ACL Re-Injury and Reconstruction

Approximately 200,000 ACL ruptures occur annually in the US, and up to 100,000 reconstructions of the ligament are performed by doctors every year.

Athletes involved in sports that include a high degree of pivoting, twisting, and cutting (basketball, football, soccer) are the most susceptible to ACL injuries.

Even though primary surgical interventions have a high success rate, about 10% of all ACL reconstructions fail within 10 years, requiring a revisionary reconstruction of the damaged ligament. This type of intervention can also amend errors stemming from the initial surgery.

What Leads to Re-Injuries?

Primary ACL reconstructions are often touted as a success after completion, but not every surgery is performed with the same level of accuracy. Improperly positioning the new ACL graft can lead to inappropriate joint mechanics that increase the likelihood of a future re-injury.

Another factor determining the need for revisionary surgery is the size and origin of the graft used in the first intervention. Studies indicate that grafts of a smaller size often have less durability than larger ones, and grafts from donors (allografts) have a higher risk of re-tear when compared to grafts from a patient's tissue (autograft).

Insufficient recovery and rehabilitation are also significant factors determining the need for a second ACL surgery. For a new graft to be adequately incorporated and normal muscle strength rebuilt for proper knee support, most specialists recommend a minimum of 6 months of recovery for autograft replacements and at least 9 months for allograft types. Overexerting the joint while the implant is still in the incorporation process is a significant risk factor that usually leads to a re-tear.

Sometimes a primary ACL reconstruction may be affected by additional knee injuries that weren't noticed, such as a damaged meniscus or cartilage deficiencies requiring transplants or replacements. Fortunately, if such problems were not addressed during the first intervention, ACL revisionary reconstruction can appropriately fix the injured knee and the surrounding tissues.

Opting for revisionary surgery is dependent on:

• the state of the patient's affected knee
• the intended post-op activity level
• the results of pre-op imaging scans

Because ACL revisionary reconstruction is more complex than the initial intervention, orthopedic surgeons with ample experience are best suited to carry out this type of operation.

Revisionary Surgery Can Fix Underlying Issues

ACL revisionary reconstruction isn't mandatory so long as the patient doesn't experience instability in the reconstructed knee. On the other hand, when knee instability is evident, ACL revisionary surgery is required to address the underlying issue.

A recent example of ACL revision surgery is the case of L.A. Rams player Odell Beckham Jr. Initially undergoing ACL surgery in 2020 while playing for the Cleveland Browns, his forced release saw him headed for the L.A. Rams, where the wide receiver managed to win Superbowl LVI. Unfortunately for him, he suffered a re-tear during the game in the operated ACL and had to undergo revision reconstruction surgery; however, insiders noted that this second intervention actually fixed underlying problems stemming from the first operation.

As with any other intervention, ACL revision reconstruction requires ample time to rehabilitate the injured area and mitigate the risk of further damage. Professional athletes intend to return to play in the shortest time possible (usually 6 to 9 months), but rushing through physical therapy is not the right approach:

• Athletes who return to high-level competition are 4 times more likely to face re-injury than low and mid-level participation.
• They were also 8 times more prone to re-damage their ACL if they returned before successfully passing functionality testing.
• The rate of injuries dropped by half with each month dedicated to rehab up until 9 months.
• Allowing sufficient time for recovery and successfully passing functionality tests reduces the risk of re-injury by a whopping 84%.

The rehab period following an ACL reconstruction is usually the same as the therapy following the initial procedure. Even if it might take longer to heal to ensure a functional return, careful planning, and proper rehabilitation following a successful second ACL surgery ensure that athletes return to a high level of activity with no issue regarding stability in their knees.