After ACL Reconstruction: Complication and post-surgery treatment options: Do you need revision surgery?

Ross Hauser, MD, Danielle R. Steilen-Matias, MMS, PA-C

After ACL Reconstruction, Complications and post-surgery knee instability treatments


When the other knee ligaments are too weak to support the new ACL, this causes ACL surgery failure.

In this article, we will discuss problems of knee instability following anterior cruciate ligament reconstruction surgery and review various non-surgical or revision treatment suggestions to stabilize the unstable post-ACL surgical knee.

ACL reconstructive surgery works for many patients. But how do we define the definition of “works?” Was the surgery successful but your knee still feels like it could give way? Maybe your knee bends backward a little further than you think it should. If so, was your surgery then really that successful?

Many patients that we see following an anterior cruciate ligament reconstruction surgery are confused. They thought for sure once they had the ACL surgery that they would be back to doing what they were doing with the same, if not better, knee than they had before the surgery. This despite the fact that their surgeon probably advised them of possible post-surgery problems, such as instability and the need for extensive rehabilitation.

Other patients recognized immediately that their surgery did not go that well. In immediate post-op rehabilitation, they suffered and may continue to suffer from post-surgical complications. They too are looking for answers beyond knee braces, extended physical therapy, painkillers, and the constant reminders from their health care providers that knee replacement will likely be the ultimate solution down the road.

My ACL was fixed great, but now it is my meniscus

Here is a situation we often hear. It may be a problem affecting you. The ACL surgery went great but now the meniscus “is shot.”

I had ACL reconstruction surgery on my right knee more than 5 years ago. The surgeons congratulated me on having such a successful surgery. As I started rehab and soon afterward my knee really started to hurt. So I went for an x-ray to see if there was a problem with the tunnels or screws. When that showed everything was okay I went for an MRI. The MRI revealed that I developed a bucket handle meniscus tear. The tear was so bad there was nothing that could be repaired, my meniscus was in a state of disintegration.

My doctors still congratulate me on my ACL having healed so well. But now my knee is in a constant state of swelling and they are considering a meniscus transplant.

The appeal and enthusiasm for ACL reconstruction surgery, is this misguided?
A patient will say: “What other choice did I have, BUT to get the surgery?”

Many times we will see a patient following anterior cruciate ligament reconstruction. To these patients we ask a simple question:

Many times the patient will give an equally simple answer:

There are options to the ACL surgery and revision surgery as we will discuss below:

I had a successful ACL surgery, but I gave up my sports anyway

Later in this article, we will discuss making ACL surgery outcomes more successful with various non-surgical options.

One of the problems we see in many people who reach out to us is unrealistic expectations of what the surgery will do for them. Watching professional athletes return from “career-threatening,” ACL injuries is somewhat normal. So is that what a non-professional athlete should expect?

In 2014 surgeons wrote in the journal International Orthopaedics: (1) “the revision ACL reconstruction procedure offers improvement in subjective and objective outcomes. Lack of improvement in sports participation was noted in non-professional athletes and patients who downgraded their sports participation opting for non-contact sports.”

You may think that that study was in 2014, things must have improved by now. In a sense, you may think they went backward.

Ten years later – still looking for explanations as to why many people need a second ACL reconstruction surgery

A May 2020 study in The Journal of Knee Surgery (2) went looking for answers by way of what doctors and researchers were looking up in the National Institutes of Health’s library at PubMed.gov to explain why: “The rate of anterior cruciate ligament retear remains high and revision ACL reconstruction has worse outcomes compared with primaries.

What paper did the surgeons overwhelmingly refer to? A 2010 study titled: “Biomechanical Measures During Landing and Postural Stability Predict Second Anterior Cruciate Ligament Injury After Anterior Cruciate Ligament Reconstruction and Return to Sport“(3) What did this paper say?

“The findings of the current study support the tested hypothesis that altered neuromuscular control patterns during landing and deficits in postural stability predict subsequent ACL injuries in a sample of athletes at the time of return to sport after initial ACLR. Specifically, transverse plane net moment impulse at the hip, dynamic frontal plane knee range of motion, side-to-side differences in sagittal plane knee moment at initial contact, and deficits in postural stability predicted a second ACL injury with both high sensitivity and specificity.”

In other words, knee instability that impacted everything from hip to foot, when present, is a high risk for a second ACL rupture. Preventing this knee instability, as we will discuss below, is paramount to preventing the second ACL rupture.

The second ACL surgery or “revision surgery” is a very popular procedure. It is also much less “successful.” Especially for the adolescent athlete

You are a young athlete, you are the parent of a young athlete, the clock is always ticking because a young athlete’s career is finite in years. There is a great sense of urgency to get the knee repaired ASAP. So the appeal to revision surgery is very strong.

We are going to take a little research journey. The purpose is to demonstrate how surgeons for the last 10 years have struggled with ACL revision surgery.

2012:


2020:

Surgeons at the University of California San Francisco issued these observations in the journal Current Reviews in Musculoskeletal Medicine. (6)

Tunnel placement complications

ACL tunnel complications

Image: Erickson B, et al. ORTHOPEDICS. 2016; 39: e456-e464.

If you had ACL surgery, you likely know all about tunnels. This is a significant complication of ACL reconstruction. As we are looking for solutions to your problem in this article we will only touch on this briefly. Tunnel problems are one of the problems where revision surgery is most likely warranted.

During the ACL reconstruction surgery, a hole is drilled in the thigh bone and the shin bone, the donor tendon that is being used as the graft is then threaded through the holes, through the knee, and fixed or screwed into place.

Why doctors want to avoid a revision surgery – for one its the inferior results

2013: Why doctors want to avoid a revision was pointed out in a study out of Norway in the journal Knee Surgery, Sports Traumatology, Arthroscopy: (7)

August 2020: In the medical journal Orthopaedic Surgery (8), orthopedic surgeons published their findings and observations on possible inferior results achieved in revision or second ACL reconstruction surgery. Here are the summary learning points:

The more revision surgeries, the fewer sports

The Department of Orthopedic Surgery at the Mayo Clinic published findings in the American Journal of Sports Medicine. (9) Here they write: “Continuously increasing numbers of primary anterior cruciate ligament reconstructions invites a parallel increase in graft failures and need for revision ACL reconstruction surgery. High failure rates has previously stigmatized the revision surgery. . . Good outcomes of revision ACL reconstruction surgery are achievable. The use of different graft types did not affect the outcome of the procedure. Most of the patients opted to less aggressive sports participation after the revision procedure.”

Avoiding “Revision – Revision” – the Third ACL surgery – Back in the tunnels


Multiple studies have shown that the rate of return to the pre-injury level of sport is significantly lower following revision ACLR than following primary ACLR procedures.

In 2017, doctors writing in The Journal of Bone and Joint Surgery (10) suggest that it is important for orthopedic surgeons to attempt to restore proper anatomy and biomechanics during revision (the second ACL surgery) ACLR to minimize the rate of re-revision. (The third ACL surgery). Here is the surgeon’s checklist of guidelines.

It is important to consider that the findings above are considered excellent ACL reconstruction patient results. We ask, do these findings really merit an excellent? Here is more research to review:

Ten years later, my knee is still not the same

Some people do very well with ACL reconstruction surgery, some do very well with second or revision ACL surgery. Some do well with the third ACL reconstruction/revision surgery. These are typically not the people we see in our office. We see the people who may have had a successful surgery, but their knee is not the same. They tell us stories like this one:

When I had the ACL reconstruction I had a difficult rehab. Maybe because I was pushing myself too hard. My knee just did not feel right. Almost a year after the surgery, the graft gave way and it pretty much wiped out my meniscus. In the revision surgery a tendon graft was used and most of my meniscus, which I was told was beyond repair, was removed. The surgery was a great success but my knee was never the same. I never really recovered. Here I am 10 years later now being managed along until I can get a knee replacement.

The fact that your knee is moving towards inevitable knee replacement should tell you that every day your knee is getting weaker.

By this time you can see that we are building an argument that instability in the ACL Reconstructed knee leads to a more accelerated breakdown of the knee. This does not have to be solely an osteoarthritis knee replacement someday in the future, it is a problem you have today. But knee replacement is the general direction you are moving in. The fact that your knee is moving towards inevitable knee replacement should tell you that every day your knee is getting weaker.

Many people have issues with knee instability and function after anterior cruciate ligament reconstruction, it is not just you.

We have just presented a lot of research on the problems some patients have following ACL reconstruction surgery. But in reality, how often do ACL reconstruction complications and post-surgical concerns occur? If you are reading this article because you are considering an ACL surgery, you may think to yourself, how many people does this really affect?

For you who had the surgery, it has happened one time too many because you have a lot of knee problems. While you may be led to believe that this is a problem you suffer from a small minority of patients, it is NOT just you, it is a lot of patients. How big a problem is this in the medical community? Consider this:

In 2015, a paper appeared in the journal Clinical Orthopedic Sports Medicine, (15) it came from researchers at Johns Hopkins University. The researchers looked at all the medical studies published in the field of clinical sports medicine with the goal of finding the top 100 most cited medical articles. This was not just a study in statistics, the subject matter of the top 100 articles would tell doctors and other health professionals what some of the biggest challenges in medicine were and how researchers were moving toward possible solutions.

In 2017, European researchers looked solely at the top ACL 50 articles. They published their results in the journal International Orthopaedics. (16)

The top three articles cited were articles that were related to defining a scoring system to help clinicians understand the severity of symptoms related to knee ligament problems. The number 1 article was the 1985 “Rating systems in the evaluation of knee ligament injuries”(17)  that lead to the “Tegner Lysholm Knee Scoring Scale.” A questionnaire to grade and assess the patient’s knee problems.

Now if you had an ACL reconstruction and you are experiencing continued problems, you may have been given the questionnaire or were asked questions that pertain to these following problems broken up into these sections.

Based on the amount of time clinicians spend researching and citing articles on “Knee scoring systems, one could suggest that the biggest problem facing the clinician is how do you determine how bad off a patient’s knee is? Second what is causing these problems?

What if I buy a really good brace? Study: Knee bracing does not appear to improve the clinical outcomes on the function and stability of ACL-reconstructed knees

An October 2019 study in the journal Orthopaedics and Traumatology, Surgery and Research (18) suggests that “knee braces could not provide superior clinical outcomes on knee functional scores and stability evaluations.”

Here is what they said:

In this study, the researchers combined data from seven studies with 440 participants. After examining the patient outcomes following ACL reconstruction outcomes, the research team found:


It is time to talk about the other ligaments of the knee –
When the other knee ligaments are too weak to support the new ACL, this causes ACL surgery failure.

The ACL ligament does not sit in isolation. Your problem may be a knee ligament problem and it is not just the ACL, it is the other ligaments.

The ACL ligament does not sit in isolation. Your problem may be a knee ligament problem and it is not just the ACL, it is the other ligaments.

The ACL ligament does not sit in isolation. Your problem may be a knee ligament problem beyond the ACL. This illustration demonstrates the interaction of the knee ligaments.

The four major ligaments of the knee are:

Study: “Generalized Hypermobility, Knee Hyperextension, and Outcomes After Anterior Cruciate Ligament Reconstruction”


Let’s examine an October 2017 study in the medical journal Arthroscopy (19) led by the Minnesota Orthopedic Sports Medicine Institute and Department of Orthopedics, University of Michigan MedSport.

The title of the paper should say it all: Generalized Hypermobility, Knee Hyperextension, and Outcomes After Anterior Cruciate Ligament Reconstruction.

Here are the summary findings:

Knee Hypermobility – instability

In this above study, the focus is put on the ACL graft being too loose or lax. The new ACL is not holding the knee together as it should and this is causing whole knee instability.

“Preoperative laxity of the knee” and “Excessive graft laxity” as a cause of ACL surgery failure

Let’s go back to 2001 and a well-documented summary of ACL complications that can be found in the abstract of a classic lecture presentation from the Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh. This lecture was delivered in 2001. (20)

From 2001: “Many factors influence the overall success or failure of anterior cruciate ligament reconstruction, including the integrity of the secondary restraints (that is the supporting structures of the knee), the collateral ligaments, the mid-third capsular ligaments, the meniscus, and the iliotibial band), the preoperative laxity of the knee, the status of the articular and meniscal cartilage. . . “

As we noted in the research above untreated associated ligaments insufficiencies, in other words, the other knee ligaments were too weak to support the new ACL, which caused the failure.

The prevalence of knee hyperextension (knee instability) in ACL revision surgery patients
Research 2018-2021

We are now going to move forward to October 2018 in the American Journal of Sports Medicine. (21)

This is a huge study listing dozens of authors. The study’s abstract lists that the investigation was performed at The Carrell Clinic, Dallas, the Department of Orthopaedics, Washington University School of Medicine, St Louis, the Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, and Reedsburg Area Medical Center, Reedsburg, Wisconsin.

The researchers in this study presented a hypothesis about the impact of knee hyperextension in revision ACL reconstruction surgery. Knee hyperextension being defined as a 5-degree ability to bend the knee backward.

So the researchers went about examining ACL reconstruction patients for two years.

Conclusion of the study? 

“Revision anterior cruciate ligament reconstruction restores knee laxity but shows inferior functional knee outcome”

Here is a 2019 study from the Stockholm Sports Trauma Research Center, Karolinska Institutet, Stockholm, Sweden published in the journal Knee surgery, sports traumatology, arthroscopy (22). What the researchers found was that a revision ACL reconstruction laxity problem can be surgically fixed, but it could not fix problems with knee function in many patients.

The researchers wrote “the final postoperative functional outcome is inferior”

“The findings of this study showed that anterior knee laxity is restored with revision bone-patellar tendon-bone autograft ACLR after failed primary hamstring tendons autograft ACLR, in the same cohort of patients. However, revision ACLR showed a significantly inferior functional knee outcome compared with primary ACLR. It is important for clinicians to inform and set realistic expectations for patients undergoing revision ACLR. Patients must be aware of the fact that having revision ACLR their knee function will not improve as much as with primary ACLR and the final postoperative functional outcome is inferior.”

 “Preoperative medial knee instability is an underestimated risk factor for revision ACLR failure”

University medical researchers in Germany published a July 2020 study in the journal Knee Surgery, Sports Traumatology, Arthroscopy (23) that warned their colleagues that a loose knee after ACL reconstruction is a leading cause for ACL reconstruction failure.

The researchers wrote: “The most important finding of this study was that preoperative medial knee instability is a risk factor for revision ACLR”

“The most important finding of this study was that preoperative medial knee instability is a risk factor for revision ACL reconstruction and should be adequately addressed at the time of revision ACL reconstruction. This study demonstrates the largest revision ACL reconstruction patient group with pre-and postoperative clinical examination data and a follow-up of 2 years published to date and it indicates that preoperative knee instability is an important factor for the treatment strategy of revision ACL reconstruction. Medial knee instability, high-grade anterior knee instability, and increased posterior tibial slope are risk factors for failure of revision ACL reconstruction and should be addressed at the time of revision surgery.”

“In spite of supposedly successful surgery, slight residual knee laxity may be found at follow-up evaluations after anterior cruciate ligament reconstruction (ACLR), and its clinical effect is undetermined”

Finally, a March 2021 study in The American Journal of Sports Medicine (24) wrote: “In spite of supposedly successful surgery, slight residual knee laxity may be found at follow-up evaluations after anterior cruciate ligament reconstruction, and its clinical effect is undetermined. . . In spite of supposedly successful surgery, slight residual knee laxity may be found at follow-up evaluations after anterior cruciate ligament reconstruction, and its clinical effect is undetermined

Conclusion: “A slightly loose graft at 6 months after anterior cruciate ligament reconstruction increased the risk of later ACL revision surgery and/or graft failure, reduced the length of the athlete’s sports career, caused permanent increased anterior laxity, and led to an inferior Lysholm (pain, disability, function) score.”

The road to preventing ACL revision surgery – ligament strengthening

In this video Ross Hauser, MD explains a simple injection technique – Prolotherapy for strengthening the ACL

Video transcript summary:

The regenerative approach to Knee ligament weakness and degenerative injury

Throughout this article, we demonstrated research from the surgical community that discusses the problems of knee instability following an ACL reconstruction surgery. These problems can be severe enough that a second or even third surgery may be suggested. We have also demonstrated that these revision surgeries are, for the most part, less successful than the patient expects.

The problem of knee instability is a problem of damaged, untreated degenerative structures. This includes the three other main stabilizing ligaments in the knee the MCL, PLC, and LCL.

In the case of an overstretched or partially torn ligament, a treatment approach to strengthen and heal the injured ligament should be utilized. The treatment that stimulates ligament healing and regeneration is Prolotherapy.

In this video, Danielle R. Steilen-Matias, MMS, PA-C, of Caring Medical demonstrates how we treat a patient with a primary complaint of knee osteoarthritis.

Questions about our treatments?

If you have questions about your knee pain and how we may be able to help you, please contact us and get help and information from our Caring Medical staff.

This is a picture of Ross Hauser, MD, Danielle Steilen-Matias, PA-C, Brian Hutcheson, DC. They treat people with non-surgical regenerative medicine injections. Offices are located in Oak Park, Illinois and Fort Myers, Florida.

Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C

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References: 

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This article was updated March 31, 2021

 

 

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