It is not always guaranteed that individuals can return safely to their activities after ACL reconstruction. Unfortunately, there are cases where re-injury or improper ACL reconstruction may lead to necessary surgery called revision ACL. Dr. Hackett compares a revision ACL to renovating an old house, where surgeons never know what they are going to run into. Depending on why your previous ACL reconstruction surgery failed or how the new graft was re-injured, revision ACL will vary and may be performed in conjunction with other operations, such as realignment or meniscus repair.
With revision ACL surgery, Dr. Hackett spends quality time gathering previous operative reports, obtaining additional X-rays or CAT scans, and sometimes alignment film, so he can identify what needs to be revised. The most common reasons ACL reconstructions fail may include:
- ACL Graft Fail from Surgery – ACL reconstruction is a very technical surgery. Misplaced graft reconstruction tunnels are a common cause of ACL reconstruction failure. This complication may be due to poor placement on the tibia, which results in a central graft that is unable to control the rotation of the knee; or poor placement on the femur, which results in stretching the graft as knee motion returns.
- Untreated Instabilities – This complication may include a meniscus injury or posterolateral corner injury. If an unrecognized injury or alignment issue occurs during ACL reconstruction, it may lead to failure.
- Re-Injury of ACL Graft – Although this does occur, it’s not as common as the previously mentioned. In this case, the individual re-injures their knee by tearing the ACL graft. Athletes generally see a positive outcome of revision surgery if re-injury is their reason.
- Biological Complications – Depending on a patient’s age, they may have a higher chance of ACL graft failure. Also, a small number of patients may not fully recover from their reconstruction surgery and the graft tears over time. This condition could be due to an immune response or an early return to an active lifestyle. It may be possible for the patient to develop Arthrofibrosis of the knee after surgery, which can lead to further complications as well.
Symptoms of an ACL reconstruction failure are similar to that of an ACL injury including:
- Pain or discomfort in the knee
- Knee instability, swelling, or stiffness
- Limping or looseness in the knee
Revision ACL Surgery
During surgery, arthroscopic portals allow Dr. Hackett to visualize and evaluate the knee within the join and any scar tissue that may need to be removed. Depending on your particular condition, procedural steps will vary. Once all the factors have been confirmed, Dr. Hackett can determine if one stage or two stage reconstruction is necessary. Possible treatments may include:
- Patients undergoing an autograft revision reconstruction, either as a first or second stage after bone grafting the tunnels
- Combined proximal tibial osteotomy
- Conjunction procedures could include meniscus repair, meniscal transplants, posterolateral corner or medial knee reconstructions
In any case of revision ACL, it is very rare that the failed ACL reconstruction is evaluated easily. A very thorough exam is necessary to choose the best plan for revision ACL surgery. In studies, the success rate for revision ACL surgery is approximately 75 percent.
After the operation, the rehabilitation program needs to develop slower than the patient’s previous ACL reconstruction rehabilitation. In most cases, patients need crutches to minimize any weight or pressure on the ACL graft. The timing of the recovery is usually slowed down about 50 percent, and full activities are rarely allowed before nine months after surgery. Although it is a lengthy recovery, following specific aftercare instructions is necessary to return safely to any physical activity.