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

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

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 does your knee still feel 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 is 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.

Discussion points of this article

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.

ACL reconstruction surgery

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) which was then updated in print in September 2021 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 re-tear 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.

A March 2022 study from the Department of Orthopaedic Surgery, Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center was published in the journal Arthroscopy (34) What this study suggested was that patients follow three different rate of Anterior Cruciate Ligament Reconstruction recovery patterns.

Patients can expect a 70% return-to-sport within seven years after ACL Reconstruction

A January 2022 study (27) in The American Journal of Sports Medicine discussed long-term patient-reported rates of return to sport and revision risk after ACL reconstruction.

There were 1045  reported patient outcomes in this study:

Why do 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 have 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 for less aggressive sports participation after the revision procedure.”

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:

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.

Now let’s talk about the meniscus – “Meniscus tears seen at the time of anterior cruciate ligament reconstruction are usually asymptomatic.”

Seen frequently in ACL rupture is the meniscus injury. There is a debate as to whether this meniscus injury should be treated or not depending on the extent of the damage to the meniscus. In December 2021 in the medical journal Arthroscopy (10), Orthopedic surgeon K. Donald Shelbourne wrote: “Meniscus tears seen at the time of anterior cruciate ligament reconstruction are usually asymptomatic, and treatment varies greatly between surgeons, with meniscus repair being used for tears that could be left in situ (or alone). Recent outcome studies of most types of lateral meniscus tears show that leaving the tears in situ can give equal or superior results. Meniscus repair being performed for degenerative medial meniscus tears does not give better results than removing the tears. As an alternative to repair, trephination (poking it with a needle) through the meniscus into the peripheral capsule can create many bloody channels to promote healing. Long-term follow-up of meniscus treatment with anterior cruciate ligament reconstruction can help us understand outcomes and prevent us from overtreating tears.”

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 (11) 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:

The young athlete’s knee is not the same after ACL reconstruction

A January 2022 study in the Orthopaedic Journal of Sports Medicine (26) suggests that athletes display persistent muscle deficits (weakness) and altered limb-loading mechanics at the time of return to sport after anterior cruciate ligament reconstruction. How much deficit and altered mechanics? To find out the researchers compared adolescent athletes’ function and playing ability when they returned to sports following ACL reconstruction to adolescent athletes who never had ACL reconstruction.

Conclusion: “Compared with matched healthy controls, the participants who underwent ACL reconstruction in this study demonstrated an inferior objective profile (less strength and function) at a return to sport, consisting of deficits in surgical limb loading, self-reported outcomes, and strength.”

The younger hamstring graft is too stiff – Younger patients have worse surgical outcomes

A January 2022 study in the International Orthopaedics (31) by researchers at the University of Auckland. In this study, they examined if a younger patient’s hamstring tendon was “too stiff.” Here are the learning points of their study:

The researchers then compared hamstring tendon samples obtained from people aged 20 years or younger to samples obtained from older people.

Knee function deficits following ACL reconstruction measured by loss of vertical jump distance

An international team of researchers published their May 2022 study (32) in the British journal of sports medicine in which they suggested that male athletes perform a single leg vertical jump test to help identify performance and knee function deficits (weakness) at return to sport after ACL reconstruction. From the study: “Vertical jump performance (the power, acceleration and height the athlete can achieve in the jump) is a more representative metric (test) for knee function than horizontal hop performance (jump height and distance) in healthy individuals.”

The purpose of this study was more to determine if the vertical test accurately portrayed knee strength in the ACL reconstruction athlete, as the researchers noted: “It is not known what the biomechanical status of athletes after anterior cruciate ligament (ACL) reconstruction (ACLR) is at the time they are cleared to return to sport or whether vertical performance metrics better evaluate knee function.”

In determining the effectiveness of the vertical test to portray knee deficits in the ACL reconstruction patient, the researchers found: Jump performance, assessed by jump height and Reactive Strength Index (a test that may be best described as “explosiveness” with a main factor of this test vertical jumping height), was significantly lower in the ACL reconstructed knee than the non reconstructed knee and compared against controls (people who did not have surgery), with large effect sizes.

The conclusion of this study was: “During vertical jumps, male athletes after ACL reconstruction at return to sport still exhibit knee biomechanical deficits, despite symmetry in horizontal functional performance and strength tests. Vertical performance metrics like jump height and Reactive Strength Index can better identify interlimb asymmetries than the more commonly used hop distance and should be included in the testing battery for the return to sport.” In other words, jumping is a problem and it is better assessed with tests that can evaluate jumping height and explosiveness.

Ten years later, my knee is still not the same

In some patients, their knee is not the same. In some patients, ten years later their knee is 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.

Does ACL reconstruction prevent posttraumatic osteoarthritis?

A September 2021 German study in the journal (translated into English) Sports Injury – Sports Damage (29) wrote: “The treatment of an anterior cruciate ligament rupture is still controversial. In particular, this applies to the question of conservative versus surgical treatment. The answer to this question is often based on consequential damage such as the development of posttraumatic osteoarthritis, secondary damage to the meniscus or cartilage, and participation in sports. ”

To answer this question, the researchers reviewed previously published studies and found: “Patients with an anterior cruciate ligament rupture are likely to be at a greater risk of developing progressive joint degeneration. A protective effect of cruciate ligament surgery has not been found in the evaluated studies. A general argument in favor of cruciate ligament surgery aiming to achieve a protective effect on hyaline articular cartilage seems obsolete based on the results and should therefore not be used in patient education in the future.”

Simply anterior cruciate ligament reconstruction does not appear to prevent posttraumatic osteoarthritis.

This was also suggested by a September 2021 paper in The Bone & Joint Journal (30) which also simply states: “Anterior cruciate ligament (ACL) rupture commonly leads to post-traumatic osteoarthritis, regardless of surgical reconstruction.”

ACL reconstruction and the development of posttraumatic osteoarthritis in more active people

A February 2021 study in The American journal of sports medicine (28) assessed the association between activity level after ACL reconstruction (ACLR) and the development of posttraumatic osteoarthritis. The focus of this study was to investigate the relationship between patient-reported outcomes and progressive cartilage degenerative changes at three years after ACL reconstruction.

In this study, the researchers used the MARX scale to determine a consistent level of activity. Patients who reported greater amounts of running, deceleration, cutting, and pivoting were more likely to develop posttraumatic osteoarthritis.

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 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, (16) 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. (17)

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”(18)  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 (19) 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:

Does hyaluronic acid injections help with swelling and joint stiffness after ACL reconstruction?

A March 2022 paper in the Journal of clinical orthopaedics and trauma (33) sought to examine the effectiveness of hyaluronic acid injections in helping post ACL reconstruction patients with their problems of pain, swelling and joint stiffness. The study notes: “The patients often receive prolonged analgesic medications to control the inflammatory response and resume the pre-injury activities.”

This review study examined data from four previously published studies. In total 303 patients were assessed, 182 patients in the intraarticular hyaluronic acid injection group and 121 patients in the control group. The study analysis revealed: “Although the individual study demonstrated a short-term positive response regarding pain control and swelling reduction, the pooled analysis did not find any clinical benefit of intraarticular hyaluronic acid injection following ACLR surgery.”

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 (20) 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. (21)

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. (22)

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 is 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 (23). 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 (24) 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 (25) 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.

Summary and Questions about our treatments?

Surgical outcomes for ACL tears have their own fair share of disappointing results, including as high failure rates as demonstrated in the research above. Second ACL tears or the need for later revision surgery will all but end a young athlete’s career. Using tissue from cadavers (allograft) or from a patient’s own tissue (autograft) is used for ACL reconstruction, as well as for many other areas of the body because it sounds promising to a patient in pain who is looking for repair, and is necessary in the instance of grade III (complete) tears. Despite the reconstructive surgery, the instability of the knee remains and that knee is in jeopardy for future injury.

ACL reconstruction can provide remarkable short-term pain relief. Temporarily they provide more stability to the joint. Unfortunately, the stability doesn’t last because the “new” ACL can not simulate exactly the same biology of the original ACL. If someone has a complete, grade 3 ligament tear, surgery is indicated. The cadaver or tendon graft that is replacing the torn ligament, however, will not function long-term like the original ACL. Once it starts becoming lax or weak, Knee instability occurs.

ACL grafts do not have the same pliability as nascent tissue. In other words, ligaments are pliable, they can stretch. Surgerized ACL no longer has the pliability and for the active person will cause long-term problems.

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.

 

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References: 

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This article was updated April 14, 2022

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