Editorial Commentary: Bone Tunnel Grafting for Two-Stage Anterior Cruciate Ligament Revision and the Meaning of Life for an Arthroscopic Surgeon

Revision anterior cruciate ligament reconstruction and additional surgeries: A review

Anterior cruciate ligament (ACL) failure is caused by medical and nonmedical factors. A thorough preoperative evaluation should include knowledge of previous injuries, physical examination, and imaging. Classic tunnel management techniques include divergent drilling technique, transtibial technique, anteromedial portal technique, outside-in technique, and over-the-top technique. Although critical tunnel widening or overlap usually requires 2-stage revision ACL reconstruction (ACLR), efforts have been made to perform 1-stage revision ACLR in these cases. Bone grafts include bone autografts and bone allografts, synthetic bone grafts, and biologics. Grafts include autografts, allografts, and artificial ligaments. Extra-articular augmentation benefits revision ACLR in selected individuals. Varus knee and excessive posterior tibial slope should be addressed in some cases. Meniscus injury and articular cartilage injury should be addressed. Although the overall outcomes of revision ACLR are worse than those of primary ACLR, revision ACLR remains important for improving knee function and return to sport. Future research should expand the indications for 1-stage revision, clarify the indications of anterior closing wedge high tibial osteotomy and extra-articular augmentation at the time of revision ACLR, based on strong evidence.

Arthroscopic Revision of Attenuated Anterior Cruciate Ligament Graft With Enlarged Bone Tunnels Using Injectable Bone Graft Substitute

Revision anterior cruciate ligament (ACL) reconstruction is a technically demanding procedure, and the surgeon should be prepared to address bone tunnel osteolysis, concurrent meniscal, ligamentous, or cartilage lesions, and limb malalignment. ACL revision can typically be done in one procedure, but it may need to be staged if there is poor previous tunnel positioning or excessive tunnel osteolysis. Bone grafting of the tunnels can be accomplished in several ways, including autograft, allograft, or bone substitutes. Currently, no consensus is available regarding the optimal choice of bone graft material for bone tunnel augmentation in revision ACL reconstruction. Bone graft substitute for tunnel augmentation has been showed to have good histologic, radiographic, and intraoperative integration, comparable to that of autologous bone. In this Technical Note, the technical details of arthroscopic treatment of attenuated anterior cruciate ligament graft with enlarged bone tunnels are described. The tunnels are debrided arthroscopically and filled up with PRO-DENSE injectable regenerative graft.