From Challenges to Solutions: Revision ACL Surgery at Knee Clinic Manchester

1. From Challenges to Solutions: Revision ACL Surgery at Knee Clinic Manchester

2. Intoduction Revision ACL surgery is a very difficult area. The term revision means re-do. If revision ACL is required this means that the patient has had a primary ACL reconstruction operation that has been carried out and has failed due to re-rupture of the reconstruction or ongoing instability due to graft stretch-out or instability of other causes around the knee.

3. What causes ACL re-rupture in order to require revision surgery? Primary ACL reconstruction surgery can fail for various reasons, some of which are beyond the control of both the patient and the surgeon. Here’s a closer look at the factors contributing to such failures: 1. Recurrent Trauma: - Despite a successful initial surgery, a recurrence of trauma can lead to ACL re-rupture. This is often unfortunate and sometimes unavoidable. - Athletes who fully recover from primary surgery and return to their sport might suffer another injury, causing the ACL to re-rupture. This can be purely coincidental or result from an early return to sports activities or inadequate muscle strength, tone, and conditioning in the leg, which predispose the individual to injury.

4. 2. Surgical and Technical Factors: - Poor Tunnel Placement: Incorrect placement of tunnels during surgery can compromise the stability and functionality of the reconstructed ACL. - Small Graft Size: Using a graft that is too small can lead to insufficient support and eventual failure. - Overlooked Structural Injuries: Missing additional injuries such as meniscal tears, meniscal ramp lesions, or other ligamentous instabilities during the primary surgery can result in ongoing knee instability. If these injuries are not addressed, they can predispose the reconstructed ACL to re-rupture and failure. Understanding these factors highlights the complexity of ACL injuries and the importance of a comprehensive approach in both primary and revision ACL surgeries to ensure long-term stability and functionality of the knee.

5. What happens in revision ACL surgery? Revision ACL surgery can be a one or two stage operation.  This depends on the individual and their personal circumstances.  There are many factors that need to be addressed in order to make sure that a further re-rupture does not happen. A complete examination and investigation work-up is carried out as well as an appropriate prehabilitation programme.  CT scans and MR scans are carried out to look at the placement of the previous tunnels and whether any other tissues have been injured that require surgery at the same time.  

6. Single Stage Revision ACL Surgery A single stage revision is where everything is removed from the primary surgery and a full revision reconstruction is carried out. This is possible when the initial bone tunnels that were drilled are small in diameter and in the correct place and no bone grafting of the femur or tibia is required. - Complete removal of primary surgery components - Full revision reconstruction - Suitable when initial bone tunnels are small and correctly placed - No need for bone grafting

7. Two Stage Revision ACL Surgery Required when initial bone tunnels are large or incorrectly placed Stage 1: - Removal of previous hardware (buttons, screws, etc.) - Bone grafting of tunnels with impaction grafting - Physiotherapy and monitoring with CT scans at 3 and 6 months to ensure incorporation Stage 2: - Conducted after full incorporation of bone graft - Selection and preparation of appropriate graft - Drilling of new bone tunnels and graft securing - Repair of other structures (e.g., meniscus) - Reconstruction of anterolateral ligament to reduce knee instability and risk of re-rupture