Revision ACL Reconstruction


Revision ACL reconstruction is performed when the original ACL reconstruction fails. Failure rates range from 5-10% after primary ACL reconstruction.1 Causes include reinjury, technical errors, failure of graft incorporation, and progressive arthrosis. Outcomes of revision ACL reconstruction are generally worse than after primary reconstruction.


A thorough history and physical exam are critical, including assessment for concurrent injuries missed at the index surgery. Imaging helps identify tunnel position and hardware. Range of motion, knee stability, strength, and subjective function are evaluated.

Causes of Failure

The most common cause of failure is technical error, including non-anatomic graft placement, improper fixation, graft damage, and untreated associated injuries.2 Recurrent trauma can also disrupt ACL grafts, as can late graft stretch-out from poor incorporation. Allografts may have delayed or impaired incorporation compared to autografts.

Surgical Techniques

Both open and arthroscopic techniques have been described.3 Hardware removal may be required for revision drilling. Tunnels are ideally placed more anatomically. Concurrent procedures like meniscus repair, cartilage restoration, or osteotomy may be needed. Autografts are favored over allografts for revision. Strong fixations like interference screws are recommended.


Reported outcomes of revision ACL reconstruction are generally inferior to primary reconstruction, with lower patient-reported function, less knee stability, and higher failure rates.4 In a systematic review, failure rates averaged around 10% after revision versus 4% after primary reconstruction.5 Patient factors like activity level and expectations strongly influence subjective outcomes.

In summary, revision ACL surgery is challenging, with clinical outcomes that are typically worse than after primary reconstruction. Careful preoperative analysis and precise tunnel placement help optimize results. Prevention of reinjury and meticulous primary surgery remain paramount.


1. Wright RW, Gill CS, Chen L, Brophy RH, Matava MJ, Smith MV, Mall NA. Outcome of Revision Anterior Cruciate Ligament Reconstruction: A Systematic Review. J Bone Joint Surg Am. 2012;94(6):531-6.

2. Noyes FR, Barber-Westin SD. Revision anterior cruciate surgery with use of bone-patellar tendon-bone autogenous grafts. J Bone Joint Surg Am. 2001;83(8):1131-43.

3. Tashman S, Collon D, Anderson K, Kolowich P, Anderst W. Abnormal rotational knee motion during running after anterior cruciate ligament reconstruction. Am J Sports Med. 2004;32(4):975-83.

4. Wright RW, Magnussen RA, Dunn WR, Spindler KP. Ipsilateral Graft and Contralateral ACL Rupture at Five Years or More Following ACL Reconstruction: A Systematic Review. J Bone Joint Surg Am. 2011;93(12):1159-65.

5. Wright RW, Magnussen RA, Dunn WR, Spindler KP. Graft failure after ACL reconstruction: a systematic review of graft failure rates. Orthop J Sports Med. 2018;6(3):2325967118759958.

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© 2023 Dr. Robert Afra – San Diego Orthopedic Surgery Shoulder – Knee – Elbow