Revision ACL Reconstructions: A Comparative Effectiveness Treatment Study

描述（由申请人提供）：前交叉韧带（ACL）重建是骨科实践中罕见但临床上重要的挑战。技术问题需要特定的翻修技术来解决并发症，如保留的硬体、骨隧道缺陷和不正确的隧道放置。此外，通常报道翻修手术的结果仍然不如初次重建。这些较差的结果包括较差的患者预后，膝关节松弛增加，移植物失败率较高，半月板变性和软骨病变。导致预后较差的一些原因已经被提出，包括隧道位置受损，在初级重建期间未治疗的病理，以及更多地依赖同种异体移植物进行修复。为了评估这些因素和其他因素对结果的影响，必须对大量正在进行翻修的患者进行识别和前瞻性随访。然而，由于在任何一个中心进行ACL重建的频率相对较低，因此有必要进行大型多中心研究，以便在合理的时间框架内积累足够的受试者，以便进行多变量分析。考虑到这一点，多中心ACL翻修研究（MARS）组成立，作为87名外科医生多中心组，对翻修ACL重建进行前瞻性纵向队列分析。这是一个由学术和私人执业医生组成的混合小组，得到了美国运动医学骨科学会（AOSSM）的支持和认可。该小组已经招募了三年多的ACL翻修重建患者，累计超过800例患者。本资助采用前瞻性队列研究设计，重点关注两年随访时ACL翻修结果的可修改预测因素。总体目标是阐明导致ACL翻修成功或失败的因素。我们假设在修正ACL重建时存在可修改的独立变量，这些变量将预测修正ACL重建的结果。这将通过关注四个具体目标来实现。具体目标1将确定移植物选择是否预测移植物再破裂、再手术、术后2年运动功能恢复和活动水平。具体目标2将确定是否可改变的手术因素影响移植物再破裂率和恢复运动功能。特异性目标3将确定在翻修前交叉韧带重建时测量的半月板和软骨损伤的患病率和/或程度是否能预测术后2年的活动水平、运动功能恢复以及疼痛和肿胀症状。特异性目的4是一个探索性目的，确定各种康复因素是否影响前交叉韧带翻修手术2年后移植物再破裂或恢复体育活动的发生率。本研究的结果将推动骨科运动医学领域的发展，因为它将指导从业者最适当地选择移植物进行重建，修改手术方法和技术，并以最佳的方式处理半月板和软骨损伤。

DESCRIPTION (provided by applicant): Revision anterior cruciate ligament (ACL) reconstruction represents an infrequent but clinically important challenge in orthopaedic practice. Technical issues require specific revision techniques to address complications such as retained hardware, bone tunnel defects, and incorrect tunnel placement. Moreover, it is commonly reported that the results of revision surgery remain inferior to primary reconstructions. These poorer outcomes include worse patient based outcomes, increased knee laxity, higher graft failure rate, meniscal degeneration, and chondral lesions. A number of reasons for the poorer outcome rate have been proposed, including compromised tunnel location, pathology untreated during the primary reconstruction, and greater reliance on allografts for revisions. In order to evaluate the contributions of these and other factors to outcome, large numbers of patients who are undergoing revisions must be identified and followed prospectively. However, due to the relative infrequency of revision ACL reconstructions in any one center, a large multi-center study is necessary to accumulate enough subjects over a reasonable time frame to allow for multivariable analyses. With this in mind, the Multi-center ACL Revision Study (MARS) group was established as an 87 surgeon multi-center group to perform a prospective longitudinal cohort analysis of revision ACL reconstruction. This is a mixed group of academic and private practice physicians and has been supported and endorsed by the American Orthopedic Society for Sports Medicine (AOSSM). The group has been enrolling revision ACL reconstruction patients for over three years and has accumulated greater than 800 patients. This grant uses a prospective cohort study design and focuses on the modifiable predictors for ACL revision outcome at two-year follow-up. The overall goal is to elucidate the factors responsible for success or failure of ACL revision. We hypothesize that modifiable independent variables exist at the time of revision ACL reconstruction that will predict revision ACL reconstruction outcomes. This will be accomplished by focusing on four Specific Aims. Specific Aim 1 will determine if graft choice predicts incidence of graft rerupture, reoperation, return to sports function and activity level 2 years post-surgery. Specific Aim 2 will determine if modifiable surgical factors influence graft rerupture rates and return to sports function. Specific Aim 3 will determine if both prevalence and/or degree of meniscal and chondral damage measured at the time of the revision ACL reconstruction predicts activity level, return to sports function, and pain and swelling symptoms 2 years post-surgery. Specific Aim 4 is an exploratory aim, which determines if various rehabilitation factors influence the incidence of graft rerupture or return to sports activity 2 years following revision ACL surgery. The results of this study will drive the field of Orthopaedics Sports Medicine, in that it will guide practitioners to most appropriately choose the graft for reconstruction, modify surgical approaches and techniques, and manage meniscal and chondral injuries in a way to provide optimal outcome.