Risk factors for ACL revision failure and optimum graft size for revision anterior cruciate ligament reconstruction

Graft re-rupture is a devastating complication after revision ACLR surgery. The literature regarding the risk factors of graft re-rupture is sparse and not definitive. Studies have suggested that a smaller graft diameter is associated with poorer outcomes after primary ACLR, however there is a paucity of literature regarding the effects of graft size on revision ACLR outcomes. This study aims to determine the risk factors for graft re-rupture after revision ACLR, and investigate the optimum graft diameter for revision ACLR.

The records of all patients who underwent revision ACLR from 2013 to 2021 were reviewed. Data collected included patient demographics, operative variables, and demographic details. To determine the optimal graft diameter, receiver operating characteristic (ROC) analysis was performed. Associations between re-rupture rate and return to pivoting sport, intra-articular knee pathologies, and graft diameter were assessed using contingency tables. Data were examined using univariable logistic regression models to explore the association between graft re-rupture after revision ACLR and prognostic variables. Co-variates with a p value p < 0.100 were included in a multivariable logistic regression model to identify independent associations with graft re-rupture.

In total, 132 revision ACLR were identified with a mean follow-up time of 3.22 ± 3.26 years. The graft re-rupture rate was 16.7% (n = 22). There were 91 (68.9%) males and 41 (31.1%) female with a mean age of 27.4 years (range 17.3-50.8 years) at revision. 87.9% (n = 116) were involved in one or more types of pivoting sports. Kaplan-Meier analysis showed that the mean survival time for revision ACL grafts was 148 months (95% CI 130-166). The mean graft diameter during revision ACLR was 9.26 mm (range 7.0-10.5 mm) and mean graft length was 43.6 mm (range 22.0-60.0 mm). No associated procedure such as anterolateral (ALL) reconstruction were performed. At the time of revision ACLR, MRI detected concomitant knee pathologies: medial meniscus pathology (n = 45; 34.1%), lateral meniscus pathology (n = 41; 31.1%), chondral pathology (n = 26; 19.7%). None were associated with an increased rate of re-rupture. Risk factors determined by the multivariable logistic regression model were graft diameter < 9 mm (OR: 3.873; 95% CI 1.128-13.293; p = 0.031) and return to pivoting sport after revision ACLR surgery (OR: 4.105; 95%CI 1.008-16.721; p = 0.049).

A graft diameter < 9 mm and return to pivoting sports after revision ACLR are risk factors for graft re-rupture. Meniscus pathology and chondral lesion were not associated with graft re-rupture. The findings of this study can be used to improve revision ACLR results for patients, but needs to be expanded in multi-centre trials with larger sample sizes.