AOSSM/AANA Specialty Day 2020-Handout 2 - Revision ACL Surgery

Handout 2 - Revision ACL Surgery_ Technical Considerations for Success

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This presentation by Dr. Mark D. Miller of the University of Virginia focuses on technical considerations to optimize success in revision anterior cruciate ligament reconstruction (ACLR). ACL graft failure, caused by factors including repeat trauma (32%), technical errors (24%) such as malpositioned tunnels, biologic failure (7%), or combinations thereof (37%), is a significant challenge.<br /><br />A common technical error is incorrect femoral or tibial tunnel placement leading to graft stress, rotational instability, and subsequent failure. Tunnel widening or osteolysis—often due to mechanical factors like graft motion ("windshield wiper" and "bungee-cord" effects), biologic reactions, or low-grade infection—complicates revision surgery. Imaging, particularly CT scans, is critical for assessing bone tunnel defects.<br /><br />Revision ACLR may be single-stage or two-stage, determined largely by the extent of tunnel widening and overlap with planned new tunnels. If tunnels exceed 14 mm or overlap above 50%, a staged approach is advised. Femoral and tibial tunnels are debrided and then filled with various graft options: autogenous iliac crest bone graft, local autografts, femoral head allograft, allograft bone dowels, or bone substitutes like calcium phosphate.<br /><br />Allograft bone dowels have been shown to provide good structural integrity and incorporate well biologically, as evidenced by CT imaging and biopsies demonstrating bone integration and cellular repopulation over months. A single-stage revision technique involves debriding graft remnants, placing bone dowels in old tunnels, then creating new tunnels. Two-stage revision involves initial tunnel grafting with dowels followed months later by new tunnel drilling and ACLR.<br /><br />Additional considerations include addressing meniscal injuries (ramp or root tears), anterolateral ligament insufficiency with augmentation procedures, and correcting excessive tibial slope via osteotomy if necessary. Hardware placement must be secure, and proper tunnel positioning using fluoroscopic guidance is stressed.<br /><br />Overall, thorough preoperative planning, meticulous tunnel management with biologically favorable graft materials, and attention to concomitant injuries are key for successful revision ACL reconstruction.

Keywords

anterior cruciate ligament reconstruction

ACLR revision

graft failure

tunnel placement errors

tunnel widening

bone grafting

CT imaging

single-stage revision

two-stage revision

meniscal and ligament repair