Revision ACL Reconstruction Dr Mbugua Francis Orthopedic Surgeon AIC CURE International Hospital

Introduction The anterior cruciate ligament (ACL) is an important stabilizing ligament of the knee that is frequently injured by athletes and trauma victims. It is the most common injured ligament of the knee in both contact and non-contact situations. Kenya is a sporting nation and sports injuries are increasingly becoming a big part of the orthopedic care that we are facing. With a growing interest in ACL reconstructions, Recurrent ACL rupture is becoming a big concern for patients and surgeons

What we do We perform ACL reconstructions for What we use All sportsmen All young patients All patients with symptomatic instability regardless of age Older patients without osteoarthritis What we use Autograft tissue – both BTB and hamstring Younger high demand pts – BTB All others - Hamstring

Method We performed a retrospective review of patients who underwent a revision ACL reconstruction over a 4-year period. Variables we looked; Mechanism of re-injury Associated injuries Initial graft choice vs revision graft choice Rehabilitation period and return to previous level of activity. Complication rate

Results Number of ACL reconstructions – 124pts No. of Revision ACLs – 10.6% (13) Primary surgery BTB – 38.5 % (5) Hamstring – 61.5% (8) Patients referred from elsewhere – 84.6% (11)

Results Mechanism of Re-injury Techniques Fixation Method Clear mechanism – 30.8% (4) Unclear – 69.2% (9) Techniques Tendon choice; BTB – 38.5% (5) Ipsilateral Hamstring – 38.5% (5) Contra-lateral hamstring – 23% (3) Fixation Method Interference screws – 76.9% (10) Dual fixation(screws, button, staples) – 23.1 % (3)

Results Intra-op findings Tunnel Malpositioning – 76.9% (10) Femoral tunnel commonest Associated pathology Meniscus tears – 30.8% (4) Chondral lesions – 38.5% (5) Arthrofibrosis – 23.1% (3) Return to pre-injury level of activity(no sports) – 76.9% (10)

Pre-op planning Multiligamentous injury – 0% Xrays – 100% - no angular deformities CT Scan – 23.1 % (3) MRI – 100%

Rehab Hinged unlocked knee brace – 2 weeks Crutches(Partial weight bearing as tolerated) – 2 weeks Full weight bearing and off brace when have quad control ROM – as tolerated Running – 4 months Return to sports – 6-9mths

Key considerations Cause of failure – Mechanism of re-injury, pre-op eval, intra-op findings Concomitant pathology Tunnel position Previous hardware Graft choice and fixation Early Rehab One Stage vs 2 stage procedure?