Revision of anterior cruciate ligament reconstruction: Interpretation of the consensus by the European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA)_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZHONG Mingjin ,  OUYANG Kan

Department of Sports Medicine, Shenzhen Second People’s Hospital, Shenzhen Guangdong, 518000, P. R. China;

Corresponding author：

OUYANG Kan, Email: 510296924@qq.com

Keywords：

Anterior cruciate ligament; revision; consensus interpretation

DOI：

10.7507/1002-1892.202409090

Video：

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Revision of anterior cruciate ligament (ACL) reconstruction is more challenging than primary ACL reconstruction and often yields less favorable outcomes. The European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA) has established a consensus regarding preoperative diagnosis, assessment, and selection criteria for ACL revision surgery. This consensus addresses 18 key issues that are most pertinent to clinical practice, providing guiding recommendations aimed at improving the prognosis of ACL revisions.

Citation： ZHONG Mingjin, OUYANG Kan. Revision of anterior cruciate ligament reconstruction: Interpretation of the consensus by the European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA). Chinese Journal of Reparative and Reconstructive Surgery, 2025, 39(1): 1-4. doi: 10.7507/1002-1892.202409090 Copy

1.	Akoto R, Alm L, Drenck TC, et al. Slope-correction osteotomy with lateral extra-articular tenodesis and revision anterior cruciate ligament reconstruction is highly effective in treating high-grade anterior knee laxity. Am J Sports Med, 2020, 48(14): 3478-3485.
2.	Alm L, Drenck TC, Frings J, et al. Lower failure rates and improved patient outcome due to reconstruction of the MCL and revision ACL reconstruction in chronic medial knee instability. Orthop J Sports Med, 2021, 9(3): 2325967121989312. doi: 10.1177/2325967121989312.
3.	Alm L, Krause M, Frosch KH, et al. Preoperative medial knee instability is an underestimated risk factor for failure of revision ACL reconstruction. Knee Surg Sports Traumatol Arthrosc, 2020, 28(8): 2458-2467.
4.	Andrä K, Prill R, Kayaalp E, et al. Increase in cartilage degeneration in all knee compartments after failed ACL reconstruction at 4 years of follow-up. J Orthop Traumatol, 2021, 22(1): 54. doi: 10.1186/s10195-021-00618-3.
5.	Battaglia MJ, Lenhoff MW, Ehteshami JR, et al. Medial collateral ligament injuries and subsequent load on the anterior cruciate ligament: a biomechanical evaluation in a cadaveric model. Am J Sports Med, 2009, 37(2): 305-311.
6.	Beaufils P, Becker R, Kopf S, et al. Surgical management of degenerative meniscus lesions: the 2016 ESSKA meniscus consensus. Knee Surg Sports Traumatol Arthrosc, 2017, 25(2): 335-346.
7.	D’Ambrosi R, Meena A, Raj A, et al. Good results after treatment of RAMP lesions in association with ACL reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc, 2023, 31(1): 358-371.
8.	Feucht MJ, Cotic M, Saier T, et al. Patient expectations of primary and revision anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc, 2016, 24(1): 201-207.
9.	Grassi A, Kim C, Marcheggiani Muccioli GM, et al. What is the mid-term failure rate of revision ACL reconstruction? A systematic review. Clin Orthop Relat Res, 2017, 475(10): 2484-2499.
10.	Grassi A, Zicaro JP, Costa-Paz M, et al. Good mid-term outcomes and low rates of residual rotatory laxity, complications and failures after revision anterior cruciate ligament reconstruction (ACL) and lateral extra-articular tenodesis (LET). Knee Surg Sports Traumatol Arthrosc, 2020, 28(2): 418-431.
11.	Salem HS, Axibal DP, Wollcott ML, et al. Two-stage revision anterior cruciate ligament reconstruction. A systematic review of bone graft options for tunnel augmentation. Am J Sports Med, 2020, 48(3): 767-777.
12.	Imhoff FB, Comer B, Obopilwe E, et al. Effect of slope and varus correction high tibial osteotomy in the ACL-deficient and ACL-reconstructed knee on kinematics and ACL graft force: A biomechanical analysis. Am J Sports Med, 2021, 49(2): 410-416.
13.	Kopf S, Beaufils P, Hirschmann MT, et al. Management of traumatic meniscus tears: the 2019 ESSKA meniscus consensus. Knee Surg Sports Traumatol Arthrosc, 2020, 28(4): 1177-1194.
14.	Magosch A, Mouton C, Nührenbörger C, et al. Medial meniscus ramp and lateral meniscus posterior root lesions are present in more than a third of primary and revision ACL reconstructions. Knee Surg Sports Traumatol Arthrosc, 2021, 29(9): 3059-3067.
15.	Pioger C, Saithna A, Rayes J, 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, 49(6): 1431-1440.
16.	Rozinthe A, van Rooij F, Demey G, et al. Tibial slope correction combined with second revision ACLR grants good clinical outcomes and prevents graft rupture at 7-15-year follow-up. Knee Surg Sports Traumatol Arthrosc, 2022, 30(7): 2336-2341.
17.	Salem HS, Axibal DP, Wolcott ML, et al. Two-stage revision anterior cruciate ligament reconstruction: a systematic review of bone graft options for tunnel augmentation. Am J Sports Med, 2020, 48(3): 767-777.
18.	Tischer T, Beaufilis P, Becker R, et al. Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus part I-diagnostics and preoperative planning. Knee Surg Sports Traumatol Arthrosc, 2023, 31(11): 4642-4651.
19.	Tischer T, Condello V, Menetrey J, et al. Time to focus on ACL revision: ESSKA 2022 consensus. Knee Surg Sports Traumatol Arthrosc, 2023, 31(11): 4637-4638.
20.	Tischer T, Paul J, Pape D, et al. The impact of osseous malalignment and realignment procedures in knee ligament surgery: A systematic review of the clinical evidence. Orthop J Sports Med, 2017, 5(3): 2325967117697287. doi: 10.1177/2325967117697287.
21.	von Recum J, Schwaab J, Guehring T, et al. Bone incorporation of silicate-substituted calcium phosphate in 2-stage revision anterior cruciate ligament reconstruction: a histologic and radiographic study. Arthroscopy, 2017, 33(4): 819-827.
22.	von Recum J, Gehm J, Guehring T, et al. Autologous bone graft versus silicate-substituted calcium phosphate in the treatment of tunnel defects in 2-stage revision anterior cruciate ligament reconstruction: a prospective, randomized controlled study with a minimum follow-up of 2 years. Arthroscopy, 2020, 36(1): 178-185.
23.	Weiler A, Gwinner C, Wagner M, et al. Significant slope reduction in ACL deficiency can be achieved both by anterior closing-wedge and medial open-wedge high tibial osteotomies: early experiences in 76 cases. Knee Surg Sports Traumatol Arthrosc, 2022, 30(6): 1967-1975.
24.	White NP, Borque KA, Jones MH, et al. Single-stage revision anterior cruciate ligament reconstruction: experience with 91 patients (40 elite athletes) using an algorithm. Am J Sports Med, 2021, 49(2): 364-373.
25.	Willinger L, Balendra G, Pai V, et al. High incidence of superficial and deep medial collateral ligament injuries in ‘isolated’ anterior cruciate ligament ruptures: a long overlooked injury. Knee Surg Sports Traumatol Arthrosc, 2022, 30(1): 167-175.
26.	Wolfson TS, Mannino B, Owens BD, et al. Tunnel management in revision anterior cruciate ligament reconstruction: current concepts. Am J Sports Med, 2023, 51(2): 545-556.
27.	Wright RW, Johnson L, Brophy RH, et al. Revision anterior cruciate ligament reconstruction outcomes at a minimum of 5-year follow-up: a systematic review. J Knee Surg, 2019, 32(3): 218-221.

1. Akoto R, Alm L, Drenck TC, et al. Slope-correction osteotomy with lateral extra-articular tenodesis and revision anterior cruciate ligament reconstruction is highly effective in treating high-grade anterior knee laxity. Am J Sports Med, 2020, 48(14): 3478-3485.
2. Alm L, Drenck TC, Frings J, et al. Lower failure rates and improved patient outcome due to reconstruction of the MCL and revision ACL reconstruction in chronic medial knee instability. Orthop J Sports Med, 2021, 9(3): 2325967121989312. doi: 10.1177/2325967121989312.
3. Alm L, Krause M, Frosch KH, et al. Preoperative medial knee instability is an underestimated risk factor for failure of revision ACL reconstruction. Knee Surg Sports Traumatol Arthrosc, 2020, 28(8): 2458-2467.
4. Andrä K, Prill R, Kayaalp E, et al. Increase in cartilage degeneration in all knee compartments after failed ACL reconstruction at 4 years of follow-up. J Orthop Traumatol, 2021, 22(1): 54. doi: 10.1186/s10195-021-00618-3.
5. Battaglia MJ, Lenhoff MW, Ehteshami JR, et al. Medial collateral ligament injuries and subsequent load on the anterior cruciate ligament: a biomechanical evaluation in a cadaveric model. Am J Sports Med, 2009, 37(2): 305-311.
6. Beaufils P, Becker R, Kopf S, et al. Surgical management of degenerative meniscus lesions: the 2016 ESSKA meniscus consensus. Knee Surg Sports Traumatol Arthrosc, 2017, 25(2): 335-346.
7. D’Ambrosi R, Meena A, Raj A, et al. Good results after treatment of RAMP lesions in association with ACL reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc, 2023, 31(1): 358-371.
8. Feucht MJ, Cotic M, Saier T, et al. Patient expectations of primary and revision anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc, 2016, 24(1): 201-207.
9. Grassi A, Kim C, Marcheggiani Muccioli GM, et al. What is the mid-term failure rate of revision ACL reconstruction? A systematic review. Clin Orthop Relat Res, 2017, 475(10): 2484-2499.
10. Grassi A, Zicaro JP, Costa-Paz M, et al. Good mid-term outcomes and low rates of residual rotatory laxity, complications and failures after revision anterior cruciate ligament reconstruction (ACL) and lateral extra-articular tenodesis (LET). Knee Surg Sports Traumatol Arthrosc, 2020, 28(2): 418-431.
11. Salem HS, Axibal DP, Wollcott ML, et al. Two-stage revision anterior cruciate ligament reconstruction. A systematic review of bone graft options for tunnel augmentation. Am J Sports Med, 2020, 48(3): 767-777.
12. Imhoff FB, Comer B, Obopilwe E, et al. Effect of slope and varus correction high tibial osteotomy in the ACL-deficient and ACL-reconstructed knee on kinematics and ACL graft force: A biomechanical analysis. Am J Sports Med, 2021, 49(2): 410-416.
13. Kopf S, Beaufils P, Hirschmann MT, et al. Management of traumatic meniscus tears: the 2019 ESSKA meniscus consensus. Knee Surg Sports Traumatol Arthrosc, 2020, 28(4): 1177-1194.
14. Magosch A, Mouton C, Nührenbörger C, et al. Medial meniscus ramp and lateral meniscus posterior root lesions are present in more than a third of primary and revision ACL reconstructions. Knee Surg Sports Traumatol Arthrosc, 2021, 29(9): 3059-3067.
15. Pioger C, Saithna A, Rayes J, 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, 49(6): 1431-1440.
16. Rozinthe A, van Rooij F, Demey G, et al. Tibial slope correction combined with second revision ACLR grants good clinical outcomes and prevents graft rupture at 7-15-year follow-up. Knee Surg Sports Traumatol Arthrosc, 2022, 30(7): 2336-2341.
17. Salem HS, Axibal DP, Wolcott ML, et al. Two-stage revision anterior cruciate ligament reconstruction: a systematic review of bone graft options for tunnel augmentation. Am J Sports Med, 2020, 48(3): 767-777.
18. Tischer T, Beaufilis P, Becker R, et al. Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus part I-diagnostics and preoperative planning. Knee Surg Sports Traumatol Arthrosc, 2023, 31(11): 4642-4651.
19. Tischer T, Condello V, Menetrey J, et al. Time to focus on ACL revision: ESSKA 2022 consensus. Knee Surg Sports Traumatol Arthrosc, 2023, 31(11): 4637-4638.
20. Tischer T, Paul J, Pape D, et al. The impact of osseous malalignment and realignment procedures in knee ligament surgery: A systematic review of the clinical evidence. Orthop J Sports Med, 2017, 5(3): 2325967117697287. doi: 10.1177/2325967117697287.
21. von Recum J, Schwaab J, Guehring T, et al. Bone incorporation of silicate-substituted calcium phosphate in 2-stage revision anterior cruciate ligament reconstruction: a histologic and radiographic study. Arthroscopy, 2017, 33(4): 819-827.
22. von Recum J, Gehm J, Guehring T, et al. Autologous bone graft versus silicate-substituted calcium phosphate in the treatment of tunnel defects in 2-stage revision anterior cruciate ligament reconstruction: a prospective, randomized controlled study with a minimum follow-up of 2 years. Arthroscopy, 2020, 36(1): 178-185.
23. Weiler A, Gwinner C, Wagner M, et al. Significant slope reduction in ACL deficiency can be achieved both by anterior closing-wedge and medial open-wedge high tibial osteotomies: early experiences in 76 cases. Knee Surg Sports Traumatol Arthrosc, 2022, 30(6): 1967-1975.
24. White NP, Borque KA, Jones MH, et al. Single-stage revision anterior cruciate ligament reconstruction: experience with 91 patients (40 elite athletes) using an algorithm. Am J Sports Med, 2021, 49(2): 364-373.
25. Willinger L, Balendra G, Pai V, et al. High incidence of superficial and deep medial collateral ligament injuries in ‘isolated’ anterior cruciate ligament ruptures: a long overlooked injury. Knee Surg Sports Traumatol Arthrosc, 2022, 30(1): 167-175.
26. Wolfson TS, Mannino B, Owens BD, et al. Tunnel management in revision anterior cruciate ligament reconstruction: current concepts. Am J Sports Med, 2023, 51(2): 545-556.
27. Wright RW, Johnson L, Brophy RH, et al. Revision anterior cruciate ligament reconstruction outcomes at a minimum of 5-year follow-up: a systematic review. J Knee Surg, 2019, 32(3): 218-221.

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