Anterior cruciate ligament (ACL) revision surgery, which addresses the failure of a previous ACL reconstruction, is a complex and increasingly common procedure. Unlike primary ACL reconstruction, revision surgery requires a more detailed approach due to factors like pre-existing bone tunnels, potential tunnel widening, and associated injuries that may have contributed to the initial failure. The lack of standardized protocols for this challenging surgery has historically led to a variety of different techniques and, at times, inconsistent outcomes. To address this, the European Society of Sports Traumatology, Knee Surgery, and Arthroscopy (ESSKA) initiated a formal consensus project to provide evidence-based recommendations.
A Collaborative Approach to Standardized Care
The 2022 ESSKA consensus is a significant step forward in standardizing the management of ACL revision in adults. This project brought together a large and diverse group of European expert surgeons and scientists to create a set of recommendations based on both a thorough review of existing literature and collective expert opinion. The process was meticulously structured, involving several independent groups—a literature group, a steering group, a rating group, and a peer review group—to ensure that the recommendations were robust and unbiased. The final document provides a clear, evidence-based guide for diagnosing and planning these complex surgeries.
Key Recommendations for Diagnosis and Preoperative Planning
This first part of the ESSKA consensus focuses specifically on diagnostics and preoperative planning. The expert groups formulated 18 key questions, with recommendations graded according to the strength of the supporting scientific evidence, from Grade A (high-level scientific support) to Grade D (expert opinion). The review revealed that, despite the importance of the topic, the scientific quality of related studies is often low. As a result, none of the 18 questions received a Grade A, while six were supported by a Grade B (scientific presumption).
Some of the key diagnostic and planning recommendations include:
- Imaging: For a suspected failed ACL reconstruction, the consensus recommends starting with weight-bearing X-rays of the knee and a non-contrast MRI. A CT scan is a more reliable tool for assessing bone tunnel widening and can be used in cases where this is a concern, though its use should be judicious due to radiation exposure.
- Assessing Failure: The consensus defines failure not just by a ruptured graft but by a functional instability of the knee. The primary goal of a revision is to restore joint stability and function, with the ultimate aim of allowing a safe return to sport while reducing the risk of further degenerative changes.
- Surgical Strategy: The consensus highlights the importance of a detailed surgical plan that considers factors such as malalignment of the knee, associated meniscal or cartilage damage, and the need for bone grafting to address enlarged tunnels.
By providing this structured framework, the ESSKA consensus offers a vital tool for orthopedic surgeons to enhance their diagnostic and planning processes for ACL revision surgery. It helps to bring a higher level of standardization to a procedure that has historically been managed with a wide variety of approaches.
Professor Wilson’s Comments
“I have been an active member of ESSKA for over 15 years and have made significant contributions to the society, serving on several key committees. I was Co-Chair of the ESSKA Osteotomy Committee, where we helped shape and develop this important part of the society, running multiple international courses and establishing visiting fellowships that have had a lasting educational impact.
Over the years, we have greatly enjoyed hosting the ESSKA Fellows in my hospital, where we have demonstrated advanced osteotomy techniques, sharing hands-on experience and innovations with the next generation of surgeons. In collaboration with the ESSKA Academy, we also helped to shape the society’s online educational offering, developing high-quality teaching resources for sports medicine and orthopaedic surgeons worldwide.
Another group I was honoured to be part of was the ESSKA ACL Group, which focused specifically on revision ACL surgery. Our aim was to provide clear, evidence-based guidance on best practice for managing failed ACL reconstructions. Over a two-year period, our group developed a comprehensive consensus on indications, techniques, and strategies, which we presented at the 2022 ESSKA Congress in Paris. The resulting consensus papers now serve as essential guides for surgeons across Europe and beyond.
I am also very proud that our team won the ESSKA Best Paper Award in Amsterdam in 2014 for our publication on the History of Osteotomy, as well as the ESSKA Best Training Video Award in the same year for our Distal Femoral Osteotomy instructional video. This video has now been watched by over 100,000 surgeons and has become a key teaching tool for both DFO and HTO surgery.”
To review the full data, methodology, and complete analysis, please refer to the original research paper:
Sources used in report overview:
- https://pubmed.ncbi.nlm.nih.gov/36322180/
- https://www.esska.org/news/703977/ESSKA-Formal-Consensus-Projects-A-Key-Pillar-of-Scientific-Education.htm
- https://www.google.com/search?q=https://www.artroskoopia.ee/wp-content/uploads/2024/05/ACL-rev-consensus-summ2022.pdf
- https://research.regionh.dk/en/publications/management-of-anterior-cruciate-ligament-revision-in-adults-the-2
- https://www.researchgate.net/publication/375329466_ESSKA_consensus_initiative_why_when_and_how
