AANA Fellowship Education - ACL Tear.…Again! Now What?-ACL Tear.…Again! Now What?

Video Transcription

Video Summary

The webinar, part of the Anna Fellowship Lecture Series, focused on management and revision strategies for anterior cruciate ligament (ACL) tear failures. Experts, including Drs. John Dickens, Brian Waterman, Michael Alea, and Bruce Levy, discussed comprehensive approaches to evaluating and treating failed ACL reconstructions.<br /><br />Key points included the high failure rate of revision ACL surgeries and the importance of identifying failure causes such as technical errors (notably femoral tunnel malposition), graft selection issues, malalignment, biological factors, and associated injuries like meniscal or collateral ligament damage. A thorough history, physical exam, and detailed imaging—weight-bearing X-rays, MRI, CT scans—are essential for diagnosis and surgical planning.<br /><br />Dr. Waterman emphasized the role of posterior tibial slope in ACL failure, advocating for osteotomies to correct excessive slope (>12 degrees) or varus malalignment, which increase graft stress and re-injury risk. Different osteotomy techniques (supratubercle, infratubercle, biplanar) were described for slope correction and alignment.<br /><br />Dr. Dickens presented tunnel management strategies, highlighting single-stage vs two-stage revisions based on tunnel positioning and size. Minimally dilated, well-positioned tunnels may allow single-stage revision; larger or malpositioned tunnels require bone grafting first to restore bone stock before reconstruction. Tunnel dilators and autografts improve graft fixation and healing.<br /><br />Dr. Alea discussed extra-articular procedures—anterolateral ligament (ALL) reconstruction versus lateral extra-articular tenodesis (LET)—as adjuncts to improve rotational stability. LET often provides superior control compared to ALL reconstruction. However, these are not cures and should be selectively used, ensuring other causes of failure are addressed first.<br /><br />Dr. Levy shared clinical cases illustrating principles of revision surgery, including the importance of addressing meniscal root tears, hardware issues, proper graft selection (preferably autograft), and the role of osteotomy in slope correction. He stressed patient counseling on complexity and staging of surgeries.<br /><br />Overall, the session underscored that successful ACL revision requires careful multifactorial evaluation, addressing mechanical alignment, graft and tunnel factors, meniscal and ligamentous integrity, and appropriate use of adjunctive procedures to optimize outcomes.

Keywords

ACL tear

revision ACL surgery

anterior cruciate ligament

femoral tunnel malposition

osteotomy techniques

posterior tibial slope

tunnel management

single-stage revision

two-stage revision

anterolateral ligament reconstruction

lateral extra-articular tenodesis

meniscal root tears

graft selection