As double-bundle ACL reconstruction increases, revision cases will arise. Limited data exist on technical considerations for revising failed double-bundle ACL surgery.

Three cases of revision double-bundle ACL surgery were reported.1 In two cases, the anteromedial (AM) bundle was ruptured and the posterolateral (PL) bundle was nonfunctional. In the third case, the AM bundle had a midsubstance tear while the PL bundle was intact.

In the first two cases, both bundles were reconstructed using the previous bone tunnels. Graft tensioning was performed at 60° flexion for the AM graft and full extension for the PL graft based on biomechanical studies. In the second case, the PL femoral tunnel was malpositioned, so a new anatomic PL tunnel was created while the old PL tunnel was used for the AM graft. In the third case, only the AM bundle was revised via the prior AM tunnels since the PL bundle was intact.

This case series demonstrates feasibility of revising failed double-bundle ACL reconstruction. Meticulous evaluation of tunnel position and bundle integrity guides the revision technique. Anatomic reconstruction principles remain essential. Adding supplementary bone tunnels is possible when needed. Further research should analyze clinical outcomes of revision double-bundle ACL surgery.

A systematic review of 33 studies found lower outcome scores and more instability with ACL revision versus primary reconstruction.2 Allografts had a higher failure rate than autografts. Concurrent ligament surgery also increased failure risk. Patients should be counseled on increased challenges with revision ACL surgery.

As double-bundle ACL reconstruction grows in popularity, revision scenarios will increase. Careful attention to anatomy and injury patterns guides surgical decision-making. Outcomes are generally inferior to primary reconstruction. Further research is needed to optimize revision techniques and results.

1. Kaz R, Starman JS, Fu FH. Anatomic double-bundle anterior cruciate ligament reconstruction revision surgery. Arthroscopy. 2007;23(11):1250.e1-1250.e3.

2. 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):1159-1165.