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Revision ACL Reconstruction

Primary Anterior Cruciate Ligament reconstruction is a common procedure that is increasing due to an increase in ACL injuries in young patients who participate in athletic activities. While the procedure is highly successful in about 70% – 95% of patients, approximately 10% -15% of patients will require a revision procedure. Failure rates are higher in young, competitive athletes. Identifying the causes of failure is vital to improve the success of revision surgery.

Revision ACL reconstruction refers to a surgical procedure performed to address a previously reconstructed ACL that has failed to improve knee stability and function.

Failure can be due to various reasons such as a new injury, technical errors in the initial surgery including graft failure, associated injuries of the meniscus or other ligaments that are not addressed, malalignment, anatomic risk factors such as high tibial slope, complications from the initial surgery, inadequate postoperative rehabilitation, and returning to high-risk sports too early. Identifying the cause of failure is crucial for successful revision ACL reconstruction. Tunnel malposition has been reported as the most common reason for failure.

Symptoms are similar to those experienced with an initial ACL tear including:

  • Recurrent instability such as the sense of the knee giving way or shifting, especially during pivoting or cutting movements
  • Persistent or recurrent pain especially during or after physical activity can indicate graft failure or associated knee damage
  • Recurrent swelling after physical activity indicates cartilage or meniscus related issues
  • Stiffness, pain and reduced range of motion can occur due to arthrofibrosis
  • A locking sensation may indicate an associate injury to the meniscus or loose bodies in the joint
  • Apprehension that the knee might give out
  • Difficulty or inability returning to previous levels of physical activity or sports due to pain, instability or lack of confidence in the knee.

Your Hyper Regen Sports Medicine professional will conduct an in-depth preoperative examination including a review of your medical history, listening to recurrent symptoms such as instability, the knee giving way, persistent pain and swelling or locking. Also, a history of recent trauma is vital.  Non-compliance with postoperative rehabilitation will also provide valuable clues.

They will also perform a physical exam using a range of tests to evaluate the integrity of the ACL, PCL, posterolateral and posteromedial corners, as well as the meniscal structures. New X-rays will be ordered to assess tunnels, hardware from the prior surgery, alignment and osseous anatomy while an MRI will be arranged to assess ligaments, meniscus and cartilage. A CT scan will likely be ordered to assess prior ACL tunnel size and location which will influence whether a one-stage or two-stage revision will be performed.

When an ACL reconstruction fails, revision surgery is indicated to improve knee function. Treatment is tailored based on the underlying cause of the failure, the patient’s individual circumstances and the presence of any associated knee injuries or complications. If prior ACL tunnels are a reasonable size and in an acceptable location, a one stage operation can be performed with a new ACL autograft.  If tunnels are too large or will influence correct tunnel placement, a two-stage operation will be performed. In this situation the first operation will allow for graft and hardware removal, diagnosis of associated injuries and bone grafting.  The second operation takes place 3-4 months later where the ACL is revised. If there are additional injuries or issues contributing to the ACL graft failure, such as meniscal tears, chondral lesions, or injuries to other knee ligaments, these will be addressed concurrently with the revision surgery.

After revision ACL reconstruction, postoperative rehabilitation is crucial. It will be tailored to the patient’s needs based on the technical details associated with revision surgery. Physical therapy will focus on restoring range of motion, strength and restoring function for activities and sports. If you are someone you know are experiencing knee symptoms such as instability following an ACL reconstruction surgery, contact HyperRegen Sports Medicine to schedule a consultation.

At a Glance

Dr. Jas Chahal

  • Head of Orthopaedic Surgery, Women’s College Hospital
  • Team Physician Toronto FC and University of Toronto Varsity Blues
  • Associate Professor, University of Toronto Orthopaedic Sports Medicine Program
  • Has more than 100 peer-reviewed publications
  • Learn more

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