In this section Dr Frank Noyes of the Cincinnati Sportsmedicine and Orthopaedic Center in Cincinnati, Ohio brings you a new course on Anterior Cruciate Ligament (ACL) reconstruction failures and revisions. Dr Noyes is one of the world's foremost knee surgeons, researcher and author of hundreds of leading publications of many many topics to do with the knee.

Part 1 - Introduction

• Definitions
• Relevant anatomy

Part 2 - What happens to an ACL graft after implantation?

• Revascularisation
• Remodelling
• Ligamentisation

Part 3 - Surgical choices for the initial ACL reconstruction

• Primary repair
• Extra-articular iliotibial band procedure
• Intra-articular reconstructions
• autograft
• allograft
• synthetic graft
• Graft fixation

Part 4 - What constitutes ACL graft failure and how do you measure it?

• The patient's subjective evaluation of instability
• The surgeon's objective evaluation of laxity
• Lachman test
• Pivot shift test
• KT 2000
• Confirmatory radiographic evaluation

Part 5 - Most common causes of ACL graft failure

5a - ACL graft failure due to inadequate graft material

• Inappropriate use of primary repair
• Poor structural mechanical property of the graft prior to implantation
• Failure of ACL graft ligamentisation

5b - ACL graft failure due to graft impingement

• Causes of graft impingement
• Cyclops lesion

5c - ACL graft failure due to problems in graft tensioning and fixation

• Improper tensioning of graft prior to fixation
• Inadequate graft fixation

5d - ACL graft failure due to failure to address associated instabilities

• Failure to adequately address the posterolateral corner
• The issue of simultaneous multiligament surgery
• Failure to stabilise existing meniscal damage

5e - ACL graft failure due to inadequate rehabilitation programme

• Inappropriate speed of rehabilitation
• Failure to recognise early arthrofibrosis

5f - ACL graft failure due to traumatic re-injury

• Injury related to proprioception deficit
• Injury related to muscle imbalance
• Injury related to returning to activities inappropriate for stage of healing

Part 6 - Compounding problems that must be addressed in revision ACL surgery

• Existing articular cartilage damage
• Damaged meniscus
• Bow legs (varus mal-alignment)
• Loss of secondary ligament restraints
• Weakened bone stock
• Pre-existing bony tunnels
• Notch problems
• Other problems

Part 7 - Graft options in revision ACL

• Allograft
• Ligament augmentation devices
• Synthetic grafts
• Autograft

Part 8 - Contraindications to ACL revision

• Partial function of a prior ACL reconstruction
• No symptoms (pain,swelling, giving way) in a patient who does not participate in strenuous or high risk activities
• Prior joint infection
• Obesity (body mass index >30)
• Bowed legs where the patient refuses to undergo a high tibial osteotomy before or with the ACL revision reconstruction
• Severe muscle atrophy (wasting)
• Poor patient motivation or expectations
• Knee arthrofibrosis
• Deficiency of the posterolateral structures where the patient refuses to undergo an associated posterolateral reconstruction with the ACL revision.

Part 9 - What can one expect after ACL revision?

• Outcomes

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