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Series Title
Chapter Title Revision of Failures After Reconstruction of the Anterior Cruciate Ligament
Chapter SubTitle
Copyright Year 2011
Copyright Holder Springer-Verlag Berlin Heidelberg
Corresponding Author Family Name Sevivas
Particle
Given Name Nuno
Suffix
Division Department of Orthopaedics
Organization Centro Hospitalar Entre Douro e Vouga, Centro Hospitalar Póvoa de
Varzim – Vila Conde, Clínica Saúde Atlântica
Address Rua Dr. Cândido de Pinho, 4520-211, Santa Maria da Feira, Portugal
Email e-mail: nunosevivas@gmail.com

Author Family Name Pereira

Particle
Given Name Hélder
Suffix
Division Department of Orthopaedics
Organization Centro Hospitalar Póvoa de Varzim – Vila Conde, Clínica Saúde Atlântica
Address Largo da Misericórdia, 4490-421, Póvoa de Varzim, Portugal
Email e-mail: heldermdpereira@gmail.com
Author Family Name Varanda
Particle
Given Name Pedro
Suffix
Division Department of Orthopaedics
Organization Centro Hospitalar Entre Douro e Vouga, Clínica Saúde Atlântica
Address Rua Dr. Cândido de Pinho, 4520-211, Santa Maria da Feira, Portugal
Email e-mail: pedrovaranda@gmail.com
Author Family Name Monteiro
Particle
Given Name Alberto
Suffix
Division Department of Orthopaedics
Organization Clínica Saúde Atlântica
Address Estádio do Dragão, 4350-415, Porto, Portugal
Email e-mail: monteirolda@sapo.pt@gmail.com
Author Family Name Espregueira-Mendes
Particle
 Given Name João
Suffix
Division Department of Orthopaedics
Organization Clínica Saúde Atlântica, Universidade do Minho
Address Estádio do Dragão, 4350-415, Porto, Portugal
Email e-mail: joaoespregueira@netcabo.pt

Abstract Surgical reconstruction of the anterior cruciate ligament (ACL) has become one of the most frequently
performed procedures in orthopaedic surgery and consequently the number of revisions of ACL
reconstructions is increasing.
Revision surgery is recommended for a patient who complains of instability, pain and/or reduced knee
mobility after ACL reconstruction and it requires a careful preoperative evaluation.
The subjective sensation of instability during sports or pivoting activities despite ACL reconstruction
without major problems identified and without significant anteroposterior instability is difficult to evaluate.
We use a new tool (PKTD) to objectively quantify both anteroposterior and rotational instability.
There is no single standard revision procedure. The strategy depends on the cause of failure, patient
characteristics and surgeon preferences.
  Revision of Failures After Reconstruction
 of the Anterior Cruciate Ligament

 Nuno Sevivas, Hélder Pereira, Pedro Varanda, Alberto Monteiro,

 and João Espregueira-Mendes

Contents Introduction 

Introduction.................................................................................. 000 Surgical reconstruction of the anterior cruciate ligament 

Causes of Failure of Primary Procedure................................... 000 (ACL) has become one of the most frequently performed 

procedures in orthopaedic surgery. It is estimated that 

Clinical Evaluation....................................................................... 000
History............................................................................................ 000 between 75,000 and 100,000 ACL repair procedures are 

Physical Examination..................................................................... 000 performed annually in the United States [16, 23]. The long 
KT-1000......................................................................................... 000 term follow-up results are good but clinical failures rates of 
Imaging.......................................................................................... 000 10–25% have been reported [29] and consequently the num- 

Treatment Options....................................................................... 000 ber of revisions of ACL reconstructions, and even repeat 

f
Surgery........................................................................................... 000 revisions (two revisions or more), are increasing [32]. 

oo
Surgical Strategy Planning............................................................. 000
Graft Choice................................................................................... 000
In the past few years, intensive basic study about ACL 

Graft Fixation................................................................................. 000 has been done and consequently marked clinical improve- 

Rehabilitation................................................................................. 000 ments have appeared in the graft selection, tunnel placement, 

Conclusion.................................................................................... 000
Pr
graft fixation and rehabilitation of the reconstructed ACL. 

Knowledge concerning the biology of graft incorporation 

References..................................................................................... 000
and “ligamentization” process has also increased [8], improv- 

ing our ability to prevent complications such as excessive 

ed

graft elongation, pullout or slippage [19]. 

Generically, ACL has been described as being composed 

N. Sevivas (*) of two different functional bundles – anteromedial (AM) 
Department of Orthopaedics, Centro Hospitalar Entre
ct

[AU1] bundle and posterolateral bundle – named for the relative 

Douro e Vouga, Centro Hospitalar Póvoa de Varzim –
Vila Conde, Clínica Saúde Atlântica, Rua Dr. Cândido de Pinho, location of the tibial insertion site [14]. These two bundles 
4520-211 Santa Maria da Feira, Portugal act together resisting anterior tibia translation [25, 28] and
re


e-mail: nunosevivas@gmail.com functioning like rotational stabilizers of the knee [11]. 
H. Pereira The single-bundle ACL reconstruction tries to reconstruct 
or

Department of Orthopaedics, Centro Hospitalar only one portion of the ACL (the AM) and the reported out- 
Póvoa de Varzim – Vila Conde, Clínica Saúde Atlântica,
Largo da Misericórdia, 4490-421 Póvoa de Varzim, Portugal
comes are generally good [10, 37]. Other authors argue that 

e-mail: heldermdpereira@gmail.com the knee rotational control only can be rehabilitate with an 
nc

anatomical double-bundle ACL reconstruction [35, 36]. 

P. Varanda
Department of Orthopaedics, Centro Hospitalar Upcoming insights concerning this issue might help us in 

Entre Douro e Vouga, Clínica Saúde Atlântica, a recent future to explain some patient’s dissatisfaction, with 
U

Rua Dr. Cândido de Pinho, 4520-211 Santa Maria da Feira, Portugal limited return to same level sports activity after ACL surgery, 
e-mail: pedrovaranda@gmail.com
in which we could not detect neither imagiologically nor on 
A. Monteiro clinical examination any relevant problem. The truth is that 
Department of Orthopaedics, Clínica Saúde Atlântica, we now face the challenge of objectively quantifying both 
Estádio do Dragão, 4350-415 Porto, Portugal
e-mail: monteirolda@sapo.pt@gmail.com anteroposterior and rotational instability. This led us to the 

development of a valuable tool to measure the rotational 

J. Espregueira-Mendes
Department of Orthopaedics, Clínica Saúde Atlântica, Universidade
instability measured during MRI or CT scan – PKTD (Knee 

do Minho, Estádio do Dragão, 4350-415 Porto, Portugal testing device – T. Lob and Espregueira-Mendes). The func- 

e-mail: joaoespregueira@netcabo.pt tional implication of these measures and the way in which 

M.N. Doral et al. (eds.), Sports Injuries, 1

DOI: 10.1007/978-3-642-15630-4_64, © Springer-Verlag Berlin Heidelberg 2011
 2 N. Sevivas et al.

 they will affect ACL reconstruction technique is to be deter- but biological factors [5, 15] or new trauma episode [12, 17] 

 mined and subject of ongoing investigation, in our depart- can also be involved. More specifically, failures can be related 

 ment. Our purpose is the definition of objective quantitative with malpositioning of the tunnels, aggressive rehabilitation 

 parameters of this ill-defined cause of failure after ACL recon- where the intraosseous incorporation and “ligamentization” 

 struction: subjective sensation of instability during sports or period were not respected and the fixation system failure (e.g. 

 pivoting activities despite ACL reconstruction without major graft pullout or slippage). 

 problems identified and without significant anteroposterior We prefer to separate the causes of failure of an ACL 

 instability (normally assessed by KT-1000 or Lachman test). reconstruction based on patient’s clinical aspects. We con- 

 Revision surgery is recommended for a patient who com- sider two major causes: instability and reduced knee mobil- 

 plains of instability, pain and/or reduced knee mobility after ity (with or without pain). 

 ACL reconstruction. It requires a careful preoperative evalu-

 ation since this will be determinant for the final result. The 1. Instability 

 compliance and motivation of the patient must be assessed (a) Always present after surgery – poor graft fixation and/ 

f
 and the patient must understand what the realistic expecta- or malpositioning; 

oo
 tions about the results are. It is well established that the (b) Initial full recovery and instability after new trauma – 

 results are not as good as in a primary procedure [18, 21, 31, usually means that a re-rupture has occurred; 

 34] and they are influenced by the cause of the failure. The (c) Initial rigidity – malpositioning of the tunnel with 

patient must also know that untreated symptoms of instabil-

Pr
 knee movement limitation that improves after graft 

 ity may contribute to meniscus and chondral damage, leading elongation or rupture has occurred and after that the 

 to an earlier progression of osteoarthritis [3, 7, 13, 22, 26]. patient begins to refer instability. 

 There is no single standard revision procedure. The strat- 2.  Reduced knee mobility 






egy depends on the cause of failure, patient characteristics
and surgeon preferences and for that a variety of techniques,
grafts and methods of fixation are available. ed (a) Extension deficit
• Cyclops (Fig. 1a and b)
• Intercondylar notch scarring





ct
 The aetiology, the clinical assessment of the patient, the • Femoral tunnel too posterior – this situation is very 

 treatment options including key surgical technical points and rare and usually is well tolerated 

 rehabilitation, after ACL reconstruction failure, will be dis- • Tibial tunnel too anterior (graft impingement)
re


 cussed in the next points. (Fig. 2) 

(b)  Flexion deficit 

or

• Femoral tunnel too anterior (Fig.  2) – it is a fre- 

quent error in the inside out technique 

 Causes of Failure of Primary Procedure • Tibial tunnel too posterior 
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(c) Extension and Flexion deficit (Capsulitis/arthrofibro- 

 There are several causes of ACL reconstruction failure and sis) – characterized by constant pain and stiffness, 

 sometimes more than one may be involved. The main recog- inflamed and swollen knee, quadriceps lag and lim- 
U

 nized cause is error in the surgical technique [1, 21, 29, 31, 34] ited patella mobility 

a
b

Fig. 1  Cyclops (a) arthroscopic

view. (b) MRI
 Revision of Failures After Reconstruction of the Anterior Cruciate Ligament  3

Physical Examination 

The gait pattern and limb alignment should be evaluated 

since the beginning. A varus alignment can cause excessive 

loads on the reconstructed ACL and, in this case, a valgus 

[AU2] osteotomy should be considered at the same time of the 

­revision [2]. 

The range of movement of the knee (ROM) must be 

assessed because a severe loss of flexion and/or extension 

might need an initial procedure to regain a pain free full 

ROM. 

We use always the Lachman test and pivot shift test to 

f
evaluate the knee stability in these patients. The pivot shift 

test is the most important test in determining ACL insuffi-

oo


ciency and is a useful method to detect clinical knee instabil- 

ity. The pivot shift test has various grades (0, ± glide; ++; 

+++) and one should be clear about that. A positive test, 

Pr
independent of the grade, is indicative of a functionally defi- 

cient anterior cruciate ligament [6] in preventing abnormal 

rotation. 

Associated knee ligamentous instability (e.g. medial, lat-

ed eral, posteromedial and posterolateral) must be searched and,




if present, addressed to avoid failure of the ACL revision 

graft. An examination under anaesthesia can help in this

ct


evaluation and should be performed [9]. 

Fig. 2  Anterior placement of tibial and femoral tunnel
re

KT-1000 
 Clinical Evaluation
or

We use KT-1000 to assess and quantify knee laxity. This is a 

 History reproducible tool to perform a quantitative evaluation of the
nc



Lachman test. A difference superior to 3  mm between the 

 One should investigate the specific details of the original knees is considered “abnormal”. 

 injury (e.g. trauma characteristics), the previous treatment

U

 details (e.g. graft choice and fixation, time between trauma
 and surgery) and rehabilitation program (e.g. time between
 surgery and return to sports activity). Imaging 

 It is important to understand what is the main problem is:

 Instability or reduced knee mobility (with or without pain). The plain x-ray series of a weight-bearing anteroposterior 

 The patient symptoms can orientate us in the differential radiograph, a correct lateral x-ray in full extension and 30° 

 diagnosis. The presence of pain can be related to a cartilage of flexion, 45° posteroanterior weight bearing, notch and 

 lesion or synovitis and must be treated accordingly. axial views are always needed. These exams can help in the 

 If instability is implicated, we should know when it has evaluation of limb alignment, original tunnel placement, 

 started after the primary repair. If there had been a gradual fixation methods used, tunnel widening, osteolysis and 

 onset of instability, there may have been gradual stretch- articular degenerative changes. 

 ing of the repair associated to a non-anatomical placement CT scan is sometimes useful to better show the extent of 

 of the graft, aggressive rehabilitation or failure of the bony defect and tunnels placement. We always ask a MRI 

 graft/fixation. If the patient states that the knee has never preoperatively to evaluate, more precisely, the ACL graft 

 been stable after surgery then it is likely a failure of graft (integrity and incorporation) and the possible associated 

 fixation. lesions (e.g. chondral, menisci and ligaments) [9]. 

 The future occupational and recreational activities desired We developed an instrument to assess the anteroposte- 

 might be answered and clarified too. rior and rotational instability during the MRI/CT scan 
 4 N. Sevivas et al.

Fig. 4  Autograft tendon with enlarged bony portion

Fig. 3  Porto KTD (Knee Testing Device)

examination – Porto KTD (Knee testing device – T. Lob

f


 and Espregueira-Mendes) (Fig. 3). This device is made in

oo
 polyethylene, has no artefacts and can be introduced in
 MRI and CT scan. It pushes the tibia anteriorly and pro-
 duces the abnormal antero-posterior and internal rotation of

Pr
 the tibia. The anterior translation and the internal rotation
 can be objectively measured between the femur and the
 tibia (between two pre-defined bony landmarks).

 Treatment Options ed

ct
 After assessment of the major complaint and the cause of Fig.  5  Fixation expansion device (ResofixTM Resoimplant GmbH,
failure identified, we must decide if the patient is suitable for Regensburg, Germany)
re


 a revision surgery. The patient must be involved in the deci-

 sion and clarified about the need of surgery to solve his prob- an outside-in technique we advise an inside-out revision 
or

 lems. Sometimes a decrease of the activity level or a specific with divergent axis (an vice-versa) and the imaging control 

 rehabilitation program with improvement of the propriocep- of the tunnel position is wise. To solve the bone loss some 

 tion may result in the resolution of the symptoms [30]. options are available like: iliac crest bone autograft, use of 
nc

 When pain is a major problem, an arthroscopy can be an autograft/allograft tendon with an enlarged bony portion 

 enough to improve patient symptoms. This will enable treat- (Fig.  4), an oversized interference screw or utilise two or 

 ment of a meniscus lesion, a cartilage lesion, a Cyclops more screws for fixation. We routinely use an expansion 
U

 lesion and synovitis. In some patients with lower level of device (ResofixTM Resoimplant GmbH, Regensburg, 

 activity the simple removing of the graft can be sufficient Germany) that fits some amount of bone loss (Fig. 5). One 

 (totally or partially). must ensure that the tunnels are placed in the correct posi- 

 Revision ACL surgery is considered a salvage procedure tion but also in good-quality bone. Only if these two points 

 and final outcomes are less optimistic than in the primary are kept in mind, we can ensure a good graft fixation in the 

 surgery [24]. desired position. 

 It is important to determine during the preoperatively A high index of suspicion about infection, like cause of 

 evaluation if the hardware needs to be removed. We remove ACL reconstruction failure, should be present when any 

 it, if it is on the way of the new tunnel and will interfere with other cause can be implicated. Blood sample analysis, bone 

 the correctly placed revision tunnel. Otherwise we will leave scan and routine multiple knee synovial biopsies should be 

 it in place, to not extend the loss of bone stock due to tunnel done to rule out this situation. 

 widening. All this points will influence the surgical options.
 In some cases of tunnel malpositioning, we can simply
 drill a new tunnel without violating the original tunnel or
 removing the hardware. However, in some cases, we are Surgery 

 obliged to overlap a previous tunnel and remove the hard-

 ware to drill the tunnel in the optimal position and in this The revision ACL surgery aims are similar to any primary 

 case we are obliged to resolve the bone stock loss. To review procedure – stable and painless knee. So attention is given 
 Revision of Failures After Reconstruction of the Anterior Cruciate Ligament  5

 to the optimal tunnel placement, correct graft choice and n­ on-anatomical position because the resultant bony defect can 

 effective method of fixation to allow an early rehabilitation be excessively large. In the presence of large bone defects, we 

 program. can solve that with bone grafting but sometimes we need to 

 In our experience between 1989 and 2007, we carried out use a two-stage procedure [29, 30]. If we find a bundle in 

 1,464 primary ACL repairs with a success rate of 96%. In the good position, we advise to revise only the wrong placed 

 same period we revised 44 patients, many of them referred bundle (“Double bundle concept”). 

 from other centres. In the revision with a mean follow-up of Associated knee ligamentous instability must be treated 

 8.5 years we found 69% of the patients classed A + B with to avoid failure of the ACL revision surgery. Acute lateral 

 IKDC score. More than 90% of the cases showed technical collateral or posterolateral ligamentous injury should be 

 errors. In 71% of the cases the X-ray showed arthrosis or repaired with or without augmentation. High-grade medial 

 subchondral sclerosis on one or both compartments with a collateral sprains with posteromedial corner injuries should 

 statistically significative relation with meniscectomy and be repaired or allowed to heal before reconstruction. 

 cartilage lesion. In this series we had 7.6% of failures. Complete posterior cruciate ligament (PCL) ruptures should 

f
 The patient must be told that the results of ACL revision undergo simultaneous or staged reconstruction [34]. 

oo
 surgery are usually good but are not as reliable as in primary
 procedures [20, 31, 33].
Graft Choice 

Pr
 Surgical Strategy Planning
It is a matter of debate whether an autograft or an allograft 

should be preferred in ACL revision surgery. Both options 

 Standard equipment is insufficient for an ACL revision and have advantages and disadvantages and the choice should be
 specific equipment for removal of previous implants (e.g.
ed decided case by case and based in the surgeon’s experience.



 trephines, screwdrivers) and drills of several sizes for over An allograft does not have donor site morbidity and can 
 drilling should be available. have a big bone block that is very useful in cases where we
ct

 We only remove material that is likely to interfere with need to fill bone loss holes. However the infection transmis- 
 the operation. An empty tunnel, after removal of a screw, can sion risk, the slower integration and possible immunological 
re

 leave bone fragility and can break the wall of the new tunnel reactions are points of concern. We can join also the increased 
 with a compromised fixation graft. cost with this option that it has to be weighted when we have 
 Removal of staples from the medial tibial metaphyseal to decide the surgical strategy.
or


 cortex may be a problem. This may result in damage to the Our rule is to use autograft and we advise the use of 
 cortical bone that may interfere with graft fixation. In some allografts only when patient’s own graft is not enough to the 
cases of severe bone loss or/and very important stiffness we patient’s needs. This is sometimes the case when we have to
nc

 
 must consider the possibility of a two steps surgery [29, 30]. repair multiligament lesions involving PCL, ACL and/or 
 Because the landmarks are often less distinct than in pri- posterolateral corner. The autograft patellar tendon is our 
 mary surgery the tibial tunnel should be referenced by imag- preferred graft, when its use is possible, because it allows a
U


 ing control. We do not advise the using of the posterior big bone block that can help us to fill a bone defect. 
 cruciate ligament or the intercondylar spines as references. Our rationale to choose the autograft, in ACL revision 
 We need to be anatomic [30]. A revision notchplasty might surgery, is explained in Table 1. Like other authors, in some 
 be needed to allow an adequate visualisation of the over-the- circumstances, we prefer to harvest the graft in the contralat- 
 top position and allow full excursion of the graft without eral limb [27] specially if the revision surgery has to be done 
 impingement. less than 18 months after the primary surgery and the initial 
 The choice of the correct position of the tunnels is the
 critical point of the operation. On the femoral side of the tun-
 nel, but also on the tibial side, the most common mistake is Table 1  Rationale of graft for revision surgery T

 to place it too anteriorly. For the femoral tunnel, the tech- Primary graft Revision graft T

 nique used at the time of revision surgery is different than Bone-patellar tendon-bone (BPTB) Four-strand T
 that used at the time of primary surgery, so we advise an in bad position hamstring T

 outside-in technique if the previous approach was inside-out Bone-patellar tendon-bone <18 M Contra-lateral T

 and vice-versa [2, 30] If the previous tunnels are in good (BPTB) well positioned BPTB T

 position, they can be redrilled at the same place and if they ³18 M Ipsilateral BPTB T

 are in a poor position, it may be possible to ream a new one Four-strand hamstring BPTB T

 without encroaching on the originals. The most difficult Prosthetic Ipsilateral BPTB T

 ­situation arises when the initial tunnels are in a slightly graft T
 6 N. Sevivas et al.

 graft is well positioned. When the initial graft was performed dynamic stability exercises. Running is started when mini- 

 18 months or more before, we reharvest the graft in the same mal swelling and knee pain have been achieved [30]. 

 location [4]. At the end of the program a sports-specific training is 

done but having always in mind the need to respect both the 

intraosseous graft incorporation and ligamentization period 

of the graft. This is a long continuous process leading to graft 

 Graft Fixation transformation in a tissue that approximates, but does not 

fully replace, the native ligament. It is commonly divided in 

 The fixation method used plays a decisive role in the suc- an early phase dominated by graft necrosis and hypocellular- 

 cessful final result. Independent to the method used, it has to ity, followed by the proliferation phase (higher biomechani- 

 withstand the early postoperative rehabilitation forces until cal fragility) and finally the ligamentization phase culminating 

 the graft integration has occurred. in graft remodelling until the maximum of resistance with 

 Several methods exist to accomplish this mission. closest resemblance to native ACL. In our opinion respect 

f
 Generically they can be classified as cortical (suspensory) or for this process is mandatory for successful rehabilitation. 

oo
 apertural (intratunnel). The analysis of the behaviour of the We can predict that generally the patient can return to contact 

 different types of fixation is not the issue of this work. sports 9 months after surgery but all factors (patient-related 

 A full range of devices for bone and soft-tissue fixation and surgery-related) must be considered and in some cases a 

longer period might be required once our main objective must

Pr
 must be available so as to not restrict the choice of the graft. 

 For us, the ideal method is a resorbable apertural method that not be jeopardized by to aggressive protocols not respecting 

 maintains the necessary fixation force to withstand the post- some golden rules dictated by biology. 

 operative forces until the graft integration has occurred and





then after disappears without a harmful reaction to the graft
substitute. We use the ResofixTM (Resoimplant GmbH,
Regensburg, Germany) that is a PLDA (Poly-D, L-Lactide) ed
Conclusion 
ct
 bioabsorbable expansion-bolt for graft fixation that guaran-
 tees both a stable fixation in the bone canal, but also a secure Revision of failures after reconstruction of the ACL is a chal- 

and defined resorption time. Other devices are available and lenging procedure and presents many clinical and technical
re
 

 might be needed like interference screws, staples, washers, challenges. It requires a careful preoperative evaluation with 

 endobuttons, transfix and rigid fix. a detailed history and comprehensive physical examination, 
or

appropriate radiological studies and careful preoperative 

planning. 

We need to identify the patient complaints with the asso- 

nc

 Rehabilitation ciated causes for failure, identify and treat associated insta- 

bilities, deal with problems resulting from the previous 

 A less aggressive postoperative rehabilitation program is surgery (e.g. bone loss, previous used graft) and choose the 
U

 needed after ACL revision surgery, with slower progression most appropriate graft, fixation method and rehabilitation 

 in weight-bearing and functional exercises. This rehabilita- program. 

 tion program must be tailored for the individual patient, tak- There are many surgical options and the surgeon must be 

 ing into account the limb alignment, bone quality, patient familiarized with several different techniques to use the most 

 compliance and the surgical variables that might interfere appropriated to the patient. 

 with the rehabilitation progression.

 General rule, the patients start knee flexion in the first
 24 h after surgery and full passive extension movement must
 be allowed immediately. We use ice therapy regularly, pre References 

 and postoperatively, to reduce the inflammatory response

 and swelling. The patients use crutches to walk, which are   1. Carson, E.W., Anisko, E.M., Restrepo, C., Panariello, R.A., 
O’Brien, S.J., Warren, R.F.: Revision anterior cruciate ligament 
 used until a good gait pattern has been achieved. The patients
reconstruction: etiology of failures and clinical results. J. Knee 
 are discharged 48 h after surgery and continue the rehabilita- Surg. 17, 127–132 (2004) 
 tion in an outpatient form.   2. Carson, E.W., Brown, C.J.: Revision Anterior Cruciate Ligament 

 The patients might achieve full knee extension and a min- Surgery. The Adult Knee. Lippincot, Williams & Wilkins, 
Philadelphia (2003) 
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 ing (isometric, closed chain and some open chain only), and degenerative change. J. Bone Joint Surg. Br. 87, 1639–1642 (2005) 
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 anterior cruciate ligament reconstruction with a reharvested ipsilat- after failed treatment of rupture of the anterior cruciate ligament. 
 eral patellar tendon. Am. J. Sports Med. 29, 746–750 (2001) J. Bone Joint Surg. Am. 76, 1019–1031 (1994) 
   5. Corsetti, J.R., Jackson, D.W.: Failure of anterior cruciate ligament 22. Ohly, N.E., Murray, I.R., Keating, J.F.: Revision anterior cruciate 
 reconstruction: the biologic basis. Clin. Orthop. Relat. Res. 325, ligament reconstruction: timing of surgery and the incidence of 
 42–49 (1996) meniscal tears and degenerative change. J. Bone Joint Surg. Br. 89, 
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 remodelling of the patella tendon graft in anterior cruciate ligament situ forces in the anterior cruciate ligament and its bundles in 
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