Single Stage Novel Method of Treating Anterior Cruciate Ligament Failure, Revision and Reconstruction using Bone-Patellar Tendon-Bone Graft with Suture Disc and Lateral Extra-Articular Tenodesis: A Retrospective Study

INTRODUCTION

Anterior cruciate ligament (ACL) injuries, including tears and ruptures, are among the most frequently encountered knee injuries in athletes.^[1] The ACL is the most commonly injured ligament in the knee, with an estimated annual incidence of 1 in 3,500 people in the United States.^[2] Anterior cruciate ligament reconstruction (ACLR) is a widely performed procedure in sports medicine, with revision surgeries comprising approximately 4.1% to 13.3% of all ACLR cases.^[3] The choice of treatment depends on long-term goals and whether the individual plans to return to high-demand physical activities. In such cases, surgical intervention is the preferred approach, with ACLR being the most widely used technique. ACLR is a complex procedure requiring careful consideration of various factors. While it effectively restores anterior tibial translation, its ability to fully re-establish rotational knee stability remains uncertain. This instability is linked to graft failure and early-onset osteoarthritis.^[4] To address this, additional surgical techniques have been introduced, including lateral extra-articular tenodesis (LET), which aims to improve rotational stability and is commonly performed alongside ACLR, particularly in athletes involved in cutting and pivoting movements.^[5] Anterior cruciate ligament (ACL) injuries are becoming more common, and surgical intervention is often required due to the limited ability of the band to heal. ACLR involves replacing the damaged ligament with a graft, which is secured within bone tunnels in the tibia and femur to restore knee stability.^[6] Graft failure can occur due to improper tensioning or a loose graft. If the reconstructed graft has residual laxity during surgery, it may lead to instability and eventual failure. Ensuring a properly tensioned graft during ACL reconstruction is crucial for restoring knee stability.^[7] Despite advancements in research, clinical outcomes after revision ACL reconstruction remain inferior to those of primary surgery. Studies have linked poor patient-reported outcomes to recurrent anterior and rotational knee instability.^{[8, 9]} Revision ACL surgery is typically indicated for patients presenting with symptomatic instability due to graft failure after a primary reconstruction. In recent years, the incidence of revision ACL procedures has notably increased. The selection of an appropriate graft for revision remains a topic of ongoing debate.^[10] Autografts are widely favored, with many experts advocating their use in both primary and revision ACL surgeries. Among these, the bone– patellar tendon–bone (BTB) autograft is commonly utilized, especially when the initial reconstruction using hamstring grafts has failed.^[11,12] The hamstring tendon (HT) graft remains one of the most commonly used options for primary ACL reconstruction worldwide. Additionally, the BTB graft is widely utilized for its strength and stability.^[13] BTB grafts, typically taken from the central third of the patellar tendon on the same side, are among the most commonly used autografts for ACL reconstruction.^[1] Understanding the various risk factors for ACL graft failure is essential for patient education and optimizing outcomes. Given the increasing incidence of ACL reconstruction failures due to reinjury or other factors, there is a need for more effective revision techniques that enhance stability and improve patient outcomes. This study explores a single-stage novel approach using a BTB graft with a suture disc and lateral extra-articular tenodesis to provide a more robust and biologically favorable reconstruction. By evaluating the clinical outcomes of 48 cases, this study aims to assess the efficacy of this technique in ensuring a stronger graft fixation, reducing rotational instability, and facilitating an earlier return to sports and daily activities.

MATERIAL AND METHODS

This retrospective study analyzed 48 patients who underwent single-stage revision ACL reconstruction using a BTB graft with a suture disc and lateral extra-articular tenodesis (LET). Patients with ACL graft failure due to reinjury or other causes were included, along with multiligament injuries of the knee are excluded. The procedure involved harvesting a BTB graft from the ipsilateral patellar tendon, securing it with a suture disc to prevent bone compression, and fixing it with an interference screw. Anatomical femoral and tibial tunnels were created, ensuring proper graft tensioning to minimize residual laxity. LET was performed using an iliotibial band strip, routed through a femoral tunnel, and secured with sutures or fixation devices to enhance rotational knee stability. The study evaluated knee stability, graft integrity, functional recovery, and complications such as infection, graft failure, and time to return to sports using clinical assessments and statistical analysis of outcome measures over time.

Surgical techniques

Correct placement of the ACL graft is crucial in minimizing the risk of graft failure. Improper graft placement can significantly impact ACL reconstruction outcomes. A graft positioned too posteriorly or too low on the femoral condyle experiences increased tension during knee extension. In contrast, a graft placed too high and anteriorly tends to be longer and more vertical, leading to greater anterior tibial translation and rotational instability. Additionally, graft positioning plays a critical role in the risk of impingement, which may affect knee mobility and increase the likelihood of graft failure.^[14] A midline incision was made over the patellar tendon to harvest its central third, measuring approximately 10-11 mm in width, along with bone plugs from both the patella and tibial tubercle. These bone plugs were carefully shaped to fit 10 mm tunnels, ensuring accurate graft placement while reducing the risk of complications. The diameter of the bone plug was modified as needed to accommodate any tunnel enlargement after the removal of the previous fixation. In this study, a single stage has been performed in cases where the bone tunnel diameter was not more than 13 mm. To minimize the risk of patellar fracture and anterior knee pain, the patellar-side bone plug was limited to a maximum of 11 mm in diameter. Femoral and tibial tunnels were drilled according to graft dimensions, typically ranging between 8–9 mm.

SMART FIX device (Chetan Meditech Pvt. Ltd. - BIOTEK, Ahmedabad, Gujarat, India) used for ACL reconstruction using BTB graft. The BTB graft was fixated using a suture disc technique, which evenly distributes fixation forces, preventing bone plug damage or compression. This approach helps maintain graft integrity during placement and fixation, ensuring a secure reconstruction. The use of LET (lateral extra-articular tenodesis) and the suture disc fixation technique are unique aspects of our method, providing a strong and cost-effective reconstruction. A LET procedure was performed to improve rotational stability. The iliotibial band (ITB) graft was harvested from its posterior two-thirds, creating an 8 cm × 10 mm distally based graft [Figures 1 to 6]. It was then passed beneath the LCL and anchored near the lateral femoral epicondyle, reducing excessive rotational stress on the knee and enhancing overall graft stability.^[15-17]

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Figure 1:

The surgical exposure reveals the patellar tendon, with precise dissection to extract the bone-patellar tendon-bone graft for ligament reconstruction.

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Figure 2:

Iliotibial band (ITB) incised for lateral extra-articular tenodesis (LET).

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Figure 3:

Intraoperative view of bone-patellar tendon-bone graft preparation in revision anterior cruciate ligament reconstruction.

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Figure 4:

View of iliotibial band (ITB) incision for distal end incised

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Figure 5:

Iliotibial band (ITB) passed deep beneath the lateral collateral ligament (LCL) during lateral extra-articular tenodesis (LET).

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Figure 6:

Fiberwirepassed through suture disc for iliotibial band fixation in lateral extra-articular tenodesis (LET).

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RESULTS

A total of 46 patients who underwent revision ACL reconstruction using the BTB graft with suture disc fixation and lateral extra-articular tenodesis (LET) were included in the study. The mean age was 39.1 ± 5.1 years. Out of 46 cases, 37 were male (80.4%) and 9 were female (19.6%), with an average age as presented in Table 1 and Figure 7.

Demographic details

The functional activity assessment using the lysholm score was conducted for all patients. The preoperative mean Lysholm score was 25.4 ± 4.4, while at 6 months postoperatively, it increased to 87.1 ± 4.6. A paired sample t-test was performed to evaluate the difference between baseline and 6-month postoperative scores. A statistically significant improvement was observed (p < 0.0001), as detailed in Table 2, indicating a notable enhancement in functional outcomes.

In a previous study evaluating ACL reconstruction outcomes, patients who underwent revision ACL reconstruction using a cadaveric BTB allograft demonstrated a mean Lysholm score of 54.7 preoperatively, which improved to 72.3 at the 1-year follow-up and further to 77.4 at 3 years postoperatively. Comparatively, in patients who underwent primary ACL reconstruction with an autologous BTB graft, the Lysholm score was 64.4 preoperatively, increasing to 85.1 at 1 year and 88.2 at 3 years postoperatively. Additionally, the primary control group achieved Tegner scores of 6.7 preoperatively, followed by 5.1 at 1-year and 6.2 at 3-year follow-up, highlighting functional improvements over time.^[19]

Another study reported^[15], a comparison of Lysholm scores between the revision ACLR and primary ACLR groups showed a significant improvement from the preoperative assessment to the final follow-up in both groups. Preoperatively, pain and swelling scores were notably lower in the revision ACLR group compared to the primary ACLR group (P < .05). Additionally, at the final follow-up, pain levels remained significantly lower in the revision ACLR group (P < .05), highlighting differences in postoperative recovery between the two groups.

The repeated measures ANOVA demonstrated a statistically significant improvement in functional outcomes over time (F = 2503.43, p < 0.00001), reflecting continuous recovery and enhanced knee stability following revision ACL reconstruction with a BTB graft and lateral extra-articular tenodesis [Table 3].

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Figure 7:

Gender distribution.

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Postoperative complications were minimal, with one patient (2.2%) developing a mild superficial infection that resolved with standard treatment. Additionally, two patients (4.3%) experienced superficial numbness. The majority of patients (93.5%) did not report any complications [Table 4].

The most frequently observed complications included infection (2.9%) and graft rupture (2.4%) were the most common complications. Infections occurred in six cases, with Staphylococcus aureus, Staphylococcus epidermidis, Klebsiella, and Enterococcus identified. Symptoms appeared within 10 days post-surgery, including elevated CRP, knee pain, and fever. Treatment involved aspiration, irrigation, drainage, and a 3-week antibiotic course until symptom resolution.^[20] Arthroscopic intraoperative and postoperative views have been represented in Figure 8.

DISCUSSION

ACL injuries are among the most common ligament injuries affecting the knee.^[21] The rate of revision ACL reconstruction is rising, particularly in young and active individuals with high functional demands. Identifying factors that impact outcomes is essential for personalized care, as revision procedures typically have less favorable results than primary ACL reconstruction.^[22] The outcome of arthroscopic ACL reconstruction is influenced by multiple factors, including graft tension at fixation, graft type and source, tunnel positioning, knee flexion angle during fixation, fixation technique, and initial graft tension. Among these, the tension applied during graft fixation is considered a key factor in determining the success of the procedure.^[7] Many surgeons prefer BTB autografts due to their strength, secure bone-to-bone healing, and availability. However, BTB allografts have gained popularity, particularly in patients over 40 years old or those with multiligament injuries, poor donor tissue quality, or early joint degeneration. The advantages of allografts include smaller incisions, reduced donor site morbidity, shorter surgery time, and potentially faster recovery with less impact on the extensor mechanism.^[23] A common method for femoral graft fixation in ACL reconstruction is suspensory fixation using a fixed- or variable-loop EndoButton. Unlike other devices, it allows graft retensioning after fixation. This technique utilizes a cost-effective suture disc device for strong tibial fixation while enabling graft retensioning by rotating it clockwise.^[7] Our study demonstrates favorable to excellent functional outcomes following revision ACL reconstruction using the graft technique, substantial enhancement in functional outcomes following ACL reconstruction, as reflected by the significant increase in Isholmknee scores at 6 months postoperatively.

The study by Schulz et al.^[24] Reported an average lsholmscore of 89 points at follow-up, while Struewer et al.^[25] observed a slight decrease from 95.7 before injury to 92.4 2 years postoperatively. In contrast, the improved outcomes in some studies may be attributed to a longer follow-up period, allowing for extended recovery and rehabilitation.^[26]

Graft selection in primary ACL reconstruction continues to be a subject of debate, with various options available and choices often influenced by surgeon preference. Although some surgeons are inclined toward patellar tendon autografts and others toward hamstring autografts.

The study by Meena et al. evaluated 97 patients who underwent revision ACL reconstruction using quadriceps tendon (QT), HT, and BTB autografts. ^[27] All three autograft types, QT, HT, and BTB—provided acceptable patient-reported outcomes following revision ACL reconstruction. However, the HT graft exhibited a comparatively higher risk of failure (19%) than the QT (10%) and BTB grafts (10%).^[27] Using data from the danish knee ligament reconstruction registry, Rahr-Wagner et al. reported that patients who received hamstring autografts for ACL reconstruction had a 1.41 times higher relative risk of requiring revision surgery compared to those who received BTB autografts.^[28] Infections following ACL reconstruction, though rare (0.14% to 1.7%), can lead to multiple reoperations, prolonged antibiotic therapy, graft removal, and delayed revision, potentially worsening outcomes due to cartilage damage and arthrofibrosis.^[29,30] While earlier studies suggested a higher infection risk with allografts, recent evidence shows no significant difference in infection rates between allograft and autograft reconstructions.^[2,30,31] Boyd E. et al. reported that complications after ACL reconstruction are rare, with anterior knee pain being more common in BTB autografts. Other issues include sensory changes, stiffness, weakness, and laxity. While no strong evidence links allografts to a higher infection risk than autografts, hamstring autografts may have a higher infection risk than BTB autografts.^[2]

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Figure 8:

(a) Arthroscopic intraoperative view of intraarticular structures. (b) Arthroscopic postoperative view with graft in-situ

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Returning to sports after ACL reconstruction is influenced by multiple factors, including the type of surgery, rehabilitation progress, psychological readiness, and social support. Younger athletes are particularly at risk for re-injury, sometimes experiencing multiple ACL tears. Premature return to sports can lead to additional injuries, such as meniscal tears or cartilage damage, which may increase the likelihood of developing osteoarthritis over time. While ACL reconstruction helps restore knee stability, it does not fully prevent long-term joint degeneration. Therefore, a structured and individualized return-to-sport program, based on strength, stability, and functional testing, is crucial to minimize risks and ensure a safe return to athletic activities.^[32]

A study reported that 83% of elite athletes successfully returned to sports following ACL reconstruction, with a graft rupture rate of 5.2%. Additionally, athletes who resumed sports demonstrated performance levels comparable to their uninjured counterparts. These findings provide valuable insights for both athletes and clinicians in setting realistic expectations regarding recovery and return to play after ACL reconstruction.^[33]

A key consideration in revision ACL reconstruction is deciding between a single-stage or “two-staged”approach.^[34] Outcomes and patient-reported scores between single-stage and two-stage ACL revisions show similar results.^[35] The decision between the two approaches primarily hinges on tunnel positioning, bone quality, and the feasibility of securing the graft. Single-stage revision is often preferred when the existing tunnels are well-positioned, bone stock is sufficient, and secure graft fixation is possible. On the other hand, two-stage revision is typically recommended when tunnel enlargement exceeds 10-15 mm.^[34] For example, Achtnich et al. (2018) found that 60% of femoral and 54% of tibial tunnels were anatomically placed, suggesting that single-stage revision can be a viable option in such cases.^[36] In contrast, Mitchell et al. (2017) advised a two-stage revision when tunnel widening or incorrect tunnel positioning compromised graft fixation.^[37] Single-stage revision offers several advantages, including avoiding a second surgery, reducing overall costs, minimizing morbidity, and shortening rehabilitation and return-to-sport times compared to two-stage procedures.^[35] Our study is limited by its retrospective design and small sample size, which may affect the generalizability of the findings. Additionally, long-term follow-up data on graft durability and functional outcomes were not assessed.

CONCLUSION

Our study demonstrates that ACL reconstruction with BTB graft with a suture disc and lateral extraarticular tenodesis was superior in single-stage revision and provides a strong and stable reconstitution. This technique ensures secure, safe fixation of the graft, lowers the rotational stress, and facilitates early recovery. Patients are attributable to normal levels of activity and have a safe return to sports within a reasonable time frame. The lack of postoperative infections continues to support the effectiveness of this approach in the treatment of ACL disorders.