Recurrent Tear of the ACL and Bucket Handle Medial Meniscus

    A 19-year-old male presents with a locked knee after a non-contact instability event playing softball. He is 14 months post-anterior cruciate ligament reconstruction with bucket handle medial meniscus repair and posterior horn lateral meniscus repair. MRI demonstrates a recurrent bucket handle medial meniscus tear with a high-grade partial ACL tear. What is the next step in treating this patient?


    Margaret Wright, MD, and Meghan E. Bishop, MD


    Graft failure after anterior cruciate ligament (ACL) reconstruction using autograft tissue occurs in 3% to 4% of patients but can occur as often as 9.2% in young, high-demand athletes. [1-3] Several risk factors for graft rupture have been identified, and they can generally be categorized as either patient-related or technical: [2-6]

    Patient/Injury Factors

    • Young age
    • Return to high-level contact/pivoting sports
    • High-grade pivot shift
    • Lower extremity alignment (varus knee, increased posterior tibial slope)
    • Ligamentous laxity
    • Family history of ACL tear
    • Unrecognized additional ligamentous/meniscal injuries (ie, posterolateral corner, lateral meniscal root)

    Technical Factors

    • Graft type (ie, allograft)
    • Small graft size
    • Tunnel position

    Complete preoperative evaluation and planning are, therefore, crucial in fully understanding each patient’s risk factors and optimizing outcomes after revision ACL reconstruction. 

    The assessment begins with a thorough history, including mechanism of graft rupture, associated injuries at the time of the initial ACL reconstruction, prior surgical technique (including implants used) and postoperative course, and goals for future athletic activity. Physical exam should include observation of gait, standing limb alignment, Beighton score, and a complete ligamentous exam of the knee, with a focus on potential posterolateral corner (PLC) injuries missed at the time of initial injury. [7]

    Imaging should include radiographs of the knee and standing full-length alignment films of the lower extremities. Radiographs of the knee can be evaluated for tunnel position and size, type of graft fixation, and posterior tibial slope. Coronal alignment of the knees should be evaluated on the standing full-length radiographs to determine if concomitant procedures, such as corrective osteotomies, may be needed.

    Magnetic resonance imaging (MRI) should always be obtained to evaluate the status of the ACL graft and any additional ligamentous, meniscal, or chondral pathology. Tunnel position and size can also be evaluated on the MRI. A computed tomography (CT) scan should be obtained for a more detailed assessment if there is any concern about tunnel position (ie, posterior wall blowout) or significant tunnel widening. [8,9]

    Finally, it is vital to have a thorough discussion with the patient about surgical options and expectations. Outcomes after revision ACL reconstruction are less predictable than after primary ACL reconstruction, in part because concurrent meniscal and cartilage injuries are common in the setting of ACL graft rupture. [10-13] Return to sport can take longer after revision ACL reconstruction and only about 53% of patients who undergo revision ACL return to sport at their pre-injury level, despite relatively similar rates of return to activity between patients with revision ACL and primary ACL reconstruction. [12,14-18]

    Risk of graft rupture is also higher after revision ACL than after primary ACL reconstruction, reported as up to 3 times higher in one study, although the more-frequent use of allograft in the revision setting may partly contribute to higher re-tear rates. [19] Additional procedures such as PLC reconstruction or realignment osteotomy can add to morbidity and rehabilitation after surgery, and patients should clearly understand the potential risks and benefits of these procedures.

    Because primary ACL reconstruction is an increasingly common procedure, surgeons are more likely to encounter patients who require a revision ACL reconstruction. [20] It is important that they become comfortable with the patient evaluation, preoperative planning, and intraoperative techniques and decision-making that can maximize the potential for surgical success and long-term health of the knee.

    Case Presentation

    A 19-year-old male patient presents after sustaining an injury to his right knee while playing softball. He reports that he planted his right foot to reach for a ground ball and felt his right knee give way. He reported immediate pain, swelling, and loss of range of motion (ROM) in the right knee.

    The patient has a history of a right ACL reconstruction with bone-patellar-bone (BTB) autograft, bucket handle medial meniscus repair, and lateral meniscus repair. This procedure had been performed 14 months earlier at another institution. The patient says that the current injury feels similar to the injury that had preceded his prior ACL surgery.

    He reports that the initial postoperative course from the prior reconstruction was complicated by stiffness early on but that he was eventually able to regain full ROM in the right knee. He left home for college about 3 months after surgery, which disrupted his physical therapy course and postoperative follow-up.

    His predominant complaints currently include loss of knee ROM with pain and swelling. He has been using crutches to ambulate since the new injury.

    Physical Exam

    • Height: 6 feet; weight: 175 pounds; BMI: 23.73kg/m2
    • Normal standing alignment of the right knee
    • Prior incisions clean, dry, intact, and well healed
    • Moderate right knee effusion
    • Right knee ROM: 30° to 100°
    • Mild medial and lateral joint line tenderness to palpation
    • 2+ anterior drawer
    • 2A Lachman (increased translation with endpoint)
    • Negative posterior drawer
    • Negative varus/valgus stress testing
    • Neurovascularly intact distally

    Imaging: Radiographs


    Figure 1. Anteroposterior (top left) and lateral (top right) radiographs of the right knee demonstrate evidence of prior BTB ACL reconstruction, with metal screw fixation in the femoral tunnel and a bioabsorbable screw in the tibial tunnel. No evidence of arthritis or gross alignment issues with a posterior tibial slope of 3.9° (bottom).

    Imaging: MRI

    Figure 2. Right knee MRI shows a highgrade ligament sprain with partial fiber disruption (top left). The MRI also demonstrates a recurrent bucket handle medial meniscus tear, (top right, bottom left) as well as a longitudinal posterior horn lateral meniscus tear (bottom right).

    Figure 3. Evaluation of the femoral and tibial tunnels shows that the femoral tunnel positioning appears anterior and vertical relative to anatomic insertion of the ACL. The tibial tunnel is fixed with a large PEEK screw. Femoral tunnel width is 10 mm to 11 mm and the tibial tunnel is 11 mm to 12 mm at maximum dimensions.


    Recurrent right knee ACL tear, bucket handle medial meniscus tear, and longitudinal posterior horn lateral meniscus tear

    Treatment Options

    The treatment options presented to the patient included:

    • Non-operative treatment: Generally not recommended given the locked bucket handle meniscus tear and the inability to range the knee.
    • Operative treatment, to include:
      • Right knee arthroscopy with ligamentous examination under anesthesia
      • Possible revision ACL reconstruction
      • Revision bucket handle medial meniscus repair versus meniscectomy
      • Revision lateral meniscus repair versus meniscectomy
      • Possible hardware removal
      • Possible lateral extra-articular tenodesis (LET)
      • Possible allograft bone dowel grafting in the setting of tunnel widening

    We discussed the nature of the surgery and the associated risks specific to revision ACL reconstruction and revision meniscus repair as outlined above. In addition, we discussed the possibility of allograft bone grafting of the tunnels as part of a staged procedure. This would be done if the tunnels were wider than 14 mm or deemed to be in a suboptimal position and unable to be repositioned based on bone loss from the current tunnels. We told the patient that the likelihood of a staged procedure was low based on our preoperative evaluation of tunnel size and position on imaging.

    Graft options were discussed in detail, including both autograft and allograft options. As this patient previously had a BTB autograft, we discussed other options, including ipsilateral hamstring tendon versus quadriceps tendon autograft or contralateral BTB autograft. We opted for ipsilateral quadriceps tendon autograft given the large cross-sectional area of the graft in the revision setting and the patient’s desire not to violate his contralateral knee. [21]

    We explained to the patient that at the time of surgery, we would assess the integrity of the ACL through exam under anesthesia and direct visualization through arthroscopy. If any signs of instability were present, we would reconstruct the ACL, especially in the setting of revision meniscus repair. In addition, we discussed with the patient that in the case of high-grade pivot shift or any residual pivot on exam after revision reconstruction, we might perform an LET tenodesis to increase the rotational stability of the knee. The patient communicated his understanding of the risks and agreed to proceed with surgery.


    Initial Examination

    • The patient received an adductor canal regional block as well as sedation.
    • He was then positioned supine on the operating room table. A tourniquet was placed on the right thigh and a sequential compression device was placed on the left leg to help with mechanical prophylaxis of deep vein thrombosis.
    • An exam under anesthesia of the right knee demonstrated ROM from 15° to 120°, a 2B Lachman, and a pivot glide with no significant pivot shift.
    • The patient was then prepped and draped in the usual sterile fashion and the tourniquet was raised to 250 mmHg.
    • An inferolateral arthroscopy portal was created, and the arthroscope was atraumatically introduced into the knee.
    • Diagnostic arthroscopy demonstrated well-preserved cartilage surfaces aside from cartilage fissuring in the middle facet of the patella.

    Meniscus Examination/Repair

    • The medial compartment contained a large bucket handle piece flipped into the notch. (Figure 4)
    • An anteromedial portal was established under direct spinal needle localization.
    • Using a blunt instrument, the bucket handle piece was reduced to its anatomic location and demonstrated healthy quality to the tissue amenable for repair. After gentle debridement with a rasp and shaver to the tear, the bucket handle was repaired in a mattress fashion using 4 all-inside suture devices. This was stable to probing after fixation.
    • The lateral compartment was then examined. It was noted that the prior posterior horn tear appeared healed and stable to probing. (Figure 5)

    Figure 4. Arthroscopic photos show a displaced bucket handle medial meniscus tear into the femoral notch (top left). The tear was reduced and fixed using all-inside fixation devices (top right and bottom).

    Figure 5. The prior posterior horn lateral meniscus tear appeared healed and was stable to probing.

    ACL Examination/Reconstruction

    • We then evaluated the ACL in the notch. It was noted to be bulbous in appearance, with significant hyperemia and fraying of fibers. The ACL lifted off the femoral wall with some intact fibers (Figure 6). Given the increased translation, the appearance of the ACL, and the patient’s prior pivoting event, we decided to reconstruct the ACL.

    Figure 6. Prior BTB autograft of the ACL has a bulbous appearance, with significant hyperemia and fraying of fibers

    • The former ACL reconstruction was taken down using a shaver, and a revision notchplasty was performed.
    • The old femoral tunnel was noted to be anterior in positioning, with adequate space to position a tunnel posterior to the original tunnel. We then proceeded with autograft harvest.
    • The quadriceps tendon was harvested using a 4-cm incision starting at the superior pole of the patella. A central slip of 1 cm of the quadriceps tendon, near full thickness in depth and about 80 mm in length, was taken from the superior pole of the patella. The tendon was first transected from the superior pole of the patella and traction was pulled distally to assure adequate length to the graft prior to proximal transection, with a goal length of 70 mm to 80 mm.
    • The graft was then fixed using a FiberTag TightRope (Arthrex; Naples, Florida) and 2 FiberLoop (Arthrex) sutures on the tibial end starting 50 mm from the femoral side of the graft. The graft was sized to be a size 9 for the femur and a size 11 for the tibia. The graft was protected for later passage.
    • The arthrotomy of the knee and tendon was then closed using #0 Vicryl (Ethicon, Inc.; Bridgewater, New Jersey) and 2-0 FiberWire (Arthrex) sutures, showing good closure of the quadriceps tendon.
    • We re-entered the knee and drilled a femoral tunnel using flexible reamers through an anteromedial portal. The femoral tunnel was drilled posterior to the prior tunnel and the metal screw from the original procedure was left in place (Figure 7). Using a flexible reamer, with the knee in hyperflexion, the guidepin was drilled through the lateral femoral cortex.
    • A size 9 reamer was then entered over this and was noted to be free of the prior hardware. We reamed to a depth of 10 mm and, after confirming a solid back wall, then reamed to a depth of 25 mm. We reamed using a 4.5 reamer over the guidepin through the contralateral cortex for button passage.
    • The flexible pin was pulled through the femoral tunnel with a suture for eventual graft passage.

    Figure 7. Arthroscopic photos of the femoral notch after revision notchplasty show anterior placement of metallic femoral screw (white arrow) with sufficient room posteriorly to drill a new tunnel (left). The new tunnel with flexible guide wire (star) and sufficient back wall (white arrow) are shown (right).

    • We then approached the tibial tunnel and made an incision over the prior incision on the prior tibial tunnel. The prior tunnel was identified. The PEEK screw was covered with bone and not able to be removed using instrumentation.
    • We identified the tibial footprint of the ACL and, using an ACL guide set at 55, we placed the guide and drilled the pin up through the prior tunnel site to the ACL tibial footprint. A size 11 reamer was used to overream through the original tunnel position and through the previously placed PEEK screw.
    • We then passed the graft through the tibial tunnel, up into the femoral tunnel, and flipped the suspensory button on the lateral femoral cortex. The button flip was confirmed using fluoroscopy.
    • The graft was then advanced into the femoral tunnel, with about 20 mm of graft into the tunnel. We checked the graft for impingement and found none with the knee in flexion or in full extension in the notch (Figure 8).

    Figure 8. Intraoperative photos of the passed quadriceps tendon ACL graft in flexion (left) and full extension (right).

    • The knee was brought into extension and fixed on the tibia using a size 11 PEEK screw. Good bite was obtained. The screw was backed up using a 4.75 SwiveLock (Arthrex) for fixation.
    • The patient was then noted to have a 1A Lachman and negative pivot shift. Given the stability of the knee, the decision was made not to perform the lateral extra-articular tenodesis.
    • All wounds were thoroughly irrigated and closed in layers and a sterile dressing was applied. The patient was placed in a brace locked in extension and taken to the recovery room.

    Postoperative FollowUp

    Although there is no standard postoperative rehabilitation protocol for revision ACL reconstruction, the emphasis is on achieving ROM, preserving quadriceps function, and protecting the tissues to allow for healing and graft incorporation. It may take up to 1 year for patients to return to prior activities: Reactive and explosive strength in patients with a revision ACL reconstruction lags behind that of primary ACL reconstruction patients at 9 months postoperatively, even when isometric strength testing is equal. [16]

    Weeks 0-4

    • Non-weight-bearing with the brace locked in extension
    • Active and passive ROM from 0° to 90°
    • Quadriceps sets, straight leg raises, and patellar mobilization permitted

    Weeks 4-8

    • Progress to weight-bearing: Toe-touch weight-bearing at weeks 4-6, full weight-bearing at weeks 6-8
    • Progress ROM from 90° to full after 6 weeks
    • Unlock the brace during weight-bearing as quadriceps function return, but no weight-bearing with the brace unlocked past 90° until week 6
    • Discontinue the brace when quadriceps strength is adequate
    • Heat before and ice after physical therapy

    Weeks 8-12

    • Weight-bearing as tolerated without the brace
    • Begin using the stationary bike
    • Full ROM
    • Begin closed chain exercises
    • Lunges and leg press are allowed from 0° to 90°

    Months 3-6

    • Continue strengthening exercises
    • Single leg strengthening permitted
    • Can begin jogging on a treadmill at 4 months and progress to running
    • Sport-specific training can be initiated at 4 to 5 months, as determined by physician based on exam and testing
    • Functional training can begin if strength is 75% or greater compared with the contralateral side

    Months 7-8

    • Continue sport-specific training
    • Consider isokinetic testing to identify strength deficits and total body conditioning

    Months 8-12: Criteria for Return to Sport

    • Quadriceps and hamstring strength at least 90% of contralateral leg
    • No effusion or quadriceps atrophy
    • Complete all running, cutting, shuttle runs, and agility runs with no limp
    • Full controlled acceleration and deceleration
    • Lower and rise from full squat position
    • Single-leg broad jump and triple jump at least 90% of contralateral leg
    • Single-leg vertical jump at least 90% of contralateral leg
    • Lower extremity functional test complete in under 1 minute, 45 seconds

    Surgical Pearls

    • Understand the primary causes of ACL reconstruction failure. An appropriate preoperative work-up should be undertaken for all revision ACLs. Lower extremity alignment films should be obtained if malalignment is thought to be a contributing factor. A CT scan should be obtained to evaluate tunnel widening if the surgeon suspects the tunnel width is 14 mm or more.
    • Autograft is preferred in younger patients, given the higher failure rates of allograft reconstructions. The quadriceps tendon is a good graft choice in a revision due to its strong mechanical properties and robust cross-sectional area.
    • Consider drilling tunnels prior to graft harvest in cases in which the tunnel width is borderline for a 2-stage procedure. Tunnels can be sequentially reamed up to a larger size with smaller-sized reamers and/or dilators. Be prepared to convert to a 2-stage procedure by ensuring that allograft bone dowels or bone grafting agents are available.
    • Consider performing a LET procedure if the patient has high-grade instability or residual pivot shift.
    • Be prepared for changes to the intraoperative plan by having multiple options for fixation available as back up.
      • For tunnel preparation, have available transtibial, anteromedial, and retrograde drill guides; a range of reamer sizes with or without coring reamers; and tunnel dilators
      • For graft fixation, have available large interference screws, knotless suture anchors, screw and washer systems, and Richards staples
      • For bone grafting, have available allograft bone dowels and bone graft substitute
      • In addition, consider having available fluoroscopy and hardware removal set for the specific system being used and/or broken screw removal set


    Anterior cruciate ligament graft rupture is an unfortunately common complication after ACL reconstruction, particularly in young and high-demand patients, and it presents many significant challenges to the treating surgeon. As discussed above, one of the first goals of treating an ACL graft rupture is to carefully investigate the patient factors, technical factors, and associated injuries that may have contributed to the graft tear so that they can be effectively addressed during the revision ACL surgery.

    Patient characteristics that are well-known risk factors for ACL graft rupture include younger age at the time of primary ACL reconstruction and desire to return to high-level contact or pivoting sports. [3,22,23] Other factors such as generalized ligamentous laxity and/or genu recurvatum, high-grade pivot shift, and family history have also been proposed as risk factors for graft tear but are not as consistently supported in the literature. [24-27]

    Another important and potentially modifiable patient factor is lower extremity alignment. Varus alignment of the knees has been shown to increase strain on the ACL compared with knees in neutral alignment and, therefore, may increase the risk of graft rupture. [6] Increased posterior tibial slope has also been identified as a risk factor for ACL graft rupture, and a recent study found that posterior tibial slope of 17° or more is predictive of ACL graft rupture. [4,27,28] Another study demonstrated early safety and efficacy of a corrective osteotomy prior to revision ACL reconstruction. [29]

    Associated injuries in the knee, either missed at the time of the initial ACL tear or sustained at the time of graft rupture, should also be carefully evaluated. Meniscal injuries are often encountered in the setting of revision ACL reconstruction, as was seen in our patient. [25,30] Given the importance of the meniscus as a secondary stabilizer of the knee, preservation of meniscal tissue is critical whenever possible. Meniscectomy increases the strain on the ACL graft and increases the risk of graft tear. [31,32] A study using the Multicenter ACL Revision Study (MARS) cohort found that meniscus repair is equally successful in revision ACL surgery as in primary ACL surgery, with meniscal failure rates of about 10%, and should still be considered in patients undergoing revision ACL surgery. [33]

    However, re-tear of a prior meniscus repair is a risk factor for ACL graft failure, and repeat repair of a meniscus tear is less likely to be as successful as the initial repair. [34,35] The size of the tear, the quality of meniscus tissue, and the presence of a prior repair should be considered when addressing meniscus pathology in revision ACL patients.

    Although not present in our patient, medial meniscal ramp lesions and lateral meniscal root tears have been increasingly recognized as biomechanically important injuries that are likely underdiagnosed. [36,37] Studies have shown that sectioning of both the posterior root of the lateral meniscus and the posteromedial meniscocapsular junction leads to further knee instability after ACL tear, and that these structures provide improved stability to the knee after concomitant repair with ACL reconstruction. [36,38,39]

    Importantly, meniscal ramp lesions are more commonly identified in the revision ACL setting than in primary ACL reconstruction. Surgeons should have a high index of suspicion for these injuries and should look for them in the posterior medial compartment during revision ACL reconstruction. [40] It is unclear whether the higher incidence of ramp lesions found during revision ACL reconstruction is due to missed injuries at the time of primary reconstruction or injuries sustained at the time of graft rupture. Either way, these lesions should be repaired at the time of revision ACL reconstruction when they are identified.

    Lateral meniscal root injuries also occur in as many as 14% of ACL tears, and because of the protective effect of the lateral meniscal root on the ACL graft, the lateral meniscal root should be carefully examined at the time of ACL revision surgery and repaired as needed. [36,37]

    Associated ligamentous injuries, particularly in the PLC, can also be missed at the time of the initial injury and increase the risk of graft rupture. [41] Untreated PLC injuries can lead to dynamic varus thrust and increased ACL graft strain and, therefore, should be carefully assessed and treated at the time of revision ACL reconstruction as necessary.

    Technical factors that may contribute to ACL graft rupture include graft type, graft size, and tunnel position. Bone-patellar-bone autografts and quadrupled hamstring autografts have low failure rates, but the rate of hamstring graft failure is higher among the youngest, most high-risk athletes compared with BTB (13% vs 7.1%). [3] If a hamstring graft was used at the time of primary ACL reconstruction in a young athlete, then a BTB autograft should be considered for the revision graft if the patient aims to return to high-level sports. In our patient, BTB autograft had been used for the initial reconstruction and, therefore, a soft tissue autograft was selected for the revision.

    Allograft was not desirable in our patient, as the use of allograft in young patients for primary ACL reconstruction has up to a 15 times higher graft failure rate. [42] Outcomes are also poor in the revision setting: The MARS findings show that patients with allograft had lower postoperative patient-reported outcome scores and Marx activity scores, as well as a 2.78 times higher risk of graft re-tear, compared with patients with autograft. [43] Despite this, the MARS study also found that surgeons are almost twice as likely to use allograft for a revision ACL than for a primary ACL reconstruction, likely because of more limited autograft choices and lower donor site morbidity. [19]

    Graft size is also a potential contributing factor to ACL graft rupture. Multiple studies have demonstrated that soft tissue autografts with less than 8.5 mm diameter have a greater risk of rupture than larger grafts, and augmentation of a small autograft with allograft may also increase the risk of re-rupture compared with the use of autograft alone. [44-46] Graft size should be considered in the evaluation of a soft tissue graft rupture, and in patients undergoing revision with soft tissue graft, the goal should be to obtain a graft of at least 8.5 mm.

    Techniques for increasing the size of hamstring grafts have been described, but a benefit of using a quadriceps tendon graft is that graft size is more predictable. [21,47,48] The quadriceps tendon graft has similar outcomes and graft rupture rates when compared with hamstring soft tissue grafts, and combined with the more predictable graft size, it is an appealing graft option in the revision setting. [49,50]

    Tunnel position and widening should be carefully evaluated after ACL graft rupture as part of the preoperative planning. Tunnel malposition can lead to abnormal graft isometry and is present in up to 50% of graft ruptures. [5] Femoral tunnels are most commonly either too vertical or too anterior, which can lead to rotational instability and loss of flexion, respectively. Anterior tibial tunnels can lead to notch impingement and loss of extension. Tunnel position and widening can be evaluated with either MRI or CT scan. A CT scan should be obtained to more carefully and accurately evaluate tunnel dimensions in cases in which widening of more than 14 mm may be present on preoperative radiographs. [9]

    The causes of tunnel widening are multifactorial and incompletely understood but widening can cause significant challenges for revision graft fixation, especially if it is not identified preoperatively. Maak et al [8] described fixation strategies for management of tunnel widening in single-stage revision ACL reconstruction, including larger interference screw sizes and/or allograft supplementation in the tunnel. If these techniques are not possible or if tunnel width is greater than 15 mm, then staged reconstruction with bone grafting is recommended.

    If single-stage reconstruction is chosen, then multiple graft fixation options should be available, with a backup plan for possible grafting and staging if unanticipated problems with tunnel size or position are encountered. It is also helpful to start with tunnel drilling prior to graft harvest if tunnel size is borderline on preoperative imaging. Smaller reamers can be used to sequentially ream up the size of the tunnels.

    Depending on the method of primary ACL tunnel drilling (ie, anteromedial or transtibial), the opposite method can be used during revision surgery if the tunnel aperture position is appropriate but a new bony pathway is desired. [7,8] In many cases the femoral tunnel is too anterior and can be avoided entirely, which was the case with our patient, and suspensory fixation was chosen in the femur to avoid convergence with the prior tunnel and loss of fixation. If interference screw fixation is chosen, larger screws should be available and backup fixation with suspensory buttons, suture anchors, or screw and washer systems should also be on hand in the event that aperture fixation is not adequate.

    Finally, after all of the above factors have been addressed, additional procedures to improve the stability of the knee after ACL reconstruction may be considered. The importance of the anterolateral ligament complex as a stabilizing structure in the knee is an area of increasing interest, and multiple techniques for LET have been described. [51-53] In patients with many of the non-modifiable risk factors discussed above, LET has been shown to decrease the risk of ACL graft tear compared with ACL reconstruction with soft tissue autograft alone. [54] In the revision setting, LET has also been shown to decrease the rate of graft re-rupture.

    Among patients with high-grade preoperative knee instability, Alm et al [55] found a decreased incidence of revision ACL failure (5% vs 21%), decreased residual pivot shift, and improved postoperative patient outcomes in patients who underwent LET during revision ACL reconstruction compared with those who underwent revision ACL reconstruction alone. Cadaveric studies have also shown that LET does not lead to over-constraint of the lateral compartment of the knee or increased tibiofemoral contact pressures, which was an early concern about the addition of LET to revision ACL reconstruction. [56,57] Lateral extra-articular tenodesis may be a helpful addition for patients with many non-modifiable risk factors who are undergoing revision ACL surgery, especially if another clear cause of graft rupture is not identified. 

    Although revision ACL reconstruction can be difficult, a thorough approach to these patients that includes careful preoperative evaluation and planning and utilization of some of the intraoperative strategies discussed above can help to optimize outcomes in these challenging patients.

    Author Information

    Margaret Wright, MD, is from The Rothman Orthopaedic Institute in Philadelphia, Pennsylvania, and Meghan E. Bishop, MD, is from The Rothman Orthopaedic Institute in New York, New York.

    Sports Medicine Section Editor

    Brandon J. Erickson, MD

    Disclosures: The authors have no disclosures relevant to this article.


    1. Kaeding CC, Pedroza AD, Reinke EK, et al. Risk Factors and Predictors of Subsequent ACL Injury in Either Knee after ACL Reconstruction. Am J Sports Med. 2015; 43(7):1583-1590.
    2. Maletis GB, Inacio MC, Funahashi TT. Analysis of 16,192 anterior cruciate ligament reconstructions from a community-based registry. Am J Sports Med. 2013; 41(9): 2090-8.
    3. MOON Knee Group. Anterior Cruciate Ligament Reconstruction in High School and College Aged Athletes. Does Autograft Choice Influence Anterior Cruciate Ligament Revision Rates? Am J Sports Med. 2020; 48(2): 298-309.
    4. Christensen JJ, et al. Lateral Tibial Posterior Slope Is Increased in Patients With Early Graft Failure After Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2015; 43(10): 2510-4.
    5. Morgan, JA, et al. Femoral tunnel malposition in ACL revision reconstruction. J Knee Surg. 2012; 25(5): 361-8.
    6. van de Pol GJ, et al. Varus alignment leads to increased forces in the anterior cruciate ligament. Am J Sports Med. 2009; 37(3): 481-7.
    7. Campbell A, Zacchilli M, Alaia M. Revision ACL Reconstruction: Current Concepts. ICJR. May 22, 2018.
    8. Maak TG, Voos JE, Wickiewicz TL, Warren RF. Tunnel Widening in Revision Anterior Cruciate Ligament Reconstruction. J Am Acad Orthop Surg. 2010: 18(11); 695-706.
    9. Marchant MH, et al., Comparison of plain radiography, computed tomography, and magnetic resonance imaging in the evaluation of bone tunnel widening after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc, 2010;18(8):1059-64.
    10. Arianjam, A., et al., Analysis of 2019 Patients Undergoing Revision Anterior Cruciate Ligament Reconstruction From a Community-Based Registry. Am J Sports Med, 2017. 45(7): p. 1574-1580.
    11. Gifstad T, Drogset JO, Viset A, Grontvedt T, Hortemo GS. Inferior results after revision ACL reconstructions: a comparison with primary ACL reconstructions. Knee Surg Sports Traumatol Arthrosc. 2013; 21(9):2011-2018.
    12. Lefevre N, Klouche S, Mirouse G, Herman S, Gerometta A, Bohu Y. Return to sport after primary and revision anterior cruciate ligament reconstruction: a prospective comparative study of 552 patients from the FAST cohort. Am J Sports Med. 2017;45(1):34-41.
    13. MARS Group. Meniscal and articular cartilage predictors of clinical outcome following revision anterior cruciate ligament reconstruction. Am J Sports Med. 2016;44(7):1671-1679.
    14. Anand B et al. Return-to-Sport Outcomes After Revision Anterior Cruciate Ligament Reconstruction Surgery. Am J Sports Med, 2016. 44(3): p. 580-4.
    15. Andriolo L, et al. Revision anterior cruciate ligament reconstruction: clinical outcome and evidence for return to sport. Knee Surg Sports Traumatol Arthrosc, 2015. 23(10): p. 2825-45.
    16. Carolan D, King E, Richter C et al. Differences in Strength, Patient-Reported Outcomes, and Return-to-Play Rates Between Athletes with Primary versus Revision ACL Reconstruction at 9 Months After Surgery. Orthop J Sports Med. 2020; 8(9): 1-7.
    17. Grassi A, Zaffagnini S, Muccioli GM et al. After revision anterior cruciate ligament reconstruction, who returns to sport? A systematic review and meta-analysis. Br J Sports Med. 2015;49(20):1295-304.
    18. Nwachukwu, B.U., et al., Return to Play and Patient Satisfaction After ACL Reconstruction: Study with Minimum 2-Year Follow-up. J Bone Joint Surg Am, 2017. 99(9): p. 720-725.
    19. Wright RW, Huston LJ, Spindler KP, et al. Descriptive epidemiology of the Multicenter ACL Revision Study (MARS) cohort. Am J Sports Med. 2010;38:1979-1986
    20. Sanders TL, Maradit Kremers H, Bryan AJ, et al. Incidence of anterior cruciate ligament tears and reconstruction: a 21-year population based study. Am J Sports Med. 2016;44(6):1502-1507.
    21. Xerogeanes JW, Mitchell PM, Karasev PA, et al. Anatomic and Morphological Evaluation of the Quadriceps Tendon Using 3-Dimensional Magnetic Resonance Imaging Reconstruction. Am J Sports Med. 2013; 41(10):2392-2399.
    22. Webster KE, Feller JA. Exploring the high reinjury rate in younger patients undergoing anterior cruciate ligament reconstruction. Am J Sports Med. 2016;44(11):2827-2832.
    23. Webster KE, Feller JA, Leigh WB, Richmond AK. Younger patients are at increased risk for graft rupture and contralateral injury after anterior cruciate ligament reconstruction. Am J Sports Med. 2014;42(3):641-647.
    24. Ayeni OR, Chahal M, Tran MN, Sprague S. Pivot shift as an outcome measure for ACL reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2012;20(4):767-777.
    25. Borchers, JR, Kaeding, CC, Pedroza, AD. Intra-articular findings in primary and revision anterior cruciate ligament reconstruction surgery: a comparison of the MOON and MARS study groups. Am J Sports Med. 2011;39(9):1889-1893.
    26. MARS Group, Cooper DE, Dunn WR, et al. Physiologic preoperative knee hyperextension is a predictor of failure in an anterior cruciate ligament revision cohort: a report from the MARS Group. Am J Sports Med. 2018;46(12):2836-2841.
    27. Zeigler CG, DePhillipo NN, Kennedy MI, et al. Beighton score, tibial slope, tibial subluxation, quadriceps circumference difference, and family history are risk factors for primary ACL graft failure: A retrospective comparison of primary and revision ACL reconstructions. Arthroscopy. 2020; online ahead of print.
    28. Ni Q, Song G, Zhi-jun Z, et al. Steep posterior tibial slope and excessive anterior tibial translation are predictive risk factors of primary anterior cruciate ligament reconstruction failure. Am J Sports Med. 2020; 48(12):2954-2961.
    29. Akoto R, Alm L, Drenck TC, et al. Slope-Correction Osteotomy with Lateral Extra-articular Tenodesis and Revision Anterior Cruciate Ligament Reconstruction is Highly Effective in Treating High-Grade Anterior Knee Laxity. Am J Sports Med. 2020; online ahead of print.
    30. Wyatt RWB, Inacio MCS, Liddle KD, Maletis GB. Prevalence and incidence of cartilage injuries and meniscus tears in patients who underwent both primary and revision anterior cruciate ligament reconstructions. Am J Sports Med. 2014; 42(8):1841-1846.
    31. Papageorgiou CD, Gil JE, Kanamori A, Fenwick JA, Woo SL, Fu FH. The biomechanical interdependence between the anterior cruciate ligament replacement graft and the medial meniscus. Am J Sports Med. 2001;29(2):226-231.
    32. Robb C, et al. Meniscal integrity predicts laxity of anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc, 2015. 23(12): 3683-90.
    33. MARS Group. Meniscal Repair in the Setting of Revision Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2020; 48(12): 2978-2985.
    34. Fuchs, A., Kloos, F., Bode, G. et al. Isolated revision meniscal repair – failure rates, clinical outcome, and patient satisfaction. BMC Musculoskelet Disord. 2018;19:446.
    35. Vindfeld S, Strand T, Solheim E, et al. Failed meniscal repairs after anterior cruciate ligament reconstruction increases risk of revision surgery. Orthop J Sports Med. 2020; 8(10): 1-6.
    36. Frank JM, Moatshe G, Brady AW, et al. Lateral meniscus posterior root and meniscofemoral ligaments as stabilizing structures in the ACL-deficient knee. Orthop J Sports Med. 2017; 5(6): 1-7.
    37. Magosch A, Mouton C et al. Medial meniscus ramp and lateral meniscus posterior root lesions are present in more than a third of primary and revision ACL reconstructions. Knee Surg Sports Traumatol Arthrosc. 2020; online ahead of print.
    38. DePhillipo NN, Moatshe G, Brady A, et al. Effect of Meniscocapsular and Meniscotibial Lesions in ACL- Deficient and ACL-Reconstructed Knees: A Biomechanical Study. Am J Sports Med. 2018;46(10):2422-2431.
    39. Stephen JM, Halewood C, Kittl C, Bollen SR, Williams A, Amis AA. Posteromedial Meniscocapsular Lesions Increase Tibiofemoral Joint Laxity With Anterior Cruciate Ligament Deficiency, and Their Repair Reduces Laxity. Am J Sports Med. 2016;44(2):400-408.
    40. Sonnery-Cottet B, Praz C, Rosenstiel N, et al. Epidemiological Evaluation of Meniscal Ramp Lesions in 3214 Anterior Cruciate Ligament-Injured Knees From the SANTI Study Group Database: A Risk Factor Analysis and Study of Secondary Meniscectomy Rates Following 769 Ramp Repairs. Am J Sports Med. 2018;46(13):3189-3197.
    41. LaPrade RF, Resig S, Wentorf F, Lewis JL. The Effects of Grade III Posterolateral Knee Complex Injuries on Anterior Cruciate Ligament Graft Force. Am J Sports Med. 1999;27(4):469-475.
    42. Ellis HB, Matheny LM, Briggs KK, Pennock AT, Steadman JR. Outcomes and revision rate after bone-patellar tendon-bone allograft versus autograft anterior cruciate ligament reconstruction in patients aged 18 years or younger with closed physes. Arthroscopy. 2012;28:1819-1825
    43. Wright RW, Huston LJ, Haas AK, et al. Effect of graft choice on the outcome of revision anterior cruciate ligament reconstruction in the Mulitcenter ACL Revision Study (MARS). Am J Sports Med. 2014: 42(10); 2301-2310.
    44. Conte EJ, Hyatt AE, Gatt CJ, Jr, Dhawan A. Hamstring autograft size can be predicted and is a potential risk factor for anterior cruciate ligament reconstruction failure. Arthroscopy. 2014;30:882-90.
    45. Darnley JE, Seger-St-Jean B, Pedroza AD, et al. Anterior Cruciate Ligament Reconstruction Using a Combination of Autograft and Allograft Tendon: A MOON Cohort Study. Orthop J Sports Med. 2016; 4(7): 2325967116662249.
    46. Mariscalco MW, Flanigan DC, Mitchell J, et al. The influence of hamstring autograft size on patient-reported outcomes and risk of revision after anterior cruciate ligament reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON) Cohort Study. Arthroscopy. 2013;29:1948-53.
    47. Lee RJ, Ganley TJ. The 5-strand hamstring graft in anterior cruciate ligament reconstruction. Arthrosc Tech. 2014;3:e627-31.
    48. Xerogeanes JW. Quadriceps Tendon Graft for Anterior Cruciate Ligament Reconstruction: THE GRAFT OF THE FUTURE! Arthroscopy. 2019 Mar;35(3):696-697.
    49. Lind M, Nielsen TG, Soerensen OG, et al. Quadriceps tendon grafts does not cause patients to have inferior subjective outcome after anterior cruciate ligament (ACL) reconstruction than do hamstring grafts: a 2-year prospective randomized controlled trial. Br J Sports Med. 2020; 54: 183-187.
    50. Mouarbes D, Menetrey J, Marot V, et al. Anterior Cruciate Ligament Reconstruction. A systematic review and meta-analysis of outcomes for quadriceps tendon autograft versus bone-patellar tendon-bone and hamstring tendon autografts. Am J Sports Med. 2019; 47(14): 3531-3540.
    51. Ferretti A, Monaco E, Fabbri M, Maestri B, De Carli A. Prevalence and classification of injuries of anterolateral complex in acute anterior cruciate ligament tears. Arthroscopy. 2017;33(1):147-154.
    52. Geeslin AG, Moatshe G, Chahla J, et al. Anterolateral knee extraarticular stabilizers: a robotic study comparing anterolateral ligament reconstruction and modified Lemaire lateral extra-articular tenodesis. Am J Sports Med. 2018;46(3):607-616.
    53. Hewison CE, Tran MN, Kaniki N, Remtulla A, Bryant D, Getgood AM. Lateral extra-articular tenodesis reduces rotational laxity when combined with anterior cruciate ligament reconstruction: a systematic review of the literature. Arthroscopy. 2015;31(10):2022-2034.
    54. Getgood AMJ, Bryant DM, Litchfield R, et al. Lateral extra-articular tenodesis reduces failure of hamstring tendon autograft anterior cruciate ligament reconstruction. 2-year outcomes from the STABILITY study randomized clinical trial. Am J Sports Med. 2020; 48(2):285-297.
    55. Alm L, Frosch KH, Akoto R. Extra articular lateral tenodesis in patients with revision anterior cruciate ligament (ACL) reconstruction and high-grade anterior instability. Orthop J Sports Med. 2020;8(5 suppl4).
    56. Novaretti JV, Arner JW, Chan CK, Polamalu S, Harner CD, Debski RE, Lesniak BP. Does Lateral Extra-articular Tenodesis of the Knee Affect Anterior Cruciate Ligament Graft In Situ Forces and Tibiofemoral Contact Pressures? Arthroscopy. 2020 May;36(5):1365-1373.
    57. Shimakawa T, Burkhart TA, Dunning CE, Degen RM, Getgood AM. Lateral Compartment Contact Pressures Do Not Increase After Lateral Extra-articular Tenodesis and Subsequent Subtotal Meniscectomy. Orthop J Sports Med. 2019;7(6).