Anterior cruciate ligament(ACL) revision surgery is a surgery performed in cases where a previous anterior cruciate ligament surgery has failed. We know that the tendon (graft) that replaces the ACL, ruptures for many reasons, especially in about 10% of patients who have undergone anterior cruciate ligament surgery.
The most common cause of re-rupture of the anterior cruciate ligament after ACL surgery is due to technical problems in the initial anterior cruciate ligament surgery. For a successful anterior cruciate ligament surgery, the angles and placement of the tunnels to the tibia and thigh bones are very important.
If the tunnel created in the shin bone (tibia) is too far back or the tunnel created in the thigh bone (femur) is too far forward, the graft reconstructed in the anterior cruciate ligament surgery will loosen and rupture over time.
The second most common cause of failed anterior cruciate ligament surgery is another injury within the knee that was missed in the initial trauma. If posterolateral corner injuries, meniscal root tears and medial meniscus posterior horn injuries are missed, in other words, if the above injuries are not treated while performing anterior cruciate ligament surgery, the graft is overloaded and the reconstructed ACL ruptures over time.
It is also possible for retear with a re-trauma, such as a twisted knee injury.
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What is Anterior Cruciate Ligament Revision Surgery?
Patients who have undergone anterior cruciate ligament surgery may rupture their anterior cruciate ligaments again. The surgery of the anterior cruciate ligament that ruptures again is called anterior cruciate ligament revision surgery. In this case, revision surgery is needed to restore stability to the knee.
Main Causes:
Re-injury
Failure of the first surgery
Weakening of connective tissue over time
What Causes a Rupture After Cruciate Ligament Surgery?
The most common cause of re-rupture of the anterior cruciate ligament is technical errors in the initial surgery.
Early return to sport.
Even if everything is in order, a new knee rotation that ruptures the anterior cruciate ligament.
Missing an additional injury to the knee in the initial injury.
The anterior cruciate ligament, which was reconstructed in the first operation, did not fuse with the bone.
Removal of the torn meniscus in the first operation, which could not be sutured.
Axis disorders in the leg bones.
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How to recognize a rupture after anterior cruciate ligament surgery?
After the examination, the anterior cruciate ligament is evaluated. In addition, the images of the graft placed in the surgery are examined with MR imaging. However, it should be noted that both the examination of the operated anterior cruciate ligament and the evaluation of MR images should be evaluated by a sports surgeon orthopedist experienced in anterior cruciate ligament surgery.
An unruptured anterior cruciate ligament may be mistakenly considered as ruptured. The opposite is also possible.
How to Plan Anterior Cruciate Ligament Revision Surgery?
In order for the anterior cruciate ligament revision surgery to be successful, it is necessary to determine why the first surgery failed and to plan the surgery accordingly. The patient's knee and neck x-rays are taken.
It is investigated whether there is an angle disorder in the leg axis. If there is an axis disorder, bone surgery to correct the bone axis is necessary. These operations are performed during anterior cruciate ligament revision surgery.
MR imaging is used to see if the patient has any other additional injuries. If there are tears in the meniscus, meniscal repair is planned. Especially in the inner meniscus, the posterior root should be investigated for ramp tears.
Knee CT showing that the screw that should be in the tibial tunnel is outside the tunnel
How Many Sessions Is Anterior Cruciate Ligament Revision Surgery Performed?
Preoperative knee tomography is performed and the angles and widths of the tunnels opened in the previous surgery are examined and it is decided whether the revision surgery will be performed in one or two times. Widening of the tunnels opened in the first surgery is one of the most common problems we encounter.
If the tunnels are larger than 12 mm in diameter, 2 operations may be required. In the first surgery, the tunnels are filled with bone tissues taken from the patient's pelvis. After 4-6 months, anterior cruciate ligament revision surgery is performed. The reason for waiting 4-6 months is the union time of the bone tissues placed in the tunnels.
What are the Differences Between Anterior Cruciate Ligament Surgery and Revision Surgery?
The most important difference is the tunnels created in the bones in the revision surgery. In anterior cruciate ligament revision surgery, these tunnels are evaluated before surgery. If they are at an appropriate angle and less than 12 mm wide, anterior cruciate ligament revision surgery is performed in a single session using these tunnels.
In my personal practice, I prefer the bone-patellar tendon-bone graft option in revision surgeries. I also always add the Modified Lameire LET procedure, which we can call a second brake mechanism that contributes to the stability of the joint. You can watch the Modified Lameire LET procedure I performed in anterior cruciate ligament revision surgery by clicking the link.
Another difference of anterior cruciate ligament revision surgery is that if the tunnel angles and tunnel widths are not appropriate, revision surgery requires 2 surgeries with an interval of 4-6 months.
In the first surgery, the tunnels are filled with bones taken from the patient's pelvis. Within 4-6 months, the bones placed in the tunnels fuse with the main bone and no tunnels are opened and the possibility of tunneling in the appropriate position in the anterior cruciate ligament revision surgery is obtained.
Possible problems after anterior cruciate ligament surgery
Some problems may occur after anterior cruciate ligament surgery. The most common problems include pain, infection, swelling and stiffness in the knee. This may lead to the need for anterior cruciate ligament revision surgery.
Common Problems:
Agri
Infection
Swelling
Stiffness in the knee
I Cannot Bend My Knee After Anterior Cruciate Ligament Surgery
Incomplete bending of the knee after anterior cruciate ligament surgery is another problem that can be encountered. This is usually due to postoperative stiffness and inadequate physical therapy.
What to do during the healing process:
Physical therapy and rehabilitation
Regular exercise and movement
Comments of Those Who Underwent Anterior Cruciate Ligament Revision Surgery
Reviews from patients who have undergone revision surgery provide valuable insight into what this process is like. Most patients report increased stability and mobility in their knees after revision surgery.
Here are some of the patient comments from our Anterior Cruciate Ligament Revision Surgery:
"After passing through the hands of Op. Dr. Utku Erdem Özer, the stability of my knee has increased incredibly. None of the problems I had after the first surgery are gone. I am grateful to him and his team."
"Dr. Özer informed me at every step before and after my revision surgery. Thanks to the postoperative physical therapy program, my knee regained its former strength. Thank you for his professionalism and interest."
Conclusion
Anterior cruciate ligament revision surgery is necessary when the initial anterior cruciate ligament surgery has failed or the graft has weakened. Technical errors and overlooking additional injuries are the most common causes of rupture.
This surgery is performed to restore knee stability. The success of the surgery is closely related to the correct identification of the causes of failure and appropriate surgical planning.
The healing process requires patience and committed physical therapy. This is a critical process to maximize the functionality of the knee.
Early diagnosis and appropriate treatment can lead to favorable results, and arthroscopic surgeries provide rapid recovery.
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