title: Additional surgery after anterior cruciate ligament reconstruction: can we improve technical aspects of the initial procedure?
abstract: OBJECTIVE
  To determine factors that cause reoperation after anterior cruciate ligament (ACL) reconstruction and determine which cause of reoperation can be addressed to help to improve technical aspects of the initial procedure.
  
  
  METHODS
  Between 1988 and 1998, 436 patients underwent an ACL reconstruction by a single surgeon. We analyzed all 207 patients who had a bone-patellar tendon-bone reconstruction (BPTB). The same technique was used in all operations, which consisted of the 1-incision endoscopic approach with autologous central third patellar-tendon graft. Of these patients, 196 were available for full evaluation. Evaluation included: a detailed history, physical examination, functional knee ligament testing, KT-1000 arthrometer testing, One-leg-hop testing, Lysholm score, Tegner score, and the International Knee Documentation Committee standard evaluation form. All technical surgical aspects concerning the index operation and the reoperations were collected and evaluated in detail to detect predictors for failure or improvement. Position of the graft was measured radiographically using the Amis circle and Taylor score.
  
  
  RESULTS
  The average age of the 196 patients at the time of the operation was 34 years, and the mean duration of follow-up was 7.4 years. Seventy-seven reoperations were performed in 54 (27.6%) patients during a period of 83 months postsurgery. Reoperations were done between day 22 and 83 months post-ACL reconstruction. Indications for reoperations were: pain caused by fixation material (n = 25); meniscal lesions (n = 24); cyclops lesion (n = 16); donor site morbidity (n = 5); re-rupture of the ACL (n = 5); posterior cruciate ligament rupture (n = 1); and a medial collateral ligament lesion (n = 1). A more ventral position of the graft on the femur (Amis <60%) was correlated with a higher frequency of meniscal lesions and cyclops lesions (P < .01). Patients who had a meniscal lesion after an ACL reconstruction had significantly lower Lysholm (P < .05) and Tegner scores (P < .01).
  
  
  CONCLUSIONS
  A large percentage of the patients (27.6%) required additional surgical procedures after patellar tendon autograft ACL reconstruction. A poor position of the graft resulted in cyclops and meniscal lesions. Analyzing the reasons for reoperations gives information about how to improve our surgical technique.
  
  
  METHODS
  Level IV, therapeutic case series.
authors.affiliation: Department of Orthopedic Surgery and Traumatology, OLVG Amsterdam, UMCU Utrecht, Amphia Hospital Breda, The Netherlands. robvang@hotmail.com
authors.forename: Robbert A H E
authors.initials: RA
authors.lastname: van Dijck
authors.forename: Daniel B
authors.initials: DB
authors.lastname: Saris
authors.forename: Jaap W
authors.initials: JW
authors.lastname: Willems
authors.forename: Alex W F M
authors.initials: AW
authors.lastname: Fievez
mesh_terms: D000293:Adolescent; D000328:Adult; D016118:Anterior Cruciate Ligament / Q000601:surgery*; D000070598:Anterior Cruciate Ligament Injuries; D050376:Bone-Patellar Tendon-Bone Grafting; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019637:Orthopedic Procedures; D019651:Plastic Surgery Procedures; D012086:Reoperation