Revision following failed ACL surgery

Why are revisions of ACL repairs increasing in numbers?

Andy: So revision ACL reconstruction is increasing and the reason for that of course, is there are more primary, first time ACL reconstructions being done. But also the incidence of ACL rupture is increasing, so as a specialist knee surgeon, we need a skill set to deal with the more complex re-do work.

How is ACL revision surgery performed?

Andy: The principle of course is exactly the same as with a first time reconstruction - that is, you have to get a good graft, you've got to put it in the right place, you've got to fix it properly, you may need to do extra surgery to help protect it such as tightening up the outside of the knee - an operation called a tenodesis. Or some people prefer an anterolateral ligament reconstruction and also deal with other injuries in the joint, such as meniscal tears, because all of those will put stress on the ACL if they're not addressed.

Why do you need a surgeon specialising in ACL revisions?

Andy: The technique is much more challenging, so the surgeon has to be very comfortable with using different types of graft, because they have pros and cons in a revision setting. They need to understand different types of fixation technique, whether they use screws or a combination of synthetic loops and buttons.

They also need to understand how to do the peripheral surgery like a tenodesis and they also have to be very skilled at repairing menisci. It's possible they might even need to consider re-aligning the bone if it was very malaligned and understanding the potential need for that. They really need to understand injury prevention and encourage the patient to take that on board because that will help reduce the burden of revision ACL reconstruction.

Are some patient groups at higher risk of ACL rupture?

Andy: There are certain groups who are particularly high risk. And the trick is to identify them at the beginning and to counsel a patient and often their children - their families - as to the risk of rerupturing their ACL being high. And also the risk of rupturing the opposite knee because in certain patient groups there is about a 1 in 4 risk of them rupturing their other ACL. So, committing to rehabilitation and understanding the importance of that via the education from the surgeon is critical.

Mr Andy Williams is an ACL revision specialist. Patients in need of a repeat reconstruction due to failure of their original surgery should ascertain whether their surgeon has expertise in this area due to the greater complexity of the procedure.