Revision ACL Reconstruction

by Dr. Robert Marx
2.12 Blog

One of the most common knee injuries is a torn ligament, and the anterior cruciate ligament (ACL) is the one we often read about in the sports pages. Athletes who participate in cutting and pivoting sports such basketball, soccer, football, skiing and lacrosse are more prone to an ACL injury.

Many people, especially younger active patients or athletes seeking to return to a sport, opt for surgery to repair the torn ligament. About 100,000 ACL reconstructions are performed in the United States each year, and overall, it is a highly successful operation. Innovative surgical techniques allow us to more precisely reproduce the anatomy and function of the original ACL.

Although primary ACL reconstruction has a high success rate, some patients are left with unsatisfactory results or they re-injure the ligament. About 10 percent of the ACL reconstructions performed in the United States fail within 10 years.

The main reasons a patient might need a revision ACL reconstruction include re-injury, problems arising from the previous surgery, or failure of the reconstructed ligament to heal properly.

Generally, patients know when there is a problem. Even after extensive rehabilitation, they may experience recurrent instability or other symptoms. After a primary ACL reconstruction, patients must also avoid returning to a sport too soon.

A second surgery to repair a torn anterior cruciate ligament is called revision ACL reconstruction. This is a more challenging operation for the orthopedic surgeon. Primary ACL reconstructions are performed using different techniques, so the surgeon must take multiple factors into account when planning for the more complex procedure.

The decision to proceed with a second ACL surgery depends on the patient, the condition and stability of his or her knee, the desired activity level and imaging findings.  Patients are advised to seek out a specialist with ample experience in revision ACL surgery for the best chance of a good outcome.

A number of options exist for revision ACL reconstruction, including using one of the patient’s own tendons. The patellar tendon, quadriceps tendon, hamstring tendon or allograft tissue may be used. The use of a tendon from the patient’s other knee is sometimes considered, as well.

Because revision ACL reconstruction is a more difficult operation to perform compared to primary ACL surgery, patients should choose an orthopedic surgeon with ample experience and with whom they feel comfortable. The doctor should take the time to answer all of a patient’s questions in nontechnical terms. With careful planning, many patients can have excellent results and return to a very high level of activity without knee instability.

Many, but not all, patients opt for revision surgery. People who do not experience instability in their knee and do not wish to return to cutting and pivoting sports may decide not to have surgery. If they wish to remain active, they may engage in a different sport.  However, patients who are left with an unstable knee or are enthusiastic about returning to their athletic activity of choice generally opt for revision surgery.

In general, rehabilitation following ACL revision reconstruction is similar to physical therapy after primary ACL reconstruction. Sometimes rehab after revision surgery takes a bit longer.

When considering whether or not to have a second ACL surgery, patients might want to ask their doctor the following questions:

  • Why was the first operation unsuccessful?
  • What will happen if I don’t have revision surgery?
  • Do I have any other knee injury, such as a torn cartilage, that may affect the outcome of revision surgery?
  • What will my recovery and rehabilitation be like?
  • What are the risks of surgery?
  • How can I avoid re-injuring my knee?

Patients are also advised to inquire about the doctor’s experience in ACL revision surgery, as well as the hospital’s safety and infection rates.

The best way to avoid revision ACL surgery in the first place is to do certain exercises to increase strength and balance. The other option is to stop playing cutting and pivoting sports, substituting other athletic activities in which the risk of ACL injury is low.  Such activities include swimming, cycling, jogging and weight training.

Dr. Robert G. Marx is an orthopedic surgeon in the Sports Medicine and Shoulder Service at Hospital for Special Surgery. He has written several books, including his most recent textbook, “Revision ACL Reconstruction: Indications and Technique,” as well as a book geared toward consumers called “The ACL Solution: Prevention and Recovery for Sports’ Most Devastating Knee Injury.”

Topics: Featured, Orthopedics
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The information provided in this blog by HSS and our affiliated physicians is for general informational and educational purposes, and should not be considered medical advice for any individual problem you may have. This information is not a substitute for the professional judgment of a qualified health care provider who is familiar with the unique facts about your condition and medical history. You should always consult your health care provider prior to starting any new treatment, or terminating or changing any ongoing treatment. Every post on this blog is the opinion of the author and may not reflect the official position of HSS. Please contact us if we can be helpful in answering any questions or to arrange for a visit or consult.

Comments

Kostas says:

Hello,i had a primary ACL recostruction before 1,5 year , but the graft it was failed because of agressive physiotherapy in the early stage(lengthening of hamstring graft because of active leg extension with gravity 1 week after the operation ) so i had a revision before 5 months(1 year after the primary).My muscles were very weak before revision(just jogging) and i afraid that i can”t get my muscles back.5 months after revision i started jogging(very slow) but my muscles are very very weak.I would like to know your opinion about the failure of the graft and about the athletic activity which i can have after ACL revision.THANKS

HSS on the Move says:

Hi Kostas, thank you for reaching out. Dr. Robert Marx, Orthopedic Surgeon, says: “Recovery after revision ACL reconstruction can take longer. The cause you describe for failure may not be accurate as it is impossible to know without more information. Some patients can be very active after revision ACL reconstruction. Be patient, make gradual progress and hopefully you will be able to return to what you want to do.”

Keith says:

Hello, I had a complete tear of my ACL 32 years ago. The tear was misdiagnosed initially. Finally a year later when the leg muscles were not as strong, an orthopedic surgeon did a scope and found the torn ACL, no cartilage damage. He removed the ACL. After discussing the alternatives we opted not to do the reconstruction. Now I am having problems with my knee. Has is been too long to have ACL reconstruction? I am now 51 years old and in good shape.

HSS on the Move says:

Hi Keith, thank you for reaching out. Dr. Robert Marx, Orthopedic Surgeon, says: “ACL reconstruction can be performed many years after the original injury, even decades. The main question is whether the ACL is the problem or whether you have developed arthritis or another problem. To answer this question, consultation with a knee specialist is necessary.” If you wish to receive care at HSS, please contact our Physician Referral Service at 877-606-1555 for further assistance.

David Driscoll says:

I’m 10 months post primary ACL surgery. Had been fully cleared to resume sports (Been cleared to begin jogging over 6 months ago). Knee felt great, really strong.
Was jogging this past week end, felt a pop there was no pain in the initial pop but felt additional pain throughout the knee…Now two days later have a lot of pain behind the knee…it’s stable but, it’s stiff and I have a lot of pain. Does this sound like a re-tear? I can’t get in my doctor’s for four days and I’m dying to know.

Thank you.

HSS on the Move says:

Hi David, thank you for reaching out. Dr. Robert Marx, Orthopedic Surgeon, says: “Although it doesn’t usually happen with jogging, it could possibly be a retear. You should consult with your surgeon.” For more information on ACL injuries, visit http://www.hss.edu/condition-list_acl-injuries.asp. If you wish to receive care at HSS, please contact our Physician Referral Service at 877-606-1555 for further assistance.

krishna says:

Hello,Now i am 21 years old.I had a complete tear of my ACL without any meniscui damage,i had a primary ACL recostruction before 6 months,but after surgery the tendon site was not healed due to infection,doctor found that after one month of surgery and he done arthosocpe knee wash and he told me to take 45 days bed rest.After 45 days i felt instability on knee.I went to doctor he said there is laxity between grade 1 and 2,and he also said there is rotational inconsistency.So he told me that i cant run any more in life and suggested to use hinged knee brace for life long.I am feeling pain some times.I want to get my previous life back.Is there any treatment other than REVISION ACL RECONSTRUCTION for getting into my previous life activity.

HSS on the Move says:

Hi Krishna, thank you for reaching out. It is best for you to seek an in-person consultation with a physician so they can better advise. If you wish to receive care at HSS, please contact our Physician Referral Service at 877-606-1555 for further assistance.

Victor Trujillo says:

Hello. I am 10 months post revision on my left knee. Hamstring allograft failed after 9 months due to lack of therapy and aggressive return to sport (indoor and college soccer). I feel fine and stable. However, in certain positions and when I bend my knee inwards I feel like the inside of my calve muscle is very weak and gets stretched. Close to the MCL area. Is this common? Does the calve really protect the ACL that much?

HSS on the Move says:

Hi Victor, thank you for reaching out. For more information on ACL injuries, please visit http://www.hss.edu/condition-list_acl-injuries.asp. It is best for you to consult with your treating physician who is familiar with your course of treatment. If you wish to receive care at HSS, please contact our Physician Referral Service at 877-606-1555 for further assistance.

Chuba Oyolu says:

This is very well written. Having gone through ACL reconstruction myself, I can tell that this would serve as a good resource for people who just got injured and don’t know what to expect. It even goes further to talk about revisions.

Is there any data that details the success rates for revisions, 3rd surgery, 4th etc? I’d be interested to see that. Also, what is the rate of re-tear at the 2 plus years post surgery mark. I’m assuming the rate of re-tears at this stage goes down considerably?

HSS on the Move says:

Hi Chuba, thank you for reaching out. Dr. Robert Marx, Orthopedic Surgeon, says: “There is very little data on multiple ACL revisions. Commonsense would have it that more revisions on the same knee has a higher risk of potential problems. In the recent text book on ACL revision, we dedicated an entire chapter to the multiply revised ACL knee. The rate remains to be approximately 1 percent per year, based on the published literature.”

Elena says:

Hi my name is Elena. I am a 17 year old girl who is involved in many sports (lacrosse,soccer, swimming, cross country, ultimate frisbee). About two years ago I tore my ACL and had it reconstructed, using hamstring auto graft, a month later. I went through physical therapy and was cleared to play after about 8 months. Now 2 years late I found out that I have retorn my ACL and have a partial meniscus tear as well. Although I don’t play lacrosse or soccer anymore I do run, yoga, swim and play pick up frisbee games. I was wondering if the revision ACL reconstruction surgery was worth it if it tore so easily the first time.

HSS on the Move says:

Hi Elena, thank you for reacing out. Unfortunately, we are not able to answer your question because you are under the age of 18. It is best for you to consult with your treating physician with a parent.

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