Failed anterior cruciate ligament reconstruction. Treatment recommendations

With increasing numbers of primary anterior cruciate ligament (ACL) reconstructions the number of patients who need revision ACL reconstruction is likely to increase as well. Revision surgery after ACL reconstruction is challenging and requires a thorough workup before considering revision surgery. As scientific data are sparse the approach to these patients has to be orientated mainly toward clinical decision criteria. First, ACL-dependent causes have to be differentiated from ACL-independent causes of failure. If ACL-independent pathologies have been ruled out a rerupture of the transplant has to be differentiated from transplant insufficiency. The patient history as well as a thorough physical examination will give decisive hints about a traumatic re-rupture or a recurrent instability, which generally needs further evaluation using imaging techniques. The purpose if this article is to review the diagnostic process as well as therapeutic considerations and to summarise the author's treatment algorithm when approaching recurrent pain and instability in failed ACL reconstruction.