Considerations and Challenges in Revision ACL Reconstruction (2025 Annual Meeting)-Considerations and Challenges in Revision ACL Reconstruction

Video Transcription

Video Summary

The panel discussion focuses on revision anterior cruciate ligament (ACL) reconstruction, addressing the complex challenges, key considerations, and surgical nuances involved in managing failed ACL repairs. Experts from various institutions explore topics including patient evaluation, surgical technique, extra-articular procedures, osteotomies for slope correction, meniscal preservation, and hardware complications.<br /><br />Dr. Edgar emphasizes thorough patient history and imaging, noting high failure rates in revision ACL surgeries (up to 83%) and the importance of factors like graft type, hyperlaxity, tunnel position, and timing of return to sport. Bone loss and tunnel malposition are critical; Dr. Newell discusses single versus two-stage revision surgeries, often determined by tunnel widening (12-14mm threshold). Bone grafting techniques, such as using allograft bone dowels, aid in restoring bone stock before revision.<br /><br />Dr. Dewan highlights the importance of lateral extra-articular tenodesis (LET) and anterolateral ligament (ALL) reconstruction to control rotational instability. LET, particularly the modified Lemaire technique, shows superior biomechanical control and can reduce re-injury rates without adding significant surgical time or complications.<br /><br />Dr. Sherman discusses osteotomies to correct increased posterior tibial slope, a recognized risk factor for ACL failure. While controversial for primary ACL reconstructions, slope correction is increasingly performed in revisions, especially when combined with coronal plane malalignment and meniscal deficiencies.<br /><br />Dr. Waterman underscores the critical but often overlooked role of the meniscus, especially lateral meniscus root and ramp lesions, in knee stability and ACL graft success. Repair of meniscal injuries and attention to tibial slope are vital to prevent re-injury and early osteoarthritis.<br /><br />The panel shares practical advice on hardware removal, recognizing intraoperative complications like tunnel blowouts, and graft choices favoring quadriceps tendon or bone-patellar tendon-bone over hamstrings in revisions. They stress careful preoperative planning, intraoperative assessment, and tailored rehabilitation to improve outcomes.<br /><br />Overall, revision ACL reconstruction requires comprehensive evaluation of patient-specific anatomical, biomechanical, and biological factors. Combining appropriate surgical techniques—including bone grafting, extra-articular procedures, slope correction, and meniscal preservation—optimizes knee stability and long-term function in this challenging patient population.

Asset Caption

Aman Dhawan, M.D. | Brian R. Waterman, M.D., FAANA | Seth L. Sherman, M.D., FAANA | Jonathan F. Dickens, M.D., COL, USAR | Clayton W. Nuelle, M.D., FAANA

Keywords

revision ACL reconstruction

anterior cruciate ligament

failed ACL repair

patient evaluation

surgical technique

extra-articular procedures

osteotomy slope correction

meniscal preservation

hardware complications

lateral extra-articular tenodesis

anterolateral ligament reconstruction

bone grafting