The American Journal of Sports

Medicine http://ajs.sagepub.com/

Revision Anterior Cruciate Ligament Reconstruction

Ganesh V. Kamath, John C. Redfern, Patrick E. Greis and Robert T. Burks
Am J Sports Med 2011 39: 199 originally published online August 13, 2010
DOI: 10.1177/0363546510370929

The online version of this article can be found at:

http://ajs.sagepub.com/content/39/1/199

Published by:

http://www.sagepublications.com

On behalf of:
American Orthopaedic Society for Sports Medicine

Additional services and information for The American Journal of Sports Medicine can be found at:

Email Alerts: http://ajs.sagepub.com/cgi/alerts

Subscriptions: http://ajs.sagepub.com/subscriptions

Reprints: http://www.sagepub.com/journalsReprints.nav

Permissions: http://www.sagepub.com/journalsPermissions.nav

>> Version of Record - Jan 4, 2011

OnlineFirst Version of Record - Aug 13, 2010

What is This?

Downloaded from ajs.sagepub.com at ORTHO ONE ORTHOPAEDICS on June 11, 2014

 Clinical Sports Medicine Update

Revision Anterior Cruciate M

Ligament Reconstruction
Ganesh V. Kamath,*y MD, John C. Redfern,z MD, Patrick E. Greis,§ MD,
and Robert T. Burks,§ MD
Investigation performed at the University of Utah, Salt Lake City, Utah

Revision reconstruction of the anterior cruciate ligament (ACL) introduces several diagnostic and technical challenges in compar-
ison with primary ACL reconstruction. With the increasing numbers of original reconstructions combined with the continued
expectation of high-level athletic participation, revision ACL reconstruction is likely to become more frequent. The purpose of
this article was to summarize the causes of failure and the evaluation of the patient with recurrent instability. A review of the lit-
erature regarding results after revision ACL reconstruction was performed to assist in the decision-making process and patient
counseling. Good results can be obtained in terms of functional stability after revision reconstruction, but chondral and meniscal
injury as well as unrecognized associated pathologic instability may play a role in diminished outcomes. In addition, a wide variety
of surgical techniques are reviewed to address problems associated with tunnel malposition, widening, and pre-existing hardware.
Keywords: anterior cruciate ligament; revision; recurrent instability; failure

The incidence rate of ACL rupture has recently been
reported to be between 36.9 and 60.9 per 100,000 person-
years.28,60 In the United States, approximately 200,000
ACL ruptures occur annually.33 Indications for primary
ACL reconstruction include patients with symptomatic
anterior instability or those wishing to return to high-level
pivoting and cutting sports. Concern exists that patients
who return to high-level activities without a functional
ACL will have continued meniscal and chondral insult, lead-
ing to progressive knee osteoarthritis.3,41,47,49 Historically,
ACL reconstruction has been a successful operation, with
satisfactory outcomes in 75% to 97% of patients.3,4,9,10,75
Failure of ACL reconstructive surgery may be considered
in the context of objective laxity, patient perception of insta-
bility, postoperative stiffness/pain, extensor mechanism
dysfunction, and infection (Table 1).10 Although risk factors
for poor outcomes have been determined, the true incidence
of failed ACL reconstruction is difficult to calculate and is
likely underreported.28 With more primary procedures
being performed each year and the high level of activity
expected in an aging population, graft failure after ACL
*Address correspondence to Ganesh V. Kamath, MD, University of
Utah Orthopaedic Center, 590 Wakara Way, Salt Lake City, UT 84108
(e-mail: ganesh.m.v.kamath@gmail.com).
y
Department of Orthopaedic Surgery, University of North Carolina at
Chapel Hill, Chapel Hill, North Carolina.
z a 3-mm side-to-side difference correlated with failure of
Colorado Springs Orthopaedic Group, Colorado Springs, Colorado.
§
Department of Orthopaedic Surgery, University of Utah, Salt Lake
City, Utah.
The authors declared that they had no conflicts of interests in their
authorship and publication of this contribution.
The American Journal of Sports Medicine, Vol. 39, No. 1
DOI: 10.1177/0363546510370929
Ó 2011 The Author(s)
reconstruction will likely become a more frequent problem.
The purpose of this article was to review the approach
toward recurrent instability after ACL reconstruction and
the surgical results and options for revision ACL reconstruc-
tion. Representative cases are presented to share the
authors’ preferred approach for revision surgery.
DEFINITION AND CAUSES OF FAILURE
No strict definition of failure after ACL reconstruction
exists. Broadly, patient dissatisfaction after surgery can
be divided into 3 general categories: recurrent instability,
postoperative complications (eg, infection, motion loss,
arthritis), and comorbidities related to concomitant patho-
logic abnormalities (eg, meniscus loss, leg alignment) or
patient characteristics. Recurrent instability is defined as
failure of the reconstructed ligament to provide adequate
anterior and rotatory stability to the knee. Graft function
after ACL reconstruction can be assessed objectively by
physical examination and subjectively through patient-
based criteria. Objective laxity is defined quantitatively
in terms of anteroposterior movement of the tibia with
the knee held in 30° of flexion, and can be measured using
a variety of commercially available instruments (eg,
KT-1000/2000 arthrometer, MEDmetric, San Diego, Cali-
fornia). Daniel et al14,15 initially found that more than
the native ACL. Many studies have used this criteria to
quantify failure of the reconstructed ACL,2,8,11,21,22,56,82
although other studies have used less rigid criteria and
defined graft failure as more than 5 mm.1,17,20,25,52,53,76
Further physical examination data can be obtained by
both the pivot shift examination and Lachman maneuver,
which may show excessive laxity on examination. A recent

199
Downloaded from ajs.sagepub.com at ORTHO ONE ORTHOPAEDICS on June 11, 2014
200 Kamath et al The American Journal of Sports Medicine

TABLE 1 (\6 months) or late (.6 months) laxity. Early laxity is typ-
Causes of ACL Reconstruction Failure ically related to poor surgical technique, failure of graft
incorporation, loss of graft fixation, premature return to
Cause of high-demand activities, and overly aggressive rehabilita-
Failure Presentation Associated Factors tion.18,37,77 Technical errors include improper tunnel place-
Recurrent Early (\6 mo) Poor operative technique ment, inadequate ACL graft, insufficient graft tensioning,
instability Failure of graft incorporation and failure to recognize and treat concomitant laxity and
Premature return to meniscal and articular cartilage injuries.36,37 In recent
high-demand activities studies, at the time of revision reconstruction, technical
Overly aggressive error has been thought to contribute to failure in 22% to
rehabilitation 79% of cases (Table 2). The most common technical error
Late (.6 mo) Repeat trauma to the graft is thought to be incorrect tunnel position, but poor graft
Poor graft placement quality or inadequate graft tensioning may also be causes
Concomitant pathology
of failure. Whether performing a single- or double-bundle
not addressed
reconstruction, failure to replicate the native ACL anatom-
Generalized ligament laxity
(ie, Ehlers-Danlos ical footprints can lead to increased graft stress and even-
syndrome) tual excessive laxity. Anterior femoral tunnel placement
Complications Stiffness Global arthrofibrosis results in excessive graft tension in flexion, leading to
Poor preoperative range either loss of flexion or stretching and resultant laxity of
of motion the graft.13 Posterior femoral tunnel placement will pro-
Prolonged postoperative duce excessive graft tension in extension and laxity in flex-
immobilization ion.13 A femoral tunnel placed vertically in the coronal
Intercondylar notch scarring plane may restore anteroposterior stability but not address
Cyclops lesion
rotational stability.84 In regard to tibial tunnel placement,
Nonanatomical graft
anterior placement will lead to impingement against the
placement
Graft overtensioning intercondylar notch and loss of extension. A tibial tunnel
Complex regional pain placed too far posterior may result in impingement against
syndrome the posterior cruciate ligament, with resultant loss of flex-
Infection Surgical contamination ion or attenuation of the graft if full flexion is achieved.13
Multiple procedures Because of the more posterior position, the moment arm
Comorbidities Extensor Quadriceps muscle of the graft is also diminished in controlling anterior trans-
mechanism inhibition lation of the tibia. Medial or lateral tunnel placement can
dysfunction Loss of patellar mobility result in intercondylar notch graft impingement and possi-
(infrapatellar contraction
ble injury to the tibial plateau cartilage.48 As a result of
syndrome)
inaccurate surgical technique, excessive graft forces and
Inadequate rehabilitation
Joint-related pain Chondral defects strain may lead to inadequate incorporation and result in
and arthritis Postmeniscectomy results early failure.
Secondary instability and malalignment may also play
an important role in failure of the reconstructed ACL. In
meta-analysis found that 32% of ACL-reconstructed knees the revision ACL series that does not exclude such
with autograft had positive findings on a Lachman test and patients, there is an incidence of failure noted between
22% had positive findings on the pivot-shift test,10 suggest- 3% and 31% of missed collateral instability or concomitant
ing that continued laxity may exist in a significant number malalignment (Table 2).jj Unrecognized injuries of the pos-
of patients after reconstruction, despite satisfactory subjec- terolateral or posteromedial structures result in unnatu-
tive outcomes. rally high forces seen in the ACL graft, which result in
The subjective sensation of instability must be evalu- gradual attenuation and eventual early failure.27 Addition-
ated independently in the context of laxity on physical ally, varus malalignment, either solitary or combined with
examination. Despite normal findings on Lachman and medial compartment narrowing from complete or partial
pivot shift examination, some patients may describe the meniscectomy, may result in varus thrust in the limb, lead-
subjective perception of knee instability and giving way, ing to repeated stretching and fatigue on the reconstructed
with the inability to trust the knee while performing pivot ACL.50 The medial meniscus acts as an important second-
and/or twisting activities. Poor muscle control, stiffness, ary restraint to tibial translation,30 and increased forces
and pain may be issues seen in the postoperative setting, are noted in the reconstructed ACL in the meniscus-defi-
which are separate from the reconstructed graft, and cient knee. In the setting of combined ACL graft failure
may be unimproved after revision reconstruction.26,39,40 and medial meniscal deficiency, meniscus transplant may
Associated meniscal and chondral injuries noted at the be considered both for treatment of the medial compart-
time of the original procedure must also be considered in ment and to protect the reconstructed ACL.
the setting of patient dissatisfaction.
The causes of recurrent instability are multifactorial
but they can be generalized into 2 typical categories: early ||
References: 1, 7, 16, 17, 20, 22, 25, 29, 51, 53, 57, 66, 76, 82.

Downloaded from ajs.sagepub.com at ORTHO ONE ORTHOPAEDICS on June 11, 2014

Vol. 39, No. 1, 2011 Revision ACL Reconstruction 201

TABLE 2
Published Results of Revision ACL Reconstructiona
Cause, % Technique, % Grafts, % Laxity OA, %

Technical 2-Incision Hamstring mean KT, mm

New Trauma AM Portal BTB .5 mm, % Mild

Time to Multiligament/ Failure, 21 Chondral Lysholm or IKDC

Ref. Pts Age, y F/U, y Revision, y Malalignment Transtibial 2-Stage Quad Allograft % pivot, % Lesions, % Cincinnatib Tegner A-B, % Mod/Sev RTP, %

Diamantopoulos 107 38.8 6.2 5 63.5 0.0 5.6 42.1 0.0 0.9 63.5 51.5 to .88.5 6.3 57.9 63.5
et al17 24.3 0.0 38.3 6.6 16.9
2.8 100.0 19.6 10.3

Ferretti et al20 30 34 5 5 33.3 0.0 13.3 100.0 0.0 10.0 2.5 10.0 65.4 to .90.0 6.2 92.9 39.3
46.7 100.0 7.1 25.0
NA 0.0 7.1

Salmon et al66 49 23 7.4 4 22.0 0.0 100.0 0.0 10.0 2.5 53.0 85 56.0 39.0 70.0
58.0 0.0 8.2 18.0
NA 100.0 6.1

Weiler et al82 62 31 2 0.0 8.0 100.0 0.0 6.0 2.2 20.0 65.0 to .90.0 91.7
0.0 2.1
Excluded 100.0 4.2

Noyes and 55 28 5 2.8 64.0 36.0 0.0 0.0 24.0 2.2 56.0 61 to .87* 58.0
Barber-Westin53
80.0 64.0 100.0 22.0
31 and 16 0.0 22.0

Garofalo et al25 28 27 4.2 2.1 79.0 0.0 0.0 0.0 3.1 46.0 93.6 6.1 93.0 20 med/14 lat 93.0
100.0 100.0 3.0 12 med/9 lat
NA 0.0 100.0 0.0

Noyes and 21 33 4.1 61.9 33.0 0.0 19.0 2.0 54 to .76* 81.0 71.4
Barber-Westin52
42.9 67.0 19.0
24 and 29 0.0 100.0 19.0

O’Neill54 48 33 7.5 5 42.0 29.2 44.0 0.0 6.0 16.7 84.0 27.0 75.0
79.0 70.8 52.0 6.0 10.0
10.4 and NA 0.0

Denti et al16 60 31 3.5 4.4 52.0 Not given 8.3 61.7 3.3 28.3 90.5 6.7 83.3 78.0
33.0 38.3 10.0
Excluded

Battaglia et al7 63 31 6.1 5 96.8 15.9 31.7 25.0 3.9 71.0 43.0 59.0
3.2 47.6 21.0 13.0
2 and 1 0.0 4.8

Ahn et al1 56 31.6 4 4.4 53.6 100.0 5.4 37.0 26.8 Ach 1.5 21.4 63.4 to .84.6 73.2 39.3
0.0 36.0 3.6 26.8
NA 0.0 0.0

Grossman et al29 29 30.2 5.6 4.7 34.5 89.7 0.0 75 BTB/ 4 Ach 2.8 24 med/24 lat 86.6 5.2 79.3 35 med/7 lat 80 of D-I athletes
48.3 10.3 20.7 3.4 14 med/0 lat
NA 0.0 0.0

Thomas et al76 49 35.4 6.2 0.0 100.0 69.4 0.0 1.36 8 med/10 lat
0.0 30.6 5.0
NA 100.0 2.0

Fox et al22 32 28 4.8 4.1 79.0 75.0 0.0 100 fresh BTB 6.0 1.9 70.0 75 6.3 93.0 35 med/21 lat
25.0 6.0 6 med/6 lat
NA 0.0 3.0

a
Pts, number of patients in study; F/U, follow-up; Rev, revision; AM, anteromedial; BTB, bone-patellar tendon-bone; Quad, quadriceps; KT, KT-1000/2000 arthrometer; IKDC, International Knee Documentation Committee
score; OA, osteoarthritis; Mod/Sev, moderate/severe; RTP, return to play; NA, not available; med, medial; lat, lateral; Ach, Achilles; D-I, Division I.
b
Refers to studies in which the Cincinnati Knee Score is used as an objective outcomes measure versus the Lysholm score.

Late laxity is usually secondary to a single or repetitive include return to competitive pivoting or jumping sports,
trauma to the graft, although technical errors and other contact sports, and young age (25 years).65,70,85 The inci-
associated ligamentous instability may not always present dence of repeat trauma as the cause of failure in recent
as early failures. In contrast to early laxity, in which poor series ranges from 24% to 100% (Table 2),{ and with the cur-
surgical technique is often cited as the primary reason for rent high-performance levels expected after successful ACL
ACL revision, recent evidence suggests that traumatic reconstruction, traumatic injury is likely to play a more
reinjury is the most common mode of late failure.70 With prominent role in graft failure.
proper surgical technique and rehabilitation, the ACL graft
is at no greater risk than the contralateral ‘‘normal’’ knee in
{
the reconstructed patient, but risk factors for re-rupture References 1, 7, 16, 17, 20, 22, 25, 29, 51, 53, 57, 66, 76, 82.

Downloaded from ajs.sagepub.com at ORTHO ONE ORTHOPAEDICS on June 11, 2014

202 Kamath et al
Many failures, however, are unlikely to be attributed to
one specific factor in either the initial surgical treatment or
postoperative course. The largest ongoing series of revision
ACL reconstructions is being collected by the MARS
(Multi-Center ACL Revision Study) group made up of par-
ticipating academic and private practice surgeons from
across the United States. A recent report including the
first 159 patients enrolled in the study examined failure
modes at the time of revision surgery (Wright et al, unpub-
lished data, 2008); 70% of the patients reported some form
of repeat trauma (55% contact and 15% noncontact). Sur-
geon assessment at the time of revision surgery deter-
mined that the mode of failure was traumatic in 32%,
technical in 27%, biologic in 7%, or mixed in 31%. These
data highlight the importance of considering multiple
modes of failure when addressing technical and patient
considerations in the revision setting.
The most common postoperative complication seen after
ACL reconstruction is stiffness, which can range from
a small decrease in terminal flexion or extension to
a marked overall decrease in range of motion.73 Significant
loss of motion is generally due to global arthrofibrosis. This
is seen as a loss of flexion and extension with fibrosis of the
medial and lateral gutters, prepatellar fat pad, and supra-
patellar pouch. Stiffness usually presents as a loss of ter-
minal extension and less commonly as a loss in flexion.
This may be the result of surgical factors such as ACL
reconstruction performed in an acute setting before regain-
ing normal range of motion, prolonged postoperative
immobilization, nonanatomical graft placement, develop-
ment of a cyclops lesion, and inappropriate tension-
ing.45,72,73 Other factors leading to stiffness that are
unrelated to surgical technique may include persistent
synovitis and complex regional pain syndrome. Indolent
infection may also manifest itself through pain, with poor
motion and functional results. Even after successful erad-
ication of infection with graft retention, diminished clinical
results and motion loss may remain persistent.46,67,78,80
Treatment of such postoperative complications should be
directed toward improvement in range of motion and
limb function and is not the primary focus of this review,
which is directed toward revision ACL reconstruction.
Patient-related comorbidities related to the ACL injury
may also result in poor outcomes after ACL reconstruction.
Meniscal and chondral lesions have been noted in published
series to have a negative effect on the clinical outcomes after
reconstruction and may influence the progression of
arthritic changes.35,69,86 Extensor mechanism dysfunction
may also result after original reconstruction and may man-
ifest itself through quadriceps muscle inhibition, loss of
patellar mobility, anterior knee pain, and kneeling
pain.18,59,83 In the setting of the failed ACL reconstruction,
it is imperative for the surgeon to recognize the factors
related to patient failure so a decision can be made as to
whether a revision procedure is necessary.
HISTORY AND PHYSICAL EXAMINATION
A thorough history regarding the injury pattern, associ-
ated ligamentous/meniscal/articular cartilage injury, graft
Downloaded from ajs.sagepub.com at ORTHO ONE ORTHOPAEDICS on June 11, 2014
The American Journal of Sports Medicine
type, graft fixation, as well as other prior procedures per-
formed is necessary when evaluating the symptomatic
ACL patient. Previous clinic notes, radiographs, operative
reports, and intraoperative arthroscopic images can pro-
vide important details regarding the extent of pathologic
changes and techniques used at the initial procedure.
Return to sports and knee function after the original sur-
gery should be documented. Failure to return to a similar
level of activity may point toward technical error associ-
ated with the initial procedure (eg, nonfunctioning graft),
postoperative complications, or inadequate rehabilitation.
Even if a reinjury is suspected, questions should be
directed toward knee performance after the original recon-
structive procedure. This provides information whether
continued problems date to the initial injury, after the first
surgery, or if the new complaint is related to a separate
reinjury or progressive degenerative pathologic changes.
Last, one should evaluate the patient’s expectations and
activity level to determine if they reasonably coincide
with the reconstructed knee or if the patient is a ‘‘knee
abuser’’ with unrealistic expectations.55
After a thorough history is obtained, examination of the
knee is performed. Observation should focus on overall
lower extremity alignment, gait pattern, skin color, muscle
tone, and previous incisions. Quadriceps muscle circumfer-
ence should be compared with the contralateral leg to eval-
uate for muscle atrophy. A goniometer should be used to
measure range of motion and assess the presence of any
flexion contracture or extensor lag. Prone examination
may allow identification of subtle flexion contractures
that may not be seen in the supine position.
Gait and standing alignment should be noted. Any signif-
icant valgus or varus deformity should be noted and then
further quantified with the use of long-cassette radiography
of the lower extremities. Any varus or valgus thrust noted
during walking should key the examiner toward other con-
comitant laxity (medial or posterolateral corner).
A thorough ligamentous examination should be per-
formed to determine associated instability. The ACL can
be evaluated with the Lachman test to determine anterior
laxity and a pivot shift examination to determine rotatory
instability. Typically, anterior laxity as determined by the
Lachman examination is reported as grade I (0-5 mm),
grade II (6-10 mm), or grade III (.0 mm) when compared
with the normal contralateral leg. The pivot shift is reported
as grade 0 (equivalent to contralateral knee), grade I (glide),
grade II (pivot shift), or grade III (gross clunk with sublux-
ation). The KT-1000/2000 arthrometer provides an objective
measurement of anteroposterior laxity and generally more
than 3 mm side-to-side difference on maximum manual test-
ing is considered significant. The posterior cruciate liga-
ment instability is tested by both posterior drawer testing
and assessment of posterior sag sign or the quadriceps
active test. The lateral and medial collateral ligaments are
tested in full extension and 30° of knee flexion. Posterolat-
eral and posteromedial instability should be determined
with the dial test in both 30° and 90° of flexion. If additional
instabilities are noted, the surgical treatment plan must be
designed to address these in either a simultaneous or
sequential fashion.
Vol. 39, No. 1, 2011 Revision ACL Reconstruction 203

PREOPERATIVE RADIOGRAPHIC EVALUATION

At the minimum, a full weightbearing radiographic knee
series should be obtained for each patient with concerns
for recurrent instability or graft failure after ACL recon-
struction. This includes a standing AP view in extension,
flexion weightbearing posteroanterior to assess for joint-
space narrowing, lateral, and Merchant view. A full-length
standing AP view is also recommended if varus or valgus
malalignment or laxity is suspected based on clinical exam-
ination. Development of degenerative changes on radio-
graphs should be documented and the patient should be
counseled on how these findings may alter the approach
and expectations with revision reconstruction.
Preoperative radiographs should be assessed for 3 major
issues regarding the original ACL reconstruction: (1) the
presence of metal hardware that will interfere with the revi-
sion procedure, (2) tunnel position, and (3) tunnel expan-
sion. Previously placed metallic fixation devices do not
always require removal. If subsequent tunnels will not be
affected by their location, removal is not necessary as this
may create residual bony defects requiring attention. If
hardware removal is necessary to facilitate the creation of
a new tunnel, a complete set of implant drivers and Figure 1. Lateral radiograph of a patient with continued insta-
screw-removal instruments must be available at the time bility after ACL reconstruction. An EndoButton is seen on the
of the revision procedure. Previous operative logs can be anterior cortex of the femur, indicative of a vertical graft.
reviewed to determine if special equipment (eg, screw-
drivers) is necessary to facilitate hardware removal as there
are multiple different driver and screw head combinations lateral wall of the notch. Information from both the lateral
in the various ACL reconstruction systems. If such informa- and AP radiographs are pooled to assess previous femoral
tion is unavailable, a wide array of retrieval devices may be tunnel placement (see discussion at case 1).
necessary to facilitate screw and implant removal. In addi- Lastly, tunnels should be assessed for expansion and
tion, commercial ACL revisions sets (such as those produced bone loss. Excessively posterior femoral tunnels at the
by Stryker and Mitek) are available, which should be made original procedure may result in posterior wall blowout,
available at the time of revision reconstruction. which will limit options for fixation at the revision proce-
Although small errors in tunnel placement may not be dure and require the use of some form of lateral cortical fix-
clearly visualized, gross tunnel malposition can usually be ation. In our experience, there are limited surgical
seen on standard radiographs (see discussion of case 3). treatment options for single-stage revision when tunnel
The tibial tunnel should penetrate the articular surface at expansion exceeds 16 to 17 mm. Because excessive tunnel
the midpoint of the tibial plateau on AP view. On the lateral expansion compromises rigid fixation of the new graft, a 2-
radiograph, the tibial plateau can be divided from anterior stage procedure with initial tunnel grafting followed by
to posterior in 4 equal quadrants as described by Harner delayed ACL revision reconstruction is recommended in
et al.32 The tibial tunnel should enter the joint in the poste- this setting. If adequate assessment of the tunnels cannot
rior third of quadrant 2. For the femoral tunnel, Blumen- be made from plain radiographs alone, CT images (with or
saat line can be divided into 4 equal quadrants and the without 3-dimensional reconstructions) can provide
tunnel should be in the most posterior quadrant. With the detailed information regarding tunnel locations and resid-
approach toward anatomical ACL reconstruction, assess- ual bony defects (Figure 2). Magnetic resonance imaging
ment of the femoral tunnel based on the lateral radiograph can also be a useful adjunctive tool, although its use may
is less useful as it emphasizes anteroposterior placement of be diminished in the presence of metal hardware because
the tunnel rather than lateral placement on the femoral of artifact. Important information, however, may be
wall. Although incorrect anterior-posterior placement of obtained regarding graft integrity as well as concomitant
tunnels can best be assessed on the lateral radiograph, an meniscal, chondral, and ligamentous injury.
assessment of graft obliquity is most easily determined on
the AP view. Fixation that is directed or fixed along the
anterior rather than the lateral cortex (eg, EndoButton, PUBLISHED RESULTS OF ACL REVISION AND
Smith & Nephew, Andover, Massachusetts, or interference PATIENT CONSIDERATIONS
screw) (Figure 1) is indicative of a vertical graft despite
potentially correct anterior-posterior placement. Often- An analysis of the results of ACL revision is difficult sec-
times, the femoral tunnel can be noted on the lateral radio- ondary to the multifactorial nature of ACL failure after
graph just inferior to Blumensaat line at a position on the reconstruction, the paucity of revision reconstructions

Downloaded from ajs.sagepub.com at ORTHO ONE ORTHOPAEDICS on June 11, 2014

204 Kamath et al The American Journal of Sports Medicine

Figure 2. Coronal and sagittal CT images of a patient with tunnel expansion after original reconstruction. The tibial tunnel is pri-
marily widened at the intra-articular aperture, which may lead to the ‘‘windshield-wiper effect’’ if the entire defect is not sufficiently
filled at the revision reconstruction. (Images courtesy of Jeffrey T. Spang, University of North Carolina, Chapel Hill, North Carolina.)

reported, and the varied techniques used by surgeons in
the revision setting. Many published reports include
patients with concomitant procedures and additional lax-
ities that complicate interpretation of results. Variations
in graft choices and surgical techniques also create diffi-
culty in drawing conclusions. For the purpose of this
review, our focus will be directed to recently published,
large series of revision ACL reconstructions in the avail-
able literature. The data will be presented to provide infor-
mation on the decision-making process regarding graft
choice, chondral injuries and degenerative changes, time
to reoperation, and return to play. In our analysis of the lit-
erature, outcomes were assessed by 3 criteria: (1) clinical
laxity as measured by pivot shift, Lachman, and KT-
1000/2000 arthrometer examinations; (2) clinical outcomes
scores and return to play; and (3) radiographic evidence of
changes seen in the knee. Information has also been
provided regarding causes of failure, concomitant patho-
logic changes, surgical technique, and patient demo-
graphics. A summary of the cited articles is available in
Table 2.1,7,16,17,20,22,25,29,51,53,57,66,76,82
Results by Graft
Authors have reported successful revision results with use
of both autograft and allograft tissue. Autograft tissue has
been shown to be an effective graft option by many authors
in the revision setting, with the exception of using prior
harvested tissue. Diamantopoulus et al,17 Ferretti et al,20
and Weiler et al82 have published large case series of
patients treated with use of autograft hamstring in revi-
sion surgery. Between 2% and 8% of patients were noted
to have increased laxity by KT-1000 arthrometer (as
defined by .5 mm side-to-side difference) and/or pivot shift
testing postoperatively. Despite addition of an extra-
articular lateral reconstruction (iliotibial band), the results
noted by Ferretti and colleagues20 did not show improved
objective laxity measurements in comparison with the
other hamstring revision reconstructions published in the
literature.
Noyes and Barber-Westin53 have published a series
with use of only autograft patellar tendon in the revision
setting. Higher failure rates were seen in terms of objective
laxity measurements (21%), but their series included sev-
eral patients with concomitant multiligamentous injuries
or malalignment that may have confounded the results.
When analyzing their results, it is important to note that
reharvest of previously used patellar tendon was associ-
ated with a much higher rate of failure than contralateral
or unharvested ipsilateral patellar tendon grafts. Garafalo
et al25 and Noyes and Barber-Westin51 have also published
case series with use of quadriceps tendon for revision ACL
reconstruction. Failure rates based on excessive laxity
range between 6% and 19%.
Other authors have reported use of mixed autograft
cohorts with a mixture of hamstring, bone-patellar tendon-
bone (BTB), and quadriceps tendon. O’Neill57 published
a failure rate of 6% in a series of 48 patients who under-
went revision surgery with unharvested ipsilateral graft
(hamstring or BTB). These findings are similar to the fail-
ure rates noted by Diamantopoulos et al17 and Denti
et al,16 7% and 12%, respectively, who used a mixture of
contralateral and ipsilateral autografts in the revision set-
ting. Importantly, the mean side-to-side KT-1000 arthrom-
eter difference noted in all the cited studies using autograft

Downloaded from ajs.sagepub.com at ORTHO ONE ORTHOPAEDICS on June 11, 2014

Vol. 39, No. 1, 2011
tissue is between 1.0 and 2.5 mm, which is similar to
reported results after primary reconstruction. No authors
have reported a difference in either clinical outcomes scores
or objective laxity measurements when comparing different
types of autograft tissue. Admittedly, because of sample
size, reports in the literature likely do not have sufficient
power to detect small differences in outcome.
Few reports exist regarding isolated use of allograft tis-
sue in the revision setting. Fox et al22 published a series of
32 patients undergoing revision using nonirradiated, fresh-
frozen patellar tendon allograft. Patients with concomitant
multiligamentous injuries or malalignment were excluded.
Only 2 patients (6%) had greater than grade II pivot shift or
more than 5 mm anteroposterior translation on examina-
tion at final follow-up. It was notable that 25% of patients
had a grade 11 pivot shift. The lack of irradiation to the
graft may explain the improved postoperative laxity pro-
files seen in this study in comparison to others.
Noyes et al54 reported results on a separate series of 66
patients undergoing revision ACL reconstruction with
irradiated (25 kGy) patellar tendon allograft. A wide vari-
ety of augmentation procedures were performed including
use of a ligament augmentation device in 32 patients and
additional lateral extra-articular reconstruction in 9
patients. A large number of patients required reconstruc-
tion of posterolateral or posteromedial structures as well.
These authors found a high rate of failure (33%) in terms
of graft laxity but again treated several patients with other
ligamentous injuries and they used irradiated grafts,
which may have affected the final results.
Other studies have described using mixed allograft
(patellar tendon and Achilles) and autograft (hamstring
and patellar tendon) sources, and have attempted to identify
differences in outcome.1,7,29 In these studies, no significant
differences were noted in clinical outcomes based on graft
choice. Ahn et al1 found no difference in KT-2000 arthrome-
ter results between autogenous patellar tendon, hamstring,
and Achilles allograft reconstructions. This is in contrast to
the results reported by Grossman et al,29 who did find signif-
icantly increased anterior translation in their allograft patel-
lar tendon group in comparison with the autograft group
(3.21 vs 1.73 mm). However, there were no differences noted
in clinical outcomes. Battaglia and Miller7 did not separate
their failures by graft type, but used 32% allografts and
found an overall failure rate of 25% (catastrophic graft fail-
ure requiring repeat revision) in their series.
Published results in the setting of primary ACL recon-
struction may provide useful information applicable to
the revision setting. Although several systematic reviews
and prospective studies have not shown clinical differences
in outcomes between autografts,42,61,64 some studies have
noted a higher incidence of clinical laxity associated with
hamstring grafts in comparison with patellar tendon auto-
grafts.8,19,75 A meta-analyses performed by Freedman
et al24 concluded that patellar tendon grafts were associ-
ated with few failures and better instrumented laxity in
comparison with hamstring tendons. Similar findings
were noted in a retrospective series by Barrett et al6 as
well. In the situation in which a patient presents with graft
failure without evidence of technical error from the
Downloaded from ajs.sagepub.com at ORTHO ONE ORTHOPAEDICS on June 11, 2014
Revision ACL Reconstruction 205
original procedure (eg, tunnel malposition, missed liga-
mentous injury, or malalignment), the contralateral or
ipsilateral patellar tendon as well as the contralateral
hamstring tendon should be considered if the original pro-
cedure was performed with hamstring autograft.
Based on the data available, as with primary recon-
struction, it would appear that failure rates are lower
with the use of autogenous tissues than with allograft,
and that no studies have determined whether autologous
hamstring, patellar tendon, or quadriceps tendon offers
any distinct advantages. Allograft must be given strong
consideration when tunnel expansion precludes use of
one of the aforementioned autologous grafts.
Chondral Lesions and Influence on Results
The rates of concomitant chondral lesions at the time of revi-
sion reconstruction range from 10% to 70% in published ser-
ies.a Although it is doubtful if these lesions affect stability in
the reconstructed knee, it is likely that they play a signifi-
cant role in clinical outcome after revision ACL reconstruc-
tion. Thomas et al76 matched their revision series to a group
of patients with primary ACL reconstructions of similar age
and gender and found a much higher rate of meniscal and
chondral lesions in the revision group. Objective laxity
results were similar between groups, but the revision group
had lower subjective outcomes scores. They concluded that
the higher rate of concomitant intra-articular injury likely
played a role in the worse outcomes seen. Grossman
et al29 also found worse outcomes in their revision ACL
group when they correlated results with increasing chon-
dral lesions seen at the time of revision. Similar findings
were also reported by Diamantopoulos et al,17 who found
that chondral lesion correlated with poorer International
Knee Documentation Committee (IKDC) and Lysholm
scores. Ahn et al1 used a primary ACL cohort for comparison
purposes in reporting their results after ACL revision but
did not use any matching criteria. The Lysholm scores
were significantly better in the primary group (93.7 vs
84.6), but the revision group had much higher rates of chon-
dral lesions (32% vs 12%) and meniscal tears (62% vs 48%).
When comparing matched cohorts by chondral lesion,
the outcomes differences between primary and revision
reconstruction are less clear. Weiler et al82 matched their
group of 62 patients from their patient database with
patients undergoing primary reconstruction using 5 crite-
ria: (1) age, (2) gender, (3) fixation, (4) graft, and (5) chon-
dromalacia and/or other concomitant pathology. When
matched by chondral and ligamentous lesions, the primary
group outscored the revision group (94 vs 90, P \ .05) on
postoperative Lysholm scores. Even though this difference
was statistically significant, the clinical significance of such
a difference is not well appreciated. Cumulatively, these
studies stress that significant chondral and meniscal lesions
that may exist in the revision setting may have a detrimen-
tal effect on ultimate clinical outcome after revision recon-
struction despite good results in terms of clinical laxity.
a
References 1, 7, 16, 17, 20, 22, 25, 29, 51, 53, 57, 66, 76, 82.
206 Kamath et al
Time to Revision and Degenerative Changes
In the recent case series of ACL revisions, the rate of
osteoarthritic changes seen on radiographic images at final
follow-up range from 37% to 80%.1,7,17,20,22,25,29,57,66 The
majority of these patients have minor degenerative
changes but significant percentages of patients with
moderate-to-severe arthritis are seen as well (Table 2). In
their study with a 5- to 9-year follow-up, Salmon et al66
found a correlation between chondral lesions seen at the
time of revision surgery and degenerative changes seen
at final follow-up. Many authors hypothesize that the
larger number of cartilage lesions seen in the revision set-
ting plays an important role in the higher rates of postop-
erative arthritis seen in this group.
Other authors have cited a higher rate of chondral and
meniscal injury in patients with delayed revision recon-
struction. Ohly et al58 retrospectively reviewed a large
series of 87 patients and divided them into an early revi-
sion group (within 6 months of failure) and a late revision
(.6 months). They found a higher incidence of cartilage
degeneration in the delayed revision group (24% vs 52%,
P \ .01). Battaglia and Miller7 found a correlation between
the development of radiographic arthritis and the duration
of instability symptoms before revision reconstruction. As
a result, many authors have emphasized the importance
of early revision surgery in the setting of instability and
primary graft failure. Although a direct causative effect
has not been proven, it is assumed that continued instabil-
ity predisposes the knee to further chondral and meniscal
damage. To date, there are no data regarding the role of
activity modification (eg, avoidance of cutting, pivoting
sports) in preventing this problem, but such measures
may have utility in limiting further injury.
Summary of Clinical Results and Return to Play
As mentioned previously, the lack of large series, combined
with concomitant ligamentous injury as well as meniscal
and articular cartilage injury, add difficulty to the assess-
ments of revision ACL reconstruction. Results as measured
by subjective IKDC, Lysholm, and Tegner activity scores
are inferior to those seen after primary ACL reconstruction
but are significantly improved with revision reconstruc-
tion. The increased incidence of meniscal and cartilage
lesions plays a significant role in the decreased clinical
results seen. Time to revision surgery has been noted in
many studies to correlate with an increased incidence of
associated intra-articular injury.
Laxity, as measured by anterior-posterior translation
and pivot shift testing, can be restored to similar levels
seen after primary ACL reconstruction. Autograft tissue
has had a trend toward improved laxity measurements in
comparison with allograft tissue, with little difference
seen in the clinical reports of different autogenous grafts—
hamstring versus patellar tendon versus quadriceps. Fewer
lax reconstructions are noted with nonirradiated grafts
compared with irradiated grafts. Patients should be coun-
seled that up to 40% of patients having revision ACL
Downloaded from ajs.sagepub.com at ORTHO ONE ORTHOPAEDICS on June 11, 2014
The American Journal of Sports Medicine
reconstructions may be unable to return to the same level
of sport or competition.7,16,25,29,51,53,57,66 In the setting of
the professional or elite-level athlete, data are scarce
regarding outcomes after revision reconstruction. Grossman
et al29 cited in their series that 4 of 5 (80%) Division-I ath-
letes were able to return to elite-level participation; the lone
failure occurred in a collegiate football player.
Two-Stage Reconstruction/Bone Grafting
Only one group has reported results after a series of
2-stage procedures in the treatment of the failed ACL
reconstruction. Thomas et al76 described their results after
2-stage revision of 49 patients and then compared them
with those of a matched cohort of primary reconstructions.
The authors performed a 2-stage revision to avoid overlap
between tunnels used at the time of revision surgery com-
pared with those used at the original procedure. Only the
tibial tunnel was grafted, and femoral tunnel position
was corrected using a 2-incision outside-in technique.
Computerized tomography was used to confirm adequate
consolidation of the graft before the second procedure.
The revision group had higher rates of chondral and
meniscal lesions and inferior outcomes by IKDC scoring
(61.8 vs 72) compared with the primary reconstruction con-
trol group. There was no difference in this study between
objective laxity measurements compared with the control
group. These results are similar to those reported in the
predominantly 1-stage reconstruction series mentioned
earlier.
Taking these data into consideration, the surgeon can
expect to obtain similar clinical profiles in terms of laxity
and stability if a 2-stage revision technique is used. How-
ever, given reports that increased time to revision corre-
lates with development of radiographic arthritis and
increased meniscal and chondral lesions,17,58 the surgeon
must use caution when deciding between a 2-stage proce-
dure when a 1-stage procedure may suffice. A 2-stage revi-
sion typically requires a 6-month window between
procedures.76 This will subject patients to a prolonged
period of continued knee instability, which may result in
further chondrosis and potential for meniscal injury to
the involved knee. Two-stage protocols require a second
anesthetic and further periods of activity modification.
When possible, preference should be given to a 1-stage pro-
cedure in all situations in which adequate placement and
fixation of the graft can be achieved. A 2-stage revision
should be reserved for use in the setting in which tunnel
expansion precludes a satisfactory 1-stage procedure.
AUTHORS’ PREFERRED TECHNIQUE
Graft Choice
Our current preference is the use of unharvested contralat-
eral and ipsilateral autografts for uncomplicated revision
ACL reconstruction in the young, active patient. In the set-
ting of multiligamentous reconstruction, allograft tissue
can diminish surgical time and associated surgical site
morbidity. Good results, however, are seen with allograft,
Vol. 39, No. 1, 2011 Revision ACL Reconstruction 207

and this may be an appropriate choice after discussion when more than 16 to 17 mm of tunnel expansion is pres-
with the patient regarding the potential benefits and dis- ent, grafting of the previously used tibial and femoral tun-
advantages. Some patients will prefer an ipsilateral har- nels is recommended. In our experience, once tunnels have
vest to avoid injury to the ‘‘normal knee,’’ but we have expanded to this size, achieving rigid fixation of the graft is
little hesitation in using a contralateral source if it seems difficult, and we prefer a 2-stage procedure. Large tunnels
most appropriate. Use of the contralateral knee also allows may also make it impossible to properly place a new graft
for goal-specific rehabilitation tailored to each side.71 In and allow for sufficient native bone to allow for incorpora-
the setting of pre-existing tunnel expansion, soft tissue tion, making 2-stage reconstruction a more advantageous
grafts are avoided because of concerns of inadequate tun- procedure.
nel fixation of the graft. In these cases, an allograft or auto- Verification must be made that all granulation tissue
graft with an affixed bone plug will be selected to allow for and foreign material has been removed with adequate
better fill and fixation in the femoral and tibial tunnels exposed bone to allow for incorporation of the introduced
either with larger graft sizes or with use of a stacked screw graft material. The tibial tunnel can often be viewed
technique. directly by placement of the arthroscope in the tunnel
through the previously used skin incision. Visualization
Technical Considerations in Revision Surgery of the femoral tunnel can be achieved with the arthroscope
moved to the anteromedial portal for direct visualization of
When planning revision ACL reconstruction, the surgeon
the lateral wall and femoral notch. Expanded tibial tunnels
must have a variety of techniques available to deal with
can typically be packed with graft material in an inferior to
malpositioned tunnels, bone loss, tunnel expansion, and
superior direction with use of a small tamp. On the femoral
other consequences of the original procedure that may
side, a small arthroscopic cannula or skid may be placed
have an effect on the graft-host knee construct. Preopera-
through an accessory medial portal in line with the previ-
tive planning is an essential part of anticipating what
ous femoral tunnels to provide access and prevent the
alternative techniques may be necessary to achieve appro-
inflow of arthroscopic fluid from washing out graft mate-
priate graft stability and location. Surgery to address addi-
rial. Dry arthroscopy can also be performed to prevent
tional pathologic changes (eg, meniscus deficiency) or
efflux of graft. Our preference is for the use of a mixture
instability (eg, posterolateral instability) can usually be
of autogenous cancellous graft obtained from Gerdy’s
performed simultaneously but may be staged depending
tubercle and allograft cancellous bone chips. If more exten-
on surgeon preference.
sive defects are seen, iliac crest harvest (either dowel or
We typically prefer to perform revision surgery in the
cancellous graft) is used. Serial radiography is recommen-
hemilithotomy position with use of an arthroscopic leg
ded to confirm complete consolidation of the tunnels before
holder on the injured side. In our experience this allows
second-stage graft reconstruction, which is typically
improved access to the medial and lateral compartments
delayed approximately 6 months.
if a concomitant meniscal repair is performed. As graft har-
Alternative graft sources and placement tools have
vest from the opposite leg may be needed, although rarely,
also been described in the literature. Both Said et al63
preparation of the opposite leg should be considered. With
and Franchesci et al23 have described the use of OATS
cautious positioning, sufficient hyperflexion of the knee
(osteochondral autograft transfer system) harvesters to
can be obtained to safely allow use of an accessory antero-
graft prior femoral and tibial tunnels. They describe har-
medial portal. Alternatively, a 2-incision technique can be
vest from either the iliac crest or medial tibial metaphy-
used in this setting. Bone graft can also be easily obtained
sis and placement of a plug 1 mm greater in diameter
from the tibial tubercle with this position. If large bony
than the debrided tunnel to allow for press-fit fixation
defects are anticipated and an iliac bone graft is planned,
of the graft within the tunnel. Unless multiple plugs or
the patient will be positioned supine with the leg straight
a custom harvesting device is used, the maximum size
and a lateral post against the leg for the application of val-
dowel that can be harvested from the autograft kit is
gus stress.
11 mm. If large allograft bone sources are available,
The prior tunnel placement should be categorized in 1 of
many allograft osteochondral harvesting sets will allow
3 ways: (1) accurate—correct position not requiring any
for larger diameter dowels as an alternative to using mul-
redirection, (2) completely inaccurate—prior tunnel place-
tiple smaller autograft plugs. In addition, there are com-
ment is in such a location that it will not interfere with
mercially available calcium phosphate putties available
new tunnel creation, and (3) overlapping—prior tunnel
(eg, Callos Impact [Acumed, Hillsboro, Oregon] and
placement is such that a new properly directed tunnel
HydroSet [Stryker Orthopaedics, Mawhah, New Jersey]),
will partially overlap with the old tunnel. Partially over-
but long-term results regarding biologic incorporation at
lapping tunnels are the most difficult of the 3 scenarios
this time are unknown.79
and may require the surgeon to make adjustments for
larger than expected tunnels.

Bone Grafting
Previous tunnels must be evaluated for expansion because
widely expanded tunnels limit graft options. In such cases,
Tunnel Preparation
The divergent tunnel concept previously described by
Bach3 (Figure 3) should be stressed when attempting to
redirect new femoral or tibial tunnels in the tunnel overlap

Downloaded from ajs.sagepub.com at ORTHO ONE ORTHOPAEDICS on June 11, 2014

208 Kamath et al
Figure 3. The divergent tunnel technique as described by
Bach.3 By approaching the intra-articular footprints from
different directions (tunnel 2) than used in the original recon-
struction (tunnel 1), overlapping tunnels can be avoided.
(Reproduced with permission from Bach BR, Fox JA, Maz-
zocca AD. Revision anterior cruciate ligament surgery, in
Grana WA, ed. Orthopaedic Knowledge Online. Rosemont,
IL: American Academy of Orthopaedic Surgeons, 2003.
Available at www.aaos.org/oko.)
scenario. The femoral and tibial footprints can be accessed
from a variety of directions. Although they may approach
previous tunnels inside the joint, as the tunnel progresses
further away from the joint (Figure 1), an intact cylinder of
native bone is present for adequate graft fixation.
Femoral Tunnel Placement. Because transtibial drilling
of the femoral tunnel places constraints on the position
from which the femoral footprint can be accessed, the sur-
geon should be prepared to access the femoral side with
other options: (1) outside-in femoral tunnel creation via
a 2-incision technique or (2) femoral tunnel creation via
an accessory anteromedial portal. Both techniques allow
for independent creation of the femoral socket relative to
the tibial tunnel. When the 2-incision technique is used,
an accessory lateral incision is made over the lateral distal
femur, splitting the iliotibial band, allowing introduction of
the ACL guide through either the anterolateral portal or
around the femur from the over-the-top position. A more
Downloaded from ajs.sagepub.com at ORTHO ONE ORTHOPAEDICS on June 11, 2014
The American Journal of Sports Medicine
oblique or horizontal tunnel can be made to avoid the prior
tunnels. A guide pin can then be directed into the joint and
then overreamed in standard fashion (Figure 4).
Use of the accessory medial portal can also allow for cre-
ation of a separate femoral socket (see Figures 12-14, case
2). By varying the inferior and medial placement of the
accessory portal, a variety of angles can be produced
approaching the femoral footprint. The portal should be
made under spinal needle visualization to allow the sur-
geon to anticipate the ‘‘line of approach’’ to the femoral
side. With the arthroscope in the standard anteromedial
portal, the lateral wall of the notch can be fully visualized.
The planned center of the femoral tunnel can be marked
with use of a 45-degree microfracture pick, electrocautery,
and so forth. A guide pin is then placed into the accessory
medial portal, directed into the designated location, and
then driven through the lateral cortex of the femur. The
knee must be hyperflexed (.120°) before guidewire pas-
sage to produce a longer, more anteriorly directed tunnel.
This helps to avoid inadvertent blowout of the posterior
condyle and prevent injury to the peroneal nerve.31 The
guidewire should exit at a point above the superior pole
of the patella and anterior to the midline of the femur.
The knee remains hyperflexed, but the guidewire can
then be overreamed to create the femoral socket. When
placing the reamer through the accessory medial portal,
care must be taken to allow the surgeon to avoid damage
to the articular cartilage of the medial femoral condyle.
We have found that unipolar reamers (Sentinel Reamers,
Linvatec, Largo, Florida, or Low-Profile Reamer, Arthrex,
Naples, Florida) have a great deal of utility when using
this technique; alternatively, an arthroscopic skid can be
used to protect the medial femoral condyle if a circular
reamer is used. Hyperflexion of the knee may limit flow
across the joint, limiting visualization and causing the
accumulation of tunnel debris. In this setting, a 70° arthro-
scope may be used in the anterolateral portal; alterna-
tively, a motorized shaver can be introduced to assist
with removal of debris.
Tibial Tunnel. A variable-angle ACL guide should be
available for tibial tunnel creation. As with femoral tunnel
creation, this enables the surgeon to avoid previously
drilled tunnels. The guide can be directed to enter the tibia
in a new location for fixation purposes but enters the joint
in the appropriate position. In addition, the angle can be
increased or decreased to create a longer or shorter tibial
tunnel if needed. One of the most challenging situations
exists when the original tibial tunnel has been placed too
posteriorly. In this situation, concern exists that a new
more anteriorized graft may undergo the windshield-wiper
effect into the previous tunnel, resulting in recurrent lax-
ity. Although previous tunnels can be incorporated into
the new tunnels and filled with additional graft material
to achieve fixation, an alternative is consideration of the
double-bundle technique. An excessively posterior tibial
tunnel can be considered for the posterolateral tibial bun-
dle in a double-bundle technique, and a new anteromedial
tibial tunnel can be created independently.
Hardware and Tunnel Creation. Biodegradable and bio-
composite hardware typically cannot be removed easily
Vol. 39, No. 1, 2011 Revision ACL Reconstruction 209

Figure 4. Two-incision technique for ACL reconstruction can be used effectively to redirect malpositioned femoral tunnels and
achieve a native bony tunnel when not otherwise possible by other means. (Reproduced with permission from Ferretti et al.20)

Figure 6. Arthroscopic view of a stacked screw technique.

Figure 5. Suture and previous graft material may make pas- Two screws have been placed anterior to the new ACL graft
sage of tunnel reamers difficult. Repeated cleaning of the fins to accommodate expanded tunnels from the original proce-
and starting with a smaller size bit is recommended. dure and provide adequate graft fixation.

and therefore should be left in place and overreamed after hardware can be left in place. When hardware is removed
guidewire placement. Metal interference screws must be to permit new tunnel preparation, a variety of options exist
removed when interfering with proper tunnel placement. for management of the residual defect. Our current strat-
If the new tunnels can be made independently, previous egy consists of either (1) incorporation of the defect into

Downloaded from ajs.sagepub.com at ORTHO ONE ORTHOPAEDICS on June 11, 2014

210 Kamath et al
the new tunnels via sequential drilling or (2) replacement
of the metal screw with a biocomposite screw followed by
overreaming as described previously.81 During tunnel cre-
ation, it is important to remember that the reamer may not
pass easily through previous soft tissue graft material and
bioabsorbable fixation, and may require repeated cleaning
of its cutting fins to pass (Figure 5). The authors prefer to
start with a smaller drill to facilitate initial passage. The
tunnel can then be increased in gradual increments to
obtain the desired size. Straight reamers may be preferred
relative to acorn reamers because of drill migration that
can occur. Guide pins can be passed across the joint provi-
sionally to provide additional stability during the reaming
process. Variable bone density from prior surgery (eg, BTB
graft, suture in soft tissue graft) can make drilling poten-
tially difficult. Live fluoroscopic imaging may be a valuable
adjunctive tool if hardware removal is necessary.
Once tunnel preparation is finished, the tunnels should
be assessed under direct visualization to ensure good bone
quality for fixation and graft incorporation. The tibial tun-
nel can be approached in a retrograde fashion through the
skin incision or viewing down from one of the anterior por-
tals. The femoral tunnel can be typically viewed en face
from the anteromedial portal or the accessory medial por-
tal (see Figure 13). Based on intraoperative assessment,
determinations can be made of what additional procedures,
if any, will be necessary to achieve rigid fixation.
GRAFT FIXATION
Once tunnel preparation has been accomplished, the qual-
ity of bone and relative size of the graft must be taken into
account to achieve adequate fixation. In cases in which
tunnel expansion is anticipated, soft tissue grafts should
be used with caution. If only 2 to 3 mm of graft-tunnel mis-
match is noted, a stacked screw technique (Figures 6 and
7) or patellar tendon graft with larger bone blocks can be
used. In the setting of a larger graft-tunnel mismatch, an
allograft with an affixed bone block is used (eg, Achilles
tendon or patellar tendon) in which larger bone plugs can
be prepared to take the mismatch into account. Alterna-
tively, either synthetic dowels or allograft bone plugs
have been described to provide supplemental interference
fixation within the tunnels.5,68
The management of prior tunnel overlap is a challenging
problem in the arthroscopic setting. Tibial tunnel manage-
ment is typically more straightforward because access to
the tunnel is more readily available through the open inci-
sion. Access to the femoral tunnel is more challenging
without the use of an accessory incision. In the setting of
overlap, it may be useful to progressively drill expanded
tunnels until a uniform cylinder has been re-created and
then fashion a custom allograft or autograft plug (eg, patel-
lar tendon) that will fill the entire defect. On the tibial side,
ease of access may allow allograft dowel placement to pro-
vide additional interference fixation. Alternatively, one
may be able to use an autograft plug in smaller defects.
Lastly, should there be a loss of bony integrity of the
tunnel (eg, previous femoral blowout) or if the bone quality
of the tunnel is suspect, one should not hesitate to use
Downloaded from ajs.sagepub.com at ORTHO ONE ORTHOPAEDICS on June 11, 2014
The American Journal of Sports Medicine
Figure 7. Postoperative radiographs of a patient in whom
the stacked screw technique was used on the femoral side.
alternative methods in lieu of screw fixation. Laterally
based bioabsorbable cross-fixation pins (eg, IntraFix or
RigidFix, Mitek, San Diego, California, or TransFix,
Arthrex), arthroscopic buttons (EndoButton or RetroBut-
ton, Arthrex) as well as other commercially available devi-
ces can be used for fixation on the intact lateral femoral
cortex. Alternatively, if these methods are unavailable or
compromised, stay sutures tied to the graft may be fixed
to a femoral post to achieve initial fixation. If there is
any question as to the fixation achieved within the bony
tunnel, a supplemental post should be placed on either
the lateral femur or anterior tibia and the graft tied with
nonabsorbable synthetic suture. In the revision setting,
a supplemental tibial post is recommended and there
should be little hesitation in adding a femoral post if fixa-
tion is less than ideal.
ADDITIONAL CONSIDERATIONS
Double-Bundle Reconstruction and Revision ACL
Reconstruction
Double-bundle ACL reconstruction has gained popularity
in recent years as its advocates claim that it better repro-
duces rotational stability and normal anatomy.74,87,88
Critics of the double-bundle procedure point to cadaveric
and clinical studies that have not shown clinical outcome
or mechanical differences between central anatomical
single-bundle and double-bundle reconstruction.34,43,44
Despite the lack of well-designed, prospective studies,
the technique remains popular with good results reported
in several small case series.12,38,62,89 Clear-cut indications
for the application of this technique to revision ACL
reconstruction have not yet been identified.
The role of double-bundle reconstruction in the setting
of a failed single-bundle reconstruction is unclear.
Although inappropriate tunnel placement is believed to
play a role in the failure of many primary reconstructions,
Vol. 39, No. 1, 2011
Figure 8. Anteroposterior and lateral MRI images of a patient
who has failed prior double-bundle ACL reconstruction. The
presence of 2 expanded residual tunnels on both the femur
and tibia is thought to preclude a single-stage reconstruc-
tion. This patient underwent tunnel grafting before staged
graft reimplantation.
no data to date suggest that double-bundle revision recon-
struction provides superior stability to single-bundle
reconstruction in a revision setting. Rather, double-bundle
reconstruction provides more significant challenges to the
surgeon in the revision setting as prior tunnel placement
is likely to partially overlap with one or both planned pos-
terolateral and anteromedial bundle femoral tunnels. Con-
version to a double-bundle technique may require a staged
bone grafting procedure unless the original tunnel place-
ments are grossly inaccurate. Brophy et al12 have
described a unique approach for patients with an intact
‘‘vertical graft’’ that provides adequate anterior-posterior
stability but inadequate rotatory instability with the pivot
shift examination. Their technique is applied to patients
with excessive posterior tibial tunnel placement and a ver-
tical femoral tunnel. In this setting, they perform a double-
bundle ‘‘augmentation’’ of the intact graft by passing
a second graft anterior to the original tibial tunnel and
into a femoral tunnel site located in the footprint of the
posterolateral bundle (an anteromedial tibial tunnel to
posterolateral femoral tunnel). At the time of report, the
procedure was performed in 3 patients with good short-
term results available in 1 patient. Despite these results,
this technique is not recommended given the paucity of
available patient data and the unknown biomechanical
implications of such a reconstruction.
At the present time in our practice, there is a limited
role for use of the double-bundle technique in either the
primary or revision setting. Primary and revision ACL
reconstruction is typically performed using a single-bundle
technique with the tunnels placed in the center of the ana-
tomical footprints. The failed double-bundle technique can
provide a great deal of challenge to the orthopaedic sur-
geon in the revision setting. The use of soft tissue grafts
will leave 2 residual tunnels, and even if not associated
with massive tunnel expansion, these may make revision
reconstruction impossible as a single-stage operation
(Figure 8). In this setting, bone grafting of previous tun-
nels will be necessary prior to revision reconstruction.
Downloaded from ajs.sagepub.com at ORTHO ONE ORTHOPAEDICS on June 11, 2014
Revision ACL Reconstruction 211
Figure 9. Preoperative radiographs of patient in case 1
showing appropriately placed tunnels from original recon-
struction. The tibial tunnel is centered and located in quad-
rant 2 on the lateral image. The femoral tunnel is
appropriately oriented on the AP radiograph and its position
on the lateral and posterior intercondylar wall can be seen on
the lateral radiograph (circle).
We have little experience with use of the double-bundle
approach for revision but have used it in a handful of
patients who have failed multiple revision procedures
without appreciable technical error. Revision of a primary
double-bundle procedure has also been reported in the lit-
erature but only as an anecdotal experience. Kaz et al38
reported technical success of revision double-bundle ACL
reconstruction in 3 patients. Results and outcomes were
not given. In 2 patients, it was possible to drill separate
posterolateral bundle femoral tunnels through the acces-
sory medial portal without convergence with the prior tun-
nel. In the group’s experience, failure of the double-bundle
procedure may have been related to ineffective graft ten-
sioning techniques, and they have since amended their
original tensioning protocol. Their report documents that
while revision double-bundle reconstruction is feasible, it
presents an increased level of complexity compared with
the single-bundle technique.
REVISION REVISIONS
To date, there has been only 1 report in the literature
describing results after repeat revision ACL reconstruc-
tions. Wegrzyn and colleagues81 reported outcomes after
second revisions in a group of 10 patients with an average
follow-up of 3.1 years. Only 20% of athletes were able to
return to the same level of play despite 70% excellent or
good results by IKDC assessment. In addition, graft func-
tion was considered good with an average side-to-side dif-
ference on KT-1000 arthrometer testing of 1.3 mm, and
no patients had rotational laxity on pivot shift examina-
tion. Excellent or good results were noted in 80% of
patients after the first revision until repeat trauma result-
ing in graft failure. These findings suggest that diminish-
ing clinical outcomes are seen with subsequent revisions.
212 Kamath et al
Figure 10. Intraoperative images showing the ruptured graft (left) and after revision reconstruction (right)
Figure 11. Postoperative radiographs showing reuse of the
previous tunnels. During preoperative planning, the EndoBut-
ton was to be retained, but during femoral socket prepara-
tion, Beath pin passage through the tunnel was not
possible because of its position. The EndoButton was
removed through a small lateral incision and the tunnels
reused. The tibial bioabsorbable screw has been overreamed
to create the new tunnel. New fixation is achieved with metal
interference screws in both tunnels.
REPRESENTATIVE CASES
To illustrate some of the previous technical considerations
on revision ACL reconstruction, we present the following 3
cases.
Case 1: Correct Tunnel Placement
The patient was a 16-year-old competitive skier who suf-
fered another injury 1 year after primary ACL reconstruc-
tion with autologous hamstring tendons. Preoperative
radiographs revealed appropriate tunnel position of both
the femoral and tibial tunnels (Figure 9). The femoral tun-
nel is noted in quadrant 4 and the tibial tunnel in quadrant
Downloaded from ajs.sagepub.com at ORTHO ONE ORTHOPAEDICS on June 11, 2014
The American Journal of Sports Medicine
Figure 12. Preoperative radiographs of patient in case 2
show previous transtibial ACL reconstruction with metal
interference screws in both tunnels. The tibial tunnel is
appropriately located.
2. The femoral tunnel has a lateral and posterior position
on the intercondylar wall, as noted by its position on the
lateral radiograph relative to Blumensaat line. Revision
reconstruction was performed with ipsilateral patellar ten-
don autograft. Because tunnel position was appropriate,
the previous tunnels were reused (Figures 10 and 11). Bio-
absorbable fixation on the tibial side was overreamed after
guidewire passage. During femoral socket preparation,
Beath pin passage through the femoral tunnel was not pos-
sible because of its position. The EndoButton was removed
through a small lateral incision and the tunnels re-created.
New fixation was achieved with metal interference screws
in both.
Case 2: Revision of Transtibial ACL With Accessory
Anteromedial Portal
The patient was a 33-year-old competitive skier who pre-
sented with reinjury 11 years after the original ACL recon-
struction with patellar tendon. Radiographs revealed
Vol. 39, No. 1, 2011 Revision ACL Reconstruction 213

Figure 13. Femoral tunnel creation through the anteromedial portal. Torn graft (upper left), spinal needle localization for access to
the lateral wall (upper right), and tunnel marking with use of a microfracture pick (lower left). The previous tunnel can be seen
(circle). We have found that a previous transtibial femoral tunnel can almost always be avoided by use of the anteromedial portal
and allows for anatomical tunnel placement. Viewing from the medial portal, the tunnel can be viewed en face. An intact cylinder
of femoral bone is seen for integration of the new graft (lower right).

Figure 14. Postoperative radiographs showing the more
horizontal tunnel achieved through the anteromedial portal
in comparison with the transtibial technique. Hamstring fixa-
tion is with EndoButton on the femoral side and bioabsorb-
able interference screw on the tibia.
Figure 15. Preoperative radiographs of patient in case 3
showing a vertical primary reconstruction. There is no perma-
nent hardware. The tibial tunnel has been placed too poste-
riorly, resulting in a lax graft. The tibia can be seen anteriorly
subluxated on the lateral image.

Downloaded from ajs.sagepub.com at ORTHO ONE ORTHOPAEDICS on June 11, 2014

214 Kamath et al The American Journal of Sports Medicine

Figure 16. Intraoperative images are seen. The original graft is vertically oriented and too posterior on the tibia, adjacent to the
posterior cruciate ligament (PCL) (upper left). Significant chondrosis of the lateral compartment is noted (upper right arthroscopic
view). Revision ACL in the anatomical position was performed (bottom).

a transtibial technique with metal interference screws on

both the femur and tibia (Figure 12). Tibial tunnel position
was accurate, and the tunnel was reused after screw
removal. An accessory medial portal was made under spi-
nal needle visualization, and a microfracture pick was
used to mark tunnel position on the lateral intercondylar
wall. A new femoral tunnel was easily created away from
the previous hardware in a more anatomical position on
the lateral wall (Figure 13). Because of the divergent tun-
nel technique used, a native cylinder of femoral bone was
available for graft passage and incorporation. Postopera-
tive radiographs reveal the divergent femoral tunnel posi-
tion possible with use of the anteromedial portal technique
(Figure 14).

Case 3: Failure of Vertical Graft
The patient was a 20-year-old collegiate football player who
had ACL reconstruction with allograft hamstring 3 years
before presentation. He had continued instability without
Figure 17. Postoperative radiographs of patient in case 3
showing the more oblique position of the revision graft.
Both femoral and tibial tunnel positions are now appropriate.
Additional backup fixation has been placed on the tibial side
with use of a post.

Downloaded from ajs.sagepub.com at ORTHO ONE ORTHOPAEDICS on June 11, 2014

Vol. 39, No. 1, 2011
significant trauma; there was a positive pivot shift on phys-
ical examination. Radiographs showed a vertical graft with
an anteriorized femoral tunnel and a posteriorized tibial
tunnel (Figure 15). Intraoperative arthroscopy revealed
a similar vertical graft, which was adjacent to the posterior
cruciate ligament (Figure 16). Significant lateral compart-
ment chondrosis was noted, likely from the patient’s contin-
ued instability combined with his clinical valgus. Revision
reconstruction was performed using separate femoral and
tibial tunnels. The tibial tunnel was drilled from a more
medial starting position on the tibia, creating a fresh tun-
nel. Because of limited intra-articular convergence of the
new tunnel, the tibial bone block was flipped and the inter-
ference screw placed posteriorly to allow the graft to lie in
the ACL footprint (Figure 17, dashed lines). The femoral
tunnel was created using the accessory anteromedial portal.
CONCLUSION
Revision ACL surgery is a challenging procedure that
requires flexibility and comfort with multiple techniques
from the surgeon’s standpoint. The results of revision sur-
gery cohorts are inferior to those of primary ACL reconstruc-
tion, and surgeon error often plays a role in initial graft
failure. Higher rates of meniscal and chondral lesions should
be anticipated. Patients should be counseled regarding
expectations and outcomes after surgery. Excellent results
can be achieved regarding graft stability, return to activity,
and resolution of instability, but persistent knee pain and
disability may be related to other abnormalities noted at
the time of revision. Careful attention to detail must be
taken to achieve adequate graft fixation and placement.
An online CME course associated with this article is
available for 1 AMA PRA Category 1 CreditTM at http://
ajsm-cme.sagepub.com. In accordance with the standards
of the Accreditation Council for Continuing Medical Edu-
cation (ACCME), it is the policy of The American Ortho-
paedic Society for Sports Medicine that authors, editors,
and planners disclose to the learners all financial rela-
tionships during the past 12 months with any commercial
interest (A ‘commercial interest’ is any entity producing,
marketing, re-selling, or distributing health care goods
or services consumed by, or used on, patients). Any and
all disclosures are provided in the online journal CME
area which is provided to all participants before they
actually take the CME activity. In accordance with
AOSSM policy, authors, editors, and planners’ participa-
tion in this educational activity will be predicated upon
timely submission and review of AOSSM disclosure. Non-
compliance will result in an author/editor or planner to be
stricken from participating in this CME activity.
REFERENCES
1. Ahn JH, Lee YS, Ha HC. Comparison of revision surgery with primary
anterior cruciate ligament reconstruction and outcome of revision
surgery between different graft materials. Am J Sports Med.
2008;36(10):1889-1895.
Downloaded from ajs.sagepub.com at ORTHO ONE ORTHOPAEDICS on June 11, 2014
Revision ACL Reconstruction 215
2. Anderson AF, Snyder RB, Lipscomb AB Jr. Anterior cruciate ligament
reconstruction: a prospective randomized study of three surgical
methods. Am J Sports Med. 2001;29(3):272-279.
3. Bach BR Jr. Revision anterior cruciate ligament surgery. Arthroscopy.
2003;19(suppl 1):14-29.
4. Baer GS, Harner CD. Clinical outcomes of allograft versus autograft
in anterior cruciate ligament reconstruction. Clin Sports Med. 2007;
26(4):661-681.
5. Barrett GR, Brown TD. Femoral tunnel defect filled with a synthetic
dowel graft for a single-staged revision anterior cruciate ligament
reconstruction. Arthroscopy. 2007;23(7): e791-794.
6. Barrett GR, Noojin FK, Hartzog CW, Nash CR. Reconstruction of the
anterior cruciate ligament in females: a comparison of hamstring ver-
sus patellar tendon autograft. Arthroscopy. 2002;18(1):46-54.
7. Battaglia TC, Miller MD. Management of bony deficiency in revision
anterior cruciate ligament reconstruction using allograft bone dowels:
surgical technique. Arthroscopy. 2005;21(6):767.
8. Beynnon BD, Johnson RJ, Fleming BC, et al. Anterior cruciate liga-
ment replacement: comparison of bone-patellar tendon-bone grafts
with two-strand hamstring grafts: a prospective, randomized study.
J Bone Joint Surg Am. 2002;84(9):1503-1513.
9. Biau DJ, Tournoux C, Katsahian S, Schranz P, Nizard R. ACL recon-
struction: a meta-analysis of functional scores. Clin Orthop Relat Res.
2007;458:180-187.
10. Biau DJ, Tournoux C, Katsahian S, Schranz PJ, Nizard RS. Bone-
patellar tendon-bone autografts versus hamstring autografts for
reconstruction of anterior cruciate ligament: meta-analysis. BMJ.
2006;332(7548):995-1001.
11. Brandsson S, Faxen E, Eriksson BI, Sward L, Lundin O, Karlsson J.
Reconstruction of the anterior cruciate ligament: comparison of
outside-in and all-inside techniques. Br J Sports Med. 1999;33(1):
42-45.
12. Brophy RH, Selby RM, Altchek DW. Anterior cruciate ligament revi-
sion: double-bundle augmentation of primary vertical graft. Arthros-
copy. 2006;22(6):e681-685.
13. Carson EW, Anisko EM, Restrepo C, Panariello RA, O’Brien SJ,
Warren RF. Revision anterior cruciate ligament reconstruction:
etiology of failures and clinical results. J Knee Surg. 2004;17(3):
127-132.
14. Daniel DM, Malcom LL, Losse G, Stone ML, Sachs R, Burks R.
Instrumented measurement of anterior laxity of the knee. J Bone
Joint Surg Am. 1985;67(5):720-726.
15. Daniel DM, Stone ML, Sachs R, Malcom L. Instrumented measure-
ment of anterior knee laxity in patients with acute anterior cruciate
ligament disruption. Am J Sports Med. 1985;13(6):401-407.
16. Denti M, Lo Vetere D, Bait C, Schonhuber H, Melegati G, Volpi P.
Revision anterior cruciate ligament reconstruction: causes of failure,
surgical technique, and clinical results. Am J Sports Med. 2008;
36(10):1896-1902.
17. Diamantopoulos AP, Lorbach O, Paessler HH. Anterior cruciate liga-
ment revision reconstruction: results in 107 patients. Am J Sports
Med. 2008;36(5):851-860.
18. Eitzen I, Holm I, Risberg MA. Preoperative quadriceps strength is
a significant predictor of knee function two years after anterior cruci-
ate ligament reconstruction. Br J Sports Med. 2009;43(5):371-376.
19. Feller JA, Webster KE. A randomized comparison of patellar tendon
and hamstring tendon anterior cruciate ligament reconstruction. Am
J Sports Med. 2003;31(4):564-573.
20. Ferretti A, Conteduca F, Monaco E, De Carli A, D’Arrigo C. Revision
anterior cruciate ligament reconstruction with doubled semitendino-
sus and gracilis tendons and lateral extra-articular reconstruction. J
Bone Joint Surg Am. 2006;88(11):2373-2379.
21. Foster TE, Wolfe BL, Ryan S, Silvestri L, Kaye EK. Does the graft
source really matter in the outcome of patients undergoing anterior
cruciate ligament reconstruction? An evaluation of autograft versus
allograft reconstruction results: a systematic review. Am J Sports
Med. 2010;38(1):189-199.
22. Fox JA, Pierce M, Bojchuk J, Hayden J, Bush-Joseph CA, Bach BR,
Jr. Revision anterior cruciate ligament reconstruction with
216 Kamath et al
nonirradiated fresh-frozen patellar tendon allograft. Arthroscopy.
2004;20(8):787-794.
23. Franceschi F, Papalia R, Di Martino A, Rizzello G, Allaire R, Denaro V.
A new harvest site for bone graft in anterior cruciate ligament revision
surgery. Arthroscopy. 2007;23(5):558 e551-554.
24. Freedman KB, D’Amato MJ, Nedeff DD, Kaz A, Bach BR Jr. Arthro-
scopic anterior cruciate ligament reconstruction: a metaanalysis
comparing patellar tendon and hamstring tendon autografts. Am J
Sports Med. 2003;31(1):2-11.
25. Garofalo R, Djahangiri A, Siegrist O. Revision anterior cruciate liga-
ment reconstruction with quadriceps tendon-patellar bone autograft.
Arthroscopy. 2006;22(2):205-214.
26. George MS, Dunn WR, Spindler KP. Current concepts review: revi-
sion anterior cruciate ligament reconstruction. Am J Sports Med.
2006;34(12):2026-2037.
27. Gersoff WK, Clancy WG Jr. Diagnosis of acute and chronic anterior
cruciate ligament tears. Clin Sports Med. 1988;7(4):727-738.
28. Gianotti SM, Marshall SW, Hume PA, Bunt L. Incidence of anterior
cruciate ligament injury and other knee ligament injuries: a national
population-based study. J Sci Med Sport. 2009;12(6):622-627.
29. Grossman MG, ElAttrache NS, Shields CL, Glousman RE. Revision
anterior cruciate ligament reconstruction: three- to nine-year follow-
up. Arthroscopy. 2005;21(4):418-423.
30. Harner CD, Giffin JR, Dunteman RC, Annunziata CC, Friedman MJ.
Evaluation and treatment of recurrent instability after anterior cruciate
ligament reconstruction. Instr Course Lect. 2001;50:463-474.
31. Harner CD, Honkamp NJ, Ranawat AS. Anteromedial portal tech-
nique for creating the anterior cruciate ligament femoral tunnel.
Arthroscopy. 2008;24(1):113-115.
32. Harner CD, Marks PH, Fu FH, Irrgang JJ, Silby MB, Mengato R. Ante-
rior cruciate ligament reconstruction: endoscopic versus two-incision
technique. Arthroscopy. 1994;10(5):502-512.
33. Hewett TE, Shultz SJ, Griffin LY, American Orthopaedic Society for
Sports Medicine. Understanding and Preventing Noncontact ACL
Injuries. Champaign, IL: Human Kinetics; 2007.
34. Ho JY, Gardiner A, Shah V, Steiner ME. Equal kinematics between
central anatomic single-bundle and double-bundle anterior cruciate
ligament reconstructions. Arthroscopy. 2009;25(5):464-472.
35. Ichiba A, Kishimoto I. Effects of articular cartilage and meniscus inju-
ries at the time of surgery on osteoarthritic changes after anterior cru-
ciate ligament reconstruction in patients under 40 years old. Arch
Orthop Trauma Surg. 2009;129(3):409-415.
36. Jaureguito JW, Paulos LE. Why grafts fail. Clin Orthop Relat Res.
1996;325:25-41.
37. Johnson DL, Swenson TM, Irrgang JJ, Fu FH, Harner CD. Revision
anterior cruciate ligament surgery: experience from Pittsburgh. Clin
Orthop Relat Res. 1996;325:100-109.
38. Kaz R, Starman JS, Fu FH. Anatomic double-bundle anterior cruciate
ligament reconstruction revision surgery. Arthroscopy. 2007;23(11):
1250 e1251-1253.
39. Kocher MS, Steadman JR, Briggs K, Zurakowski D, Sterett WI, Haw-
kins RJ. Determinants of patient satisfaction with outcome after ante-
rior cruciate ligament reconstruction. J Bone Joint Surg Am. 2002;
84(9):1560-1572.
40. Kocher MS, Steadman JR, Briggs KK, Sterett WI, Hawkins RJ. Rela-
tionships between objective assessment of ligament stability and
subjective assessment of symptoms and function after anterior cru-
ciate ligament reconstruction. Am J Sports Med. 2004;32(3):629-634.
41. Lee GC, Cushner FD, Vigoritta V, Scuderi GR, Insall JN, Scott WN.
Evaluation of the anterior cruciate ligament integrity and degenerative
arthritic patterns in patients undergoing total knee arthroplasty. J
Arthroplasty. 2005;20(1):59-65.
42. Maletis GB, Cameron SL, Tengan JJ, Burchette RJ. A prospective
randomized study of anterior cruciate ligament reconstruction:
a comparison of patellar tendon and quadruple-strand semitendino-
sus/gracilis tendons fixed with bioabsorbable interference screws.
Am J Sports Med. 2007;35(3):384-394.
43. Markolf KL, Park S, Jackson SR, McAllister DR. Anterior-posterior
and rotatory stability of single and double-bundle anterior cruciate
Downloaded from ajs.sagepub.com at ORTHO ONE ORTHOPAEDICS on June 11, 2014
The American Journal of Sports Medicine
ligament reconstructions. J Bone Joint Surg Am. 2009;91(1):
107-118.
44. Markolf KL, Park S, Jackson SR, McAllister DR. Simulated pivot-shift
testing with single and double-bundle anterior cruciate ligament
reconstructions. J Bone Joint Surg Am. 2008;90(8):1681-1689.
45. Marzo JM, Bowen MK, Warren RF, Wickiewicz TL, Altchek DW. Intra-
articular fibrous nodule as a cause of loss of extension following
anterior cruciate ligament reconstruction. Arthroscopy. 1992;
8(1):10-18.
46. McAllister DR, Parker RD, Cooper AE, Recht MP, Abate J. Outcomes
of postoperative septic arthritis after anterior cruciate ligament
reconstruction. Am J Sports Med. 1999;27(5):562-570.
47. Mullaji AB, Marawar SV, Luthra M. Tibial articular cartilage wear in
varus osteoarthritic knees: correlation with anterior cruciate ligament
integrity and severity of deformity. J Arthroplasty. 2008;23(1):128-135.
48. Muneta T, Yamamoto H, Ishibashi T, Asahina S, Murakami S, Furuya K.
The effects of tibial tunnel placement and roofplasty on reconstructed
anterior cruciate ligament knees. Arthroscopy. 1995;11(1):57-62.
49. Nebelung W, Wuschech H. Thirty-five years of follow-up of anterior
cruciate ligament-deficient knees in high-level athletes. Arthroscopy.
2005;21(6):696-702.
50. Noyes FR, Barber SD, Simon R. High tibial osteotomy and ligament
reconstruction in varus angulated, anterior cruciate ligament-
deficient knees. A two- to seven-year follow-up study. Am J Sports
Med. 1993;21(1):2-12.
51. Noyes FR, Barber-Westin SD. Anterior cruciate ligament revision
reconstruction: results using a quadriceps tendon-patellar bone
autograft. Am J Sports Med. 2006;34(4):553-564.
52. Noyes FR, Barber-Westin SD. Revision anterior cruciate ligament
reconstruction using a 2-stage technique with bone grafting of the
tibial tunnel. Am J Sports Med. 2006;34(4):678-680.
53. Noyes FR, Barber-Westin SD. Revision anterior cruciate surgery with
use of bone-patellar tendon-bone autogenous grafts. J Bone Joint
Surg Am. 2001;83(8):1131-1143.
54. Noyes FR, Barber-Westin SD, Roberts CS. Use of allografts after
failed treatment of rupture of the anterior cruciate ligament. J Bone
Joint Surg Am. 1994;76(7):1019-1031.
55. Noyes FR, Mooar LA, Moorman CT 3rd, McGinniss GH. Partial tears
of the anterior cruciate ligament: progression to complete ligament
deficiency. J Bone Joint Surg Br. 1989;71(5):825-833.
56. O’Neill DB. Arthroscopically assisted reconstruction of the anterior
cruciate ligament: a follow-up report. J Bone Joint Surg Am.
2001;83(9):1329-1332.
57. O’Neill DB. Revision arthroscopically assisted anterior cruciate liga-
ment reconstruction with previously unharvested ipsilateral auto-
grafts. Am J Sports Med. 2004;32(8):1833-1841.
58. Ohly NE, Murray IR, Keating JF. Revision anterior cruciate ligament
reconstruction: timing of surgery and the incidence of meniscal tears
and degenerative change. J Bone Joint Surg Br. 2007;89(8):
1051-1054.
59. Palmieri-Smith RM, Thomas AC, Wojtys EM. Maximizing quadriceps
strength after ACL reconstruction. Clin Sports Med. 2008;27(3):
405-424.
60. Parkkari J, Pasanen K, Mattila VM, Kannus P, Rimpela A. The risk for
a cruciate ligament injury of the knee in adolescents and young
adults: a population-based cohort study of 46 500 people with a 9
year follow-up. Br J Sports Med. 2008;42(6):422-426.
61. Pinczewski LA, Lyman J, Salmon LJ, Russell VJ, Roe J, Linklater J. A
10-year comparison of anterior cruciate ligament reconstructions
with hamstring tendon and patellar tendon autograft: a controlled,
prospective trial. Am J Sports Med. 2007;35(4):564-574.
62. Royalty RN, Junkin DM Jr, Johnson DL. Anatomic double-bundle
revision anterior cruciate ligament surgery using fresh-frozen allograft
tissue. Clin Sports Med. 2009;28(2):311-326, ix.
63. Said HG, Baloch K, Green M. A new technique for femoral and tibial
tunnel bone grafting using the OATS harvesters in revision anterior
cruciate ligament reconstruction. Arthroscopy. 2006;22(7):e791-793.
64. Sajovic M, Vengust V, Komadina R, Tavcar R, Skaza K. A prospec-
tive, randomized comparison of semitendinosus and gracilis tendon
Vol. 39, No. 1, 2011
versus patellar tendon autografts for anterior cruciate ligament
reconstruction: five-year follow-up. Am J Sports Med. 2006;34(12):
1933-1940.
65. Salmon L, Russell V, Musgrove T, Pinczewski L, Refshauge K. Inci-
dence and risk factors for graft rupture and contralateral rupture after
anterior cruciate ligament reconstruction. Arthroscopy. 2005;21(8):
948-957.
66. Salmon LJ, Pinczewski LA, Russell VJ, Refshauge K. Revision anterior
cruciate ligament reconstruction with hamstring tendon autograft: 5- to
9-year follow-up. Am J Sports Med. 2006;34(10):1604-1614.
67. Schulz AP, Gotze S, Schmidt HG, Jurgens C, Faschingbauer M. Sep-
tic arthritis of the knee after anterior cruciate ligament surgery:
a stage-adapted treatment regimen. Am J Sports Med. 2007;35(7):
1064-1069.
68. Sgaglione NA, Douglas JA. Allograft bone augmentation in anterior cru-
ciate ligament reconstruction. Arthroscopy. 2004;20(suppl 2):171-177.
69. Shelbourne KD, Gray T. Results of anterior cruciate ligament recon-
struction based on meniscus and articular cartilage status at the time
of surgery: five- to fifteen-year evaluations. Am J Sports Med.
2000;28(4):446-452.
70. Shelbourne KD, Gray T, Haro M. Incidence of subsequent injury to either
knee within 5 years after anterior cruciate ligament reconstruction with
patellar tendon autograft. Am J Sports Med. 2009;37(2):246-251.
71. Shelbourne KD, O’Shea JJ. Revision anterior cruciate ligament
reconstruction using the contralateral bone-patellar tendon-bone
graft. Instr Course Lect. 2002;51:343-346.
72. Shelbourne KD, Patel DV. Treatment of limited motion after anterior
cruciate ligament reconstruction. Knee Surg Sports Traumatol
Arthrosc. 1999;7(2):85-92.
73. Shelbourne KD, Patel DV, Martini DJ. Classification and management
of arthrofibrosis of the knee after anterior cruciate ligament recon-
struction. Am J Sports Med. 1996;24(6):857-862.
74. Shen W, Forsythe B, Ingham SM, Honkamp NJ, Fu FH. Application of
the anatomic double-bundle reconstruction concept to revision and
augmentation anterior cruciate ligament surgeries. J Bone Joint
Surg Am. 2008;90(suppl 4):20-34.
75. Spindler KP, Kuhn JE, Freedman KB, Matthews CE, Dittus RS, Har-
rell FE Jr. Anterior cruciate ligament reconstruction autograft choice:
bone-tendon-bone versus hamstring: does it really matter? A sys-
tematic review. Am J Sports Med. 2004;32(8):1986-1995.
76. Thomas NP, Kankate R, Wandless F, Pandit H. Revision anterior cru-
ciate ligament reconstruction using a 2-stage technique with bone
grafting of the tibial tunnel. Am J Sports Med. 2005;33(11):1701-1709.
77. Uribe JW, Hechtman KS, Zvijac JE, Tjin-A-Tsoi EW. Revision anterior
cruciate ligament surgery: experience from Miami. Clin Orthop Relat
Res. 1996;325:91-99.
78. Van Tongel A, Stuyck J, Bellemans J, Vandenneucker H. Septic
arthritis after arthroscopic anterior cruciate ligament reconstruction:
For reprints and permission queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav
Downloaded from ajs.sagepub.com at ORTHO ONE ORTHOPAEDICS on June 11, 2014
Revision ACL Reconstruction 217
a retrospective analysis of incidence, management and outcome.
Am J Sports Med. 2007;35(7):1059-1063.
79. Vaughn ZD, Schmidt J, Lindsey DP, Dragoo JL. Biomechanical eval-
uation of a 1-stage revision anterior cruciate ligament reconstruction
technique using a structural bone void filler for femoral fixation.
Arthroscopy. 2009;25(9):1011-1018.
80. Wang C, Ao Y, Wang J, Hu Y, Cui G, Yu J. Septic arthritis after arthro-
scopic anterior cruciate ligament reconstruction: a retrospective
analysis of incidence, presentation, treatment, and cause. Arthros-
copy. 2009;25(3):243-249.
81. Wegrzyn J, Chouteau J, Philippot R, Fessy MH, Moyen B.
Repeat revision of anterior cruciate ligament reconstruction: a ret-
rospective review of management and outcome of 10 patients with
an average 3-year follow-up. Am J Sports Med. 2009;37(4):
776-785.
82. Weiler A, Schmeling A, Stohr I, Kaab MJ, Wagner M. Primary versus
single-stage revision anterior cruciate ligament reconstruction using
autologous hamstring tendon grafts: a prospective matched-group
analysis. Am J Sports Med. 2007;35(10):1643-1652.
83. Williams GN, Buchanan TS, Barrance PJ, Axe MJ, Snyder-Mackler L.
Quadriceps weakness, atrophy, and activation failure in predicted
noncopers after anterior cruciate ligament injury. Am J Sports Med.
2005;33(3):402-407.
84. Woo SL, Kanamori A, Zeminski J, Yagi M, Papageorgiou C, Fu FH.
The effectiveness of reconstruction of the anterior cruciate ligament
with hamstrings and patellar tendon: a cadaveric study comparing
anterior tibial and rotational loads. J Bone Joint Surg Am.
2002;84(6):907-914.
85. Wright RW, Dunn WR, Amendola A, et al. Risk of tearing the intact
anterior cruciate ligament in the contralateral knee and rupturing
the anterior cruciate ligament graft during the first 2 years after ante-
rior cruciate ligament reconstruction: a prospective MOON cohort
study. Am J Sports Med. 2007;35(7):1131-1134.
86. Wu WH, Hackett T, Richmond JC. Effects of meniscal and articular
surface status on knee stability, function, and symptoms after ante-
rior cruciate ligament reconstruction: a long-term prospective study.
Am J Sports Med. 2002;30(6):845-850.
87. Yagi M, Wong EK, Kanamori A, Debski RE, Fu FH, Woo SL. Biome-
chanical analysis of an anatomic anterior cruciate ligament recon-
struction. Am J Sports Med. 2002;30(5):660-666.
88. Yamamoto Y, Hsu WH, Woo SL, Van Scyoc AH, Takakura Y, Debski
RE. Knee stability and graft function after anterior cruciate ligament
reconstruction: a comparison of a lateral and an anatomical femoral
tunnel placement. Am J Sports Med. 2004;32(8):1825-1832.
89. Zantop T, Petersen W. Double bundle revision of a malplaced single
bundle vertical ACL reconstruction: ACL revision surgery using a two
femoral tunnel technique. Arch Orthop Trauma Surg. 2008;128(11):
1287-1294.