Timing of ACL Reconstruction After Graft Failure
Early reconstruction is preferred after ACL graft failure to minimize the risk of additional cartilage and meniscal injury, following the same principles as primary ACL tears. 1
Recommended Timing Approach
The American Academy of Orthopaedic Surgeons recommends prompt intervention for revision ACL reconstruction after graft failure, similar to the approach for primary ACL injuries. 1 This recommendation is based on the principle that delayed reconstruction increases the risk of secondary damage to other knee structures. 1
Key Timing Considerations
Minimize delay between graft failure recognition and revision surgery to prevent progressive cartilage and meniscal damage that occurs with continued knee instability. 1
Early reconstruction (within 3 months) is recommended to reduce the risk of additional intra-articular injury, applying the same evidence-based timeline used for primary ACL tears. 2
Address any complications first before proceeding with revision surgery. The workup must distinguish between true graft failure, infection, and arthrofibrosis, as these require different management strategies before revision reconstruction can proceed. 3
Pre-Revision Rehabilitation
While awaiting revision surgery, patients should undergo preoperative rehabilitation similar to primary ACL reconstruction protocols:
At least one preoperative visit is recommended to ensure adequate voluntary muscle activation and absence of flexion contracture. 4
Preoperative rehabilitation may improve postoperative outcomes including quadriceps strength, knee range of motion, and potentially decrease time to return to sport. 4
Measure preoperative range of motion and strength deficits, as a preoperative extension deficit is a major risk factor for postoperative extension problems, and quadriceps strength deficits >20% negatively impact outcomes at 2 years. 4
Graft Selection for Revision
When planning the revision procedure:
Bone-patellar tendon-bone (BPTB) autograft reduces graft failure and infection risk compared to hamstring grafts, though it increases anterior/kneeling pain. 1
Lateral extra-articular augmentation (ALL reconstruction or lateral extra-articular tenodesis) is recommended to reduce re-rupture risk, particularly when using hamstring grafts in revision settings. 1
Post-Revision Rehabilitation Timeline
Following revision ACL reconstruction, the rehabilitation approach mirrors primary reconstruction but requires careful attention to graft biology:
Rehabilitation should continue for 9-12 months depending on the patient's return-to-work or return-to-play goals, using criterion-based rather than purely time-based progression. 4
Goal-based rehabilitation with functional criteria should guide progression through phases rather than rigid time-based protocols, as individual differences in healing and neuromuscular learning vary significantly. 4
Return to running should not occur before 12 weeks minimum, with most evidence suggesting this timeframe allows adequate graft remodeling, though some protocols suggest 8-16 weeks based on individual criteria. 4
Critical Pitfalls to Avoid
Do not rush revision surgery without proper workup - distinguish between graft rupture, functional failure with intact graft, infection, and arthrofibrosis before proceeding. 3
Do not ignore surgeon-controllable factors from the initial reconstruction (tunnel position, graft choice, alignment) that may have contributed to failure and must be corrected during revision. 3
Younger patients (≤22 years) have significantly higher graft failure rates (6.3% vs 4.6% in older patients), requiring more conservative return-to-sport criteria and potentially longer rehabilitation. 5