Differences in mechanisms of failure, intraoperative findings, and surgical characteristics between single- and multiple-revision ACL reconstructions: a MARS cohort study

Am J Sports Med. 2013 Jul;41(7):1571-8. doi: 10.1177/0363546513487980. Epub 2013 May 22.


Background: The factors that lead to patients failing multiple anterior cruciate ligament (ACL) reconstructions are not well understood.

Hypothesis: Multiple-revision ACL reconstruction will have different characteristics than first-time revision in terms of previous and current graft selection, mode of failure, chondral/meniscal injuries, and surgical charactieristics.

Study design: Case-control study; Level of evidence, 3.

Methods: A prospective multicenter ACL revision database was utilized for the time period from March 2006 to June 2011. Patients were divided into those who underwent a single-revision ACL reconstruction and those who underwent multiple-revision ACL reconstructions. The primary outcome variable was Marx activity level. Primary data analyses between the groups included a comparison of graft type, perceived mechanism of failure, associated injury (meniscus, ligament, and cartilage), reconstruction type, and tunnel position. Data were compared by analysis of variance with a post hoc Tukey test.

Results: A total of 1200 patients (58% men; median age, 26 years) were enrolled, with 1049 (87%) patients having a primary revision and 151 (13%) patients having a second or subsequent revision. Marx activity levels were significantly higher (9.77) in the primary-revision group than in those patients with multiple revisions (6.74). The most common cause of reruptures was a traumatic, noncontact ACL graft injury in 55% of primary-revision patients; 25% of patients had a nontraumatic, gradual-onset recurrent injury, and 11% had a traumatic, contact injury. In the multiple-revision group, a nontraumatic, gradual-onset injury was the most common cause of recurrence (47%), followed by traumatic noncontact (35%) and nontraumatic sudden onset (11%) (P < .01 between groups). Chondral injuries in the medial compartment were significantly more common in the multiple-revision group than in the single-revision group, as were chondral injuries in the patellofemoral compartment.

Conclusion: Patients with multiple-revision ACL reconstructions had lower activity levels, were more likely to have chondral injuries in the medial and patellofemoral compartments, and had a high rate of a nontraumatic, recurrent injury of their graft.

Keywords: ACL; ACL revision; allograft; autograft.

Publication types

  • Comparative Study
  • Multicenter Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Adolescent
  • Adult
  • Anterior Cruciate Ligament Reconstruction / statistics & numerical data*
  • Case-Control Studies
  • Child
  • Female
  • Humans
  • Knee Injuries / epidemiology
  • Knee Injuries / surgery*
  • Male
  • Middle Aged
  • Prospective Studies
  • Reoperation / statistics & numerical data
  • Transplantation, Autologous / statistics & numerical data
  • Transplantation, Homologous / statistics & numerical data
  • Treatment Failure
  • United States / epidemiology
  • Young Adult