[Comparison of the Outcomes of Revision Anterior Cruciate Ligament Reconstruction Using Cadaverous BTB Graft with the Outcomes of Primary ACL Reconstruction with Filtering out the Effects of Age and Sex]. / Srovnání výsledku revizní rekonstrukce predního zkrízeného vazu kolenního kloubu kadaverózním BTB stepem s výsledky po primární rekonstrukci LCA s odfiltrováním efektu veku a pohlaví.

PURPOSE OF THE STUDY Evaluation of the success rate of revision ACL reconstruction using the cadaverous BTB allogeneic graft and comparison of the outcomes achieved with the data of patients after the primary ACL reconstruction using the autologous BTB graft with filtering out the potential effect of diversity of the groups of patients as concerns sex and age. MATERIAL AND METHODS The evaluated outcomes of 34 patients operated in the period 2004-2017, i.e. with the minimum follow-up period of three years, were compared with the outcomes of 34 patients selected individually so that in pairs the age and sex are identical - 10 women and 24 men in the range of age from 20 to 44 years, with the median of 29 years at the time of surgery. The assessment and comparison of the outcomes achieved are done according to the Lysholm and Tegner scores. RESULTS The mean Lysholm score of the patients after the revision ACL reconstruction using the cadaverous BTB allograft achieved 54.7 points preoperatively, 72.3 points at the 1-year follow-up and 77.4 points at the 3-year follow-up. The Tegner score at the time of full performance before the injury was 7.7 points, whereas it was 5.8 points after the injury and 6.5 points three years after the surgery. In the group of patients after the primary ACL reconstruction using the autologous BTB graft, the Lysholm score was 64.4 points preoperatively, 85.1 points one year postoperatively and 88.2 points three years postoperatively. The results according to the Tegner score achieved by the primary control group at respective follow-up periods were 6.7 points, 5.1 points and 6.2 points respectively. DISCUSSION The increase in the number of performed ACL reconstructions leads also to an increase in the number of revision surgeries. This trend is also fuelled by the change in the lifestyle, the shift in age-related indication criteria for surgery, and other factors. The realistic expectations regarding the outcome of the revision ACL reconstruction shall take into account the effect of multiple insults that the knee must withstand. Even though subjective improvement of the knee condition is usually experienced postoperatively, the achieved outcomes tend to be less positive than in primary reconstructions. The return to the original pre-injury level of sports activities is achieved less frequently after revision surgeries. CONCLUSIONS The revision surgery of ACL rupture using the cadaverous BTB graft is a safe and reliable technique. It has a potential to improve the subjective satisfaction of the patient, nonetheless the mean postoperative Lysholm score is not so high as that achieved in patients after primary ACL reconstruction. Key words: anterior cruciate ligament, revision ACL reconstruction, cadaverous BTB graft, ACL graft rerupture.

[The Use of BTB Allograft in Revision Reconstruction of the Anterior Cruciate Ligament and Its Success Rate in Terms of Subjective Patient Satisfaction]. / Úspesnost kadaverózních náhrad predního zkrízeného vazu kolenního kloubu se zamerením na subjektivní spokojenost pacientu.

PURPOSE OF THE STUDY A retrospective evaluation of the success rate of revision ACL reconstruction performed using BTB allograft in terms of the life expectancy of the procedure up to and over five years from surgery. MATERIAL AND METHODS Over a ten-year period, from 2003 to 2013, we performed 47 revision ACL reconstruction surgeries. The majority of the primary ACL reconstructions using BTB autografts were not performed at our site. The group observed included 16 women (34%) and 31 men (66%). The women were aged between 25 and 48 years, the median age being 32.5, and the men were aged between 25 and 46 years with the median age of 35. We were able to make a full pre- and post-operative evaluation of 22 out of 47 patients who underwent secondary ACL reconstruction surgery using a cadaverous BTB graft. This evaluation included an objective clinical testing and a subjective evaluation of the function and stability of the knee joint using the Tegner activity score, Lysholm score, and a modified Cincinatti score. The set of 22 patients was split into two groups: up to five years from revision surgery and over five years from the procedure. RESULTS In the group of patients who were fully evaluated within five years of revision reconstruction there was an average improvement of 16.4 points on the Cincinatti score, 19.9 points on the Lysholm score, and an upward movement averaging 1.5 levels on the Tegner activity score. In the over five years from surgery category the average improvement was 15.5, 15.9, and 1.2 levels upward movement, respectively. We were unable to prove a significantly increased level of failure in BTB allografts after five and more years from revision ACL reconstruction. DISCUSSION The two strongest factors affecting the life expectancy of ACL replacements are the age of the patient and the type of the graft used, allograft or autograft. The most at risk, in terms of how long the graft will last, is the age group of 10 - 19 years old. With each ten-year increase in age the risk of rupture is reduced more-or-less by half. Patients with ACL allograft replacement show a fourfold increased risk of the graft rupturing. The younger and more active the patient requiring revision ACL reconstruction is, the greater the need for an autograft. If an allograft has been used in revision reconstruction on an athlete, a great emphasis must be placed on the necessity of delaying the return to previous sporting activities for at least nine months. CONCLUSIONS The mid-term results of revision ACL reconstruction show that, subject to reasonable levels of stress, a correctly performed procedure using cadaverous BTB grafts is a good option to restore the stability of the knee joint over a period of five years and more from surgery. An increased incidence of reruptures or greater insufficiency of the cadaverous graft were not evident in our group after five and more years. The risk of cadaverous grafts failure is just like in the autologous replacement directly linked to the return to sport interval, frequency and intensity of stress to which the graft is subjected over a long period of time. The risk of rerupture is always higher in allograft reconstructions that have already stood in need of restructuring for a longer period of time. For this reason, a delay in returning to sports activity must be emphasized. As a rule, we recommend a return to full athletic training only after nine months to a year after surgery. Key words: anterior cruciate ligament, revision ACL reconstruction, tendon graft insufficiency, BTB autograft insufficiency, BTB allograft of the ACL, cadaverous BTB graft, ACL graft rerupture.

[Most frequent causes of autologous graft failure in anterior cruciate ligament replacement]. / Nejcastejsí príciny selhání autologních náhrad predního zkrízeného vazu kolenního kloubu.

PURPOSE OF THE STUDY: The aim of this retrospective study was to present a comprehensive overview of the causes of bone-tendon-bone (BTB) autograft failure after primary anterior cruciate ligament (ACL) reconstruction. MATERIAL AnD METHODS: Between 2003 and 2013, we performed revision ACL replacement in 47 patients who had undergone primary BTB autograft ACL reconstruction in other hospitals. The group consisted of 16 women (aged 25 to 48 years) and 31 men (25 to 46 years). Surgery was performed on the right knee in 26 and on the left knee in 21 patients. In each of the 47 patients, two different assessments were made: 1. Analysis of causes of failure based on surgical protocols and/or intra-operative video records taken during most of the procedures. 2. Evaluation of bone tunnel location on lateral knee radiograms, using the method described by Harner for femoral tunnels and that reported by Stäubli and Rauschning for tibial tunnels. RESULTS: The most frequent cause of knee instability, occurring in 51.1% of the patients, was new trauma to the knee. nontraumatic instability in the remaining 48.9% was due to insuffiiency of the graft, and resulted from an incorrect surgical technique (42.5%) or biological causes (6.4%). The most common surgical mistake found was incorrect bone tunnel placement in the tibia or femur, with a malpositioned femoral tunnel being most frequent. This was diagnosed in 32 patients (68.1% of all patients) and, in 17, was the main or major cause of BTB graft failure. DISCUSSION: Based on relevant literature data and our experience, principles for prevention of graft failure after ACL reconstruction can be summarised as follows: 1. harvest of a suffiiently strong BTB autograft 2. accurate anatomical bone tunnel placement 3. appropriate tension of the BTB autograft 4. preventing graft impingement 5. secure graft fiation 6. early functional rehabilitation with an accent on delaying full weight-bearing on the knee (6 to 9 months post-operatively) CONCLUSIONS: New trauma to the knee is the most frequent cause of BTB autograft failure after ACL reconstruction. This can be avoided by participating in a professionally guided rehabilitation programme and not returning to sports activities earlier than 9 months after ACL reconstruction. The most common technical error in ACL reconstruction is non-anatomical tunnel placement in the tibia and femur. Femoral tunnel malposition is most frequent while incorrect tibial tunnel placement, which does not inflence graft failure so much, is less common.