Revision ACL Reconstruction | Failed ACL Surgery

What is a revision ACL reconstruction?

The anterior cruciate ligament (ACL) is a commonly torn ligament in the knee. This ligament connects the femur (thighbone) to the tibia (shinbone) and helps to stabilize the knee. ACL tears and injuries are most often experienced by athletes participating in sports that involve jumping, twisting, and changing direction (soccer, basketball, lacrosse, downhill skiing). Patients who experienced a severe ACL injury will typically undergo ACL reconstruction surgery; ACL reconstruction repairs the damage and restores normal function to the knee joint. ACL reconstruction surgery has a very high rate of success.  However, ACL tears can reoccur. Athletes who return to pivoting sports are at risk for recurrent ACL tear even following a successful rehabilitation. In these cases, revision ACL reconstruction is required to restore the knee and to repair the damage and restore functional knee stability. Dr. Riley Williams, a complex knee surgeon, successfully performs revision ACL reconstruction for patients in Manhattan, Brooklyn, New York City, NY and surrounding areas who have experienced failure after a recent ACL reconstruction.

What causes an ACL reconstruction to fail?

The goal of ACL reconstruction is to restore knee stability, and to restore normal knee function. Failure of an ACL reconstruction occurs when the patient experiences a tear of the reconstructed ligament or if the knee is unable to function properly after the index procedure. ACL reconstruction failure may result in knee pain, loss of range of motion, or recurrent knee instability. ACL reconstructions may fail for a variety of reasons. The procedure may have been performed before normal range of motion is restored to the injured knee; these circumstances may result in knee loss of motion following surgery. MRI of such knees often demonstrate the presence of “cyclops lesion” or scar tissue in the front of the knee. Fortunately, removal of this scar tissue can alleviate this problem and allow for a full recovery.  Other causes of ACL surgery failure include failure to adequately follow the post-operative rehabilitation plan, technical issue with ACL graft placement, and new trauma to the ACL-reconstructed knee.

Who should have a revision ACL reconstruction?

Most active patients who suffer a recurrent ACL tear will likely need a revision reconstruction. Dr. Williams will discuss the pros and cons of such a procedure and how best to optimize the clinical results following this surgery.  Dr. Williams believe that it is crucial to understand the causes of the failed ACL procedure in order to avoid similar issues following the revision reconstruction. It is important to follow the post-operative plan delineated to the patient by Dr. Williams. Following surgery, it is normal to experience some swelling, pain, and decreased range of motion while in the acute healing phase. Over time, patients are advised to begin strength exercises and more stretching. This process helps to gradually regain strength and flexibility in the knee and may take a few months to complete. After about six months, the knee should be fully functional and stable.

Revision ACL reconstruction surgery is an excellent choice for patients who have undergone primary ACL reconstruction surgery and experienced another injury. If the patient returns to sports or weight-bearing activities too quickly following surgery, they run the risk of tearing the new tendon and causing further damage to the knee joint. In general, if patients expect to return to pivoting sports, revision ACL reconstruction will be necessary to achieve this desired goal.

How is revision ACL reconstruction performed?

Before revision ACL reconstruction surgery is performed, patients meet with Dr. Williams to discuss the cause of the ACL graft failure. A full understanding of the graft failure is needed so that the risk of repeat failure the revision surgery is minimized. Revision ACL reconstruction is a similar procedure to primary ACL reconstruction. Dr. Williams prefers the use of the patient’s tissue (autograft) for revision ACL reconstruction as these tissues are very strong and heal quickly and predictably.

During the first reconstruction, tunnels were created in the tibia and femur bones to facilitate ACL graft placement. If these tunnels have been damaged or expanded, bone graft may be used to repair the bone defect so the new tendon graft can be secured in place. In some cases, the original ACL graft may have been placed in the wrong footprint; if this is the case, the bony portion of the original graft may be left in place. Dr. Williams will do that which is necessary to place the revised ACL ligament graft into the proper location within the knee joint.

Sometimes, revision ACL reconstruction requires two separate surgeries. The first operation is performed to restore the bony integrity of the knee joint. Bone plugs and bone graft are used to restore the bony anatomy of the tibia and femur. Reconstitution of the tibia and femur allows for the placement of the revision ACL graft in the correct anatomic location. After about 3-6 months, Dr. Williams will check the graft procedure using a CT or MRI scan. Once the bony repair is physiologically complete, Dr. Williams will perform a second surgery to place the new ACL graft. During this operation, Dr. Williams creates new tunnels in the tibia and femur to secure the graft. He takes care to ensure that the new grafts are in the correct anatomical position and will allow the optimal range of motion and stability.

Revision ACL graft sources include use of a hamstring tendon autograft, quadriceps tendon autograft, and contralateral patellar tendon graft. The patient’s own tissue is Dr. Williams’ preferred revision graft of choice. In some cases, donor tissue (allograft) may be indicated. Dr. Williams will discuss all these options with the patient prior to performing the revision ACL procedure.

In addition, adjunctive procedures such as a lateral extra-articular tenodesis, iliotibial band tenodesis, or anterior lateral ligament (ALL) may be recommended by Dr. Williams to increase the likelihood of clinical success of revision ACL reconstruction.

How long is the recovery after revision ACL reconstruction?

In general, the recovery is the same as primary ACL reconstruction: 6 months. Bracing is used for 6 weeks after surgery. Physical therapy starts one week following surgery and continues for approximately 3-4 months following surgery. Strength and conditioning is very important near the end of the initial six-month postoperative interval. Patients should expect a measure approach to a full return to play. A full functional recovery must be established prior to a return to sports and full activity. Dr. Williams recommends the use of objective strength measures, movement analysis and an assessment psychological readiness prior to full clearance following revision ACL reconstruction.  It is important not to rush the recovery and rehabilitation process after revision ACL reconstruction. Recovery will often take longer the first reconstruction. The goal is to optimize stability and movement without damaging the graft or knee joint. In general, patients can expect to return to their athletic activities approximately 9 months after surgery.

For more information about revision ACL reconstruction or the causes of ACL reconstruction failure and the best treatment options available, please contact the office of Riley J. Williams, MD, orthopedic knee surgeon serving Manhattan, Brooklyn, New York City, NY and surrounding areas.