Revision anterior cruciate ligament reconstruction: Preoperative assessment and planning

The anterior cruciate ligament (ACL) is essential for proper knee mechanics and failure to restore these mechanics following ACL reconstructions can lead to intra-articular pathology, stiffness, graft failure, or early arthritis. Moreover, failure to accurately diagnose and treat the cause of the ACL reconstruction failure can lead to poor results with revision surgery. The incidence of graft rupture is similar to that of the contralateral native ACL, and thus, other causes of graft failure should be investigated, including: graft impingement, poor graft incorporation, malpositioning of the graft, or failure to address secondary knee stabilizers at the time of surgery. Loss of motion, extensor mechanism dysfunction, and arthritis can cause poor outcomes in ACL reconstruction surgery, which may necessitate revision surgery. Proper history, including previous operative notes and arthroscopic pictures as well as comprehensive radiographic evaluation can help to elucidate the cause of failure as well as corrective surgical approaches. Selection of a graft for revision surgery can be complex and must require an informed discussion with the patient. Special considerations must be made regarding operative technique and graft fixation in the revision setting. ACL revision surgery is technically demanding and achieving good outcomes can be challenging; therefore, a thorough preoperative plan is essential for maximizing patient satisfaction and restoring proper knee mechanics to minimize risk of future knee pathology.