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Two-stage revision inductive cruciate ligament reconstruction

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With the rising number of anterior cruciate ligament (ACL) reconstructions, revision ACL reconstructions are condign increasingly common. A revision procedure may be performed to improved human knee role, correct instability, and facilitate a return to normal activities. When performing a revision reconstruction, the surgeon decides between a single-phase or a two-phase revision. Two-stage revisions are rarely performed, just are particularly useful when addressing substantial tunnel-widening, active infection, and concomitant knee pathology (east.g., malalignment, other ligamentous injuries, meniscal or chondral lesions). Among these potential scenarios requiring a two-stage revision, tunnel-widening is the nearly common crusade; the start stage involves graft removal, tunnel curettage, and bone grafting, followed by revision ACL reconstruction in the second phase. The purpose of this article is to review the preoperative planning, surgical considerations, rehabilitation, and outcomes of ii-phase revision ACL reconstructions and summarize the recent literature outlining treatment results.


Inductive cruciate ligament (ACL) reconstruction rates have increased over the past 20 years to roughly 200,000 per twelvemonth [1]. As this number has continued to increment, the incidence of revision ACL reconstruction (ACLR) has as well grown to a rate of betwixt four.1 and 13.3% of all primary ACLRs performed [2]. The goal of revision ACLR is to ameliorate knee stability and activeness levels, but the outcomes are reported to be inferior to those of primary ACLR [3]. Successful revision surgery requires an agreement of the crusade of failure, careful preoperative planning, meticulous surgical execution, proper postoperative rehabilitation, and advisable patient counseling [four].

Revision ACLR surgeries tin can exist mainly divided into one-stage and two-phase procedures. Two-stage revision ACLR typically involves an initial os-graft process—to fill the widened or misplaced tunnels—and subsequent fourth dimension to permit for the bone graft to heal sufficiently before the 2nd phase is undertaken [5]. A relatively small-scale simply challenging subset of patients requires two-stage revision ACLR. Reports suggest that a two-stage procedure is performed in simply viii to 9% of revision ACLRs [6].

To appointment, the literature on revision ACLR surgery has primarily focused on comparing the outcomes to those of master ACLR. While one-stage revision ACLR is well described and reported, few studies have reported the outcomes of two-stage revision ACLR. For the aforementioned reasons, in this review, we will provide an overview of two-stage revision ACLR in the post-obit order: preoperative planning, surgical considerations, rehabilitation, outcomes, and conclusions.

Preoperative planning for 2-stage ACLR

Preoperative planning for revision ACL surgery is essential for a successful outcome. The important stages in assessing a patient with failed ACL surgery include history, patient selection, concrete exam and investigations, option of graft, surgical technique, and rehabilitation [seven]. Major reasons to proceed with a 2-stage strategy include tunnel-widening or other loss of os stock, tunnel malposition, arthrofibrosis, active infection, concomitant meniscal deficiency, malalignment, and focal chondral lesions and/or other ligamentous laxity that may require a staged approach [eight, 9] (Table 1).

Table 1 Indications for two-stage revision anterior cruciate ligament reconstruction

Full size table

An agile infection should exist treated with irrigation and debridement with confirmation of eradication (due east.k., normalized laboratory exam results, negative cultures) before a patient has a new graft and implant put in place. Similarly, a patient with a loss of more than than 5° of extension or 20° of flexion of knee joint motion should exist considered for lysis of adhesions and manipulation under anesthesia followed by rehabilitation [4, 10].

Tunnel orientation and size are the virtually of import causes related to the 2-stage procedure, as these enlarged tunnels may complicate graft placement and fixation [eleven, 12]. Although in that location are many proposed theories for tunnel lysis, it is most accurate to state that this status has a multifactorial origin; mechanical and biologic causes have been reported, and both contribute to enlarged graft tunnels [eleven, 13]. Tunnel malpositioning that volition interfere with new revision reconstruction tunnel placement can reduce graft apposition within the tunnels at the time of graft fixation, thereby placing the graft stability and subsequent incorporation at greater take a chance of failure [11].

Currently, the “gold standard” for measuring tunnel size is the computed tomography (CT) method. Studies have shown that CT outperforms magnetic resonance imaging (MRI) and radiographs in both inter- and intra-observer reliability for evaluating tunnel-widening [14, xv]. When measuring with CT, the centric-plane image is considered wrong because the airplane of cuts is inconsistent. Therefore, the coronal and sagittal images (4-tunnel view; femur-coronal, tibia-coronal, femur-sagittal, tibia-sagittal) are primarily used (Fig. one). Measurements are made perpendicular to the centric plane of the tunnel at the widest indicate [15].

Fig. ane

Coronal (a) and sagittal (b) view of computed tomography (CT) images demonstrate widening of the tibial tunnel in the setting of a failed anterior cruciate ligament reconstruction. Measurements are made perpendicular to the axial plane of the tunnel at the widest bespeak

Full size epitome

Previous literature has reported that if the tunnel size exceeds 10–15 mm, two-stage surgery should be performed. However, an accented threshold for how much tunnel-widening and bone loss is adequate to undergo a single stage with an intraoperative os graft prior to drilling has non been established [4, xvi,17,18,19]. Battaglia and Miller [12] indicated that os grafting should be performed in cases with a tunnel bore of 10–fifteen mm. Additionally, Chocolate-brown and Carson [20] regarded patients with a os tunnel of < 15 mm diameter equally good candidates for grafting. They explained that because a bone tunnel of 15 mm bore with 45° of inclination resulted in a tibial tunnel discontinuity of > twenty mm, a xx-mm tunnel aperture was regarded equally a candidate for grafting. Yoon et al. [21] evaluated 88 patients who underwent ane-stage revision ACLR. The patients were divided into two groups based on the tunnel diameter (group A, < 12 mm; group B, < 12 mm). At a hateful follow-upward of 7.nine years, clinical scores following revision ACLR did not differ significantly according to the tunnel size. However, the results of the postoperative side-to-side differences of the Lachman test as well as the pivot-shift test were significantly superior in grouping A (< 12 mm).

Surgical considerations of ii-stage ACL reconstruction

Os grafting

Autograft bone, either from the iliac crest or anterior tibial plateau, is yet considered the golden standard source for grafting because of its osteoconductive, osteoinductive, and osteogenic properties. Clinically, many authors have reported adept results for two-staged revision ACLR using autograft bone [4, eleven]. Thomas et al. reported that the laxity measurements achieved with a 2-phase revision ACLR using autograft iliac os could be like to those achieved afterward main ACLR and clinical comeback [11]. But an iliac-crest autograft is comparatively invasive with relatively loftier donor-site morbidity and the potential for bereft yield quantities [11, 22]. For an allograft, a single bone dowel approximately 1 mm larger than the diameter of the tunnel is used and placed using a bone tamp for a printing-fit technique, ensuring that the entire tunnel is filled [four]. The utilize of allograft cloth negates the issue of donor-site morbidity but carries the potential risk of disease or infection transmission [23, 24]. To minimize the take chances of viral and bacterial contamination, allograft bone is sterilized. However, methods used to sterilize allograft material (eastward.one thousand., gamma irradiation and autoclaving), are known to adversely affect the structural and other properties of the graft material [25].

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Recently, a technique for sterilizing musculoskeletal allografts using supercritical carbon dioxide (sCO2) has been developed [26]. In theory, the sCO2-sterilized graft only provides osteoconductive properties to the grafted os tunnels. The metaphyseal location and predominantly cancellous bone surrounding the graft tissue result in high osteoinductive and osteogenic potential from the host’s bone marrow [26]. Van de pol et al. [26] reported the utilise of a sCO2-sterilized bone allograft to fill tunnel defects equally the first stage of a two-stage revision ACLR. The mean time between the two stages was 8.eight months and in the second phase, bone-biopsy specimens were taken from the tibia. They plant that a sCO2-sterilized bone allograft showed graft incorporation and remodeling through creeping substitution.

Silicate-substituted calcium phosphate (Si-CaP), which represents a synthetic, porous bone-graft substitute, may also be an appropriate bone-graft substitute [27,28,29,30]. Si-CaP appears to provide a more stable osteoconductive scaffold to support faster angiogenesis. Von recum et al. [31] used Si-CaP for a os-graft substitute for tunnel augmentation in two-stage revision ACLR. Dial-biopsy specimens of the augmented tunnels were taken at the ii-phase procedure, and histologic examination included quantitative assay of the area of immature bone formation, lamellar os, and bone marrow. CT analysis likewise included the determination of the filling rates of the tunnels. They reported that Si-CaP as a bone-graft substitute for tunnel augmentation showed favorable histologic, radiologic, and intraoperative integration comparable to the autologous iliac bone graft.

Timing of ii-phase revisional ACL reconstruction

The optimal and earliest possible timing of the two-stage procedure is still not clear. Typically, a staged procedure requires an average delay of 4 to half-dozen months to let for the os defect to heal [11, eighteen], likely subjecting patients to a prolonged period of knee joint instability and thus adding to the gamble of meniscal injury, additional deterioration of muscle strength, and osteochondrosis [32]. For assessment of bone-graft incorporation, radiographs are routinely used. Some authors have described the additional utilize of CT scans to confirm healing at 3–5 months later on bone grafting [iv, 12, 33, 34]. Thomas et al. performed a CT scan at 4 months to assess healing of the os graft in the tibial tunnel. Blurring of the tunnel margins, reactive sclerosis, and the presence of os within the tunnel were used as signs of acceptable healing. They observed that an average of 5.8 months was needed for healing of the autograft dowel to become visible on CT scans [xi]. Uchida et al. [34] reported 10 sequent patients (four female and half dozen male person patients with a mean age of 28 years) who underwent autogenous os grafting prior to ACLR revision. CT examinations were performed at iii, 12, and 24 weeks after bone grafting. Evaluations were performed in the axial plane of the tibia using three parameters (occupying ratio, union ratio, and bone mineral density). They recommended that 2-phase reconstruction could be safely performed at 24 weeks later on os grafting past the iliac-bone block-grafting technique.

Graft choice and fixation

At that place has been a long-standing argue as to whether an autograft or an allograft should exist used for revision ACLR. A conclusion that will often depend on the graft used during the main ACLR. However, many authors prefer using an autograft for revision ACLR when possible. According to the result of the multicenter ACL Revision Study (MARS) Grouping, the take a chance of graft re-rupture post-obit revision ACLR in patients receiving an autograft is two.78 times less likely than in those receiving an allograft [35]. Noyes et al. advocate that the allograft should not exist considered as the starting time choice of graft for revision surgery [36]. If no autograft is bachelor for revision surgery, they propose augmentation of the allograft with the lateral extra-articular iliotibial ring procedure to reduce the high failure charge per unit associated with the use of the allograft.

Patient age and activity level are as well important factors when deciding on graft choice for revision procedures. Allografts may be well suited for recreational athletes older than 30 years of historic period, but autografts may be a better choice for younger athletes who wish to render to college-level athletics [iv].

Secure graft fixation is critical in ensuring a successful 2-staged ACLR. Because of weak bone from bone-grafted tunnels or enlarged tunnels, the surgeons should pay conscientious attention to the fixation methods and consider double fixation in all revisions [37]. The insertion of an interference spiral not merely compresses the graft in the tunnel but likewise leads to an enlargement of the bone tunnel itself [13]. When discontinuity fixation is not possible, familiarity with, and use of, all-inside tibial and femoral sockets with cortical suspensory fixation may be necessary [4].

Additional procedure

Numerous studies have reported that boosted procedures (e.g., actress-articular tenodesis, anatomical anterolateral ligament (ALL) reconstruction) could be a meaningful option in cases of revision ACLR to improved rotatory stability which is associated with re-injury.

Trojani et al. [38] accept reported the outcomes of revision ACLR with and without lateral extra-articular tenodesis. They noted that although additional lateral tenodesis did not influence the International Knee Documentation Committee (IKDC) score in a multicenter study of 163 revision ACLRs, the proportion of negative pivot shifts was 80% with lateral tenodesis plus revision ACLR versus 63% without tenodesis. Louis et al. [39] have demonstrated that 349 patients who underwent revision ACLR-combined-ALL reconstructions showed improving rotational stability without increasing the risk of early and tardily complications and the re-rupture rate was one.two% in their multicenter study.

Lee et al. [40] reported the results of 87 patients who underwent revision ACLR with a follow-up of more than 3 years. Patients were divided into the isolated revision ACLR group (northward = 45) and the revision ACLR group in combination with ALL reconstruction (due north = 42). They observed that revision ACLR in combination with ALL reconstruction significantly reduced rotational laxity and showed a higher rate of return to the aforementioned level of sports activeness than revision ACLR alone, although there were no significant differences in inductive laxity or functional test results between the ii groups.


In the immediate postoperative menses, the weakest office of whatsoever ACLR is the fixation. After vi to 12 weeks, failures tend to occur in mid-substance [eleven]. Some authors suggest that an accelerated rehabilitation program for revision ACLR is not advisable because of weaker initial graft fixation [twenty]. Nonetheless, Thomas et al. [11] noted that this suggestion is unnecessary, as using a two-stage technique ensures that there is adept-quality bone around the tunnels, and the initial graft fixation is as secure as in the master reconstruction.

Rehabilitation afterward the initial bone-grafting stage shares similarities with standard ACLR protocols [17]. The initial rehabilitation emphasis is focused on restoring tibiofemoral and patellofemoral passive range of motion, restoring quadriceps’ activation, and decision-making and resolving any joint effusion. No restrictions are placed on their range of movement and patients were allowed to weightbear on the affected leg using crutches [17]. Physical therapy with muscle-strengthening and proprioceptive preparation can be performed. Improved muscle strength may be the decisive factor; however, changes in functional motion patterns after intensive physical therapy are likewise important to consider [41].

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Few studies report the outcomes of two-stage revision ACLR lone. Current studies study an boilerplate-low failure rate of iii.6% (wide range of 0–eight.1%) for utilizing 2-stage revision ACLR [11, 33, 34, 42, 43] (Table 2).

Table 2 Electric current reports on upshot of 2-stage revision anterior cruciate ligament reconstruction

Full size tabular array

Thomas et al. [eleven] reported the results of 49 consecutive ii-stage revision ACLRs in which the tibial tunnel was grafted (the bone graft was taken from the ipsilateral iliac crest) during the first stage, followed by an ACLR using diverse grafts and fixation methods for the second stage. The results from this group were compared to the results of a matched group of patients with primary ACLR. The two-stage grouping contained significantly more than patients with meniscal and chondral pathology compared with the primary ACLR group. At a hateful follow-up of 6 years, the laxity measurements achieved with a 2-stage revision ACLR can be similar to those accomplished after principal ACLR, although the IKDC rating is lower.

Franceschi et al. [33] evaluated 30 patients who underwent 2-staged ACLR revision procedure after a traumatic re-rupture of the ACL. All the patients in the study underwent spiral removal and filling of the tunnels with an autograft harvested from the anterior tibial metaphysis. The 2d stage of the revision ACLR was performed a minimum of 3 months later, after obtaining a CT demonstrating acceptable filling of the tunnels using a hamstring autograft though a transtibial drilling technique. The new ligament was stock-still to the tibia past a metallic screw and to the femur by a bioabsorbable screw. At a mean follow-upward half-dozen.seven years postoperatively, 66.7% of patients had returned to their preoperative sports activity level, 23.three% had changed to lower, not-impact sports, and 10% had given up any sports action. At that place was also a significant improvement in the Lysholm score when comparing preoperative and postoperative values.

Uchida et al. [34] evaluated 10 consecutive patients who underwent staged revision ACLR using autogenous os grafting and reported that all patients had a total range of motility of the knees, a negative Lachmann sign and negative pivot-shift exam . An average Lysholm score at two years postal service operation was 96.6 points ± 2.1 (91–100 points).

One comparative cohort study reported that objective outcomes and subjective patient scores and satisfaction were non significantly unlike between one-stage and ii-stage revision ACLRs and both groups had significantly improved objective outcomes and patient subjective outcomes without notable differences in failure rates [42]. They observed that the the failure charge per unit was x.iii% in the one-stage revision group and half-dozen.ane% in the two-stage group. In boosted analyses, 24% (12/49) of patients were newly plant to have concomitant genu injuries (e.g., chondral defects, meniscal lesions) at the time of the second-phase operative process.

Diermeier et al. [43] reported the results of 54 patients who underwent bone grafting due to recurrent, symptomatic ACL deficiency following ACLR. Only 44 patients underwent a staged revision ACLR after bone grafting and 10 patients refused to undergo a revision ACLR. At a mean menstruum of 33.ix months, in that location was an improvement in the Lysholm score (77.ii ± 15.5 vs 72.9 ± xviii.vii), IKDC score (69.0 ± 13.4 vs 69.iii ± 13.4) and Tegner activity score (four.1 ± 1.5 vs 4.vi ± 1.2) for both groups. But no significant deviation was observed between the two groups. Genu-laxity measurements were elevated in the without-revision group, simply the difference was non significant. Postoperatively, no complications were reported and none of the included patients had a flexion or extension deficit. Withal, the small number of included patients, especially in the group of patients without revision ACLR, is express.


In active immature patients, failed primary ACLR may require a revision ACLR. Two-stage revision ACLR should be considered in cases of tunnel lysis, infection, malalignment, meniscal deficiency, or chondral lesions. A two-stage process is technically more demanding than the primary or one-stage procedure and outcomes are potentially junior, especially for agile patients who make a high need on their bodies. However, with precise indications, proper preoperative planning and operative-technique pick, 2-stage revision ACLR tin achieve favorable outcomes.

Availability of data and materials

Not applicative, this is a review article.



Anterior cruciate ligament


Anterior cruciate ligament reconstruction


Anterolateral ligament


Supercritical carbon dioxide


Silicate-substituted calcium phosphate


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We give thanks Eun-Ji Jeon and Min-Ji Kim for their support.

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Kim, DH., Bae, KC., Kim, DW.
et al.
Two-phase revision anterior cruciate ligament reconstruction.
Knee Surg & Relat Res
10 (2019). https://doi.org/10.1186/s43019-019-0010-half-dozen

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  • Human knee
  • Anterior cruciate ligament
  • Reconstruction
  • Revision
  • Stage

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