Revision ACL reconstruction

Background: Anterior cruciate ligament reconstruction (ACLR) failure occurs in 7% to 25% of cases, necessitating revision surgery. Challenges in revision ACLR include identifying the etiology of failure—categorized as biological, traumatic, or technical—and managing bone loss, specifically tunnel expansion. Severe tibial tunnel widening often complicates graft placement and fixation, requiring staged procedures or alternative tunnel trajectories to ensure mechanical stability.

Objective: This case report describes a surgical strategy for a patient with multiple failed ACLRs and significant tibial tunnel expansion, utilizing a laterally-based tibial tunnel and lateral extra-articular tenodesis.

Key Points: A 28-year-old female with three prior ACLRs presented with recurrent instability and a 23-mm tibial tunnel. Following an initial stage of bone grafting and hardware removal, persistent tibial bone deficiency necessitated a modified second-stage approach. A contralateral patellar tendon autograft was utilized. To avoid the expanded defect, a laterally-based tibial tunnel was drilled through virgin bone adjacent to the tibial tubercle. On the femoral side, an anteromedial portal was used for hand-reaming to prevent posterior cortex blowout, followed by suspensory fixation. To address the high-risk nature of multiple failures, a lateral extra-articular iliotibial band tenodesis was performed, docking the graft into a femoral socket isometric from 0° to 30° of flexion.

Conclusion: In cases of severe, recurrent tibial tunnel expansion where traditional bone grafting is insufficient, a laterally-based tibial tunnel combined with lateral extra-articular tenodesis provides a viable salvage option. This approach facilitates stable graft fixation in virgin bone and enhances rotational stability, as evidenced by the elimination of instability at two-year follow-up.