Allen Christina R, Anderson Allen F, Cooper Daniel E, DeBerardino Thomas M, Dunn Warren R, Haas Amanda K, Huston Laura J, Lantz Brett Brick A, Mann Barton, Nwosu Sam K, Spindler Kurt P, Stuart Michael J, Wright Rick W, Albright John P, Amendola Annunziato Ned, Andrish Jack T, Annunziata Christopher C, Arciero Robert A, Bach Bernard R, Baker Champ L, Bartolozzi Arthur R, Baumgarten Keith M, Bechler Jeffery R, Berg Jeffrey H, Bernas Geoffrey A, Brockmeier Stephen F, Brophy Robert H, Bush-Joseph Charles A, Butler J Brad, Campbell John D, Carey James L, Carpenter James E, Cole Brian J, Cooper Jonathan M, Cox Charles L, Creighton R Alexander, Dahm Diane L, David Tal S, Flanigan David C, Frederick Robert W, Ganley Theodore J, Garofoli Elizabeth A, Gatt Charles J, Gecha Steven R, Giffin James Robert, Hame Sharon L, Hannafin Jo A, Harner Christopher D, Harris Norman Lindsay, Hechtman Keith S, Hershman Elliott B, Hoellrich Rudolf G, Hosea Timothy M, Johnson David C, Johnson Timothy S, Jones Morgan H, Kaeding Christopher C, Kamath Ganesh V, Klootwyk Thomas E, Levy Bruce A, Ma C Benjamin, Maiers G Peter, Marx Robert G, Matava Matthew J, Mathien Gregory M, McAllister David R, McCarty Eric C, McCormack Robert G, Miller Bruce S, Nissen Carl W, O'Neill Daniel F, Owens Brett D, Parker Richard D, Purnell Mark L, Ramappa Arun J, Rauh Michael A, Rettig Arthur C, Sekiya Jon K, Shea Kevin G, Sherman Orrin H, Slauterbeck James R, Smith Matthew V, Spang Jeffrey T, Svoboda Steven J, Taft Timothy N, Tenuta Joachim J, Tingstad Edwin M, Vidal Armando F, Viskontas Darius G, White Richard A, Williams James S, Wolcott Michelle L, Wolf Brian R, York James J
Investigation performed at Department of Orthopaedics, Washington University School of Medicine, St Louis, Missouri, USA, and Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
Am J Sports Med. 2017 Sep;45(11):2586-2594. doi: 10.1177/0363546517712952. Epub 2017 Jul 11.
Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes compared with primary ACL reconstruction.
Certain factors under the control of the surgeon at the time of revision surgery can both negatively and positively affect outcomes.
Case-control study; Level of evidence, 3.
Patients undergoing revision ACL reconstruction were identified and prospectively enrolled between 2006 and 2011. Data collected included baseline demographics, intraoperative surgical technique and joint disorders, and a series of validated patient-reported outcome instruments (International Knee Documentation Committee [IKDC] subjective form, Knee Injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Marx activity rating scale) completed before surgery. Patients were followed up for 2 years and asked to complete an identical set of outcome instruments. Regression analysis was used to control for age, sex, body mass index (BMI), activity level, baseline outcome scores, revision number, time since last ACL reconstruction, and a variety of previous and current surgical variables to assess the surgical risk factors for clinical outcomes 2 years after revision ACL reconstruction.
A total of 1205 patients (697 male [58%]) met the inclusion criteria and were successfully enrolled. The median age was 26 years, and the median time since their last ACL reconstruction was 3.4 years. Two-year follow-up was obtained on 82% (989/1205). Both previous and current surgical factors were found to be significant contributors toward poorer clinical outcomes at 2 years. Having undergone previous arthrotomy (nonarthroscopic open approach) for ACL reconstruction compared with the 1-incision technique resulted in significantly poorer outcomes for the 2-year IKDC ( P = .037; odds ratio [OR], 2.43; 95% CI, 1.05-5.88) and KOOS pain, sports/recreation, and quality of life (QOL) subscales ( P ≤ .05; OR range, 2.38-4.35; 95% CI, 1.03-10.00). The use of a metal interference screw for current femoral fixation resulted in significantly better outcomes for the 2-year KOOS symptoms, pain, and QOL subscales ( P ≤ .05; OR range, 1.70-1.96; 95% CI, 1.00-3.33) as well as WOMAC stiffness subscale ( P = .041; OR, 1.75; 95% CI, 1.02-3.03). Not performing notchplasty at revision significantly improved 2-year outcomes for the IKDC ( P = .013; OR, 1.47; 95% CI, 1.08-1.99), KOOS activities of daily living (ADL) and QOL subscales ( P ≤ .04; OR range, 1.40-1.41; 95% CI, 1.03-1.93), and WOMAC stiffness and ADL subscales ( P ≤ .04; OR range, 1.41-1.49; 95% CI, 1.03-2.05). Factors before revision ACL reconstruction that increased the risk of poorer clinical outcomes at 2 years included lower baseline outcome scores, a lower Marx activity score at the time of revision, a higher BMI, female sex, and a shorter time since the patient's last ACL reconstruction. Prior femoral fixation, prior femoral tunnel aperture position, and knee flexion angle at the time of revision graft fixation were not found to affect 2-year outcomes in this revision cohort.
There are certain surgical variables that the physician can control at the time of revision ACL reconstruction that can modify clinical outcomes at 2 years. Whenever possible, opting for an anteromedial portal or transtibial surgical exposure, choosing a metal interference screw for femoral fixation, and not performing notchplasty are associated with significantly better 2-year clinical outcomes.
与初次前交叉韧带（ACL）重建相比，翻修ACL重建的疗效更差已得到证实。
翻修手术时外科医生可控的某些因素会对疗效产生负面和正面影响。
病例对照研究；证据等级，3级。
确定2006年至2011年间接受翻修ACL重建的患者并进行前瞻性入组。收集的数据包括基线人口统计学资料、术中手术技术和关节疾病，以及一系列经过验证的患者报告结局指标（国际膝关节文献委员会[IKDC]主观量表、膝关节损伤和骨关节炎结局评分[KOOS]、西安大略和麦克马斯特大学骨关节炎指数[WOMAC]以及马克思活动评分量表），这些指标在手术前完成。对患者进行2年随访，并要求他们完成一套相同的结局指标。采用回归分析来控制年龄、性别、体重指数（BMI）、活动水平、基线结局评分、翻修次数、距上次ACL重建的时间，以及各种既往和当前的手术变量，以评估翻修ACL重建术后2年临床结局的手术危险因素。
共有1205例患者（697例男性[58%]）符合纳入标准并成功入组。中位年龄为26岁，距上次ACL重建的中位时间为3.4年。82%（989/1205）的患者获得了2年随访。既往和当前的手术因素均被发现是导致术后2年临床结局较差的重要因素。与单切口技术相比，既往采用关节切开术（非关节镜下开放入路）进行ACL重建导致2年IKDC评分（P = 0.037；比值比[OR]，2.43；95%可信区间[CI]，1.05 - 5.88）以及KOOS疼痛、运动/娱乐和生活质量（QOL）子量表评分显著更差（P≤0.05；OR范围，2.38 - 4.35；95%CI，1.03 - 10.00）。当前股骨固定使用金属挤压螺钉导致2年KOOS症状、疼痛和QOL子量表评分显著更好（P≤0.05；OR范围，1.70 - 1.96；95%CI，1.00 - 3.33）以及WOMAC僵硬子量表评分（P = 0.041；OR，1.75；95%CI，1.02 - 3.03）。翻修时不进行髁间窝成形术显著改善了2年IKDC评分（P = 0.013；OR，1.47；95%CI，1.08 - 1.99）、KOOS日常生活活动（ADL）和QOL子量表评分（P≤0.04；OR范围，1.40 - 1.41；95%CI，1.03 - 1.93）以及WOMAC僵硬和ADL子量表评分（P≤0.04；OR范围，1.41 - 1.49；95%CI，1.03 - 2.05）。翻修ACL重建术前增加术后2年临床结局较差风险的因素包括较低的基线结局评分、翻修时较低的马克思活动评分、较高的BMI、女性以及距患者上次ACL重建的时间较短。在该翻修队列中，既往股骨固定、既往股骨隧道开口位置以及翻修移植物固定时的膝关节屈曲角度未发现影响2年结局。
在翻修ACL重建时，医生可以控制某些手术变量，这些变量可改变术后2年的临床结局。只要有可能，选择前内侧入路或经胫骨手术显露、选择金属挤压螺钉进行股骨固定以及不进行髁间窝成形术与术后2年显著更好的临床结局相关。
