For a brief overview of knee anatomy, physiology, and biomechanics, please click here.

Clinical Sports Medicine Update: Current Concepts Review: Revision Anterior Cruciate Ligament Reconstruction, Michael S. George et al.; The American Journal of Sports Medicine, Baltimore; December 2006, Volume 34/12, pages 2026-2037. Comments: This superb article is a must-read for anyone who has experienced ACL-reconstruction failure and is planning to undergo revision ACL reconstruction.

Anterior Cruciate Ligament Revision Reconstruction -- Results Using a Quadriceps Tendon–Patellar Bone Autograft , Frank R. Noyes, MD and Sue D. Barber-Westin; The American Journal of Sports Medicine, Baltimore; April 2006, Volume 34, pages 553-564. Comments: Surgeon error is the #1 cause of ACL-graft failure, and despite the commonness of ACL injuries and reconstructions, this surgery remains technically demanding for even the most experienced of surgeons. Noyes and Barber-Westin describe a viable autograft source for revision-reconstruction cases, in particular in cases where the patient's patellar tendon has already been harvested and where the patient would prefer not to harvest the patellar tendon from the contralateral knee. The authors note that, prior to pursuing revision ACL reconstruction, full knee motion should be achieved. They note that in cases where a full extension may not be obtainable because the first graft was placed too far forwards, or because of the presence of a cyclops lesion, or because the posterior capsular structures may have undergone unbidden shortening, a staged arthroscopic debridement procedure (entailing removal of the original ACL graft as well as notchplasty [i.e. widening of the femoral notch where the ACL resides]) is needed. The authors note that the correction of badly misplaced bone tunnels often requires bone grafting in advance.

Revision Anterior Cruciate Ligament Reconstruction Using a 2-Stage Technique With Bone Grafting of the Tibial Tunnel, Neil P. Thomas; The American Journal of Sports Medicine, Baltimore; November 2005, Vol 33, p. 1701-1709. Comments: Given that the major cause of ACL-graft failure tends to be surgeon error (i.e. incorrectly located graft tunnels; note that even a few millimetres of error here will guarantee that the graft will stretch out and eventually fail), revision reconstructions are sometimes a necessity. This study describes a two-stage revision method. First, in order to properly fill the tibial tunnel, bone grafting is done. Then, in a second surgery at a later date, a new graft in installed. It goes without saying that revision ACL reconstruction is technically extremely demanding, and therefore requires a top-notch, highly experienced surgeon. A surgeon who has done only first-time ACL grafts is not a good choice for revision reconstructions.

Revision Arthroscopically Assisted Anterior Cruciate Ligament Reconstruction With Previously Unharvested Ipsilateral Autografts, Daniel B. O’Neill; The American Journal of Sports Medicine, Baltimore; December 2004, Vol 32, p. 1833-1841. Comments: In this study, ACL-revision reconstruction was performed with the hamstring-group autograft (DLSTG) on 23 patients and with the patellar-tendon autograft on 25 patients. At follow-up (which ranged from 2 to 13 years), 73% of the reconstructions were functional, 21% were partially functional, and 6% had failed. (Although the failed grafts were all from the patellar-tendon group [which is known to have the highest success rate for first-time reconstructions because of the security of bone-plug-to-bone-tunnel healing, an advantage which one would expect to clearly see in the context of revision ACL reconstructions as well], the authors note that these three failures were from the first four ACL-revision grafts done in the study, and so the surgeon had the least amount of experience in this regard. As well, because these failures were the first reconstructions in this study, the follow-up period was longest. If the three failures are excluded from the statistical analysis, then both hamstring and patellar-tendon autografts bring similar success rates for revision ACL reconstruction.) As expected, the results were not as good as those typically found in first-time (also known as primary) ACL recontructions. In any case, for revision ACL reconstructions, autografting brings better results than allografting. (None of the patients in this study had any comcomitant ligament deficiencies.)

Revision Anterior Cruciate Ligament Reconstruction with a Reharvested Ipsilateral Patellar Tendon, Angelo J. Colosimo et al.; The American Journal of Sports Medicine, Baltimore; November 2001, Vol 29, p. 746-750. Comments: This study shows that reharvesting the patellar tendon is a viable option, and that the resulting graft brings satisfactory results. (This disagrees with the July 1998 AJSM study by Kartus, which found that reharvesting the patellar tendon brings complications and problems. It would have been nice if Colosimo's study would have involved more than 13 knees.) It is interesting to note that Colosimo et al. describe ACL-revision reconstruction as a salvage procedure, a term which might carry an ominous connotation from the viewpoint of the patient. Clearly, it behooves anyone undergoing a revision reconstruction to ensure that the surgeon is well-experienced not only with first-time ACL reconstructions, but with revision reconstructions and complex knee surgeries as well. This study provides a good overview of the dangers inherent in placing excessive demands on a recently reconstructed knee, and it describes the stages through which an ACL graft goes through.

Revision Anterior Cruciate Surgery with Use of Bone-Patellar Tendon-Bone Autogenous Grafts, Frank R. Noyes and Sue D. Barber-Westin; The Journal of Bone and Joint Surgery; August 2001, Vol 83, p. 1131-1143. Comments (provided by Sue Barber-Westin): This investigation followed 52 knees that received a patellar tendon autograft for revision reconstruction from 24 to 74 months postoperatively. KT-1000 testing found that 24% of the grafts failed. However, the failure rate differed according to additional procedures required. In knees in which only an ACL reconstruction was done, the failure rate was 16%; in those that also required a high tibial osteotomy, it was 22%. At follow-up, 63% had returned to mostly light sports without problems, and 94% believed their knee condition had improved compared to the preoperative status. Additionally, in 11 knees the patellar tendon was re-harvested for the revision procedure. Six of these 11 grafts subsequently failed, and the authors warned against using a PT which had previously been harvested, regardless of the time interval between the original and revision operations. (This article includes follow-up commentaries by Scott Rodeo and Martha Murray.)

Ipsi- or Contralateral Patellar Tendon Graft in Anterior Cruciate Ligament Revision Surgery: A Comparison of Two Methods, Jüri Kartus et al.; The American Journal of Sports Medicine, Baltimore; December 2004, Vol 26, p. 499-504. Comments: Kartus et al. studied 24 ACL-revision-reconstruction knees. Of these knees, 12 underwent ipsilateral (same-knee) patellar-tendon reharvesting, while the remaining 12, the contralateral (opposite-knee) patellar tendon was harvested. The results for the former group were not as good as in the latter group. Therefore, it is not a good idea to reharvest an already-once-harvested patellar tendon. The best option was found to entail harvesting from the patellar tendon of the opposite knee (assuming no previous graft-harvesting was done from said knee). Note that in this study, the revision-reconstructed knees were graded on a scale rather than as failed-versus-successful.

Click here to return to the Main Entrance Page of the Knee Library.

Looking for the Main Index Page of Bob's ACL WWWBoard? Click here!

To find recent postings on Bob's ACL WWWBoard, use the Search Engine.

To find older postings on Bob's ACL WWWBoard, use the On-Line Archive.