Abstract & Commentary
Synopsis: With appropriate preoperative planning, a reharvested patellar tendon can successfully be used for revision anterior cruciate ligament reconstruction.
Source: O’Shea JJ, Shelbourne KD. Anterior cruciate ligament reconstruction with a reharvested bone-patellar tendon-bone graft. Am J Sports Med. 2002;30(2):208-213.
Revision ACL reconstruction when both patellar tendons have previously been harvested is an unusual occurrence and thus has not been closely investigated. The present study evaluates knee stability and quadriceps strength following ACL reconstruction using a reharvested bone-patellar tendon-bone graft.
Eleven patients who underwent revision ACL reconstruction with a reharvested bone-patellar tendon-bone graft were evaluated. All patients had previously undergone at least 2 ACL reconstructions in which they had bone-patellar tendon-bone grafts harvested from each of their knees. After each patient was diagnosed with a recurrent ACL injury, any knee effusion was eliminated and full range of motion was obtained. Each patient was subsequently evaluated objectively for range of motion, stability, and isokinetic leg strength. Prior to surgery, an MRI scan was conducted to determine the width of the patellar tendon and the quality of the tissue, thus assisting in the location of the tendon to be reharvested. Each patient underwent a miniarthrotomy ACL reconstruction. The graft was harvested from 7 to 8 mm of the regenerated tendon and 2 to 3 mm of untouched tendon. In all cases, 5 mm of tendon at the border of the harvest site was left to allow for suture closure of the tendon defect.
The rehabilitation protocol was based upon whether the graft was reharvested from the ACL-injured knee or the contralateral knee. Subjective evaluation included the modified Noyes knee questionnaire and a return-to-activity questionnaire. Range of motion, stability, and quadriceps strength were measured objectively.
All 11 patients were available for subjective follow-up and 8 patients were available for objective follow-up for at least 2 years postoperatively. The mean modified Noyes total score (100 points possible) was 89.3 ± 6.9. The average return to light sports was 5.1 weeks and the average return to full sports was 5.4 months.
The mean range of motion for the ACL-reconstructed knee was 6/0/133 at 1 month postoperatively and 6/0/145 at long-term follow-up. The KT-1000 side-to-side difference in stability between the knees was 1.6 ± 1.2 mm. Subjectively, 9 of the 11 patients reported a stability of 20 out of 20 (normal stability), and 2 patients reported 16 out of 20 (mild instability with twisting/pivoting). The mean isokinetic quadriceps muscle strength was 103% of that of the opposite knee.
Comment by Brian J. Cole, MD, & Nina Shervin
Revision surgery following ACL reconstruction when bone-patellar tendon-bone grafts have already been harvested from both knees is very uncommon. The findings of the present study suggest, however, that revision ACL reconstruction with reharvested bone-patellar tendon-bone grafts is a viable course of action when coupled with the appropriate preoperative planning (ie, use of MRI to evaluate best quality tendon and remaining patellar and tibial bone). A previous study found that such a procedure resulted in a higher complication rate and lower functional scores1 while another found mixed results.2 Although the strength and stability of the patients following the surgery were compared to preoperative baseline values, a study comparing the operative group to a control group may enhance the findings. Given the small number of patients evaluated and the paucity of literature on the topic, further investigation is required to establish the use of reharvested bone-patellar tendon-bone grafts in revision ACL reconstruction. Clearly, other options such as hamstring autograft or allograft reconstruction offer alternatives to reharvesting a bone-patellar tendon-bone graft.
Dr. Cole, Assistant Professor, Orthopaedic Surgery, Rush Presbyterian Medical Center, Midwest Orthopaedics, Chicago, IL, is Associate Editor of Sports Medicine Reports.
1. Kartus J, et al. Ipsi- or contralateral patellar tendon graft in anterior cruciate ligament revision surgery. A comparison of the two methods. Am J Sports Med. 1998;26:499-504.
2. Colosimo AJ, et al. Revision anterior cruciate ligament reconstruction with a reharvested ipsilateral patellar tendon. Am J Sports Med. 2001;29:746-750.