This document summarizes a case presentation of a 23-year-old male college student undergoing revision anterior cruciate ligament (ACL) reconstruction surgery due to a failed primary ACL reconstruction surgery two years prior. The patient reported pain, swelling, and instability in his right knee. His surgical history included an ACL reconstruction with a soft tissue allograft and partial meniscectomies two years ago. During the revision surgery, the surgeons found remnants of the previous ACL graft with few fibers left and new meniscus tears. The revision surgery involved constructing a new ACL graft and additional partial meniscectomies. Post-operatively, the patient was doing well with pain controlled and no complications.

1. UK Sports Medicine Conference
Revision Anterior Cruciate Ligament
(ACL) Reconstruction
Case Presentation
Jeremy M. Burnham, MD
UK Orthopaedic Surgery and Sports Medicine

2. History:
• CC: trouble with right knee
• HPI: 23 yo WM, college student
• c/o sharp/stabbing intermittent pain, mostly on medial side of
knee
• Occasional feelings of instability
• Unable to stop, cut, or change direction
• 2 year history of pain and swelling, recent progression of
symptoms
• No recent injury

3. History:
• PMH/PSH: Non-contact ACL tear sometime in 2009,
subsequently developed symptomatic medial meniscus tear
• ACL Recon with soft tissue allograft 2/2010
• Partial medial menisectomy
• 9x35 Stryker bioabsorbable screw proximally, distal fixation
was 9x20mm retro Arthrex bioabsorbable inside-out
• Describes femoral tunnel at 11 o’clock
• MRI read 8/2012 shows intact graft with increased intra-
substance signal

4. Physical Exam:
• No effusion, knee ROM 0-135, positive Lachman, positive
anterior drawer, positive pivot shift
• TTP medial jointline
• Stable to v/v at 0/30, no patellar maltracking

5. Preop XR’s:

6. Surgical Findings:
• Previous ACL remnant with very few fibers left
• Tibial side noted to be posterior
• Bucket handle medial meniscus tear
• Radial tear of lateral meniscus

7. Surgical Procedures 8/22/13:
• Revision right ACL-R
• 80% partial medial menisectomy
• 15% partial lateral menisectomy

8. Surgical Findings – Old ACL Graft Remnants:

9. Surgical Findings – Medial Meniscus:

10. Surgical Findings – Old Femoral Tunnel:

11. Surgical Findings – Old Femoral Tunnel:

12. Surgical Findings – New Graft:

13. Recent Postop Visit:
• Pain controlled
• Expected effusion
• Drain was pulled POD#1
• Advanced per protocol
• No postoperative complications

14. Postop XR’s:

15. Morgan, J. A., Dahm, D., Levy, B., Stuart, M. J., & Group, M. S. (2012). Femoral tunnel malposition in ACL revision
reconstruction. J Knee Surg, 25(5), 361-368. doi: 10.1055/s-0031-1299662
Of the 460 revisions included for study, 276 (60%) cases cited a specific
"technical cause of failure." Femoral tunnel malposition was cited in
219 (47.6%) of 460 cases. Femoral tunnel malposition was cited as the
only cause of failure in 117 cases (25.4%). Surgeons judged the femoral
tunnel too vertical in 42 cases (35.9%), too anterior in 35 cases
(29.9%), and too vertical and anterior in 31 cases (26.5%). Revision
reconstruction involved the drilling of an entirely new femoral tunnel in 91
cases (82.1%). For primary reconstruction, autograft tissue was used in
82 cases (70.1%). For revision reconstruction, autograft tissue was used
in 61 cases (52.1%) and allograft tissue in 56 cases (47.9%). Femoral
tunnel malposition in primary ACL reconstruction was the most
commonly cited reason for graft failure in this cohort. Graft selection
is widely variable among surgeons.

16. Getgood, A., & Spalding, T. (2012). The evolution of anatomic anterior cruciate ligament reconstruction. Open Orthop
J, 6, 287-294. doi: 10.2174/1874325001206010287

17. MoChen, J. L., Allen, C. R., Stephens, T. E., Haas, A. K., Huston, L. J., Wright, R. W., . . . Multicenter, A. C. L. R. S. G.
(2013). Differences in mechanisms of failure, intraoperative findings, and surgical characteristics between single-
and multiple-revision ACL reconstructions: a MARS cohort study. Am J Sports Med, 41(7), 1571-1578. doi:
10.1177/0363546513487980
• RESULTS: A total of 1200 patients
• The most common cause of reruptures was a traumatic, noncontact
ACL graft injury in 55%
• 25% of patients had a nontraumatic, gradual-onset recurrent injury, and
• 11% had a traumatic, contact injury.

18. Getgood, A., & Spalding, T. (2012). The evolution of anatomic anterior cruciate ligament reconstruction. Open Orthop
J, 6, 287-294. doi: 10.2174/1874325001206010287

19. Getgood, A., & Spalding, T. (2012). The evolution of anatomic anterior cruciate ligament reconstruction. Open Orthop
J, 6, 287-294. doi: 10.2174/1874325001206010287

20. Illingworth, KD, et. Al., Fu, “A Simple Evaluation of Anterior Cruciate Ligament Femoral Tunnel Position: The
Inclination Angle and Femoral Tunnel Angle,” Am. J. Sports Med 39:12 (December, 2011), pp. 2611-2618.

21. Ahn, J. H., et al (2013). 3-D reconstruction computed tomography evaluation of tunnel location during single-
bundle anterior cruciate ligament reconstruction: a comparison of TT and 2-incision TTI techniques. Clin
Orthop Surg, 5(1), 26-35.