Revision ACL Reconstructions: A Comparative Effectiveness Treatment Study

描述(由申请人提供)：翻修前交叉韧带(ACL)重建在骨科实践中是一种不常见但临床上重要的挑战。技术问题需要特定的修订技术来解决并发症，如保留的硬件、骨隧道缺陷和错误的隧道放置。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基于患者的更差的结果、增加的膝关节松弛、较高的移植物失败率、半月板变性和软骨损伤。手术成功率较低的原因有很多，包括隧道位置受损、初次重建过程中未对病理进行处理以及更多地依赖同种异体移植物进行翻修。为了评估这些因素和其他因素对预后的贡献，必须确定并前瞻性地跟踪大量正在进行修订的患者。然而，由于在任何一个中心进行前交叉韧带重建术的频率相对较低，一个大型的多中心研究是必要的，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，多中心前交叉韧带翻修研究(MARS)组被建立为87名外科医生多中心组，以执行翻修前交叉韧带重建的前瞻性纵向队列分析。这是一个学术和私人执业医生混合的团体，并得到了美国运动医学整形外科学会(AOSSM)的支持和认可。该组织已经招募了三年多的翻修前交叉韧带重建患者，并积累了800多名患者。这项资助采用前瞻性队列研究设计，重点放在两年随访时前交叉韧带翻修结果的可修改预测因素上。总体目标是阐明影响前交叉韧带修复术成功或失败的因素。我们假设，在翻修前交叉韧带重建时存在可修改的自变量，它们将预测翻修前交叉韧带重建的结果。这将通过专注于四个具体目标来实现。具体目标1将决定移植物的选择是否能预测移植物再发、再次手术、术后2年恢复运动功能和活动水平的发生率。具体目标2将确定可改变的手术因素是否影响移植物复发率和恢复运动功能。具体目标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/或程度是否可以预测术后2年的活动水平、运动功能恢复以及疼痛和肿胀症状。具体目标4是一个探索性目标，它决定了各种康复因素是否会影响前交叉韧带翻修术后2年移植物复发或重返运动。这项研究的结果将推动骨科运动医学领域的发展，因为它将指导医生最适当地选择重建的移植物，修改手术入路和技术，并以提供最佳结果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.