APKASS 2024 consensus statement on anterior cruciate ligament reconstruction, Part II: Management of anterior cruciate ligament revision in adults.

BACKGROUND

Revision anterior cruciate ligament reconstruction (ACLR) is a complex procedure with varying diagnostic, surgical, and rehabilitation approaches. This study aimed to develop a consensus among surgeons from APKASS on key aspects of revision ACLR to improve clinical outcomes.

METHODS

A total of 23 expert surgeons from eight member countries participated in the survey. Topics included diagnostics, surgical indications, techniques, graft selection, rehabilitation protocols, and return-to-play (RTP) considerations for revision ACLR. Responses were analyzed in comparison with the current literature to identify areas of agreement and divergence.

RESULTS

A consensus was reached on the importance of clinical and imaging criteria, including the pivot shift test, KT-2000 measurements, and MRI for identifying ACL failure. CT was preferred for evaluating tunnel placement. Poor tunnel placement was identified as the leading cause of ACL failure. One-stage revision surgeries were favoured unless significant tunnel enlargement required a two-stage approach. Bone-patellar tendon-bone (BTB) autografts were the preferred graft choice, while quadriceps tendon (QT) autografts emerged as a viable alternative. Revision ACLR was deemed critical for active patients engaged in high-impact sports, while older age and established osteoarthritis were considered relative contraindications. Additional procedures, such as lateral extra-articular tenodesis (LET), were selectively indicated based on individual patient factors. Conservative, patient-specific rehabilitation protocols were recommended, with an emphasis on addressing psychological factors. RTP rates varied widely, highlighting the importance of tailored recovery plans to optimize outcomes.

CONCLUSION

This consensus emphasizes the importance of individualized and evidence-based approaches in revision ACLR, from diagnostics and surgical techniques to rehabilitation and RTP. Standardized criteria and further research are essential to refine strategies and improve outcomes in this patient population.

LEVEL OF EVIDENCE: V (Expert opinion).