Failed ACL reconstruction occurs when a previously reconstructed anterior cruciate ligament (ACL) graft fails and the knee becomes unstable again. Following ACL reconstruction, failure may result from technical errors from the initial surgery, incomplete rehabilitation, returning to sports too soon, biological graft failure or rejection, failure to retrain proper cutting, pivoting, and landing mechanics, or re-injury.
Revision ACL reconstruction can be more complex than the initial surgery because it may need to address issues such as limited graft options, scar tissue, old hardware, bone loss, or infection.
What Is a Failed ACL Reconstruction?
The ACL is one of the four major ligaments of the knee. It is a ropelike structure in the center of the knee that helps maintain the normal relationship between the femur (thigh bone) and tibia (leg bone).
When an ACL graft fails after reconstruction, the knee may again become unstable, shifting or giving way during activities that require pivoting, changing direction, jumping, or landing.
After a failed ACL reconstruction, it is important to determine the cause of the failure so the reconstruction can be successfully revised. Revision surgery often is more complex because it may need to address limited graft options, scar tissue, old hardware, bone loss, or infection.
Causes and Risk Factors
Causes of failed ACL reconstruction may include:
- Non-contact re-injury, such as landing awkwardly or cutting
- Contact injury involving a direct hit to the knee
- Failure to complete rehabilitation
- Failure to retrain proper running, cutting, and landing mechanics
- Failure to pass a validated post-ACL surgery functional testing program
- Technical errors from the initial surgery
- Infection
Risk factors include:
- Returning to high-risk sports that require pivoting, jumping, cutting, or changing direction, such as basketball, soccer, and volleyball
- Returning to contact sports such as football and rugby
- Returning to sports too early
- Poor physical conditioning, including strength and flexibility
- Female gender
- High friction or traction between the playing surface and shoe
Symptoms
Signs and symptoms may include:
- A pop or tearing sensation heard or felt at the time of re-injury
- Inability to continue playing after the injury
- A large amount of knee swelling within six to eight hours after the injury, often within three hours
- Inability to straighten the knee after an injury
- Knee instability, shifting, or giving way, particularly when pivoting, cutting, or jumping
- Swelling with repeated episodes of giving way
- Occasional locking when there is an associated meniscus injury
- Knee pain and swelling
Treatment
Initial treatment focuses on returning the knee toward its pre-injury condition by reducing pain and swelling and restoring range of motion, strength, and normal walking.
Walking with crutches until the patient can walk without a limp is often recommended. Range-of-motion, stretching, and strengthening exercises may be performed at home, although referral to a physical therapist or athletic trainer is often recommended. If other ligaments are injured along with the ACL, Dr. Chudik may recommend a brace to help keep the knee stable.
For patients who do not participate in sports requiring frequent pivoting, cutting, jumping, and landing, surgery may not be required and rehabilitation may be recommended. Rehabilitation usually focuses on:
- Reducing knee swelling
- Regaining knee range of motion
- Regaining muscle control and strength
- Functional training
- Avoiding activities that require pivoting, cutting, changing direction, jumping, and landing
Individuals may be able to continue jogging, cycling, weightlifting, and swimming without ACL surgery. However, they are at greater risk for progressive damage to the meniscus and cartilage from abnormal knee mechanics.
For patients who participate in sports requiring frequent pivoting, cutting, jumping, and landing, revision ACL reconstruction usually is recommended to allow a return to these sports. Surgery also is appropriate when the ACL injury is combined with injuries to other ligaments, the meniscus, or articular cartilage.
Revision surgery often is more complex because of issues such as limited graft options, scar tissue, old hardware, bone loss, or infection. Many revision ACL procedures are performed in two stages. Dr. Chudik has developed techniques to perform ACL revision reconstruction in one stage with one surgery and one recovery.
Nonsteroidal anti-inflammatory medications such as aspirin and ibuprofen, or minor pain relievers such as acetaminophen, are sometimes recommended as directed by a physician.
Cold can be used to relieve pain and reduce inflammation. It may be applied for 15 to 20 minutes every two to three hours and immediately after activities that aggravate symptoms. A cloth should be placed between the ice and skin.
Recovery and Outcomes
For patients who want to return to sports that require pivoting, cutting, jumping, and landing, revision surgery usually is required. Surgery also is recommended when ACL injuries are combined with other ligament, meniscus, or cartilage injuries.
Outcomes after revision ACL surgery depend on the ability to identify and address the cause of the original failure, which may include technical problems with the first surgery, infection, incomplete rehabilitation, or poor pivoting, cutting, and landing mechanics.
Most patients elect to undergo revision ACL reconstruction to obtain a stable knee, return to activities without restriction, and protect the remaining cartilage and meniscus from further injury.
Patients who have injured an ACL graft may be at higher risk for failure of revision surgery.
When to See Dr. Chudik
Contact Dr. Chudik’s office if symptoms worsen, particularly if the knee continues to shift or give way, swell, lock, or develop new symptoms after a previous ACL reconstruction.
Call 630-324-0402, request an appointment online, or email contactus@chudikmd.com.