2-stage Revision Anterior Cruciate Ligament Reconstruction Research Articles

Two-Stage Revision ACL Reconstruction with Arthroscopic Tunnel Bone Grafting

Background: Anterior cruciate ligament (ACL) reconstruction is a common orthopedic surgery, and due to the increased number of primary reconstructions being performed, the number of revision ACL reconstructions is also increasing. Indications: Two-stage revision ACL reconstruction has lower failure rates compared to 1-stage and is indicated when significant tunnel expansion has occurred or malpositioned tunnels prohibit an adequate reconstruction. In this presentation, 2-stage revision ACL reconstruction was performed with an arthroscopic bone grafting technique of both the femoral and tibial tunnels secondary to tunnel osteolysis. Technique Description: Standard diagnostic arthroscopy is performed, and any chondral or meniscal pathology is addressed. The remnant ACL graft and all hardware are removed. The tunnels are debrided thoroughly. Using a modified syringe, the tunnels are packed with a mixture of cancellous bone chips and cortical fibers that have been hydrated with whole blood and platelet-rich plasma (PRP). The patient is placed into a brace postoperatively, and a computed tomography (CT) is obtained approximately 4 to 6 months postoperatively to assess for bone healing. Revision ACL reconstruction is performed once indicated with standard rehabilitation and return to play protocol. Results: Both 1-stage and 2-stage revision ACL reconstructions have been demonstrated to have significant improvement in outcomes scores preoperatively to postoperatively. However, 2-stage has lower failure rates compared to single-stage and has a high return to level of play. Discussion/Conclusion: Revision ACL reconstruction is becoming more commonly performed, and 2-stage revision is frequently required due to multiple factors. In this video, we demonstrate bone grafting for revision ACL reconstruction for tunnel osteolysis. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Combined Revision Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction

There has been a substantial increase in the number of revision anterior cruciate ligament (ACL) reconstructions performed in the past decade. This Technical Note describes combined revision ACL and anterolateral ligament reconstruction using outside-in drilling, which avoids the need for 2-stage revision ACL reconstruction because it allows unconstrained anatomic placement.

Hybrid Bone-Grafting Technique for Staged Revision Anterior Cruciate Ligament Reconstruction.

Hybrid Bone-Grafting Technique for Staged Revision Anterior Cruciate Ligament Reconstruction.

Allograft Bone Dowel Incorporation to Tibial and Femoral Tunnels in Two–Stage Revision Anterior Cruciate Ligament Reconstruction (173)

Objectives:The purpose of this study was to quantitatively evaluate the radiographic outcomes of allograft dowels used as bone grafts in two-stage revision anterior cruciate ligament reconstruction (ACLR).Methods:Prospective review of patients who underwent 2-stage revision ACLR with allograft bone dowels. Inclusion criteria were tibial/femoral tunnel diameter of >14 mm on pre-operative computed tomography (CT), overlapping prior tunnels with new tunnels (Figure 1). Allograft dowels were placed during the first stage and arthroscopic assessment of dowels was performed at the second-stage revision (Figure 2). Quantitative analysis of radiographic incorporation rates was performed with the Union Ratio (UR, Figure 3A) and Occupying Ratio (OR, Figure 3B) on post-operative CT scans. Biopsy specimens were obtained to analyze incorporation.Results:21 patients were included. Second-stage revision surgeries were performed at 6.5 months (SD, 2.1 months) after first-stage revision. All dowels preserved their integrity without any signs of degradation and complete incorporation at the host bone and graft junction at the second stage procedure. The average diameter of the dowels placed in tibial tunnels were greater than those placed in femoral tunnels (16.1 mm [SD, 2.3 mm] vs 12.4 mm [SD, 1.6 mm]; p = < .05). CT scans were obtained at 121 days (SD, 28 days) after the first-stage. There was no difference between the OR of femoral and tibial tunnels (87.6% [SD, 4.8%] vs 85.7% [SD, 10.1%]; p = .484), however, the UR was significantly higher in femoral tunnels (74% [SD, 10.5%] vs 83%[ SD, 6.2%], p = 0.005). Histological examination revealed osseous incorporation between the host bone and allograft dowel (Figure 4).Conclusions:Allograft bone dowels are a safe graft choice to replenish bone stock in the setting of a staged revision ACL reconstruction and dowels placed in femoral tunnels had a higher healing union ratio. Further studies are warranted to evaluate long-term clinical outcomes in this subset of patients.

Allograft Bone Dowels Show Better Incorporation in Femoral Versus Tibial Tunnels in 2-Stage Revision Anterior Cruciate Ligament Reconstruction: A Computed Tomography–Based Analysis

The purpose of this study was to quantitatively evaluate the radiographic outcomes of allograft dowels used in 2-stage revision anterior cruciate ligament reconstruction (ACLR) and to compare the incorporation rates of dowels placed in tibial and femoral tunnels. Prospective review of patients who underwent 2-stage revision ACLR with allograft bone dowels. Inclusion criteria were tibial/femoral tunnel diameter of ≥14 mm on preoperative computed tomography (CT) or overlapping of prior tunnels with planned tunnels. Second-stage timing was determined based on qualitative dowel integration on CT obtained at ∼3 months after the first stage. Quantitative analysis of incorporation rates was performed with the union ratio (UR) and occupying ratio (OR) on postoperative CT scans. Twenty-one patients, with a mean (SD) age of 32.1 (11.4; range, 18-50) years, were included. Second-stage procedures were performed at a mean (SD) of 6.5 (2.1; range, 2.4-11.5) months after first-stage revision. All dowels showed no signs of degradation at the host bone/graft junction at the second-stage procedure. The mean (SD) diameter of the dowels placed in tibial tunnels was greater than those placed in femoral tunnels (16.1 [2.3] mm vs 12.4 [1.6] mm; P < .05). CT was obtained at a mean (SD) of 121 (28; range, 59-192) days after the first-stage surgery. There was no difference between the OR of femoral and tibial tunnels (mean [SD], 87.6% [4.8%] vs 85.7% [10.1%]; P= .484), but the UR was significantly higher in femoral tunnels (mean [SD], 83% [6.2%] vs 74% [10.5%], P= .005). The intraclass correlation coefficients of OR and UR measurements indicated good reliability. Allograft bone dowels are a viable graft choice to replenish bone stock in the setting of a staged revision ACL reconstruction. Allograft dowels placed in femoral tunnels had a higher healing union ratio than tibial tunnel allografts and no evidence of degradation at the bone/graft junction, with no difference seen in occupying ratio. Level IV, case series.

Clinical and radiological outcome after anterior cruciate ligament reconstruction using the T-lock Osteotrans resorbable tendon anchor: early experience and midterm follow-up

PurposeReconstruction of the Anterior cruciate ligament (ACL) using tendon grafting is an established method for restoring knee function and stability. Multiple methods are established for graft fixation. Several involve anchoring the autograft distant to the joint with hardware that remains implanted. This study reports the first early to midterm results in patients who received ACL reconstruction (ACLR) using the T-Lock Osteotrans femoral near joint fixation method with a tibial fixation using the BioactIF Osteotrans interference screw.MethodsThis consecutive prospective series included 20 Patients (14 Male, 6 Female) with a primary ACL rupture. All patients were treated with an ACLR using a semitendinosus autograft fixated with the T-Lock Osteotrans and were followed-up postoperatively. The following parameters were assessed: Side-to-side difference of the posterior-anterior translation measured using the KT-1000 arthrometer, Tegner activity score, Lysholm score, IKDC subjective knee evaluation form. Magnetic resonance imaging (MRI) was done to assess tunnel enlargement and integrity of the anchoring device.ResultsThe average follow-up duration was 2 years (range 1–4.2 years). One patient was lost to follow-up. Two Patients suffered a traumatic ACL re-rupture 2 years postoperatively and received a 2-stage revision ACLR. Difference in the posterior-anterior translation was 1.8 mm (range 0–5). The median Tegner score was 6 (range 4–10) and 9 patients (45%) returned to their preinjury level of activity. The mean IKDC subjective knee evaluation form scored 91 points (range 77–100). The mean Lysholm score was 86 points (74–96). All mentioned scores were significantly better compared to preoperative values. No relevant tunnel enlargement was seen on MRI. The anchoring device was evaluated to be intact in all patients.ConclusionACLR with the aforementioned procedure leads to good clinical and radiological outcome.

Outcomes of 1- Versus 2-Stage Revision Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

Background: Anterior cruciate ligament reconstruction (ACLR) is a common orthopaedic sports medicine procedure, but graft failure is not uncommon and often leads to revision ACLR. Revision surgery can be performed in a 1- or 2-stage fashion. Hypothesis: Graft failure risk, patient-reported outcomes, and anterior knee laxity are similar after 1- and 2-stage revision ACLR. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of the literature was performed to evaluate patient outcomes after 1- versus 2-stage revision ACLR. A search was performed with the phrase “revision anterior cruciate ligament reconstruction” across Embase, PubMed, Scopus, and SportDiscus from the beginning of their archives through July 12, 2019. Results: Thirteen studies met inclusion criteria and included 524 patients: 319 patients who underwent 1-stage revision ACLR and 205 patients who underwent 2-stage revision ACLR. Two studies compared outcomes of 1- versus 2-stage revision ACLR; 4 studies reported outcomes after 2-stage revision ACLR; and the remaining 7 studies documented outcomes after 1-stage ACLR. The mean follow-up was 4.1 years. The 2 studies that compared 1- versus 2-stage ACLR reported no differences in functional, radiologic, or patient-reported outcomes or failure risk. Overall, 9 studies reported subjective International Knee Documentation Committee (IKDC) scores; 4 studies, Knee injury and Osteoarthritis Outcome Score values; 8 studies, Lysholm scores; and 7 studies, Tegner scores; 8 studies measured anterior laxity with a KT-1000 arthrometer. The mean weighted subjective IKDC score for all studies including this outcome at final follow-up was 66.6 for 1-stage revisions and 65.9 for 2-stage revisions. Conclusion: The available evidence comparing 1- versus 2-stage revision ACLR is retrospective and limited. The results of each approach are similar in appropriately selected patients.

Autologous Bone Graft Versus Silicate-Substituted Calcium Phosphate in the Treatment of Tunnel Defects in 2-Stage Revision Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized Controlled Study With a Minimum Follow-up of 2 Years

To compare and evaluate knee laxity and functional outcomes between autologous bone graft and silicate-substituted calcium phosphate (Si-CaP) in the treatment of tunnel defects in 2-stage revision anterior cruciate ligament reconstruction (ACLR). This prospective, randomized controlled trial was conducted between 2012 and 2015 with a total of 40 patients who underwent 2-stage revision ACLR. The tunnels were filled with autologous iliac crest cancellous bone graft in 20 patients (control group) and with Si-CaP in the other 20 patients (intervention group). After a minimum follow-up period of 2years, functional outcomes were assessed by KT-1000 arthrometry (side-to-side [STS] difference), the Tegner score, the Lysholm score, and the International Knee Documentation Committee score. A total of 37 patients (follow-up rate, 92.5%) with an average age of 31years were followed up for 3.4years (range, 2.2-5.5years). The KT-1000 measurement did not show any STS difference between the bone graft group (0.9 ±1.5mm) and the Si-CaP group (0.7 ± 2.0mm)(P= .731). One patient in the intervention group (5%) had an STS difference greater than 5mm. Both groups showed significant improvements in the Tegner score, Lysholm score, and International Knee Documentation Committee score from preoperative assessment to final follow-up (P ≤ .002), without any difference between the 2 groups (P ≥ .396). Complications requiring revision occurred in 4 control patients (22%) and in 2 patients in the intervention group (11%) (P= .660). No complications in relation to Si-CaP were observed. Equivalent knee laxity and clinical function outcomes were noted 3years after surgery in both groups of patients. Si-CaP bone substitute is therefore a safe alternative to autologous bone graft for 2-stage ACLR. Level I, prospective, randomized controlled clinical trial.

Incidence and Healing Rates of Meniscal Tears in Patients Undergoing Repair During the First Stage of 2-Stage Revision Anterior Cruciate Ligament Reconstruction

Background: Meniscal tears, including tears at the root attachment, have been associated with tears of the anterior cruciate ligament (ACL) in both primary and revision settings. However, there is a paucity of literature reporting the healing rates of meniscal repair during 2-stage revision ACL reconstruction (ACLR). Purpose: To evaluate the healing rates of meniscal repairs performed during 2-stage revision ACLR in ACL-deficient knees and to report the incidence of meniscus root tears in patients undergoing primary ACLR as compared with revision ACLR. Study Design: Case series; Level of evidence, 4. Methods: Patients who underwent primary and revision ACLR by a single surgeon were retrospectively identified. Revision ACLRs were grouped according to 1- or 2-stage ACLR. Meniscal tears were grouped according to laterality (medial, lateral) and location of tears. Meniscal repair technique was recorded, including transtibial or inside-out. Meniscal repair healing was assessed via second-look arthroscopy at the time of second-stage revision ACLR. Results: There were 1168 patients identified who underwent ACLR: 851 primary and 317 revision procedures. Sixty-four patients underwent meniscal repair during first-stage bone grafting in ACL-deficient knees, with an overall healing rate of 86%. The healing rates were 82.3% for meniscus root tears via the transtibial repair technique and 92.4% for meniscal peripheral tears via the inside-out repair technique. Meniscus root tears had overall incidences of 15.5% and 26.2% in primary and revision ACLRs, respectively. The incidence of lateral meniscus posterior root tears was approximately 4 times higher than of medial meniscus posterior root tears in both primary (12.2% vs 3.2%) and revision (20.5% vs 5.6%) ACLRs. Conclusion: A high incidence of meniscus root tears was found in patients undergoing revision ACLRs as compared with primary ACLRs. Meniscal repairs have a high rate of healing and success when performed during the first stage of revision ACLR in ACL-deficient knees.

Two-Stage Revision Anterior Cruciate Ligament Reconstruction: A Systematic Review of Bone Graft Options for Tunnel Augmentation

Background: No consensus is available regarding the optimal choice of bone graft material for bone tunnel augmentation in revision anterior cruciate ligament (ACL) surgery. Purpose: To compare the outcomes of different bone graft materials for staged revision ACL reconstruction. Study design: Systematic review. Methods: A systematic review using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed. PubMed, EMBASE, and the Cochrane Library were queried through use of the terms anterior cruciate ligament and revision to identify all studies reporting outcomes of bone tunnel grafting in 2-stage revision ACL reconstruction. Data extracted included indications for 2-stage surgery, surgical technique, graft material, time between surgeries, rehabilitation protocols, physical examination findings, patient-reported outcomes, and radiographic and histologic findings. Results: The analysis included 7 studies with a total of 234 patients. The primary outcome in 2 studies was graft incorporation (mean follow-up, 8.8 months), whereas the other 5 studies reported clinical outcomes with follow-up mean ± SD of 4.2 ± 2.1 years. The indication for bone grafting and between-stage protocol varied among studies. Autograft was used in 4 studies: iliac crest bone autograft (ICBG, n = 3) and tibial bone autograft (TBA, n = 1). In 2 studies, the authors investigated the outcomes of allograft: allograft bone matrix (ABM) and allograft bone chips (AC). Finally, 1 study compared ICBG to a synthetic bone substitute. Radiographic evaluation of bone graft integration after the first stage was reported in 4 studies, with an average duration of 4.9 months. In 4 studies, the authors reported the time interval between first and second surgeries, with an average of 6.1 months for ICBG compared with 8.7 months for allogenic and synthetic grafts. Revision ACL graft failure rates were reported by 5 studies, including 1 study with ABM (6.1%), 1 study with AC (8.3%), 1 study with TBA (0%), and 2 studies with ICBG (0% and 2%). Conclusion: The indications for staged ACL reconstruction and the rehabilitation protocol between stages need to be clearly established. The available data indicate that autograft for bone tunnel grafting in 2-stage ACL revision may be associated with a lower risk of revision ACL reconstruction graft failure compared with allograft bone.

Supercritical Carbon Dioxide–Sterilized Bone Allograft in the Treatment of Tunnel Defects in 2-Stage Revision Anterior Cruciate Ligament Reconstruction: A Histologic Evaluation

To examine the histologic properties of supercritical carbon dioxide (sCO2)-sterilized bone allograft for tunnel grafting and determine invivo graft quality, as well as graft incorporation and remodeling, in 2-stage revision anterior cruciate ligament (ACL) surgery. Histologic evaluation was performed in 12 subjects undergoing 2-stage revision ACL reconstruction. In the first stage, the femoral and tibial tunnels were debrided, tunnel dimensions were measured, and tunnels were grafted with sCO2-sterilized bone allograft. In the second stage, revision ACL reconstruction was performed and bone biopsy specimens were taken from the tibia. Tissue, bone, and graft volumes were measured, and histomorphometric analysis was performed. The mean time between the 2 stages was 8.8months (range, 5.6-21.3months). In the second stage, bone graft material was easily identified by its necrotic appearance comprising mature lamellar bone devoid of osteocyte nuclei within osteocyte lacunae. In all tissue samples, host-bone apposition of predominantly mature lamellar bone was noted on the surface of graft fragments in keeping with "creeping substitution." In several regions in 3 cases, osteoblastic and osteoclastic activity was evident in keeping with ongoing creeping substitution and remodeling. The mean bone volume over tissue volume was 68% (range, 33%-92%), and the mean graft volume over bone volume was 41% (range, 19%-70%). The mean graft volume (8 cases) harvested at less than 7months (44%; 95% confidence interval, 31.4%-56.8%) was not significantly different than the mean graft volume (4 cases) harvested at greater than 10months (34%; 95% confidence interval, 14.3%-54.2%; P= .214). The sCO2-sterilized bone allograft showed graft incorporation and remodeling through creeping substitution. The initial bone apposition and graft fragment bridging appear to provide a strong environment for ACL graft fixation resulting in technically successful 2-stage revision ACL reconstruction.

Management of bone deficiency in revision anterior cruciate ligament reconstruction

A failed anterior cruciate ligament reconstruction (ACLR) not only can be a difficult situation for the patient, but also a challenging clinical scenario for the treating surgeon from a technical perspective. This review article discusses the etiology of primary graft failure; the importance of adequate history taking and need for an appropriate physical examination with diagnostic imaging; and the treatment decision making process for single vs. 2-stage revision ACLR with technical considerations reviewed as it pertains to bone deficiency and tunnel osteolysis.

Outcomes After 1-Stage Versus 2-Stage Revision Anterior Cruciate Ligament Reconstruction

Background: Revision anterior cruciate ligament reconstruction (ACLR) is becoming increasingly common as the number of primary ACLR cases continues to rise. Despite this, there are limited data on the outcomes of revision ACLR and even less information specifically addressing the differences in 1-stage revision reconstruction versus those performed in a 2-stage fashion after primary reconstruction. Purpose: To compare the outcomes, patient satisfaction, and failure rates of 1-stage versus 2-stage revision ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: All patients who underwent revision ACLR between 2010 and 2014 by a single surgeon were collected, and skeletally mature patients over the age of 17 years were included. Patients were excluded if they were skeletally immature; had a previous intra-articular infection in the ipsilateral knee; underwent a prior alignment correction procedure, cartilage repair or transplant procedure, or meniscal allograft transplantation; or had an intra-articular fracture. An ipsilateral or contralateral bone–patellar tendon–bone (BPTB) autograft was the graft of choice. A BPTB allograft was considered for patients aged ≥50 years, for any patient with an insufficient ipsilateral or contralateral patellar tendon, or for those who chose not to have the contralateral patellar tendon graft harvested. Patients completed a subjective questionnaire preoperatively and at a minimum of 2 years postoperatively. Magnetic resonance imaging and computed tomography of all knees were performed preoperatively to assess for associated injuries and to evaluate the ACLR tunnel size and location. Patients with malpositioned tunnels that would critically overlap with an anatomically placed tunnel or those with tunnels ≥14 mm in size underwent bone grafting. Results: A total of 88 patients met the inclusion criteria for this study. There were 39 patients in the 1-stage revision surgery group (19 male, 20 female) and 49 patients in the 2-stage revision surgery group who underwent tunnel bone grafting first (27 male, 22 female). In both groups, the 12-item Short Form Health Survey (SF-12) Physical Component Summary, Western Ontario and McMaster Universities Arthritis Index, Lysholm, and Tegner activity scale scores significantly improved from preoperatively to postoperatively. There was no significant difference in the SF-12 Mental Component Summary score before and after surgery in either group. Furthermore, there was no significant difference in failure rates or other demographic data between the groups. We observed 4 failures in the 1-stage reconstruction group (10.3%) and 3 failures in the 2-stage reconstruction group (6.1%). Conclusion: In this study, objective outcomes and subjective patient scores and satisfaction were not significantly different between 1-stage and 2-stage revision ACLRs. Both groups had significantly improved objective outcomes and patient subjective outcomes without notable differences in failure rates. Further longitudinal studies comparing 1-stage and 2-stage revision ACLRs over a longer time frame are recommended.

Bone Incorporation of Silicate-Substituted Calcium Phosphate in 2-Stage Revision Anterior Cruciate Ligament Reconstruction: A Histologic and Radiographic Study

To evaluate the histologic and radiographic outcomes of using silicate-substituted calcium phosphate (Si-CaP) as bone graft substitute for the augmentation of tunnel defects in 2-stage revision anterior cruciate ligament (ACL) reconstruction. Forty patients undergoing 2-stage revision ACL reconstruction were included in a prospective, randomized controlled clinical trial between 2012 and 2015. The inclusion criteria were tunnel diameter of the tibial and/or femoral tunnel of 10mm or greater after failed ACL reconstruction. Twenty patients received autologous bone from the iliac crest and 20 patients received Si-CaP as a bone graft substitute for tunnel grafting at the first-stage procedure. Punch biopsy specimens of the augmented tunnels were taken at the second-stage procedure, and histologic examination included quantitative analysis of the area of immature bone formation, lamellar bone, and bone marrow. Radiographic analysis included determination of the filling rates of the tunnels on postoperative computed tomography scans. Forty patients with a mean age of 32years (standard deviation [SD], 11.0years) were analyzed. Histologic examination of the tunnels filled with Si-CaP showed that 15% (SD, 14%) of the area was covered with immature bone formation, 41% (SD, 10%) with well-organized lamellar bone, and 44% (SD, 8%) with bone marrow. In the control group (autologous bone), 58% (SD, 3%) of the area was covered with well-organized lamellar bone and 42% (SD, 3%) with bone marrow. Quantitative evaluation of the postoperative computed tomography scans showed a trend of better filling rates in patients with Si-CaP for the tibial tunnel (86% [SD, 17%] vs 78% [SD, 14%]; P= .131). Intraoperatively, Si-CaP was completely integrated into the original bone tunnel providing good stability for tunnel placement and tendon graft fixation comparable to autologous bone. Si-CaP as bone graft substitute for tunnel augmentation in 2-stage revision ACL reconstruction shows good histologic, radiographic, and intraoperative integration comparable to autologous bone. Level I, prospective randomized controlled trial.

Two-Stage Revision Anterior Cruciate Ligament Reconstruction.

The number of primary anterior cruciate ligament (ACL) tears is rapidly increasing. In patients who wish to return to their preoperative level of function, specifically as it pertains to participation in sports, the gold standard of treatment following an ACL tear remains an anterior cruciate ligament (ACL) reconstruction. Despite a majority of good/excellent results following primary ACL reconstruction, there is a growing subset of patients with persistent or recurrent functional instability who require revision ACL reconstruction. Preoperative planning for revision ACL reconstruction requires a careful understanding of the root cause of ACL failure, including possible technical causes of primary ACL failure and the presence of combined knee pathology that was not addressed at the index ACL reconstruction. The decision to perform 2-stage revision ACL reconstruction is multifactorial and is reached by technical considerations that may make a 1-stage revision less optimal, including tunnel widening, arthrofibrosis, active infection, and others. Concomitant knee pathology such as meniscal deficiency, malalignment (including an increase in posterior tibial slope), chondral lesions, and other ligamentous laxity may also require a staged approach to treatment. This evidence-based review covers the indications for 2-stage revision ACL reconstruction, surgical techniques, evidence for and technique of bone grafting prior ACL tunnels, and outcomes of 2-stage revision stratified by initial cause of ACL reconstruction failure. With proper preoperative planning and an understanding of the cause of failure following the primary ACL reconstruction, revision ACL reconstruction can offer excellent outcomes in the motivated patient. [Orthopedics. 2016; 39(3):e456-e464.].