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.”