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Background: Tibiofemoral anatomic parameters, such as tibial slope, femoral condyle shape, and anterior tibial subluxation, have been suggested to increase the risk of anterior cruciate ligament (ACL) reconstruction failure. However, such features have never been assessed among patients experiencing multiple failures of ACL reconstruction. Purpose: To compare the knee anatomic features of patients experiencing a single failure of ACL reconstruction with those experiencing multiple failures or with intact ACL reconstruction. Study: Case-control study; Level of evidence, 3. Methods: Twenty-six patients who experienced failure of revision ACL reconstruction were included in the multiple-failure group. These patients were matched to a group of 25 patients with failure of primary ACL reconstruction and to a control group of 40 patients who underwent primary ACL reconstruction with no failure at a minimum follow-up of 24 months. On magnetic resonance imaging (MRI), the following parameters were evaluated: ratio between the height and depth of the lateral and medial femoral condyles, the lateral and medial tibial plateau slopes, and anterior subluxation of the lateral and medial tibial plateaus with respect to the femoral condyle. The presence of a meniscal lesion during each procedure was evaluated as well. Anatomic, demographic, and surgical characteristics were compared among the 3 groups. Results: The patients in the multiple-failure group had significantly higher values of lateral tibial plateau slope ( P < .001), medial tibial plateau slope ( P < .001), lateral tibial plateau subluxation ( P < .001), medial tibial plateau subluxation ( P < .001), and lateral femoral condyle height/depth ratio ( P = .038) as compared with the control group and the failed ACL reconstruction group. Moreover, a significant direct correlation was found between posterior tibial slope and anterior tibial subluxation for the lateral ( r = 0.325, P = .017) and medial ( r = 0.421, P < .001) compartments. An increased anterior tibial subluxation of 2 to 3 mm was present in patients with a meniscal defect at the time of the MRI as compared with patients who had an intact meniscus for both the lateral and the medial compartments. Conclusion: A steep posterior tibial slope and an increased depth of the lateral femoral condyle represent a common finding among patients who experience multiple ACL failures. Moreover, higher values of anterior subluxation were found among patients with repeated failure and those with a medial or lateral meniscal defect.

Background Residual rotational instability remains a controversial factor when analysing failure rates of anterior cruciate ligament (ACL) reconstruction. Anatomical and biomechanical studies have demonstrated a very important role of anterolateral structures for rotational control. Revision ACL is considered one of the main indications for a lateral extra‐articular tenodesis (LET). Yet, few series evaluating these procedures are published. Purpose To perform a systematic review of studies that assessed outcomes in patients treated with revision ACL surgery associated with a lateral extra‐articular procedure. Study design Systematic review. Methods A comprehensive literature search was performed in February 2018 using PubMed, Scopus, Web of Search and Cochrane. Inclusion criteria were series of ACL revision reconstructions associated with lateral extra‐articular procedures. Clinical outcomes (Lysholm, subjective IKDC, KOOS, Cincinnati and WOMAC), joint stability measures (Lachman test, pivot‐shift, arthrometer assessment and navigation assessment), graft type, reported chondral and meniscal injury, radiographic outcomes, complications and failures were recorded. Articles were assessed for level of evidence and methodology using a modification of the ACL Methodology Score (AMS) system. Results Twelve studies met the inclusion criteria out of the 231 abstracts; 9 retrospective evaluations, two prospective cohorts and one combination of two populations (a retrospective and prospective series). A total of 851 patients evaluated with a mean age of 28.8 years (range 16–68 years) and a weighted mean follow‐up of 4.9 years (range 1–10 years). The mean time from primary ACL reconstruction to revision was 5.3 years (reported in 7 studies, including 710 patients). The Lysholm, IKDC, and KOOS scores indicated favorable results in studies that reported these outcomes. Objective evaluations reported 86% objective A and B IKDC results, 2.6 mm mean side‐to‐side arthrometric difference and 80% negative pivot‐shift. About 74% of patients returned to their previous sport (evaluated in six studies). Few studies reported radiological evaluation. Fifty‐nine complications (8.0%) and 24 failures (3.6%) were reported. The mean modified ACL Methodology Score was 55.5 (range 32–72). Conclusion Good mid‐term results were obtained for combined revision ACL reconstruction and lateral extra‐articular procedures. Despite the fact that in clinical practice LET are a common indication associated with revision ACL, there are no high‐level studies supporting this technique. Level of evidence IV.

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