First anterior cruciate ligament revision in adults: the ESSKA formal consensus

recommendations

I. Introduction

II. Diagnosis and preoperative planning (formal consensus)

D1) How is a failed ACL Reconstruction (ACLR) defined?
D2) Which aspect(s) of the patient status and surgical history should be documented in the
setting of a known or suspected failed ACL Reconstruction?
D3) Which aspect(s) of the physical examination should be performed/documented in the
setting of a known or suspected failed ACL Reconstruction?
D4) What is the role of hyperextension in ACL Revisions?
D5) Are instrumental devices helpful to evaluate knee laxity in the setting of a known or
suspected failed ACL Reconstruction?
D6) Which radiographic/imaging studies should be used to evaluate a known or suspected
failed ACL Reconstruction?
D7) Which additional radiographic/imaging studies can be used to evaluate a known or
suspected failed ACL Reconstruction?
D8) Can MRI assess the ACL graft status in the setting of a known or suspected failed ACL
Reconstruction?
D9) What additional pathologies and specific features in the setting of known or suspected
failed ACL reconstruction should be assessed by MRI?
D10) What imaging is recommended to assess lower leg alignment?
D11) How should Tibial Slope be assessed in the setting of a known or suspected failed ACL
Reconstruction and what is the optimal method?
D12) When is a specific assessment of tunnel widening necessary and how should it be done?
D13) How can the assessment of tunnel placement be performed and what is the definition
of tunnel misplacement in the setting of a known or suspected failed ACL Reconstruction?
D14) What is the optimal method to assess concomitant ligament injuries?
D15) How can osteoarthritic changes be assessed in the setting of a known or suspected failed
ACL Reconstruction?
D16) Is there a role for bone scan, PET, CT?
D17) Does infection need to be ruled out on a routine basis and if so, how?
D18) What is the role of preoperative neuromuscular assessment?

III. Surgical Strategy (formal consensus)

S1: Which factors are relevant to the surgical strategy when the indication is made to revise
a previously reconstructed ACL?
S2: Which factors influence the decision to perform a single- vs. two-stage procedure?
S3: When is bone grafting of a widened or malpositioned tunnel indicated?
S4: What is the best material for tunnel grafting (autograft, allograft, synthetic bone
substitutes)?
S5: When is it safe to perform ACLR after staged bone grafting (time)?
S6: When is an osteotomy indicated to correct coronal malalignment (Varus/Valgus)?
S7: When is an osteotomy indicated to correct sagittal malalignment (Slope) in ACL revision
surgery?
S8: When is an additional extraarticular anterolateral procedure indicated in ACLR Surgery?
S9: When should additional medial laxity be treated or addressed?
S10: When should additional lateral laxity be treated or addressed?
S11: When could be an additional meniscal substitute or meniscal allograft be indicated?
S12: What factors influence the decision in graft choice for ACLR?
S13: Are allografts comparable to autografts regarding outcome?
S14: Is there a role for synthetic grafts or synthetic augmentation (internal brace)?
S15: What is the place of graft harvesting from the contralateral knee and graft re-harvesting
from the ipsilateral knee?
S16: What is the ideal tendinous graft diameter in ACL Revision Surgery?
S17: What is the best treatment in the case of a planned ACL revision in a patient with a
suspected low-grade infection?
S18. Is antibiotic soaking of grafts useful for reducing post-operative infections?

IV. Indications (formal consensus / RAM method)

I1: What is the indication for performing an ACL revision in people older than 60 years?
I2: Are there indications to perform ACL revision in patients with Kellgren Lawrence IV grade
osteoarthritis?
First anterior cruciate ligament revision in adults: the ESSKA formal consensus
recommendations

I. Introduction

Anterior cruciate ligament (ACL) tears are one of the most common sports injuries and
anterior cruciate ligament reconstruction (ACLR) is one of the most commonly performed
surgery, with ACL repairs getting recently some attention. However, these procedures can fail
in a number of ways, requiring ACL revision (ACL Rev), which is technically more demanding
than primary reconstruction. Many variables including tibial slope, anterolateral stabilization,
the role of the meniscus for stability, hidden meniscus lesions/root lesions, treatment of
associated ligament injuries, and cartilage lesions in conjunction with increasing patient
expectations and activity have made the topic even more significant in recent years. Also,
psychological readiness to return to sport after ACL revision is an important issue. Due to the
complex nature of revision surgery, an in-depth preoperative examination using history,
clinical examinations, advanced imaging and other methods as appropriate is of the utmost
importance.

The aim of this ESSKA Consensus is to provide a combination of evidence-based and expert
opinions about the diagnosis, preoperative assessment and management of patients with
failed ACL reconstructions, regardless of the time from initial surgery. However, this
consensus is not focused on specific surgical techniques.

Goal of treatment and expected clinical outcome of ACL revision surgery:

The goal of ACL revision surgery is to achieve a stable, pain-free knee, close to full range of
motion, allowing sport and unrestricted daily activities while slowing down the long-term
progression of osteoarthritis (OA). However, several studies have shown that the outcomes
of revision ACL reconstruction are less predictable compared to primary reconstructions.
Although stability can be restored with revision ACL reconstruction, patient-reported outcome
measures are worse and the rate of return to sport is lower compared with patients after
primary ACLR. Furthermore, the rate of recurrent instability/re-rupture has been reported to
be higher after revision procedures.

Definitions

Definition of ACL revision: inclusion and exclusion criteria

“All surgical procedures involving replacement of the ACL graft with a new graft.”
On this basis, partial meniscectomy after ACLR is not defined as ACL revision; nor is a cyclops
resection, nor are isolated peripheral ligamentous reconstructions. Associated additional
procedures such as osteotomy, meniscus repair or replacement, peripheral ligament
reconstruction and cartilage surgery are included, providing a revision ACL reconstruction has
been performed.
Exclusion criteria (for consensus):
- Patients with open growth plates at time of revision
- Multiligament injuries involving ACL and PCL
- Any concomitant prosthesis
- Second or more ACL revision

Definition of knee instability and laxity:

Pathological laxity is a sign defined as “increased passive response of a joint to an externally
applied force or torque in biomechanical terms. Thus, laxity tests for evaluating knee injury
evaluate the passive limits of motion in a particular direction or plane”.

Instability is defined as a functional symptom: “an abnormal dynamic joint motion that can
occur in response to the complex, high-magnitude loads encountered during activities of daily
living and sport activities.”

The terms stable or unstable knees have created ambiguity. A patient may sustain functional
instability without laxity and vice versa. In the following discussion, instability will only refer
to a functional symptom (such as giving way) and laxity will refer to an objective clinical sign.
Subtle laxity is difficult to define. The IKDC (1995/2000) has defined normal laxity as -1 to 2
mm (compared to the healthy side), nearly normal laxity as 3 to 5mm, abnormal laxity as 6 to
10mm and severely abnormal laxity as over 10mm during Lachman, anterior/posterior
drawer, medial and lateral joint opening.

IKDC 1995/2000 definitions of knee laxity

Instrumented measurements or stress x-ray, examined with Lachman's test (ACL/PCL), drawer
test anterior-posterior(ACL/PCL), medial(MCL/POL) or lateral(LCL/Popliteus) opening.
Laxity measurements Side to side difference
Compared to the normal knee
-1 - 2 mm Normal laxity
3 - 5 mm Nearly normal laxity
5 - 10 mm Abnormal laxity
> 10 mm Severely abnormal laxity

Definition of partial meniscectomy:

The definition of partial meniscectomy includes a wide range in terms of size and location of
the tissue resection. While the amount of removed meniscus is not sufficient to define this,
newer biomechanical studies have evaluated the influence of the type of meniscus tear on
articular pressure distribution (Lau et al. JBJS Rev 2018). Partial meniscectomy with less than
50% removed has no significant increased contact pressure, whereas complete meniscectomy
more than doubles the contact pressures. From biomechanical studies the impact of radial
tears is still debated. Root tears are comparable to total meniscectomy.

For the purpose of our consensus we define partial meniscectomy as resection of up to 50%
of the meniscus depth but not more, and the presence of intact roots with no meniscus
extrusion. This leaves three groups that are relevant for decision making and surgical strategy:
- Intact meniscus or partial meniscectomy (without compromised meniscus function)
- Repairable meniscus lesion (e.g. bucket handle tear, root tear, ramp lesion)
- Nonrepairable tear (greater than around 50%), subtotal meniscectomy or
nonfunctional meniscus (extrusion >3mm) (compromised meniscus function)
The exact cutoff values are seen as a rough estimate and can vary somewhat.
Definition of Hyperextension/Hyperlaxity:
Hyperextension of the knee can be posttraumatic or congenital, which can be differentiated
by side-to-side difference (increased in traumatic hyperextension vs. bilateral in hyperlaxity
(hypermobility)). The MARS group found knee hyperextension of more than 5° to be a risk
factor for ACL injury (MARS Group; Daniel E. Cooper, Am J Sports Med, 2018).
General hyperlaxity is defined by a Beighton score >5 (Beighton, J Bone Joint Surg Br. 1969).

Methodology:
It is the aim of the ESSKA consensus to assist surgeons in the treatment of patients after failure
of an ACL reconstruction. Our goal is to propose a “framework” rather than strict guidelines.
We have set up the “Formal Consensus Project” (derived from a Delphi methodology) for
diagnosis and preoperative planning and surgical strategy as well as a “RAND/UCLA
Appropriateness Method” (RAM) process for indication of the first ACL graft revision. To
define treatment indications, the RAM combines the best available scientific evidence with
the collective judgment of a panel of experts, guided by a core panel and multidisciplinary
discussers. Since ACL revision is highly specific, a “multidisciplinary” discussion was not
performed. A list of specific clinical scenarios was produced regarding ACL graft re-rupture
with increased laxity in an aligned knee in adults. Each scenario underwent discussion and a
two-round vote on a nine-point Likert-scale, and scores were pooled to generate expert
patient-specific recommendations on the appropriateness of revision ACL reconstruction.
Scenarios not pertaining to this definition were considered in a Delphi indications section. For
the Delphi process the core group comprised a steering group of 14 experts assisted by a
literature group of three additional experts. Based on the diagnostic and therapeutic workup
for ACL revision, they proposed a series of relevant questions, their respective answers, and
applied a scientific grade based upon existing literature (screened from 2005 - 2020) and their
expert opinion.

Grade A: high scientific level

Grade B: scientific presumption
Grade C: low scientific level
Grade D: expert opinion
A first draft was reviewed and amended twice by another independent panel of 19
experienced orthopaedic surgeons (rating group). The final text underwent a second review
process by an additional peer review group comprising 51 clinicians and clinical scientists from
different European countries. This long and complex process has two main advantages. It
limits any individual or organizational bias or conflict of interest and it may have a better
chance of general acceptance due to the involvement of a large number of participants from
different countries (88 people from 27 European countries were involved). For indications we
used the RAM methodology. This reflected the large diversity of clinical presentations in our
daily practice. Just like the large amount of individual anatomical variations, the orthopaedic
clinician needs to approach each individual patient bearing in mind his or her unique medical
history, individual physiology, gender, activity level, weight and a number of other variables
that do not fit into a single statistical picture. This “consensus investigation” has attempted to
shed some light on these important clinical entities. In addition, the recommendations are
presented free from economic constraints.

We hope the following recommendations will take into account these messages, avoid any
conflicting or political statements, and provide a well-balanced treatment algorithm with a
place for both non-operative and arthroscopic treatment in the orthopaedic armamentarium.
Our findings will hopefully assist every orthopaedic clinician in their decision making when
confronted with patients with ACL graft tears.
The following people were involved in the consensus:

ACL Revision Consensus Chairmen:

Thomas Tischer (Germany) and Vincenzo Condello (Italy)

ESSKA Consensus Projects Advisor:

Philippe Beaufils

Steering Group:
Thomas Tischer (Germany), Philippe Beaufils (France), Vincenzo Condello (Italy), Roland
Becker (Germany), David Dejour (France), Giuseppe Filardo (Italy) (leader of RAND/UCLA
Appropriateness method), Karl Eriksson (Sweden), Adrian Wilson (UK), Martin Rathcke
(Denmark), Marc Strauss (Norway), Romain Seil (Luxembooug), Jacques Menetrey
(Switzerland), Nicolas Pujol (France)

Literature Group:
Alberto Grassi (Italy), Marco Bonomo (Italy), Matthias Feucht (Germany), Sufian Ahmad
(Germany)

RAM methodological support and analysis:

Luca Andriolo (Italy)

Rating Group:
Sven Scheffler (Germany), Edoardo Monaco (Italy), Christian Hoser (Austria), Etienne
Cavaignac (France), Riccardo Cristiani (Sweden), Markas Fiodorovas (Lithuania), Mustafa
Karahan (Turkey), Tomasz Piontek (Poland), Corrado Bait (Italy), Vincenzo Madonna (Italy),
George Komnos (Greece), Juan Carlos Monllau (Spain), Koen Carl Lagae, (Belgium) Matthieu
Ollivier (France), Bertrand Sonnery-Cottet (France), Mikko Ovaska (Finland), Gijs Helmerhorst
(Netherlands), Wolf Petersen (Germany), James Robinson (UK), Kristian Samuelson (Sweden)
Peer review group:
Oleg Eismont (Belarus), Peter Verdonk (Belgium), Pieter Jan Vandekerckhove (Belgium), Maki
Grle (Bosnia), Vojtěch Havlas (Czech Republic), Lars Konradsen (Denmark), Ole Gade Sørensen
(Denmark), Morten Foverskov (Denmark), Leho Rips (Estonia), Ari Itälä (Finland), Jukka
Ristiniemi (Finland), Jérôme Murgier, (France) Natalie Mengis (Germany), Raymond Best
(Germany), Christian Schoepp (Germany), Casper Grim (Germany), Lukas Weisskopf
(Germany), Iosifidis Michael (Greece), Houliaras Vasileios (Greece), Giovanni Bonaspetti
(Italy), Davide Bonasia (Italy), Rocco Papalia (Italy), Arcangelo Russo (Italy), Alberto Vascellari
(Italy), Giacomo Zanon (Italy), Eriks Ozols (Latvia), Renaud Siboni (Luxembourg), Jacco A.C. Zijl
(Netherlands), Cathrine Aga (Norway), Jon Olav Drogset (Norway), Søren Vindfeld (Norway),
Pawel Skowronek (Poland), Konrad Malinowski (Poland), Vieira da Silva (Portugal), Octav
Russu (Romania), Stefan Mogos (Romania), Mikhail Ryazantev (Russia), Airat Siyndiykov
(Russia), Vaso Kecojevic (Serbia), Tomaz Malovrih (Slovenia), Xavier Pelfort López (Spain),
Antonio Maestro (Spain), Carlos Martin (Spain), Luís Prieto (Spain), Juan Ayala (Spain), Rafael
Arriaza (Spain), Anders Stålman (Sweden), Björn Engström (Sweden), Emin Bal (Turkey), Eray
Kılınç (Turkey), Fares Haddad (UK)

Proof reading:
Judy C Mac Donald (New Zealand)

ESSKA Office coordination

And of course many thanks to the ESSKA Office and especially Anna Hansen Rak
(Luxembourg) for her continuous and endless support of the consensus group!
II. Diagnosis and preoperative planning (formal consensus)

D1) How is a failed ACL Reconstruction (ACLR) defined?

Consensus answer:
Failure of ACLR is defined by abnormal knee function associated with a previous primary
reconstruction. This could be due to graft failure itself with abnormal laxity (IKDC C/D) or
failure to recreate a functional knee according to the expected outcome. Reasons for failure
could be a new trauma with graft rupture, repeated microtrauma, surgical technical errors,
biological failure, unaddressed associated lesions, or complications associated with the
primary procedure.

Agreement: 8.6/9

Grade of recommendation: B

Literature review:
ACL reconstruction is considered a successful procedure with satisfactory outcomes ranging
from 75% to 97% of cases1-4,18.

No precise and universal definition of failure after ACL reconstruction has been produced, as
it is due to a combination of technical errors, biological causes and/or new trauma5. Biau et
al.6 reported in their meta-analysis that 34% of patients treated for an ACL reconstruction with
autograft had positive results on a Lachman test and 24% on the pivot-shift test. These results
suggest that residual laxity may exist in a large number of patients after reconstruction, in
spite of satisfactory subjective outcomes. However, the causes of ACL reconstruction failure
can be grouped into one or a combination of different problems such as recurrent instability,
graft failure, loss of motion, extensor mechanism dysfunction, OA, infection and comorbidities
related to concomitant pathological abnormalities7. As we reported, failure has a
multifactorial nature, generated by objective and subjective factors. The causes of recurrent
instability are multiple, but they can be divided into early and late failure: an exact cut-off
point does not exist.
Early failure is usually related to poor operative technique, failure of graft incorporation,
premature return to high-demand activities, aggressive rehabilitation or a new trauma1,7. Late
failures may also depend on technical errors, repeated trauma to the graft and/or associated
pathology (e.g. lower limb malalignment, collateral ligament injury and ligamentous laxity).

Technical errors
Technical errors include tunnel malposition, insufficient or excessive graft tensioning, fixation
problems, concomitant untreated laxity and additional pathologies being inappropriately
addressed (meniscal and cartilage injuries).
Tunnel malposition may lead to an excessive change in length of the graft during knee
movement. Such changes can lead to graft stress with consequent elongation or rupture. A
tunnel malposition may lead to graft impingement with soft tissue (e.g. posterior cruciate
ligament) or bone (e.g. intercondylar notch).
The tension that should be applied to a graft during an ACL reconstruction has not been
defined as it depends on several factors, such as the type and size of graft material, the type
of fixation, and the degree of knee flexion at the time of graft tensioning8. However, it has
been demonstrated that over-tensioning the graft can be associated with over-constraint of
the joint, with loss of joint motion and increased joint contact pressures.
Concomitant untreated laxity and intraarticular deficiency have an important role in
predicting ACL reconstruction failure (see also D4 and S10); indeed, knee hyperlaxity is
correlated with non-contact ACL injuries and may lead to an increased risk of ACL injury9. The
medial and lateral collateral ligaments provide secondary stability in the ACL-deficient knee
and must also be carefully assessed for injury. Bonanzinga et al.10 reported that isolated ACL
reconstruction is able to control antero-posterior knee laxity with a combined complete lesion
of the postero-lateral corner (PLC) at 30° of knee flexion, but not at a higher angle of knee
flexion. Moreover, Zhu et al.11 suggest that in the case of a combined ACL and severe
superficial medial collateral ligament (sMCL) injury, both ligaments should be reconstructed,
as single-bundle ACL reconstruction alone is not able to restore anterior tibial translation,
valgus rotation, and external rotation in the case of combined ACL and sMCL injuries.
In the existing literature it is estimated that more than 15% of ACL reconstruction failures are
a result of missed diagnosis of an associated ligament, meniscus or cartilage lesion at the time
of surgery12.

Meniscal deficiency
Meniscal deficiency is an important factor in predicting graft failure. The medial meniscus
contributes to protecting the anterior tibial translation, and the lateral meniscus is an
important restraint to anterior tibial translation during internal tibial rotation13,14. Seon et al.1
found, in a cadaveric study, that a subtotal medial meniscectomy and an ACL reconstruction
was unable to completely restore normal anterior stability with a residual laxity of 2.6 to 5.5
mm.

Early return to activity

Premature return to high-demand activities or aggressive rehabilitation can alter
neuromuscular control patterns during landing. However improved postural stability and
control of the center of mass may help minimize subsequent ACL injury16.

Traumatic reinjury
Traumatic reinjury is responsible for 24% to 32% of graft failures, compared to surgical error
with tunnel malposition, which causes graft failures in 24% to 63.5% of cases 2,17.

References:

1) Kamath GV, Redfern JC, Greis PE, Burk RT. Revision Anterior Cruciate Ligament Reconstruction. The American
Journal of Sports Medicine. 2011 Jan;39(1):199-217.
2) Salem HS, Axibal DP, Wolcott ML, et al. Two-Stage Revision Anterior Cruciate Ligament Reconstruction A
Systematic Review of Bone Graft Options for Tunnel Augmentation. The American Journal of Sport Medicine.
2020;48(3):767-777.
3) Biau DJ, Tournoux C, Katsahian S, Schranz P, Nizard R. ACL Reconstruction: a Meta-analysis of Functional Scores.
Clinical Orthopaedics and Related Research. 2007;458:180-187.
4) Baer GS, Harner CD. Clinical Outcomes of Allograft Versus Autograft in Anterior Cruciate Ligament Reconstruction.
Clinics in Sports Medicine. 2007; 26(4):661-681.
5) Kraeutler MJ, Welton KL, McCarty EC, Bravman JT. Current Concepts Review Revision Anterior Cruciate Ligament
Reconstruction. The Journal of Bone and Joint Surgery. 2017;99:1689-1696.
6) Biau DJ, Tournoux C, Katsahian S, Schranz PJ, Nizard RS. Bone- patellar tendon-bone autografts versus hamstring
autografts for reconstruction of anterior cruciate ligament: meta-analysis. British Medical Journal.
2006;332(7548):995-1001.
7) Whitehead TS. Failure of Anterior Cruciate Ligament Reconstruction. Clinics in Sports Medicine. 2013
Jan;32(1):177-204.
8) Mae T, Shino K, Nakata K, et al. Optimization of graft fixation at the time of anterior cruciate ligament
reconstruction. Part I: effect of initial tension. American Journal of Sports Medicine. 2008;36(6):1087–1093.
9) Ramesh R, Von Arx O, Azzopardi T, et al. The risk of anterior cruciate ligament rupture with generalised joint
laxity. Journal of Bone and Joint Surgery. Br 2005;87(6):800–803.
10) Bonanzinga T, Signorelli C, Lopomo N, Grassi A, Neri MP, Filardo G, Zaffagnini S, Marcacci M. Biomechanical effect
of posterolateral corner sectioning after ACL injury and reconstruction. Knee Surgery, Sports Traumatology,
Arthroscopy. 2015 Oct;23(10):2918-2924.
11) Zhu J, Dong J, Marshall B, Linde MA, Smolinski P, Fu FH. Medial collateral ligament reconstruction is necessary to
restore anterior stability with anterior cruciate and medial collateral ligament injury. Knee Surgery, Sports
Traumatology, Arthroscopy . 2018 Feb;26(2):550-557.
12) Samitier G, Marcano AI, Alentorn-Geli E, Cugat R, Farmer KW, Moser MW. Failure of Anterior Cruciate Ligament
Reconstruction. Archives of Bone and Joint Surgery. 2015 Oct;3(4):220-240.
13) Parkinson B, Robb C, Thomas M, Thompson P, Spalding T. Factors That Predict Failure in Anatomic Single-Bundle
Anterior Cruciate Ligament Reconstruction. The American Journal of Sport Medicine. 2017 Jun;45(7):1529-1536.
14) Grassi A, Dal Fabbro G, Di Paolo S, Stefanelli F, Macchiarola L, Lucidi GA, Zaffagnini S. Medial and lateral meniscus
have a different role in kinematics of the ACL-deficient knee: a systematic review. Journal of ISAKOS Joint
Disorders & Orthopaedic Sport Medicine. 4(5):jisakos-2019-000293.
15) Seon JK, Gadikota HR, Kozanek M, Oh LS, Gill TJ, Li G. The effect of anterior cruciate ligament reconstruction on
kinematics of the knee with combined anterior cruciate ligament injury and subtotal medial meniscectomy: an in
vitro robotic investigation. Arthroscopy. 2009; 25(2):123-130.
16) Paterno MV, Schmitt LC, Ford KR, et al. Biomechanical measures during landing and postural stability predict
second anterior cruciate ligament injury after anterior cruciate ligament reconstruction and return to sport.
American Journal of Sports Medicine 2010; 38(10):1968–1978.
17) Wright RW, Huston LJ, Spindler KP, et al. Descriptive epidemiology of the Multicenter ACL Revision Study (MARS)
cohort. American Journal of Sports Medicine. 2010;38(10):1979-1986.
18) Crawford SN, Waterman BR, Lubowitz JH. Long-Term Failure of Anterior Cruciate Ligament Reconstruction.
Arthroscopy 2013; 29(9): 1566-1571

D2) Which aspect(s) of the patient’s status and surgical history should be documented in the
setting of a known or suspected failed ACL Reconstruction?

Consensus answer: The following aspects of the patient’s history should be documented in
the setting of a known or suspected failed ACL Reconstruction: (1) demographics, including
gender/age/BMI; (2) date of previous ACL replacement; (3) previous treatment (including
surgical report, imaging and associated lesions); (4) surgical technique (previous errors); (5)
graft used; (6) graft fixation; (7) timepoint of return to activity/sports; (8) current
ADLs/sporting activities before reinjury; (9) duration of symptoms; (10) pain; (11) swelling;
(12) giving way; (13) history of trauma; (14) mechanism of injury; (15) status of opposite side;
(16) patient expectations.

Agreement: 8.3/9

Grade of recommendation: D
Literature review:
No level I-II studies exist in order to identify which aspects of patient history should be
documented in the setting of known or suspected failed ACL reconstruction. Based on the
available low-level evidence, history is fundamental to diagnosis of the ACL failure,
identification of its etiology and optimization of management planning.

Failures of ACL reconstruction are multifactorial and influenced partly by surgeon-dependent

technical issues [1], and by patient-related factors. Basic non-modifiable demographics
characteristics have been reported to affect the failure rate of ACL reconstruction, such as
young age (usually under 25 years [2]. Some authors found up to 19% failure rates in patients
younger than 18 years [3]) and in male patients [4].
Other patient-specific modifiable characteristics have been considered to affect ACL failure,
in particular related to the type of sport and the timing of return to sport after ACL
reconstruction. Especially young female athletes are at increased risk [17]. Noyes and Barber-
Westin, in a systematic review, reported that 90% of ACL failures occurred in high-risk sports
(pivoting, jumping, landing, cutting) [5], while Beischer et al. reported a 7-fold risk of a second
ACL injury in those returning to sport before 9 months [6]. Similarly, Dekker et al. identified
the time to return to sport as the only predictor of second ACL injuries [3]. In this regard,
Nagelli and Hewett suggested delaying the return to sport for up to 2 years following
reconstruction, particularly in high-risk young athletes [7]. On the other hand, other authors
reported good outcomes and limited failure rates with early return to sport [8,9], before 6
months, even if the biomechanical properties of the graft 6 months after ACL reconstruction
remained unclear. If sport practice itself does not represent a cause of ACL failure, it can be
responsible for a higher chance of traumatic events and knee sprains. Sport practice and level
are thus considered important factors to take into account in the diagnosis and management
of many sport-related injuries and probably should be approached more individually.
The interval between failure or re-rupture after ACL reconstruction is another important
variable and has been investigated, particularly after primary reconstruction. Larger intervals
between ACL rupture and treatment affect the outcomes because of the incidence of meniscal
injuries and overall knee laxity [10-11].
Finally, considering the multiple pathologies associated with multiple ACL failures and
reconstructions, such as meniscal injuries [12], cartilage lesions [13], other ligament ruptures
[14] and OA [15], it is considered important to pay attention to every symptom, including
those not strictly specific to ACL insufficiency, such as multi-planar instabilities, pain, swelling
and locking, in order to tailor adequate treatment for each patient based on possible co-
morbidities.
Most of these aspects were included in the 1995 version of the International Knee
Documentation Committee (IKDC) evaluation form, specifically designed by ESSKA and AOSSM
to document ligament diseases. With regard to patient history, the form included
demographic information, occupation and sport, date and cause of injury, level of activity,
previous surgeries, self-reported knee function and symptoms such as pain, swelling and
giving way, based on the intensity of activity [16]

References:

1) de Sa D, Crum RJ, Rabuck S, et al. The REVision Using Imaging to Guide Staging and Evaluation (REVISE) in ACL
Reconstruction Classification [published online ahead of print, 2019 Sep 30]. J Knee Surg. 2019;10.1055/s-0039-1697902.
doi:10.1055/s-0039-1697902

2) Wiggins AJ, Grandhi RK, Schneider DK, Stanfield D, Webster KE, Myer GD. Risk of Secondary Injury in Younger Athletes
After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. Am J Sports Med.
2016;44(7):1861-1876. doi:10.1177/0363546515621554

3) Dekker TJ, Godin JA, Dale KM, Garrett WE, Taylor DC, Riboh JC. Return to Sport After Pediatric Anterior Cruciate Ligament
Reconstruction and Its Effect on Subsequent Anterior Cruciate Ligament Injury. J Bone Joint Surg Am. 2017;99(11):897-904.
doi:10.2106/JBJS.16.00758

4) 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. doi:10.1177/0363546516651845

5) Barber-Westin S, Noyes FR. One in 5 Athletes Sustain Reinjury Upon Return to High-Risk Sports After ACL Reconstruction:
A Systematic Review in 1239 Athletes Younger Than 20 Years [published online ahead of print, 2020 May 6]. Sports Health.
2020;1941738120912846. doi:10.1177/1941738120912846

6) Beischer S, Gustavsson L, Senorski EH, et al. Young Athletes Who Return to Sport Before 9 Months After Anterior Cruciate
Ligament Reconstruction Have a Rate of New Injury 7 Times That of Those Who Delay Return. J Orthop Sports Phys Ther.
2020;50(2):83-90. doi:10.2519/jospt.2020.9071

7) Nagelli CV, Hewett TE. Should Return to Sport be Delayed Until 2 Years After Anterior Cruciate Ligament Reconstruction?
Biological and Functional Considerations. Sports Med. 2017;47(2):221-232. doi:10.1007/s40279-016-0584-z

8) Waldén M, Hägglund M, Magnusson H, Ekstrand J. ACL injuries in men's professional football: a 15-year prospective
study on time trends and return-to-play rates reveals only 65% of players still play at the top level 3 years after ACL rupture.
Br J Sports Med. 2016;50(12):744-750. doi:10.1136/bjsports-2015-095952

9) Zaffagnini S, Grassi A, Marcheggiani Muccioli GM, et al. Return to sport after anterior cruciate ligament reconstruction in
professional soccer players. Knee. 2014;21(3):731-735. doi:10.1016/[Link].2014.02.005

10) Signorelli C, Filardo G, Bonanzinga T, Grassi A, Zaffagnini S, Marcacci M. ACL rupture and joint laxity progression: a
quantitative in vivo analysis. Knee Surg Sports Traumatol Arthrosc. 2016;24(11):3605-3611. doi:10.1007/s00167-016-4158-2

11) Wasilewski SA, Covall DJ, Cohen S. Effect of surgical timing on recovery and associated injuries after anterior cruciate
ligament reconstruction. Am J Sports Med. 1993;21(3):338-342. doi:10.1177/036354659302100302
12) Trojani C, Sbihi A, Djian P, et al. Causes for failure of ACL reconstruction and influence of meniscectomies after revision.
Knee Surg Sports Traumatol Arthrosc. 2011;19(2):196-201. doi:10.1007/s00167-010-1201-6

13) Chen JL, Allen CR, Stephens TE, et al. 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.
2013;41(7):1571-1578. doi:10.1177/0363546513487980

14) Alm L, Krause M, Frosch KH, Akoto R. Preoperative medial knee instability is an underestimated risk factor for failure of
revision ACL reconstruction [published online ahead of print, 2020 Jul 3]. Knee Surg Sports Traumatol Arthrosc.
2020;10.1007/s00167-020-06133-y. doi:10.1007/s00167-020-06133-y

15) Grassi A, Zaffagnini S, Marcheggiani Muccioli GM, et al. Revision anterior cruciate ligament reconstruction does not
prevent progression in one out of five patients of osteoarthritis: a meta-analysis of prevalence and progression of
osteoarthritis. Journal of ISAKOS: Joint Disorders & Orthopaedic Sports Medicine 2016;1:16-24.

16) Hefti F, Müller W, Jakob RP, Stäubli HU. Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports
Traumatol Arthrosc. 1993;1(3-4):226-234. doi:10.1007/BF01560215

17) Montalvo AM, Schneider DK, Yut L, Webster KE, Beynnon B, Kocher MS, Myer GD. What’s my risk of sustaining an ACL
injury while playing sports? A systematic review with meta- analysis. Br J Sports Med 2019;53:1003–1012.
doi:10.1136/bjsports-2016-096274

D3) Which aspect(s) of the physical examination should be performed/documented in the

setting of a known or suspected failed ACL Reconstruction?

Consensus answer: The following aspects of the physical examination should be

performed/documented in the setting of a known or suspected failed ACL reconstruction, in
comparison with the non-injured leg: (1) assessment of AP and rotatory laxity (e.g. Lachman,
anterior drawer, pivot-shift); (2) assessment of other laxities (e.g. Varus-Valgus, Dial Test,
Posterior Drawer); (3) range of motion; (4) alignment (varus/valgus) including dynamic thrust;
(5) tenderness and meniscus tests; (6) donor site morbidity or other specific pain locations;
(7) swelling; (8) hyperextension (>5°) and generalized hyperlaxity; (9) muscle status (atrophy);
and (10) neurovascular status

Agreement: 8.5/9

Grade of recommendation: D

Literature review:
No high-level studies exist aimed at identifying which aspects of physical examination should
be performed in the setting of known or suspected failed ACL reconstruction. Based on the
available low-level evidence and expert opinion, all the aspects which contribute – together
with patient’s history – to the definition of “failure” and the establishment of an adequate
surgical planning should be assessed.

The mainstay of ligament assessment is manual evaluation through the anterior drawer and
Lachman tests to evaluate antero-posterior laxity. However, the rotatory laxity evaluated with
the pivot-shift is considered fundamental since it better correlates with patient’s clinical
symptoms and subjective instability but is often difficult to perform in the awake patient [1].
It plays a crucial role in the revision ACL setting, especially considering the relevant percentage
of patients with residual pivot-shift after primary ACL reconstruction [2] (usually due to
technical issues). However, significant differences in the grading of the pivot shift test have
been reported between awake and anesthetized patients, regardless of the use of
quantitative instruments during the evaluation, with lower values of both tibial acceleration
and lateral compartment translation in awake patients compared to those under anesthesia
[3]. Moreover, the pivot-shift is the most widely used test to identify antero-lateral laxity,
which has been suggested as a risk factor for Primary and Revision ACL failure [4].
Assessment of varus-valgus laxity and signs of rotatory laxity could identify undiagnosed
concomitant ligament injuries, especially MCL and PLC, which have been proved to contribute
to the failure of primary ACL reconstructions. In fact, Akoto et al. identified medial instability
as a predictor of ACL revision failure, and medial stabilization as a protective factor against
failure [4]. Similarly, Noyes et al. reported the necessity to perform a PLC reconstruction in
29% of ACL revision procedures due to persistent postero-lateral laxity imputed to be
responsible for primary ACL failure [5]. The recognition of such complex laxities is considered
the basis of correct treatment planning.
Considering the multifactorial nature of ACL failures and the broad spectrum of possible
symptoms also due to multiple injuries or previous surgeries, aspects such as possible range
of motion limitations, pain or impairment due to donor site morbidity should be assessed.
Kraeutler et al. reported that it is essential to look for signs and symptoms of indolent
infections, even if this occurs without defining them in detail [6].
Finally, patient-inherent features such as hyperextension or lower-limb malalignment have
been reported to play a role: hyperextension has been proved to be associated with higher
post-operative laxity and inferior patient-reported outcomes in a systematic review
(especially when considering knee hyperextension) [7], while varus malalignment has been
demonstrated to have a two-fold occurrence in a revision setting with respect to primary ACL
reconstruction [8], even if no impact on failure rate has been reported in the case of primary
varus with no medial OA [8]. In this regard, it was suggested to also assess the patient’s gait
and the possible presence of varus thrust [6].
Most of these aspects were included in the 1995 and 2000 versions of the International Knee
Documentation Committee (IKDC) evaluation form. Thus, physical examination included the
documentation of severity of swelling (especially the amount of effusion), passive motion
deficit, ligament examination (Lachman, AP translation, posterior drawer, medial and lateral
joint opening, external rotation test, pivot shift and reverse pivot shift), crepitus and harvest
site pathology [9]. The form also included the “One Leg Hop” test, which was, however,
referred to as a functional assessment and was not included in the calculation of the final
overall IKDC grading.

References:

1) Kocher MS, Steadman JR, Briggs KK, Sterett WI, Hawkins RJ. Relationships between objective assessment of ligament
stability and subjective assessment of symptoms and function after anterior cruciate ligament reconstruction. Am J Sports
Med. 2004;32(3):629-634. doi:10.1177/0363546503261722

2) Grassi A, Ardern CL, Marcheggiani Muccioli GM, Neri MP, Marcacci M, Zaffagnini S. Does revision ACL reconstruction
measure up to primary surgery? A meta-analysis comparing patient-reported and clinician-reported outcomes, and
radiographic results. Br J Sports Med. 2016;50(12):716-724. doi:10.1136/bjsports-2015-094948

3) Lopomo N, Signorelli C, Rahnemai-Azar AA, Raggi F, Hoshino Y, Samuelsson K, Musahl V, Karlsson J, Kuroda R, Zaffagnini
S; PIVOT Study Group. Analysis of the influence of anaesthesia on the clinical and quantitative assessment of the pivot shift:
a multicenter international study. Knee Surg Sports Traumatol Arthrosc. 2017 Oct;25(10):3004-3011.

4) Alm L, Krause M, Frosch KH, Akoto R. Preoperative medial knee instability is an underestimated risk factor for failure of
revision ACL reconstruction [published online ahead of print, 2020 Jul 3]. Knee Surg Sports Traumatol Arthrosc.
2020;10.1007/s00167-020-06133-y. doi:10.1007/s00167-020-06133-y

5) Noyes FR, Barber-Westin SD. Revision anterior cruciate surgery with use of bone-patellar tendon-bone autogenous
grafts. J Bone Joint Surg Am. 2001;83(8):1131-1143. doi:10.2106/00004623-200108000-00001

6) Kraeutler MJ, Welton KL, McCarty EC, Bravman JT. Revision Anterior Cruciate Ligament Reconstruction. J Bone Joint Surg
Am. 2017;99(19):1689-1696. doi:10.2106/JBJS.17.00412

7) Sundemo D, Hamrin Senorski E, Karlsson L, et al. Generalised joint hypermobility increases ACL injury risk and is
associated with inferior outcome after ACL reconstruction: a systematic review. BMJ Open Sport Exerc Med.
2019;5(1):e000620. Published 2019 Nov 10. doi:10.1136/bmjsem-2019-000620
8) Won HH, Chang CB, Je MS, Chang MJ, Kim TK. Coronal limb alignment and indications for high tibial osteotomy in
patients undergoing revision ACL reconstruction. Clin Orthop Relat Res. 2013;471(11):3504-3511. doi:10.1007/s11999-013-
3185-2

9) Hefti F, Müller W, Jakob RP, Stäubli HU. Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports
Traumatol Arthrosc. 1993;1(3-4):226-234. doi:10.1007/BF01560215

D4) What is the role of hyperextension in ACL Revisions?

Consensus answer:
Knee hyperextension regardless the cause, is a risk factor for ACL reconstruction failure. The
cut-off value is still under debate, but recent multicenter studies (MARS group) showed that
more than 5° is a risk factor for failure. Patients’ expectations should be managed accordingly.
The surgical strategy may change according to further risk factors.

Agreement: 7.7/9

Grade of recommendation: C

Literature review:
Knee hyperextension can be found on both sides due to generalized hyperlaxity or on the
index side due to ligamentous/capsular injuries or posttraumatic bone deformities.
Knee hyperlaxity can lead to an increased risk of failure in ACL reconstruction: it is correlated
with noncontact ACL injuries1-2 and excessive knee joint laxity after ACL reconstruction may
increase the risk of another graft failure3.
In patients with knee hyperextension, the graft suffers increased stress compared to grafts in
patients with normal joint laxity. This may be due to the absence of tautly stretched ligaments
and tendons, which stabilize the knee, absorbing the ground reaction forces2.
Moreover, in patients with excessive hyperextension, the reconstructed graft can create an
impingement against the intercondylar roof, which may lead to a deterioration of the graft or
re-rupture.
Therefore, an ACL reconstruction in these patients should be undertaken with caution.
Patients with ligamentous hyperlaxity represent a known risk group for both primary ACL
injury and failure after reconstruction.
The MARS study4 showed that passive extension of more than 5° is an important predictor of
failure of ACL revision surgery. Guimaraes et al., in a cohort study of patients who had primary
ACL reconstruction with hamstring tendon autograft, reported that patients with more than
5° of hyperextension, compared to the contralateral knee, had a higher failure rate than
patients with less than this value5. A case control study showed that passive anteroposterior
tibiofemoral laxity and passive knee hyperextension may contribute to increased ACL injury
risk6. Helito et al.7 reported that patients with ligamentous hyperlaxity should receive both
ACL and anterolateral ligament (ALL) reconstruction in order to reduce the likelihood of
failure, due to the improved anteroposterior and rotation stability compared with isolated
ACL reconstruction. A study by Larson et al.8 showed a significant increase in the risk of failure
after ACL reconstruction in patients with generalized hyperlaxity. More than one-third (34.1%)
of the patients categorized as hyperlax sustained an ACL graft injury or developed excessive
graft laxity in comparison with 12.0% of those without hypermobility at a mean 6-year follow-
up. In this study graft failure rates were higher and inferior subjective outcomes were
observed after ACL reconstruction in patients with hypermobility.

References:
1) Ramesh R, Von Arx O, Azzopardi T, et al. The risk of anterior cruciate ligament rupture with generalised joint
laxity. Journal of Bone and Joint Surgery. Br 2005;87(6):800–803.
2) Kim SJ, Kim TE, Lee DH, et al. Anterior cruciate ligament reconstruction in patients who have excessive joint laxity.
Journal of Bone and Joint Surgery. Am 2008;90(4): 735–741.
3) Whitehead TS. Failure of Anterior Cruciate Ligament Reconstruction. Clinics in Sports Medicine. 2013
Jan;32(1):177-204.
4) 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. American Journal of Sports
Medicine.2018;46: 2836-2841.
5) Guimarães TM, Giglio PN, Sobrado MF, Bonadio MB, Gobbi RG, Pécora JR, Helito CP. Knee Hyperextension
Greater Than 5° Is a Risk Factor for Failure in ACL Reconstruction Using Hamstring Graft. Orthop J Sports Med.
2021 Nov 17;9(11):23259671211056325. doi: 10.1177/23259671211056325.
6) Myer GD, Ford KR, Paterno MV, et al. The effects of generalized joint laxity on risk of anterior cruciate ligament
injury in young female athletes. American Journal of Sports Medicine. 2008;36(6):1073–1080.
7) Helito CP, Sobrado MF, Giglio PN, et al..Combined Reconstruction of the Anterolateral Ligament in Patients With
Anterior Cruciate Ligament Injury and Ligamentous Hyperlaxity Leads to Better Clinical Stability and a Lower
Failure Rate Than Isolated Anterior Cruciate Ligament Reconstruction. Arthroscopy. 2019 Sep;35(9):2648-2654.
8) Larson CM, Bedi A, Dietrich ME, et al. Generalized hypermobility, knee hyperextension, and outcomes after
anterior cruciate ligament reconstruction: Prospective, case-control study with mean 6 years follow-up.
Arthroscopy. 2017;33:1852-1858.
D5) Are instrumental devices helpful to evaluate knee laxity in the setting of a known or
suspected failed ACL Reconstruction?

Consensus answer:
The use of devices does not replace careful manual evaluation and clinical history taking.
However, arthrometers, Rolimeters, accelerometers, image-based and electromagnetic
systems are helpful to quantify laxity, especially in unclear cases or research settings.

Agreement: 8.2/9

Grade of recommendation: C

Literature review:
The degree of laxity that defines graft failure is not universally recognized, according to the
International Knee Documentation Committee (IKDC) evaluation form. The anterior drawer
test, Lachman test, and pivot shift test laxity can be graded as normal, nearly normal,
abnormal, and severely abnormal, although the limitation of these tests is their subjective
nature. Usually IKDC “B” is considered “nearly normal” and an acceptable outcome for
patients treated for ALCR1.
The assessment of knee laxity is a crucial step in ACL reconstruction and physical exam
maneuvers depend on a variety of factors, including clinical experience, patient relaxation and
patient hyperlaxity. In addition, MRI is a fundamental examination but while it can diagnose a
graft rupture it can only evaluate knee instability by indirect signs. Arthrometers are devices
designed to apply reproducible force to the joint, allowing measurement and quantification
of the resulting anterior translation.
According to the literature these devices are easy to use, allowing a rapid and reproducible
measurement, and guaranteeing greater objectivity when compared with simple manual
testing.
Multiple devices have been developed, with testing techniques that differ somewhat for each
device.
The most commonly used arthrometers was the KT-1000 Knee Ligament Arthrometer
(MEDmetric Corp, San Diego, CA, USA), which was introduced in 1982 and first reported in
1985; the KT-2000, which adds a two-dimensional display that can produce a force-
displacement curve; the GNRB (Genourob, Laval, France), first documented in 2009 and
frequently cited in the arthrometry literature, especially in the past 3 years; the Rolimeter
(Aircast Europa, Neubeuern, Germany); the Genucom Knee Analysis System (FARO Medical
Technologies Inc, Montreal, Canada); the Stryker Knee Laxity Tester (Stryker, Kalamazoo, MI,
USA); and the Vermont Knee Laxity Device (VKLD) 2,3.
The KT-1000 was the most commonly used arthrometer worldwide; it quantifies the degree
of antero-posterior (AP) tibial-femoral displacement. A side-to-side (STS) distance greater of
than 5 mm6-9 is considered to represent graft failure; however, others believe an STS
difference of 3 mm4,5 classifies as graft failure. As reported by Wiertsema et al., over the past
two decades some authors believe that STS distance should not be over 3 mm. While clinical
tests are easier to perform (Lachman test, drawer tests), the KT-1000 arthrometer is reported
to more precisely quantify the amount of AP laxity.
Kamath et al.10, in a systematic review of STS difference in KT 1000 measurements, reported
1.0 to 2.5mm displacement after ACL revision surgery using autografts, which is similar to the
results after primary reconstruction. Roham et al.2 reported that laximetry is a useful
technique in clinical practice, but the validity measures of these methods vary, depending on
the examiner. The KT series of devices is the current gold standard for quantifying AP laxity.
However, Wiertsema et al.4 reported that the reliability of the KT1000 measurements is
inadequate, whereas the Lachman test was found to be reliable in diagnosing ACL ruptures,
although it should be carried out by experienced examiners. Goodwillie et al.11 noted that a
postoperative laxity greater than 5 mm STS difference as measured using a KT-1000
arthrometer did not show worse clinical outcome scores at long-term follow-up in a group of
171 consecutive patients who had undergone a transtibial bone–patellar tendon–bone ACL
reconstruction. 50 out of 53 arthroscopically verified complete ACL tears were preoperatively
diagnosed with KT1000.12

References:
1) Rahnemai-Azar AA, Naendrup JH, Soni A, Olsen A, Zlotnicki J, Musah V. Knee Instability Scores for ACL
Reconstruction. Current Reviews in Musculoskeletal Medicine. 2016 Jun; 9(2): 170–177
2) Rohman EM, Macalena JA, Anterior cruciate ligament assessment using arthrometry and stress imaging.
Current Reviews in Musculoskeletal Medicine. 2016 Jun;9(2):130-138.
3) Klasan A, Putnis SE, Kandhari V, Oshima T, Fritsch AB, Parker DA. Healthy knee KT1000 measurements of anterior
tibial translation have significant variation. Knee Surgery, Sports Traumatology, Arthroscopy. 2020 Jul;28(7):2177-
2183.
4) Wiertsema SH, van Hooff HJA, Migchelsen LAA, Steultjens MPM. Reliability of the KT1000 arthrometer and the
Lachman test in patients with an ACL rupture. Knee. 2008 Mar;15(2):107-10.
5) WeilerA, SchmelingA, Stohr I,etal. Primary versus single-stage revision anterior cruciate ligament reconstruction
using autologous hamstring tendon grafts: a prospective matched-group analysis. American Journal of Sports
Medicine. 2007;35(10):1643–52.
6) Diamantopoulos AP, Lorbach O, Paessler HH. Anterior cruciate ligament revision reconstruction: results in 107
patients. American Journal of Sports Medicine. 2008;36(5):851–60.
7) Ahn JH, Lee YS, Ha HC. Comparison of revision surgery with primary anterior cruciate ligament reconstruction and
outcome of revision surgery between different graft materials. American Journal of Sports Medicine.
2008;36(10):1889–95.
8) Cristiani R, Sarakatsianos V, Engström B, Samuelsson K, Forss- blad M, Stålman A (2019) Increased knee laxity with
hamstring tendon autograft compared to patellar tendon autograft: a cohort study of 5462 patients with primary
anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy.27:381–388
9) Benner RW, Shelbourne KD, Gray T (2016) The degree of knee extension does not affect postoperative stability or
subsequent graft tear rate after anterior cruciate ligament reconstruction with patellar tendon autograft.
American Journal of Sports Medicine.44:844–849.
10) Kamath GV, Redfern JC, Greis PE, Burk RT. Revision Anterior Cruciate Ligament Reconstruction. The American
Journal of Sports Medicine. 2011 Jan;39(1):199-217.
11) Goodwillie AD, Shah SS, McHugh MP, Nicholas SJ, The Effect of Postoperative KT-1000 Arthrometer Score on
Long-Term Outcome After Anterior Cruciate Ligament Reconstruction. American Journal of Sports Medicine. 2017
Jun;45(7):1522-1528.
12) Daniel DM, Stone ML, Sachs R, Malcom L. Instrumented measurement of anterior knee laxity in patients with
acute anterior cruciate ligament disruption. Am J Sports Med. 1985 Nov-Dec;13(6):401-7. doi:
10.1177/036354658501300607.

D6) Which radiographic/imaging studies should be used to evaluate a known or suspected

failed ACL Reconstruction?

Consensus answer: Weight-bearing anteroposterior (AP) and lateral x-rays (superimposed

posterior condyles, preferably in monopodal stance), with at least 15cm of proximal tibia
visible, as well as MRI (without contrast agent) should be used in every case of suspected ACL
reconstruction failure. Parameters assessed on x-ray include joint narrowing, patellar height,
tibial slope, static anterior tibial translation, tunnel placement and widening, and retained
hardware. For CT scans, see D7. For MRI parameters, see D8.

Agreement: 8.7/9

Grade of recommendation: D

Literature review:
The literature review of D6 has been performed in common with D7 since both questions look
for evidence from radiographic/imaging studies to evaluate known or suspected failed ACL
Reconstruction.
D7) Which additional radiographic/imaging studies can be used to evaluate a known or
suspected failed ACL Reconstruction?

Consensus answer: Based on patient history, symptoms, physical evaluation and results of
initial radiological assessment, further studies can be used:
- Long weight bearing radiographs can be used to measure lower limb axes in the case of
suspected knee malalignment and/or unicompartimental OA.
- Lateral long leg radiographs can be used when there is suspicion of extraarticular tibial
deformity (tibial bowing), to accurately measure the tibial slope.
- CT scan is the most reliable method to assess tunnel widening and osteolysis, but due to
costs and radiation exposure, should be used only if there is concern about tunnel widening
and osteolysis, or if it is not possible to properly identify tunnel placement. 3D CT might be of
additional value.
- Flexed knee postero-anterior weight bearing radiographs (Schuss or Rosenberg) can be
used to increase the sensitivity of standard x-rays in order to document joint space narrowing
- Axial view radiographs can be used to document the amount PF OA and its progression
- Stress radiographs (bilateral) can be used to quantify the amount of laxity, or in cases of
chronic multidirectional laxity, to quantify the main directions of laxity.
Detailed explanation of when and how to use radiological studies is provided in the following
dedicated questions.

Agreement: 8.5/9

Grade of recommendation: D

Literature review:
Based on the available evidence, a variety of radiographic exams have been suggested to be
useful in the diagnosis and management of known or suspected failure ACL reconstruction.
Kraeuteler et al. [1], in a recent (2017) review, reported that initial radiographic series should
include standing anteroposterior radiographs at 0°, lateral radiographs in full extension,
Rosenberg views, and patellofemoral axial views. Long weight-bearing radiographs of both
lower extremities to include the femoral heads and ankle joints should be obtained if
malalignment is a concern. They also reported that varus-valgus and/or lateral stress views (in
20-30° flexion) can objectively evaluate the integrity of the ligamentous structures about the
knee, but without specifying the indications [2]. MRI was considered important to provide
critical information about the primary graft, location, orientation, and diameter of the existing
bone tunnels, as well as information about the integrity of the other ligamentous structures,
cartilage surfaces, menisci and the possible existence of pathognomonic traumatic bone
edema. They considered the CT scan as a second-level exam to be conducted if there is
concern about tunnel widening and osteolysis on radiographic or MR imaging [1, 2]. However,
each imaging serves a specific purpose.

Criteria for correct AP and lateral x-rays:

For multiple parameter assessment with the purpose of diagnosis and pre-operative planning,
standard antero-posterior radiographs should be performed with the patient in a monopodal
stance, with an extended knee and the radiography directed perpendicularly to the coronal
plane; the femoral and tibial condyles should be symmetrical, the head of the fibula slightly
superimposed to the lateral tibial condyle and showing the femorotibial joint space correctly.
The lateral radiograph should be performed with patient in a monopodal stance, with
superimposed femoral condyles and including at least 15 cm of proximal tibia, especially if
slope assessment is required. Lateral radiographs can be made in extension, which has the
advantage of evaluating the relationship of the extension angle of the knee and the roof angle
(Blumensaat line), which is helpful in evaluating “unforgiving knees” at risk of graft
impingement, as is the case in hyperextension. In these cases the tibial tunnel must be slightly
more posterior [3-5]. Lateral radiographs in 20-30° of flexion allow the measurement of static
anterior tibial translation. The position of the tibia in respect to the femoral condyles under
axial compression during monopodal stance has been considered a useful parameter for pre-
and post-operative assessment.
Dejour et al. reported a higher static anterior translation in patients with increased posterior
tibial slope and partial medial meniscectomy [6-7], while other authors also reported a
correlation with longer time from ACL injury to reconstruction [8-9]. Higher lateral tibial
plateau subluxation has been reported in multifailure ACLR when compared with first ACL
revision according to MRI [10] and weight-bearing radiographs [11]. Usually, studies that
assessed the anterior tibial subluxation on lateral radiographs reported performing the exam
on weightbearing monopodal stance; if from one side the single or double leg weightbearing
have been reported to increase the varus deformity on the coronal plane [12], there is
however no clinical evidence of altering the anterior subluxation on sagittal plane. Thus, the
monopodal stance during lateral radiographs is recommended, if possible, but not mandatory.
A particular mention is reserved for lateral radiographs, due to the role of posterior tibial
slope. In the literature it is not possible to find a clear indication of when to perform long-leg
lateral radiographs. Independently from different measurement reliabilities (which will be
discussed in the question dedicated to slope assessment), in the two available studies on ACL
revision and slope-correcting deflexion osteotomy, long-leg lateral radiographs were obtained
only by Sonnery-Cottet et al. [13], while Dejour et al. [14] relied on knee true lateral
radiographs obtained under fluoroscopic control.

Long weightbearing radiographs

Regarding the use of long weightbearing radiographs, Borphy et al. reported that among 1200
patients included in the Multicenter Revision ACL Study (MARS) only 246 (20.5%) had bilateral
weightbearing long-leg alignment films taken just before their revision surgery. They reported
that although these films had been recommended for all patients enrolled in the MARS study,
they were not required and were only collected if surgeons used them as a standard of care
[15]. Considering the higher chance of meeting the general indications of HTO in patients with
failed ACL reconstruction compared to patients undergoing primary ACL reconstruction [16],
it is suggested to assess limb alignment through long weightbearing radiographs in the case
of suspect knee malalignment and/or unicompartmental OA [See D10 for specific literature
search].

CT scan
Kosy and Mandalia [17], in a recent systematic review, analyzed the different methods for
tunnel placement assessment and reported that CT is advantageous when tunnel placement
is planned for revision surgery (and if there are anticipated potential conflicts with existing
tunnels) and in assessing the shape of the tunnel aperture created or tunnel widening, using
serial scans [See D12 and D13 for specific literature search]. Marchant et al. [18] in a
comparative study of different imaging methods, supported the use of CT scans for the
evaluation of bone tunnels in patients with tunnel widening, regardless of plain radiograph
quality. With regard to clinical practice, in a recent clinical study that aimed to correlate the
outcomes of ACL revision with tunnel enlargement (<12 mm or >12 mm), Yoon et al. [19]
performed only radiographic tunnel assessment. Franceschi et al. [20], evaluating the
outcome of 2-stage ACL revision, used only radiographs and MRI pre-operatively, while CT
scanning was reserved for the evaluation 3 months after tunnel grafting. In contrast, Mitchell
et al. [21], comparing the outcome of 1-stage and 2-stage ACL revisions, reported that each
patient underwent serial measurements of the previous reconstruction tunnel diameters in
several sequences of plain radiographs, MRI and CT. A limit of these studies was that,
considering the length of follow-up and year of publication, patients were treated 10 years
ago or more.

Flexed knee postero-anterior weightbearing radiographs

With regard to the use of radiographs with a flexed knee (Schuss and Rosenberg view), these
have been suggested in the preoperative planning stage in the Manual “Revision ACL
Reconstruction” [2] and by Krautler et al. [1], because of their higher sensitivity in detecting
joint space narrowing compared to standard AP radiographs with an extended knee [see D15
for specific literature search]. However, no studies were found regarding the clinical utility of
such radiographs in the specific context of Revision ACL, rather than for detecting joint space
narrowing.

Axial view radiographs

With regard to patello-femoral axial radiographs, the IKDC Evaluation Form dedicates an item
to the assessment of radiographic PF OA [22], since PF OA is considered a common occurrence
after ACL reconstruction, especially with BPTB autograft [23]. However, in the context of
Revision ACL reconstruction, the role of PF axial radiographs has not been deeply investigated.

Stress radiographs
A 2013 systematic review reported that “the diagnostic accuracy of stress radiography
including the sensitivity, specificity, and positive and negative predictive values varied
considerably depending on the technique and choice of displacement or gapping threshold“
but that “excellent reliability was reported for the diagnosis of anterior cruciate ligament,
posterior cruciate ligament, varus, and valgus knee injuries“. The authors were not able to
make specific recommendations with regard to the best stress radiography technique for the
diagnosis of knee ligament injury and stated that no gold standard for a specific stress
radiographic technique or the magnitude of force applied during testing was established for
assessing anterior, posterior, varus, and valgus knee stability. However, they recognized the
utility of stress radiography in offering an objective, quantifiable, non-invasive, and retrievable
record that can be used to augment the diagnosis of knee ligament injuries [See D14 for
specific literature search] [24]

Considering the large variety of possible radiological exams for assessing patients with known
or suspected failure of ACL reconstruction, a case-by-case approach is suggested based on the
patient’s history and physical evaluation, in order to minimize costs and radiation exposure.

References:

1) Kraeutler MJ, Welton KL, McCarty EC, Bravman JT. Revision Anterior Cruciate Ligament Reconstruction. J Bone Joint Surg
Am. 2017;99(19):1689-1696. doi:10.2106/JBJS.17.00412

2) Marx RG. Revision ACL Reconstruction: Indications and Techniques. Springer 2014

3) Howell SM, Barad SJ (1995) Knee extension and its relation-ship to the slope of the intercondylar roof. Implications for
positioning the tibial tunnel in anterior cruciate ligament recon-structions. Am J Sports Med 23:288–294

4) Howell SM, Taylor MA (1993) Failure of reconstruction of the anterior cruciate ligament due to impingement by the
intercon-dylar roof. J Bone Joint Surg Am 75:1044–1055

5) Schützenberger S, Grabner S, Schallmayer D, Kontic D, Keller F, Fialka C. The risk of graft impingement still exists in
modern ACL surgery and correlates with degenerative MRI signal changes. Knee Surg Sports Traumatol Arthrosc. 2020 Oct
3. doi: 10.1007/s00167-020-06300-1. Epub ahead of print. PMID: 33009942.

6) Dejour D, Pungitore M, Valluy J, Nover L, Saffarini M, Demey G. Tibial slope and medial meniscectomy significantly
influence short-term knee laxity following ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2019 Nov;27(11):3481-
3489. doi: 10.1007/s00167-019-05435-0. Epub 2019 Feb 26. PMID: 30809722.

7) Dejour D, Pungitore M, Valluy J, Nover L, Saffarini M, Demey G. Preoperative laxity in ACL-deficient knees increases with
posterior tibial slope and medial meniscal tears. Knee Surg Sports Traumatol Arthrosc. 2019 Feb;27(2):564-572. doi:
10.1007/s00167-018-5180-3. Epub 2018 Sep 29. PMID: 30269166.

8) Mishima S, Takahashi S, Kondo S, Ishiguro N. Anterior tibial subluxation in anterior cruciate ligament-deficient knees:
quantification using magnetic resonance imaging. Arthroscopy. 2005 Oct;21(10):1193-1196.

9) Nishida K, Matsushita T, Araki D, Sasaki H, Tanaka T, Hoshino Y, Kanzaki N, Matsumoto T, Nagamune K, Niikura T,
Kurosaka M, Kuroda R. Analysis of anterior tibial subluxation to the femur at maximum extension in anterior cruciate
ligament-deficient knees. J Orthop Surg (Hong Kong). 2019 Jan-Apr;27(1):2309499019833606.
10) Grassi A, Macchiarola L, Urrizola Barrientos F, Zicaro JP, Costa Paz M, Adravanti P, Dini F, Zaffagnini S. Steep Posterior
Tibial Slope, Anterior Tibial Subluxation, Deep Posterior Lateral Femoral Condyle, and Meniscal Deficiency Are Common
Findings in Multiple Anterior Cruciate Ligament Failures: An MRI Case-Control Study. Am J Sports Med. 2019 Feb;47(2):285-
295.

11) Macchiarola L, Jacquet C, Dor J, Zaffagnini S, Mouton C, Seil R. Side-to-side anterior tibial translation on monopodal
weightbearing radiographs as a sign of knee decompensation in ACL-deficient knees. Knee Surg Sports Traumatol Arthrosc.
2021 Aug 30. doi: 10.1007/s00167-021-06719-0. Epub ahead of print. PMID: 34459934.

12) Bardot, LP., Micicoi, G., Favreau, H. et al. Global varus malalignment increase from double-leg to single-leg stance due
to intra-articular changes. Knee Surg Sports Traumatol Arthrosc 30, 715–720 (2022). [Link]
06446-6

13) Sonnery-Cottet B, Mogos S, Thaunat M, et al. Proximal Tibial Anterior Closing Wedge Osteotomy in Repeat Revision of
Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2014;42(8):1873-1880.

14) Dejour D, Saffarini M, Demey G, Baverel L. Tibial slope correction combined with second revision ACL produces good
knee stability and prevents graft rupture. Knee Surg Sports Traumatol Arthrosc. 2015;23(10):2846-2852.

15) Brophy RH, Haas AK, Huston LJ, Nwosu SK; MARS Group, Wright RW. Association of Meniscal Status, Lower Extremity
Alignment, and Body Mass Index With Chondrosis at Revision Anterior Cruciate Ligament Reconstruction. Am J Sports Med.
2015;43(7):1616-1622. doi:10.1177/0363546515578838

16) Won HH, Chang CB, Je MS, Chang MJ, Kim TK. Coronal limb alignment and indications for high tibial osteotomy in
patients undergoing revision ACL reconstruction. Clin Orthop Relat Res. 2013;471(11):3504-3511. doi:10.1007/s11999-013-
3185-2

17) Kosy JD, Mandalia VI. Plain radiographs can be used for routine assessment of ACL reconstruction tunnel position with
three-dimensional imaging reserved for research and revision surgery. Knee Surg Sports Traumatol Arthrosc.
2018;26(2):534-549. doi:10.1007/s00167-017-4462-5

18) Marchant MH Jr, Willimon SC, Vinson E, Pietrobon R, Garrett WE, Higgins LD. 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):1059-1064. doi:10.1007/s00167-009-0952-4

19) Yoon KH, Kim JS, Park SY, Park SE. One-Stage Revision Anterior Cruciate Ligament Reconstruction: Results According to
Preoperative Bone Tunnel Diameter: Five to Fifteen-Year Follow-up. J Bone Joint Surg Am. 2018;100(12):993-1000.

20) Franceschi F, Papalia R, Del Buono A, et al. Two-stage procedure in anterior cruciate ligament revision surgery: a five-
year follow-up prospective study. Int Orthop. 2013;37(7):1369-1374.

21) Mitchell JJ, Chahla J, Dean CS, Cinque M, Matheny LM, LaPrade RF. Outcomes After 1-Stage Versus 2-Stage Revision
Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2017;45(8):1790-1798. doi:10.1177/0363546517698684

22) Hefti F, Müller W, Jakob RP, Stäubli HU. Evaluation of knee ligament injuries with the IKDC form. Knee Surg Sports
Traumatol Arthrosc. 1993;1(3-4):226-234. doi:10.1007/BF01560215

23) Huang W, Ong TY, Fu SC, Yung SH. Prevalence of patellofemoral joint osteoarthritis after anterior cruciate ligament
injury and associated risk factors: A systematic review. J Orthop Translat. 2019 Aug 6;22:14-25. doi:
10.1016/[Link].2019.07.004. PMID: 32440495; PMCID: PMC7231960.

24) James EW, Williams BT, LaPrade RF. Stress radiography for the diagnosis of knee ligament injuries: a systematic review.
Clin Orthop Relat Res. 2014 Sep;472(9):2644-57. doi: 10.1007/s11999-014-3470-8. PMID: 24504647; PMCID: PMC4117881.

D8) Can MRI assess the ACL graft status in the setting of a known or suspected failed ACL
Reconstruction?
Consensus answer: MRI for the diagnosis of an ACL graft tear is limited (sensitivity 60%,
specificity 87%). However, graft functionality can be assessed by indirect signs, such as
anterior tibial translation or angulation of the PCL and typical bone bruise patterns. Clinical
evaluation is still mandatory to assess graft integrity and functionality.

Agreement: 8.2/9

Grade of recommendation: C

Literature review:
The evidence on the optimal method for assessing graft status in the setting of known or
suspected ACL reconstruction is limited. MRI is universally accepted as the best non-invasive
method to assess the graft after ACL reconstruction; however, different methods of
measurement have been proposed and no gold standard exists; moreover, the clinical
relevance is controversial [1-2].

For assessing graft integrity, the performance of MRI was tested in a series of 50 revision ACL
reconstructions with a graft lesion confirmed by arthroscopy as diagnostic standard. The graft
was reported to be intact on MRI evaluation in 24% of cases. The discordance between MRI
and clinical evaluation, and between MRI and arthroscopic evaluation was 52% and 44%
respectively, especially in the cases of an insidious-onset mechanism of injury [3]. With
arthroscopic evaluation as the diagnostic standard, the sensitivity of MRI to diagnose an ACL
graft tear was 60%, and specificity was 87%. The authors concluded that caution should be
used when evaluating a failed ACL graft with MRI, especially in the absence of an acute
mechanism of injury, as it may be unreliable and inconsistent [3].

Regarding graft signal, a recent systematic review of 34 studies assessing graft signal intensity
with MRI concluded that the MRI protocols (including sequence type, acquisition parameters,
coil design, and field strength) and methods used for evaluating the ACL graft signal intensity
differed widely across the studies, and that the wide variety of scan protocols and image
assessment techniques impedes comparison of signal intensity between successive scans and
between independent studies [2]. MRI qualitative (scores) [4-6] and quantitative (signal-to-
noise quotient; SNQ) [6] methods have been proposed to assess graft status [2,7]. However,
the role of MRI in monitoring and predicting outcomes after ACL surgery remains uncertain.
Only seven studies examined the correlation between MRI findings and clinical outcomes after
ACL surgery [2]. Overall, the T2-weighted graft signal was not reliable and did not predict
clinical or functional outcomes after ACL reconstruction at both early and long-term follow-
up. Biercevicz et al. [8] found that only the combined parameters of graft volume and median
graft SI derived from T1-weighted 3D Gradiant Recalled Echo (GRE)-MRI had the ability to
predict clinical or in vivo outcomes in patients at 3- and 5-year follow-up after ACL
reconstruction. Moreover, even if technical and biological aspects such as graft types, graft
position, insertion-preserved vs detached hamstring graft, navigated vs manual surgery, and
minimal debridement vs conventional clearance of the intercondylar notch exhibited
differences in graft signal intensity at follow-up, similar final clinical outcomes were reported
[2].

Indirect MRI signs for ACL insufficiency

Apart from graft structural integrity, MRI can be helpful to identify signs of ACL insufficiency.
Bone Bruise: The presence of bone bruises, especially on the lateral tibio-femoral
compartment, has been considered a reliable radiological sign of traumatic ACL rupture;
therefore, their presence has been considered useful in the diagnosis of ACL injury and the
understanding of rupture mechanisms [9-11].
Anterior tibial translation (ATT): The ATT with respect to the posterior femoral condyles has
been reported to be increased in patients with ACL injury compared to those with intact ACL;
moreover, the maximum amount of translation has been reported in patients with failed ACL
reconstruction or multiple failures [12].
PCL buckling: Finally, a hyper-buckled PCL (defined as a PCL with vertical straightening of the
mid-distal fibers at MRI) is suggested to be present in ACL deficient knees: although Van Dyck
et al. [13] reported its presence in only 4/97 (4%) patients with ACL injury, it was noted only
in patients with complete ruptures.

References:
1) Grassi A, Bailey JR, Signorelli C, et al. Magnetic resonance imaging after anterior cruciate ligament reconstruction: A
practical guide. World J Orthop. 2016;7(10):638-649. Published 2016 Oct 18. doi:10.5312/wjo.v7.i10.638
2) Van Dyck P, Zazulia K, Smekens C, Heusdens CHW, Janssens T, Sijbers J. Assessment of Anterior Cruciate Ligament Graft
Maturity With Conventional Magnetic Resonance Imaging: A Systematic Literature Review. Orthop J Sports Med.
2019;7(6):2325967119849012. Published 2019 Jun 3. doi:10.1177/2325967119849012

3) Waltz RA, Solomon DJ, Provencher MT. A Radiographic Assessment of Failed Anterior Cruciate Ligament Reconstruction:
Can Magnetic Resonance Imaging Predict Graft Integrity?. Am J Sports Med. 2014;42(7):1652-1660.
doi:10.1177/0363546514532335

4) Howell SM, Berns GS, Farley TE. Unimpinged and impinged anterior cruciate ligament grafts: MR signal intensity
measurements. Radiology. 1991;179(3):639-643. doi:10.1148/radiology.179.3.2027966

5) Figueroa D, Melean P, Calvo R, et al. Magnetic resonance imaging evaluation of the integration and maturation of
semitendinosus-gracilis graft in anterior cruciate ligament reconstruction using autologous platelet
concentrate. Arthroscopy. 2010;26(10):1318-1325. doi:10.1016/[Link].2010.02.010

6) Grassi A, Casali M, Macchiarola L, et al. Hamstring grafts for anterior cruciate ligament reconstruction show better
magnetic resonance features when tibial insertion is preserved [published online ahead of print, 2020 Apr 7]. Knee Surg
Sports Traumatol Arthrosc. 2020;10.1007/s00167-020-05948-z. doi:10.1007/s00167-020-05948-z

7) Weiler A, Peters G, Mäurer J, Unterhauser FN, Südkamp NP. Biomechanical properties and vascularity of an anterior
cruciate ligament graft can be predicted by contrast-enhanced magnetic resonance imaging. A two-year study in sheep. Am
J Sports Med. 2001;29(6):751-761. doi:10.1177/03635465010290061401

8) Biercevicz AM, Akelman MR, Fadale PD, et al. MRI volume and signal intensity of ACL graft predict clinical, functional, and
patient-oriented outcome measures after ACL reconstruction. Am J Sports Med. 2015;43(3):693-699.
doi:10.1177/0363546514561435

9) Grassi A, Agostinone P, Di Paolo S, Zaffagnini S. Letter to the Editor on "Prediction of Knee Kinematics at Time of
Noncontact Anterior Cruciate Ligament Injuries Based on Bone Bruises". Ann Biomed Eng. 2020 Jul 20:1–3. doi:
10.1007/s10439-020-02574-1.

10) Patel SA, Hageman J, Quatman CE, Wordeman SC, Hewett TE. Prevalence and location of bone bruises associated with
anterior cruciate ligament injury and implications for mechanism of injury: a systematic review. Sports Med. 2014
Feb;44(2):281-293. doi: 10.1007/s40279-013-0116-z. PMID: 24158783; PMCID: PMC3946752.

11) Zhang L, Hacke JD, Garrett WE, Liu H, Yu B. Bone Bruises Associated with Anterior Cruciate Ligament Injury as Indicators
of Injury Mechanism: A Systematic Review. Sports Med. 2019 Mar;49(3):453-462. doi: 10.1007/s40279-019-01060-6. PMID:
30689129.

12) Grassi A, Macchiarola L, Urrizola Barrientos F, Zicaro JP, Costa Paz M, Adravanti P, Dini F, Zaffagnini S. Steep Posterior
Tibial Slope, Anterior Tibial Subluxation, Deep Posterior Lateral Femoral Condyle, and Meniscal Deficiency Are Common
Findings in Multiple Anterior Cruciate Ligament Failures: An MRI Case-Control Study. Am J Sports Med. 2019 Feb;47(2):285-
295.

13) Van Dyck P, Gielen JL, Vanhoenacker FM, Wouters K, Dossche L, Parizel PM. Stable or unstable tear of the anterior
cruciate ligament of the knee: an MR diagnosis? Skeletal Radiol. 2012 Mar;41(3):273-280. doi: 10.1007/s00256-011-1169-4.

D9) What additional pathologies and specific features in the setting of known or suspected
failed ACL reconstruction should be assessed by MRI?

Consensus answer: Important aspects to evaluate with MRI in the cases of known or
suspected failed ACL reconstruction are: (1) meniscal status (defects, radial tears, root tears,
ramp tears, longitudinal\bucket handle tears) (grade B); (2) other ligament status (PCL, MCL,
LCL, popliteus) (grade C); (3) extensor apparatus (grade C); (4) cartilage and subchondral status
(grade B); (5) location of bone bruises (grade B); (6) hardware position (depending on
artefacts); (7) tunnel position (see D12/D13); and (8) posterior tibial slope.

Agreement: 8.5/9

Grade of recommendation: B

Literature review:
Menisci, cartilage and subchondral bone lesions are frequently found during an ACL revision:
the rates of concomitant chondral damage at the time of revision reconstruction range from
10% to 70% in published studies1-3. Thomas et al.4 found a much higher rate of meniscal and
chondral lesions in a group of patients treated for ACL revision compared to a group of
patients with primary ACL reconstruction. In addition, Chen et al. 5 encountered significantly
more chondral injuries in the medial compartment during a second ACL revision compared
with a primary reconstruction and first revision surgery. It can therefore be assumed that a
direct effect of continued instability is to predispose the knee to further chondral and meniscal
damage.

Meniscal status
The role of the menisci as secondary anterior stabilizers of the knee is known; however, there
are few papers in the literature correlating meniscal status and graft failure in primary ACL
reconstruction6-7.
Biomechanical studies have underlined the roles of the menisci in knee stability. The medial
meniscus contributes to resisting direct anterior tibial translation and the lateral meniscus is
an important restraint to anterior tibial translation during internal tibial rotation. Parkinson et
al.8 demonstrated that meniscal deficiency is the most significant factor in predicting graft
failure in single-bundle ACL reconstruction. The MARS Group reported9 that patients with
partial lateral meniscectomy and current grade III–IV articular cartilage damage to the
trochlear groove at the time of the revision scored significantly lower on the IKDC, KOOS and
WOMAC questionnaires at the 2-year follow-up than revision ACL reconstruction patients with
other injuries. Anand et al.10 reported that meniscal status at the time of revision did not affect
the return to sport rates. Patients with lesions involving <50% of the thickness of the articular
cartilage at the time of revision were more likely to have returned to their pre-injury level of
sport and had significantly better Marx Activity Scale, Knee injury and Osteoarthritis Outcome
Score-Quality of Life (KOOS-QOL) and International Knee Documentation Committee (IKDC)
scores at the mean 5-year follow-up.
MRI seems to demonstrate moderate accuracy in the diagnosis of ramp lesions in patients
with ACL tear (although considerable heterogeneity in study results) and the surgical repair of
ramp lesions could improve knee laxity and thus possibly leading to better outcomes.25 A
posterior lateral meniscus root tear is a clinical relevant but most likely underrecognized
concomitant injury in patients with a tear of the ACL.26

Other ligament status

There is a lack of literature on associated ligament tears in MRI imaging of an ACL revision.
However, Temponi et al.11 in their retrospective study demonstrated that nearly 20% of
patients with an ACL rupture had some injury to the PLC when evaluated by MRI, and
Medvecky et al.12 reported that early MRI evaluation is important in the assessment of 3-
degree superficial medial collateral ligament (sMCL) sprains and associated posterior oblique
ligament (POL) injuries to rule out associated problematic injuries that may lead to surgical
reconstruction. There is evidence of increased failure of ACL reconstruction with unaddressed
MCL laxity 13.
Willinger et al. 14 reported that a truly ‘isolated’ ACL rupture is uncommon; 67% of them have
a complex medial collateral ligament (MCL) injury, with 62% of these involving the sMCL and
31% the deep medial collateral ligament (dMCL), a higher incidence than reported in previous
studies 15, probably due to a shorter time from injury to MRI assessment.

Extensor apparatus
Emerson et al.16 underline the importance of being familiar with normal post-operative MRI
changes as well as having an understanding of the appearance of each post-operative
complication. Indeed, a rupture of the knee extensor mechanism is a rare complication 17 after
harvesting either the quadriceps or patellar tendon. A quadriceps tendon tear is shown by a
hematoma formation at the superior pole of the patella in the post-operative MRI in
conjunction with patella infera.

Cartilage and subchondral status

The current literature shows that severe chondral damage and meniscal lesions at the time of
ACL revision have a negative effect on the clinical outcome, activity levels and return to sport
rates, despite good results in terms of clinical laxity1,18.

Location of bone bruises

Bone bruises in the setting of known or suspected failed ACL reconstruction could suggest a
traumatic type of failure if present in the posterior lateral tibial plateau and the anterior
portion of the lateral femoral condyle. Posterior medial tibial plateau bone bruising could
indicate possible medial meniscus ramp tear, while patellar and anteromedial tibial bone
bruises could suggest severe trauma. Medial or lateral subchondral bone bruises with cartilage
thinning could indicate a chronic overload or a chronic meniscal root tear. Although magnetic
resonance imaging (MRI) of the injured knee provides critical information about the graft
rupture as well as information about menisci, cartilage surfaces and subchondral bone19, bone
edema in the lateral compartment can indicate whether the rupture was traumatic in
nature20.

Hardware position
Fixation devices can lead to ACL reconstruction failure or be a cause for complications such
as mal-positioning, mobilization and fracture. Unfortunately the hardware position can be an
issue in an ACL MRI evaluation, because metallic devices can cause image artifacts. However,
hardware mobilization, migration or rupture can easily be shown on MRI with specific
software techniques21. Hardware failure in the early postoperative period may lead to the
loss of graft fixation and cause instability; nevertheless, MRI findings of device mobilization
should be correlated with clinical findings of joint instability or pain 22-23.
Once an ACL graft has healed and is firmly integrated, stability may not be compromised, but
hardware mobilization or fractures of fixation hardware components can lead to intra-
articular bodies24.
References:
1) Kamath GV, Redfern JC, Greis PE, Burk RT. Revision Anterior Cruciate Ligament Reconstruction. The American
Journal of Sports Medicine. 2011 Jan;39(1):199-217.
2) Buda R, Ruffilli A, Di Caprio F, et al. Allograft salvage procedure in multiple-revision anterior cruciate ligament
reconstruction. American Journal of Sports Medicine. 2013;41:402-410.
3) Griffith TB, Allen BJ, Levy BA, Stuart MJ, Dahm DL. Outcomes of repeat revision anterior cruciate ligament
reconstruction. American Journal of Sports Medicine. 2013;41:1296-1301.
4) Thomas NP, Kankate R, Wandless F, Pandit H. Revision anterior cruciate ligament reconstruction using a 2-stage
technique with bone grafting of the tibial tunnel. American Journal of Sports Medicine. 2005;33(11):1701-1709.
5) Chen JL, Allen CR, Stephens TE, et al. Differences in mechanisms of failure, intraoperative findings, and surgical
characteristics between single-and multiple-revision ACL reconstructions: a MARS cohort study. American Journal
of Sports Medicine. 2013;41:1571-1578.
6) Robb C, Kempshall P, Getgood A, et al. Meniscal integrity predicts laxity of anterior cruciate ligament
reconstruction. Knee Surgery, Sports, Traumatology Arthroscopy. 2015;23(12):3683-3690.
7) Musahl V, Citak M, O’Loughlin PF, Choi D, Bedi A, Pearle AD. The effect of medial versus lateral meniscectomy on
the stability of the anterior cruciate ligament-deficient knee. American Journal of Sports Medicine.
2010;38(8):1591-1597.
8) Prakinson B, Robb C, Thomas M, Thompson P, Spalding T. Factors That Predict Failure in Anatomic Single-Bundle
Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2017 Jun;45(7):1529-1536.
9) MARS Group, Meniscal and Articular Cartilage Predictors of Clinical Outcome After Revision Anterior Cruciate
Ligament Reconstruction. American Journal of Sports Medicine. 2016 Jul;44(7):1671-1679.
10) Anand BS, Feller JA, Richmond AK, Webster KE. Return-to-sport outcomes after revision anterior cruciate ligament
reconstruction surgery. American Journal of Sports Medicine. 2016 Mar;44(3):580-4. Epub 2015 Dec 15.
11) Temponi EF, de Carvalho Júnior LH, Saithna A, Thaunat M, Sonnery-Cottet B. Incidence and MRI characterization
of the spectrum of posterolateral corner injuries occurring in association with ACL rupture. Skeletal Radiology,
46(8), 1063–1070.
12) Medvecky MJ, Tomaszewski P. Management of Acute Combined ACL-Medial and Posteromedial Instability of the
Knee. Sports Medicine and Arthroscopy Review. 23(2), e7–e14.
13) Alm L, Krause M, Frosch K, Akoto R (2020) Preoperative medial knee instability is an underestimated risk factor for
failure of revi- sion ACL reconstruction. Knee Surgery, Sports Traumatology, Arthrosccopy 28:2458–2467.
14) Willinger L, Balendra G, Pai V, Lee J, Mitchell A, Jones M, Williams A. High incidence of superficial and deep medial
collateral ligament injuries in 'isolated' anterior cruciate ligament ruptures: a long overlooked injury. Knee
Surgery, Sports Traumatology Arthroscopy. 2021 DOI: 10.1997/s00167-021-06514-x
15) Kim SH, Seo HJ, Seo DW, Kim KI, Lee SH (2020) Analysis of risk factors for ramp lesions associated with anterior
cruciate liga- ment injury. American Journal of Sports Medicine 48:1673–1681.
16) Emerson CP, Bernstein JM, Nham F, Barnhill S, Baraga MG, Bogner E, Jose J. Magnetic resonance imaging of the
quadriceps tendon autograft in anterior cruciate ligament reconstruction. Skeletal Radiology (2019) 48:1685–
1696.
17) Pandey V, Madi S, Joseph A, Acharya K. Late quadriceps tendon rupture at the donor site following cruciate
ligament reconstruction using central quadriceps tendon graft. BMJ Case Rep. 2015;2015: bcr2015212621.
18) Webster KE, Feller JA, Kimp A, Devitt BM. Medial meniscal and chondral pathology at the time of revision anterior
cruciate ligament reconstruction results in inferior mid-term patient-reported outcomes. Knee Surgery, Sports
Traumatology, Arthroscopy. 2018 Apr;26(4):1059-1064.
19) Kraeutler MJ, Welton KL, McCarty EC, Bravman JT. Current Concepts Review Revision Anterior Cruciate Ligament
Reconstruction. The Journal of Bone and Joint Surgery. 2017;99:1689-1696.
20) Ahn JH, Lee YS, Chang MJ, Yim HS. Analysis of revision anterior cruciate ligament reconstruction according to the
combined injury, degenerative change, and MRI findings. Knee. 2011 Dec;18(6):382-386. Epub 2010 Dec 24.
21) Grassi A, Bailey JR, Signorelli C, Carbone G, Tchonang Wakam A, Lucidi GA, Zaffagnini S. Magnetic resonance
imaging after anterior cruciate ligament reconstruction: A practical guide. World Journal of Orthopedics. 2016 Oct
18;7(10):638-649.
22) Zappia M, Capasso R, Berritto D, Maggialetti N, Varelli C, D’Agosto G, Martino MT, Carbone M, Brunese L. Anterior
cruciate ligament reconstruction: MR imaging findings. Musculoskeletal Surgery. 2017 Mar;101(Suppl 1):23-35.
23) Studler U, White LM, Naraghi AM, Tomlinson G, Kunz M, Kahn G, Marks P. Anterior cruciate ligament
reconstruction by using bioabsorbable femoral cross pins: MR imaging findings at follow-up and comparison with
clinical findings. Radiology. 255:108–116. doi:10.1148/radiol.09091119.
24) Naraghi A, White LM, MR imaging of cruciate ligaments. Magnetic Resonance Imaging Clinics of North
America. 2014 Nov;22(4):557-80.
25) Moreira J, Almeida M, Lunet N, Gutierres M. Ramp lesions: a systematic review of MRI diagnostic accuracy and
treatment efficacy. J Exp Orthop. 2020 Sep 25;7(1):71. doi: 10.1186/s40634-020-00287-x.
26) Feucht MJ, Salzmann GM, Bode G, Pestka JM, Kühle J, Südkamp NP, Niemeyer P. Posterior root tears of the lateral
meniscus. Knee Surg Sports Traumatol Arthrosc. 2015 Jan;23(1):119-25. doi: 10.1007/s00167-014-2904-x. Epub
2014 Feb 15.
D10) What imaging is recommended to assess lower leg coronal alignment?

Consensus answer: The optimal method to assess lower limb alignment is the measurement
of the mechanical axis either with mechanical femoro-tibial angle or weight bearing line, as
well as mechanical medial proximal tibial angle (mMPTA), mechanical lateral distal femoral
angle (mLDFA) and joint line convergence angle (JCLA), on long leg weightbearing radiographs
(with centered patella).

Agreement: 8.7/9

Grade of recommendation: C

Literature review:
A limited number of studies investigated when and how to assess lower limb alignment in the
setting of Revision ACL reconstruction, and which is the optimal method. Borphy et al.
highlighted the role of lower limb alignment in patients from the Multicenter Revision ACL
Study (MARS). The authors included only 246/1200 patients (20.5%) with bilateral
weightbearing long-leg alignment films taken just before their revision surgery. They reported
that although these films had been recommended for all patients enrolled in the MARS study,
they were not required, and were only collected if surgeons used them as a standard of care.
Measuring the distance from the medial border of the tibial plateau and the mechanical axis,
the authors reported that for every 10% shift in the weightbearing line (WBL) lateral on the
tibial plateau, the risk of medial compartment chondrosis decreased by 9.7%. In contrast,
alignment was not associated with chondrosis in the lateral compartment [1].

In a Level III therapeutic study, Won et al. compared the mechanical tibio-femoral angle, the
weight bearing line (%) and the Kellgren-Lawrence (KL) of 58 Asian patients undergoing
Revision ACL with 116 undergoing primary ACL reconstruction. The authors found that the
revision ACL reconstruction group had more frequent varus malalignment in terms of the
proportion of knees with a mechanical tibiofemoral >5° of varus (19% versus 8%, p=0.029) and
knees with a weightbearing line of less than 25% (22% versus 9%, p=0.011). This group also
showed more frequent high-grade injury of the medial meniscus (34% versus 16%, p=0.007)
and tended to more frequently have more advanced radiographic signs of OA at the medial
tibiofemoral compartment (19% versus 9%, p=0.076). Moreover, the percentage of patients
meeting potential indications for high tibial osteotomy was greater in this group (14% versus
2%, p=0.003), considering as HTO criteria (1) weight loading line less than 5% from the medial
edge of the tibial plateau regardless of any other condition; (2) weight loading line less than
25% plus radiographic OA of KL Grade III or higher at the medial tibiofemoral joint regardless
of meniscal condition; and (3) weight loading line less than 25% plus KL Grade II at the medial
tibiofemoral compartment and after subtotal or total medial meniscectomy. HTO was not
considered in the case of KL grade III or higher at the lateral compartment and/or subtotal or
total lateral meniscectomy. The authors concluded that many patients undergoing revision
ACL surgery may also be reasonable candidates for concurrent high tibial osteotomy to
address concomitant alignment and OA issues in the medial compartment [2]. However, a
meticulous differentiation during clinical examination between instability and medial joint line
pain is crucial.

With regard to the importance of alignment in the context of ACL reconstruction, a

biomechanical study by Van de Pol et al. aimed to assess ACL tension and lateral joint opening,
after recreating a neutral axis, an axis passing through the midpoint of the medial
compartment and an axis passing at the medial margin of the medial compartment. They
reported that the ACL tension was significantly higher with the weightbearing line passing
through the medial border of the medial compartment (53.9 N) compared with its midpoint
(37.9 N) and neutral axis (31 N). Moreover, a significant lateral joint opening (thrust) was
observed only in the most severe varus setting. They concluded that a slight varus alignment
does not yield clinically relevant ACL tensions, while a severe varus alignment, especially with
a varus thrust, can yield high ACL tensions that can be responsible for the failure of an ACL
reconstruction. It is therefore important to rule out a varus thrust by carefully examining
patients [3]. Varus thrust, which is defined as an abrupt worsening of existing varus during the
weightbearing phase of gait, with a return to a reduced varus alignment during the non-
weightbearing (swing) phase, is in fact considered a general indication for HTO even in the
case of no medial OA [2-5].
To investigate the clinical consequences of varus malalignment and primary ACL
reconstruction, Kim et al. (Ref.) retrospectively evaluated 201 primary single-bundle ACL
reconstructions, stratifying them into 4 groups based on the deviation in mm of the
mechanical axis from the center of the joint. With a minimum of 2 years of follow-up, no
differences were reported for the Lachman-Test, Pivot-Shift, Lysholm, IKDC and KT-1000
between those with neutral alignment and varus alignment with the weightbearing line
passing within the medial compartment. In fact, patients with varus thrust, subtotal
meniscectomy and Chondrosis > grade II were excluded from the study. The authors
concluded that if there is no OA in the medial compartment and no varus thrust, HTO is not
indicated in varus knees undergoing ACL reconstruction [6].

Criteria for long weightbearing radiographs

Regarding the technical execution of long-leg weightbearing radiographs, the true AP view is
defined with the knee in forward position with the patella centered on the femoral condyles,
independent of the foot position. In the case of patella dislocation, the knee flexion-extension
axis is used as a reference [7]. It is also suggested to use blocks in the case of limb discrepancies
to adjust length and avoid compensatory knee flexion. A long cassette (130 cm) is also
preferable due to lower magnification [7]. Despite these suggestions, studies with 3D models
reported that the hip-knee-ankle angle in the cases of limb alignments from 9° of varus to 9°
of valgus, does not substantially vary with internal rotation, external rotation or flexion up to
30° [Lukas jud 2019], and the measurement error rarely exceeds 3° [8]. In contrast, other
authors suggested the assessment of fibular overlapping to determine the exact amount of
rotation in order to avoid errors in axis measurements [9,10].
Legend: The Femoro-Tibial Angle (FTA) (green line) is the angle formed by the intersection of
the line connecting the femoral head and the center of the knee, and the line connecting the
center of the knee and the midpoint of the talus surface. The weightbearing line (red line)
connects the center of the femoral head and the midpoint of the talus surface; the amount of
malalignment is measured as the distance from the medial border of the tibial plateau to the
mechanical axis, calculated as % of the whole tibial plateau.
References:

1) Brophy RH, Haas AK, Huston LJ, Nwosu SK; MARS Group, Wright RW. Association of Meniscal Status, Lower Extremity
Alignment, and Body Mass Index With Chondrosis at Revision Anterior Cruciate Ligament Reconstruction. Am J Sports Med.
2015;43(7):1616-1622. doi:10.1177/0363546515578838

2) Won HH, Chang CB, Je MS, Chang MJ, Kim TK. Coronal limb alignment and indications for high tibial osteotomy in
patients undergoing revision ACL reconstruction. Clin Orthop Relat Res. 2013;471(11):3504-3511. doi:10.1007/s11999-013-
3185-2

3) van de Pol GJ, Arnold MP, Verdonschot N, van Kampen A. Varus alignment leads to increased forces in the anterior
cruciate ligament. Am J Sports Med. 2009;37(3):481-487. doi:10.1177/0363546508326715

4) Southam BR, Colosimo AJ, Grawe B. Underappreciated Factors to Consider in Revision Anterior Cruciate Ligament
Reconstruction: A Current Concepts Review. Orthop J Sports Med. 2018;6(1):2325967117751689. Published 2018 Jan 24.
doi:10.1177/2325967117751689

5) Imhoff FB, Comer B, Obopilwe E, Beitzel K, Arciero RA, Mehl JT. Effect of Slope and Varus Correction High Tibial
Osteotomy in the ACL-Deficient and ACL-Reconstructed Knee on Kinematics and ACL Graft Force: A Biomechanical Analysis.
Am J Sports Med. 2021 Feb;49(2):410-416. doi: 10.1177/0363546520976147. Epub 2020 Dec 3. PMID: 33270464.

6) Kim SJ, Moon HK, Chun YM, Chang WH, Kim SG. Is correctional osteotomy crucial in primary varus knees undergoing
anterior cruciate ligament reconstruction?. Clin Orthop Relat Res. 2011;469(5):1421-1426. doi:10.1007/s11999-010-1584-1

7) Paley D. Principles of Deformity Corrections. Springer 2002.

8 ) Jud L, Trache T, Tondelli T, Fürnstahl P, Fucentese SF, Vlachopoulos L. Rotation or flexion alters mechanical leg axis
measurements comparably in patients with different coronal alignment. Knee Surg Sports Traumatol Arthrosc. 2019 Nov 8.
doi: 10.1007/s00167-019-05779-7. Epub ahead of print. PMID: 31705148.

9) Maderbacher G, Matussek J, Greimel F, Grifka J, Schaumburger J, Baier C, Keshmiri A. Lower Limb Malrotation Is
Regularly Present in Long-Leg Radiographs Resulting in Significant Measurement Errors. J Knee Surg. 2019 Jul 29. doi:
10.1055/s-0039-1693668. Epub ahead of print. PMID: 31357220.

10) Maderbacher G, Schaumburger J, Baier C, Zeman F, Springorum HR, Dornia C, Grifka J, Keshmiri A. Predicting knee
rotation by the projection overlap of the proximal fibula and tibia in long-leg radiographs. Knee Surg Sports Traumatol
Arthrosc. 2014 Dec;22(12):2982-2988.

D11) How should Tibial Slope be assessed in the setting of a known or suspected failed ACL
Reconstruction and what is the optimal method?

Consensus answer: In the setting of known or suspected failed ACL Reconstruction, Posterior
Tibial Slope (PTS) should be assessed, but an optimal method has not been universally defined.
It is suggested to measure the medial posterior tibial slope on a lateral view of the proximal
tibia, measuring the angle between the tangent of the medial tibial plateau and the proximal
anatomical tibial axis (normal value 9° ± 3°). The normal value depends on measurement
methods. An angle ≥12° should be considered critical using the described measurement
method. MRI methods can independently measure lateral and medial soft tissue tibial slope,
but should be used with caution for surgical planning due to the high variability of
measurements and the lack of solid evidence.

Agreement: 8.1/9

Grade of recommendation: C

Literature review:
Posterior tibial slope (PTS) has received particular attention in recent years due to the
increasing evidence of its role as risk factor for anterior cruciate ligament (ACL) injury [1], ACL
reconstruction failure and ACL multiple failures [2-8]. The biomechanical rationale is that axial-
loading tasks, such as walking, squatting, and jump landing, produce a vertical shear force
through the tibiofemoral joint that is converted to a slope-related, anteriorly directed tibial
translational force [4-9]. Moreover, a cadaveric model demonstrated that PTS strongly
correlates directly with the amount of graft force experienced by an ACL graft in axially loaded
knees with flexion between 0° and 60°. Thus, a flatter tibial slope has significantly less loading
of ACL grafts, while steeper slopes increase ACL graft loading, supporting their role as risk
factors for ACL graft failures demonstrated clinically [9-10]. Therefore, PTS should be taken
into account when assessing failed ACL reconstruction, to optimize the treatment strategy.
However, there is no consensus on how to measure the PTS and where the critical cutoff may
lie.

Several case-controlled studies used MRI to measure the medial and lateral PTS,
demonstrating higher values on failed ACL reconstructions compared to non-failed ACL
reconstructions [2,4-6,11]. In a retrospective comparative trial of 232 patients with at least 10
years of follow-up, a higher failure rate was reported in patients with medial PTS>5.6° (16.1%
vs 5.1%; p=0.01) and with lateral PTS>3.8° (14.5% vs 4.7%; p=0.01) [11]. However, MRI
measurement is considered demanding, cut-off values varied significantly among studies, and
reliability of measurements was lacking in absolute precision (ICC=0.4276) [12].
The radiographic method is most commonly used to also measure PTS in the assessment of
ACL reconstruction outcomes, even if different measurement methods exist and PTS
magnitude can be dependent on the measurement method [13]. Also in this case,
comparative, prospective and retrospective studies of primary ACL and revision ACL
reconstructions are available [6,7,13,14]. The results seem more homogenous than for MRI.
In fact, Webb et al., in 200 consecutive patients, showed that the odds of further ACL injuries
(either ipsilateral or contralateral) after reconstruction were increased by a factor of 5, to an
incidence of 59%, in those with a posterior tibial slope of ≥12° [8]. The authors measured the
PTS on lateral radiographs, as the angle between a line drawn tangentially to the medial tibial
plateau and a perpendicular line to the proximal anatomical axis of the tibia, which was
determined from a line connecting the mid-cortical diameters of the tibia at a point between
5 cm and 15 cm distal to the knee joint [8]. Using the same measurement method, Salmon et
al. identified a PTS ≥12° as having an Odds Ratio=3 compared to patients with PTS <12°.
Moreover, the ACL survival for adolescents with a PTS≥ 12° was 22% at the 20-year follow-up
[7]. In addition, Ahmed et al. reported that among 11 patients with 3 or more ACL
reconstructions, 64% had a PTS ≥12° [14]. Using the same measurement but a different study
design, through Receiver Operating Characteristics (ROC) analysis, Lee at al. identified PTS
≥12° as the optimal cut-off to predict failure of ACL reconstruction, with a sensitivity of 0.703
and a specificity of 0.344 [15]. Grassi et al. identified the same PTS measurement as a predictor
of contralateral ACL injury in patients aged under 18 years after ACL reconstruction and lateral
plasty in the cases of values ≥12°, but not for failure of ipsilateral primary reconstruction [3].
Su et al. found no significant differences in radiographic PTS with different measurement
methods between patients undergoing primary ACL reconstruction, Revision ACL and patients
with intact ACL [16].

Finally, measurement methods have also been reported with CT [17], but their use in clinical
and research settings in the context of Revision ACL Reconstruction is limited.

A recent study aimed to compare the reliability and variability of PTS according to radiographs,
MRI and CT measurements. The authors reported good reliability (ICC between 0.80-0.90), but
they found a mean difference of up to 5.4° ± 2.8° and 4.9° ± 2.6° between different
measurement methods for the medial and lateral tibial slope, respectively. They concluded
that PTS measurements have a high degree of variability and inaccuracy between imaging
modalities and different measurement methods and that care must be taken when deciding
on indications based on individual modality measurements [17]. Similarly, Dean et al. assessed
the variability of different radiographic measurements. In 140 patients, the authors found that
the measurement of PTS using the anatomic tibial axis was similar if measured on standard
lateral radiographs or in long-leg lateral radiographs. However, a significant difference was
present between the PTS measured using the anatomical axis and the mechanical axis in the
lateral view, with an overestimation of the anatomical axis in respect to the mechanical axis
of at least 2° in 55% of cases. The authors concluded that lateral knee radiographs are
adequate to accurately obtain PTS measurements, and advocated for consistency in the
technique for obtaining PTS measurement by using anatomic axis PTS measurements from
both lateral knee and full-length lateral tibia radiographs in order to accurately and reliably
compare PTS measurements [18]. Similarly, Faschinbauer et al. suggested using expanded
lateral radiographs with more than 10 cm of proximal tibia, since long-leg lateral radiographs
are not always feasible in everyday practice and short radiographs lead both to overestimation
of PTS by nearly 3° and provide less reproducible results [19]. Other measurement methods
have been suggested to have good reliability, such as those using the tibial cortex, but
experimental and clinical evidence are still limited [20].

In clinical practice, only three studies applied a cut-off value of PTS to perform deflexion HTO
in the setting of multiple failures of ACL reconstruction [21-24]. Sonnery-Cottet et al. used a
cut-off of ≥12°, measuring the angle between the tangent to the medial tibial plateau and the
mechanical axis of the leg on a true long-leg lateral radiograph obtained under fluoroscopic
control [21]. Similarly, Dejour et al. also used a cut-off of ≥12°, but this was obtained from
measurement of the angle between the anatomical proximal tibial diaphyseal axis and the
tangent to the most superior points at the anterior and posterior edges of the medial tibial
plateau, on true lateral knee radiographs, without mentioning (or illustrating) the use of long
leg lateral radiographs [22]. Akoto et al. used the same measurement method (anatomical axis
measured at 9 cm and 15 cm from the joint line) and cut-off (≥12°) to indicate 2-stage
deflexion HTO and ACL revision+lateral plasty [23]. It should be noted that most of literature
regarding PTS and its correction is based on studies on European patients. Considering that
PTS values >12° have been reported in Asian patients with no mention of ACL injury [25],
caution should be used when generalizing the normal values and cut-offs [26].

Recommended method for assessing tibial slope on x-rays: The posterior tibial slope is
measured by calculating the angle between the perpendicular to the tibial diaphysis, and the
tangent to the anterior and posterior edges of the medial tibial plateau. The axis of the tibial
diaphysis is obtained by creating a vertical line beginning at the midpoint between the anterior
and posterior tibial cortex, 5 cm distal to the joint line, and ending at the midpoint between
the anterior and posterior tibial cortex, 10-15 cm distal to the joint line.

Legend: The posterior tibial slope can be measured on ‘true lateral view’ radiographs, by
calculating the angle between proximal anatomical axis (red “a” line) and the line tangent to
the anterior and posterior edges of the medial tibial plateau (yellow “b” line). The proximal
anatomical axis was obtained by connecting the midpoints between the anterior and posterior
tibial cortex at 5- and 10-cm distance to the joint line.

References
1) Todd MS, Lalliss S, Garcia E, DeBerardino TM, and Cameron KL. The relationship between posterior tibial slope and
anterior cruciate ligament injuries. Am J Sports Med. United States; 2010;38(1):63-7.

2) Christensen JJ, Krych AJ, Engasser WM, Vanhees MK, Collins MS, Dahm DL. Lateral Tibial Posterior Slope Is Increased in
Patients With Early Graft Failure After Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2015 Oct;43(10):2510-
4. doi: 10.1177/0363546515597664. Epub 2015 Aug 28. PMID: 26320223.

3) Grassi A, Pizza N, Zambon Bertoja J, Macchiarola L, Lucidi GA, Dal Fabbro G, Zaffagnini S. Higher risk of contralateral
anterior cruciate ligament (ACL) injury within 2 years after ACL reconstruction in under-18-year-old patients with steep
tibial plateau slope. Knee Surg Sports Traumatol Arthrosc. 2020 Jul 31. doi: 10.1007/s00167-020-06195-y. Epub ahead of
print. PMID: 32737527.

4) Grassi A, Macchiarola L, Urrizola Barrientos F, Zicaro JP, Costa Paz M, Adravanti P, Dini F, Zaffagnini S. Steep Posterior
Tibial Slope, Anterior Tibial Subluxation, Deep Posterior Lateral Femoral Condyle, and Meniscal Deficiency Are Common
Findings in Multiple Anterior Cruciate Ligament Failures: An MRI Case-Control Study. Am J Sports Med. 2019 Feb;47(2):285-
295. doi: 10.1177/0363546518823544. Epub 2019 Jan 18. PMID: 30657705.

5) Grassi A, Signorelli C, Urrizola F, Macchiarola L, Raggi F, Mosca M, Samuelsson K, Zaffagnini S. Patients With Failed
Anterior Cruciate Ligament Reconstruction Have an Increased Posterior Lateral Tibial Plateau Slope: A Case-Controlled
Study. Arthroscopy. 2019 Apr;35(4):1172-1182. doi: 10.1016/[Link].2018.11.049. Epub 2019 Mar 14. PMID: 30878331.

6) Jaecker V, Drouven S, Naendrup JH, Kanakamedala AC, Pfeiffer T, Shafizadeh S. Increased medial and lateral tibial
posterior slopes are independent risk factors for graft failure following ACL reconstruction. Arch Orthop Trauma Surg. 2018
Oct;138(10):1423-1431. doi: 10.1007/s00402-018-2968-z. Epub 2018 May 28. PMID: 29808437.

7) Salmon LJ, Heath E, Akrawi H, Roe JP, Linklater J, Pinczewski LA. 20-Year Outcomes of Anterior Cruciate Ligament
Reconstruction With Hamstring Tendon Autograft: The Catastrophic Effect of Age and Posterior Tibial Slope. Am J Sports
Med. 2018 Mar;46(3):531-543. doi: 10.1177/0363546517741497. Epub 2017 Dec 15. PMID: 29244525.

8) Webb JM, Salmon LJ, Leclerc E, Pinczewski LA, Roe JP. Posterior tibial slope and further anterior cruciate ligament injuries
in the anterior cruciate ligament-reconstructed patient. Am J Sports Med. 2013 Dec;41(12):2800-4. doi:
10.1177/0363546513503288. Epub 2013 Sep 13. PMID: 24036571.

9) Bernhardson AS, Aman ZS, Dornan GJ, Kemler BR, Storaci HW, Brady AW, Nakama GY, LaPrade RF. Tibial Slope and Its
Effect on Force in Anterior Cruciate Ligament Grafts: Anterior Cruciate Ligament Force Increases Linearly as Posterior Tibial
Slope Increases. Am J Sports Med. 2019 Feb;47(2):296-302. doi: 10.1177/0363546518820302. Epub 2019 Jan 14. PMID:
30640515.

10) Imhoff FB, Comer B, Obopilwe E, Beitzel K, Arciero RA, Mehl JT. Effect of Slope and Varus Correction High Tibial
Osteotomy in the ACL-Deficient and ACL-Reconstructed Knee on Kinematics and ACL Graft Force: A Biomechanical Analysis.
Am J Sports Med. 2021 Feb;49(2):410-416. doi: 10.1177/0363546520976147. Epub 2020 Dec 3. PMID: 33270464.

11) Yoon KH, Park SY, Park JY, Kim EJ, Kim SJ, Kwon YB, Kim SG. Influence of Posterior Tibial Slope on Clinical Outcomes and
Survivorship After Anterior Cruciate Ligament Reconstruction Using Hamstring Autografts: A Minimum of 10-Year Follow-
up. Arthroscopy. 2020 Jun 15:S0749-8063(20)30527-2. doi: 10.1016/[Link].2020.06.011. Epub ahead of print. PMID:
32554080.

12) Grassi A, Signorelli C, Urrizola F, Raggi F, Macchiarola L, Bonanzinga T, Zaffagnini S. Anatomical features of tibia and
femur: Influence on laxity in the anterior cruciate ligament deficient knee. Knee. 2018 Aug;25(4):577-587. doi:
10.1016/[Link].2018.03.017. Epub 2018 May 24. PMID: 29802076.

13) Dejour H, Bonnin M.J Tibial translation after anterior cruciate ligament rupture. Two radiological tests compared. Bone
Joint Surg Br. 1994 Sep;76(5):745-9.

14) Ahmed I, Salmon L, Roe J, Pinczewski L. The long-term clinical and radiological outcomes in patients who suffer
recurrent injuries to the anterior cruciate ligament after reconstruction. Bone Joint J. 2017 Mar;99-B(3):337-343. doi:
10.1302/0301-620X.99B3.37863. PMID: 28249973.

15) Lee CC, Youm YS, Cho SD, Jung SH, Bae MH, Park SJ, Kim HW. Does Posterior Tibial Slope Affect Graft Rupture Following
Anterior Cruciate Ligament Reconstruction? Arthroscopy. 2018 Jul;34(7):2152-2155. doi: 10.1016/[Link].2018.01.058.
Epub 2018 Mar 9. PMID: 29530354.

16) Su AW, Bogunovic L, Smith MV, et al. Medial Tibial Slope Determined by Plain Radiography Is Not Associated with
Primary or Recurrent Anterior Cruciate Ligament Tears. J Knee Surg. 2020;33(1):22-28. doi:10.1055/s-0038-1676456
17) Naendrup JH, Drouven SF, Shaikh HS, Jaecker V, Offerhaus C, Shafizadeh ST, Pfeiffer TR. High variability of tibial slope
measurement methods in daily clinical practice: Comparisons between measurements on lateral radiograph, magnetic
resonance imaging, and computed tomography. Knee. 2020 Jun;27(3):923-929. doi: 10.1016/[Link].2020.01.013. Epub
2020 Feb 12. PMID: 32061503.

18) Dean RS, DePhillipo NN, Chahla J, Larson CM, LaPrade RF. Posterior Tibial Slope Measurements Using the Anatomic Axis
Are Significantly Increased Compared to Those That Use the Mechanical Axis. Arthroscopy. 2020 Sep 16:S0749-
8063(20)30737-4. doi: 10.1016/[Link].2020.09.006. Epub ahead of print. PMID: 32949632.

19) Faschingbauer M, Sgroi M, Juchems M, Reichel H, Kappe T. Can the tibial slope be measured on lateral knee
radiographs? Knee Surg Sports Traumatol Arthrosc. 2014 Dec;22(12):3163-7. doi: 10.1007/s00167-014-2864-1. Epub 2014
Jan 31. PMID: 24482216.

20) Gaj E, Monaco E, De Carli A, Wolf MR, Massafra C, Redler A, Mazza D, Ferretti A. Measurement technique for posterior
tibial slope on radiographs can affect its relationship to the risk of anterior cruciate ligament rupture. Int Orthop. 2020 Nov
4. doi: 10.1007/s00264-020-04865-7.

21) Sonnery-Cottet B, Mogos S, Thaunat M, et al. Proximal Tibial Anterior Closing Wedge Osteotomy in Repeat Revision of
Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2014;42(8):1873-1880. doi:10.1177/0363546514534938

22) Dejour D, Saffarini M, Demey G, Baverel L. Tibial slope correction combined with second revision ACL produces good
knee stability and prevents graft rupture. Knee Surg Sports Traumatol Arthrosc. 2015;23(10):2846-2852.
doi:10.1007/s00167-015-3758-6

23) Akoto R, Alm L, Drenck TC, Frings J, Krause M, Frosch KH. 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 Nov 2:363546520966327. doi: 10.1177/0363546520966327. Epub ahead of print. PMID:
33135908.

24) Tischer T, Paul J, Pape D, Hirschmann MT, Imhoff AB, Hinterwimmer S, Feucht MJ. The Impact of Osseous Malalignment
and Realignment Procedures in Knee Ligament Surgery: A Systematic Review of the Clinical Evidence. Orthop J Sports Med.
2017 Mar 27;5(3):2325967117697287. doi: 10.1177/2325967117697287.

25) Yoo JH, Chang CB, Shin KS, Seong SC, Kim TK. Anatomical references to assess the posterior tibial slope in total knee
arthroplasty: a comparison of 5 anatomical axes. J Arthroplasty. 2008 Jun;23(4):586-92. doi: 10.1016/[Link].2007.05.006.
Epub 2007 Nov 9. PMID: 18514879.

26) Brazier J, Migaud H, Gougeon F, Cotton A, Fontaine C, Duquennoy A. [Evaluation of methods for radiographic
measurement of the tibial slope. A study of 83 healthy knees]. Rev Chir Orthop Reparatrice Appar Mot. 1996;82(3):195-200.
[Article in French]
D12) When is a specific assessment of tunnel widening necessary and how should it be
done?

Consensus answer: Radiographs (AP and lateral) should be considered an inexpensive first
level method to assess tunnel position, osteolysis and enlargement (especially of the tibial
tunnel). When the tunnel is not properly positioned, expanded or abnormally shaped, or
cannot be safely evaluated on x-ray, a CT scan is required, including 3D reconstructions when
available. Measurements should be performed in each plane, with a straight line from the
tunnel side-to-side, in the portion of its more relevant enlargement.
High-quality MRI could also be used for tunnel diameter measurement, although it is less well
evaluated.

Agreement: 8.5/9

Grade of recommendation: B

Literature review:
Several studies assessed the reliability of tunnel measurement, with good-moderate quality
due to sound statistical analysis and blinding of evaluators. Based on the current evidence, CT
scanning is generally considered the optimal method for evaluating tunnel enlargement. This
was confirmed in a recent review, which suggested performing a CT scan if there are concerns
with tunnel widening or osteolysis [1].
Merchant et al. [2] tried to define the optimal method to evaluate tunnel diameter, comparing
the reliability of plain radiographs, MRI and CT scans. Five observers measured the tunnel size
in 12 patients using the different methods and reported that the CT scan was the only method
that allowed tunnel identification in 100% of cases for both tibial and femoral tunnels in either
the coronal or the sagittal plane. Moreover, CT had the highest inter- and intra-observer
agreement for the measurement of tunnel diameter, with “substantial” (k=0.60-0.80) to
“moderate” (k=0.40-0.60) agreement in most cases. However, CT was similar to MRI in coronal
images and to radiographs in sagittal images in measuring tibial tunnel diameter. Finally, with
regard to tunnel cross sectional area, CT scans were superior to both MRI and radiographs,
with “substantial” intra- and inter-observer agreement.
Another systematic review of diagnostic modalities to assess tunnel enlargement, which
included 103 studies and 6383 patients, reported that 44/103 studies used radiographs,
21/103 used MRI and 20/103 used CT scan, with radiographs considered the most used
method at all time points of follow-up [3]. However, the authors reported that CT scanning
was the most sensitive method for detecting tunnel widening. The authors thus concluded
that “CT scans remain the optimal modality for diagnosis“. Factors such as costs, time, and
radiation explain why plain radiographs are still commonly used for the assessment of tunnel
widening. Plain radiographs are limited by their two-dimensional nature and, therefore,
differences in knee position and distance from the film surface can affect results [3].
Another debated and less standardized issue is the method for concretely obtaining the
measurement of the tunnel. Merchant et al., in a study on tunnel measurement reliability
described the tunnel measurement as the distance between the tunnel’s sclerotic margins,
perpendicular to the tunnel axis, at its widest point [2]. A similar method was employed by
Yoon et al. [4] and Choi et al. [5] in clinical studies on revision ACL reconstruction. Mitchell et
al. [6], in another clinical study on revision ACL performed in either a 1-stage or 2-stage
fashion, performed the tunnel measurement “in any sequence that was in the desired
anatomic tunnel location or would critically overlap with these tunnels“. Groves at al. [7], in a
pictorial review of the use of CT in the management of revision ACL, reported that “tibial
tunnels should be measured in the sagittal and coronal plane at their midpoint, and at their
proximal and distal apertures, whereas femoral tunnels should be measured at their midpoint
and at the notch aperture“.
Meuffels et al. [8] used a 3D approach to assess tunnels, reporting higher reliability compared
to CT, MRI and radiographs; however, the authors studied only tunnel placement with no
mention of diameters. Crespo et al. [9] also used 3D models, reporting a higher accuracy in
comparison to 2D methods; however, it was used only in a controlled setting with no tunnel
enlargement and dedicated software was necessary.
Legend: When the CT scan is used, the tibial tunnel enlargement is measured on axial (a),
coronal (b) and sagittal (c) slices, with a straight line from the tunnel side-to-side, in the
portion of its more relevant enlargement. The same is done for femoral tunnel (d, e, f)

References:
1) Kraeutler MJ, Welton KL, McCarty EC, Bravman JT. Revision Anterior Cruciate Ligament Reconstruction. J Bone Joint Surg
Am. 2017;99(19):1689-1696. doi:10.2106/JBJS.17.00412

2) Marchant MH Jr, Willimon SC, Vinson E, Pietrobon R, Garrett WE, Higgins LD. 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):1059-1064. doi:10.1007/s00167-009-0952-4

3) Bhullar R, Habib A, Zhang K, et al. Tunnel osteolysis post-ACL reconstruction: a systematic review examining select
diagnostic modalities, treatment options and rehabilitation protocols. Knee Surg Sports Traumatol Arthrosc.
2019;27(2):524-533. doi:10.1007/s00167-018-5142-9

4) Yoon KH, Kim JS, Park SY, Park SE. One-Stage Revision Anterior Cruciate Ligament Reconstruction: Results According to
Preoperative Bone Tunnel Diameter: Five to Fifteen-Year Follow-up. J Bone Joint Surg Am. 2018;100(12):993-1000.
5) Choi NH, Lee SJ, Park SC, Victoroff BN. Comparison of Postoperative Tunnel Widening After Hamstring Anterior Cruciate
Ligament Reconstructions Between Anatomic and Nonanatomic Femoral Tunnels. Arthroscopy. 2020;36(4):1105-1111.
doi:10.1016/[Link].2019.10.021

6) Mitchell JJ, Chahla J, Dean CS, Cinque M, Matheny LM, LaPrade RF. Outcomes After 1-Stage Versus 2-Stage Revision
Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2017;45(8):1790-1798. doi:10.1177/0363546517698684

7) Groves C, Chandramohan M, Chew C, Subedi N. Use of CT in the management of anterior cruciate ligament revision
surgery. Clin Radiol. 2013;68(10):e552-e559. doi:10.1016/[Link].2013.06.001

8) Meuffels DE, Potters JW, Koning AH, Brown CH Jr, Verhaar JA, Reijman M. Visualization of postoperative anterior cruciate
ligament reconstruction bone tunnels: reliability of standard radiographs, CT scans, and 3D virtual reality images. Acta
Orthop. 2011;82(6):699-703. doi:10.3109/17453674.2011.623566

9) Crespo B, Aga C, Wilson KJ, Pomeroy SM, LaPrade RF, Engebretsen L, Wijdicks CA. Measurements of bone tunnel size in
anterior cruciate ligament reconstruction: 2D versus 3D computed tomography model. J Exp Orthop. 2014 Dec;1(1):2. doi:
10.1186/s40634-014-0002-0. Epub 2014 Jun 26. PMID: 26914747; PMCID: PMC4648836.

D13) How can the assessment of tunnel placement be performed and what is the definition
of tunnel misplacement in the setting of a known or suspected failed ACL Reconstruction?

Consensus answer: Tunnel placement can be assessed with standard AP and lateral
radiographs (grade B), but the definition of femoral tunnel misplacement is not universally
accepted and remains controversial (Grade C).
However, as a general rule to help pre-operative management, a misplaced femoral tunnel
may be considered when the center is outside an area within 19-29% of the proximo-distal
dimension and within 22-53% of the antero-posterior dimension, according to Bernard and
Hertel’s grid method.
A misplaced tibial tunnel may be considered when it is outside the range of 30-50% of the
antero-posterior distance, according to the method of Staubli and Raushning, or when the
tunnel is anterior to the Blumensaat line in full knee extension.
In cases where it is impossible to detect either tunnel, their positions can be assessed with a
CT scan, using the same references for a sagittal slide parallel to the notch for femoral tunnel
and an axial slide parallel to the posterior border of the tibial plateau for the tibial tunnel. A
surrogate for abnormal tunnel placement is an abnormal graft inclination on MRI, which can
be considered when >60° on the sagittal MRI plane and >75° on the coronal MRI plane.
Considering the existing controversies relating to anatomy, measurement methods and
individual characteristics, the ranges provided do not represent absolute values or stand-
alone parameters to determine ACL failure or indication for revision. Rather, they should be
interpreted critically and used in combination with clinical evaluation and other objective
assessments to develop adequate pre-operative planning.

Agreement: 8.1/9

Grade of recommendation: B/C

Literature review:
The assessment of tunnel placement in a known or suspected failed ACL reconstruction is
considered a mainstay in diagnosis and surgical planning [1]. However, there are controversies
regarding the optimal methods and the cut-off do define placed graft [2], especially in the light
of new science and evidence in the field of ACL anatomy [3].

A systematic review of the radiological methods used to assess tunnel placement was
conducted in 2018 by Kosi and Mandalia [3]. They concluded that “plain radiographs are
adequate for the surveillance of the ACL graft position with normal values defined for the
commonest methods used”. The authors added that “despite continued debate about optimal
positioning of the graft, plain radiograph measurements provide the surgeon with adequate
information to monitor their performance in the majority of cases” and that “CT and MRI have
been shown to provide additional information about the tunnels and graft that are of
importance in comparative studies and in revision surgery”.

Femoral tunnel assessment:

Regarding the radiographic assessment of the femoral tunnel, its position is commonly
assessed in the lateral view, using several different methods. The methods developed by
Harner, Aglietti, and Amis, all use Blumensaat’s line as a reference, while the grid\quadrant
method, described by Bernard and Hertel, uses Blumensaat’s line and the posterior aspect of
the lateral femoral condyle to draw a 4 X 4 grid. Evidence exists that correlates clinical
outcomes with tunnel placement according to the Harner, Aglietti or Amis methods [3], but
the largest literature is for the grid method [3]. According to the Bernard and Hertel grid
method, the center of ACL insertion has been reported to be at 24.8 ± 2.2% of the sagittal
width of the femoral condyle and at 28.5 ± 2.5% of the height of the intercondylar fossa [4],
therefore its center is located in the distal corner of the most supero-posterior quadrant.
Zantop et al. investigated the position of the two ACL bundles according to the Bernard and
Hertel method, describing the center of AM bundle at 18.5% of the lateral condyle height and
22.3% of the Blumensaat line, while the center of the PL bundle at 53.6% of lateral condyle
height and at 29.3% of the Blumensaat line [5]. It can thus be deduced that an ACL tunnel can
fall within a range of 18.5-29.3% of the Blumensaat line and 22.3-53.6% of the lateral condyle
height. Moreover, a systematic review of 13 studies, that however used different
measurement methods (radiographs, CT, MRI and direct anatomical measurements) reported
the normal range of centers of ACL between 24-37% on the Blumensaat line and at 28-43% of
lateral femoral condyle height [6].
Measurement of the femoral tunnel using AP radiographs has also been described; however,
their reliability has been reported to be inferior compared to lateral radiographs, which have
higher inter class correlation (ICC) values >0.80-0.90) [7].

Tibial tunnel assessment:

Tibial tunnels can be assessed radiographically in a lateral view using the method of Staubli
and Raushning, which is the distance of the ACL from the anterior tibial margin, as a % of the
whole tibial length [8,9]; based on this, the ACL tibial insertion has been defined at 43%.
However, more recent studies analyzing the double-bundle structure of the ACL have reported
the center of the AM bundle to be located at 30% of the antero-posterior tibial dimension,
with the center of the PL bundle at 44% [2,5]. Moreover, according to this measurement
method, studies had reported higher failures with this distance >50% and also with tunnels
anterior with respect to the intersection between the tibial plateau line and the extension of
the Blumensaat line [3]. Merchant et al. reported a high prevalence of tibial tunnels positioned
more than 50% outside the anatomical insertion (43%) [10]. With regard to tunnel placement
on antero-posterior radiographs, a midline position with respect to the tibial plateau width is
suggested, with no relevant controversies [3]. If lateral radiographs are performed in
extension, “unforgiving knees” can be evaluated, by measuring the relationship between the
extension angle of the knee and the roof angle (Blumensaat line), suggesting the risk for graft
impingement as is the case in hyperextention [11-12].
Legend: (a) Femoral tunnel placement can be assessed with the Bernard and Hertel’s grid
methods; correct placement is considered when the tunnel center falls within an area
comprised between the 19% and 29% of the proximo-distal dimension and between the 22%
and 53% of the antero-posterior dimension (red square).
(b) Tibial tunnel placement can be assessed according to the Staubli method; correct
placement is considered when the tunnel center falls within the range between the 30% and
50% of the antero-posterior distance (red square)

CT assessment:
For the CT assessment of femoral tunnel placement, most methods adopted have similarities
to the grid method used to interpret plain radiographs. 3D-CT allows the medial wall of the
lateral femoral condyle to be viewed directly (with the medial condyle removed) and
positioned with a “strictly lateral” orientation of the femur, rotating the reconstruction until
the condyles are overlapping. Several methods with different references have been suggested
[3]. However, no substantial changes have been made with respect to the CT-adaptation of
the Bernard and Hertel method. This method has been used to assess failed ACL
reconstruction: non-anatomic tunnel placement was defined by Parkinson et al. [13] if it was
more than 2 standard deviations from the normal position based on the weighted mean in the
literature (AMB=25%, PLB=34%, Central=29.3% on Blumensaat or Deep/Shallow position;
AMB=22.4%, PLB=48.6%, Central=34.7% on lateral condyle height or High-Low position); by
Jaecker et al. [14] as being outside the range of 19-29% for depth and 22-53% for height; by
Ziegler et al. [15] as outside the range of 23-33% for depth and 28-38% for height. All three
studies reported high rates of malpositioned tunnels in patients with failed ACL
reconstruction, according to their cut-offs, especially in those with non-traumatic failures. For
CT assessment of the tibial tunnel, measurements have largely been made in the axial plane
using a grid method, orienting the grid to be parallel to the posterior border of the tibial
plateau. The anterior, medial and lateral borders are then defined by the respective borders
of the greatest dimension of the plateau. According to this method, the center of the ACL has
been reported at 38.7% from anterior to posterior and at 49.1% from medial to lateral [3].
This method was used to assess failed ACL reconstruction: non-anatomic tunnel placement
was defined by Parkinson et al. [13] as being more than 2 standard deviations from the normal
position based on the weighted mean of the literature for the antero-posterior position (39 ±
3 %) and the medio-lateral position (48 ± 2%); by Jaecker et al. [14] as being outside the range
of 30-44% (presumably from the anterior margin); by Ziegler et al. [15] as outside the range
of 36-46% from the anterior margin and 40-50% from the medial margin. Also in this case,
high rates of non-anatomical placement were found in failed ACL reconstructions.

Legend: When the CT scan is used, tibial tunnel can be assessed on axial slices (a) while the
femoral tunnel can be assessed on sagittal slices (b) according to modifications of the grid
methods and with specific cut-off values.

MRI assessment:
MRI has been reported to be sub-optimal for assessing tunnel size and position, due to
hardware artifacts [16]. However, it can be useful to assess graft orientation, which can be
considered a “surrogate” for tunnel placement. A graft angulated >55-60° on the sagittal plane
has been reported in patients with non-anatomical graft placement, failed ACL or greater
laxity [16-18]. Sub-optimal results have also been reported with vertical grafts on coronal
planes, usually with a coronal angle >75°, even if a consensual cut-off has not been defined [3,
16, 19].

Legend: a) The coronal graft inclination is calculated measuring the angle between the tangent
line to the tibial plateau (line a) and the line which best defines the course of the intra-articular
part of the graft (line b). A high angle represents a vertical graft in the coronal plane.
b) The sagittal graft inclination is calculated by measuring the angle between the
perpendicular line (line a) to the proximal tibial axis, and the line which best defines the course
of the intra-articular part of the graft (line b). A high angle represents a vertical graft in the
sagittal plane.

Comparing CT and radiographs, a higher ability to identify tunnels has been reported with CT
scans [20], leading the author to conclude that CT scanning is required to accurately assess
cases where tunnel position is vital. However, experimental settings showed small differences
and a high correlation (Pearson correlation=0.840-0858) between CT and radiographic
measurements, suggesting reasonable accuracy of the radiographic grid method compared to
CT measurement. In contrast, when assessing potential tunnel conflicts, Tscholl et al. [21]
found 9/20 potential conflicts with CT compared to only 1/20 potential conflicts after
radiographic assessment. However, the study was performed only on 20 patients and the
setting was experimental, using primary reconstruction as a reference group.

References:
1) Kraeutler MJ, Welton KL, McCarty EC, Bravman JT. Revision Anterior Cruciate Ligament Reconstruction. J Bone Joint Surg
Am. 2017;99(19):1689-1696.

2) Kosy JD, Mandalia VI. Plain radiographs can be used for routine assessment of ACL reconstruction tunnel position with
three-dimensional imaging reserved for research and revision surgery. Knee Surg Sports Traumatol Arthrosc. 2018
Feb;26(2):534-549.

3) Śmigielski R, Zdanowicz U, Drwięga M, Ciszek B, Ciszkowska-Łysoń B, Siebold R. Ribbon like appearance of the
midsubstance fibres of the anterior cruciate ligament close to its femoral insertion site: a cadaveric study including 111
knees. Knee Surg Sports Traumatol Arthrosc. 2015 Nov;23(11):3143-3150.

4) Bernard M, Hertel P, Hornung H, and Cierpinski T. Femoral insertion of the ACL. Radiographic quadrant method. Am J
Knee Surg. 1997;10(1):14-21; discussion 21-2.

5) Zantop T, Wellmann M, Fu FH, and Petersen W. Tunnel positioning of anteromedial and posterolateral bundles in
anatomic anterior cruciate ligament reconstruction: anatomic and radiographic findings. Am J Sports Med. 2008;36(1):65-
72.

6) Parkar AP, Adriaensen MEAPM, Vindfeld S, Solheim E. The Anatomic Centers of the Femoral and Tibial Insertions of the
Anterior Cruciate Ligament: A Systematic Review of Imaging and Cadaveric Studies Reporting Normal Center Locations. Am
J Sports Med. 2017 Jul;45(9):2180-2188. doi: 10.1177/0363546516673984. Epub 2016 Nov 29. PMID: 27899355.

7) Sullivan JP, Matava MJ, Flanigan DC, Gao Y, Britton CL, Amendola A, and Wolf BR. Reliability of tunnel measurements and
the quadrant method using fluoroscopic radiographs after anterior cruciate ligament reconstruction. Am J Sports Med.
2012;40(10):2236-2241.

8) Stäubli HU, Rauschning W. Tibial attachment area of the anterior cruciate ligament in the extended knee position.
Anatomy and cryosections in vitro complemented by magnetic resonance arthrography in vivo. Knee Surg Sports Traumatol
Arthrosc. 1994;2(3):138-146. doi: 10.1007/BF01467915. PMID: 7584195.

9) Amis AA, Beynnon B, Blankevoort L, Chambat P, Christel P, Durselen L, Friederich N, Grood E, Hertel P, Jakob R, et al.
Proceedings of the ESSKA Scientific Workshop on Reconstruction of the Anterior and Posterior Cruciate Ligaments. Knee
Surg Sports Traumatol Arthrosc. 1994;2(3):124-132. doi: 10.1007/BF01467913. PMID: 7584193.

10) Merchant TC. Comparison of three patellar tendon anterior cruciate ligament reconstruction techniques with emphasis
on tunnel location and outcome. Are our results improving? Iowa Orthop J. 2001;21:25-30.

11) 3) Howell SM, Barad SJ (1995) Knee extension and its relation-ship to the slope of the intercondylar roof. Implications
for positioning the tibial tunnel in anterior cruciate ligament recon-structions. Am J Sports Med 23:288–294

12) Howell SM, Taylor MA (1993) Failure of reconstruction of the anterior cruciate ligament due to impingement by the
intercon-dylar roof. J Bone Joint Surg Am 75:1044–1055

13) Parkinson B, Robb C, Thomas M, Thompson P, Spalding T. Factors That Predict Failure in Anatomic Single-Bundle
Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2017 Jun;45(7):1529-1536. doi: 10.1177/0363546517691961.
Epub 2017 Mar 15. PMID: 28296429.

14) Jaecker V, Naendrup JH, Pfeiffer TR, Bouillon B, Shafizadeh S. Radiographic Landmarks for Femoral Tunnel Positioning in
Lateral Extra-articular Tenodesis Procedures. Am J Sports Med. 2019 Sep;47(11):2572-2576.
15) Ziegler CG, DePhillipo NN, Kennedy MI, Dekker TJ, Dornan GJ, LaPrade RF. Beighton Score, Tibial Slope, Tibial
Subluxation, Quadriceps Circumference Difference, and Family History Are Risk Factors for ACL Graft Failure: A
Retrospective Comparison of Primary and Revision ACL Reconstructions. Arthroscopy. 2020 Sep 7:S0749-8063(20)30725-8.

16) Grassi A, Bailey JR, Signorelli C, Carbone G, Tchonang Wakam A, Lucidi GA, Zaffagnini S. Magnetic resonance imaging
after anterior cruciate ligament reconstruction: A practical guide. World J Orthop. 2016 Oct 18;7(10):638-649.

17) Mall NA, Abrams GD, Azar FM, Traina SM, Allen AA, Parker R, Cole BJ. Trends in primary and revision anterior cruciate
ligament reconstruction among National Basketball Association team physicians. Am J Orthop (Belle Mead NJ). 2014
Jun;43(6):267-271. PMID: 24945476.

18) Hosseini A, Lodhia P, Van de Velde SK, Asnis PD, Zarins B, Gill TJ, Li G. Tunnel position and graft orientation in failed
anterior cruciate ligament reconstruction: a clinical and imaging analysis. Int Orthop. 2012 Apr;36(4):845-52. doi:
10.1007/s00264-011-1333-4. Epub 2011 Aug 9. PMID: 21826407; PMCID: PMC3311801.

19) Fujimoto E, Sumen Y, Deie M, Yasumoto M, Kobayashi K, Ochi M. Anterior cruciate ligament graft impingement against
the posterior cruciate ligament: diagnosis using MRI plus three-dimensional reconstruction software. Magn Reson Imaging.
2004 Oct;22(8):1125-1129.

20) Hoser C, Tecklenburg K, Kuenzel KH, and Fink C. Postoperative evaluation of femoral tunnel position in ACL
reconstruction: plain radiography versus computed tomography. Knee Surg Sports Traumatol Arthrosc. 2005;13(4):256-262

21) Tscholl PM, Biedert RM, Gal I. Radiological evaluation for conflict of the femoral tunnel entrance area prior to anterior
cruciate ligament revision surgery. Int Orthop. 2014 Mar;38(3):607-615. doi: 10.1007/s00264-013-2126-8.

22) Ayala-Mejias JD, Garcia-Gonzalez B, Alcocer-Perez-España L, Villafañe JH, Berjano P. Relationship between Widening
and Position of the Tunnels and Clinical Results of Anterior Cruciate Ligament Reconstruction to Knee Osteoarthritis: 30
Patients at a Minimum Follow-Up of 10 Years. J Knee Surg. 2017 Jul; 30(6):501-508
D14) What is the optimal method to assess concomitant ligament injuries?

Consensus answer: Clinical evaluation is crucial (posterior drawer, varus-valgus stress,

internal-external rotation) always comparing the injured to the uninjured side. MRI can help
to find associated ligament injuries but is less sensitive in chronic cases. Bilateral stress x-rays
are helpful to exactly classify laxity in the AP and mediolateral plane.

Agreement: 8.4/9

Grade of recommendation: C

Literature review:
Clinical examination
Clinical evaluation is crucial: posterior cruciate ligament (PCL) laxity is tested by both posterior
drawer testing and assessment of posterior sag sign or the quadriceps active test, whereas
the lateral and medial collateral ligaments are tested in full extension and 30° of knee flexion1.
Moreover, a careful examination under anesthesia, including a complete assessment of varus,
valgus, and rotational laxity to recognize all associated deficiencies, could be helpful to
determine the right treatment2.
Posterolateral and posteromedial laxity should be tested with the dial test at 30° and 90° of
knee flexion: the last test discriminates the involvement of the posterior cruciate ligament.

MRI
MRI allows us to detect acute associated ligament injuries with direct and indirect signs (i.e.
bone bruising and hematoma). Willinger et al.3 reported that the presence of bone edema at
the medial femoral condyle (MFC ) adjacent to the dMCL attachment site, and MRI grade II
sMCL injury are significant risk factors for having a dMCL injury.
In chronic cases MRI is much less sensitive. See D9 for MRI.

Bilateral stress x-rays

Stress radiography offers objective and quantifiable values with a non-invasive procedure,
which can be used to reinforce and confirm the diagnosis of knee ligament injuries. A variety
of stress techniques4,5 have been described that assess ligament stability using an anteriorly,
posteriorly, varus-, or valgus-directed force to the knee. Kennedy et al.6 reported that the gold
standard for posterolateral corner (PLC) injuries are varus stress radiographs. Varus stress
radiographs have been validated as a reliable and repeatable objective examination for both
isolated fibular collateral ligament (FCL) injuries and combined PLC injuries.

Rolimeter
A study by Höher et al.7 showed how Rolimeter® measurements have delivered comparable
results to stress radiograph measurements in the evaluation of posterior knee laxity. Due to
its low cost and lack of exposure to radiation for the patient, its use may be considered a
valuable alternative to stress radiography in the evaluation of patients with posterior cruciate
ligament (PCL) injuries.

KT 1000
As mentioned above, the KT-1000 is the recommended device for assessing suspected ACL
reconstruction failure. It could also be a valid option for assessing PCL deficiency; however,
stress radiography seems to be superior for the assessment of posterior laxity.8

References:
1) Kamath GV, Redfern JC, Greis PE, Burk RT. Revision Anterior Cruciate Ligament Reconstruction. The American
Journal of Sports Medicine. 2011 Jan;39(1):199-217.
2) George MS, Dunn WR, Spindler KP. Current concepts review: revision anterior cruciate ligament reconstruction.
American Journal of Sports Medicine. 2006 Dec;34(12):2026-2037.
3) Willinger L, Balendra G, Pai V, Lee J, Mitchell A, Jones M, Williams A. High incidence of superficial and deep
medial collateral ligament injuries in 'isolated' anterior cruciate ligament ruptures: a long overlooked injury. Knee
Surgery, Sports Traumatology Arthroscopy. 2021 Mar 4, doi: 10.1007/s00167-021-06514-x.
4) James EW, Williams BT, LaPrade RF. Stress radiography for the diagnosis of knee ligament injuries: a systematic
review. Clinical Orthopaedics and Related Research. 2014 Sep;472(9):2644-57.
5) Lee YS, Han SH, Jo J, Kwak KS, Nha KW, Kim JH. Comparison of 5 different methods for measuring stress
radiographs to improve reproducibility during the evaluation of knee instability. American Journal of Sports
Medicine. 2011;39:1275–1281.
6) Kennedy NI, LaPrade CM, Laprade RF. Surgical Management and Treatment of the Anterior Cruciate
Ligament/Posterolateral Corner Injured Knee. Clinical Sports Medicine. 2017 Jan;36(1):105-117.
7) Höher J, Akoto R, Helm P, Shafizadeh S, Bouillon B, Balke M. Rolimeter measurements are suitable as substitutes
to stress radiographs in the evaluation of posterior knee laxity. Knee Surgery, Sports Traumatology,
Arthroscopy. 2015 Apr;23(4):1107-1112.
8) Pugh L, Mascarenhas R, Arneja S, Chin PYK, Leith JM, Current concepts in instrumented knee-laxity testing. The
American Journal of Sports Medicine. 2009 Jan;37(1):199-210
D15) How can osteoarthritic changes be assessed in the setting of a known or suspected
failed ACL Reconstruction?

Consensus answer: The recommended method to assess tibiofemoral osteoarthritic changes

is the KL score on weightbearing radiographs (AP full extension), although there are limitations
in its use. “No to Mild OA” is defined as Grades 0, I, and II, while “Moderate OA” is defined as
Grade III, and “Severe OA” is defined as Grade IV. A flexed weightbearing view
(Schuss/Rosenberg) has higher sensitivity than x-rays in extension. The IKDC grading system is
a valid alternative to the KL, especially in less advanced OA. Axial view radiographs can be
used to grade patellofemoral (PF) OA. MRI provides a comprehensive assessment of early OA,
cartilage lesions, subchondral bone status and PF OA.

Agreement: 8.6/9

Grade of recommendation: B

Literature review:
Only one study investigated the optimal method to assess osteoarthritic changes in the
specific context of Revision ACL, but only used radiographs [1]. Therefore, the literature
regarding primary ACL reconstruction and general knee OA is investigated. To identify the
optimal method, the features of instruments (MRI, radiographs), the reliability of OA
classification systems and the technical execution of radiological exams should be taken into
account.

A 2019 narrative review regarding imaging for OA [2] concluded that “an increasing number
of articles have been published over the past year using conventional and compositional MRI
to detect early structural joint pathology in subjects with OA or risk factors for OA“. Moreover,
MRI has been reported to have a high sensitivity in detecting cartilage lesions, even in the
patello-femoral joint [3], and a correlation with radiographic OA grading [4]. Regarding MRI
scores such as WORMS and BLOKS, although they have been reported to have high reliability
[5], due to their time-consuming nature and limited popularity, use has been reserved mostly
for research settings rather than for clinical purposes, especially in the assessment of early OA
and cartilage/subchondral bone pathologies [6].

In the context of ACL reconstruction, a 2019 meta-analysis assessed the risk of OA after ACL
reconstruction in 41 studies, relying exclusively on knee radiographs [6], which are considered
the easiest and cheapest first-line method of assessment, according to the literature. When
assessing knee OA through radiographs, several classification systems and scales are available.
A study by the Multicenter ACL Revision Study (MARS) group, using 632 patients, assessed
inter-observer reliability for 6 common OA scales (KL, IKDC, Fairbanks, Brandt, Ahlback, Jager-
Wirth) on standing AP extension and/or Rosenberg views, and the correlation between
radiographs and arthroscopic findings [1]. The authors concluded that the IKDC score had the
“the best combination of good interobserver reliability (AP=0.59, Rosenberg=0.66) and
medium correlation with arthroscopic findings (AP=0.32, Rosenberg=0.37). The KL appeared
to have an inferior interobserver reliability (AP=0.38, Rosenberg=0.54) compared to the other
scales, but the correlation with arthroscopic findings (AP=0.30, Rosenberg=0.40) was similar
or slightly higher. The authors acknowledged that the IKDC system places more emphasis on
joint space narrowing than does the more traditional KL system, which relies mostly on the
presence of osteophytes and joint deformity. Another recent study assessed the reliability of
KL, IKDC and Ahlbäck in 112 patients who were candidates for TKA [7]. The authors reported
adequate inter- and intra-observer reliability of all scores, with the IKDC classification having
the greatest reliability (imputed to its conservative definitions) and the Ahlbäck and KL
classifications better reflecting the spectrum of disease severity encountered in an older
patient cohort. This finding was confirmed by Keenan et al. [8] in another cohort of patients
undergoing TKA, reporting that KL systems (and Ahlbäck) had the highest correlation with
confirmed cartilage loss at the time of TKA. However, these patients presented a more
advanced stage of OA when comparing with patients after ACL injury. It is well known that the
definition of KL II is the most debatable one [9]. It is of interest that the KL showed a clear
clinical implication, since it had a high correlation with subjective clinical scores after HTO [10].

In defining knee OA, a popular meta-analysis assessing OA after ACL reconstruction, in order
to pool the results of studies assessing OA through different systems, considered the cut-off
for OA diagnosis to be as follows: grade II of KL, grade C of the IKDC and grade 1 for Ahlback
[11]. This approach has been used consistently in the literature [6, 12].

Finally, particular mention must be made of the technical execution of radiographs. Based on
several comparative studies, postero-anterior radiographs with flexed knees have been
reported to have higher reliability compared to standard weightbearing full-extension
radiographs [1]; higher correlation with intra-articular cartilage status [1]; the highest
correlation with subjective clinical outcomes after HTO [10]; the highest precision in
measurement of joint space narrowing particularly on the lateral side [13]; and to possibly
influence the management of knee OA in up to 50% of cases compared to the assessment of
knee OA using only standard radiographs [14]. The most popular PA views with flexed knee
are the Rosenberg view obtained at 45° of flexion (Rosenberg+knee+OA = 46 pubmed results)
and with a beam inclination of 10° centered on the patella [15], and the Lyon Schuss view
(Schuss+knee+OA = 32 pubmed results) obtained at 30° of flexion and with beam inclination
to superimpose the anterior and posterior margin of the medial tibial plateau under
fluoroscopic guidance [16]. However, no studies have been found comparing the Rosenberg
and Schuss views (Rosenberg+Schuss = 0 pubmed results). Only one study compared the
traditional Schuss view with a PA view at 30° without fluoroscopic guidance and standard
beam inclination at 10° [17]. In patients with OA and KL grade II-III, the authors concluded that
PA views at 30° with or without fluoroscopic guidance to superimpose medial tibial plateau
“offer similar reproducibility in Joint Space Width measurement. However, presumably due
to its superiority in aligning the medial tibal plateau, the Schuss view [with fluoroscopy] is
much more sensitive to joint space narrowing in OA knees”. However, considering the
radiation exposure, the limited improvement in sensitivity and the time-consuming use of
fluoroscopy, this modality should be reserved for the research setting rather than clinical
practice.

Considering the advantages of PA views with flexed knee, Roux et al. reported that there are
“no differences between Schuss x-ray alone and Schuss plus AP view in detecting femoro-tibial
compartment OA features such as osteophytes and JSN in general practice” and that “the
superiority of the combination of two images to detect a knee OA with KL ≥ II suggests that
Schuss alone should be used in general practice for femoro-tibial OA detection, and the use
of both views should be restricted to clinical studies”. However, they did not assess patients
undergoing revision ACL in which other parameters other than OA should be assessed [18].

References

1) MARS Group. Radiographic findings in revision anterior cruciate ligament reconstructions from the Mars cohort. J Knee
Surg. 2013;26(4):239-247. doi:10.1055/s-0032-1329717

2) Kijowski R, Demehri S, Roemer F, Guermazi A. Osteoarthritis year in review 2019: imaging. Osteoarthritis Cartilage.
2020;28(3):285-295. doi:10.1016/[Link].2019.11.009

3) Harris JD, Brophy RH, Jia G, et al. Sensitivity of magnetic resonance imaging for detection of patellofemoral articular
cartilage defects. Arthroscopy. 2012;28(11):1728-1737. doi:10.1016/[Link].2012.03.018

4) Agnesi F, Amrami KK, Frigo CA, Kaufman KR. Comparison of cartilage thickness with radiologic grade of knee
[Link] Radiol. 2008;37(7):639-643. doi:10.1007/s00256-008-0483-y

5) Lynch JA, Roemer FW, Nevitt MC, et al. Comparison of BLOKS and WORMS scoring systems part I. Cross sectional
comparison of methods to assess cartilage morphology, meniscal damage and bone marrow lesions on knee MRI: data from
the osteoarthritis initiative. Osteoarthritis Cartilage. 2010;18(11):1393-1401. doi:10.1016/[Link].2010.08.017

6) Lie MM, Risberg MA, Storheim K, Engebretsen L, Øiestad BE. What's the rate of knee osteoarthritis 10 years after
anterior cruciate ligament injury? An updated systematic review. Br J Sports Med. 2019;53(18):1162-1167.
doi:10.1136/bjsports-2018-099751

7) Wing N, Van Zyl N, Wing M, Corrigan R, Loch A, Wall C. Reliability of three radiographic classification systems for knee
osteoarthritis among observers of different experience levels [published online ahead of print, 2020 Aug 11]. Skeletal
Radiol. 2020;10.1007/s00256-020-03551-4. doi:10.1007/s00256-020-03551-4

8) Keenan OJF, Holland G, Maempel JF, Keating JF, Scott CEH. Correlations between radiological classification systems and
confirmed cartilage loss in severe knee osteoarthritis. Bone Joint J. 2020;102-B(3):301-309. doi:10.1302/0301-
[Link]-2019-0337.R1

9) Felson DT, Niu J, Guermazi A, Sack B, and Aliabadi P. Defining radiographic incidence and progression of knee
osteoarthritis: suggested modifications of the Kellgren and Lawrence scale. Ann Rheum Dis. England; 2011;70(11):1884-6

10) Nha KW, Oh SM, Ha YW, Patel MK, Seo JH, Lee BH. Radiological grading of osteoarthritis on Rosenberg view has a
significant correlation with clinical outcomes after medial open-wedge high-tibial osteotomy. Knee Surg Sports Traumatol
Arthrosc. 2019;27(6):2021-2029. doi:10.1007/s00167-018-5121-1

11) Øiestad BE, Engebretsen L, Storheim K, Risberg MA. Knee osteoarthritis after anterior cruciate ligament injury: a
systematic review. Am J Sports Med. 2009;37(7):1434-1443. doi:10.1177/0363546509338827

12) Grassi A, Ardern CL, Marcheggiani Muccioli GM, Neri MP, Marcacci M, Zaffagnini S. Does revision ACL reconstruction
measure up to primary surgery? A meta-analysis comparing patient-reported and clinician-reported outcomes, and
radiographic results. Br J Sports Med. 2016;50(12):716-724. doi:10.1136/bjsports-2015-094948

13) Merle-Vincent F, Vignon E, Brandt K, et al. Superiority of the Lyon schuss view over the standing anteroposterior view
for detecting joint space narrowing, especially in the lateral tibiofemoral compartment, in early knee osteoarthritis. Ann
Rheum Dis. 2007;66(6):747-753. doi:10.1136/ard.2006.056481

14) Ritchie JF, Al-Sarawan M, Worth R, Conry B, Gibb PA. A parallel approach: the impact of schuss radiography of the
degenerate knee on clinical management. Knee. 2004;11(4):283-287. doi:10.1016/[Link].2003.09.001

15) Rosenberg TD, Paulos LE, Parker RD, Coward DB, Scott SM. The forty-five-degree posteroanterior flexion weight-bearing
radiograph of the knee. J Bone Joint Surg Am. 1988;70(10):1479-1483.

16) Piperno M, Hellio Le Graverand MP, Conrozier T, Bochu M, Mathieu P, Vignon E. Quantitative evaluation of joint space
width in femorotibial osteoarthritis: comparison of three radiographic views. Osteoarthritis Cartilage. 1998;6(4):252-259.
doi:10.1053/joca.1998.0118
17) Head-to-head comparison of the Lyon Schuss and fixed flexion radiographic techniques. Long-term reproducibility in
normal knees and sensitivity to change in osteoarthritic knees

18) Roux CH, Mazieres B, Verrouil E, et al. Femoro-tibial knee osteoarthritis: One or two X-rays? Results from a population-
based study. Joint Bone Spine. 2016;83(1):37-42. doi:10.1016/[Link].2015.04.013

19) Cuzzolin M, Previtali D, Zaffagnini S, Deabate L, Candrian C, Filardo G. Anterior Cruciate Ligament Reconstruction versus
Nonoperative Treatment: Better Function and Less Secondary Meniscectomies But No Difference in Knee Osteoarthritis-A
Meta-Analysis. Cartilage. 2021 Dec;13(1_suppl):1658S-1670S. doi: 10.1177/[Link]: 34929763

D16) Is there a role for bone scan, PET-CT

Consensus answer: Currently the role of bone scans and PET-CT are subject to scientific
investigations and no clear recommendations about their use in ACLR can be given.

Agreement: 8.2/9

Grade of recommendation: C

Literature review:
Very few articles have been published in the past 15 years which correlate the use of bone
scans and PET-CT with a revision anterior cruciate ligament (ACL) reconstruction.
All the publications focus on the use of single photon emission computerized tomography and
conventional computerized tomography (SPECT/CT) for evaluation of patients after anterior
cruciate ligament reconstruction.
The benefit of SPECT/CT in comparison with magnetic resonance imaging (MRI) is under
debate. Mathis et al.1 investigated whether bone tracer uptake (BTU) intensity and
distribution in SPECT/CT correlated with MRI findings in symptomatic patients after ACL
reconstruction. The study reported that MRI findings such as graft tear, graft signal hyper-
intensity, bone marrow edema and knee joint effusion were significantly correlated with
increased BTU in SPECT/CT, concluding that SPECT/CT can be used to assess increased loading
in lax knee, graft incorporation and bone tunnel remodeling of the bone. However BTU in
SPECT/CT is also rather unspecific and can be found in a number of conditions1.
Hirschmann et al.2 proposed a novel standardized algorithm using SPECT/CT, which combines
the 3D-mechanical information on tunnel placement, bone-graft-fixation and 3D metabolic
data, and is helpful in evaluating patients with pain after ACL reconstruction.
A further two papers3,4 were published by the same authors, in which they reported that
SPECT/CT tracer uptake intensity and distribution showed a significant correlation with
femoral and tibial tunnel position and orientation in patients with relevant symptoms after
ACL reconstruction, but no correlations were found with stability or clinical laxity. SPECT/CT
tracer uptake may help to predict ACL graft failure.
Moreover, the BTU intensity and distribution in SPECT/CT may help to predict the
development of OA at an early stage.

References:
1) Mathis DT, Hirschmann A, Falkowski AL, Kiekara T, Amsler F, Rasch H, Hirschmann MT. Increased bone tracer
uptake in symptomatic patients with ACL graft insufficiency: a correlation of MRI and SPECT/CT findings. Knee
Surgery, Sports Traumatology, Arthroscopy. 2018 Feb;26(2):563-573.
2) Hirschmann MT, Mathis D, Afifi FK, Rasch H, Henckel J, Amsler F, Wagner CR, Friederich NF, Arnold MP. Single
photon emission computerized tomography and conventional computerized tomography (SPECT/CT) for
evaluation of patients after anterior cruciate ligament reconstruction: a novel standardized algorithm combining
mechanical and metabolic information. Knee Surgery, Sports Traumatology, Arthroscopy. 2013 Apr;21(4):965-74.
3) Hirschmann MT, Mathis D, Rasch H, Amsler F, Friederich NF, Arnold MP. SPECT/CT tracer uptake is influenced by
tunnel orientation and position of the femoral and tibial ACL graft insertion site. International Orthopaedics . 2013
Feb;37(2):301-9.
4) Mathis DT, Buel L, Rasch H, Amsler F, Hirschmann, Hugli RW. Distribution of bone tracer uptake in symptomatic
knees after ACL reconstruction compared to asymptomatic non-operated knees: a method for better
differentiating patient-specific from disease-specific bone tracer uptake in SPECT/CT. Annals of Nuclear
Medicine. 2019 Mar;33(3):201-210.

D17) Does infection need to be ruled out on a routine basis and if so, how?

Consensus answer: Infection after ACL reconstruction is a rare complication; therefore

routine screening is not recommended. While acute infections are mostly easy to diagnose
(clinical, CRP, leucocytes, aspiration), low-grade infection is even rarer and more difficult to
diagnose. Sensitivity and specificity can be increased by taking tissue biopsies (three but not
more than six distinct intraoperative tissue samples). Additionally, newer studies show a
higher incidence of occult low-grade infections during ACL revision surgery. Further studies
are needed.
Agreement: 8.4/9

Grade of recommendation: B

Literature review:
Septic arthritis after ACL reconstruction is an uncommon complication, with a reported
incidence between 0.14% and 1.7%, although most studies have documented rates of less
than 1%1-3. The highest rate was published by Torres-Claramunt et al.4 (1.8 % in a series of 810
consecutive ACL reconstruction).
Infection after ACL reconstruction is a rare complication. Alomar et al., in a controlled study,
despite finding high rates of contamination on the intraoperative hamstring autograft during
harvesting and preparation, or by accidentally dropping the graft in the operating room, found
low bacterial counts, below the threshold for infection.5
Greenberg et al.6 found no increased clinical risk of infection with the use of allograft tissue
compared to autologous tissue for primary ACL reconstruction; however, the theoretical risk
of disease transmission inherent to allograft tissue cannot be eliminated.
Staphylococcus aureus and coagulase-negative staphylococci (CNS) are the most common
bacteria found in most series. Different methicillin-resistant Staphylococcus aureus or
anaerobium microorganisms have also been cultured as the origin of such infections 7.
Postoperative infections are divided into three groups: acute infection (less than 2 weeks),
subacute infection (between 2 weeks and 2 months) and late infection (after 2 months).
The new ACL, whether autograft or allograft, is nonviable tissue that can be colonized by
bacteria (especially low virulence bacteria) for a long time until it is replaced by the host tissue;
moreover, concomitant surgical procedures and previous knee surgery can be a risk factor for
septic knee arthritis, due to increased operative time and additional or larger incisions 7.
Mouzopoulos et al.8 recommend the following principles of diagnostic workup: baseline white
blood cell count, C-reactive protein, erythrocyte sedimentation rate, culture, and microscopic
examination of knee fluid.
Costa et al.9, in a retrospective study, concluded that a synovial white blood cell (WBC) count
is the most reliable test for the diagnosis of septic arthritis after ACL reconstruction. They
reported that a cutoff value of 28,100 cells/mL presented the good accuracy, and with the
threshold set at 40,000 cells/mL, postoperative infection could be diagnosed with 100%
accuracy.
In spite of what was previously mentioned, Everhart et al.10 and Flanigan et al.11 reported
that bacterial DNA was detectable in between 85% and 87% of their revision ACL
reconstructions. This finding did not cause clinically apparent infection symptoms but higher
bacterial DNA concentrations were associated with tibial tunnel widening.
Despite infection after ACL reconstruction being a rare complication, as reported before, some
studies have demonstrated that septic arthritis following this procedure can be significantly
reduced by pre-soaking ACL autografts in a vancomycin solution.12,13
In a recent International Consensus Meeting on Surgical Site and Periprosthetic Joint Infection
(PJI) it was agreed on the question on “how many intra-operative tissue samples should be
sent for culture in suspected PJI cases and cases of suspected aseptic failure?” that more than
three but not more than six distinct intra-operative tissue samples should be sent for aerobic
and anaerobic culture.14

References:
1) Whitehead TS. Failure of Anterior Cruciate Ligament Reconstruction. Clinics in Sports Medicine. 2013
Jan;32(1):177-204.
2) Wang C, Lee YHD, Siebold R. Recommendations for the management of septic arthritis after ACL reconstruction.
Knee Surgery, Sports Traumatology, Arthroscopy. 2014 Sep;22(9):2136-2144.
3) Wright RW, Huston LJ, Spindler KP, et al. Descriptive epidemiology of the multicenter ACL revision study (MARS)
cohort. American Journal of Sports Medicine.2010;38(10): 1979–1986.
4) Torres-Claramunt R, Pelfort X, Erquicia J, Gil-González S, Gelber PE, Puig L, Monllau JC. Knee joint infection after
ACL reconstruction; prevalence, management and functional outcomes. Knee Surgery, Sports Traumatology,
Arthroscopy. 2013; 21(12):2844–2849.
5) Abdulaziz Z Alomar , Saud M Alfayez, Ali M Somily. Hamstring autografts are associated with a high rate of
contamination in anterior cruciate ligament reconstruction Knee Surg Sports Traumatol Arthrosc 2018
May;26(5):1357-1361. doi: 10.1007/s00167-017-4686-4. Epub 2017 Aug 29.
6) Greenberg DD, Robertson M, Vallurupalli S, et al. Allograft compared with autograft infection rates in primary
anterior cruciate ligament reconstruction. Journal of Bone and Joint Surgery. 2010;92(14):2402–2408.
7) Torres-Claramunt R, Gelber P, Pefort X, Hinarejos P, Leal-Blanquet J, Perez-Prieto D, Monllau JC. Managing septic
arthritis after knee ligament reconstruction. International Orthopaedics. 2016 Mar;40(3):607-614.
8) Mouzopoulos G, Fotopoulos VC, Tzurbakis M. Septic knee arthritis following ACL reconstruction: a systematic
review. Knee Surgery, Sports Traumatology, Arthroscopy. 2009;17(9):1033–4102.
9) Costa GG, Grassi A, Lo Presti M, Cialdella S, Zamparini E, Viale P, Filardo G, Zaffagnini S. White Blood Cell Count Is
the Most Reliable Test for the Diagnosis of Septic Arthritis After Anterior Cruciate Ligament Reconstruction: An
Observational Study of 38 Patients. Arthroscopy. 2020 Dec 2:S0749-8063(20)31048-3.
10) Everhart JS, DiBartola AC, Dusane DH, Magnussen RA, Kaeding CC, Stoodley P, Flanigan DC. Bacterial
Deoxyribonucleic Acid Is Often Present in Failed Revision Anterior Cruciate Ligament Reconstructions.
Arthroscopy. 2018 Nov;34(11):3046-3052.
11) Flanigan DC, Everhart JS, DiBartola AC, Dusane DH, Abouljoud MM, MagnussenRA, Kaeding CC, Stoodley P.
Bacterial DNA is associated with tunnel widening in failed ACL reconstructions. Knee Surgery, Sports
Traumatology, Arthroscopy. 2019 Nov;27(11):3490-3497.
12) Schuster P, Schlumberger M, Mayer P, Eichinger M, Geßlein M, Richter J. Soaking of autografts in vancomycin is
highly effective in preventing postoperative septic arthritis after revision anterior cruciate ligament reconstruction.
Knee Surg Sports Traumatol Arthrosc. 2020 Apr;28(4):1154-1158. doi: 10.1007/s00167-019-05820-9. Epub 2019
Dec 3.
13) Vertullo CJ, Quick M, Jones A, Grayson JE. A surgical technique using presoaked vancomycin hamstring grafts to
decrease the risk of infection after anterior cruciate ligament reconstruction. Arthroscopy. 2012;28(3):337-342.
14) Parvizi J, Gehrke T, Chen AF. Proceedings of the International Consensus on Periprosthetic Joint Infection. Bone
Joint J. 2013 Nov;95-B(11):1450-2. doi: 10.1302/0301-620X.95B11.33135.

D18) What is the role of preoperative neuromuscular assessment?

Consensus answer:
Neuromuscular assessment is necessary in cases of discrepancy between subjective instability
and objective clinical (laxity) findings. However, preoperative neuromuscular assessment is
rarely performed and valid studies are lacking. No specific tests can be recommended at that
time, but commonly performed tests currently are isokinetic quadriceps and hamstring
strength tests and hop tests.
Arthrogenic muscle inhibition can be very frequent after knee trauma and may contribute to
the development of postoperative stiffness.

Agreement: 8.2/9

Grade of recommendation: D

Literature review:
Neuromuscular control is important in predicting failure of ACL reconstruction and a second
rupture1,2.
Studies have shown that neuromuscular deficits after ACL reconstruction are common and
persistent in the short and long term, sometimes persisting for longer than 24 months and
therefore possibly play a role in ACL revision surgery3-4. Tayfur et al.3, in a systematic review,
reported that strength and voluntary activation deficits are accompanied by changes in
cortical and spinal excitability for ACL injured patients in both the short and long term, as well
as deficits in force control and rapid force production.
Paterno et al.1 found that altered neuromuscular control of the hip and knee during a dynamic
landing exercise, as well as postural instability after ACL reconstruction, are predictors of a
second ACL injury. Premature return to high-demand activities or aggressive rehabilitation can
alter these neuromuscular patterns; however, improved postural stability and control of the
center of mass may help minimize subsequent ACL injury. Premature return to high level
sports before complete restoration of neuromuscular control leaves the knee less able to
resist stress and more prone to recurrent injury5. In a recent systematic review it was found,
that returning to level I sports after ACL reconstruction leads to a more than 4-fold increase
in reinjury rates over 2 years. RTS 9 months or later after surgery and more symmetrical
quadriceps strength prior to return substantially reduce the reinjury rate. 15
The MARS6 group reported that rehabilitation-related factors may have the ability to modify
clinical outcomes 2 years after an ACL revision. This multicenter study demonstrated that
bracing during the early postoperative period is not helpful; in fact patients who had a revision
ACL reconstruction and were prescribed a postoperative ACL derotation device (or “ACL
functional brace”) during rehabilitation were 2.3 times more likely to have subsequent knee
surgery within 2 years.
However, patients with a postoperative ACL functional brace for use when returning to sports
had a better knee injury and Osteoarthritis Outcome Score (KOOS) for sports/recreation 2
years postoperatively.
In addition, it has been proved that early weight-bearing is safe and in fact decreases the risk
of patellofemoral pain7.
If proper postoperative rehabilitation is not performed, extensor mechanism dysfunction can
complicate ACL reconstruction; indeed, inadequate rehabilitation may lead to inhibition of the
quadriceps, loss of patellar mobility, and loss of knee motion. If left untreated, patellar
entrapment may progress to infrapatellar contracture syndrome5.
Sonnery-Cottet et al. demonstrated in their scoping review that cryotherapy and physical
exercise are recommended in the management of arthrogenic muscle inhibition. This therapy
can improve quadriceps activation failure after ACL injury and reconstruction. 14
Correct surgical technique and adequate postoperative rehabilitation reduce the incidence of
extensor mechanism dysfunction8.
The literature has shown that for revision ACL reconstruction the mean rate of return to sport
at pre-injury level varies from 52%9 to values lower than 40%10,11. In view of the above,
considering that the return to sport outcomes differ between primary and revision ACL
reconstruction, it is important for surgeons to provide patients with adequate and realistic
expectations after revision procedures12.
Dalla Villa et al.13 reported that a higher compliance in rehabilitation significantly increased
the chances of returning to sport at the same pre-injury level after ACL revision
reconstruction. Patients have to be motivated to be compliant with the rehabilitation
protocol, including an on-field-rehabilitation phase, to increase the possibility of returning to
their pre-injury sport level.
A study from Grindem et al shows: More symmetrical quadriceps strength before Return-to-
sports and a delayed return to level-1 sports (>9 months) decreases the reinjury rate after
primary ACL reconstructions.

References:
1) Paterno MV, Schmitt LC, Ford KR, et al. Biomechanical measures during landing and postural stability predict
second anterior cruciate ligament injury after anterior cruciate ligament reconstruction and return to sport.
American Journal of Sports Medicine.2010; 38(10):1968–1978.
2) Myer GD, Ford KR, Hewett TE. New method to identify athletes at high risk of ACL injury using clinic-based
measurements and freeware computer analysis. British Journal of Sports Medicine.2011;45(4):238–244.
3) B Tayfur, C Charuphongsa, D Morrissey, SC Miller Neuromuscular Function of the Knee Joint Following Knee
Injuries: Does It Ever Get Back to Normal? A Systematic Review with Meta-Analyses. Sports Medicine. 2021
Feb;51(2):321-338. doi: 10.1007/s40279-020-01386-6.
4) SA Xergia, JA Mcclelland, J Kvist, HS Vasiliadis, AD Georgoulis. The influence of graft choice on isokinetic muscle
strength 4-24 months after anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology,
Arthroscopy. 2011;5:768–780.
5) George MS, Dunn WR, Spindler KP. Current concepts review: revision anterior cruciate ligament reconstruction.
American Journal of Sports Medicine. 2006 Dec;34(12):2026-2037.
6) MARS Group, Rehabilitation Predictors of Clinical Outcome Following Revision ACL Reconstruction in the MARS
Cohort. Journal of Bone and Joint Surgery. 2019 May 1;101(9):779-786.
7) Kruse LM, Gray BL, Wright RW. Anterior cruciate ligament reconstruction rehabilitation in the pediatric
population. Clinics in Sports Medicine. 2011 Oct;30(4):817-24.
8) Whitehead TS. Failure of Anterior Cruciate Ligament Reconstruction. Clinics in Sports Medicine. 2013
Jan;32(1):177-204.
9) Grassi A, Zaffagnini S, Marcheggiani Muccioli GM, Neri MP, Della Villa S, Marcacci M. After revision anterior
cruciate ligament reconstruction, who returns to sport? A systematic review and meta-analysis. British Journal of
Sports Medicine. 2015 Oct;49(20):1295-1304.
10) Andriolo L, Filardo G, Kon E, Ricci M, Della Villa F, Della Villa S et al (2015) Revision anterior cruciate ligament
reconstruction: clinical outcome and evidence for return to sport. Knee Surgery, Sports Traumatology,
Arthroscopy. 23:2825–2845.
11) Gifstad T, Drogset JO, Viset A, Grontvedt T, Hortemo GS (2013) Inferior results after revision ACL reconstructions:
a comparison with primary ACL reconstructions. Knee Surgery, Sports Traumatology, Arthroscopy. 21:2011–2018.
12) Kraeutler MJ, Welton KL, McCarty EC, Bravman JT. Current Concepts Review Revision Anterior Cruciate Ligament
Reconstruction. The Journal of Bone and Joint Surgery. 2017;99: 1689-1696.
13) Dalla Villa F, Andriolo L, Ricci M, Filardo G, Gamberini J, Caminati D, Dalla Villa S, Zaffagnini S. Compliance in post-
operative rehabilitation is a key factor for return to sport after revision anterior cruciate ligament reconstruction.
Knee Surgery, Sports Traumatology, Arthroscopy. 2020 Feb;28(2):463-469.
14) Sonnery-Cottet B, Saithna A, Quelard B, Daggett M, Borade A, Ouanezar H, Thaunat M, Blakeney WG.
Arthrogenic muscle inhibition after ACL reconstruction: a scoping review of the efficacy of interventions. Br J
Sports Med. 2019 Mar;53(5):289-298. doi: 10.1136/bjsports-2017-098401.
15) Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Arna Risberg M. 5 Simple decision rules reduce reinjury
risk after Anterior cruciate ligament reconstruction: The Delaware-Oslo ACL cohort study”, Br J Sports Med 2016
Jul;50(13):804-8. doi: 10.1136/bjsports-2016-096031
Flow chart Management of failed ACL reconstruction
III. Surgical Strategy (formal consensus)

Introduction:

Revision ACL reconstruction is technically more demanding than primary ACL reconstruction
and multiple factors other than ACL insufficiency must be taken into consideration.
Preoperative elaboration of a surgical strategy is mandatory in order to be optimally prepared
for revision surgery. Essential aspects of the surgical strategy include deciding whether a
single-stage procedure is possible or whether a two-stage procedure may be necessary; how
to deal with previous tunnels and graft fixation material; the necessity for concomitant
procedures to treat accompanying meniscal and chondral injuries, combined ligamentous
insufficiency or bony malalignment; and determination of the ideal graft material and graft
fixation method. In general, a single-stage procedure should be used whenever possible;
however, in certain cases, a two-stage procedure may be necessary. In patients undergoing
revision surgery, bony malalignment and concomitant insufficiency of other ligamentous
structures, especially of the anterolateral structures and the medial ligamentous complex, is
more common than in patients undergoing primary ACL reconstruction. Since these
associated pathologies are thought to be important risk factors for ACL graft failure, revision
ACL reconstruction must often be combined with osteotomies, anterolateral procedures,
stabilization of the medial ligamentous complex and meniscal reconstruction surgery.
S1: Which factors are relevant to the surgical strategy when the decision is made to revise
a previously reconstructed ACL?

Steering group answer:

The following factors are relevant to the surgical strategy:
- Range of motion
o Severely Restricted ROM
o Significant Hyperextension (>5°)
- Availability of graft material
o Autograft or allograft? Ipsilateral or contralateral graft harvesting? Bone block
or soft tissue graft?
- Previous tunnel size and location
o Are the tunnel diameters of preexisting tunnels acceptable? Can the tunnels
be reused or are new tunnels necessary? Can new tunnels be drilled without
creating a bony defect (confluent tunnels)? Can stable fixation be achieved?
- Previous graft fixation
o Is it necessary to remove previous fixation material? Will removal of fixation
material create a relevant bony defect?
- Limb alignment (coronal/sagittal)
o Is limb alignment a possible factor for ACL graft failure? Can limb alignment
be corrected in a single stage procedure or is a two-stage procedure
preferred?
- Meniscal status
o Does a specific meniscal tear need to be addressed (root tear, ramp lesion)? Is
significant meniscal loss a possible reason for ACL graft failure? Is meniscal
reconstruction or transplantation necessary?
- Cartilage status / Preexisting OA
o Is a cartilage repair procedure indicated? May an osteotomy to unload
unicompartmental OA be an option?
- Concomitant ligament insufficiency
o Are there relevant concomitant ligament insufficiencies contributing to ACL
graft failure? Can all ligaments be treated in a single-stage procedure? May
the patient benefit from additional anterolateral stabilization?
- Grade of laxity
o Is concomitant anterolateral stabilization indicated? Is a posterolateral root
tear or posteromedial ramp lesion present?
- Bone quality
o Can adequate fixation stability be achieved with standard fixation methods?
Are alternative techniques necessary (e.g. back-up fixation or oversized
screws?)
- Patient activity and expectation
o May the patient benefit from an additional anterolateral stabilization?
- Infection status
o Is an active infection evident? Suspected low-grade infection?

Grade of recommendation: B

Literature review:
Revision ACL reconstruction is a complex procedure with several potential complications and
pitfalls, and the expected outcome is generally inferior compared to primary ACL
reconstruction [1, 2, 3]. Surgeons should therefore be familiar with different techniques and
a sophisticated surgical strategy is mandatory to increase the likelihood of a successful
outcome. Several factors are relevant for surgical strategy, which have been extensively
described in several review articles about revision ACLR [4, 5, 6, 7, 8, 9]. A synthesis of these
articles is as follows:

Range of motion: Revision ACL reconstruction should only be performed in knees with an
acceptable range of motion. Small restrictions can be treated during revision reconstruction;
however, in patients with arthrofibrosis, a staged procedure is necessary to restore range of
motion first. Furthermore, generalized joint hypermobility has been associated with inferior
outcomes after ACL reconstruction [10] and preoperative hyperextension >5° has been shown
to be an independent, significant predictor of graft failure after primary [11] and revision
ACLR [12]. The consequences of hypermobility on surgical strategy remain largely unknown;
however, slight modifications of the surgical technique, such as graft tensioning in
hyperextension or additional extraarticular stabilization, should be considered.

Availability of graft material: Depending on the graft used for primary ACL reconstruction,
the surgeon must decide which graft is the most appropriate for the individual patient. Both
autografts and allografts can be used. Graft choice may also be influenced by tunnel size, since
a graft with a bone block may allow compensation for larger bony defects.

Tunnel size and location: The surgeon must decide if the position of the previous tunnels is
anatomic, partially anatomic, or completely non-anatomic. Furthermore, tunnel widening
must be determined since severe tunnel widening may affect tunnel placement and graft
fixation. Anatomic tunnels with no significant widening can generally be reused, whereas a
new tunnel can usually be drilled in the event of a completely non-anatomic tunnel position.
In cases with severe tunnel widening or partially malpositioned tunnels, which may interfere
with placement of a new anatomic tunnel, single-stage or two-stage bone grafting should be
considered.

Previous graft fixation: It must be determined whether hardware will interfere with new
tunnel placement. If hardware has to be removed, the surgeon must make sure to have the
necessary instruments available. Furthermore, hardware removal can create a bony defect,
which may require bone grafting.

Limb alignment: Coronal (varus/valgus) and sagittal (posterior tibial slope) malalignment can
contribute to ACL graft failure. It is therefore necessary to decide whether limb malalignment
is considered significant and requires correction. Furthermore, in patients with degenerative
changes, an unloading osteotomy may be beneficial to slow osteoarthritic progression.

Meniscal status: Both the medial and lateral meniscus function as secondary stabilizers.
Previously untreated meniscal tears, especially root tears and ramp lesions, may have
contributed to failure of the primary ACL reconstruction. It is therefore important to
adequately treat such tears during revision surgery. Parkinson et al. demonstrated that
meniscal deficiency is the most significant factor in predicting graft failure in single-bundle
ACL reconstruction (13). Where there is significant meniscal loss, concomitant or staged
meniscal transplantation should therefore be considered.

Cartilage status/preexisting OA: In patients with deep focal chondral defects, cartilage repair
procedures should be considered. In patients with unicompartmental OA and coronal
malalignment, an unloading osteotomy may be more important than revision ACLR, especially
in patients with low functional demands.

Concomitant ligament insufficiency: Insufficiency of other ligaments such as MCL or

anterolateral structures results in complex instability patterns, which cannot be treated with
isolated ACL reconstruction. During revision surgery, all ligaments involved should be repaired
or reconstructed.

Grade of laxity: In patients with a high-grade pivot shift, ACL insufficiency is usually combined
with other structural damage such as a posterolateral root tear and/or insufficiency of the
anterolateral structures. Isolated revision ACLR may not be able to restore normal knee
kinematics and all involved structures should be addressed.

Bone quality: Especially in older individuals, bone quality may be reduced, resulting in inferior
graft fixation strength. Fixation techniques should therefore be individualized and alternative
techniques such as oversized screws or backup-fixation should be considered.

Patient activity: Failure rate is higher in active patients, especially in those involved in pivoting
sports. Therefore, additional anterolateral stabilization should be considered.

Infection status: In patients with active or suspected infection, initial treatment requires
washout, removal of hardware, and debridement with subsequent antibiotic treatment to
achieve complete bacterial eradication.

References:
[1] Grassi A, Ardern CL, Marcheggiani Muccioli GM, Neri MP, Marcacci M, Zaffagnini S. Does revision ACL reconstruction
measure up to primary surgery? A meta-analysis comparing patient-reported and clinician-reported outcomes, and
radiographic results. Br J Sports Med. 2016 Jun;50(12):716-24

[2] Gifstad T, Drogset JO, Viset A, Grøntvedt T, Hortemo GS. Inferior results after revision ACL reconstructions: a comparison
with primary ACL reconstructions. Knee Surg Sports Traumatol Arthrosc. 2013 Sep;21(9):2011-8

[3] Weiler A, Schmeling A, Stöhr I, Kääb MJ, Wagner M. Primary versus single-stage revision anterior cruciate ligament
reconstruction using autologous hamstring tendon grafts: a prospective matched-group analysis. Am J Sports Med. 2007
Oct;35(10):1643-52

[4] Erickson BJ, Cvetanovich GL, Frank RM, Riff AJ, Bach BR Jr.
Revision ACL Reconstruction: A Critical Analysis Review.
JBJS Rev. 2017 Jun;5(6):e1

[5] Kraeutler MJ, Welton KL, McCarty EC, Bravman JT.

Revision Anterior Cruciate Ligament Reconstruction.
J Bone Joint Surg Am. 2017 Oct 4;99(19):1689-1696

[6] George MS, Dunn WR, Spindler KP. Current concepts review: revision anterior cruciate ligament reconstruction. Am J
Sports Med. 2006 Dec;34(12):2026-37.

[7] Kamath GV, Redfern JC, Greis PE, Burks RT. Revision anterior cruciate ligament reconstruction. Am J Sports Med. 2011
Jan;39(1):199-217

[8] Mayr R, Rosenberger R, Agraharam D, Smekal V, El Attal R. Revision anterior cruciate ligament reconstruction: an
update. Arch Orthop Trauma Surg. 2012 Sep;132(9):1299-313

[9] Southam BR, Colosimo AJ, Grawe B. Underappreciated Factors to Consider in Revision Anterior Cruciate Ligament
Reconstruction: A Current Concepts Review. Orthop J Sports Med. 2018 Jan 24;6(1):2325967117751689

[10] Generalised joint hypermobility increases ACL injury risk and is associated with inferior outcome
after ACL reconstruction: a systematic review.
Sundemo D, Hamrin Senorski E, Karlsson L, Horvath A, Juul-Kristensen B, Karlsson J, Ayeni OR, Samuelsson [Link] Open
Sport Exerc Med. 2019 Nov 10;5(1):e000620. doi: 10.1136/bmjsem-2019-000620.

[11] Guimarães TM, Giglio PN, Sobrado MF, Bonadio MB, Gobbi RG, Pécora JR, Helito CP. Knee Hyperextension Greater
Than 5 Is a Risk Factor for Failure in ACLReconstruction Using Hamstring Graft.
Orthop J Sports Med. 2021 Nov 17;9(11):23259671211056325. doi: 10.1177/23259671211056325.

[12] Physiologic Preoperative Knee Hyperextension Is a Predictor of Failure in an Anterior Cruciate Ligament Revision
Cohort: A Report From the MARS Group.
MARS Group, Am J Sports Med. 2018 Oct;46(12):2836-2841. doi: 10.1177/0363546518777732.

[13] Factors That Predict Failure in Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction.
Parkinson B, Robb C, Thomas M, Thompson P, Spalding [Link] J Sports Med. 2017 Jun;45(7):1529-1536. doi:
10.1177/0363546517691961.
S2: Which factors influence the decision to perform a single- vs. two-stage procedure?

Steering group answer:

The following factors influence the decision of single- vs. two-stage procedures:

Absolute indications for two-stage Relative indications for two-stage

• Clinically relevant reduced range of • Tunnel widening around > 12 mm
motion due to arthrofibrosis [2, 3,8] (depending on graft choice,
• Infection/suspicion of infection drilling technique, and fixation
• Impossible to achieve secure graft technique)
fixation at the anatomic insertion • Partially malpositioned tunnel
sites due to insufficient bone stock interfering with a new, anatomically
placed tunnel
• Complex combined surgery

Grade of recommendation: C

Literature review:
Revision ACL reconstruction can be performed as a single- or two-stage procedure.
Although a single-stage procedure is preferable from both the patient’s and the economic
perspective, there are specific scenarios requiring other surgical interventions before revision
ACLR can be performed. Factors that have to be considered in the decision process include
ROM, infection status, tunnel size and position, and concomitant pathologies such as limb
alignment, cartilage and meniscal status, and concomitant ligament insufficiency [1, 2, 3, 4].
The decision of whether to perform a single- or two-stage procedure is always an individual
decision and the indication is often relative. Overall, the available evidence is low, and
recommendations are mainly based on expert opinions and common good clinical practice.
Absolute indications for a two-stage procedure are significantly restricted range of motion
due to Arthrofibrosis and active infection or clinical suspicion of infection [1, 2]. In patients
with Arthrofibrosis, a staged motion-restoring procedure such as arthroscopic arthrolysis [11
] followed by an aggressive rehabilitation program should be performed first. In patients with
failed ACL reconstruction and active infection, adequate treatment consists of irrigation,
debridement, and synovectomy followed by a period of antibiotic treatment. Revision ACLR
should only be performed if eradication has been achieved [7, 12]. In patients with clinical
suspicion of infection, a two-stage procedure is also recommended to prove either eradication
by multiple biopsies or to treat the patient with irrigation and debridement.
The decision process regarding tunnel management is less straightforward and is also
influenced by details of the planned surgical technique, such as graft choice, drilling technique
and fixation technique. In general, the inability to achieve secure graft fixation at the anatomic
insertion sites due to insufficient bone stock represents an absolute indication for a staged
procedure [1,2,6]. Insufficient bone stock can be the result of either excessive tunnel widening
or convergence of preexisting partially anatomic tunnels with newly placed anatomic tunnels.
In this case, bone grafting of preexisting tunnels followed by staged revision ACLR after bony
incorporation of the graft is usually performed [6, 8]. However, no uniform threshold exists
regarding the critical tunnel size and values between 10 and 15 mm have been recommended
[8]. The value for a critically sized tunnel may also vary with regard to graft choice, drilling
technique, and fixation technique. In the authors’ opinion, tunnel widening with a diameter
of >12 mm is considered a relative indication for a staged procedure. Furthermore, bone
grafting must not necessarily be performed as a two-stage procedure but can also be
performed concomitant with revision ACLR as a single-stage procedure [9,10].
Another relative indication is the necessity to address one or more concomitant pathologies
such as meniscal deficiency, limb malalignment, or combined ligamentous insufficiency.
Depending on the pathologies involved, a complex combined surgery may be necessary to
achieve the best possible outcome. Such procedures can be performed as a one- or two-stage
procedure without evidence in favor for one specific approach. The decision is mainly based
on technical feasibility and the surgeon’s preference/experience. Another relative indication
for a staged procedure is significant varus or valgus malalignment associated with
unicompartmental OA Grade III or IV according to KL. In such patients, isolated realignment
osteotomy without revision ACLR may be appropriate, especially in older, less active patients
with no or only mild instability symptoms. If instability symptoms remain after the osteotomy,
revision ACLR can still be performed in a second operation.
If the indications for a staged procedure are relative, the advantages and disadvantages of
each approach must be weighted up. The disadvantages of a two-stage procedure are the
necessity for more operative procedures, longer rehabilitation, and a prolonged period of ACL
deficiency with a potential risk for secondary cartilage and meniscal injuries. However, current
evidence suggests that comparable results can be achieved in patients who require a staged
approach [4, 6]. Of note, a systematic review from 2018 comparing outcomes and failure rates
of single- vs. two-stage ACLR found comparable clinical outcomes and lower rate of revision
surgery and clinical failure after a two-staged approach [5]. Although these results must be
interpreted with caution, both options for revision ACLR are appropriate in carefully selected
patients [4,5,6].

References:

[1] Erickson BJ, Cvetanovich G, Waliullah K, Khair M, Smith P, Bach B Jr, Sherman S.
Two-Stage Revision Anterior Cruciate Ligament Reconstruction.
Orthopedics. 2016 May 1;39(3):e456-64.

[2] Erickson BJ, Cvetanovich GL, Frank RM, Riff AJ, Bach BR Jr.
Revision ACL Reconstruction: A Critical Analysis Review.
JBJS Rev. 2017 Jun;5(6):e1

[3] Kraeutler MJ, Welton KL, McCarty EC, Bravman JT.

Revision Anterior Cruciate Ligament Reconstruction.
J Bone Joint Surg Am. 2017 Oct 4;99(19):1689-1696

[4] Colatruglio M, Flanigan DC, Long J, DiBartola AC, Magnussen RA.

Outcomes of 1- Versus 2-Stage Revision Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-
analysis.
Am J Sports Med. 2020 Jul 16:363546520923090. doi: 10.1177/0363546520923090. Epub ahead of print.

[5] Mathew CJ, Palmer JE, Lambert BS, et al

Single-stage versus two-stage revision anterior cruciate ligament reconstruction: a systematic review
Journal of ISAKOS: Joint Disorders & Orthopaedic Sports Medicine Published Online First: 15 September
2018. doi: 10.1136/jisakos-2017-000192

[6] Mitchell JJ, Chahla J, Dean CS, Cinque M, Matheny LM, LaPrade RF. Outcomes After 1-Stage Versus 2-Stage Revision
Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2017 Jul;45(8):1790-1798.

[7] Pogorzelski J, Themessl A, Achtnich A, Fritz EM, Wörtler K, Imhoff AB, Beitzel K, Buchmann S. Septic Arthritis After
Anterior Cruciate Ligament Reconstruction: How Important Is Graft Salvage? Am J Sports Med. 2018 Aug;46(10):2376-2383

[8] Salem HS, Axibal DP, Wolcott ML, Vidal AF, McCarty EC, Bravman JT, Frank RM. Two-Stage Revision Anterior Cruciate
Ligament Reconstruction: A Systematic Review of Bone Graft Options for Tunnel Augmentation. Am J Sports Med. 2020
Mar;48(3):767-777

[9] Werner BC, Gilmore CJ, Hamann JC, Gaskin CM, Carroll JJ, Hart JM, Miller MD. Revision Anterior Cruciate Ligament
Reconstruction: Results of a Single-stage Approach Using Allograft Dowel Bone Grafting for Femoral Defects. J Am Acad
Orthop Surg. 2016 Aug;24(8):581-7

[10] Ra HJ, Ha JK, Kim JG. One-stage revision anterior cruciate ligament reconstruction with impacted bone graft after failed
primary reconstruction. Orthopedics. 2013 Nov;36(11):860-3

[11] Mayr HO, Brandt CM, Weig T, Koehne M, Bernstein A, Suedkamp NP, Hube R, Stoehr A. Long-term Results of
Arthroscopic Arthrolysis for Arthrofibrosis After Anterior Cruciate Ligament Reconstruction. Arthroscopy. 2017
Feb;33(2):408-414
[12] Waterman BR, Arroyo W, Cotter EJ, Zacchilli MA, Garcia EJ, Owens BD. Septic Arthritis After Anterior Cruciate Ligament
Reconstruction: Clinical and Functional Outcomes Based on Graft Retention or Removal. Orthop J Sports Med. 2018 Mar
1;6(3):2325967118758626

S3: When is bone grafting of a widened or malpositioned tunnel indicated?

Steering group answer:

Bone grafting is generally recommended if secure graft fixation cannot be achieved in an
anatomic position due to an increased tunnel diameter. No absolute threshold exists for the
“critical tunnel diameter”, with values ranging between 12 and 15 mm. In fact, the threshold
may vary with regard to graft choice, drilling technique, fixation technique, and knee size.
Three scenarios exist in which bone grafting may be indicated:
1. A previously partially malpositioned tunnel, which will interfere with a new anatomic
tunnel, resulting in a confluent tunnel exceeding the critical diameter
2. A previous anatomic tunnel position exceeding the critical diameter
3. Intra OP widening caused by difficult fixation hardware removal
However, by using specific techniques such as outside-in drilling with a different tunnel
trajectory, over the top technique, using grafts with large bone blocks and large interference
screws, bone grafting may not be necessary.
Bone grafting is usually performed as a two-stage procedure; however, with specific
techniques (e.g. impaction bone grafting) bone grafting can also be performed as a one-stage
procedure.
If preexisting tunnels do not interfere with new tunnel placement or graft fixation, they can
usually be left alone, and bone grafting is not necessary/indicated.

Grade of recommendation: C

Literature review:
One of the main goals during revision ACL reconstruction is to achieve secure fixation of an
anatomically placed graft in good quality bone. However, prior tunnel placement and/or
tunnel widening may impair anatomic graft positioning, initial fixation strength, and biological
graft incorporation.
A single-stage procedure without bone grafting can generally be performed in patients with
appropriately placed tunnels without widening, which can be reused, or in patients with
completely malpositioned tunnels that do not interfere with placement of new anatomic
tunnels [1, 3, 4, 5].
On the other hand, bone grafting is generally indicated if the position or size of previous
tunnels precludes anatomic graft placement and secure fixation in good quality bone [1]. Two
scenarios are common in which bone grafting is indicated: (1) A previously partially
malpositioned tunnel which will interfere with a new anatomic tunnel, resulting in a confluent
tunnel exceeding the “critical diameter”; and (2) a previously anatomic tunnel position
exceeding the “critical diameter” [2, 3]. With regard to the “critical diameter”, no uniformly
accepted threshold exists. In a recent systematic review of studies reporting outcomes of bone
tunnel grafting in two-stage revision ACLR [2], the upper limits of tunnel diameter varied
between 10 and 15 mm. These values have also been proposed in other review articles [4, 5].
The critical value of diameter is also dependent on graft choice and graft fixation: an allograft
with a large bone block can compensate for a larger bony defect, whereas soft tissue grafts
cannot compensate for any bony defect. Furthermore, an interference screw may allow a
larger tunnel [15], whereas suspensory fixation may require a smaller tunnel diameter.
Therefore, the cut-off value for bone grafting must always be customized to the planned
surgical technique [5]. White et al. demonstrated that single-stage revision ACLR could be
performed reliably in the majority of patients by using a decision-making algorithm [15].
Furthermore, it has been shown that an inside-out drilling technique with a different tunnel
trajectory can be safely performed even in patients with significant tunnel widening [16].
Bone grafting is most commonly performed as a two-stage procedure [3, 9, 10, 11]. During
the first stage, all previous graft and fixation material is removed, the tunnel walls are
debrided, and the tunnels grafted with autologous or allogenic bone (see also S4). Revision
ACLR is than performed in the second stage after a minimum period of 3-6 months and
confirmation of good graft incorporation. The advantage of this approach is that new
anatomic tunnels can be created without compromises, similar to a primary ACLR. However,
the disadvantages of a staged procedure include the necessity for more operative procedures,
longer rehabilitation, and a prolonged period of ACL deficiency with a potential risk for
secondary cartilage and meniscal injuries. Although two systematic reviews could not
demonstrate negative effects of a staged procedure [1, 8], several alternative techniques have
been described to avoid a two-stage procedure in the case of partially malpositioned or
significantly widened tunnels, including one-stage bone grafting and revision ACLR [6, 7, 12,
14, 17] or using an anterolateral tibial tunnel [13]. Although some case series have been
published with encouraging results [6, 7, 12,13], further studies are required before these
techniques can be recommended for widespread use. At present, these techniques should be
reserved for experienced surgeons who are familiar with these techniques.

References:

[1] Colatruglio M, Flanigan DC, Long J, DiBartola AC, Magnussen RA.

Outcomes of 1- Versus 2-Stage Revision Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-
analysis.
Am J Sports Med. 2020 Jul 16:363546520923090. doi: 10.1177/0363546520923090. Epub ahead of print.

[2] Salem HS, Axibal DP, Wolcott ML, Vidal AF, McCarty EC, Bravman JT, Frank RM. Two-Stage Revision Anterior Cruciate
Ligament Reconstruction: A Systematic Review of Bone Graft Options for Tunnel Augmentation. Am J Sports Med. 2020
Mar;48(3):767-777

[3] Mitchell JJ, Chahla J, Dean CS, Cinque M, Matheny LM, LaPrade RF. Outcomes After 1-Stage Versus 2-Stage Revision
Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2017 Jul;45(8):1790-1798.

[4] Erickson BJ, Cvetanovich GL, Frank RM, Riff AJ, Bach BR Jr.
Revision ACL Reconstruction: A Critical Analysis Review.
JBJS Rev. 2017 Jun;5(6):e1

[5] Kraeutler MJ, Welton KL, McCarty EC, Bravman JT.

Revision Anterior Cruciate Ligament Reconstruction.
J Bone Joint Surg Am. 2017 Oct 4;99(19):1689-1696

[6] Werner BC, Gilmore CJ, Hamann JC, Gaskin CM, Carroll JJ, Hart JM, Miller MD. Revision Anterior Cruciate Ligament
Reconstruction: Results of a Single-stage Approach Using Allograft Dowel Bone Grafting for Femoral Defects. J Am Acad
Orthop Surg. 2016 Aug;24(8):581-7

[7] Ra HJ, Ha JK, Kim JG. One-stage revision anterior cruciate ligament reconstruction with impacted bone graft after failed
primary reconstruction. Orthopedics. 2013 Nov;36(11):860-3

[8] Mathew CJ, Palmer JE, Lambert BS, et al

Single-stage versus two-stage revision anterior cruciate ligament reconstruction: a systematic review
Journal of ISAKOS: Joint Disorders & Orthopaedic Sports Medicine Published Online First: 15 September
2018. doi: 10.1136/jisakos-2017-000192

[9] Franceschi F, Papalia R, Del Buono A, Zampogna B, Diaz Balzani L, Maffulli N, Denaro V. Two-stage procedure in anterior
cruciate ligament revision surgery: a five-year follow-up prospective study. Int Orthop. 2013 Jul;37(7):1369-74

[10] von Recum J, Gehm J, Guehring T, Vetter SY, von der Linden P, Grützner PA, Schnetzke M. 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. Arthroscopy.
2020 Jan;36(1):178-185

[11] Thomas NP, Kankate R, Wandless F, Pandit H. Revision anterior cruciate ligament reconstruction using a 2-stage
technique with bone grafting of the tibial tunnel. Am J Sports Med. 2005 Nov;33(11):1701-9

[12] Dragoo JL, Kalisvaart M, Smith KM, Pappas G, Golish R. Single-stage revision anterior cruciate ligament reconstruction
using bone grafting for posterior or widening tibial tunnels restores stability of the knee and improves clinical outcomes.
Knee Surg Sports Traumatol Arthrosc. 2019 Nov;27(11):3713-3721
[13] Keyhani S, Hanafizadeh B, Verdonk R, Sajjadi MM, Soleymanha M. Revision Single-Stage Anterior Cruciate Ligament
Reconstruction Using an Anterolateral Tibial Tunnel. J Knee Surg. 2020 Apr;33(4):410-416

[14] Battaglia TC, Miller MD. Management of bony deficiency in revision anterior cruciate ligament reconstruction using
allograft bone dowels: surgical technique. Arthroscopy. 2005 Jun;21(6):767.

[15] White NP, Borque KA, Jones MH, Williams A. Single-Stage Revision Anterior Cruciate Ligament Reconstruction:
Experience With 91 Patients (40 Elite Athletes) Using an Algorithm. Am J Sports Med. 2021 Feb;49(2):364-373

[16] Pioger C, Saithna A, Rayes J, Haidar IM, Fradin T, Ngbilo C, Vieira TD, Cavaignac E, Sonnery-Cottet B. Influence of
Preoperative Tunnel Widening On the Outcomes of a Single Stage-Only Approach to Every Revision Anterior Cruciate
Ligament Reconstruction: An Analysis of 409 Consecutive Patients From the SANTI Study Group. Am J Sports Med. 2021
May;49(6):1431-1440

[17] Schliemann B, Treder M, Schulze M, Müller V, Vasta S, Zampogna B, Herbort M, Kösters C, Raschke MJ, Lenschow S.
Influence of Different Tibial Fixation Techniques on Initial Stability in Single-Stage Anterior Cruciate Ligament Revision With
Confluent Tibial Tunnels: A Biomechanical Laboratory Study. Arthroscopy. 2016 Jan;32(1):78-89.

S4: What is the best material for tunnel grafting (autograft, allograft, synthetic bone
substitutes)?

Steering group answer:

Both autologous and allogenic bone are suitable for tunnel grafting. Autologous bone is
osteogenic, osteoinductive and osteoconductive, whereas allogenic bone is mainly
osteoconductive. Therefore, autologous bone may represent the best graft material, but there
is some donor side morbidity. Good filling rates have been reported with both graft materials
(Salem et al.). Because of limited data and unfavorable results observed after open wedge
high tibial osteotomy, synthetic bone substitutes should be used with care. Nevertheless, two
studies have reported comparable results between autologous bone and silicate-substituted
calcium phosphate (von Recum et al. 2017 / 2020). Whatever material is used, careful tunnel
preparation with removal of all graft material and sutures and breaking up of sclerotic bone is
important.

Grade of recommendation: B

Literature review:
Options for tunnel grafting include autograft, allograft, and commercially available bone
substitutes. The most commonly used material for tunnel grafting is allogenic or autologous
bone [1].
Successful incorporation of any graft material depends on mechanical and biological
properties and occurs through different mechanisms including osteogenic, osteoconductive,
and osteoinductive pathways [3, 4, 5]. Osteogenesis describes bone formation by cells derived
from the graft; osteoinduction is the process by which mesenchymal stem cells are recruited
and stimulated to differentiate into chondroblasts and osteoblasts; and osteoconduction
describes the ability of the graft to provide a scaffold for the ingrowth of capillaries,
perivascular tissue, and mesenchymal stem cells [3, 4[. The osteoconductive, osteoinductive,
and osteogenic properties of different graft materials used for tunnel grafting are summarized
in Table 1.

Table 1: Osteoconductive, osteoinductive, and osteogenic properties of different graft

material (modification based on [3])
Osteoconduction Osteoinduction Osteogenicity
Cancellous Yes Yes Yes
autograft
Cortical autograft Yes No Yes
Structural allograft Yes No No
Particulate allograft Yes No No
Demineralized Bone Yes Yes No
Matrix
CaP and CaS bone Yes No No
substitutes

Because of their osteogenic, osteoinductive, and osteoconductive properties, autologous

bone grafts seem to be the ideal material for bone grafting. For tunnel grafting, autograft bone
is usually harvested at the iliac crest [9] or proximal tibia [7]. Cancellous bone contains a large
number of cells and growth factors and the cancellous matrix provides an excellent scaffold
for vascular ingrowth and infiltration of osteoblastic cells [3]. Drawbacks of autologous grafts
include donor-site morbidity and limited quantity. Allogenic bone is a favorable alternative
but has also specific drawbacks including the potential risk of disease or infection transmission
and immunological reactions. For this reason, allogenic bone must be sterilized and processed
for storage, which limits its osteoinductive properties. Great variability exists with regard to
tissue processing and sterilization processes, which may influence the incorporation of
allograft bone [6]. The most commonly used allogenic bone grafts are fresh frozen or freeze-
dried. Freeze-drying eliminates the risk of disease transmission almost completely, but also
eliminates the osteoinductive properties of the graft [5]. Fresh-frozen grafts have an
intermediate immunogenicity and intermediate osteoinductive capacity, but also a higher risk
of disease transmission than freeze-dried grafts [5]. Another allogenic option is demineralized
bone matrix (DBM), which is produced through acid extraction to remove the mineralized
component. DBM contains collagen, proteins, and growth factors and is therefore considered
osteoconductive and osteoinductive [3, 5]. However, its osteoinductive properties can vary
greatly due to donor characteristics [3].
Synthetic bone substitutes commonly consist of calcium phosphate or calcium sulfate
compounds. These materials act as osteoconductive matrices, which imitate the cancellous
bony structure and allow for the incorporation and proliferation of mesenchymal stem cells
[3].
Only a few studies have specifically analyzed different graft materials for tunnel grafting.
Franceschi et al. [7] performed CT scans 3 months after bone grafting using autologous plugs
from the proximal tibia in 30 patients and found complete integration of the bone plug into
the tunnel in all patients. Theodorides and Wall [8] used preshaped allograft bone dowels in
19 patients and performed CT scans at an average of 3.6 months (range 3-11 months) after
grafting. In 11 cases, the bone integration was rated to be very good (>75%) and in the
remaining five cases excellent (100%). Van de Pol et al. [2] examined the histologic properties,
graft quality, and graft incorporation of so-called supercritical carbon dioxide sterilized bone
allograft for tunnel grafting in 12 patients. After a mean time interval of 8.8 months (range, 6-
21 months), the authors found good graft incorporation and remodeling.
Prall et al. [10 ] compared allogenic (peracetic acid sterilized freeze-dried cancellous bone
chips) and autologous (cylindric bone blocks and cancellous bone from the iliac crest) bone
grafting in 103 patients. Postoperative CT scans were obtained after an interval of 5.2 months
and the filling rates of both graft materials were comparable. In a recent systematic review
[1], the outcomes of different bone graft materials for staged revision ACL reconstruction
were compared. The analysis included 7 studies with a total of 234 patients. Autograft was
used in 4 studies (iliac crest bone graft in 3 studies and tibial bone autograft in 1 study),
allograft in 2 studies, and synthetic bone substitutes in 1 study. Based on the available data,
autologous bone grafts from the iliac crest were associated with a lower risk of revision ACLR
graft failure compared with allograft bone. However, it must be noted that graft failure cannot
be attributed solely to the grafting material used, given the multifactorial nature of ACL graft
failure. Von Recum et al. [11] compared bone incorporation of silicate-substituted calcium
phosphate and iliac crest bone grafts in a prospective randomized controlled trial. No
significant differences between the two graft materials were observed with regard to
histologic, radiographic, and intraoperative integration. On histologic examination 6 months
after grafting, Si-CaP was transformed into immature and lamellar bone formation. In a further
study [12] , the same authors compared the clinical results of both groups after revision ACL
reconstruction at a minimum follow-up of 2 years and found no difference with regard to
laxity, functional scores, or ACL failure rate. Therefore, Si-CaP seems to be a valid option for
bone grafting. However, it must be noted that synthetic bone substitutes have been shown to
be inferior compared to autologous or allogenic bone after other operative procedures, such
as open wedge high tibial osteotomy [13]. Further studies are therefore needed to better
define the role of synthetic bone substitutes.

References:

[1] Salem HS, Axibal DP, Wolcott ML, Vidal AF, McCarty EC, Bravman JT, Frank RM. Two-Stage Revision Anterior Cruciate
Ligament Reconstruction: A Systematic Review of Bone Graft Options for Tunnel Augmentation. Am J Sports Med. 2020
Mar;48(3):767-777

[2] Van de Pol GJ, Bonar F, Salmon LJ, Roe JP, Pinczewski LA. Supercritical Carbon Dioxide-Sterilized Bone Allograft in the
Treatment of Tunnel Defects in 2-Stage Revision Anterior Cruciate Ligament Reconstruction: A Histologic Evaluation.
Arthroscopy. 2018 Mar;34(3):706-713.

[3] Baldwin P, Li DJ, Auston DA, Mir HS, Yoon RS, Koval KJ. Autograft, Allograft, and Bone Graft Substitutes: Clinical Evidence
and Indications for Use in the Setting of Orthopaedic Trauma Surgery. J Orthop Trauma. 2019 Apr;33(4):203-213.

[4] Khan SN, Cammisa FP Jr, Sandhu HS, Diwan AD, Girardi FP, Lane JM. The biology of bone grafting. J Am Acad Orthop
Surg. 2005 Jan-Feb;13(1):77-86.

[5] Eagan MJ, McAllister DR. Biology of allograft incorporation. Clin Sports Med. 2009 Apr;28(2):203-14

[6] Kattz J. The effects of various cleaning and sterilization processes on allograft bone incorporation. J Long Term Eff Med
Implants. 2010;20(4):271-6.

[7] Franceschi F, Papalia R, Del Buono A, Zampogna B, Diaz Balzani L, Maffulli N, Denaro V. Two-stage procedure in anterior
cruciate ligament revision surgery: a five-year follow-up prospective study. Int Orthop. 2013 Jul;37(7):1369-74
[8] Theodorides AA, Wall OR. Two-stage revision anterior cruciate ligament reconstruction: Our experience using allograft
bone dowels. J Orthop Surg (Hong Kong). 2019 May-Aug;27(2):2309499019857736

[9] Thomas NP, Kankate R, Wandless F, Pandit H. Revision anterior cruciate ligament reconstruction using a 2-stage
technique with bone grafting of the tibial tunnel. Am J Sports Med. 2005 Nov;33(11):1701-9

[10] Prall WC, Kusmenkov T, Schmidt B, Fürmetz J, Haasters F, Naendrup JH, Böcker W, Shafizadeh S, Mayr HO, Pfeiffer TR.
Cancellous allogenic and autologous bone grafting ensure comparable tunnel filling results in two-staged revision ACL
surgery. Arch Orthop Trauma Surg. 2020 Sep;140(9):1211-1219

[11] von Recum J, Schwaab J, Guehring T, Grützner PA, Schnetzke M. Bone Incorporation of Silicate-Substituted Calcium
Phosphate in 2-Stage Revision Anterior Cruciate Ligament Reconstruction: A Histologic and Radiographic Study.
Arthroscopy. 2017 Apr;33(4):819-827.

[12] von Recum J, Gehm J, Guehring T, Vetter SY, von der Linden P, Grützner PA, Schnetzke M. 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. Arthroscopy.
2020 Jan;36(1):178-185

[13] Slevin O, Ayeni OR, Hinterwimmer S, Tischer T, Feucht MJ, Hirschmann MT. The role of bone void fillers in medial
opening wedge high tibial osteotomy: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2016 Nov;24(11):3584-
3598

S5: When is it safe to perform ACLR after staged bone grafting (time)?

Steering group answer:

An interval of 3 to 6 months of follow-up before second stage revision ACLR is recommended
after staged bone grafting, and CT imaging could be considered to determine adequate graft
incorporation. Incorporation of allogenic bone may require a longer time period as compared
to autologous bone.

Grade of recommendation: C

Literature review:
The exact time period required between staged bone grafting and revision ACL reconstruction
remains unknown; however, a minimum 3-month period of follow-up is generally
recommended [1, 4]. Franceschi et al. [2] performed CT scans 3 months after bone grafting
using autologous plugs from the proximal tibia in 30 patients and found complete integration
of the bone plug into the tunnel in all patients. However, no details were provided on how
this determination was made.
In a recent systematic review [1] of 7 studies reporting outcomes of bone tunnel grafting in
two-stage revision ACLR, no consensus was available regarding the length of time that should
elapse between the first and second stage or regarding the imaging modality that should be
used to determine adequate graft incorporation. The minimum interval before assessing
radiographic bone healing was 3 months in 2 studies, 4 months in 3 studies, and 6 months in
2 studies. Therefore, an interval of 3 to 6 months seems to be adequate. Evaluation of graft
incorporation was conducted by CT imaging in 5 studies and blurring of the tunnel margins,
reactive sclerosis, and presence of bone within the tunnel were used as signs of adequate
healing. Standard radiographs were used in 2 studies and the presence of bone resorption,
cyst formation, sclerosis, and the appearance of trabecular bone in the grafted area were used
to assess adequate graft incorporation.
The most comprehensive analysis of time-dependent incorporation of bone grafts was
conducted by Uchida et al. [3]. The authors quantitatively evaluated healing of autologous
iliac crest bone block grafting in 10 consecutive patients by CT at 3, 12 and 24 weeks after
grafting. Evaluation was performed on 15 axial planes at 1-mm intervals using the following
three parameters: occupying ratio, union rate, and bone mineral density of the grafted bone.
The average occupying ratio was 81, 85, and 94% at three, 12, and 24 weeks, respectively. The
average union rate was 49, 75, and 89% at three, 12, and 24 weeks, respectively. Both
parameters significantly increased over time. The same was true for bone mineral density. The
authors concluded that both bone density and bone healing were more improved after 24
weeks compared to 12 weeks, indicating that an interval of 24 weeks is favorable for safe
implantation and fixation of ACL grafts. It must be noted, however, that only autologous grafts
were analyzed and that these data may not be transferable to allogenic grafts. It is thought
that incorporation of allogenic bone requires longer compared to autologous bone [5, 6, 7].
In the aforementioned systematic review by Salem et al. [1], the time interval between the
first and second staged procedures was 5.8 months, 6.3 months, and 24-30 weeks after
autologous grafts, whereas the time interval was 8.7 months and 8.8 months after Si-CaP and
allogenic bone, respectively. The authors hypothesized that, although many factors could
account for delay between stages, patients treated with autologous grafts may have a
decreased interstage time interval.

References:
[1] Salem HS, Axibal DP, Wolcott ML, Vidal AF, McCarty EC, Bravman JT, Frank RM. Two-Stage Revision Anterior Cruciate
Ligament Reconstruction: A Systematic Review of Bone Graft Options for Tunnel Augmentation. Am J Sports Med. 2020
Mar;48(3):767-777

[2] Franceschi F, Papalia R, Del Buono A, Zampogna B, Diaz Balzani L, Maffulli N, Denaro V. Two-stage procedure in anterior
cruciate ligament revision surgery: a five-year follow-up prospective study. Int Orthop. 2013 Jul;37(7):1369-74

[3] Uchida R, Toritsuka Y, Mae T, Kusano M, Ohzono K. Healing of tibial bone tunnels after bone grafting for staged revision
anterior cruciate ligament surgery: A prospective computed tomography analysis. Knee. 2016 Oct;23(5):830-6

[4] Erickson BJ, Cvetanovich GL, Frank RM, Riff AJ, Bach BR Jr.
Revision ACL Reconstruction: A Critical Analysis Review.
JBJS Rev. 2017 Jun;5(6):e1

[5] Baldwin P, Li DJ, Auston DA, Mir HS, Yoon RS, Koval KJ. Autograft, Allograft, and Bone Graft Substitutes: Clinical Evidence
and Indications for Use in the Setting of Orthopaedic Trauma Surgery. J Orthop Trauma. 2019 Apr;33(4):203-213.

[6] Khan SN, Cammisa FP Jr, Sandhu HS, Diwan AD, Girardi FP, Lane JM. The biology of bone grafting. J Am Acad Orthop
Surg. 2005 Jan-Feb;13(1):77-86.

[7] Eagan MJ, McAllister DR. Biology of allograft incorporation. Clin Sports Med. 2009 Apr;28(2):203-14

S6: When is an additional osteotomy indicated to correct coronal malalignment

(Varus/Valgus ) in ACL revision surgery?

Steering group answer:

An osteotomy to correct coronal malalignment is indicated in patients with varus or valgus
deviation >=5° accompanied by early OA, significant cartilage damage and/or symptomatic
meniscal deficiency, and in patients with varus or valgus deviation associated with
ligamentous insufficiency (e.g. a thrust phenomenon (dynamic joint space opening)). The
threshold of 5° is based on common indications for varus or valgus correction reported in the
literature; however, a shift towards even smaller thresholds has occurred in recent years.
Therefore, an osteotomy to correct varus or valgus deviation <5° may be indicated in selected
cases, such as patients undergoing concomitant meniscal transplantation, cartilage repair
procedures, or collateral ligament reconstruction. An isolated varus malalignment without the
above-mentioned associated conditions is not an indication per se for an osteotomy.

Grade of recommendation: C

Literature review:
Chronic ligamentous laxity is often associated with malalignment, which can be the cause or
consequence of recurrent or chronic instability [1, 3, 4, 5]. Won et al. [6] compared 58 patients
undergoing revision ACLR and 116 patients undergoing primary ACLR and found a significantly
higher proportion of knees with varus malalignment greater than 5° in patients undergoing
ACL revision surgery (19% vs. 8%). Although no comparative data are available for valgus
alignment, coronal malalignment in general must be considered a frequent observation in
patients undergoing revision ACLR.
Based on the work of Frank Noyes [9], varus malalignment in an ACL deficient knee can be
classified in 3 types:
Primary varus: Varus alignment due to the osseous geometry with or without medial joint
space narrowing.
Double varus: Varus alignment due to the osseous geometry and separation of the lateral
compartment (“varus thrust”) under load.
Triple varus: Varus alignment due to the osseous geometry, separation of the lateral
compartment, and increased external tibial rotation and hyperextension with an abnormal
varus recurvatum position (“hyperextension-varus thrust”).
Whether a primary varus has a negative impact on a reconstructed ACL remains unclear. Kim
et al. [8] compared the results of 201 patients with primary varus knees who underwent
primary ACLR. Patients were grouped based on the severity of their varus deformity. After a
mean follow-up of 45 months, no difference with regard to stability and functional scores was
observed between the groups. The authors therefore concluded that if no medial
compartment OA or varus thrust is present, correctional osteotomy is not necessary in
primary varus knees undergoing ACLR.
However, in biomechanical studies, both varus and valgus malalignment increased ACL graft
forces, especially in the case of an accompanying varus or valgus thrust, respectively [2, 7].
Therefore, significant varus or valgus alignment may be considered a risk factor for ACL graft
failure due to repetitive overloading. Furthermore, the prevalence of cartilage lesions,
meniscal deficiency, and osteoarthritic changes is higher in patients undergoing revision ACLR
compared to patients undergoing primary ACLR, especially in patients with varus
malalignment [10]. The rationale for correcting coronal malalignment in patients undergoing
revision ACLR is therefore twofold: first, to protect the graft from increased loading and
second to unload a degenerative compartment. Indications for osteotomies to correct coronal
malalignment are based on low-level evidence and depend on multiple factors such as
cartilage and meniscal status. In general, axis deviation of 5° or more accompanied by
meniscal or cartilage damage is considered an indication for osteotomy to lower the risk of
OA progression [1, 3, 4, 5]. However, a shift towards even smaller thresholds has occurred in
recent years [11]. Therefore, an osteotomy to correct varus or valgus deviation <5° may be
indicated in selected cases, such as patients undergoing concomitant meniscal
transplantation, cartilage repair procedures, or collateral ligament reconstruction [1, 11].
Whether correction of coronal malalignment decreases failure after ACL revision
reconstruction in patients without degenerative changes remains unknown. However, given
the fact that varus or valgus alignment associated with a thrust phenomenon increases ACL
graft forces, realignment osteotomies are theoretical beneficial in protecting the graft from
repetitive overloading [1, 2, 7].

References:

[1] Tischer T, Paul J, Pape D, Hirschmann MT, Imhoff AB, Hinterwimmer S, Feucht MJ. The Impact of Osseous Malalignment
and Realignment Procedures in Knee Ligament Surgery: A Systematic Review of the Clinical Evidence. Orthop J Sports Med.
2017 Mar 27;5(3):2325967117697287

[2] Mehl J, Otto A, Kia C, Murphy M, Obopilwe E, Imhoff FB, Feucht MJ, Imhoff AB, Arciero RA, Beitzel K. Osseous valgus
alignment and posteromedial ligament complex deficiency lead to increased ACL graft forces. Knee Surg Sports Traumatol
Arthrosc. 2020 Apr;28(4):1119-1129.

[3] Dean CS, Liechti DJ, Chahla J, Moatshe G, LaPrade RF. Clinical Outcomes of High Tibial Osteotomy for Knee Instability: A
Systematic Review. Orthop J Sports Med. 2016 Mar 7;4(3):2325967116633419

[4] Cantin O, Magnussen RA, Corbi F, Servien E, Neyret P, Lustig S. The role of high tibial osteotomy in the treatment of knee
laxity: a comprehensive review. Knee Surg Sports Traumatol Arthrosc. 2015 Oct;23(10):3026-37

[5] Gupta A, Tejpal T, Shanmugaraj A, Horner NS, Simunovic N, Duong A, Ayeni OR. Surgical Techniques, Outcomes,
Indications, and Complications of Simultaneous High Tibial Osteotomy and Anterior Cruciate Ligament Revision Surgery: A
Systematic Review. HSS J. 2019 Jul;15(2):176-184. doi: 10.1007/s11420-018-9630-8.

[6] Won HH, Chang CB, Je MS, Chang MJ, Kim TK. Coronal limb alignment and indications for high tibial osteotomy in
patients undergoing revision ACL reconstruction. Clin Orthop Relat Res. 2013 Nov;471(11):3504-11

[7] van de Pol GJ, Arnold MP, Verdonschot N, van Kampen A. Varus alignment leads to increased forces in the anterior
cruciate ligament. Am J Sports Med. 2009 Mar;37(3):481-7

[8] Kim SJ, Moon HK, Chun YM, Chang WH, Kim SG. Is correctional osteotomy crucial in primary varus knees undergoing
anterior cruciate ligament reconstruction? Clin Orthop Relat Res. 2011 May;469(5):1421-6

[9] Noyes FR, Barber-Westin SD, Hewett TE. High tibial osteotomy and ligament reconstruction for varus angulated anterior
cruciate ligament-deficient knees. Am J Sports Med. 2000 May-Jun;28(3):282-96

[10] Brophy RH, Haas AK, Huston LJ, Nwosu SK; MARS Group, Wright RW. Association of Meniscal Status, Lower Extremity
Alignment, and Body Mass Index With Chondrosis at Revision Anterior Cruciate Ligament Reconstruction. Am J Sports Med.
2015 Jul;43(7):1616-22
[11] Bode G, Schmal H, Pestka JM, Ogon P, Südkamp NP, Niemeyer P. A non-randomized controlled clinical trial on
autologous chondrocyte implantation (ACI) in cartilage defects of the medial femoral condyle with or without high tibial
osteotomy in patients with varus deformity of less than 5°. Arch Orthop Trauma Surg. 2013 Jan;133(1):43-9
S7: When is an additional osteotomy indicated to correct sagittal malalignment (Slope) in
ACL revision surgery?

Steering group answer:

A slope-reducing osteotomy (extension osteotomy) should be considered in patients with
failed primary ACL reconstruction and PTS >=12° as measured on lateral radiographs. The
indication may be even stronger in patients with increased static anterior tibial translation
(>5mm on monopodal stance), multiple failed ACL reconstructions, and/or deficiency of the
posterior medial meniscal horn. Careful consideration should be given if there is preexisting
hyperextension of the knee as this may be a contraindication.

Grade of recommendation: B

Literature review:
The tibial slope has a direct influence on sagittal plane biomechanics and therefore
contributes to the loading pattern of the cruciate ligaments. From a biomechanical point of
view, the tibial slope produces an anteriorly directed shear force component when
compressive tibiofemoral load or quadriceps muscle force is applied to the knee joint,
resulting in anterior translation of the tibia [1, 2]. In a radiographic in vivo study by Dejour and
Bonnin [6], a steeper slope resulted in a significantly greater amount of anterior tibial
translation in both ACL-deficient and ACL-intact knees. Since the ACL is the primary restraint
against anterior tibial translation, the tibial slope has an important effect on the in-situ forces
of the ACL or an ACL graft, respectively [8, 9].
A steep posterior tibial slope (PTS) has been shown to be a risk factor not only for primary ACL
rupture [17], but also for increased antero-posterior laxity and failure after primary ACL
reconstruction [4, 10, 11, 12, 16]. Furthermore, Napier et al. [3] showed that an increased PTS
was associated with graft rupture and contralateral ACL injury after revision ACL
reconstruction. Biomechanical studies have shown that tibial slope has a strong linear
relationship to the amount of graft force experienced by an ACL graft in axially loaded knees
and that slope-reducing osteotomies can decrease ACL graft forces [8, 9]. Therefore, slope-
reducing osteotomies should be considered in patients with failed ACL reconstruction and an
increased PTS [2, 13, 14, 15]. The indication may even be stronger in patients with deficiency
of the posterior medial horn, since this condition potentiates the effect of increased tibial
slope on ACL graft forces and anterior tibial translation [4, 5, 7]. However, no uniform cutoff
value for PTS exists and different measurement methods are used. Most authors recommend
considering a slope-reducing osteotomy if PTS exceeds 12° on lateral knee radiographs [14,
15].
An increased tibial slope is usually corrected via an anterior closing-wedge osteotomy at the
proximal tibia. Different techniques have been described without evidence that one specific
technique is superior [13, 14, 15]. An anterior closing wedge osteotomy can be performed
with or without detachment of the tibial tubercle, depending on the surgeon’s preference.
It remains controversial to what extent PTS should be corrected and target PTS have been
proposed between 8-10° [14] and 3-5° [15]. Range of motion must be taken into consideration
and postoperative hyperextension >5° should be avoided [2].

References:

[1] Feucht MJ, Mauro CS, Brucker PU, Imhoff AB, Hinterwimmer S. The role of the tibial slope in sustaining and treating
anterior cruciate ligament injuries. Knee Surg Sports Traumatol Arthrosc. 2013 Jan;21(1):134-45

[2] Tischer T, Paul J, Pape D, Hirschmann MT, Imhoff AB, Hinterwimmer S, Feucht MJ. The Impact of Osseous Malalignment
and Realignment Procedures in Knee Ligament Surgery: A Systematic Review of the Clinical Evidence. Orthop J Sports Med.
2017 Mar 27;5(3):2325967117697287

[3] Napier RJ, Garcia E, Devitt BM, Feller JA, Webster KE. Increased Radiographic Posterior Tibial Slope Is Associated With
Subsequent Injury Following Revision Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med. 2019 Nov
5;7(11):2325967119879373

[4] Dejour D, Pungitore M, Valluy J, Nover L, Saffarini M, Demey G. Tibial slope and medial meniscectomy significantly
influence short-term knee laxity following ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2019 Nov;27(11):3481-
3489

[5] Dejour D, Pungitore M, Valluy J, Nover L, Saffarini M, Demey G. Preoperative laxity in ACL-deficient knees increases with
posterior tibial slope and medial meniscal tears. Knee Surg Sports Traumatol Arthrosc. 2019 Feb;27(2):564-572

[6] Dejour H, Bonnin M. Tibial translation after anterior cruciate ligament rupture. Two radiological tests compared. J Bone
Joint Surg Br. 1994 Sep;76(5):745-9

[7] Samuelsen BT, Aman ZS, Kennedy MI, Dornan GJ, Storaci HW, Brady AW, Turnbull TL, LaPrade RF. Posterior Medial
Meniscus Root Tears Potentiate the Effect of Increased Tibial Slope on Anterior Cruciate Ligament Graft Forces. Am J Sports
Med. 2020 Feb;48(2):334-340

[8] Bernhardson AS, Aman ZS, Dornan GJ, Kemler BR, Storaci HW, Brady AW, Nakama GY, LaPrade RF. Tibial Slope and Its
Effect on Force in Anterior Cruciate Ligament Grafts: Anterior Cruciate Ligament Force Increases Linearly as Posterior Tibial
Slope Increases. Am J Sports Med. 2019 Feb;47(2):296-302

[9] Imhoff FB, Mehl J, Comer BJ, Obopilwe E, Cote MP, Feucht MJ, Wylie JD, Imhoff AB, Arciero RA, Beitzel K. Slope-reducing
tibial osteotomy decreases ACL-graft forces and anterior tibial translation under axial load. Knee Surg Sports Traumatol
Arthrosc. 2019 Oct;27(10):3381-3389
[10] Salmon LJ, Heath E, Akrawi H, Roe JP, Linklater J, Pinczewski LA. 20-Year Outcomes of Anterior Cruciate Ligament
Reconstruction With Hamstring Tendon Autograft: The Catastrophic Effect of Age and Posterior Tibial Slope. Am J Sports
Med. 2018 Mar;46(3):531-543

[11] Li Y, Hong L, Feng H, Wang Q, Zhang J, Song G, Chen X, Zhuo H. Posterior tibial slope influences static anterior tibial
translation in anterior cruciate ligament reconstruction: a minimum 2-year follow-up study. Am J Sports Med. 2014
Apr;42(4):927-33

[12] Webb JM, Salmon LJ, Leclerc E, Pinczewski LA, Roe JP. Posterior tibial slope and further anterior cruciate ligament
injuries in the anterior cruciate ligament-reconstructed patient. Am J Sports Med. 2013 Dec;41(12):2800-4

[13] Akoto R, Alm L, Drenck TC, Frings J, Krause M, Frosch KH. 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 Dec;48(14):3478-3485

[14] Sonnery-Cottet B, Mogos S, Thaunat M, Archbold P, Fayard JM, Freychet B, Clechet J, Chambat P. Proximal Tibial
Anterior Closing Wedge Osteotomy in Repeat Revision of Anterior Cruciate Ligament Reconstruction. Am J Sports Med.
2014 Aug;42(8):1873-80

[15] Dejour D, Saffarini M, Demey G, Baverel L. Tibial slope correction combined with second revision ACL produces good
knee stability and prevents graft rupture. Knee Surg Sports Traumatol Arthrosc. 2015 Oct;23(10):2846-52

[16] Grassi A, Signorelli C, Urrizola F, Macchiarola L, Raggi F, Mosca M, Samuelsson K, Zaffagnini S. Patients With Failed
Anterior Cruciate Ligament Reconstruction Have an Increased Posterior Lateral Tibial Plateau Slope: A Case-Controlled
Study. Arthroscopy. 2019 Apr;35(4):1172-1182

[17] Zeng C, Cheng L, Wei J, Gao SG, Yang TB, Luo W, Li YS, Xu M, Lei GH. The influence of the tibial plateau slopes on injury
of the anterior cruciate ligament: a meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2014 Jan;22(1):53-65

S8: When is an additional extraarticular anterolateral procedure indicated in ACLR

surgery?

Systematic use of additional extraarticular anterolateral procedure should be considered in

revision ACL-reconstruction, especially when patients present with gross laxity (pivot shift +++,
grade II and III (IKDC) of AP instability and/or in pivoting sports or in hyperlaxity). Also check
for laxity on the medial side, because it can also increase anterolateral instability. However,
there is still a lack of high levels of evidence in existing studies.

Grade of recommendation: B

Literature review:
The general term additional extraarticular anterolateral procedure has been adopted in this
consensus. It merges from different terms which can be found in the literature (Lateral
tenodesis, Antero Lateral Complex Reconstruction or ALL reconstruction ...).
Despite the minority of published studies due to the recent emergence of the issue, the
available reports have clearly demonstrated a low rate of failure of the revision graft when
combined with an extraarticular anterolateral procedure. In a recent systematic review
published by Alberto Grassi in KSSTA, twenty-four failures were reported in a total of 658
patients, giving an overall failure rate of 3.6%, over a mid-term follow-up period of 5 years (1).
Given that this figure is lower than the failure rate of isolated ACL revision, extraarticular
anterolateral procedure stabilization is surely worth considering in a revision setting. In a
study published by Porter et al., a pivot shift grade II or more was selected as a criterion for
extraarticular anterolateral stabilization (2). The results demonstrated a significant
improvement in laxity with an additional extra-articular iliotibial band tenodesis (2).
In a further study, Colombet et al. demonstrated that the addition of an extra-articular
procedure provided improved internal tibial rotation control (3). A multicenter study
published by the French Arthroscopy Society (SFA) showed a marked improvement in
rotational stability and a reduction in re-rupture risk (4). The highly cited study published by
Sonnery-Cottet (>300 citations) has captured the attention of the orthopedic community by
highlighting the power of additive ALL stabilization in eliminating pivot shift in primary ACL
reconstruction (5,9). A study by Trojani demonstrated a marked reduction in the rate of pivot
shift when lateral tenodesis was performed: 80% had a negative pivot shift with the tenodesis,
versus 63% without (6).

General overall hyperlaxity in an ACL deficient patient has been also defined as an indication
for ALL stabilization (7).
The International Anterolateral Complex Consensus group published an expert opinion
regarding the indication for ALL stabilization. The group underlined the following indications:
ACL revision, hyperlaxity, high grade pivot shift and young patients returning to pivoting
activities (8).

References:

[1] Grassi A, Zicaro JP, Costa-Paz M, Samuelsson K, Wilson A, Zaffagnini S, Condello V; ESSKA Arthroscopy Committee. Good
mid-term outcomes and low rates of residual rotatory laxity, complications and failures after revision anterior cruciate
ligament reconstruction (ACL) and lateral extra-articular tenodesis (LET). Knee Surg Sports Traumatol Arthrosc. 2020
Feb;28(2):418-431.
[2] Porter MD, Shadbolt B, Pomroy S. The Augmentation of Revision Anterior Cruciate Ligament Reconstruction with Modified
Iliotibial Band Tenodesis to Correct the Pivot Shift: A Computer Navigation Study. Am J Sports Med. 2018 Mar;46(4):839-845.
doi: 10.1177/0363546517750123. Epub 2018 Feb 1.

[3] Colombet P. Knee Laxity Control in Revision Anterior Cruciate Ligament Reconstruction Versus Anterior Cruciate Ligament
Reconstruction and Lateral Tenodesis. Am J Sports Med. 2011 Jun;39(6):1248-54.

[4] Louis ML, D'ingrado P, Ehkirch FP, Bertiaux S, Colombet P, Sonnery-Cottet B, Schlatterer B, Pailhé R, Panisset JC, Steltzlen
C, Lustig S, Lutz C, Dalmay F, Imbert P, Saragaglia D; French Arthroscopy Society (Société Francophone d’Arthroscopie,
SFA).Combined intra- and extra-articular grafting for revision ACL reconstruction: A multicentre study by the French
Arthroscopy Society (SFA). Orthop Traumatol Surg Res. 2017 Dec;103(8S):S223-S229.

[5] Sonnery-Cottet B, Thaunat M, Freychet B, Pupim BH, Murphy CG, Claes S. Outcome of a Combined Anterior Cruciate
Ligament and Anterolateral Ligament Reconstruction Technique With a Minimum 2-Year Follow-up. Am J Sports Med. 2015
Jul;43(7):1598-605.

[6] Trojani C, Beaufils P, Burdin G, Bussière C, Chassaing V, Djian P, Dubrana F, Ehkirch FP, Franceschi JP, Hulet C, Jouve F,
Potel JF, Sbihi A, Neyret P, Colombet P. Revision ACL reconstruction: influence of a lateral tenodesis. Knee Surg Sports
Traumatol Arthrosc. 2012 Aug;20(8):1565-70. doi: 10.1007/s00167-011-1765-9.

[7] Helito CP, Sobrado MF, Giglio PN, Bonadio MB, Pécora JR, Camanho GL, Demange MK. Combined Reconstruction of the
Anterolateral Ligament in Patients With Anterior Cruciate Ligament Injury and Ligamentous Hyperlaxity Leads to Better
Clinical Stability and a Lower Failure Rate Than Isolated Anterior Cruciate Ligament Reconstruction. Arthroscopy. 2019
Sep;35(9):2648-2654

[8] Getgood A, Brown C, Lording T, Amis A, Claes S, Geeslin A, Musahl V; ALC Consensus Group. The anterolateral complex of
the knee: results from the International ALC Consensus Group Meeting. Knee Surg Sports Traumatol Arthrosc. 2019
Jan;27(1):166-176

[9] Sonnery-Cottet B, Haidar I, Rayes J, Fradin T, Ngbilo C, Vieira TD, Freychet B, Ouanezar H, Saithna A. Long-term Graft
Rupture Rates After Combined ACL and Anterolateral Ligament Reconstruction Versus Isolated ACL Reconstruction: A
Matched-Pair Analysis From the SANTI Study Group. Am J Sports Med. 2021 Sep;49(11):2889-2897. doi:
10.1177/03635465211028990. Epub 2021 Aug 5.

S9: When should additional medial laxity be treated or addressed?

Steering group answer:

Pre-operative medial laxity is a risk factor for poorer ACL revision outcomes. Consideration
should be given to concomitant MCL reconstruction for grade 2 and 3 (IKDC C and D) MCL
laxity. However, high-quality comparative studies are lacking.

Grade of recommendation: B

Literature review:
• Basic research:
Biomechanical studies have shown that partial and complete medial collateral ligament tears
increase the load on the ACL (1). MCL deficiency may also lead to increased ACL reconstruction
graft strain (3). It has also been demonstrated that single-bundle ACL reconstruction alone
cannot restore anterior tibial translation, valgus rotation and external rotation in knees with
combined ACL and MCL injury (2). In vivo, animal studies have shown that re-establishing the
stabilizing function of the MCL improves biological healing and integration of ACL
reconstructions (4).

• Clinical evidence:
There is evidence to support the link between MCL insufficiency (grade II and III) and higher
failure rates of ACL revision, as has been shown in the study by Alm and Ahn (8, 13). Ahn and
Lee detected MCL grade II lesion as a risk factor for ACLR failure (OR 13) and Alms showed that
with medial knee instability (grade II and III) in ACL revision, patients had a 17 times greater
risk of failure. National registry data have also highlighted a possible link between the
presence of a concomitant MCL injury and failure of ACL reconstruction, as shown in a recent
systematic review (5). A further recent study by Svantesson et. al (6), based on Swedish
registry data, found an increased risk of ACL revision with the non-surgical treatment of
concomitant MCL injuries.
Thus MCL should be evaluated pre-operatively and laxity should be considered as a risk factor
for subsequent revision ACL graft failure. Both valgus and tibiofemoral rotation should be
assessed and taken into consideration when planning treatment. It is noteworthy that
significant injuries to the dMCL and sMCL, in the context of ACL rupture, which might lead to
AMRI (antero medial rotatory instability), may be missed as there may not be valgus laxity in
extension if the POL remains intact. Stress radiographs are important in the determination of
a concomitant medial laxity. Laprade et al. demonstrated, in vitro, that > 3.2 mm of valgus
opening was associated with smCL rupture and that > 9.8 mm of opening was associated with
injury to the whole MCL complex (sMLC and POL) (7). Although clinical thresholds are lacking,
surgeons should critically assess gapping and medial rotational laxity. Grade II laxity (5-10mm
increased gapping compared to the healthy side) is likely to be a reasonable threshold for
intervention (8). Studies suggest that combined ACL / MCL reconstruction affords good results
(11, 12). However, Lind et al. (13) found that results were inferior to isolated ACL
reconstruction. This may be due to failure of current MCL reconstructions to fully address
anteromedial rotational laxity. Unfortunately, clinical studies reporting the results of
simultaneous MCL and revision ACL reconstruction are lacking, although some case series
report promising results and the results for primary ACL reconstruction with combined MCL
reconstruction seem superior. Funchal et al. conducted a prospective randomized trial for
primary ACL# + Grade II medial laxity in which they compared ACLR with MCL reconstruction
with ACLR alone (N=58 vs 54, FU 24M) (14). ACLR with MCL reconstruction showed
significantly fewer failures (2 vs 16) and remaining medial instability, and better functional
scores (Tegner, Lysholm). Alm et al. also showed in a small case series that MCL reconstruction
led to lower failure rates in patients with combined revision ACLR and chronic medial
instability as compared with MCL repair (15).
MCL repair in the acute scenario may be reasonable, while reconstruction should be
considered for chronic laxity.

References:

[1] Battaglia MJ, IInd, Lenhoff MW, Ehteshami JR, Lyman S, Provencher MT et al (2009) Medial collateral ligament injuries and
subsequent load on the anterior cruciate ligament: a biomechanical evaluation in a cadaveric model. Am J Sports Med
37(2):305–311

[2] Zhu J, Dong J, Marshall B, Linde MA, Smolinski P et al (2018) Medial collateral ligament reconstruction is necessary to
restore anterior stability with anterior cruciate and medial collateral ligament injury. Knee Surg Sports Traumatol Arthrosc
26(2):550–557

[3] Mazzocca AD, Nissen CW, Geary M, Adams DJ. Valgus medial collateral ligament rupture causes concomitant loading and
damage of the anterior cruciate ligament. J Knee Surg. 2003 Jul;16(3):148-51.

[4] Woo SL, Young EP, Ohland KJ, Marcin JP, Horibe S et al (1990) The effects of transection of the anterior cruciate ligament
on healing of the medial collateral ligament. A biomechanical study of the knee in dogs. J Bone Jt Surg Am 72(3):382–392

[5] Rahardja R, Zhu M, Love H, Clatworthy MG, Monk AP, Young SW. Factors associated with revision following anterior
cruciate ligament reconstruction: A systematic review of registry data. Knee. 2020 Mar;27(2):287-299.

[6] Svantesson E, Hamrin Senorski E, Alentorn-Geli E, Westin O, Sundemo D, Grassi A, Čustović S, Samuelsson K. Increased
risk of ACL revision with non-surgical treatment of a concomitant medial collateral ligament injury: a study on 19,457 patients
from the Swedish National Knee Ligament Registry. Knee Surg Sports Traumatol Arthrosc. 2019 Aug;27(8):2450-2459.

[7] Laprade RF, Bernhardson AS, Griffith CJ, Macalena JA, Wijdicks CA. Correlation of valgus stress radiographs with medial
knee ligament injuries: an in vitro biomechanical study. Am J Sports Med. 2010 Feb;38(2):330-8.

[8] Alm L, Krause M, Frosch KH, Akoto R. Preoperative medial knee instability is an underestimated risk factor for failure of
revision ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2020 Aug;28(8):2458-2467.
[9] Zhang H, Sun Y, Han X, Wang Y, Wang L, Alquhali A, Bai X. Simultaneous Reconstruction of the Anterior Cruciate Ligament
and Medial Collateral Ligament in Patients With Chronic ACL-MCL Lesions: A Minimum 2-Year Follow-up Study. Am J Sports
Med. 2014 Jul;42(7):1675-81.

[10] Ateschrang A, Döbele S, Freude T, Stöckle U, Schröter S, Kraus TM. Acute MCL and ACL injuries: first results of minimal-
invasive MCL ligament bracing with combined ACL single-bundle reconstruction. Arch Orthop Trauma Surg. 2016
Sep;136(9):1265-1272.

[11] Tapasvi S, Shekhar A, Patil S, Getgood [Link] medial knee reconstruction restores stability and function at
minimum 2 years follow-up. Knee Surg Sports Traumatol Arthrosc. 2021

[12] Varelas AN, Erickson BJ, Cvetanovich GL, Bach BR, Jr. Medial Collateral Ligament Reconstruction in Patients With
Medial Knee Instability: A Systematic Review. Orthop J Sports Med. 017;5(5):2325967117703920

[13] Lind M, Jacobsen K, Nielsen T. Medial collateral ligament (MCL) reconstruction results in improved medial stability:
results from the Danish knee ligament reconstruction registry (DKRR). Knee Surg Sports Traumatol
Arthrosc. 2020;28(3):881-887

[13] Ahn JH, Lee SH. Risk factors for knee instability after anterior cruciate ligament reconstruction. Knee Surg Sports
Traumatol Arthrosc. 2016 Sep;24(9):2936-2942. doi: 10.1007/s00167-015-3568-x. Epub 2015 Mar 19.

[14] Funchal LFZ, Astur DC, Ortiz R, Cohen M. The Presence of the Arthroscopic "Floating Meniscus" Sign as an Indicator for
Surgical Intervention in Patients With Combined Anterior Cruciate Ligament and Grade II Medial Collateral Ligament Injury.
Arthroscopy. 2019 Mar;35(3):930-937. doi: 10.1016/[Link].2018.10.114. Epub 2019 Feb 4.

[15] Alm L, Drenck TC, Frings J, Krause M, Korthaus A, Krukenberg A, Frosch KH, Akoto R. Lower Failure Rates and Improved
Patient Outcome Due to Reconstruction of the MCL and Revision ACL Reconstruction in Chronic Medial Knee Instability.
Orthop J Sports Med. 2021 Mar 15;9(3):2325967121989312. doi: 10.1177/2325967121989312. eCollection 2021 Mar.

S10: When should additional lateral laxity be treated or addressed?

Steering group answer:

A true lateral laxity, including a subtle isolated FCL, posterolateral corner or complete lateral
injury, should also be detected and is evidently associated with failure of revision. Clinical
thresholds regarding gapping are lacking. However a lateral or posterolateral injury has to be
clearly delineated from anterolateral instability (which does not cause gapping) and should be
treated accordingly to prevent failure of the ACL revision graft.

Grade of recommendation: C

Literature review:
Much of the focus in the literature has been on concomitant anterolateral injuries. However,
the influence of injury to more posterolateral structures, including the FCL, is not to be
neglected. The biomechanical effect of the FCL on the anterior cruciate ligament has been well
described (1). Therefore, the early conclusions of a rather highly cited study are based on
biomechanical findings, demonstrating a significant increase in forces acting on the ACL graft
after transection of the FCL and posterolateral structures (1). Further biomechanical studies
using stress radiography proposed thresholds that assist clinicians during the diagnostic
workup (2).
It was further shown that clinician-applied valgus loads at 20° of flexion resulted in 2.7mm of
increased lateral gapping, in association with an isolated FCL injury, and 4.0mm or more in
association with an additional lesion of the posterolateral corner (2). These thresholds are
based on biomechanical tests and a general recommendation of these values in the clinical
setting would be difficult, given the wide range of confounding factors. The minority of clinical
studies reporting the results of lateral reconstruction set the indication based on at least 2
grades of lateral instability to IKDC objective scoring criteria (3).

References:
[1] LaPrade RF, Resig S, Wentorf F, Lewis JL. The effects of grade III posterolateral knee complex injuries on anterior cruciate
ligament graft force. A biomechanical analysis. Am J Sports Med. Jul-Aug 1999;27(4):469-75.

[2] LaPrade RF, Heikes C, Bakker AJ, Jakobsen RB. The reproducibility and repeatability of varus stress radiographs in the
assessment of isolated fibular collateral ligament and grade-III posterolateral knee injuries. An in vitro biomechanical study.
J Bone Joint Surg Am. 2008 Oct;90(10):2069-76.

[3] Geeslin AG, LaPrade RF. Outcomes of Treatment of Acute Grade-III Isolated and Combined Posterolateral Knee Injuries. J
Bone Joint Surg Am. 2011 Sep 21;93(18):1672-83.

S11: When could an additional meniscal substitute or meniscal allograft be indicated?

Steering group answer:

Meniscus substitutes and meniscus allografts are able to improve clinical outcomes in selected
indications. A chondroprotective effect is expected but not yet proven at long-term follow-up.
Substitute: With failed previous PARTIAL meniscectomy and meniscus-related complaints, an
additional meniscal substitute may be considered in rare cases, in conjunction with ACL
revision for such patients (Grade C). However, the implantation of a substitute at the same
time as a partial meniscectomy (“prophylactic” substitute) is not recommended (Grade A).
Meniscus Allograft: an additional meniscus allograft may be considered in conjunction with
ACL revision in patients with failed previous TOTAL or SUBTOTAL meniscectomy and meniscus-
related complaints without significant cartilage wear (Grade B). Meniscal allograft as a
concomitant procedure in ACL revision reconstruction may be performed to aid in joint
stability when meniscus deficiency is believed to be a contributing factor to failure (Grade D).

Literature review:
Although the literature around this topic is somewhat limited, the evidence that we do have
points homogeneously in one direction, emphasizing the important association between the
meniscus as a secondary stabilizer of the knee joint and the ACL.

The biomechanical importance of the meniscus and its secondary stabilizing role in the knee
have been underlined in basic research studies (1,2). Biomechanical studies demonstrated the
effect of a meniscectomy on the knee by showing a significant increase in anterior tibial
translation at all degrees of flexion. The results of anterior tibial translation were normalized
after allograft transplantation (2).

There is also evidence to show that meniscus transplantation in an ACL reconstructed knee
adds to stability by further reducing anterior-posterior translation, and improving rotational
stability (3). This theoretically provides an ACL protective effect.
On the other hand, patients with meniscal disease who are primarily being considered for a
meniscal transplant would also obviously benefit from protective ACL reconstruction (4).

It is fair to say that there still is a lack of evidence regarding combined allograft meniscal
transplantation and ACL reconstruction. However, published reports are very promising.
Saltzman showed that concomitant ACL reconstruction and meniscal allograft transplantation
could provide significant improvements in clinical outcomes and enhancement in objective
knee stability (4). Furthermore, the study showed an insignificant degree of radiographic joint-
space narrowing changes, with a 5-year survivorship of more than 80% (4).
Stefano Zaffagnini’s group showed that in the following situations, a significant benefit is to
be expected after a combined meniscal allograft transplant procedure at medium-term
follow-up (5): 1) ACL injury in a patient with post-meniscectomy syndrome, 2) failed ACL
reconstruction in patients with a meniscus defect, and 3) ACL reconstruction in patients with
malalignment due to a meniscal defect.

The International Meniscus Reconstruction Experts Forum (IMREF) recommended meniscal

transplantation as a concomitant procedure with ACL revision, especially when deficiency of
the meniscus is believed to be a contributing factor to failure (6). However, the issue of donor
tissue availability would need particular consideration and may represent a limiting factor in
the therapeutic decision tree.

The question of whether a meniscal collagen scaffold is a sufficient substitute has been raised.
Despite evidence of some form of regeneration and organization of the scaffold material that
is reflected in improvement of clinical scores (14,15), two important questions are yet to be
answered, including the long-term chondroprotective effect of the scaffold and its superiority
to partial or total meniscectomy (16). The reality is that evidence to sufficiently answer the
last two questions is lacking. A general recommendation regarding scaffolds is therefore
difficult due to the current scarcity of evidence. At the current juncture, all that may be said
is that implantation of a collagen or polyurethane scaffold may improve clinical scores.

References:

[1] Roldan E, Reeves ND, Cooper G, Andrews K-In vivo mechanical behaviour of the anterior cruciate ligament: a study of six
daily and high impact activities. Gait Posture 2017 58:201–207

[2] Spang JT, Dang AB, Mazzocca A, Rincon L, Obopilwe E, Beynnon B et al. The effect of medial meniscectomy and meniscal
allograft transplantation on knee and anterior cruciate ligament biomechanics. Arthroscopy 2010 26:192–201

[3] Yoon KH, Lee HW, Park SY, Yeak RDK, Kim JS, Park JY. Meniscal Allograft Transplantation After Anterior Cruciate
Ligament Reconstruction Can Improve Knee Stability: A Comparison of Medial and Lateral Procedures. Am J Sports Med.
2020 Aug;48(10):2370-2375.

[4] Saltzman BM, Meyer MA, Weber AE, Poland SG, Yanke AB, Cole BJ (2017) Prospective clinical and radiographic
outcomes after concomitant anterior cruciate ligament reconstruction and meniscal allograft transplantation at a mean 5-
year follow-up. Am J Sports Med 45:550–562.
[5] Zaffagnini S, Grassi A, Romandini I, Marcacci M, Filardo G. Meniscal allograft transplantation combined with anterior
cruciate ligament reconstruction provides good mid-term clinical outcome. Knee Surg Sports Traumatol Arthrosc. 2019
Jun;27(6):1914-1923.

[6] Getgood A, LaPrade RF, Verdonk P, Gersoff W, Cole B, Spalding T; IMREF Group. International Meniscus Reconstruction
Experts Forum (IMREF) 2015 Consensus Statement on the Practice of Meniscal Allograft Transplantation. Am J Sports Med.
2017 May;45(5):1195-1205.

[7] Management of traumatic meniscus tears: the 2019 ESSKA meniscus consensus.
Kopf S, Beaufils P, Hirschmann MT, Rotigliano N, Ollivier M, Pereira H, Verdonk R, Darabos N, Ntagiopoulos P, Dejour D, Seil
R, Becker [Link] Surg Sports Traumatol Arthrosc. 2020 Apr;28(4):1177-1194. doi: 10.1007/s00167-020-05847-3. Epub 2020
Feb 13.

[8] Bulgheroni E, Grassi A, Bulgheroni P, Marcheggiani Muccioli GM, Zaffagnini S, Marcacci M (2015) Long-term outcomes of
medial CMI implant versus partial medial meniscectomy in patients with concomitant ACL reconstruction. Knee Surg Sports
Traumatol Arthrosc 23:3221-3227

[9] Rodkey WG, DeHaven KE, Montgomery WH, Baker CL, Beck CL, Hormel SE, Steadman JR, Cole BJ, Briggs KK (2008)
Comparison of the collagen meniscus implant with partial meniscectomy. A prospective randomized trial. J Bone Joint Surg
Am 90:1413-1426

[10] Polyurethane Meniscal Scaffold for the Treatment of Partial Meniscal Deficiency: 5-Year Follow-up Outcomes: A
European Multicentric Study.
Toanen C, Dhollander A, Bulgheroni P, Filardo G, Zaffagnini S, Spalding T, Monllau JC, Gelber P, Verdonk R, Beaufils P, Pujol
N, Bulgheroni E, Asplin L, Verdonk [Link] J Sports Med. 2020 May;48(6):1347-1355. doi: 10.1177/0363546520913528. Epub
2020 Apr [Link]: 32267737

[11] Meniscal allograft transplantation after meniscectomy: clinical effectiveness and cost‑effectiveness
Norman Waugh1 · Hema Mistry1 · Andrew Metcalfe2 · Emma Loveman3 · Jill Colquitt3 · Pamela Royle1 · Nick A. Smith4 ·
Tim Spalding4 Knee Surgery, Sports Traumatology, Arthroscopy (2019) 27:1825–1839

[12] Allografts in joint reconstruction: ESSKA making a difference. EDITORIAL

Tim Spalding1 · Peter Verdonk2 · Laura de Girolamo3 · Romain Seil4 · David Dejour5 Knee Surgery, Sports Traumatology,
Arthroscopy [Link]

[13] A pilot randomized trial of meniscal allograft transplantation versus personalized physiotherapy for. patients with a
symptomatic meniscal deficient knee compartment
N. A. Smith, N. Parsons, D. Wright, C. Hutchinson, A. Metcalfe, P. Thompson, M. L. Costa, T. Spalding. The Bone & Joint
Journal Vol. 100-B, No. 1

[14] Filardo, Giuseppe, et al. "Meniscal scaffolds: results and indications. A systematic literature review." International
orthopaedics 39.1 (2015): 35-46.

[15] Houck, D.A., Kraeutler, M.J., Belk, J.W. et al. Similar clinical outcomes following collagen or polyurethane meniscal
scaffold implantation: a systematic review. Knee Surg Sports Traumatol Arthrosc 26, 2259–2269 (2018).

[16] Warth, Ryan J., and William G. Rodkey. "Resorbable collagen scaffolds for the treatment of meniscus defects: a
systematic review." Arthroscopy: The Journal of Arthroscopic & Related Surgery 31.5 (2015): 927-941
S12: Which factors influence the decision in graft choice for ACLR?

Steering group answer:

Before choosing the proper graft in ACLR, the following questions should be answered:
1. Which previous graft has been harvested?
2. Is there a need to fill bone tunnel(s)?
3. Is there a need for a multiligament reconstruction?
4. What are the advantages and disadvantages of the different autografts (hamstring
vs. quad vs. BPTB, …)?
5. What are the respective advantages and disadvantages of autografts vs. allografts
(see question 13). What is the allograft availability?
6. Is it pertinent to reharvest the same graft on the ipsilateral knee or harvest from the
contralateral knee (see question 15)?
7. Are there abnormalities (e.g. degenerative changes or patella height) of the
patellofemoral joint?
Depending on these factors, the choice is often a compromise; in other words a necessity
rather than a real choice.

Grade of recommendation: C

Literature review:
The literature provides a variety of proposed graft options that may used in ACL reconstruction
and ACL revision. Comparisons have also been performed as shown below.
A recent study compared both hamstring and quadriceps autograft tendons in a revision
situation and found no difference regarding outcome (1). Wolf Petersen’s group showed no
difference between ACL reconstruction using a quadriceps tendon graft or a contralateral
semitendinosus-gracilis graft in terms of knee stability and function (2).

The use of hamstring grafts for revision has been well established in ACL revision surgery. The
problem of graft availability led surgeons to harvest contralateral tendons. Both ipsi- and
contralateral hamstring tendons were shown to provide similar results regarding overall
outcome (3).
Further studies looked into the use of bone-patella tendon-bone autografts for ACL revision,
the outcome of which was comparable to primary ACL reconstruction using a BTB graft (4).
The MARS group published its findings showing no superiority of one autograft over the other
(5). In particular, no differences were noted in re-rupture or patient-reported outcomes
between soft tissue and bone–patellar tendon–bone grafts (5).
The MARS group also highlighted factors influencing graft choice in ACL revision surgery (6).
They showed that the use of an autograft in the primary reconstruction procedure increases
the likelihood of using an allograft during a revision procedure. This indicates that graft
availability is undoubtedly a main determinant of graft choice (6).
Interestingly, there are more studies comparing allografts to autografts than comparing
different types of allografts in revision ACL surgery. This may be attributed to the increased
tendency to use allografts in revision surgery. We therefore refer to the next question for
more information in that regard.
The advantages and disadvantages of the various grafts that have been frequently linked to
donor site morbidity and rotational stability (7) are less likely to influence graft decision in a
revision setting, due to the fact that the individual situation is likely to define the choice of the
revision graft.

References:
[1] Barié A, Ehmann Y, Jaber A, Huber J, Streich NA. Revision ACL reconstruction using quadriceps or hamstring autografts
leads to similar results after 4 years: good objective stability but low rate of return to pre-injury sport level. Knee Surg
Sports Traumatol Arthrosc. 2019 Nov;27(11):3527-3535.

[2] Häner M, Bierke S, Petersen W. Anterior Cruciate Ligament Revision Surgery: Ipsilateral Quadriceps Versus Contralateral
Semitendinosus-Gracilis Autografts. Arthroscopy. 2016 Nov;32(11):2308-2317.

[3] Legnani C, Peretti G, Borgo E, Zini S, Ventura A. Revision anterior cruciate ligament reconstruction with ipsi- or
contralateral hamstring tendon grafts. Eur J Orthop Surg Traumatol. 2017 May;27(4):533-537.

[4] Tomihara T, Hashimoto Y, Taniuchi M, Takigami J, Han C, Shimada N. One-stage revision ACL reconstruction after
primary ACL double bundle reconstruction: is bone-patella tendon-bone autograft reliable? Knee Surg Sports Traumatol
Arthrosc. 2017 May;25(5):1653-1661.

[5] MARS Group. Effect of graft choice on the outcome of revision anterior cruciate ligament reconstruction in the
Multicenter ACL Revision Study (MARS) Cohort. Am J Sports Med. 2014 Oct;42(10):2301-10.

[6] MARS Group. Factors Influencing Graft Choice in Revision Anterior Cruciate Ligament Reconstruction in the MARS
Group. J Knee Surg. 2016 Aug;29(6):458-63.

[7] Ahmad SS, Meyer JC, Krismer AM, Ahmad SS, Evangelopoulos DS, Hoppe S, Kohl S. Outcome measures in clinical ACL
studies: an analysis of highly cited level I trials. Knee Surg Sports Traumatol Arthrosc. 2017 May;25(5):1517-1527.
S13: Are allografts comparable to autografts regarding outcome?

Steering group answer:

Allografts are more frequently used in ACL revisions than in primary ACL reconstruction.
Allografts offer the advantages of decreased operative times and low average pain during the
entire rehab period. The disadvantages of allografts include a risk of disease transmission,
immune rejection, delay in the remodeling, a prolonged integration process and possibly
higher revision rates, depending on graft processing. Historically, results have been recognized
to be inferior when using irradiated grafts. Non-irradiated grafts (cryo-preserved or fresh
frozen) are a plausible alternatives to autografts, but it is unclear whether failure rates are
comparable, and caution still remains for use of allografts in younger patients. Such patients
tend to be more active and there is increasing understanding of the higher risks in this age
group. The evidence is weak, but allografts in the young are likely to carry increased risk of
failure (9). This is an area for further comparative work. The choice for using allografts is based
on preference, while taking into account the longer maturation of allografts. Graft availability
and donor-site morbidity become the dominant factors in decision making in these clinical
situations. Cost issues have also been underlined.

Grade of recommendation: A

Literature review:
There have been several studies comparing allografts to autografts in revision ACL surgery.
Keizer et al. demonstrated higher rates of return to sports when using patella tendon
autografts compared to allografts (1). The MARS group demonstrated improved sports
function and patient-reported outcome measures when an autograft was used. Additionally,
the use of an autograft showed a decreased risk in graft re-rupture at the 2-year follow-up (2).
In a meta-analysis published in 2017, 32 studies dealing with the question of superiority of
autografts over allografts were included. The authors concluded that following revision ACL
reconstruction, autografts performed better than allografts, with lower post-operative laxity
and rates of complications and re-operations. However, if only non-irradiated allografts were
considered, the outcomes were similar to autografts (3).
A meta-analysis published in 2018 in the Journal of Arthroscopy included 3000 patients and
showed no difference between autografts and allografts with regard to failure rate (4).
It is still important to mention that there has been some evidence demonstrating poorer
results of allografts in revision ACL surgery (5). Martin Lind showed 2.2 times increased re-
revision rates after allograft ACL revision, compared to autografts, based on Danish registry
data (5). However, it is important to consider the fact that no differentiation between
irradiated and non-irradiated grafts was made or at least no clarification in that regard was
present in the study. Therefore, the results of the study are to be considered with caution (5).
It is important to underline that irradiation of allografts has deleterious effects on quality and
subsequent surgical outcome (6). Guo et al. demonstrated statistically poorer KT-1000 results
and higher failure rates in γ-irradiated allografts compared with autografts and fresh-frozen
allografts (6). On a basic research level, the maximum stress, maximum strain, and strain
energy density were significantly reduced by irradiation of allografts (7).
A randomized controlled study by Sun et al. showed that patients undergoing ACL
reconstruction with BPTB non-irradiated allografts were likely to demonstrate comparable
clinical outcomes to patients undergoing autograft ACL reconstruction (8).
Looking at infection risk, analyses performed on large cohorts of patients or registries
documented that the choice of allograft does not imply a higher risk of infection compared to
autografts: a Canadian cohort study on 827 revision ACLRs (225 allografts) found a post-
operative infection rate of 0.8% (7 patients) requiring surgery and an additional 1.2% treated
by antibiotics only. The authors also demonstrated that graft selection (autograft versus
allografts of any type) did not influence the risk for infection (9).
The ESSKA initiative underlined the likelihood that younger patients with high demand may
put the allograft at risk in ACL reconstruction (9). However, the evidence is weak. Cost issues
in association with allografts and the impact on graft choice have also been emphasized in a
recent systematic review (11).

References:
[1] Keizer MNJ, Hoogeslag RAG, van Raay JJAM, Otten E, Brouwer RW. Superior return to sports rate after patellar tendon
autograft over patellar tendon allograft in revision anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol
Arthrosc. 2018 Feb;26(2):574-581.
[2] MARS Group. Effect of graft choice on the outcome of revision anterior cruciate ligament reconstruction in the
Multicenter ACL Revision Study (MARS) Cohort. Am J Sports Med. 2014 Oct;42(10):2301-10.

[3] Grassi A, Nitri M, Moulton SG, Marcheggiani Muccioli GM, Bondi A, Romagnoli M, Zaffagnini S. Does the type of graft
affect the outcome of revision anterior cruciate ligament reconstruction? a meta-analysis of 32 studies. Bone Joint J. 2017
Jun;99-B(6):714-723.

[4] Mohan R, Webster KE, Johnson NR, Stuart MJ, Hewett TE, Krych AJ. Clinical Outcomes in Revision Anterior Cruciate
Ligament Reconstruction: A Meta-analysis. Arthroscopy. 2018 Jan;34(1):289-300.

[5] Nissen KA, Eysturoy NH, Nielsen TG, Lind M. Allograft Use Results in Higher Re-revision Rate for Revision Anterior
Cruciate Ligament Reconstruction. Orthop J Sports Med. 2018 Jun 5;6(6).

[6] Gibbons MJ, Butler DL, Grood ES, Bylski-Austrow DI, Levy MS, Noyes FR (1991) Effects of gamma irradiation on the initial
mechanical and material properties of goat bone-patellar tendon-bone allografts. J Orthop Res 9:209–218

[7] Guo L, Yang L, Duan XJ et al (2012) Anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft:
comparison of autograft, fresh-frozen allograft, and gamma-irradiated allograft. Arthroscopy 28:211–217

[8] Sun K, Tian S, Zhang J, Xia C, Zhang C, Yu T (2009) Anterior cruciate ligament reconstruction with BPTB autograft,
irradiated versus non-irradiated allograft: a prospective randomized clinical study. Knee Surg Sports Traumatol Arthrosc
17:464–474

[9] Leroux T, Wasserstein D, Dwyer T, Ogilvie-Harris DJ, Marks PH, Bach BR Jr et al (2014) The epidemiology of revision
anterior cruciate ligament reconstruction in Ontario, Canada. Am J Sports Med 42:2666–2672

[10] Spalding, T., Verdonk, P., de Girolamo, L. et al. Allografts in joint reconstruction: ESSKA making a difference. Knee Surg
Sports Traumatol Arthrosc 27, 1701–1703 (2019).

[11] Mistry, H., Metcalfe, A., Colquitt, J. et al. Autograft or allograft for reconstruction of anterior cruciate ligament: a health
economics perspective. Knee Surg Sports Traumatol Arthrosc 27, 1782–1790 (2019)

[12] Condello V,·Zdanowicz U, Di Matteo B, Spalding T, Gelber PE, Adravanti P, Heuberer P, Dimmen S, Sonnery‑Cottet B,
Hulet C, Bonomo M, Kon E. Allograft tendons are a safe and effective option for revision ACL reconstruction: a clinical
review g Sports Traumatol Arthrosc. 2019 Jun;27(6):1771-1781

S14: Is there a role for synthetic grafts or synthetic augmentation?

Steering group answer:

The use of synthetic grafts is not recommended (grade B). For synthetic augmentation there
is currently not sufficient data for an evidence-based recommendation (grade D).

Literature review:
Although the use of synthetic grafts has been described for primary ACL reconstruction, there
is absolutely no evidence, nor is there any clinical study reporting the use of synthetic material
in revision ACL surgery. In primary ACL replacement using synthetic grafts (carbon fibers,
polypropylene, Dacron and polyester), high failure rates due to graft failure have been
reported due to mechanical fatigue. Reported complications include immunological
responses, breakage, debris dispersion leading to synovitis, chronic effusions, recurrent
instability and knee OA. Therefore synthetic graft options occupy a controversial position in
primary ACL reconstruction (1,2).

References:
[1] Legnani, C., Ventura, A., Terzaghi, C. et al. Anterior cruciate ligament reconstruction with synthetic grafts. A review of
literature. International Orthopaedics (SICOT) 34, 465–471 (2010).

[2] Ventura, A., Terzaghi, C., Legnani, C., Borgo, E., & Albisetti, W. (2010). Synthetic grafts for anterior cruciate ligament
rupture: 19-year outcome study. The Knee, 17(2), 108-113.

S15: What is the place of graft harvesting from the contralateral knee and graft re-
harvesting from the ipsilateral knee?

Steering group answer:

Contralateral graft harvesting is considered a valid alternative to ipsilateral autografts or to
allografts.
Although ACL reconstruction using re-harvested BPTB tendon may be possible, tendon quality
(histologically) is lower than primary tendon harvest and there is no available literature
concerning the quadriceps tendon.

Grade of recommendation: C

Literature review:
Several studies have dealt with the issue of graft harvesting from the contralateral knee.
Ferretti et al. concluded that the use of hamstring tendons harvested from the unaffected
knee represents a valid option for revision ACL surgery, with satisfying results (1).
Shelbourne et al. concluded that primary ACL reconstruction using a contralateral patellar
tendon autograft is an effective means of achieving symmetrical range of motion and strength
after surgery (2). He also stated that hypothetically, when the graft is harvested from the
ipsilateral knee, the rehabilitations for the ACL graft and for the graft-donor site are different
and have opposing goals. Rehabilitation for the ACL graft involves obtaining full range of
motion, reducing swelling, and providing the appropriate stress to achieve graft maturation.
Rehabilitation for the graft-donor site involves performing high-repetition strengthening
exercises to regain size and strength, best achieved when begun immediately after surgery
(2).
In a further study by Kartus, comparing ipsilateral re-harvesting of the patella tendon with
contralateral patella tendon harvesting, it was shown that re-harvesting the ipsilateral patellar
tendon resulted in lower functional scores and a higher rate of complications than revision
with the contralateral patellar tendon or primary anterior cruciate ligament reconstruction
(3).
A further study demonstrated that patients undergoing revision surgery with a contralateral
hamstring autograft experienced a quicker return to sports compared to patients who
underwent ipsilateral hamstring grafts in revision surgery (4).

Regarding graft re-harvesting, there have been some reports indicating recovery of the
harvested tendon (5,6,7). However, there is no clinical evidence that could be applied to justify
the use of the regenerated hamstring as a graft in revision surgery.
A clinical study looking into patella-tendon re-harvesting showed inferior results in terms of
recovery of the patella tendon and clinical outcome of the ACL (8).

References:
[1] Ferretti A, Monaco E, Caperna L, Palma T, Conteduca F. Revision ACL reconstruction using contralateral hamstrings. Knee
Surg Sports Traumatol Arthrosc. 2013 Mar;21(3):690-5. doi: 10.1007/s00167-012-2039-x. Epub 2012 May 10. PMID:
22572869.
[2] Shelbourne KD, O'Shea JJ. Revision anterior cruciate ligament reconstruction using the contralateral bone-patellar
tendon-bone graft. Instr Course Lect. 2002;51:343-6. PMID: 12064123.

[3] Kartus J, Stener S, Lindahl S, Eriksson BI, Karlsson J. Ipsi- or contralateral patellar tendon graft in anterior cruciate
ligament revision surgery. A comparison of two methods. Am J Sports Med. 1998 Jul-Aug;26(4):499-504. doi:
10.1177/03635465980260040401. PMID: 9689367.

[4] Legnani C, Peretti G, Borgo E, Zini S, Ventura A. Revision anterior cruciate ligament reconstruction with ipsi- or
contralateral hamstring tendon grafts. Eur J Orthop Surg Traumatol. 2017 May;27(4):533-537. doi: 10.1007/s00590-016-
1894-4. Epub 2017 Jan 4. PMID: 28054146.

[5] Yoshiya S, Matsui N, Matsumoto A, Kuroda R, Lee S, Kurosaka M. Revision anterior cruciate ligament reconstruction
using the regenerated semitendinosus tendon: analysis of ultrastructure of the regenerated tendon. Arthroscopy. 2004
May;20(5):532-5. doi: 10.1016/[Link].2004.01.031. PMID: 15122146.
[6] Stevanović V, Blagojević Z, Petković A, Glišić M, Sopta J, Nikolić V, Milisavljević M. Semitendinosus tendon regeneration
after anterior cruciate ligament reconstruction: can we use it twice? Int Orthop. 2013 Dec;37(12):2475-81. doi:
10.1007/s00264-013-2034-y. Epub 2013 Aug 28. PMID: 23982635; PMCID: PMC3843191.

[7] Tsifountoudis I, Bisbinas I, Kalaitzoglou I, Markopoulos G, Haritandi A, Dimitriadis A, Papastergiou S. The natural history
of donor hamstrings unit after anterior cruciate ligament reconstruction: a prospective MRI scan assessment. Knee Surg
Sports Traumatol Arthrosc. 2017 May;25(5):1583-1590. doi: 10.1007/s00167-015-3732-3. Epub 2015 Aug 4. PMID:
26239861.

[8] Kartus J, Stener S, Lindahl S, Eriksson BI, Karlsson J. Ipsi- or contralateral patellar tendon graft in anterior cruciate
ligament revision surgery. A comparison of two methods. Am J Sports Med. 1998 Jul-Aug;26(4):499-504. doi:
10.1177/03635465980260040401. PMID: 9689367.

S16: What is the minimal tendinous graft diameter in ACL Revision Surgery?

Steering group answer:

The same requirements regarding graft thickness and length are necessary for the grafts used
in revision surgery as in primary ACL surgery. A minimum graft diameter of 8 mm is advised
and is dependent on many factors (knee size, surgical technique, type of graft, gender).

Grade of recommendation: C

Literature review:
Large registry data demonstrate the importance of choosing a graft diameter of >8mm. This
was shown by large reports from both the New Zealand registry and the Swedish and
Norwegian national registries.
There is a lack of research dealing with graft size in revision surgery. However, several studies
have dealt with that question in primary ACL reconstruction. It would be plausible to assume
that the same rules apply to revision ACL surgery.
Magussen et al. demonstrated that hamstring autograft size is a predictor of early graft
revision. Use of hamstring autografts 8 mm in diameter or less was shown to be associated
with higher revision rates (1). In a large cohort of patients who underwent primary ACL
reconstruction with hamstring autografts, an increase in the graft diameter between 7.0 and
10.0 mm resulted in a 0.86 times lower likelihood of revision surgery with every 0.5-mm
increase (2). In a further study, it was shown that within the range of 7.0 to 9.0 mm graft
diameter, there was a 0.82 times lower likelihood of being a revision case with every 0.5-mm
incremental increase (3). The MOON study showed that revision was required in 0 of 64
patients (0.0%) with grafts greater than 8 mm in diameter and 14 of 199 patients (7.0%) with
grafts 8 mm in diameter or smaller (P = .037) (4).

It is still fair to mention that despite the above evidence, commonly referring to 8mm or more
as the necessary graft size, the Norwegian registry data contradicted prevailing evidence prior
evidence by showing that graft size is possibly less important than previously stated (5,6).

References:
[1] Magnussen RA, Lawrence JT, West RL, Toth AP, Taylor DC, Garrett WE. Graft size and patient age are predictors of early
revision after anterior cruciate ligament reconstruction with hamstring autograft. Arthroscopy. 2012 Apr;28(4):526-31.

[2] Snaebjörnsson T, Hamrin Senorski E, Ayeni OR, Alentorn-Geli E, Krupic F, Norberg F, Karlsson J, Samuelsson K. Graft
Diameter as a Predictor for Revision Anterior Cruciate Ligament Reconstruction and KOOS and EQ-5D Values: A Cohort
Study From the Swedish National Knee Ligament Register Based on 2240 Patients. Am J Sports Med. 2017 Jul;45(9):2092-
2097.

[3] Spragg L, Chen J, Mirzayan R, Love R, Maletis G. The Effect of Autologous Hamstring Graft Diameter on the Likelihood for
Revision of Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2016 Jun;44(6):1475-81.

[4] Mariscalco MW, Flanigan DC, Mitchell J, Pedroza AD, Jones MH, Andrish JT, Parker RD, Kaeding CC, Magnussen RA. 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 Dec;29(12):1948-
53.

[5] Inderhaug E, Drogset JO, Lygre SHL, Gifstad T. No effect of graft size or body mass index on risk of revision after ACL
reconstruction using hamstrings autograft. Knee Surg Sports Traumatol Arthrosc. 2020 Mar;28(3):707-713.

[6] Murgier J, Powell A, Young S, Clatworthy M. Effectiveness of thicker hamstring or patella tendon grafts to reduce graft
failure rate in anterior cruciate ligament reconstruction in young patients. Knee Surg Sports Traumatol Arthrosc. 2020 Apr
18.

S17: What is the best treatment in the case of a planned ACL revision in a patient with a
suspected low-grade infection?

Steering group answer:

Infection after primary ACL reconstruction has a low incidence and there is little evidence to
guide the correct treatment. However, in the case of a suspected infection it is mandatory to
perform blood tests and joint aspiration (white blood cell count, C-reactive protein,
erythrocyte sedimentation rate, culture and microscopic examination). Tissue biopsy may be
important to rule out low-grade infection in case of doubt and to identify bacteria (see also
question D17).
A multi-staged procedure in suspected low-grade infection is mandatory, with a thorough
debridement (including ACL graft remnant excision and hardware removal) and antibiotic
therapy prior to the second stage ACL reconstruction.

Grade of recommendation: D

Literature review:
The literature in this regard is scarce. Most of the literature is based on the concepts of
treatment of septic joint arthritis. There are some concepts regarding the treatment of septic
arthritis in an ACL reconstructed knee. The most important issue that has been emphasized is
early diagnosis, based on joint aspiration (1). Joint aspiration allows for a sensitive and specific
diagnosis of infection and should be considered upon suspicion (2). The gold standard of
treatment in septic arthritis following ACL reconstruction is arthroscopic washout with
debridement with graft retention (3). Such an approach is likely to be successful without the
need for graft removal (3,4).
Andreas Imhoff’s group concluded that while graft-retaining protocols should have the highest
priority in the treatment of septic arthritis after ACL reconstruction, two-stage procedures
should be performed in cases where graft resection becomes necessary, to avoid future
cartilage and meniscal lesions (4). It is important to acknowledge septic arthritis after ACL
reconstruction as a complication resulting in reduced long-term subjective, functional, and
radiographic outcomes (5).

References:
[1] Mouzopoulos G, Fotopoulos VC, Tzurbakis M. Septic knee arthritis following ACL reconstruction: a systematic review.
Knee Surg Sports Traumatol Arthrosc. 2009 Sep;17(9):1033-42.

[2] Torres-Claramunt R, Gelber P, Pelfort X, Hinarejos P, Leal-Blanquet J, Pérez-Prieto D, Monllau JC. Managing septic
arthritis after knee ligament reconstruction. Int Orthop. 2016 Mar;40(3):607-14.

[3] Schuster P, Schulz M, Immendoerfer M, Mayer P, Schlumberger M, Richter J. Septic Arthritis After Arthroscopic Anterior
Cruciate Ligament Reconstruction: Evaluation of an Arthroscopic Graft-Retaining Treatment Protocol. Am J Sports Med.
2015 Dec;43(12):3005-12.
[4] Pogorzelski J, Themessl A, Achtnich A, Fritz EM, Wörtler K, Imhoff AB, Beitzel K, Buchmann S. Septic Arthritis After
Anterior Cruciate Ligament Reconstruction: How Important Is Graft Salvage? Am J Sports Med. 2018 Aug;46(10):2376-2383.

[5] Schub DL, Schmitz LM, Sakamoto FA, Winalski CS, Parker RD. Long-term outcomes of postoperative septic arthritis after
anterior cruciate ligament reconstruction. Am J Sports Med. 2012 Dec;40(12):2764-70.

S18. Is antibiotic soaking of grafts useful for reducing post-operative infections?

Steering group answer:

Soaking the graft in antibiotics (vancomycin (grade A), gentamycin (grade C)) solution prior to
graft implantation is a valid option to reduce the incidence of postoperative septic arthritis.
However the development of resistance may be of concern (grade D).

Literature Review
This is a reasonably well-investigated topic in primary ACL reconstruction.
A meta-analysis by Naendrup showed a significant decrease in infection after graft soaking
with Vancomycin. The meta-analysis included 5,075 patients with ACL reconstruction,
followed from 6 to 52 weeks post-operatively. Of 2099 patients in the routine pre-operative
IV prophylaxis group, 44 (2.1%) cases of early septic arthritis were reported. In contrast, there
were no reports of septic arthritis following ACLR in 2976 cases of vancomycin-soaked grafts.
The meta-analysis yielded an odds ratio of 0.04 (0.01-0.16) favouring the addition of intra-
operative vancomycin soaking of grafts (1). This meta-analysis underlines the power of
vancomycin soaking in reducing postoperative infections.
In a recent study by Banios et al., it was concluded that septic arthritis following ACL
reconstruction can be significantly reduced (or even eliminated) by soaking ACL autografts in
a 5 mg/ml vancomycin solution. Of note, this strategy seems to be more effective in the setting
of hamstring tendon autograft use, since the risk of postoperative knee infection is
significantly higher when this type of graft is used (2). The article was published later and
therefore not included in the meta-analysis above.
A further review identified 306 bacterial infections in 68,453 grafts across 198 studies. The
overall estimated ACL graft infection rate in our meta-analysis was 0.9% (95% confidence
interval [CI] = 0.8% to 1.0%). Hamstring autografts were associated with a higher infection rate
(1.1%, CI = 0.9% to 1.2%) than bone-patella tendon-bone autografts (0.7%, CI = 0.6% to 0.9%)
and allografts (0.5%, CI = 0.4% to 0.8%) (Q = 15.58, p < 0.001). Presoaking hamstring autografts
in vancomycin reduced infection rates to 0.1% (CI = 0.0% to 0.4%) (Q = 10.62, p = 0.001) (3).
A systematic review from Stanford University demonstrated a 15-fold reduced risk of infection
after vancomycin graft soaking, based on 10 articles including 21,368 patients (4).
Further study showed that vancomycin presoaking does not affect immediate biomechanical
properties or re-rupture rates(5,6).
Regarding revision ACL reconstruction, Schuster et al. showed that soaking of the graft in
vancomycin solution prior to implantation dramatically reduced the incidence of
postoperative septic arthritis in R-ACLR (7).
Two studies also evaluated the effect of gentamycin and found that gentamycin presoaking
also decreased joint infections (8,9).

References:
[1] Naendrup JH, Marche B, de Sa D, Koenen P, Otchwemah R, Wafaisade A, Pfeiffer TR. Vancomycin-soaking of the graft
reduces the incidence of septic arthritis following ACL reconstruction: results of a systematic review and meta-analysis.
Knee Surg Sports Traumatol Arthrosc. 2020 Apr;28(4):1005-1013.

[2] Banios K, Komnos GA, Raoulis V, Bareka M, Chalatsis G, Hantes ME. Soaking of autografts with vancomycin is highly
effective on preventing postoperative septic arthritis in patients undergoing ACL reconstruction with hamstrings autografts.
Knee Surg Sports Traumatol Arthrosc. 2020 May 3.

[3] Kuršumović K, Charalambous CP. Relationship of Graft Type and Vancomycin Presoaking to Rate of Infection in Anterior
Cruciate Ligament Reconstruction: A Meta-Analysis of 198 Studies with 68,453 Grafts. JBJS Rev. 2020 Jul;8(7):e1900156.

[4] Xiao M, Sherman SL, Safran MR, Abrams GD. Significantly Lower Infection Risk for Anterior Cruciate Ligament Grafts
Presoaked in Vancomycin Compared With Unsoaked Grafts: A Systematic Review and Meta-analysis. Arthroscopy. 2021
May;37(5):1683-1690.

[5] Jacquet C, Jaubert M, Pioger C, Sbihi A, Pithioux M, Le Baron M, Sharma A, Ollivier M. Presoaking of Semitendinosus
Graft With Vancomycin Does Not Alter Its Biomechanical Properties: A Biomechanical In Vitro-Controlled Study Using Graft
From Living Donors. Arthroscopy. 2020 Aug;36(8):2231-2236.

[6] The vancomycin soaking technique: no differences in autograft re-rupture rate. A comparative study. Pérez-Prieto D et
al. Int Orthop. 2021 Jun;45(6):1407-11).

[7] Schuster P, Schlumberger M, Mayer P, Eichinger M, Geßlein M, Reddemann F, Richter J. Soaking of the graft in
vancomycin dramatically reduces the incidence of postoperative septic arthritis after anterior cruciate ligament
reconstruction. Knee Surg Sports Traumatol Arthrosc. 2020 Aug;28(8):2587-2591.

[8] Yazdi H, Yousof Gomrokchi A, Nazarian A, Lechtig A, Hanna P, Ghorbanhoseini M. The Effect of Gentamycin in the
Irrigating Solution to Prevent Joint Infection after Anterior Cruciate Ligament (ACL) Reconstruction. Arch Bone Jt Surg. 2019
Jan;7(1):67-74.
[9] Moriarty P, Kayani B, Wallace C, Chang J, Plastow R, Haddad FS. Gentamicin pre-soaking of hamstring autografts
decreases infection rates in anterior cruciate ligament reconstruction. Bone Jt Open. 2021 Jan 22;2(1):66-71.

IV. Indications
Revision ACL reconstruction is generally recommended in active patients suffering from
instability symptoms. To date, no study has directly compared the results of operative and
non-operative treatment in patients with failed primary ACL reconstruction. However, as
known from primary ACL tears, non-operative treatment is most likely associated with a
higher risk of secondary meniscal and chondral lesions, and a reduced activity level.
Nevertheless, non-operative treatment may be considered in less active patients or patients
with advanced OA in whom pain is the main complaint.

The “Formal Consensus” approach has been used in this section on specific treatment
indications not covered by the “RAND/UCLA Appropriateness Method” (RAM) method, please
see I1 and I2.
The RAM process was set up specifically to deepen the investigation of the indications for first
ACL graft revision. To define treatment indications, the RAM combined the best available
scientific evidence with the collective judgment of a panel of experts (corresponding to the
Formal Consensus Rating Group) guided by a core panel (corresponding to the Formal
Consensus Steering Group). A list of specific clinical scenarios was produced regarding ACL re-
rupture with increased laxity in an aligned knee in adults. Each scenario underwent discussion
and a two-round vote on a nine-point Likert scale, and scores were pooled to generate expert
patient-specific recommendations on the appropriateness of revision ACL reconstruction.
For the appropriateness of indications for ACL revision surgery in different clinical scenarios
the base case was defined by age (3 groups: 18-35, 36-50, 51-60 years), sport expectation (3
groups: Tegner 0-3, 4-6, 7-10), instability symptoms (2 groups: subjective instability vs no
subjective instability), meniscus status (3 groups: functional meniscus, repairable meniscus,
non-functional meniscus) and OA (2 groups: 0,I,II grade vs III grade KL). It was defined without
gross osseous malalignment (varus/valgus within 5°, slope less than 12°), no additional
ligamentous injuries, no advanced OA (KL IV grade), and over 18 years of age.
However, since older age and advanced OA are also important factors to be considered in the
clinical practice when deciding for an ACL revision, they will be commented on below.
I1: What is the indication for performing an ACL revision in people older than 60 years?

Steering group answer: No evidence is available on the outcomes of Revision ACL

reconstruction in patients older than 60 years of age. However, based on evidence available
for primary ACL reconstruction, revision ACL is not contraindicated, especially in active
patients with symptomatic instability and limited OA.

Grade: D

Literature review:
No studies are available on Revision ACL reconstruction in patients older than 60 years. The
average age of the ACL Revision case series is usually between 25-35 years [1], with very few
patients exceeding 60 years of age [2,3]. Therefore, the data on the outcomes of Revision ACL
reconstruction in patients >60 years of age are scarce.
Only one study specifically assessed the role of age in the ACL Revision outcomes: Yoon et al.
[4] compared 24 patients over 40 years of age with 62 patients aged less than 40 years, at a
minimum 2-year follow-up. The IKDC, Lysholm, AP laxity and Pivot-Shift significantly improved
from preoperative status to final follow-up in both groups, without differences between
patients older and younger than 40 years. Similar failure rates of nearly 30% were registered
in both groups. The authors concluded that outcomes and failures were independent of the
patient’s age; however, they did not report how many patients were older than 60 years of
age, and they reported an overall high failure rate and generally poor outcomes. However,
some evidence is available for Primary ACL reconstruction. A recent systematic review titled
“Age over 50 years is not a contraindication of anterior cruciate ligament reconstruction” [5]
reported that ACL reconstruction in patients older than 50 years is a safe procedure with good
results that are comparable to those in younger patients, and that physiological age, clinical
symptoms, and functional requests are more important than chronological age in the decision
process. However, in this review only 2 studies [6,7] specifically included patients older than
60 years. Toanen et al. reported an average 93 points on the Lysholm score, 83% return to
sport (50% at pre-injury level) and no knee deterioration at 4-year follow-up in 12 over-60
patients with no or minimum OA (Ahlback 0 or I). The authors concluded that older and active
patients with nonarthritic ACL-deficient knees can be considered for a knee stabilizing
procedure [6]. Baker Jr et al., screening a 25-year institutional database, found only 15
patients and reported good to excellent clinical results at nearly 10 years of follow-up, return
to sport exercise, complete satisfaction, and superior PROMS compared to age and sex-
matched patients. The authors concluded that patients of any age who are active, desire to
maintain their level of activity and have symptomatic instability can be successfully treated
with ACL reconstruction if there are no contraindications [7].

References:
1) Grassi A, Nitri M, Moulton SG, Marcheggiani Muccioli GM, Bondi A, Romagnoli M, Zaffagnini S. Does the type of graft affect
the outcome of revision anterior cruciate ligament reconstruction? a meta-analysis of 32 studies. Bone Joint J. 2017 Jun;99-
B(6):714-723. doi: 10.1302/[Link]-2016-0929.R2. PMID: 28566389.

2) Grassi A, Kim C, Marcheggiani Muccioli GM, Zaffagnini S, Amendola A. What Is the Mid-term Failure Rate of Revision ACL
Reconstruction? A Systematic Review. Clin Orthop Relat Res. 2017 Oct;475(10):2484-2499. doi: 10.1007/s11999-017-5379-5.
PMID: 28493217; PMCID: PMC5599393.

3) Louis ML, D'ingrado P, Ehkirch FP, Bertiaux S, Colombet P, Sonnery-Cottet B, Schlatterer B, Pailhé R, Panisset JC, Steltzlen
C, Lustig S, Lutz C, Dalmay F, Imbert P, Saragaglia D; French Arthroscopy Society (Société Francophone d’Arthroscopie, SFA).
Combined intra- and extra-articular grafting for revision ACL reconstruction: A multicentre study by the French Arthroscopy
Society (SFA). Orthop Traumatol Surg Res. 2017 Dec;103(8S):S223-S229. doi: 10.1016/[Link].2017.08.007. Epub 2017 Sep 7.
PMID: 28889985.

4) Yoon KH, Lee HW, Park JY, Kim SJ, Kim SG. Clinical Outcomes and the Failure Rate of Revision Anterior Cruciate Ligament
Reconstruction Were Comparable Between Patients Younger Than 40 Years and Patients Older Than 40 Years: A Minimum 2-
Year Follow-Up Study. Arthroscopy. 2020 Sep;36(9):2513-2522. doi: 10.1016/[Link].2020.06.012. Epub 2020 Jun 15. PMID:
32554076.

5) Costa GG, Grassi A, Perelli S, Agrò G, Bozzi F, Lo Presti M, Zaffagnini S. Age over 50 years is not a contraindication for
anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2019 Nov;27(11):3679-3691. doi:
10.1007/s00167-019-05450-1. Epub 2019 Apr 3. PMID: 30944945.

6) Toanen C, Demey G, Ntagiopoulos PG, Ferrua P, Dejour D. Is There Any Benefit in Anterior Cruciate Ligament
Reconstruction in Patients Older Than 60 Years? Am J Sports Med. 2017 Mar;45(4):832-837. doi:
10.1177/0363546516678723. Epub 2017 Jan 5. PMID: 28056178.

7) Baker CL Jr, Jones JC, Zhang J. Long-term Outcomes After Anterior Cruciate Ligament Reconstruction in Patients 60 Years
and Older. Orthop J Sports Med. 2014 Dec 12;2(12):2325967114561737. doi: 10.1177/2325967114561737. PMID:
26535289; PMCID: PMC4555533.
I2: Are there indications to perform ACL revision in patients with KL IV grade OA?

Steering group answer: ACL reconstruction can be effective in reducing activity-induced pain
and instability in early OA. For advanced OA (KL 4) there is no indication to perform isolated
ACL reconstruction. Data for combined surgery are only rarely available, but high tibial
osteotomy can be combined with ACL reconstruction in special indications to improve
symptomatic instability in the OA knee.

Grade: D

Literature review:
It is well known that ACL reconstruction protects the meniscus from further damage and
probably slows OA development. However, the literature is very scarce on whether
performing ACL reconstruction in cases of already existing OA can be successful, and even less
literature is available concerning the revision setting.
Some case series describe successful ACL reconstruction in early OA (1,2,3). Very limited
evidence was generated suggesting that ACL reconstruction could be advantageous even in
advanced OA (Shelbourne n=3 patients). Fayard et al. showed that signs of medial OA in
patients over 50 years of age are indicative of poor outcomes (4). Regarding the outcome of
revision ACL replacement, cartilage damage and OA are worse prognostic factors, as the MARS
data show (5). Furthermore, ACL revision reconstruction cannot reliably delay the progression
of OA (6). A recent systematic review showed that combined surgery with HTO and ACL
replacement may be beneficial in selected cases; however, the role of ACL reconstruction in
severe OA is unclear, whereas the role of HTO is well evaluated (7). Indications for combining
HTO with ACL replacement could include pain from subjective instability. Mehl et al. showed
that additional ACL reconstruction versus HTO alone resulted in higher Lysholm and IKDC
scores and did not accelerate OA development (8).

References:
1) Sung-Jae Kim 1 , Kwang-Hwan Park, Sung-Hoon Kim, Sul-Gee Kim, Yong-Min Chun. Anterior cruciate ligament
reconstruction improves activity-induced pain in comparison with pain at rest in middle-aged patients with significant
cartilage degeneration. Am J Sports Med 2010 Jul;38(7):1343-8. doi: 10.1177/0363546509360406.

2) Noyes FR, Barber-Westin SD. Anterior cruciate ligament reconstruction with autogenous patellar tendon graft in patients
with articular cartilage damage. Am J Sports Med. 1997 Sep-Oct;25(5):626-34.
3) K D Shelbourne, K C Stube. Anterior cruciate ligament (ACL)-deficient knee with degenerative arthrosis: treatment with an
isolated autogenous patellar tendon ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 1997;5(3):150-6. doi:
10.1007/s001670050043.

4) Fayard JM, Wein F, Ollivier M, Paihle R, Ehlinger M, Lustig S, Panisset JC; French Arthroscopic Society. Factors affecting
outcome of ACL reconstruction in over-50-year-olds. .Orthop Traumatol Surg Res. 2019 Dec;105(8S):S247-S251. doi:
10.1016/[Link].2019.09.011.

5) Predictors of Patient-Reported Outcomes at 2 Years After Revision Anterior Cruciate Ligament Reconstruction. MARS
Group, Wright RW, Huston LJ, Haas AK, et al. Am J Sports Med. 2019 Aug;47(10):2394-2401. doi:
10.1177/0363546519862279.

6) Alberto Grassi, Clare L Ardern, Giulio Maria Marcheggiani Muccioli, Maria Pia Neri, Maurilio Marcacci, Stefano Zaffagnini.
Does revision ACL reconstruction measure up to primary surgery? A meta-analysis comparing patient-reported and clinician-
reported outcomes, and radiographic results. Br J Sports Med 2016 Jun;50(12):716-24. doi: 10.1136/bjsports-2015-094948.

7) Li Y, Zhang H, Zhang J, Li X, Song G, Feng H. Clinical outcome of simultaneous high tibial osteotomy and anteriorcruciate
ligament reconstruction for medial compartmentosteoarthritis in young patients with anterior cruciate ligament-deficient
knees: a systematic review. Arthroscopy. 2015 Mar;31(3):507-19.

8) Julian Mehl, Jochen Paul, Matthias J Feucht, Gerrit Bode, Andreas B Imhoff, Norbert P Südkamp, Stefan Hinterwimmer.
ACL deficiency and varus osteoarthritis: high tibial osteotomy alone or combined with ACL reconstruction? Arch Orthop
Trauma Surg. 2017 Feb;137(2):233-240. doi: 10.1007/s00402-016-2604-8.

For the indications to perform additional osseous corrections, meniscus surgery, or

additional ligamentous procedures please see the chapters on surgical strategy.

RAM (RAND/UCLA Appropriateness Method) - indications

For the RAM consensus method on treatment indications, the scenarios are built around this
question:

"A .. -year-old patient with ACL re-rupture presents with an aligned knee, increased laxity, and
the following characteristics. How appropriate are the indications for revision ACL
reconstruction?"

The term “re-rupture” in the RAM consensus question used to build the scenarios should be
interpreted in light of the concept of “failure” as described in D1, which refers not specifically
to an acute episode, but rather to a loss of function after a previous primary reconstruction
(see D1 for the complete definition).

In more detail, the scenarios are built according to the most important selected factors as
follows:
- Age: the category 18-35 years old has been chosen to identify the indications in patients in
the age group where there are commonly the highest functional requests; i.e. competitive
athletes. The category 35-50 years old has been selected to identify patients who are still
active but often with lower functional requests, and many years ahead before considering
metal resurfacing, which offers poor results in patients younger than 50 years old. A final
category of patients from 50-60 years old has been identified, as the functional requests are
usually lower and prostheses start to emerge among the suitable options to be considered for
treatment indication. A specific Delphi question has been dedicated to the few cases involving
patients >60 years of age.
- Expectations to go back to sport/activity level: 3 categories have been defined according to
the Tegner score (0-3 vs 4-6 vs 7-10, see below).
- Meniscus status: as there are countless scenarios related to specific meniscus lesion
patterns, the RAM scenarios considered 3 broad conditions: one where the meniscus is
functionally working; one where the meniscus is damaged but repairable to return to a
functional status; and one where meniscus is damaged to the point that it cannot be
considered functional. As scaffolds and meniscus allografts are not commonly available, a
specific Delphi question has been previously dedicated to the possibility of restoring meniscus
function through scaffolds and allografts.
- OA: the level of joint degeneration has been dichotomized into no or mild OA (KL 0 to II
grade) vs moderate OA (KL III grade), while a specific Delphi question has been previously
dedicated to patients affected by ACL re-rupture in advanced KL IV grade OA knees (see
above).
- Subjective instability: this has been dichotomized to represent two main conditions: one
where patients complain of instability symptoms; and another where they do not perceive
instability despite the increased laxity objectively documented by the surgeon (for the
methods to document instability please see the specific Delphi question).
10. Competitive sports 5. Work
Soccer–national and international Heavy labor (e.g., building, forestry)
elite Competitive sports
9. Competitive sports Cycling
Soccer, lower divisions Cross-country skiing
Ice hockey Recreational sports
Wrestling Jogging on uneven ground at least
Gymnastics twice weekly
8. Competitive sports 4. Work
Bandy Moderately heavy labor
Squash or badminton (e.g., truck driving, heavy domestic
Athletics (jumping, etc.) work)
Downhill skiing Recreational sports
7. Competitive sports Cycling
Tennis Cross-country skiing
Athletics (running) Jogging on even ground at least
Motorcross, speedway twice weekly
Handball 3. Work
Basketball Light Labor (e.g., nursing)
Recreational sports Competitive and recreational sports
Soccer Swimming
Bandy and ice hockey Walking in forest possible
Squash 2. Work
Athletics (jumping) Light Labor
Cross-country track findings both Walking on uneven ground possible but
recreational and competitive impossible to walk in forest
6. Recreational sports 1. Work
Tennis and badminton Sedentary work
Handball Walking on even ground possible
Basketball 0. Sick leave or disability pension because
Downhill skiing of knee problems
Jogging, at least five times per week

Y Tegner, J Lysholm. Rating systems in the evaluation of knee ligament injuries. Clin Orthop
Relat Res. 1985 Sep;(198):43-9.
Modified from P Chen, L Gao, X Shi, K Allen, L Yang. Fully automatic knee osteoarthritis
severity grading using deep neural networks with a novel ordinal loss. Comput Med Imaging
Graph. 2019 Jul;75:84-92.

Based on the five clinical variables identified as more relevant for the treatment choice, a set
of 108 clinical scenarios was developed. Panelists were asked to individually assess the
appropriateness for revision ACL reconstruction for all scenarios, for a total of 108 indications
organized in three main chapters based on the three age categories. The appropriateness of
the treatment indications in the different scenarios was rated in two rounds, to sort out
whether discrepant ratings are due to real clinical disagreement over the use of the procedure
("real" disagreement) or to fatigue or misunderstanding ("artefactual" disagreement). Each
panelist ranked, independently from the other panelists, the appropriateness for each
scenario on a nine-point Likert-scale, in which a score in the range 1-3 is considered
‘inappropriate’, 4-6 ‘uncertain’, and 7-9 ‘appropriate’. The final scores of the nine-point Likert-
scale of each expert were then pooled to generate a median appropriateness score for each
scenario. In addition, the presence of “disagreement” was calculated according to the
following definition: At least six panelists rate the indication in the 1-3 region and at least six
panelists rate it in the 7-9 region. Finally, the use of the treatment for each scenario was
classified:
- “appropriate”: median score of ≥7 without disagreement
- “inappropriate”: median vote of ≤3 without disagreement
A scenario receiving a score between 4 and 6, or a scenario with disagreement, was classified
as “uncertain”. An “uncertain” recommendation can reflect either the ambiguous state of
current evidence or equivocal appropriateness either due to a moderately unfavorable risk
profile or to limited efficacy. The ‘uncertain’ classification is not intended to be a negative
recommendation or to preclude a priory the use of the treatment for the specific scenario,
relying on the physician-patient interaction in determining treatment decision in the context
of the individual characteristics, co-morbidities, and preferences.

RAM results
Overall, in 63 scenarios revision ACL reconstruction was considered appropriate without
disagreement, in 13 inappropriate without disagreement, and in 32 scenarios the indication
was uncertain.
Chapter 1
A 18-35 years old patient with ACL re-rupture presents to your attention with an aligned knee, increased laxity, and the following characteristics.
How appropriate do you rate the indication for revision ACL reconstruction?
Sport level/expectations Concomitant meniscal lesion OA grade Subjective Instability No Subjective Instability Indication n°

0 0 0 0 0 0 0 0 17 M DIS 0 0 1 0 0 0 2 8 6 M DIS
KL 0-I-II 1 2 3 4 5 6 7 8 9 9 A+ 1 2 3 4 5 6 7 8 9 8 A+ (1-2)
Functional meniscus 0 0 0 1 0 0 1 4 11 1 0 0 0 0 2 7 2 5
KL III 1 2 3 4 5 6 7 8 9 9 A+ 1 2 3 4 5 6 7 8 9 7 A+ (3-4)

0 0 0 0 0 0 0 0 17 0 0 1 0 0 0 1 6 9
KL 0-I-II 1 2 3 4 5 6 7 8 9 9 A+ 1 2 3 4 5 6 7 8 9 9 A+ (5-6)
Tegner 7-10 Repairable meniscus 0 0 0 1 0 0 1 3 12 1 0 0 0 0 0 5 6 5
KL III 1 2 3 4 5 6 7 8 9 9 A+ 1 2 3 4 5 6 7 8 9 8 A+ (7-8)

0 0 0 0 0 1 0 2 14 0 0 1 1 0 1 4 5 5
KL 0-I-II 1 2 3 4 5 6 7 8 9 9 A+ 1 2 3 4 5 6 7 8 9 8 A+ (9-10)
Non functional meniscus 0 1 0 0 0 1 2 7 6 2 0 0 1 1 2 6 1 4
KL III 1 2 3 4 5 6 7 8 9 8 A+ 1 2 3 4 5 6 7 8 9 7 A+ (11-12)

0 0 0 0 0 0 0 1 16 0 0 1 0 2 1 4 5 4
KL 0-I-II 1 2 3 4 5 6 7 8 9 9 A+ 1 2 3 4 5 6 7 8 9 8 A+ (13-14)
Functional meniscus 0 0 0 1 0 0 5 5 6 1 0 0 1 2 2 8 1 2
KL III 1 2 3 4 5 6 7 8 9 8 A+ 1 2 3 4 5 6 7 8 9 7 A+ (15-16)

0 0 0 0 0 0 0 1 16 0 0 1 0 0 1 1 8 6
KL 0-I-II 1 2 3 4 5 6 7 8 9 9 A+ 1 2 3 4 5 6 7 8 9 8 A+ (17-18)
Tegner 4-6 Repairable meniscus 0 0 0 1 0 0 3 6 7 1 0 0 0 0 1 9 3 3
KL III 1 2 3 4 5 6 7 8 9 8 A+ 1 2 3 4 5 6 7 8 9 7 A+ (19-20)

0 0 0 0 0 1 2 3 11 0 1 1 0 2 5 5 2 1
KL 0-I-II 1 2 3 4 5 6 7 8 9 9 A+ 1 2 3 4 5 6 7 8 9 6 U+ (21-22)
Non functional meniscus 0 1 0 0 0 3 5 5 3 1 1 1 4 4 3 1 2 0
KL III 1 2 3 4 5 6 7 8 9 7 A+ 1 2 3 4 5 6 7 8 9 5 U+ (23-24)

0 0 0 0 0 0 3 7 7 0 1 2 1 3 2 4 2 2
KL 0-I-II 1 2 3 4 5 6 7 8 9 8 A+ 1 2 3 4 5 6 7 8 9 6 U+ (25-26)
Functional meniscus 0 0 0 1 0 1 8 3 4 1 1 2 2 3 3 4 1 0
KL III 1 2 3 4 5 6 7 8 9 7 A+ 1 2 3 4 5 6 7 8 9 5 U+ (27-28)

0 0 0 0 0 0 2 4 11 0 0 1 0 1 3 7 4 1
KL 0-I-II 1 2 3 4 5 6 7 8 9 9 A+ 1 2 3 4 5 6 7 8 9 7 A+ (29-30)
Tegner 0-3 Repairable meniscus 0 0 0 1 0 1 5 5 5 1 0 0 0 2 6 4 4 0
KL III 1 2 3 4 5 6 7 8 9 8 A+ 1 2 3 4 5 6 7 8 9 6 U+ (31-32)

0 0 0 1 1 2 4 7 2 1 0 4 3 5 1 2 1 0
KL 0-I-II 1 2 3 4 5 6 7 8 9 8 A+ 1 2 3 4 5 6 7 8 9 5 U+ (33-34)
Non functional meniscus 0 1 1 1 2 8 4 0 0 2 2 8 2 1 2 0 0 0
KL III 1 2 3 4 5 6 7 8 9 6 U+ 1 2 3 4 5 6 7 8 9 3 I+ (35-36)

Appropriateness scale: 1 = extremely inappropriate, 5 = uncertain, 9 = extremely appropriate

Chapter 2
A 36-50 years old patient with ACL re-rupture presents to your attention with an aligned knee, increased laxity, and the following characteristics.
How appropriate do you rate the indication for revision ACL reconstruction?
Sport level/expectations Concomitant meniscal lesion OA grade Subjective Instability No Subjective Instability Indication n°

0 0 0 0 0 0 0 4 13 M DIS 0 0 2 0 0 1 3 7 4 M DIS
KL 0-I-II 1 2 3 4 5 6 7 8 9 9 A+ 1 2 3 4 5 6 7 8 9 8 A+ (37-38)
Functional meniscus 0 0 1 0 1 0 1 8 6 1 1 0 0 0 1 8 3 3
KL III 1 2 3 4 5 6 7 8 9 8 A+ 1 2 3 4 5 6 7 8 9 7 A+ (39-40)

0 0 0 0 0 0 0 3 14 0 0 1 0 0 0 4 8 4
KL 0-I-II 1 2 3 4 5 6 7 8 9 9 A+ 1 2 3 4 5 6 7 8 9 8 A+ (41-42)
Tegner 7-10 Repairable meniscus 0 0 1 0 1 0 1 5 9 1 0 0 0 1 1 2 8 4
KL III 1 2 3 4 5 6 7 8 9 9 A+ 1 2 3 4 5 6 7 8 9 8 A+ (43-44)

0 0 0 0 1 0 1 3 12 0 1 1 1 0 4 4 3 3
KL 0-I-II 1 2 3 4 5 6 7 8 9 9 A+ 1 2 3 4 5 6 7 8 9 7 A+ (45-46)
Non functional meniscus 0 1 0 0 2 0 0 10 4 2 0 1 2 7 2 2 0 1
KL III 1 2 3 4 5 6 7 8 9 8 A+ 1 2 3 4 5 6 7 8 9 5 U+ (47-48)

0 0 0 0 0 0 2 6 9 0 1 1 0 3 5 2 3 2
KL 0-I-II 1 2 3 4 5 6 7 8 9 9 A+ 1 2 3 4 5 6 7 8 9 6 U+ (49-50)
Functional meniscus 0 0 1 1 0 1 5 7 2 1 1 1 2 5 3 2 2 0
KL III 1 2 3 4 5 6 7 8 9 8 A+ 1 2 3 4 5 6 7 8 9 5 U+ (51-52)

0 0 0 0 0 0 2 4 11 0 1 0 0 0 1 9 5 1
KL 0-I-II 1 2 3 4 5 6 7 8 9 9 A+ 1 2 3 4 5 6 7 8 9 7 A+ (53-54)
Tegner 4-6 Repairable meniscus 0 0 1 1 0 1 3 5 6 1 0 0 0 3 8 3 2 0
KL III 1 2 3 4 5 6 7 8 9 8 A+ 1 2 3 4 5 6 7 8 9 6 U+ (55-56)

0 0 0 0 1 0 5 7 4 0 1 3 2 6 3 0 1 1
KL 0-I-II 1 2 3 4 5 6 7 8 9 8 A+ 1 2 3 4 5 6 7 8 9 5 U+ (57-58)
Non functional meniscus 0 1 0 1 1 3 7 3 1 1 1 5 6 4 0 0 0 0
KL III 1 2 3 4 5 6 7 8 9 7 A+ 1 2 3 4 5 6 7 8 9 4 U+ (59-60)

0 0 0 0 2 2 3 8 2 2 0 3 5 3 2 1 1 0
KL 0-I-II 1 2 3 4 5 6 7 8 9 8 A+ 1 2 3 4 5 6 7 8 9 4 U+ (61-62)
Functional meniscus 0 0 2 1 2 1 8 2 1 2 2 4 6 1 1 1 0 0
KL III 1 2 3 4 5 6 7 8 9 7 A+ 1 2 3 4 5 6 7 8 9 4 U+ (63-64)

0 0 0 0 1 1 4 8 3 1 0 1 0 3 4 7 1 0
KL 0-I-II 1 2 3 4 5 6 7 8 9 8 A+ 1 2 3 4 5 6 7 8 9 6 U+ (65-66)
Tegner 0-3 Repairable meniscus 0 0 2 1 0 2 8 3 1 1 1 2 3 5 4 0 1 0
KL III 1 2 3 4 5 6 7 8 9 7 A+ 1 2 3 4 5 6 7 8 9 5 U+ (67-68)

0 0 2 0 1 3 6 4 1 4 0 7 2 1 2 1 0 0
KL 0-I-II 1 2 3 4 5 6 7 8 9 7 A+ 1 2 3 4 5 6 7 8 9 3 I+ (69-70)
Non functional meniscus 2 0 1 3 5 2 4 0 0 4 4 7 2 0 0 0 0 0
KL III 1 2 3 4 5 6 7 8 9 5 U+ 1 2 3 4 5 6 7 8 9 3 I+ (71-72)

Appropriateness scale: 1 = extremely inappropriate, 5 = uncertain, 9 = extremely appropriate

Chapter 3
A 51-60 years old patient with ACL re-rupture presents to your attention with an aligned knee, increased laxity, and the following characteristics.
How appropriate do you rate the indication for revision ACL reconstruction?
Sport level/expectations Concomitant meniscal lesion OA grade Subjective Instability No Subjective Instability Indication n°

0 0 0 0 1 1 2 6 7 M DIS 0 3 0 0 1 3 6 3 1 M DIS
KL 0-I-II 1 2 3 4 5 6 7 8 9 8 A+ 1 2 3 4 5 6 7 8 9 7 A+ (73-74)
Functional meniscus 0 1 1 0 0 3 5 4 3 1 2 2 1 4 4 1 1 1
KL III 1 2 3 4 5 6 7 8 9 7 A+ 1 2 3 4 5 6 7 8 9 5 U+ (75-76)

0 0 0 0 2 0 1 8 6 0 1 0 1 0 3 7 4 1
KL 0-I-II 1 2 3 4 5 6 7 8 9 8 A+ 1 2 3 4 5 6 7 8 9 7 A+ (77-78)
Tegner 7-10 Repairable meniscus 0 2 0 0 1 2 5 3 4 1 1 1 2 1 5 4 1 1
KL III 1 2 3 4 5 6 7 8 9 7 A+ 1 2 3 4 5 6 7 8 9 6 U+ (79-80)

0 0 0 1 1 1 7 4 3 1 3 0 8 3 1 0 1 0
KL 0-I-II 1 2 3 4 5 6 7 8 9 7 A+ 1 2 3 4 5 6 7 8 9 4 U+ (81-82)
Non functional meniscus 0 3 0 0 1 3 6 4 0 2 6 5 1 1 1 0 1 0
KL III 1 2 3 4 5 6 7 8 9 7 A+ 1 2 3 4 5 6 7 8 9 3 I+ (83-84)

0 0 0 1 1 1 5 6 3 1 3 3 5 2 1 2 0 0
KL 0-I-II 1 2 3 4 5 6 7 8 9 8 A+ 1 2 3 4 5 6 7 8 9 4 U+ (85-86)
Functional meniscus 0 2 1 0 1 6 5 1 1 4 4 5 2 0 1 1 0 0
KL III 1 2 3 4 5 6 7 8 9 6 U+ 1 2 3 4 5 6 7 8 9 3 I+ (87-88)

0 0 0 1 1 0 6 6 3 0 1 1 2 3 5 5 0 0
KL 0-I-II 1 2 3 4 5 6 7 8 9 8 A+ 1 2 3 4 5 6 7 8 9 6 U+ (89-90)
Tegner 4-6 Repairable meniscus 0 2 0 0 2 3 7 2 1 1 5 0 4 4 2 1 0 0
KL III 1 2 3 4 5 6 7 8 9 7 A+ 1 2 3 4 5 6 7 8 9 4 U+ (91-92)

0 0 1 1 3 5 5 1 1 3 6 4 1 3 0 0 0 0
KL 0-I-II 1 2 3 4 5 6 7 8 9 6 U+ 1 2 3 4 5 6 7 8 9 2 I+ (93-94)
Non functional meniscus 1 2 1 2 6 3 1 1 0 6 7 2 0 2 0 0 0 0
KL III 1 2 3 4 5 6 7 8 9 5 U+ 1 2 3 4 5 6 7 8 9 2 I+ (95-96)

0 1 1 0 3 6 4 1 1 3 7 4 1 1 1 0 0 0
KL 0-I-II 1 2 3 4 5 6 7 8 9 6 U+ 1 2 3 4 5 6 7 8 9 2 I+ (97-98)
Functional meniscus 2 0 4 1 2 5 2 0 1 7 3 6 0 0 1 0 0 0
KL III 1 2 3 4 5 6 7 8 9 5 U+ 1 2 3 4 5 6 7 8 9 2 I+ (99-100)

0 1 1 0 2 3 7 2 1 1 2 3 6 5 0 0 0 0
KL 0-I-II 1 2 3 4 5 6 7 8 9 7 A+ 1 2 3 4 5 6 7 8 9 4 U+ (101-102)
Tegner 0-3 Repairable meniscus 2 1 2 1 7 2 0 1 1 2 4 7 2 2 0 0 0 0
KL III 1 2 3 4 5 6 7 8 9 5 U+ 1 2 3 4 5 6 7 8 9 3 I+ (103-104)

1 1 2 3 6 2 1 0 1 7 6 4 0 0 0 0 0 0
KL 0-I-II 1 2 3 4 5 6 7 8 9 5 U+ 1 2 3 4 5 6 7 8 9 2 I+ (105-106)
Non functional meniscus 4 3 5 3 1 1 0 0 0 13 3 1 0 0 0 0 0 0
KL III 1 2 3 4 5 6 7 8 9 3 I+ 1 2 3 4 5 6 7 8 9 1 I+ (107-108)

Appropriateness scale: 1 = extremely inappropriate, 5 = uncertain, 9 = extremely appropriate

Appropriateness, inappropriateness, and uncertain areas

Experts consider appropriate revision ACL reconstruction for every patient with subjective
instability aged ≤50 years, regardless of sport activity level, meniscus status, and OA grade,
with the only exception of the 2 scenarios regarding patients having low Tegner level requests,
non-functional meniscus, and OA KL III.
If subjective instability is present in patients over 50 years old, revision ACL reconstruction is
always indicated in patients with high sport expectations. For lower activity requests (Tegner
4-6), the only cases where the treatment is considered appropriate are patients with
functional meniscus and without moderate OA, and patients with repairable meniscus
regardless OA grade. For Tegner 0-3 the only appropriate scenario is a repairable meniscus
without OA, whereas the revision surgery is considered inappropriate for OA KL III knees with
non-functional meniscus. The remaining scenarios are evaluated as uncertain.
The results are much more controversial in patients without subjective instability, and a more
significant role is played by age and sport expectation. In fact, for high sport requests (Tegner
7-10), revision ACL reconstructions is indicated in all patients ≤50 years old, with the only
exception of patient aged 36-50 with non-functional meniscus and moderate OA. For lower
sport expectations or older age, the only area of agreement toward appropriateness is found
for patients 18-35 years old, with Tegner 4-6 expectation, with functional or repairable
meniscus. Among the remaining scenarios, only 4 are considered appropriate, that are in 3
cases patients with repairable meniscus and no mild OA (aged 18-35 and low sport level, aged
36-50 and intermediate sport level, and aged 51-60 and high sport level) and in one case a
patient aged 51-60, with high sport expectation, a functional meniscus a KL 0-I-II OA.
In patients without subjective instability several scenarios are considered inappropriate for
revision ACL reconstruction, in particular for non-functional meniscus with or without OA
together with lower sport expectations or older age, and in other scenarios regarding older
patients with low or intermediate sport expectations. In almost half of the scenarios regarding
patients without subjective instability the indication for revision ACL reconstruction is
considered uncertain.

Appropriateness changes within parameters

The analysis of the role of the evaluated factors showed a different weight in influencing the
treatment indication appropriateness. Beside the presence of subjective instability, which
influenced 34 out of 54 treatment indications, sport expectation was the most discriminating
factor. Compared to these factors, age, meniscus status, and KL OA grade influenced the
appropriateness to a lower degree.

Table. Rate of scenarios evaluated as Appropriate, Uncertain, or Inappropriate, for each

parameter considered
CATEGORIES A U I
18-35 77.8% 19.4% 2.8%
AGE 36-50 63.9% 30.6% 5.6%
51-60 33.3% 38.9% 27.8%

SUBJECTIVE YES 81.5% 16.7% 1.9%

INSTABILITY NO 35.2% 42.6% 22.2%

7-10 86.1% 11.1% 2.8%

SPORT 4-6 55.6% 36.1% 8.3%
0-3 33.3% 41.7% 25.0%

FUNCTIONAL 61.1% 30.6% 8.3%

MENISCUS REPAIRABLE 72.2% 25.0% 2.8%
NON FUNCTIONAL 41.7% 33.3% 25.0%

KL 0-I-II 66.7% 25.9% 7.4%

OA
KL III 50.0% 33.3% 16.7%

As reported in the above, the parameters which determined the highest rate of appropriate
scenarios were sport level expectation Tegner 7-10 (86.1% of appropriate scenarios),
subjective instability (81.5% of appropriate scenarios), and age 18-35 (77.8% of appropriate
scenarios). Conversely, the parameters associated with higher inappropriateness rate were
age 51-60 (27.8% of inappropriate scenarios), sport level expectation Tegner 0-3, and non-
functional meniscus (25.0% each). Interestingly, among meniscal status the parameter
associated with the higher rate of appropriateness was repairable meniscus (72.2%),
compared to functional meniscus (61.1%) and non-functional meniscus (41.7%). The
parameter determining the lowest rate of appropriateness and inappropriateness was OA
(66.7% of appropriate scenarios for OA KL 0-I-II, and 16.7% of inappropriate scenarios for OA
KL III).
A graphic representation of the most influencing parameters is found below.
AGE
18-35 36-50 51-60
OA 0-II OA III OA 0-II OA III OA 0-II OA III

non funct men

non funct men

non funct men

non funct men

non funct men

non funct men

repair men

repair men

repair men

repair men

repair men

repair men
funct men

funct men

funct men

funct men

funct men

funct men
7-10
SPORT

SUBJ INST 4-6

0-3

7-10
SPORT

NO SUBJ INST 4-6

0-3

Figure. Schematic representation of the appropriate (green), inappropriate (red), and

uncertain (yellow) scenarios for the first ACL revision in adults based on the RAM consensus.