Practical strategies for dealing with bone tunnels in revision ACL reconstruction

Background: Increasing rates of primary anterior cruciate ligament (ACL) reconstruction have led to a higher incidence of revision cases. While two-stage revision with preliminary bone grafting was popularized in the mid-2000s to address tunnel defects, this approach involves increased morbidity, extended recovery periods, and higher costs compared to single-stage procedures.

Objective: This article evaluates the technical considerations, preoperative planning, and surgical strategies required to successfully perform single-stage revision ACL reconstruction while minimizing the necessity for two-stage interventions.

Key Points: Failure analysis must address surgical technique, limb alignment, and secondary stabilizers. Preoperative CT scanning with three-dimensional reformatting is superior to plain radiography for assessing tunnel position and volume. Autografts, specifically patellar or quadriceps tendons with bone blocks, are preferred over allografts due to lower rupture rates and improved defect filling. To address anterolateral rotatory instability, the author performs lateral extra-articular tenodesis in nearly all revision cases, prioritizing it over anterolateral ligament reconstruction. Technical strategies for managing bone voids include eccentric drilling, the use of oversized interference screws for graft shifting, and impacted bone dowels. In a series of 135 consecutive revisions, only two cases required a two-stage approach.

Conclusion: Single-stage revision ACL reconstruction is feasible in the majority of cases through meticulous preoperative imaging, strategic graft selection, and specialized drilling techniques. While two-stage procedures remain a salvage option for severe tunnel expansion, most patients can be managed effectively in one operation, facilitating earlier return to function.