Anterior Cruciate Ligament Reconstruction: Contemporary Revision Options

Ljiljana Bogunovic, MD, Justin S. Yang, MD, and Rick W. Wright, MD

Rupture of the ACL is a common sports injury often managed with ligament reconstruction. Despite relatively high success rates, ACL graft failures do occur, providing frustration for the patient and presenting a challenge for the surgeon. Fortunately our understanding of ACL anatomy, biomechanics and reconstruction has increased dramatically in recent years. The challenge with revision ACL reconstruction begins with determining the reason for failure. Poor surgical technique with improper tunnel placement has been identied in a high proportion of failed reconstructions. Unlike primary reconstructions, additional variables including bone loss, retained hardware and concomitant meniscal, chondral and/or ligamentous injury are often present and must be addressed at the time of revision. This chapter provides an algorithm for the evaluation of patients with a failed ACL graft and guideline to revision ligament reconstruction. Oper Tech Sports Med 21:64-71 2013 Elsevier Inc. All rights reserved. KEYWORDS ACL graft failure, ACL revision reconstruction, ACL rupture, tunnel malposition

n estimated 200,000 anterior cruciate ligament (ACL) ruptures occur each year in the United States, and ACL reconstruction is performed in 175,000.1,2 For the majority of patients, the procedure will be a success, but failure rates averaging 3%3-5 and as high as 10%-25% have been reported.6 In the setting of failure, the surgeon is faced with a new set of challenges unique to ACL revision. The focus of this review will be the evaluation and treatment of patients after failed primary ACL reconstruction.

revision reconstruction. For this article, ACL failure will be dened as recurrent instability of the knee.

Etiology of Failure
The rst step in evaluating a patient with recurrent instability after primary ACL reconstruction is determining the etiology of failure. Failure is often attributed to one of the following causes: traumatic, technical, biological, and mixed (Table 1). The majority of surgeons believe technical errors are the most common preventable reason for failed primary ACL reconstruction. The most common technical error is inaccurate tunnel placement (Fig. 1).5,7 Failure to properly position the tibial and femoral tunnels leads to excessive strain within the graft and attenuation over time (Table 2). Other potential surgical errors may include inadequate notchplasty with residual impingement and abrasion of the graft, graft issues of choice or size, inappropriate graft tensioning, and inadequate graft xation. Clinical diagnostic errors can also lead to failure of ACL reconstruction. Unrecognized associated instability or malalignment results in abnormal stress on the graft and contributes to early graft failure. Commonly missed items include varus knee with associated thrust and posterolateral corner injury. ACL reconstruction can also fail secondary to repeat trauma. With trauma, the timing of recurrent instability can provide clues to the cause. Early failure (12 weeks postoperatively) typically occurs at the sites of xation and is often the result of

Dening Failure
The denition of failure can be mixed. Failure has been dened as incapacitating postoperative pain, limited range of motion, extensor mechanism dysfunction, and recurrent instability. Instability can be further divided into isolated rotary instability, as seen with a vertical graft, and combined anterior and rotatory instability. In selecting patients for revision anterior cruciate ligament (ACL) reconstruction, those with primary complaints and physical examination ndings indicative of recurrent instability are the ones likely to benet from

Department of Orthopaedic Surgery, Washington University, Saint Louis, MO. Address reprint requests to Rick W. Wright, MD, Department of Orthopaedic Surgery, Washington University, Campus Box 8233, 660 Euclid Avenue, Saint Louis, MO 63110. E-mail: Rwwright1@aol.com

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1060-1872/13/$-see front matter 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1053/j.otsm.2012.12.002

Contemporary revision options

Table 1 Causes of ACL Failure5,6,7,37 Example Technical Inaccurate femoral tunnel placement Inadequate notchplasty Inadequate graft xation Inappropriate graft tensioning Missed associated injury Repeat injury Aggressive rehabilitation Early return to sports Failure of graft incorporation Infection Immune reaction to allograft Femoral tunnel Table 2 Implications of Improper Tunnel Placement37 Too anterior Excessive graft strain in exion Excessive graft laxity in extension Impingement on intercondylar notch in extension Too posterior

65

Traumatic

Tibial tunnel

Excessive graft strain in extension Excessive graft laxity in exion Impingement on the posterior cruciate ligament with exion

Biological

aggressive rehabilitation, early return to sports, or poor initial xation. Late failure (12 weeks postoperatively) takes place after adequate incorporation of the graft. Graft failure occurs secondary to external forces across the graft, as seen during the initial injury, and results in midsubstance disruption. Finally, poor biology can contribute to postoperative laxity. Ligamentization, the process by which the graft evolves to assume characteristics similar to the native ACL, can be impaired by factors such as postoperative infection, host immune response to allograft tissue, and allograft sterilization. In rare cases, tunnel widening can occur, leading to alteration of graft position and stability.

Preoperative Planning
Patient Interview
Preoperative planning is an essential component of a successful ACL revision surgery. The evaluation begins with the patient interview. The chief complaint should be one of instability rather than pain. The timing of symptoms and details of the postoperative course and rehabilitation should be

elicited. Acute instability after a stable postoperative period is more suggestive of a traumatic cause, whereas the gradual development of instability over time or the complete lack of a stable period postoperatively is more suggestive of a technical or biological cause of failure. The patient expectations and postoperative goals should be discussed. Higher graft failure rates and lower patient satisfaction have been reported with revision surgery when compared with primary ACL reconstruction.8,9 An increased incidence of associated intra-articular pathology present at the time of revision surgery is believed to contribute to worsened outcome. According to the Multicenter ACL Revision Study (MARS) cohort, patients presenting for revision surgery had an increased incidence of chondral damage in the lateral and patellofemoral compartments when compared with those undergoing primary reconstruction, even after controlling for associated meniscal injury.10 Given these underlying comorbidities, a return to full high-level activity may no longer be realistic for many revision patients. The patient should be counseled on the goal of revision reconstruction, which is restoration of knee stability to allow activities of daily living. Finally, operative details of the primary reconstruction should be obtained. Information regarding diagnostic intra-articular ndings, graft choice, and xation method is invaluable in planning the revision procedure.

Figure 1 Standing Rosenberg (A) and lateral (B) radiographs demonstrating anterior placement of the femoral tunnel high in the notch.

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L. Bogunovic, J.S. Yang, and R.W. Wright

Physical Examination
A thorough patient examination should be performed. The skin should be evaluated, and previous incisions noted. Range of motion should approximate near-normal levels. In the setting of signicant extension (5) or exion loss (20), preoperative physical therapy, manipulation, and/or surgical release is recommended to restore motion before revision surgery.11 Graft failure should be conrmed through assessment of stability. Lachman, anterior drawer, and KT1000 testing can be helpful in eliciting anterior/posterior instability, and the presence of a pivot-shift signals rotatory instability. The knee should be carefully examined for associated injuries that may have been missed at the time of primary reconstruction. Residual laxity from unaddressed associated injuries has been implicated in 3% of graft failures attributed to technical error.5 Injury to the posterolateral corner is most commonly missed and leads to increased hyperextension and varus forces across the graft.12,13 Signicant medial instability may also contribute to graft attenuation and early failure. The medial meniscus is an important secondary restraint against tibial translation. In the setting of signicant or complete medial meniscal loss, forces across the ACL are increased.14,15 In a patient with combined ACL failure and medial meniscal deciency, meniscal transplant should be considered for protecting the revised graft. Finally, lower-extremity malalignment, especially genu varum with an associated lateral thrust, places signicant strain on an ACL graft and has been implicated in 4% of ACL reconstruction failures.5 Over time, this stress can stretch and weaken the graft.16 Correction of signicant varus deformity with high tibial osteotomy has been described and recommended in the ACL-decient knee to limit damaging forces on the ACL graft.16

Figure 2 Lateral (A) and full extension lateral (B) radiographs. Anterior placement of the tibial tunnel (anterior to Blumansaats line) is clearly depicted with the full extension lateral.

Radiographic Evaluation
Preoperative plain radiographs should be obtained in every patient. Weight-bearing anteroposterior, lateral, and 45exion (Rosenberg) views allow for assessment of degenerative changes, tunnel placement, tunnel widening, retained hardware, and notch geometry. The position of the tibial tunnel, which should be posterior and parallel to Blumansaat line, can be determined from a full-extension lateral radiograph, which should be obtained on all revision patients (Fig. 2).6 Full-length standing alignment radiographs provide information on the mechanical axis. Additional imaging with computed tomography can determine exact tunnel location and be helpful when signicant tunnel lysis and/or widening is suspected and a detailed assessment of bone stock is required for preoperative planning.

surgical manipulation and/or release, malalignment (genu varum) requiring correction, and associated patholaxity (posterolateral corner injury) requiring reconstruction.11,12,16 These associated problems can be addressed before graft revision or in a single combined procedure. Excessive tunnel widening is a potential indication for staged reconstruction. With increasing tunnel expansion, options for rigid graft xation diminish. When widening exceeds 16 mm, a staged procedure with bone grafting is recommended.17 A minimum of 6 months are typically allotted to ensure proper autograft bone graft incorporation; more time may be needed when allograft is used. A computed tomography scan can be helpful to conrm graft incorporation before revision reconstruction.

Bone Grafting
Bone grafting is a frequent challenge of revision ACL reconstruction. Grafting needs can range from small voids of tunnel widening to large defects accentuated with hardware removal. Various techniques have been described to address these different situations. The rst step in bone grafting is dbridement of soft tissue from the defect or tunnel. A clean bed of bone is needed for graft incorporation. Next, the source bone graft must be determined. Both autograft and allograft options exist. Common autograft harvest sites include Gerdy tubercle, iliac crest, and the tibial metaphysis.

Single-Stage Versus Double-Stage Procedure

The decision to proceed with single- versus double-stage revision surgery is dependent on several factors identied during the preoperative evaluation. Relative indications for double-stage procedure include signicant stiffness requiring

Contemporary revision options

The femoral tunnel is the most difcult to graft. Arthroscopic uid can wash graft material out of the femoral tunnel and back into the joint. A chest tube, as described by Wong and Yip, can be used to deliver graft material into the femoral tunnel.18 The technique involves a size 10 or 11 chest tube, which is packed with graft and subsequently placed into the joint through the anteromedial or accessory portal such that it is in line with the femoral tunnel. A metal stylet is then passed through the chest tube and used to impact the graft material into the femoral tunnel. Shetty et al describe a similar technique in which an insulin syringe is used to deliver bone graft to the femoral tunnel.19 Bone grafting of the tibial tunnel is simpler and can often be achieved with retrograde (inferior to superior) packing of graft with a bone tamp. Harvesting systems have been used when large bone amounts of bone graft are needed. Use of the Osteoarticular Transfer System (OATS) harvesters has been described by Said et al for obtaining custom-sized bone graft plugs.20 The technique begins with sizing of the tunnel diameter using the OATS reamer. A harvester 1 mm larger than the tunnel diameter is selected, and a plug of graft is obtained from the anterior iliac crest. The harvester, and its graft, is placed back into the joint and delivered into the tunnel using the graft impactor. A press-t is achieved between the graft plug and the tunnel. Graft plugs as large as 11 mm in diameter can be harvested using this technique. Allograft bone can also be used as graft bone if donor site morbidity is a concern or if several bone graft plugs are needed.

67 49%; combination, 3%).5 The most common autografts used in a revision setting include an ipsilateral bone-tendon-bone patellar graft or 4-strand hamstring graft.5 Quadriceps and contralateral patellar tendon grafts have also been reported with mixed results in literature.21 Ipsilateral patellar tendon autograft is the most popular graft option, if it has not been previously used. Advantages of patellar tendon include boneto-bone healing and secure initial xation. Repeated harvest of the previously used patellar tendon has also been described; however, complications such as patellar fracture, higher graft failure rates, and patellofemoral pain have been reported at an increased rate. LaPrade et al reported unfavorable biomechanical properties with a reharvested patellar tendon.22 In addition, there is histologic evidence that the reharvested tendon contains more scar tissue. Kartus et al reported lower functional scores and a higher incidence of complications, including patellar fracture and patellar tendon rupture, in patients receiving a reharvested patellar tendon graft.23 Contralateral patellar tendon harvest has also been described, but should be avoided in patients who have a history of patellar femoral pain, or unacceptable anterior knee pain after ipsilateral patellar tendon harvest.23,24 Currently, a popular graft in the setting of a previously harvested patellar tendon is the 4-strand autologous hamstring graft. Eighteen percent of the MARS cohort has received this graft.5 In the revision setting, hamstring autograft shows similar International Knee Documentation Committee scores and KT-1000 results but worse Lysholm knee scores, compared with the primary reconstruction.25 Biomechanically, the hamstring tendon has the highest ultimate tensile yield strength of all the current options.26,27 In addition, the stiffness and stress relaxation curve of the hamstring more closely match the native ACL.28 Using a hamstring graft in the revision setting, one must carefully assess the previous tunnel size owing to the grafts smaller size and need to obtain healing in the tunnels. In the setting of a previously malpositioned or enlarged tunnel, a new tunnel should be drilled in the correct position. Allografts are another potential graft option in revision ACL reconstruction. Advantages include lack of donor site morbidity, decreased operative time, and availability of a variety of graft types and sizes. An increased variety of size options is particularly helpful in the revision setting when widened tunnels may require larger bone plugs. The most common allograft options include anterior tibialis, Achilles tendon, and patellar tendon grafts. The outcome of autograft versus allograft in the revision setting is mixed in the current literature.24,29-32 Several studies have identied no signicant difference between the allograft and autograft groups with regard to pivot shift, Lachman test results, or failure rates.24 Other studies have reported an increase in laxity in the rst 2 years in patients revised with allograft.30 Recent data from the Danish registry showed a higher graft failure rate with allograft.33 A possible reason for this may lie in the use of highdose gamma irradiation (20 kGy) used for sterilization or a host immunologic response to the foreign tissue; both have been theorized to contribute to inferior graft properties sometimes seen with allograft tissues.30,34,35 Currently, the

Graft Choice
The ideal graft should reproduce the biomechanics of the native ACL, promote fast and secure graft incorporation, and minimize donor site complications. Similar to primary ACL reconstruction, the graft options for revision ACL reconstruction can be broadly divided into autograft, allograft, and synthetic options. However, revision surgery presents a challenge in that some of those options may be limited by the previous procedure. As described earlier in the text, a careful preoperative evaluation with focus on history, physical examination, previous operative procedures, mode of failure, and previous complications will often dene graft options for the revision procedure. In contrast to primary ACL reconstruction, there is very little quality research investigating ideal graft options in revision surgery. Wright et al, in a systematic review of outcome of revision ACL reconstructions, reviewed 259 potential studies from 1966 to 2010. They found only 4 articles that had level I or II evidence. Three of the 4 studies examined graft selection in a prospective randomized trial. At the time of writing this chapter, only 2 additional studies with level I or II evidence have been published regarding graft selection in revision ACL reconstructions.9 On the horizon, an ongoing multicenter prospective longitudinal cohort analysis of revision ACL reconstruction (MARS) should help provide quality level I evidence regarding graft selection.5 Early data from the MARS cohort shows that autograft and allograft have been equally used (autograft, 48%; allograft,

68 risk of HIV transmission with allograft tissue is 1 in 1.67 million. Transmission risk of hepatitis C has not been carefully studied but is estimated to be higher than HIV owing to the increased prevalence of the disease.36 Owing to the low level of evidence of studies, no consensus regarding graft choice can be denitively stated. Additional prospective research will be needed to determine what graft choices are best in the revision setting.

L. Bogunovic, J.S. Yang, and R.W. Wright

revision surgery. At the time of revision, the surgeon is faced with 1 of 3 situations: accurate tunnels, inaccurate tunnels, or partially accurate tunnels. Appropriately positioned tunnels can generally be reused after removal of the previous graft and hardware (as previously discussed). Tunnel widening is often encountered, making xation difcult. Various techniques (discussed later in the text) can be used to achieve xation within widened original tunnels; alternatively, new tunnels can be created using the 2-incision technique. Grossly inaccurate tunnels can often be left alone, as they should not interfere with placement of new tunnels. Partially accurate tunnels generate the greatest challenges because it is often difcult to avoid creation of blended tunnels.

Technical Points
Diagnostic Arthroscopy
After an examination under anesthesia, revision ACL reconstruction should begin with a thorough arthroscopic assessment. Previous incisions should be used for portal placement whenever possible. The knee should be examined for evidence of chondral and/or meniscal damage, and all ndings documented in the operative report. Any residual graft tissue must be dbrided along with scar tissue commonly present within the intracondylar notch and overlying interference xation. If a failed synthetic graft is encountered, it should be removed en bloc. Dbridement of a synthetic graft (Gortex, W.L. Gore, Flagstaff, AR) using an arthroscopic shaver generates irritative debris within the joint that can be difcult to remove.37 Notchplasty may be indicated if a tight A-frame type notch is present and if visualization of lateral femoral condyle and femoral tunnel site is restricted. Notchplasty, if performed, should involve minimal removal of bone necessary to prevent graft impingement and provide an adequate view of the femoral footprint.37

Femoral Tunnel
The femoral tunnel should be positioned in line with the ACL origin in the posterior aspect of the femoral notch. Anterior placement of the femoral tunnel is a common technical mistake. With signicant anterior malposition, a new tunnel can be drilled posterior to the original one using an accessory anteromedial portal or a 2-incision technique. Previous hardware can be left in place. When the original tunnel is only slightly anterior, revision is more complicated, but can be managed in the following ways. A 2-incision technique can be used to generate a new tunnel, or the original tunnel can also be expanded posteriorly. The latter technique generates an oblong tunnel with an oval-shaped aperture with excessive anterior expansion. Fixation in this situation can be difcult. A larger bone plug (11-13 mm) can be used, with the tendinous portion of the graft oriented in the posterior aspect of the tunnel (isometric position).37 Alternatively, a standardsized graft can be placed eccentrically within the tunnel, and the anterior portion of the tunnel lled with allograft or autograft bone. Posterior placement of the femoral tunnel is less common but is often associated with deciency in the posterior femoral wall. Again, new tunnel drilling with a 2-incision technique can be helpful when adequate bone stock in the posterior condyle is available. In the setting of posterior wall blowout, an over-the-top extra-articular technique can be used. As described by Yiannakopoulos et al, an incision is made over the lateral distal thigh, and dissection carried through the iliotibial band and to the lateral distal femur. Careful blunt dissection is then carried along the medial aspect of the lateral femoral condyle into the posterior part of the notch. A groove is created with a rasp exiting the notch (over the top position) and along the posterior lateral femoral condyle. The graft is positioned lying in the groove. Femoral xation is achieved along the lateral cortex using a specially designed soft-tissue device.38

Hardware Removal
Management of previous hardware is dependent on the position of the original tunnels. As a general rule, hardware should be left untouched if revision tunnels can be drilled and graft xation achieved without interference from previous hardware. Often, previous xation hinders revision tunnel drilling or graft xation and needs to be removed. Removal of previous hardware, especially inference screws, can be difcult, and the following tips can facilitate this process. The screw head should be completely cleared of any bone or soft-tissue debris. A shaver, burr, and/or curette can be useful with this step. The appropriate-sized screwdriver must be available and can often be determined from the initial operative report. If cannulated screws are encountered, placement of a guide wire into the screw can aid with seating and alignment of the screwdriver and retrieval of the screw from the joint. In the setting of solid screws, proper seating of the screwdriver within the head is critical because stripping of the screw can easily occur. No attempts should be made to remove biocomposite/bioabsorbable screws, given their tendency to crumble. Instead, these screws should be overdrilled if they interfere with revision surgery.

Tibial Tunnel
A properly positioned tibial tunnel should enter the joint at the posteromedial third of the ACL footprint, approximately 7 mm anterior to the posterior cruciate ligament and in line with the posterior aspect of the anterior horn on of the lateral meniscus.31 On lateral extension radiographs, it should be

Tunnels
Proper tunnel placement is critical to the success of primary ACL reconstruction and one of the greatest challenges of

Contemporary revision options

positioned parallel and posterior to Blumansats line.6 As on the femoral side, grossly inaccurate original tibial tunnels and their associated hardware can be avoided, and new appropriate tunnels drilled. When the original tunnels are only slightly anteriorly or posteriorly malpositioned, the original tunnels can be expanded in the direction of the desired position. A guide pin can be used to aid in this maneuver. The guide pin is placed eccentrically in the original tunnel in line with the newly planned tunnel.37 Fixation of the pin into the distal femur helps to maintain position as a new tunnel is drilled. Defects that arise from the creation of blended tunnels can be managed with bone grafting. A technique using allografts struts has been described.39 After femoral xation of the graft, the tibial bone block is held in the desired position, and allograft struts are impacted longitudinally within the voids of the tunnel. Finally, recent biomechanical studies have investigated the use of calcium phosphate cement for lling bone defects and avoiding staged bone grafting procedures. After hardware removal, the femoral tunnel is arthroscopically lled with calcium phosphate cement. The cement is allowed to harden, and a new tunnel is then drilled through the cement and native bone. A bone-patellar-bone graft is then xed within the tunnel using the standard interference screw technique. Mechanical testing demonstrated no difference in xation strength between knees treated with cement and those treated with standard graft xation.40,41 Although promising, the clinical implications of this technique remain unknown.

69 xation can provide further rigidity. A post-and-washer device can also be used to increase the pullout strength of screws. Other commercially available devices such as the Endobutton (Smith & Nephew, Andover, MA) can be used on the femoral side to secure either soft-tissue or patellar bone-tendon-bone BPTB grafts to osteopenic bone, or if there is femoral tunnel blowout precluding interference xation. Biomechanical studies have shown the EndoButton with a continuous polyester loop is the strongest xation device available, with a mean failure load of 1345-1430 N.44 In comparison, interference screws have been shown to have ultimate failure loads from 562 to 710 N, and post-andwasher devices to have 644-791 N.45 A drawback to this device is lack of aperture xation at the femoral tunnel aperture that some surgeons believe is an important goal.

Special Considerations
Vertical Graft
In the past decade, there has been increased awareness of vertical grafts contributing to failure in ACL reconstruction. Typically, this is caused by the combination of central placement of the femoral tunnel and posterior placement of the tibial tunnel that results in a graft that is malpositioned in both the sagittal and coronal planes (Fig. 3). The patient presents with complaints of instability, and on physical examination, is found to have a normal Lachman test result but a positive pivot shift. The traditional approach would be to remove the graft and replace it with a better positioned graft. However, by removing the graft, the surgeon risks increasing the tibial tunnel defect. A new technique described in literature involves keeping the original graft and adding a second graft, similar to a double-bundle ACL reconstruction. The new graft typically is more anterior and medial on the tibial side and more lateral on the femoral side. The technique, as described by Brophy et al, recommends placement of a new tibial tunnel anterior to the previous one, with care taken to preserve as much anterior tibia as possible. The new graft and tunnel should be downsized (8 or 9 mm) in effort to achieve this. On the femoral side, the concern is creating enough room for the new grafts xation. If a metallic interference screw was originally used, it may need to be removed and replaced with a smaller bioabsorbable screw. A second femoral tunnel can then typically be created lateral to the original one, and the graft xed with an interference screw.46

Fixation Options
Graft xation is potentially the weakest link in the ACL construction in the early postoperative period. Rigid xation prevents early failure or graft elongation at the xation site before biological incorporation. This is particularly important in todays rehabilitation protocols, which emphasize motion, early muscle strengthening, and immediate weight bearing. Weak graft xation, especially on the tibial side, is one of the reasons for early failure (6 months).42 In the setting of a failed graft, factors such as tunnel location, tunnel size, and available graft material must play a role in choosing the type of xation. Interference screws must be used with care in the setting of revision owing to potentially insufcient interference t (from oversized tunnels) or inadequate bony purchase (secondary to osteopenia). Preexisting tunnels should be sized both preoperatively and intraoperatively. In the setting of using previous tunnels or having to account for tunnel osteolysis, larger-diameter screws or the use of stacked screws may be needed. In general, interference screws should be positioned with no more than 15 of divergence from the bone plug. Additionally, bioabsorbable implants should be used cautiously in ACL revision because of biomechanical evidence of decreased pullout strength in poorer-quality bone.43 When interference screws are not enough, other xation and augments should be considered. When using a graft with bone plugs, bone blocks augmented with sutures and staple

Rehabilitation
The fundamentals of rehabilitation after revision ACL reconstruction are similar to those used for primary reconstruction. The early phase (week 1-2) is focused on control of pain and swelling, recovery of range of motion, return of normal gait, and quadriceps control (straight leg raise). In the isolated ACL revision, the patient is allowed to weight bear as tolerated without a brace. In phase 2 (2 to 6 weeks), cryotherapy and gait training are continued as strengthening is progressed with closed chain exercises, and early neuromus-

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L. Bogunovic, J.S. Yang, and R.W. Wright

Figure 3 Standing AP (A) and lateral (B) radiographs demonstrating bilateral vertical graphs with the femoral tunnel positioned high in the notch.

cular retraining is initiated. Straight-line running is introduced in phase 3 (7-12 weeks), and agility exercises started in phase 4 (13-16 weeks). The patient is allowed to begin sportspecic training in phase 5 (17-20 weeks). Although similar milestones are achieved for both primary and revision ACL reconstruction, therapy typically progresses at a slower rate in the revision setting. The aforementioned schedule provides a general guideline; however, the exact therapy must be tailored to meet the specic needs of the patient. A higher incidence of associated injury to menisci and/or cartilage may dictate postoperative rehabilitation protocols in the revised patient.

10.

11. 12.

13. 14.

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36. 37. 38.

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42. 43.

31. 32.

44. 45.

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34.