5.6
5.3
4.6
Type of graft
PT: 100%
Ipsilateral PT: 5.1% Contralateral PT: 39.3% ST-G: 44.6
Ipsilateral ST-G: 100%
Ipsilateral ST-G: 100%
QT: 100%
PT allograft: 75.9%
PT autograft: 50%
Fascia lata autograft
PT autograft: 20.7%
ST-G autograft: 29%
CT allograft: 3.4%
QT: 6% PT allograft: 9% CT allograft: 3%
Return to sport Return to previous level Postoperative functional scores
100%
86%
69%
13%
67%
76%
Subjective IKDC: 86.1 ± 11.7
Lysholm: 80 ± 15
Lysholm: 90.2 ± 7.9
Lysholm: 87.8 ± 6.7
KOOS: 70 ± 21
IKDC: A and B: 27 C: 3
CKRS: 89.7 ± 11.
Other allograft: 3% 84%
100%
68%
52%
43.3%
Subjective IKDC: 85.8
IKDC: A: 45% B: 41% C: 12% D: 2%
Subjective IKDC: 83
71%
IKDC: A and B: 17 C: 3 D: 1
Lysholm: 86.6
Lysholm: 90.5
PT: patella tendon; ST-G: semitendinosus-gracilis; CT: calcaneus tendon; QT: quadriceps tendon; PT: patella tendon.
Please cite this article in press as: Mirouse G, et al. Return to sports and functional results after revision anterior cruciate ligament reconstruction by fascia lata autograft. Orthop Traumatol Surg Res (2016), http://dx.doi.org/10.1016/j.otsr.2016.06.017
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activity despite having normal knee function [30]. Iterative ACL reconstruction provides an improvement in clinical results, but less than from the primary surgery [24]. Numerous psychological tests have been developed; the main two are the ERAIQ (Emotional Responses of Athletes to Injury Questionnaire) and ACL-RSI [31]. A prospective study by Langford et al. [32] showed that patients with ACL-RSI >63.18 at 6 months resumed competition sport at 1 year. In the present study, ACL-RSI scores were lower, which may explain the less frequent return to competition sports after iterative surgery. The present study is alone in assessing functional results and return to sport after iterative ACL reconstruction by fascia lata graft. Assessment was performed by an independent investigator. The drawbacks of the study lie in its retrospective design, lack of comparison, and small number of patients. Tunnel positioning was not analyzed, but this was not the study objective, which focused on functional assessment and return to sport. The results encourage us in using the study technique for revision, but highlight the need to take account of the psychological dimension, probably by means of more personalized follow-up. 5. Conclusion The present study was the first analysis of functional results and return to work after fascia lata graft for failure of ACL reconstruction. Results were comparable to those in the most recent series of revision surgery, although poorer than in primary ACL repair; on the other hand, return-to-sport rates were almost as good as after primary surgery, encouraging the use of this graft in this indication, despite a certain morbidity. Disclosure of interest The authors declare that they have no competing interest. References [1] Lind M, Menhert F, Pedersen AB. Incidence and outcome after revision anterior cruciate ligament reconstruction: results from the Danish registry for knee ligament reconstructions. Am J Sports Med 2012;40:1551–7. [2] Lind M, Menhert F, Pedersen AB. The first results from the Danish ACL reconstruction registry: epidemiologic and 2 year follow-up results from 5,818 knee ligament reconstructions. Knee Surg Sports Traumatol Arthrosc 2009;17:117–24. [3] Carlisle JC, Parker RD, Matava MJ. Technical considerations in revision anterior cruciate ligament surgery. J Knee Surg 2007;20:312–22. [4] Grossman MG, ElAttrache NS, Shields CL, Glousman RE. Revision anterior cruciate ligament reconstruction: three- to nine-year follow-up. Arthrosc J Arthrosc Relat Surg 2005;21:418–23. [5] Rodríguez-Roiz JM, Caballero M, Ares O, Sastre S, Lozano L, Popescu D. Return to recreational sports activity after anterior cruciate ligament reconstruction: a one- to six-year follow-up study. Arch Orthop Trauma Surg 2015;135: 1117–22. [6] Noyes FR, Barber-Westin SD. Revision anterior cruciate surgery with use of bone-patellar tendon-bone autogenous grafts. J Bone Joint Surg Am 2001;83:1131–43. [7] Taggart TF, Kumar A, Bickerstaff DR. Revision anterior cruciate ligament reconstruction: a midterm patient assessment. Knee 2004;11:29–36. [8] Carson EW, Anisko EM, Restrepo C, Panariello RA, O’Brien SJ, Warren RF. Revision anterior cruciate ligament reconstruction: etiology of failures and clinical results. J Knee Surg 2004;17(July):127–32. [9] Garofalo R, Djahangiri A, Siegrist O. Revision anterior cruciate ligament reconstruction with quadriceps tendon-patellar bone autograft. Arthrosc J Arthrosc Relat Surg 2006;22:205–14.
[10] Ferretti A, Conteduca F, Monaco E, De Carli A, D’Arrigo C. Revision anterior cruciate ligament reconstruction with doubled semitendinosus and gracilis tendons and lateral extra-articular reconstruction. J Bone Joint Surg Am 2006;88:2373–9. [11] Noyes FR, Barber-Westin SD. Anterior cruciate ligament revision reconstruction: results using a quadriceps tendon-patellar bone autograft. Am J Sports Med 2006;34:553–64. [12] Battaglia MJ, Cordasco FA, Hannafin JA, Rodeo SA, O’Brien SJ, Altchek DW. Results of revision anterior cruciate ligament surgery. Am J Sports Med 2007;35:2057–66. [13] Denti M, Lo Vetere D, Bait C, Schönhuber H, Melegati G, Volpi P. Revision anterior cruciate ligament reconstruction: causes of failure, surgical technique, and clinical results. Am J Sports Med 2008;36:1896–902. [14] Wegrzyn J, Chouteau J, Philippot R, Fessy M-H, Moyen B. Repeat revision of anterior cruciate ligament reconstruction: a retrospective review of management and outcome of 10 patients with an average 3-year follow-up. Am J Sports Med 2009;37:776–85. [15] Khiami F, Wajsfisz A, Meyer A, Rolland E, Catonné Y, Sariali E. Anterior cruciate ligament reconstruction with fascia lata using a minimally invasive arthroscopic harvesting technique. Orthop Traumatol Surg Res 2013;99:99–105. [16] Bohu Y, Klouche S, Lefevre N, Webster K, Herman S. Translation, cross-cultural adaptation and validation of the French version of the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale. Knee Surg Sports Traumatol Arthrosc 2015;23:1192–6. [17] West RV, Harner CD. Graft selection in anterior cruciate ligament reconstruction. J Am Acad Orthop Surg 2005;13:197–207. [18] Chan DB, Temple HT, Latta LL, Mahure S, Dennis J, Kaplan LD. A biomechanical comparison of fan-folded, single-looped fascia lata with other graft tissues as a suitable substitute for anterior cruciate ligament reconstruction. Arthrosc J Arthrosc Relat Surg 2010;26:1641–7. [19] Grassi A, Zaffagnini S, Marcheggiani Muccioli GM, Neri MP, Della Villa S, Marcacci M. After revision anterior cruciate ligament reconstruction, who returns to sport? A systematic review and meta-analysis. Br J Sports Med 2015;49:1473–80. [20] Trojani C, Beaufils P, Burdin G, Bussière C, Chassaing V, Djian P. Revision ACL reconstruction: influence of a lateral tenodesis. Knee Surg Sports Traumatol Arthrosc 2012;20:1565–70. [21] Muneta T, Hara K, Ju Y-J, Mochizuki T, Morito T, Yagishita K, et al. Revision anterior cruciate ligament reconstruction by double-bundle technique using multi-strand semitendinosus tendon. Arthrosc J Arthrosc Relat Surg 2010;26:769–81. [22] Shelbourne KD, Benner RW, Gray T. Return to sports and subsequent injury rates after revision anterior cruciate ligament reconstruction with patellar tendon autograft. Am J Sports Med 2014;42:1395–400. [23] Franceschi F, Papalia R, Del Buono A, Zampogna B, Diaz Balzani L, Maffulli N. Two-stage procedure in anterior cruciate ligament revision surgery: a five-year follow-up prospective study. Int Orthop 2013;37:1369–74. [24] Gifstad T, Drogset JO, Viset A, Grøntvedt T, Hortemo GS. Inferior results after revision ACL reconstructions: a comparison with primary ACL reconstructions. Knee Surg Sports Traumatol Arthrosc 2013;21:2011–8. [25] Rollier J-C, Besse J-L, Lerat J-L, Moyen B. Anterior cruciate ligament revision: analysis and results from a series of 74 cases. Rev Chir Orthop Réparatrice Appar Mot 2007;93:344–50. [26] Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and metaanalysis of the state of play. Br J Sports Med 2011;45:596–606. [27] Gobbi A, Francisco R. Factors affecting return to sports after anterior cruciate ligament reconstruction with patellar tendon and hamstring graft: a prospective clinical investigation. Knee Surg Sports Traumatol Arthrosc 2006;14:1021–8. [28] Brewer BW, Cornelius AE, Van Raalte JL, Tennen H, Armeli S. Predictors of adherence to home rehabilitation exercises following anterior cruciate ligament reconstruction. Rehabil Psychol 2013;58:64–72. [29] Swirtun LR, Renström P. Factors affecting outcome after anterior cruciate ligament injury: a prospective study with a six-year follow-up. Scand J Med Sci Sports 2008;18:318–24. [30] Everhart JS, Best TM, Flanigan DC. Psychological predictors of anterior cruciate ligament reconstruction outcomes: a systematic review. Knee Surg Sports Traumatol Arthrosc 2015;23:752–62. [31] Webster KE, Feller JA, Lambros C. Development and preliminary validation of a scale to measure the psychological impact of returning to sport following anterior cruciate ligament reconstruction surgery. Phys Ther Sport Off J Assoc Chart Physiother Sports Med 2008;9:9–15. [32] Langford JL, Webster KE, Feller JA. A prospective longitudinal study to assess psychological changes following anterior cruciate ligament reconstruction surgery. Br J Sports Med 2009;43:377–81.
Please cite this article in press as: Mirouse G, et al. Return to sports and functional results after revision anterior cruciate ligament reconstruction by fascia lata autograft. Orthop Traumatol Surg Res (2016), http://dx.doi.org/10.1016/j.otsr.2016.06.017
ARTICLE IN PRESS Orthopaedics & Traumatology: Surgery & Research xxx (2016) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Original article
Return to sports and functional results after revision anterior cruciate ligament reconstruction by fascia lata autograft G. Mirouse a,∗ , R. Rousseau a , L. Casabianca a , M.A. Ettori a , B. Granger b , H. Pascal-Moussellard a , F. Khiami a a Département de Chirurgie Orthopédique et Traumatologie du Sport, Groupe Hospitalier Pitié-Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France b Département de Biostatistiques, de Santé Publique et d’Information Médicale, Groupe Hospitalier Pitié-Salpêtrière-Charles Foix, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
a r t i c l e
i n f o
Article history: Received 9 January 2016 Accepted 17 June 2016 Keywords: Anterior cruciate ligament Ligament reconstruction Revision surgery Fascia lata Return to sports
a b s t r a c t Introduction: The surgical revision rate following anterior cruciate ligament (ACL) surgery is 3% at 2 years and 4% at 5 years. Revision ACL surgery raises the question of the type of graft to be used. The present study assessed return to sports and functional results after revision ACL reconstruction by fascia lata graft. The hypothesis was that fascia lata provides a reliable graft in revision ACL surgery. Material and methods: A single-center retrospective continuous study included 30 sports players with a mean age of 26.8 ± 8 years undergoing surgical revision for iterative ACL tear between 2004 and 2013. Multi-ligament lesions were excluded. Type and level of sports activity were assessed preoperatively, after primary surgery and at end of follow-up. Clinical assessment used subjective IKDC, Lysholm and KOOS scores. Results: At a mean 4.6 ± 1.6 years’ follow-up, all patients had resumed sport activity, but only 12 with the same sport at the same level. Median subjective IKDC score increased from 57 [54.3; 58.5] preoperatively to 82 [68.3; 90] at last follow-up, and Lysholm score from 46 [42.3; 51] to 90.5 [80.8; 96.8]; KOOS score at last follow-up was 94.7 [83; 100]. Conclusion: Functional results in revision ACL reconstruction by fascia lata graft were satisfactory, with similar return-to-sports rates as with other techniques. Fascia lata provides a reliable graft in revision ACL surgery. Level of evidence: IV, retrospective study. © 2016 Elsevier Masson SAS. All rights reserved.
1. Introduction Anterior cruciate ligament (ACL) tear is frequent in sports players. First-line treatment most often uses hamstring or patellar tendon graft, with good functional results but an iterative tear rate of 3% at 2 years and 4% at 5 years [1,2]. Complications of reconstruction comprise recurrent instability, postoperative stiffness and pain that may prevent resumption of sport [3,4]. Return-to-sports rates following primary reconstruction range from 50% to 70% [5], and are even lower after revision reconstruction [6–14]. Revision ACL surgery may raise several problems, which should be analyzed preoperatively to avoid reproducing the causes of failure: management of existing material, bone-tunnels, cartilage and meniscal capital.
∗ Corresponding author. E-mail address: [email protected] (G. Mirouse).
There is no consensus on type of graft or surgical technique: hamstring, patella or quadriceps tendon or allograft may all be used [3–11]. Fascia lata autograft is an old technique, but which has been improved [15]; there have been several studies of its use in primary surgery but, to our knowledge, none in revision surgery. The present study assessed return to sports and functional results after revision ACL reconstruction by fascia lata autograft. The hypothesis was that fascia lata provides a reliable graft in revision ACL surgery.
2. Material and methods A single-center retrospective continuous series included all sport-playing patients aged 18–50 years operated on for isolated revision ACL reconstruction by fascia lata graft between 2004 and 2013.
http://dx.doi.org/10.1016/j.otsr.2016.06.017 1877-0568/© 2016 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Mirouse G, et al. Return to sports and functional results after revision anterior cruciate ligament reconstruction by fascia lata autograft. Orthop Traumatol Surg Res (2016), http://dx.doi.org/10.1016/j.otsr.2016.06.017
G Model
ARTICLE IN PRESS
OTSR-1571; No. of Pages 4
G. Mirouse et al. / Orthopaedics & Traumatology: Surgery & Research xxx (2016) xxx–xxx
2
Table 1 Clinical and pre-injury sports characteristics. Patient
Age
Gender
Graft
Reasons for revision
Sport
Pre-injury level
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
20 22 27 17 17 27 21 18 28 20 31 17 36 25 27 33 34 35 19 29 36 29 45 20 18 24 30 25 46 18
M M M M M M M F F M F F M F F F F F M F F F F F F F F F M F
ST-G ST-G ST-G ST-G ST-G + lat tenodesis Patella tendon ST-G ST-G Patella tendon ST-G ST-G ST-G ST-G Patella tendon Patella tendon Patella tendon ST-G Synthetic ligament cv ST-G Patella tendon ST-G ST-G ST-G ST-G ST-G + Lat Tenodesis Patella tendon ST-G ST-G ST-G ST-G+ Lat Tenodesis
Instability Repeat trauma Repeat trauma Repeat trauma Instability Pain Pain Instability Repeat trauma Repeat trauma Repeat trauma Repeat trauma Pain Instability Instability Repeat trauma Repeat trauma Repeat trauma Repeat trauma Repeat trauma Repeat trauma Instability Instability Repeat trauma Repeat trauma Pain Repeat trauma Repeat trauma Instability Instability
Soccer Soccer Soccer Soccer Handball Soccer Soccer Handball Basketball Handball Soccer Soccer Kite-surfing Volleyball Skiing Handball Tennis Tennis Volley Fencing Fencing Skiing Handball Handball Rugby Running Skiing Running Running Running
Competition Competition Competition Professional Professional Competition Competition Competition Competition Competition Regular recreational Competition Competition Competition Competition Competition Professional Occasional recreational Professional Regular recreational Competition Regular recreational Regular recreational Competition Competition Occasional recreational Regular recreational Occasional recreational Occasional recreational Competition
ST-G: semitendinosus-gracilis.
Exclusion criteria comprised: multi-ligament tears, non-sportsplayers, contralateral ACL tear or surgery, and septic complications. All patients were operated on by a single senior surgeon, using the modified MacIntosh fascia lata technique [15]. Assessment was performed independently, on subjective IKDC and Lysholm scores ahead of primary ACL surgery and at last follow-up, and on KOOS score at last follow-up. The ACL-RSI scale, a psychological scale correlating with Return to Sport after Injury in ACL reconstruction, was administered at last follow-up [16]. Assessment included type of sport and level, before injury, after primary surgery and at last follow-up. Sports were classified as pivot-contact, pivot, and line. Levels were classified as professional, competition, regular recreational (same sport more than twice weekly) and occasional recreational (less than twice weekly). All patients were seen at last follow-up and filled out a questionnaire assessing sports activity and functional scores. The series comprised 30 patients, at a mean 4.6 ± 1.6 years’ follow-up; there was no loss to follow-up. Clinical and sport-related characteristics are shown in Table 1. 2.1. Statistical analysis Quantitative variables were expressed as median [1st quartile; 3rd quartile]. Qualitative variables were expressed in absolute values. The Wilcoxon test for matched data analyzed significant change in IKDC and Lysholm scores. The significance threshold was set at 0.05. All analyses were performed on R software, version 3.1.3. 3. Results At last follow-up, all patients had returned to sport after revision surgery: 12 to the same sport at the same level, 15 to the same sport
at a lower level, and 3 to a different sport. Fig. 1 presents return to sport according to primary versus revision surgery. Median subjective IKDC rose from 57 [54.3; 58.5] preoperatively to 83 [68.3; 90] at last follow-up (: 26 [8.3; 32.5]; P < 0.0001) and Lysholm score from 46 [42.3; 51] to 90.5 [80.8; 96.8] (: 41 [36.3; 48.8]; P < 0.0001). At last follow-up, global KOOS score was 94.7 [83; 100]: 97.2 [90.9; 100] for stiffness, 98.6 [95.8; 100] for pain, 80 [62.5; 93.8] for daily activity, and 75 [43.4; 93.8] for sports activity. Mean ACL-RSI score was 59 ± 24. There were 4 postoperative complications: 3 harvesting site hematomas not requiring surgical drainage, and 1 small asymptomatic muscle hernia. At last follow-up, there were no cases of surgical revision for meniscus or cartilage lesion.
4. Discussion All patients returned to sport. Twelve returned to the same sport, at pre-injury level, after revision surgery; this is one of the objectives of ACL reconstruction. Functional scores (subjective IKDC and Lysholm) improved systematically. Autograft biomechanics in ACL reconstruction should approximate native ACL, while showing low morbidity [17]. Fascia lata is biomechanically suitable. According to Chan et al. [18], initial traction resistance (3266 N) and rigidity are equal to or greater than those of several other ACL graft candidate tissues, including patella tendon. Meta-analyses of iterative ACL surgery report that grafts are autografts in 85% of cases (50% patella, 29% hamstring and 6% quadriceps tendon), with allograft in the remaining 15% [19]. Our own preference is for fascia lata, associating mixed intraarticular reconstruction and above all lateral tenodesis, very often used in revision ACL surgery to improve control of knee rotation [20]. Performing an out-in femoral tunnel facilitates the creation of the new tunnel, controls the intra- and extra-articular exit point, and reduces the risk of posterior cortical collapse.
Please cite this article in press as: Mirouse G, et al. Return to sports and functional results after revision anterior cruciate ligament reconstruction by fascia lata autograft. Orthop Traumatol Surg Res (2016), http://dx.doi.org/10.1016/j.otsr.2016.06.017
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Fig. 1. Sports level before ACL tear, after primary surgery and after revision surgery.
One objective of ACL surgery is return to sports, with the same sport at the same level. There is a vast literature on return to sport after revision surgery [9,10,19,21–23]. A 2015 meta-analysis [19] reported 84% return to sport, whatever the sport and level, 52% for return to previous level, and 51% for return to competition sport. Our results are similar to those of the literature (Table 2). The literature reports mean subjective IKDC scores of 75.8 and Lysholm scores of 82.1 [19,25]. Return to sport after primary ligament reconstruction has been widely studied, with divergent findings; return to the previous level of sport, however, has never been clearly defined, despite being a prime objective of ACL surgery. Rodríguez-Roiz et al. [5] reported 91.9% return to recreational sports, but only 51.2% at the
previous level. Ardern, in a meta-analysis [26], reported that the rate of return to sport after primary surgery had increased over the previous 10 years: 78% before 2000, and 85% in 2011; return to competition level rose from 44% to 56%. Return to sport after primary or revision surgery seems not to differ in the literature. There have been no studies of return to sport after primary ACL reconstruction using fascia lata. Return to sport after ACL surgery involves several factors, some of which are difficult to assess. The patient has to be able to overcome the fear of further injury if he or she is to return to the same level, and there are close correlations between self-confidence, optimism, motivation and return to sport [27–29]. These psychological factors may explain why some patients fail to resume sport
Table 2 Return to sport after revision ACL surgery in the literature. Shelbourne et al. (2014) [22]
Gifstad et al. (2013) [24]
Franceschi et al. (2013) [23]
Muneta et al. (2010) [21]
Noyes et al. (2006) [11]
Grossman et al. (2005) [4]
Grassi et al. (2015) [19]
Our series
Number of patients Population
259
56
30
21
21
29
1090
30
Competition
Mixed
Mixed
Mixed
Mixed
Mixed
Mixed
Mixed
Mean age (yrs)
22.4
26.5
29.1
27
33
30.2
27.7
26
Follow-up (yrs)
7.2
7.5
6.8
3.3
4.1
5.6
5.3
4.6
Type of graft
PT: 100%
Ipsilateral PT: 5.1% Contralateral PT: 39.3% ST-G: 44.6
Ipsilateral ST-G: 100%
Ipsilateral ST-G: 100%
QT: 100%
PT allograft: 75.9%
PT autograft: 50%
Fascia lata autograft
PT autograft: 20.7%
ST-G autograft: 29%
CT allograft: 3.4%
QT: 6% PT allograft: 9% CT allograft: 3%
Return to sport Return to previous level Postoperative functional scores
100%
86%
69%
13%
67%
76%
Subjective IKDC: 86.1 ± 11.7
Lysholm: 80 ± 15
Lysholm: 90.2 ± 7.9
Lysholm: 87.8 ± 6.7
KOOS: 70 ± 21
IKDC: A and B: 27 C: 3
CKRS: 89.7 ± 11.
Other allograft: 3% 84%
100%
68%
52%
43.3%
Subjective IKDC: 85.8
IKDC: A: 45% B: 41% C: 12% D: 2%
Subjective IKDC: 83
71%
IKDC: A and B: 17 C: 3 D: 1
Lysholm: 86.6
Lysholm: 90.5
PT: patella tendon; ST-G: semitendinosus-gracilis; CT: calcaneus tendon; QT: quadriceps tendon; PT: patella tendon.
Please cite this article in press as: Mirouse G, et al. Return to sports and functional results after revision anterior cruciate ligament reconstruction by fascia lata autograft. Orthop Traumatol Surg Res (2016), http://dx.doi.org/10.1016/j.otsr.2016.06.017
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activity despite having normal knee function [30]. Iterative ACL reconstruction provides an improvement in clinical results, but less than from the primary surgery [24]. Numerous psychological tests have been developed; the main two are the ERAIQ (Emotional Responses of Athletes to Injury Questionnaire) and ACL-RSI [31]. A prospective study by Langford et al. [32] showed that patients with ACL-RSI >63.18 at 6 months resumed competition sport at 1 year. In the present study, ACL-RSI scores were lower, which may explain the less frequent return to competition sports after iterative surgery. The present study is alone in assessing functional results and return to sport after iterative ACL reconstruction by fascia lata graft. Assessment was performed by an independent investigator. The drawbacks of the study lie in its retrospective design, lack of comparison, and small number of patients. Tunnel positioning was not analyzed, but this was not the study objective, which focused on functional assessment and return to sport. The results encourage us in using the study technique for revision, but highlight the need to take account of the psychological dimension, probably by means of more personalized follow-up. 5. Conclusion The present study was the first analysis of functional results and return to work after fascia lata graft for failure of ACL reconstruction. Results were comparable to those in the most recent series of revision surgery, although poorer than in primary ACL repair; on the other hand, return-to-sport rates were almost as good as after primary surgery, encouraging the use of this graft in this indication, despite a certain morbidity. Disclosure of interest The authors declare that they have no competing interest. References [1] Lind M, Menhert F, Pedersen AB. Incidence and outcome after revision anterior cruciate ligament reconstruction: results from the Danish registry for knee ligament reconstructions. Am J Sports Med 2012;40:1551–7. [2] Lind M, Menhert F, Pedersen AB. The first results from the Danish ACL reconstruction registry: epidemiologic and 2 year follow-up results from 5,818 knee ligament reconstructions. Knee Surg Sports Traumatol Arthrosc 2009;17:117–24. [3] Carlisle JC, Parker RD, Matava MJ. Technical considerations in revision anterior cruciate ligament surgery. J Knee Surg 2007;20:312–22. [4] Grossman MG, ElAttrache NS, Shields CL, Glousman RE. Revision anterior cruciate ligament reconstruction: three- to nine-year follow-up. Arthrosc J Arthrosc Relat Surg 2005;21:418–23. [5] Rodríguez-Roiz JM, Caballero M, Ares O, Sastre S, Lozano L, Popescu D. Return to recreational sports activity after anterior cruciate ligament reconstruction: a one- to six-year follow-up study. Arch Orthop Trauma Surg 2015;135: 1117–22. [6] Noyes FR, Barber-Westin SD. Revision anterior cruciate surgery with use of bone-patellar tendon-bone autogenous grafts. J Bone Joint Surg Am 2001;83:1131–43. [7] Taggart TF, Kumar A, Bickerstaff DR. Revision anterior cruciate ligament reconstruction: a midterm patient assessment. Knee 2004;11:29–36. [8] Carson EW, Anisko EM, Restrepo C, Panariello RA, O’Brien SJ, Warren RF. Revision anterior cruciate ligament reconstruction: etiology of failures and clinical results. J Knee Surg 2004;17(July):127–32. [9] Garofalo R, Djahangiri A, Siegrist O. Revision anterior cruciate ligament reconstruction with quadriceps tendon-patellar bone autograft. Arthrosc J Arthrosc Relat Surg 2006;22:205–14.
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Please cite this article in press as: Mirouse G, et al. Return to sports and functional results after revision anterior cruciate ligament reconstruction by fascia lata autograft. Orthop Traumatol Surg Res (2016), http://dx.doi.org/10.1016/j.otsr.2016.06.017