Current Trends and Indications for Extra-Articular Reconstruction in Revision ACL Reconstruction: A Cross-Sectional...

The management of revision anterior cruciate ligament reconstruction (ACLR) presents unique challenges that require careful consideration of graft selection and the role of anterolateral complex (ALC) augmentation. Although surgical techniques continue to evolve, there is variability in clinical practice patterns for revision ACLR.

To assess current trends in revision ACLR, including ALC augmentation indications, preferred augmentation techniques, and choice of graft type.

Cross-sectional study; Level of evidence, 3.

A survey was distributed by email to all members of the American Orthopaedic Society for Sports Medicine (AOSSM). The survey included a demographics section (5 questions) and a revision ACLR section (12 questions). Descriptive statistics were performed.

There were 469 responses (response rate, 14%), with respondents more commonly being male (90%), fellowship-trained (95%), and in private practice (42%). The revision ACLR volume rose with the number of years in practice (P = .008). The autograft patellar tendon (47%) was the most frequently selected revision graft, followed by the quadriceps tendon (22%). The graft choice was associated with fellowship training (P = .006), years of experience (P < .001), and type of practice (P = .015). ALC augmentation was used by 70% of respondents, mostly for multiple (52%) or single (37%) previous ACLR failures and contact athlete status (17%). Its use was more common among early-career (88%; P = .006) and academic (87%; P < .001) surgeons. Practice setting correlated with the choice between lateral extra-articular tenodesis (LET) and anterolateral ligament reconstruction (ALL) (P = .03), with academic surgeons utilizing LET at the highest rate. ALL was favored in patients with a body mass index of >35 kg/m² (P = .003) and LET in contact sport athletes (P = .006). Altogether, 80% of the surgeons preferred LET over ALL as their primary choice for augmentation.

Revision ACLR practices vary widely, with no uniform consensus on graft choice and indications for ALC augmentation. ALC augmentation is most frequently indicated for patients with multiple previous failures. LET is the preferred augmentation technique, and the autograft patellar tendon is the most utilized graft in revision ACLR. Long-term outcomes of revision ACLR should be further studied to define ideal indications for augmentation and graft selection to address the relatively poor outcomes observed in patients undergoing revision ACLR.