Nicole is a competitive cheerleader from a local University. She had aspirations of pursuing her dream until it was cut short during an injury which left her knee unstable, unable to cheer and unable to complete. She was crushed.

Three years later, and after her ACL repair and subsequent revision repair, she was still unstable. She had given up on pursuing her dream. “Doctor why did this happen?”

Nicole’s story is unfortunately not unique. About 20,000 to 35,000 people who have ACL reconstruction will fail and need to be revised. The need for a third revision is more unique. These revision surgeries are much more complex, often require staged procedures, have higher complication rates, and a more conservative rehabilitation than the first surgery.

The first question I try to answer is why did this happen: Both for the patient and for myself. A better understanding of the ‘why’ will help to maximize the chance that the next surgery will be successful.

An ACL repair or reconstruction, which I perform frequently, is done by using a tissue graft in the place of the torn ligament. This graft either comes from your knee, or from a donor. When done correctly, many patients are able to return to sports, and have normal knee function and stability.

I believe the most common reason for failure of an ACL repair is a technical concern on the part of the surgeon related to tunnel placement. Getting the graft in exactly the right place is essential for a good outcome. To the layman, this seems it should be easy. The reality is there are several pitfalls that can occur and the result can be wrong tunnel placement that will lead to failure. Anatomic landmarks in the knee must be carefully identified and checked before committing to the location of a tunnel. Placement of the femoral tunnel too forward (anterior) or two vertical is far too common. A tunnel in the wrong place creates abnormal stress on the graft which can cause it to stretch out or tear.

Return to activities too early: Go back to sports too soon and the chance of failure goes up. Patients need to be sure they are ready. This isn’t just a time consideration (like 6 months out), but rather a functional consideration. Once normal strength, endurance and agility are possible, return to sport may be considered. Running a patient through a ‘sport test’ may help. I like to follow patients out until they are back completely to be sure they are ready.

Other key factors include
• Recurrence of injury
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• Poor muscle function
• Infection
• Other injuries

Find a surgeon with experience

Surgeons who perform more than a few ACLs a month are more likely to have better outcomes than patients who do a 0-4 a month. Staying up with the most common and up-to-date techniques is important. Find someone who performs an true anatomic reconstruction.

Don’t be afraid to ask your surgeon how many ACLs he does a month. We are honest people and will tell you. Get a second opinion if you like. A confident surgeon will give you the option of looking elsewhere if you like.

At the time of Nicole’s surgery, Her tunnels were in the wrong place – too forward on the femur, too far back on the tibial side. The tunnels were close to the right place. Both tunnels were grafted with bone. Four months later, she went back to the OR for her staged reconstruction. Nicole rehab’d hard. At one year out, she started back to competition. Last month, she competed and medaled in the world cheer competition.

I hope this was her last knee surgery. Five surgeries later, she is back chasing her passion and not looking back.