International Perspective on Revision Anterior Cruciate Ligament Reconstruction: What Have We Been Missing?

Primary anterior cruciate ligament (ACL) reconstruction is a common orthopaedic procedure. A graft failure rate of 5% to 10% after primary ACL reconstruction has resulted in an increased need for revision ACL reconstruction. ACL reconstruction failure etiologies include trauma, technical errors, and biologic factors. Based on the current literature, the outcomes of revision ACL reconstruction are clearly inferior compared with those of primary reconstruction. A thorough patient evaluation, including surgical history, a physical examination, and imaging studies, is crucial in the assessment of a failed ACL reconstruction. Tunnel malposition, which is a technical error, is the most common reason for ACL reconstruction failure. Tunnel positioning and widening are important factors to consider in the decision to perform either one-stage or two-stage revision ACL reconstruction. Other concomitant factors such as malalignment, pathologic posterior tibial slope, and meniscal or ligamentous deficiency (in particular, deficiency of the anterolateral ligament) must be considered and addressed to achieve an optimal outcome. Patients who have a positive pivot shift test and rotational instability may require extra-articular anterolateral ligament reconstruction. In addition, patients who have severe pathologic tibial slope and anterior tibial translation may require a tibial deflexion osteotomy.