The Sanders Clinic regularly sees athletes who have had failed Anterior Cruciate Ligament (ACL) surgery. Such surgery may fail for many reasons. The principle reasons for failure are permanent stiffness of the knee manifested by lack of full extension, and recurrent instability or giving way.
The most common failure is the failure to regain Range of Motion, particularly the loss of full knee extension. This will lead to pain and grinding at the patellofemoral joint. When this occurs, it is nearly impossible for an athlete to live a normal sedentary life, much less one allowing for successful competition in sports. The development of post traumatic arthritis is now a certainty if this problem is not corrected.
Reasons for Failed ACL Surgery
Failure of an ACL surgery can occur when the surgery is done too soon following an injury, and before normal range of motion is achieved. Other reasons for failed results include the use of a postoperative brace or cast, which prevents full extension.
Often times it is a misplacement of the graft, or a graft that is properly placed, though too tight, which limits range of motion. This occurs when two interference bone screws are used. The last common cause of a failed ACL surgery lies in the rehabilitation – either a poorly designed program or the lack of motivation on the athletes’ part to do the necessary rehabilitation.
But, most often, the cause of failure is a combination of the above. When it occurs, the condition is called Arthrofibrosis. Left alone, it will lead to posttraumatic arthritis. The best treatment for this problem is prevention. The Sanders Clinic protocol for knee rehabilitation is designed for exactly that.
Salvaging a Previously Failed ACL Surgery
Unfortunately, not all surgeons performing ACL surgery have the same philosophy – resulting in stiff knees following ligament reconstruction. If the knee lacks only a small amount of extension, then redirecting the rehabilitation to include the use of the Elite Seat will be successful. If a large amount of extension or flexion is lost, then arthroscopic surgery is necessary to cut scar tissue, release abnormal adhesions between the moving parts, and sometimes resect part or all of the cruciate graft – which has now become the problem rather than the solution to the overall problem.
Following this procedure to salvage a previously failed ACL surgery, a multimodal pain management program is instituted. By attacking the pain through several different pathways, fewer narcotics will be necessary, and subsequently, the negative side effects of narcotic use can be diminished or eliminated. These medications include an anti-inflammatory such as Meloxicam, a nonnarcotic analgesic such as Tramadol, acetaminophen, also known as Tylenol and gabapentin which calms down peripheral nerve pain. These medications are taken around the clock. The need for a Class 3 narcotic analgesic, such as hydrocodone, is drastically diminished so fewer side effects such as effects such as nausea and/or constipation occur. Phenergan is prescribed to help with nausea. Taking two Tylenol every four hours is a good alternative. And Tylenol PM (a preparation that includes benedryl) is encouraged over other medications in the event of sleep disturbance, which is common after such procedures. Ambien, which is also prescribed, is a stronger sleep aid. with our typical post ACL reconstruction protocol. .
In years past, we utilized leg casts set in full extension. We have found that this is no longer necessary. Specific work on knee extension is rarely needed, as that is accomplished during surgery and maintained by positioning of the limb with the foot elevated eight inches above the bed, and nothing under the crease of the knee. This allows gravity to extend the knee into its physiological amount of hyperextension, equal to the other side.
Athletes must take responsibility for the maintenance of their knee Range of Motion. Exercises must be continued indefinitely in these cases. The surgeon’s work takes place over a one-hour period in the operating room. Following that, it is the athlete’s responsibility to get those exercises done. Period.
Problems with Allograft and Hamstring Reconstructions
Unfortunately, this decade has become the decade of the Allografts and the hamstring tendons. More than one half of the ACL reconstructions performed in the United States include tissue from cadavers, or tendons from the hamstrings.
When a graft tissue from the patient is used, the body recognizes it as its own and embraces it. And while the body may not reject an Allograft outright, it, like a kidney, creates an uncertainty with regard to the body’s willingness to accept or reject it. The best we can expect is that the body will tolerate it.
Problems with Allograft Tissue
An allograft tissue is dead. It is frozen and then thawed and installed as a graft. This dead tissue must then be vascularized – prompting new cells to move into the place where the dead cells existed. This rarely happens in allografts, and many rupture before they can revascularize. This process takes nearly a year at best. And athletes must remain on the sidelines during this time. Since most young athletes do not want, or cannot afford, to miss a year of competition, they return to their sport too early for this type of graft. For this reason many of the allografts put into serious young athletes FAIL!
Unfortunately, failed allograft surgery often causes comprise and resorption of the bone of the lower femur and upper tibia. Many surgeons believe that in order to remedy the problem, a two-stage procedure is necessary – the first stage involves bone grafting the defects and the second is performing the ACL reconstruction. At the Sanders Clinic, results show that this is almost never necessary, as a standard reconstruction using the athlete’s opposite patella tendon can be done in a single procedure – avoiding a second surgery.
At the Sanders Clinic, we use a rule of thumb regarding ACL graft choices. This rule is based on excellent scientific research done by Drs. Frank Noyes and Sue Barber-Westin. They have shown that the survival rate of an athlete’s own tissue as an ACL is approximately 93 percent and the survival rate of allograft tissue as an ACL approximately 70 percent. A recent publication in the 2012 American Journal of Sports Medicine followed United States Military Academy Cadets who started at West Point. Many of these young people had had ACL reconstruction as a result of high school sports accidents. Those who had had an allograft reconstruction suffered an odds ratio of 7:1 for the need to revise the reconstruction when compared to those Cadets who had had an autograft reconstruction!
Unfortunately, while Dr. Sanders can repair the knee of a previously failed reconstruction, he is unable to return the lost years of a sport to the athlete, which is why he encourages young athletes to fully understand the differences between the graft choices before having their first surgery.
Problems with Hamstring Tendons
Hamstring tendons are live tendons taken from the back of the injured athlete’s knee. Because it is technically easy for the surgeon to harvest them, they have become popular graft sources.
By themselves they are alive and strong. Unfortunately, they have no bone attached to them – and the healing of these tendons, installed into the knee as an ACL, must occur by the tendon healing to the bone. This is at best an uncertain process and is not complete before nearly one year. Furthermore, as these tendons heal to the bone, significant stretching can occur – which can lead to a loose knee.
Another major problem with the hamstring tendon repair is that the harvest of the hamstring tendons ablates two important muscle tendon units that serve with the ACL and hold the tibia backward. Removing these important tendons means that the nascent hamstring ACL graft has to “go it alone.” This is another common reason for failure.
During this first year, just like those who have had allograft reconstructions, an athlete must restrict him or herself to working out at the health club or gym, rather than the field of play.