AOSSM/AANA Specialty Day 2020-Handout 1 - Revision ACL Surgery

Handout 1 - Revision ACL Surgery_ Technical Considerations for Success

Pdf Summary

This presentation by Dr. Mark D. Miller from the University of Virginia discusses technical considerations for successful revision anterior cruciate ligament reconstruction (ACLR). ACL graft failure, often caused by repeat trauma (32%), technical errors (24%), biologic failure (7%), or combined factors (37%), demands careful evaluation and planning to optimize outcomes.<br /><br />A critical cause of failure is incorrect tunnel placement—femoral side errors account for 80% of malpositioning, leading to rotational instability despite anterior-posterior stability. Hardware issues such as improper interference screw interference or cortical button engagement are also highlighted.<br /><br />Tunnel widening and osteolysis, common in failed ACLRs, present major challenges in revision cases. The etiology is not fully understood but may include mechanical factors (like windshield-wiper and bungee-cord motion) and possible low-grade infections with bacterial biofilms. Imaging—including radiographs, MRI, and especially CT scans—is essential to assess tunnel size, bone loss, and planning.<br /><br />The decision between one-stage versus two-stage revision depends on the degree of tunnel widening and location, especially when tunnels exceed 14mm in diameter or overlap planned tunnels. One-stage revisions may use allograft bone dowels to fill previous tunnels, allowing new tunnels to be drilled with partial dowel overlap. Two-stage revisions involve grafting tunnels initially with allograft dowels, allowing bone integration over months before reconstructing the ACL.<br /><br />Allograft bone dowels from proximal femur are preferred for filling, inserted carefully with serial drilling and tamping. Histological studies show good host bone integration and cellular repopulation at 4 months to 1 year post-grafting. Alternative grafting materials such as calcium phosphate cements are under investigation but lack definitive clinical evidence.<br /><br />Additional factors addressed include meniscal ramp and root repairs, lateral complex augmentation, and corrections for excessive tibial slope, all crucial for revision success.<br /><br />Overall, meticulous surgical technique, accurate imaging-based planning, appropriate tunnel management, and addressing associated pathologies are key ingredients for successful revision ACL reconstruction.

Keywords

anterior cruciate ligament reconstruction

ACLR revision

graft failure causes

tunnel placement errors

femoral tunnel malpositioning

hardware complications

tunnel widening and osteolysis

imaging techniques in ACLR

one-stage vs two-stage revision

allograft bone dowels