Indications and Planning of the Two-Stage Revision of Anterior Cruciate Ligament Surgery: A Narrative Review
DOI:
https://doi.org/10.63403/re.v32i1.371Keywords:
ACL Reconstruction, ACL Failure, ACL Revision, Two-Stage Surgery, Tunnel DilationAbstract
The increase in anterior cruciate ligament reconstruction (ACLR) surgeries has led to a proportional rise in revision procedures. Canadian statistics estimate approximately 13 000 annual revisions, while in the United States, the reported incidence ranges from 4.1% to 13.3% of all ACLRs
The success of a revision surgery depends on a systematic approach that identifies the cause of failure, such as rerupture or persistent instability, and allows for the planning of the definitive procedure. While most of these revisions are performed in a single stage, 8% to 9% require a two-stage approach. This decision depends on factors such as bone quality, tunnel size and position, previous fixation methods, and the presence of associated injuries.
The primary indication for a two-stage revision is osteolysis with tunnels larger than 14 mm or the risk of convergence between primary and revision tunnels. This article presents a narrative review analyzing the indications and surgical planning for two-stage ACL revision procedures.
In conclusion, there is limited and generally short-term evidence on the outcomes of ACL reconstruction in two-stage revisions. Although two-stage revisions are typically performed in more complex cases, the reported outcomes of these procedures have shown comparable clinical results.
Level of Evidence: V
References
Gianotti SM, Marshall SW, Hume PA, Bunt L. Incidence of anterior cruciate ligament injury and other knee ligament injuries: a national population-based study. J Sci Med Sport. 2009 Nov;12(6):622-627. doi: https://www.doi.org/10.1016/j.jsams.2008.07.005. DOI: https://doi.org/10.1016/j.jsams.2008.07.005
Brophy RH, Wright RW, Matava MJ. Cost analysis of converting from single-bundle to double-bundle anterior cruciate ligament reconstruction. Am J Sports Med. 2009 Apr;37(4):683-687. doi: https://www.doi.org/10.1177/0363546508328121. DOI: https://doi.org/10.1177/0363546508328121
Mall NA, Chalmers PN, Moric M, Tanaka MJ, Cole BJ, Bach BR Jr, Paletta GA Jr. Incidence and trends of anterior cruciate ligament reconstruction in the United States. Am J Sports Med. 2014 Oct;42(10):2363-2370. doi: https://www.doi.org/10.1177/0363546514542796. DOI: https://doi.org/10.1177/0363546514542796
Kim S, Bosque J, Meehan JP, Jamali A, Marder R. Increase in outpatient knee arthroscopy in the United States: a comparison of National Surveys of Ambulatory Surgery, 1996 and 2006. J Bone Joint Surg Am. 2011 Jun 1;93(11):994-1000. doi: https://www.doi.org/10.2106/JBJS.I.01618. DOI: https://doi.org/10.2106/JBJS.I.01618
Wright RW, Dunn WR, Amendola A, Andrish JT, Bergfeld J, Kaeding CC, et al. Risk of tearing the intact anterior cruciate ligament in the contralateral knee and rupturing the anterior cruciate ligament graft during the first 2 years after anterior cruciate ligament reconstruction: a prospective MOON cohort study. Am J Sports Med. 2007 Jul;35(7):1131-1134. doi: https://www.doi.org/10.1177/0363546507301318. DOI: https://doi.org/10.1177/0363546507301318
Salmon L, Russell V, Musgrove T, Pinczewski L, Refshauge K. Incidence and risk factors for graft rupture and contralateral rupture after anterior cruciate ligament reconstruction. Arthroscopy. 2005 Aug;21(8):948-957. doi: https://www.doi.org/10.1016/j.arthro.2005.04.110. DOI: https://doi.org/10.1016/j.arthro.2005.04.110
Kim DH, Bae KC, Kim DW, Choi BC. Two-stage revision anterior cruciate ligament reconstruction. Knee Surg Relat Res. 2019 Sep 18;31(1):10. doi: https://www.doi.org/10.1186/s43019-019-0010-6. DOI: https://doi.org/10.1186/s43019-019-0010-6
Erickson BJ, Cvetanovich G, Waliullah K, Khair M, Smith P, Bach B Jr, et al. Two-stage revision anterior cruciate ligament reconstruction. Orthopedics. 2016 May 1;39(3):e456-e464. doi: https://www.doi.org/10.3928/01477447-20160324-01. DOI: https://doi.org/10.3928/01477447-20160324-01
Webster KE, Hewett TE. What is the evidence for and validity of return-to-sport testing after anterior cruciate ligament reconstruction surgery? a systematic review and meta-analysis. Sports Med. 2019 Jun;49(6):917-929. doi: https://www.doi.org/10.1007/s40279-019-01093-x. DOI: https://doi.org/10.1007/s40279-019-01093-x
MARS Group; Wright RW, Huston LJ, Spindler KP, Dunn WR, Haas AK, et al. Descriptive epidemiology of the Multicenter ACL Revision Study (MARS) cohort. Am J Sports Med. 2010 Oct;38(10):1979-1986. doi: https://www.doi.org/10.1177/0363546510378645. DOI: https://doi.org/10.1177/0363546510378645
Gopinatth V, Casanova FJ, Knapik DM, Mameri ES, Jackson GR, Khan ZA, et al. Consistent indications and good outcomes despite high variability in techniques for two-stage revision anterior cruciate ligament reconstruction: a systematic review. Arthroscopy. 2023 Sep;39(9):2098-2111. doi: https://www.doi.org/10.1016/j.arthro.2023.02.009. DOI: https://doi.org/10.1016/j.arthro.2023.02.009
Mitchell JJ, Chahla J, Dean CS, Cinque M, Matheny LM, LaPrade RF. Outcomes after 1-stage versus 2-stage revision anterior cruciate ligament reconstruction. Am J Sports Med. 2017 Jul;45(8):1790-1798. doi: https://www.doi.org/10.1177/0363546517698684. DOI: https://doi.org/10.1177/0363546517698684
Pioger C, Saithna A, Rayes J, Haidar IM, Fradin T, Ngbilo C, et al. Influence of preoperative tunnel widening on the outcomes of a single stage-only approach to every revision anterior cruciate ligament reconstruction: an analysis of 409 consecutive patients from the SANTI Study Group. Am J Sports Med. 2021 May;49(6):1431-1440. doi: https://www.doi.org/10.1177/0363546521996389. DOI: https://doi.org/10.1177/0363546521996389
Kamath GV, Redfern JC, Greis PE, Burks RT. Revision anterior cruciate ligament reconstruction. Am J Sports Med. 2011 Jan;39(1):199-217. doi: https://www.doi.org/10.1177/0363546510370929. DOI: https://doi.org/10.1177/0363546510370929
Thomas NP, Kankate R, Wandless F, Pandit H. Revision anterior cruciate ligament reconstruction using a 2-stage technique with bone grafting of the tibial tunnel. Am J Sports Med. 2005 Nov;33(11):1701-1709. doi: https://www.doi.org/10.1177/0363546505276759.
Oetgen ME, Smart LR, Medvecky MJ. A novel technique for arthroscopically assisted femoral bone tunnel grafting in two-stage ACL revision. Orthopedics. 2008 Jan;31(1):16-18. doi: https://www.doi.org/10.3928/01477447-20080101-31. DOI: https://doi.org/10.3928/01477447-20080101-31
Uchida R, Shiozaki Y, Tanaka Y, Kita K, Amano H, Kanamoto T, et al. Relationship between bone plug position and morphological changes of tunnel aperture in anatomic rectangular tunnel ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2019 Aug;27(8):2417-2425. doi: https://www.doi.org/10.1007/s00167-018-5224-8. DOI: https://doi.org/10.1007/s00167-018-5224-8
Noyes FR, Barber-Westin SD. Revision anterior cruciate surgery with use of bone-patellar tendon-bone autogenous grafts. J Bone Joint Surg Am. 2001 Aug;83(8):1131-1143. doi: https://www.doi.org/10.2106/00004623-200108000-00001 DOI: https://doi.org/10.2106/00004623-200108000-00001
Franceschi F, Papalia R, Di Martino A, Rizzello G, Allaire R, Denaro V. A new harvest site for bone graft in anterior cruciate ligament revision surgery. Arthroscopy. 2007 May;23(5):558.e1-e4. doi: https://www.doi.org/10.1016/j.arthro.2006.07.054 DOI: https://doi.org/10.1016/j.arthro.2006.07.054
Kemler B, Coladonato C, Perez A, Erickson BJ, Tjoumakaris FP, Freedman KB. Considerations for revision anterior cruciate ligament reconstruction: a review of the current literature. J Orthop. 2024 May 11;56:57-62. doi: https://www.doi.org/10.1016/j.jor.2024.05.012. DOI: https://doi.org/10.1016/j.jor.2024.05.012
Wright RW, Gill CS, Chen L, Brophy RH, Matava MJ, Smith MV, et al. Outcome of revision anterior cruciate ligament reconstruction: a systematic review. J Bone Joint Surg Am. 2012 Mar 21;94(6):531-536. doi: https://www.doi.org/10.2106/JBJS.K.00733 DOI: https://doi.org/10.2106/JBJS.K.00733
Wilson TC, Kantaras A, Atay A, Johnson DL. Tunnel enlargement after anterior cruciate ligament surgery. Am J Sports Med. 2004 Mar;32(2):543-549. doi: https://www.doi.org/10.1177/0363546504263151 DOI: https://doi.org/10.1177/0363546504263151
Sawant M, Narasimha Murty A, Ireland J. Valgus knee injuries: evaluation and documentation using a simple technique of stress radiography. Knee. 2004 Feb;11(1):25-28. doi: https://www.doi.org/10.1016/S0968-0160(03)00009-7. DOI: https://doi.org/10.1016/S0968-0160(03)00009-7
Dave LY, Leong OK, Karim SA, Chong CH. Tunnel enlargement 5 years after anterior cruciate ligament reconstruction: a radiographic and functional evaluation. Eur J Orthop Surg Traumatol. 2014 Feb;24(2):217-223. doi: https://www.doi.org/10.1007/s00590-013-1175-4. DOI: https://doi.org/10.1007/s00590-013-1175-4
Marchant MH Jr, Willimon SC, Vinson E, Pietrobon R, Garrett WE, Higgins LD. Comparison of plain radiography, computed tomography, and magnetic resonance imaging in the evaluation of bone tunnel widening after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2010 Aug;18(8):1059-1064. doi: https://www.doi.org/10.1007/s00167-009-0952-4. DOI: https://doi.org/10.1007/s00167-009-0952-4
Parkar AP, Adriaensen ME, Fischer-Bredenbeck C, Inderhaug E, Strand T, Assmus J, et al. Measurements of tunnel placements after anterior cruciate ligament reconstruction-- a comparison between CT, radiographs and MRI. Knee. 2015 Dec;22(6):574-579. doi: https://www.doi.org/10.1016/j.knee.2015.06.011. DOI: https://doi.org/10.1016/j.knee.2015.06.011
de Beus A, Koch JE, Hirschmann A, Hirschmann MT. How to evaluate bone tunnel widening after ACL reconstruction - a critical review. Muscles Ligaments Tendons J. 2017 Sep 18;7(2):230-239. DOI: https://doi.org/10.11138/mltj/2017.7.2.230
Drews BH, Merz C, Huth J, Gulkin D, Guelke J, Gebhard F, et al. Magnetic resonance imaging in evaluation of tunnel diameters prior to revision ACL reconstruction: a comparison to computed tomography. Skeletal Radiol. 2017 Oct;46(10):1361-1366. doi: https://www.doi.org/10.1007/s00256-017-2704-8. DOI: https://doi.org/10.1007/s00256-017-2704-8
Mayr R, Rosenberger R, Agraharam D, Smekal V, El Attal R. Revision anterior cruciate ligament reconstruction: an update. Arch Orthop Trauma Surg. 2012 Sep;132(9):1299-1313. doi: https://www.doi.org/10.1007/s00402-012-1552-1. DOI: https://doi.org/10.1007/s00402-012-1552-1
Miller MD, Kew ME, Quinn CA. Anterior cruciate ligament revision reconstruction. J Am Acad Orthop Surg. 2021 Sep 1;29(17):723-731. doi: https://www.doi.org/10.5435/JAAOS-D-21-00088. DOI: https://doi.org/10.5435/JAAOS-D-21-00088
Horvath A, Senorski EH, Westin O, Karlsson J, Samuelsson K, Svantesson E. Outcome after anterior cruciate ligament revision. Curr Rev Musculoskelet Med. 2019 Jul 8;12(3):397-405. doi: https://www.doi.org/10.1007/s12178-019-09571-5. DOI: https://doi.org/10.1007/s12178-019-09571-5
Thomas NP, Kankate R, Wandless F, Pandit H. Revision anterior cruciate ligament reconstruction using a 2-stage technique with bone grafting of the tibial tunnel. Am J Sports Med. 2005 Nov;33(11):1701-1709. doi: https://www.doi.org/10.1177/0363546505276759. DOI: https://doi.org/10.1177/0363546505276759
Mathew CJ, Palmer JE, Lambert BS, Harris JD, McCulloch PC. Single-stage versus two-stage revision anterior cruciate ligament reconstruction: a systematic review. J ISAKOS. 2017;3(6):345-352. doi: https://www.doi.org/10.1136/jisakos-2017-000192. DOI: https://doi.org/10.1136/jisakos-2017-000192
Grassi A, Nitri M, Moulton SG, Marcheggiani Muccioli GM, Bondi A, Romagnoli M, et al. Does the type of graft affect the outcome of revision anterior cruciate ligament reconstruction? a meta-analysis of 32 studies. Bone Joint J. 2017 Jun;99-B(6):714-723. doi: https://www.doi.org/10.1302/0301-620X.99B6.BJJ-2016-0929.R2. DOI: https://doi.org/10.1302/0301-620X.99B6.BJJ-2016-0929.R2
Franceschi F, Papalia R, Del Buono A, Zampogna B, Diaz Balzani L, Maffulli N, et al. Two-stage procedure in anterior cruciate ligament revision surgery: a five-year follow-up prospective study. Int Orthop. 2013 Jul;37(7):1369-1374. doi: https://www.doi.org/10.1007/s00264-013-1886-5. DOI: https://doi.org/10.1007/s00264-013-1886-5
Barrett GR, Brown TD. Femoral tunnel defect filled with a synthetic dowel graft for a single-staged revision anterior cruciate ligament reconstruction. Arthroscopy. 2007 Jul;23(7):796.e1-e4. doi: https://www.doi.org/10.1016/j.arthro.2006.10.025. DOI: https://doi.org/10.1016/j.arthro.2006.10.025
Kaeding CC, Aros B, Pedroza A, Pifel E, Amendola A, Andrish JT, et al. Allograft versus autograft anterior cruciate ligament reconstruction: predictors of failure from a MOON prospective longitudinal cohort. Sports Health. 2011 Jan;3(1):73-81. doi: https://www.doi.org/10.1177/1941738110386185. DOI: https://doi.org/10.1177/1941738110386185
Getgood A. Hamstring autograft had better long-term survivorship than tibialis posterior tendon allograft for anterior cruciate ligament reconstruction. J Bone Joint Surg Am. 2016 May 18;98(10):872. doi: https://www.doi.org/10.2106/JBJS.16.00209. DOI: https://doi.org/10.2106/JBJS.16.00209
Marmura H, Getgood AMJ, Spindler KP, Kattan MW, Briskin I, Bryant DM. Validation of a risk calculator to personalize graft choice and reduce rupture rates for anterior cruciate ligament reconstruction. Am J Sports Med. 2021 Jun;49(7):1777-1785. doi: https://www.doi.org/10.1177/03635465211010798. DOI: https://doi.org/10.1177/03635465211010798
MARS Group; MARS Group. Effect of graft choice on the outcome of revision anterior cruciate ligament reconstruction in the Multicenter ACL Revision Study (MARS) cohort. Am J Sports Med. 2014 Oct;42(10):2301-2310. doi: https://www.doi.org/10.1177/0363546514549005.
Duerr R, Ormseth B, Adelstein J, Garrone A, DiBartola A, Kaeding C, et al. Elevated posterior tibial slope is associated with anterior cruciate ligament reconstruction failures: a systematic review and meta-analysis. Arthroscopy. 2023 May;39(5):1299-1309.e6. doi: https://www.doi.org/10.1016/j.arthro.2022.12.034. DOI: https://doi.org/10.1016/j.arthro.2022.12.034
Dracic A, Zeravica D, Zovko I, Jäger M, Beck S. Cut-off value for the posterior tibial slope indicating the risk for retear of the anterior cruciate ligament. Knee Surg Sports Traumatol Arthrosc. 2024 Dec 6. doi: https://www.doi.org/10.1002/ksa.12552. DOI: https://doi.org/10.1002/ksa.12552
Tollefson LV, Rasmussen MT, Guerin G, LaPrade CM, LaPrade RF. Slope-reducing proximal tibial osteotomy improves outcomes in anterior cruciate ligament reconstruction patients with elevated posterior tibial slope, especially revisions and posterior tibial slope ≥12. Arthroscopy. 2024 Nov 12:S0749-8063(24)00901-0. doi: https://www.doi.org/10.1016/j.arthro.2024.10.048. DOI: https://doi.org/10.1016/j.arthro.2024.10.048
Published
How to Cite
Issue
Section
License
Copyright (c) 2025 Rafael Calvo Rodríguez, Waldo González Duque, David Figueroa Poblete, Rafael Calvo Mena, Sebastián Monge Berrios, Claudio Yáñez Lagos
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
This work is published under a Creative Commons Attribution–NonCommercial–ShareAlike 4.0 International License (CC BY-NC-SA 4.0). The authors retain the copyright.
