Chinese expert consensus on failure and revision after anterior cruciate ligament reconstruction

With the recent rise in anterior cruciate ligament (ACL) reconstruction surgeries in China, a corresponding increase in surgical failures has been observed. Variability in primary surgical techniques and the intricacies of failure mechanisms have introduced significant challenges in diagnosing failures, planning procedures, and conducting revision surgeries.

In response to these challenges, the Chinese Association of Orthopaedic Surgeons (CAOS) and the Chinese Society of Sports Medicine (CSSM) initiated the development of an expert consensus on ACL reconstruction failure and revision. Utilizing a modified Delphi method, 67 domestic experts from relevant fields were invited for consensus formulation and review.

The expert panel achieved a high degree of consensus on twelve key aspects. The consensus clearly defines ACL reconstruction failure and outlines multiple contributing factors, with surgical errors, especially incorrect bone tunnel placement, identified as primary causes. It also emphasizes the significant impact of patient-specific variables on the likelihood of failure. Recommendations for revision surgeries include careful determination of revision indications, preserving meniscal integrity to reduce the risk of joint degeneration, and a preference for single-stage or two-stage surgeries based on individual patient evaluations. A unified approach for managing bone defects remains absent, necessitating comprehensive assessments. Graft selection should be tailored to each patient, with autografts, allografts, or synthetic ligaments as viable options. For patients with a highly positive pivot shift test or those engaged in high-demand athletic activities, anterolateral structure augmentation or reconstruction is recommended.

The consensus emphasizes the critical need for individualized approaches in ACL revision surgery. By clearly defining failure criteria and outlining strategies for surgical revisions, these statements are expected to serve as a guide for refining clinical practice, reducing complications, and improving surgical outcomes.

1)Establishment of Evidence-Based Clinical Guidelines: This article presents a rigorously developed expert consensus on ACL reconstruction failure and revision, providing evidence-based clinical guidelines that are directly applicable in surgical practice. The standardization of these protocols across medical institutions has the potential to reduce variability in patient care and improve surgical outcomes on a national scale.2)Advancement of Precision Medicine in ACL Surgery: By emphasizing the need for patient-specific approaches in the management of ACL reconstruction failure, this consensus supports the advancement of precision medicine in orthopaedic surgery. The tailored recommendations for graft selection, surgical techniques, and rehabilitation protocols can lead to more personalized and effective treatments, reducing the risk of complications and enhancing recovery.3)Catalyst for Innovation in Surgical Techniques: The article identifies critical gaps and challenges in current ACL revision practices, providing a foundation for future research and innovation. By outlining the complexities and controversies in surgical decision-making, this work serves as a catalyst for the development of new surgical techniques and technologies aimed at improving patient outcomes.4)Framework for Future Research and Development: The consensus not only addresses immediate clinical needs but also sets a clear agenda for future research in ACL revision. By offering a structured approach to the diagnosis and management of ACL failures, this article guides both basic and translational research efforts, ensuring that future innovations are aligned with clinical realities and patient needs.