August 2026 | Revision ACL Reconstruction

Identifying Failure, Addressing Risk Factors and Optimizing Outcomes

By: Jarod A. Richards, M.D. Member, AANA Communications and Technology Committee 

 

As August arrives, many of us enjoy the final weeks of summer – a last opportunity for family vacations, weekends at the lake and a brief pause before the pace of fall returns. For orthopaedic sports medicine surgeons, however, August also signals the beginning of another athletic season. As student-athletes return to football, soccer, volleyball and other cutting and pivoting sports, clinics and operating rooms will soon fill with the familiar wave of ACL injuries that accompanies the start of every school year. Although primary anterior cruciate ligament reconstruction (ACLR) reliably restores stability for most patients, a small but important subset will ultimately present with recurrent instability and graft failure. These cases remind us that successful revision ACLR is rarely about replacing a failed graft. Rather, it requires understanding why the first reconstruction failed and addressing the factors that place the next reconstruction at risk. 

 

Recognizing the Clues of ACL Failure 

 

Every failed ACL leaves clues. The challenge for the revision surgeon is recognizing them before entering the operating room. 

 

Large contemporary registry studies identify new trauma as the leading indication for revision ACLR, yet experienced surgeons appreciate that the inciting event is often only one part of a much larger story.1 Failure is frequently multifactorial, reflecting an interaction between patient anatomy, surgical technique, biologic healing, rehabilitation and subsequent injury.2 Technical factors – including nonanatomic tunnel placement, untreated rotatory instability, graft selection, fixation strategy and unrecognized collateral or posterolateral corner injury – remain important contributors to recurrent instability.2-4 Equally important are patient-specific risk factors such as generalized ligamentous laxity, meniscal deficiency, coronal malalignment and increased posterior tibial slope (PTS), each of which may increase graft loading despite an otherwise well-performed reconstruction.2,4 

 

A Comprehensive Evaluation Drives Better Decisions 

 

Revision ACLR begins with a deliberate and systematic evaluation. History should establish the mechanism of failure, previous graft choice, rehabilitation course, return-to-sport timeline and whether instability followed a discrete reinjury or developed progressively over time. Physical examination should then define the pattern of instability by assessing sagittal and rotatory laxity, generalized hypermobility, collateral ligament competence, meniscal integrity and lower-extremity alignment.2,4 

 

Imaging should answer the questions raised during the clinical evaluation – not replace it. Standard radiographs, including long-leg alignment films when appropriate, remain fundamental for assessing alignment and osseous morphology. MRI characterizes meniscal, chondral and associated ligament pathology, whereas three-dimensional CT has become indispensable for evaluating tunnel position, tunnel widening, retained hardware and available bone stock before revision surgery.3,4 This information ultimately determines whether a single-stage revision is feasible or whether staged tunnel grafting will provide the best opportunity for an anatomic reconstruction. 

 

Treat the Knee, Not Just the Ligament 

 

One of the most important advances in revision ACL surgery has been the recognition that restoring the ACL alone is often insufficient. Contemporary revision surgery emphasizes correction of the biomechanical environment responsible for graft overload rather than simply replacing the graft itself.2 

 

Persistent anterolateral rotatory instability has emerged as an important contributor to recurrent failure. In appropriately selected patients – including revision cases, those with a high-grade pivot shift, generalized ligamentous laxity or participation in pivoting sports – adjunctive lateral procedures such as lateral extra-articular tenodesis (LET) or anterolateral ligament (ALL) reconstruction improve rotational stability while reducing graft failure rates.5,6 

 

Attention has similarly shifted toward osseous morphology. Increased PTS increases anterior tibial translation and places greater in situ forces across the reconstructed ACL.7 For carefully selected patients with recurrent graft failure and excessive PTS, slope-reducing proximal tibial osteotomy has emerged as a valuable adjunct to revision reconstruction.7-10 Importantly, slope should not be considered in isolation. Patient age, activity level, meniscal status, ligamentous laxity and the overall mechanism of failure remain equally important determinants of surgical decision-making.4,8-10 

 

The Modern Revision Mindset 

 

Once the mechanism of failure has been defined and modifiable risk factors addressed, graft selection becomes one component of a broader revision strategy rather than the primary decision. Autograft remains the preferred choice for most revision procedures because of lower reported rerupture rates than allograft.2 Bone-patellar tendon-bone and quadriceps tendon autografts have both demonstrated excellent outcomes, with graft selection individualized according to previous graft use, remaining autograft options, patient goals and surgeon experience.11,12 

 

The modern revision surgeon recognizes that successful ACL reconstruction is no longer defined by simply replacing a failed graft. Every failed ACL leaves clues. Our responsibility is to recognize those clues through thoughtful analysis of the index procedure, patient-specific anatomy and mechanism of failure, then develop a reconstruction strategy that addresses each modifiable risk factor. Successful revision ACLR requires more than replacing a graft – it requires understanding the knee in which it failed. As another fall sports season begins and ACL injuries once again become part of our daily practice, our greatest successes will come not from performing another reconstruction, but from creating the biomechanical environment that gives the next reconstruction the greatest opportunity to succeed. 

 

References 

  1. Vindfeld, S., Persson, A., Lindanger, L., Fenstad, A.M., Visnes, H., Inderhaug, E. Revision Anterior Cruciate Ligament Reconstruction: Surgeon-Reported Causes of Failure From the Norwegian Knee Ligament Register. American Journal of Sports Medicine. 2025 Mar;53(4):801-808. doi: 10.1177/03635465251316308. Epub 2025 Feb 7. PMID: 39920566. 
  2. Kemler, B., Coladonato, C., Perez, A., Erickson, B.J., Tjoumakaris, F.P., Freedman, K.B. Considerations for Revision Anterior Cruciate Ligament Reconstruction: A Review of the Current Literature. Journal of Orthopaedics. 2024 May 11;56:57-62. doi: 10.1016/j.jor.2024.05.012. PMID: 38784949; PMCID: PMC11109325. 
  3. Wolfson, T.S., Mannino, B., Owens, B.D., Waterman, B.R., Alaia, M.J. Tunnel Management in Revision Anterior Cruciate Ligament Reconstruction: Current Concepts. American Journal of Sports Medicine. 2023 Feb;51(2):545-556. doi: 10.1177/03635465211045705. Epub 2021 Nov 12. PMID: 34766840. 
  4. Condello, V., Beaufils, P., Becker, R., Ahmad, S.S., Bonomo, M., Dejour, D., Eriksson, K., Filardo, G., Feucht, M.J., Grassi, A., Wilson, A., Menetrey, J., Pujol, N., Rathcke, M., Seil, R., Strauss, M.J., Tischer, T. Management of Anterior Cruciate Ligament Revision in Adults: The 2022 ESSKA Consensus: Part II-Surgical Strategy. Knee Surgery, Sports Traumatology, Arthroscopy. 2023 Nov;31(11):4652-4661. doi: 10.1007/s00167-023-07550-5. Epub 2023 Sep 12. PMID: 37700168; PMCID: PMC10598082. 
  5. Boksh, K., Sheikh, N., Chong, H.H., Ghosh, A., Aujla, R. The Role of Anterolateral Ligament Reconstruction or Lateral Extra-articular Tenodesis for Revision Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Comparative Clinical Studies. American Journal of Sports Medicine. 2024 Jan;52(1):269-285. doi: 10.1177/03635465231157377. Epub 2023 Mar 24. PMID: 36960926. 
  6. Jones, E.N., Post, H.K., Stovall, B.A., Ierulli, V.K., Vopat, B.G., Mulcahey, M.K. Lateral Extra-Articular Tenodesis Augmentation of Anterior Cruciate Ligament Reconstruction Is Most Commonly Indicated for Pivot Shift of Grade 2 or Greater and for Revision Anterior Cruciate Ligament Reconstruction. Arthroscopy. 2024 Oct;40(10):2624-2632. doi: 10.1016/j.arthro.2024.01.031. Epub 2024 Feb 7. PMID: 38331370. 
  7. Tollefson, L.V., Rasmussen, M.T., Guerin, G., LaPrade, C.M., LaPrade, R.F. Slope-Reducing Proximal Tibial Osteotomy Improves Outcomes in Anterior Cruciate Ligament Reconstruction Patients With Elevated Posterior Tibial Slope, Especially Revisions and Posterior Tibial Slope ≥12°. Arthroscopy. 2025 Aug;41(8):3184-3195. doi: 10.1016/j.arthro.2024.10.048. Epub 2024 Nov 12. PMID: 39536996. 
  8. Vivekanantha, P., Aziz, A., Ali, M., Martin, R., Tapasvi, S., de SA, D. The Commonest Indication for Performing a Slope-Reducing Osteotomy With an Anterior Cruciate Ligament Reconstruction Is Graft Failure With a Posterior Tibial Slope of 12° or Greater: A Systematic Review of Indications, Techniques, and Outcomes. Arthroscopy. 2025 Oct;41(10):4346-4356.e4. doi: 10.1016/j.arthro.2025.04.028. Epub 2025 Apr 24. PMID: 40286998. 
  9. Wang, D., Di, M., Zheng, T., Lv, C., Liu, Y., Song, G., Zhang, H. Effect of Slope-Reducing Tibial Osteotomy With Primary Anterior Cruciate Ligament Reconstruction on Clinical and Radiological Results in Patients With a Steep Posterior Tibial Slope and Excessive Anterior Tibial Subluxation. American Journal of Sports Medicine. 2025 May;53(6):1381-1391. doi: 10.1177/03635465251330976. Epub 2025 Apr 15. PMID: 40230218. 
  10. Pineda, M., Seil, R., Sonnery-Cottet, B., Dejour, D.H., Hirschmann, M.T., Ollivier, M. Slope-Reducing Osteotomy: The Emerging Gap Between Indication, Safety and Proportionality. Knee Surgery, Sports Traumatology, Arthroscopy. 2026 Jul;34(7):2334-2339. doi: 10.1002/ksa.70488. Epub 2026 Jun 15. PMID: 42294531. 
  11. Schmücker, M., Haraszuk, J., Hölmich, P., Barfod, K.W. Graft Failure, Revision ACL Reconstruction, and Reoperation Rates After ACL Reconstruction With Quadriceps Tendon Versus Hamstring Tendon Autografts: A Registry Study With Review of 475 Patients. American Journal of Sports Medicine. 2021 Jul;49(8):2136-2143. doi: 10.1177/03635465211015172. Epub 2021 Jun 8. PMID: 34102074. 
  12. Lind, M., Strauss, M.J., Nielsen, T., Engebretsen, L. Low Surgical Routine Increases Revision Rates After Quadriceps Tendon Autograft for Anterior Cruciate Ligament Reconstruction: Results From the Danish Knee Ligament Reconstruction Registry. Knee Surgery, Sports Traumatology, Arthroscopy. 2021 Jun;29(6):1880-1886. doi: 10.1007/s00167-020-06220-0. Epub 2020 Sep 4. PMID: 32886156. 

 

Interested in More Clinical Resources? 

 

Arthroscopy Journal 

 

  1. Operative Management for Anterior Cruciate Ligament Injury in Patients Over 40 Years Old Yields Increased Clinical Outcome: A Systematic Review
    John Roberts IV, B.A., Brandon Ness, P.T., D.P.T., Ph.D., Josh Cleland P.T., Ph.D., F.A.P.T.A., Richard Puzzitiello, M.D., Mark Marinch, B.A., Alexis Wright, P.T., D.P.T., Ph.D., Megan Donaldson, P.T., Ph.D., Matthew Salzaler, M.D. 
  2. Concomitant Medial Collateral Ligament Injury Increases Risk of Revision Anterior Cruciate Ligament Reconstruction
    Kian Niknam, M.A.S., Daniel Goldberg, M.D., Alexander R. Markes, M.D., Brian T. Feeley, M.D., Alan L. Zhang, M.D., C. Benjamin Ma, M.D., Drew A. Lansdown, M.D. 
  3. Editorial Commentary: Revision Anterior Cruciate Ligament Using Soft Tissue Autograft Quadriceps is Effective but Not Recommended for All Comers
    Sarav S. Shah, M.D. 
  4. Location and Progression of Chondral Injures at the Time of Revision Anterior Cruciate Ligament Surgery Varies by Sex
    Mark P. Cote, P.T., D.P.T., M.S.C.T.R., Garrett J. Kearney, B.S., B.A., Maxwell J. McKay, B.S., Miho J. Tanaka, M.D., Ph.D. 
  5. Partial Meniscectomy Increases Risk of Anterior Cruciate Ligament Revision Surgery Compared With Meniscus Repair in Patients With Concurrent Meniscus and Anterior Cruciate Ligament Tears After Anterior Cruciate Ligament Reconstruction
    Abhinav R. Balu, B.S., Avani Chopra, B.S., Augustus Demanes, M.D., Peter C. Shen, B.A., Rithvik R. Balu, Michael Terry, M.D., Vehniah K. Tjong, M.D. 

 

 

Arthroscopy Techniques 

 

  1. One-Stage ACL Revision Using a Bone Allograft Plug for a Semianatomic Tibial Tunnel That is Too Anterior
    Corentin Philippe, M.D., Vincent Marot, M.D., Louis Courtot, M.D., Timothee Mesnier, M.D., Nicolas Reina, M.D., Ph.D., Etienne Cavaignac, M.D., Ph.D. 
  2. Ipsilateral Quadriceps Tendon-Bone ACL Revision Reconstruction to Address Failed Primary Bone-Patellar Tendon-Bone ACL Reconstruction with Persistent Patellar Bone Defect
    Iftach Hetsroni, M.D., Yuval Fuchs, M.D., Gideon Mann, M.D., Nissim Ohana, M.D. 
  3. Complex Anterior Cruciate Ligament Revision and Lateral Extra-Articular Tenodesis With Achilles Tendon Allograft: The “Monoloop” Technique
    Mattia Chirico, M.D., Zyad Ayman Taha, M.D., Mattia Carminati, M.D., Roberto Civinini, M.D., Fabrizio Matassi, M.D. 
  4. Bone Grafting Technique in Revision ACL Reconstruction: Coring Reamer and Dowel Trick
    Nels D. Leafbald, M.D., Travis G. Maak, M.D. 
  5. Augmented Over-The-Top Technique for Revision Anterior Cruciate Ligament Reconstruction
    Simone Perelli, M.D., Ph.D., Matteo Messori, M.D., Jesus Dueñas, M.D., Nicola Pizza, M.D., Ph.D., Rodolfo Morales Avalos, M.D., Maximiliano Ibañez, M.D., Joan Carles Monllau, M.D., Ph.D. 

 

 

Arthroscopy, Sports Medicine and Rehabilitation 

 

  1. Patient-Reported Outcomes After Multiple-Revision ACL Reconstruction: Good but Not Great
    Ian D. Engler, M.D., Matthew J. Salzler, M.D., Andrew J. Wall, M.D., William R. Johnson, M.D., Amun Makani, M.D., Margaret V. Shields, M.D., Thomas J. Gill, M.D. 
  2. Higher Incidence of Complete Lateral Meniscal Root Tears in Revision Compared With Primary Anterior Cruciate Ligament Reconstruction
    Brian J. Vial, M.D., Andrew B. Kohner, M.D., Theodore B. Shybut, M.D. 
  3. 3-Dimensional Printed Models May Be a Useful Tool When Planning Revision Anterior Cruciate Ligament Reconstruction
    Gene Kitamura, M.D., Marcio Bottene Villa Albers, M.D., Bryson P. Lesniak, M.D., Stephen Joseph Rabuck, M.D., Volker Musahl, M.D., Carol L. Andrews, M.D., Anish Ghodadra, M.D., Freddie Fu, M.D. 

 

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