Second-Stage Revision Anterior Cruciate Ligament Reconstruction After Three Failures With Anterolateral Ligament Reconstruction, Medial Meniscal Root Repair With Centralization Suture, and Inside-Out Lateral Meniscal Repair

Background: Anterior cruciate ligament (ACL) graft failure is a relatively common occurrence and is even more likely in the presence of medial meniscal deficiency. ACL tears cause significant knee instability, particularly anterolaterally, and are commonly treated with a surgical reconstruction. Indications: During a revision ACL reconstruction (ACLR), clinical studies have demonstrated that correcting medial meniscus pathologies and reconstructing the anterolateral ligament (ALL) improve outcomes. This is the patient's fourth ACLR, complicated by a concomitant extruded medial meniscal root tear, and confirmed on clinical examination and imaging. An ALL reconstruction (ALLR) and medial meniscal root repair with a centralization suture were therefore indicated during the revision ACLR. Technique Description: The technique described was used for a revision ACLR after 3 failed reconstructions with a concomitant ALLR and lateral meniscal peripheral and medial meniscal root repair as part of the second stage of a 2-stage surgery. The first stage of surgery included ACL tunnel debridement and bone grafting. The second stage procedure described here included a revision ACLR with bone-patellar tendon-bone autograft and an ALLR using the inferior portion of the iliotibial band, fixated with suture anchors to recreate the anatomic proximal and distal attachment sites. For the menisci, a lateral meniscal posterolateral peripheral tear was repaired using an inside-out technique, and the medial meniscal root tear was repaired with a double transtibial tunnel root repair with a centralization suture to reduce extrusion. Results: Recent literature has demonstrated that rerevision ACLR improved functional outcomes and overall knee stability. Despite these improvements, the overall rate of return to preinjury activity levels was poor, with high inter-study variability. Discussion: A complex revision ACLR with an ALLR and multiple meniscal repairs is described, along with technical considerations to improve long-term outcomes and minimize complication risks. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.