Revision Anterior Cruciate Ligament Reconstruction

Abstract

Context:Reconstruction of the anterior cruciate ligament (ACL) is one of the most common surgical procedures, with more than 200,000 ACL tears occurring annually. Although primary ACL reconstruction is a successful operation, success rates still range from 75% to 97%. Consequently, several thousand revision ACL reconstructions are performed annually and are unfortunately associated with inferior clinical outcomes when compared with primary reconstructions.Evidence Acquisition:Data were obtained from peer-reviewed literature through a search of the PubMed database (1988-2013) as well as from textbook chapters and surgical technique papers.Study Design:Clinical review.Level of Evidence:Level 4.Results:The clinical outcomes after revision ACL reconstruction are largely based on level IV case series. Much of the existing literature is heterogenous with regard to patient populations, primary and revision surgical techniques, concomitant ligamentous injuries, and additional procedures performed at the time of the revision, which limits generalizability. Nevertheless, there is a general consensus that the outcomes for revision ACL reconstruction are inferior to primary reconstruction.Conclusion:Excellent results can be achieved with regard to graft stability, return to play, and functional knee instability but are generally inferior to primary ACL reconstruction. A staged approach with autograft reconstruction is recommended in any circumstance in which a single-stage approach results in suboptimal graft selection, tunnel position, graft fixation, or biological milieu for tendon-bone healing.Strength-of-Recommendation Taxonomy (SORT):Good results may still be achieved with regard to graft stability, return to play, and functional knee instability, but results are generally inferior to primary ACL reconstruction: Level B.

Revision Anterior Cruciate Ligament Reconstruction after Surgical Management of Multiligament Knee Injury

“…[1][2][3][4][5][6][7][8][9][10][11][12][13][14] Revision ACLR presents many technical challenges, namely the presence of previously placed implants, existing bone tunnels/sockets and related bone abnormalities, limited autograft availability, arthrofibrosis, and other concomitant pathology. 15 Variables that increase the risk for failure in patients undergoing primary ACL reconstruction have been well documented for isolated ACL injuries but are not well established for MLKI, which may present additional challenges due to the complexity of the injury. Large cohort studies examining revision ACL reconstruction, including the Swedish, MOON, and MARS studies, have excluded patients with MLKI.…”

“…Large cohort studies examining revision ACL reconstruction, including the Swedish, MOON, and MARS studies, have excluded patients with MLKI. 11,[15][16][17][18] Similarly, Mohan et al (2018) performed a meta-analysis that provided level II evidence regarding revision ACLR functional and patient reported outcomes in patients with isolated ACL injury but not MLKI. 12 One large registry, the Danish ACL reconstruction registry, included multiligament knee injuries, but results of revision ACLR for MLKI were not specifically distinguished among the results.…”

Two-Stage Anterior Cruciate Ligament Reconstruction Revision Surgery for Severe Bone Defects With Anterolateral Ligament Reconstruction Technique

“…The tunnels are filled with dry graft to avoid graft migration (Figs 4-6, Video 1). 6 Our approach Once the tunnels are exposed, they are cleaned thoroughly. It is important to eliminate the remains of the fixation systems used in the previous operation.…”

“…The Achilles tendon provides adequate mechanical strength and sufficient length to both act as an ACL graft and reinforce the ALL in an extra-articular ALL reconstruction stage. 6,11,12 In addition, we carve the bone block into a stopper that self-blocks in the tibial tunnel, resulting in a more natural fixation. 14 The graft can be prepared on a separate table, concurrently with the arthroscopic procedure, to shorten the surgical time.…”

“…4 Therefore, 2-stage revision is reserved for cases wherein 1-stage reconstruction may yield a suboptimal graft choice, tunnel position, graft fixation, or biological environment for graft-bone interface healing. [5][6][7][8] We use allografts for cavity filling and grafting, which helps avoid donor-area morbidity. In addition, we combine ACL repair with an extra-articular anterolateral ligament (ALL) reconstruction stage to increase the knee rotational stability.…”