- 1.All patients (and most surgeons) prefer a 1-stage approach. However, it is better to have a successful 2-stage revision ACL reconstruction than a failed 1-stage procedure.
- 2.Obtain a noncontrast computed tomography scan for every planned ACL revision. Tunnel widening (osteolysis) is best characterized with this study.6Study the sagittal and coronal images for both the femoral and tibial tunnels.
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: 1059-1064
- Marchant Jr., M.H.
- Willimon S.C.
- Vinson E.
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- Garrett W.E.
- Higgins L.D.
- 3.If the previous tunnel diameter on either the femoral or tibial side is ≥14 mm, then plan for a 2-stage approach.
- 4.If your planned tunnel will result in a greatly expanded or oval tunnel aperture, then fill the previously drilled tunnel before reaming the new tunnel. Sometimes you can fill the previous tunnel (I prefer bone dowels7,8) and ream a new tunnel with a single-stage approach.9Substantial overlap at the aperture may require a 2-stage approach.
- 5.It is a good idea to plan for your new tunnel to diverge from the previous tunnel(s). This may require a different technique than what was done with the index surgery (e.g., outside-in or independent femoral tunnel drilling).
- 6.You can also fill voids with a retrograde approach—this may help avoid injury to the medial femoral condyle.
- 7.Plan on back-up fixation for all revision ACL reconstructions—you can never trust the bony integrity. This includes using extended buttons for cortical fixation.
- 8.Never compromise on tunnel location to do a single-stage revision. Anatomical tunnel position is more important than having to stage the revision.
- 9.Always be prepared for plan B (and sometimes plan C) with revision ACL reconstruction. I believe that it is better to prepare the patient for a 2-stage procedure preoperatively. If you are then able to do it in 1 stage, it is a pleasant surprise.
- 10.Address all risk factors at the time of surgery—correct excessive tibial slope, double (or triple) check for missed collateral ligament injuries, consider lateral extra-articular tenodesis augmentation, preserve or replace significant meniscal deficiency, etc.
- ICMJE author disclosure forms
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- 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: 1059-1064
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The author reports the following potential conflicts of interest or sources of funding: other from Arthrex , during the conduct of the study; and other from Elsevier/Wolters-Kluwer, outside the submitted work. Full ICMJE author disclosure forms are available for this article online, as supplementary material.