Revision ACL Reconstruction: Principles and Practice

Abstract

Introduction: The incidence of anterior cruciate ligament reconstruction (ACLR) surgeries is increasing and so is the number of revision surgeries for a failed ACLR. The spectrum of ACL failure includes symptoms of recurrent instability, pain, and/or stiffness.

Discussion: Factors contributing to ACL failure may be classified as patient-related, surgeon-related, and biological factors. Of these, tunnel malposition and recurrent trauma are the most common causes. Detailed patient assessment, imaging, and studying details of the index surgery are critical prior to planning revision surgery. Infection has to be ruled out prior to planning any reconstructive surgical procedure. Osseous malalignment in the coronal or sagittal planes would also need correction along with or prior to revision ACL surgery. Revision ACL reconstruction maybe performed as a one-stage or two-stage procedure. Severe tunnel dilatation, infection, or arthrofibrosis necessitates a two-stage approach. Autografts are preferred for revision ACL due their lesser re-tear rates and better outcomes. Associated meniscus tears and cartilage injuries are more common in revision than in primary surgery and need to be managed appropriately. Extra-articular reconstruction for controlling anterolateral instability is frequently required as well.

Conclusion: Revision ACL reconstruction is a complex undertaking due to limited graft options, compromised anatomy and high frequency of associated injuries. Patient expectations must be tempered because functional outcomes and return to pre-injury sports are inferior to a primary surgery.

Keywords: Anterior cruciate ligament; Anterior cruciate ligament reconstruction; Autograft; One-stage reconstruction; Posterior tibial slope; Re-tear; Revision; Tunnel dilatation; Tunnel malposition; Two-stage reconstruction.

Fig. 1

Etiological factors responsible for failure of an anterior cruciate ligament failure (RTS return to sports, CRPS complex regional pain syndrome)

Fig. 2

Right knee arthroscopy, viewing from the anterolateral portal, knee in 90º flexion. Malpositioned femoral tunnel (shown with chondral pick) above the intercondylar ridge (dotted line) seen during revision surgery. The anatomic tunnel position shown with blue arrow

Fig. 3

Authors’ decision-making algorithm for a patient with a failed ACLR (CBC complete blood count, ESR erythrocyte sedimentation rate, CRP C-reactive protein, ROM range of motion, ALRI anterolateral rotary instability, AMRI anteromedial rotary instability, PLC posterolateral corner, MCL medial collateral ligament)

Fig. 4

Bone–patella tendon–bone graft with a tongue of bone on the tibial side which can be used to fill up defect in the tunnel during a one-stage revision ACL reconstruction

Fig. 5

a Arthroscopic image of a dilated femoral tunnel following a double-bundle ACL failure measuring 16 mm. b Bone grafting performed using iliac crest autograft to fill up the defect. c Tibial tunnels were also enlarged but with intact cortical bridge. d Cancellous chips from iliac crest used for grafting the tibial tunnels. CT scan after four months showing bony consolidation in the tunnels seen on sagittal (e), coronal (f) and axial (g) sections

Fig. 6

a Anteroposterior standing full-length scanogram showing the Mikulicz line passing medially at the knee in a patient who had an ACL graft rupture. b High tibial osteotomy performed to correct the varus malalignment

Fig. 7

a Full-length lateral radiograph of tibia showing the proximal posterior tibia slope as 74º in a patient whose ACL failed. Anteroposterior (b) and lateral (c) radiographs after a de-flexion osteotomy via a tibial tubercle osteotomy approach to reduce the slope and revision ACL reconstruction with quadriceps tendon graft

Fig. 8

Right knee arthroscopy, viewing from the anterolateral portal, knee is 30º flexion and valgus force applied. a The medial meniscus is absent due to a subtotal meniscectomy performed during primary ACL reconstruction. b Medial meniscus allograft transplantation performed during revision ACL reconstruction (MFC medial femoral condyle, MTC medial tibial condyle)