Revision ACL reconstruction

While ACL reconstruction is a very successful operation, 5% of reconstructions will fail.  Usually this is as a result of a second injury playing sport, although the ACL can also stretch with time, making the knee unstable again.

Dr Dwyer treats failed ACL reconstructions using two important principles.  The first is that if at all possible, revision surgery should use autograft, or the patient’s own tissue.  This may mean using hamstring or patella tendon from the same knee, or even from the other knee.  Dr Dwyer will avoid the use of allograft or cadaveric tissue if possible, as the failure rate with allograft is 10X that of autograft.

The second principle is that the only thing worse than having a ACL reconstruction surgery fail, is having a second ACL reconstruction fail. For this reason, Dr Dwyer will often perform a revision in two stages.  The first stage is a simple surgery, where all screws and implants are removed, and the previous ACL tunnels bone grafted.  This surgery is well tolerated, and patients can walk immediately on the knee.  Recovery is swift.  The second surgery is performed three months later, during which the surgery can be performed almost exactly as though the surgery is happening for the first time.

In order to reduce your risk of tearing the ACL again, Dr Dwyer will often perform a Lateral Extra-articular Tenodesis (LET) as well.  This involves a second, small incision on the outside of your knee, and using some of your own tissue (IT band) to help tighten and stabilize the knee.

Postoperative rehabilitation

Revision ACL reconstruction is performed as day surgery at Women’s College Hospital. Someone must come and pick you up and take you home. It is advised to have someone around to help you for the first two days. All patients will be provided with a script for medications that should be filled at the hospital prior to going home. Medications will usually be Celebrex in the morning for 2 weeks, Aspirin at night for two weeks, and Tylenol regularly for the first week. A script for Oxycodone will also be provided.

Patients can walk on the knee immediately, although most patients use crutches for a week or two.  A brace is used to sleep and walk for the first six weeks, and is removed after 2 days to begin bending the knee, when sitting in a chair.  If possible, patients should rent a Gameready machine, which provides ice and compression to the knee, significantly reducing postoperative pain. The information for the rental company will be provided to you.

During surgery, your meniscus will be carefully examined for signs of injury. Sometimes, a meniscal repair will be required – if so you will need to wear the brace for the first 6 weeks after surgery, and limit your range of motion to 90 degrees. You will still be able to fully walk on the knee.

Physiotherapy is required twice a week, immediately after surgery.  A physiotherapy referral and protocol will be provided for you on the day of surgery. Patients are seen in clinic two weeks after surgery, for wound review. 

Patients should take a week off work after the surgery, and then work from home for another 2 weeks if possible. Patients are not allowed to play sport for 9 months after surgery, as it takes this period of time for full quadriceps strength to be restored.

Risks of surgery

Revision ACL reconstruction is a safe operation. There is a 1/1000 risk of deep infection, major stiffness, DVT/PE, major nerve or blood vessel damage, and patella fracture. Patients can get local areas of numbness around the graft harvest incisions, which typically improves over a year or two. The risk of retear of the ACL over your lifetime is 5%.

Sometimes patients may need a second arthroscopy to remove scar tissue or assess the knee in the event of ongoing swelling and or pain. The chance of returning to sport is approximately 90%.