Revision ACL Reconstruction

Indications

• Functional instability with desired or daily activities

• Positive pivot shift, Lachman test consistent with anterior cruciate ligament (ACL) insufficiency

• KT 1000 >5 mm

• MRI demonstrating

Preoperative Evaluation

History

• Determining the reason for failure is crucial.

• Technical

• Trauma

• Biological

• Failure within 6 months without an interlude of full functional activity may indicate biological graft issues or technical issues.

• Difficulty achieving motion with rehabilitation may indicate technical tunnel placement issues.

• Failure and giving way with minimal trauma may indicate that the graft failed before the recent trauma.

• A significant period of full functional activity followed by a significant traumatic episode—pure traumatic failure and an approach similar to that used in the primary anterior cruciate ligament reconstruction (ACLR) may be successful.

Physical Examination

• Should focus on knee motion and other ligament or structural laxities that may contribute to graft stretching and ultimate failure.

• Range of motion—emphasis on knee extension; significant hyperextension usually requires graft fixation with knee in full extension

• Effusion

• Posterior drawer to evaluate posterior cruciate ligament

• Medial and lateral collateral testing

• Dial test to evaluate posterolateral corner

• Gait observation to demonstrate subtle valgus thrust issues

Imaging

• Imaging should focus on issues that will require modification of the primary procedure.

• Radiographs

• Long-leg bilateral standing film to demonstrate varus or valgus alignment that may affect symptom outcomes and graft stretching.

• Standing lateral view can demonstrate any tibial slope issues.

• Weight-bearing (bent-knee 45-degree posteroanterior) radiographs to evaluate for degenerative changes.

• Full extension lateral, with bolster under the ankle, shows tibial tunnel position.

• Other imaging modalities used at surgeon’s discretion

• CT scans give best information regarding precise tunnel location and size.

▪ If tibial or femoral tunnels have enlarged to 15 mm or larger in diameter, some form of singlestage or two-stage bone grafting is indicated.

• MRI shows meniscal and cartilage damage.

Sterile Instruments/Equipment

• Previous operative note

• C-arm fluoroscopy

• Implant removal set

• Microfracture awls

• Osteochondral autografting sets

• Meniscal repair equipment

• Bone-graft harvesting instruments if indicated

• Allograft for primary or backup use as graft choice

Surgical Procedure

• Surgical approach

• Previous incisions are used or extended if possible.

• Skin bridges <7 cm wide should be avoided.

• Anteromedial.

• Transtibial.

• Rear-incision or two-entry—can utilize new femoral bone vs anteromedial or transtibial based on different angle of tunnel (Figs. 44-1, 44-2, 44-3 and 44-4).

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