AANA24 Knee All-Access Pass-CONCURRENT SCIENTIFIC SESSION 3D: Revision ACL Considerations

Video Transcription

Video Summary

This session focused on revision anterior cruciate ligament (ACL) reconstruction and debated key considerations such as lateral extra-articular procedures, graft choice, tunnel management, and addressing concomitant injuries like meniscal root tears and malalignment.<br /><br />In the debate on lateral stabilization, Adnan Saifna advocated for anatomic anterolateral ligament (ALL) reconstruction, emphasizing restoration of native anatomy and knee kinematics with less risk of over-constraint and long-term osteoarthritis compared to non-anatomic lateral extra-articular tenodesis (LET). He cited evidence favoring combined procedures in revision ACL and highlighted lower complication rates and tunnel collision risks with ALL reconstruction. Conversely, Rahul Patel supported LET via iliotibial band tenodesis, arguing that LET better controls internal tibial rotation near extension by engaging the Kaplan fibers and ITB complex, showing biomechanical superiority in rotational stability. He acknowledged ALL’s role in select cases but prefers LET for its effectiveness.<br /><br />Regarding graft choice in a 17-year-old female revision case, Dr. Scott Fawcett promoted ipsilateral quadriceps tendon autograft due to its large size, adaptability, less donor site morbidity, and faster recovery in quadriceps strength compared to patellar tendon or hamstring grafts. Dr. Eric McCarty advocated contralateral bone-patellar tendon-bone (BTB) autograft, citing its reliability, lower cost, superior early quadriceps strength recovery, and established long-term outcomes. Both agreed autografts outperform allografts in reducing re-rupture.<br /><br />Nick Scaglione discussed management of imperfectly placed or overlapping tunnels in revision ACL, emphasizing CT imaging for accurate assessment and proposing single-stage bone graft substitutes and outside-in drilling techniques to avoid tunnel convergence. Rahul Patel highlighted challenges in lateral meniscal root repair during revision, recommending parallel tunnel drilling to minimize convergence and stressing careful rehabilitation to protect repairs.<br /><br />A challenging pediatric case illustrated complexities: a 12-year-old female with failed ACL and MCL reconstructions underwent staged surgery including bone grafting, allograft MCL reconstruction, and eventual valgus-correcting distal femoral osteotomy with combined revision ACL and MCL reconstruction, resulting in good functional recovery.<br /><br />Overall, the session stressed individualized approaches in revision ACL, balancing anatomic restoration, graft selection, tunnel management, and addressing concomitant pathology to optimize outcomes.

Asset Caption

Introduction by Moderators: Craig H. Bennett, M.D., Catherine Hui, M.D.

Keywords

revision ACL reconstruction

lateral extra-articular procedures

anterolateral ligament reconstruction

lateral extra-articular tenodesis

graft choice

tunnel management

meniscal root repair

quadriceps tendon autograft

bone-patellar tendon-bone autograft

valgus-correcting distal femoral osteotomy