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Revision ACL reconstruction – causes of failure and graft choices
  1. M A Akhtar,
  2. R Bhattacharya,
  3. N Ohly,
  4. J F Keating
  1. Knee Injury Clinic, Royal Infirmary of Edinburgh, Edinburgh, Scotland


Anterior cruciate ligament (ACL) rupture is a common sporting injury. Reconstruction of the ruptured ACL is accepted as standard treatment for athletes as it allows them to resume sporting activities. Revision reconstruction of the ACL is becoming a common operation following the failure of primary graft. This study looked at the aetiology of primary ACL graft failure and choices of graft used for primary and revision surgery. Prospective data was collected for 98 patients undergoing revision ACL reconstruction between 1996 and 2010 under the care of a single knee surgeon, including demographic details, type of graft used in primary and revision ACL reconstruction and possible cause of failure of the primary ACL reconstruction. The mean age was 31 y (range 13–50 y), with 69 males (70%) and 29 females (30%). 24 patients (27%) were involved in sports and the most common sport played was football (n =10, 42%). The most common graft used for primary ACL reconstruction was hamstring tendon in 39 patients (54%) followed by patella tendon in 20 patients (28%). The commonest reason for graft failure after primary ACL surgery was trauma (in 47 patients: 52%) followed by “biological” (in 36 patients-40%), technical errors (in 5 patients-5.5%) and infection (in 2 patients-2.2%). The commonest graft used for revision ACL reconstruction was bone patella tendon in 49 patients (58%) followed by allograft in 20 patients (24%) and hamstring tendon in 13 patients (15%). The commonest cause of failure of primary ACL reconstruction surgery appears to be trauma (52%) followed by “biological failure” (40%). The commonest graft used for primary ACL reconstruction was hamstring tendon in 54% and for revision ACL reconstruction was patella tendon in 58%. Appropriate advice on return to play should be given to athletes to avoid traumatic failure of primary ACL reconstruction. Biological failure is a relatively new concept and further studies are needed to fully understand this mechanism of failure.

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