AANA Lab Course 913 - Advanced Knee Course-Revision ACL-Considerations to Maximize Successful Outcomes Faculty Lecture

Revision ACL-Considerations to Maximize Successful Outcomes Faculty Lecture_ Robert F. LaPrade, MD

Pdf Summary

This presentation by Dr. Robert F. LaPrade from the AANA Complex Knee Course (2019) addresses revision anterior cruciate ligament reconstruction (ACLR), emphasizing considerations to optimize successful outcomes. Revision ACLR failures commonly arise from technical errors (50%), malalignment in coronal and sagittal planes, recurrent trauma, graft choice issues, concurrent instabilities (notably posterolateral corner), and meniscal deficiencies such as posterior horn medial meniscus (PHMM) and root tears.<br /><br />Indications for revision include recurrent instability, pain, effusions, and need for concurrent surgeries like meniscal repair or ligament reconstructions. Positive pivot shift tests correlate with poorer outcomes, including osteoarthritis and reduced return to play rates.<br /><br />Preoperative assessment should include CT scans to evaluate tunnel placement and osteolysis, crucial for planning single or two-stage revision surgery. Sagittal malalignment, notably increased posterior tibial slope (>9°), raises graft loads and failure risk—corrective proximal tibial osteotomy may be required. Coronal malalignment (varus or valgus) and physiological laxity affect revision strategies.<br /><br />Technical errors often involve femoral and tibial tunnel placement, hardware complications, and graft choices. Specific surgical tips include hardware removal techniques, assessing whether to perform one- or two-stage revisions, and managing extension deficits with posterior capsular release and rehabilitation.<br /><br />Graft selection favors autografts, especially contralateral bone-patellar tendon-bone (BTB) grafts, due to better outcomes over allografts or hamstring autografts in lax patients. Addressing secondary stabilizers like lateral meniscus root tears and posterolateral corner injuries is critical; combined anatomic reconstructions should be performed concurrently when possible.<br /><br />Adding anterolateral ligament (ALL) or lateral extra-articular tenodesis (LET) procedures may reduce failure rates in hyperlax patients or those with increased slope. Revision ACLR has historically poorer outcomes than primary surgery, but staged and unstaged approaches show similar functional results and failure rates.<br /><br />In summary, revision ACLR is complex and requires comprehensive evaluation of alignment, tunnel position, graft choice, concurrent pathologies, and tailored surgical planning to maximize success.

Keywords

Revision ACL Reconstruction

Technical Errors

Malalignment

Graft Selection

Posterolateral Corner Instability

Meniscal Deficiencies

Preoperative CT Assessment

Proximal Tibial Osteotomy

Anterolateral Ligament Reconstruction

Surgical Planning