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Fixing the Failed ACL Reconstruction
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| The ACL, torn at left, reconstructed at right. Click on the picture above for a larger image. |
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Orthopaedic surgeon Andrew Cosgarea, M.D., recalls a 29-year-old computer programmer who, while playing soccer one weekend, had injured his anterior cruciate ligament, or ACL, a ligament deep inside the knee that controls knee stability.
Like many weekend warriors anxious to resume their sport, the patient elected to have surgery on the ligament, which connects the thigh bone and the top of the shin. All seemed to go well until the patient's knee started giving out.
In addition to having retorn his ACL, the patient also had a tear of his meniscus, which serves as a shock absorber in the knee.
That's when the patient came to Cosgarea, known for specializing in so-called revision reconstructions -- fixing what the first operation, for various reasons, failed to fix.
"Sometimes the original ACL reconstruction is done appropriately, but a concomitant ligament injury is perhaps unrecognized, resulting in the ultimate failure of the operation," explains Cosgarea. "The reconstructed ligament may stretch, tear or break loose from the fixation at the two ends."
Restoring stability in the knee and getting patients back in their sport or job in such situations is no easy chore. In an initial operation, surgeons drill a tunnel into the ends of the thigh bone and shin, or femur and tibia. They then thread a graft into the two ends, commonly using tissue from the patellar tendon below the kneecap. The graft is then secured by wedging a screw between the side of the bone and the tunnel.
A revision reconstruction becomes more complicated and challenging, in part, because the surgeon may have to reconstruct other knee ligaments that may have contributed to the failure of the first operation. Also, depending upon what tissue was used in the first operation and the condition of other ligaments, the surgeon may have to harvest new graft tissue from quadricep, hamstring or patellar tendons.
"I look at the specific needs of individuals, what level of activity they're at, how old they are, whether they have other factors that might predispose them to problems with a particular graft source," Cosgarea explains. "For people with chronic knee cap problems, for example, I'm more likely to use the hamstring tendons." The greater the surgeon's experience in using these multiple graft sources, outcomes studies show, the greater the likelihood of not only permanently restoring stability in the knee, but also helping the patient avoid disabling arthritis down the road.
"You need to have a high enough volume with this operation to be good at a variety of different techniques, depending upon what that patient needs," says Cosgarea, who has done more than 500 ACL reconstructions.
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