Failed Anterior Cruciate Ligament Reconstruction with Residual Laxity

Diagnosis

Your diagnosis is a failed anterior cruciate ligament (ACL) reconstruction with persistent laxity.

Injury or Condition

This condition represents a permanent deformation of the graft tissue which was previously used for reconstruction of the ACL. Its failure may lead to failure of cartilage repair procedures or to new injury.

Cause

Common causes of ACL failure include suboptimal positioning of the graft or incomplete healing (incorporation) of the graft. Failure of the graft is sometimes associated with use of cadaver tissue. Other associated ligament insufficiencies, like attenuation of the medial collateral ligament, may be present. The graft may also stretch out because of inadequate protection during the first six months of recovery. Occasionally, the reason for failure may not be discernable.

Symptoms

Typical symptoms are a return of giving way (instability) that can be confirmed by laxity measurements. Loss of strength after the previous surgical intervention may be difficult to regain. Pain about the kneecap (patella) may be present.

Treatment

Standard treatment includes:

1. An additional period of rehabilitation aimed at muscle strengthening and relief of pain.
2. Permanent knee bracing for rotational control and for limiting terminal extension.
3. Permanent restriction of Level III sports.
4. Surgery to revise the previously unsuccessful graft. This may include two stages.
   • Stage 1: Bone grafting unhealthy tunnels
   • Stage 2: Ligament revision (approximately 3-6 months following stage 1)

Precautions

Important precautions:

1. Do not participate in jumping, cutting or twisting sports until you have recovered from your instability.
2. Although cadaver grafts (allografts) have been suggested for revision surgery, these grafts are associated with a greater chance of failure and should generally be avoided.
3. Do not interrupt your conditioning program. Strength achieved now will facilitate recovery after revision surgery, if necessary.
4. Staged rehabilitation supervised by an experienced physical therapist is critical following revision surgery. Do not return to jumping or twisting sports (even golf) until approved, usually after six months.

Recovery

Expected recovery time for this condition is dependant upon the treatment option. At times a bone grafting procedure (stage 1) must be performed prior to revision ligament surgery (stage 2) with an interval of about 3-6 months between procedures. Once the ligament revision is complete, the rehabilitation prepares you for return to sports activities or heavy labor after 6 months.