AANA/SOMOS Course Materials (August 2021)-Revision ACL Surgery

Revision ACL Surgery_ Maximizing Outcomes Under Duress

Pdf Summary

This presentation by Dr. Julie A. Dodds focuses on maximizing outcomes in revision anterior cruciate ligament (ACL) surgery, emphasizing the challenges ("under duress") inherent in such procedures. Key points include understanding why initial ACL reconstructions fail—common causes are early laxity due to fixation failure, poor tunnel positioning, graft failure after return to sports, missed secondary laxity, meniscal deficiency, malalignment, or forces exceeding normal ACL tolerance.<br /><br />Successful revision requires thorough preoperative planning: studying imaging (X-rays, MRI, possibly CT for tunnel dilation), assessing tunnel position, fixation hardware, and conducting a detailed history and physical exam, especially noting posterolateral (PL) laxity.<br /><br />Flexibility in technique is critical. Surgeons should have multiple graft options ready (allograft and autograft), multiple tunnel drilling methods (transtibial, anteromedial portal with flexible reamers, flip cutters, over-the-top guides), and fixation choices (metal or biocomposite screws, suspensory fixation). Tunnel condition dictates whether a single- or two-stage surgery is needed; single-stage is preferred when tunnels are anatomic with little expansion, whereas two-stage is for overlapping tunnels, poor bone stock, or limited motion.<br /><br />Dr. Dodds’s preferred method is a single-stage revision using bone-patellar tendon-bone (BTB) allograft or autograft, with AM or transtibial portal femoral drilling, and biocomposite screws (with metal as backup). She stresses “tunneloscopy” (arthroscopic evaluation of tunnels) prior to graft harvest to guide surgery plans. Overlapping or dilated tunnels may require bone grafting using allograft or TCP dowels to restore bone stock.<br /><br />In all cases, having a clear primary plan and a contingency plan, patient counseling about the possibility of two-stage procedures, and meticulous execution are essential to minimize intraoperative stress and optimize outcomes in complex revision ACL surgery.

Keywords

revision ACL surgery

anterior cruciate ligament

surgical outcomes

graft options

tunnel drilling techniques

bone-patellar tendon-bone graft

tunneloscopy

two-stage surgery

preoperative planning

fixation hardware