Lower Failure Rates and Improved Patient Outcome Due to Reconstruction of the MCL and Revision ACL Reconstruction in Chronic Medial Knee Instability

Background: Concomitant lesion of the medial collateral ligament (MCL) is associated with a greater risk of anterior cruciate ligament (ACL) graft failure. Purpose: The aim of this study was to compare two medial stabilization techniques in patients with revision ACL reconstruction (ACLR) and concomitant chronic medial knee instability. Study Design: Cohort study; Level of evidence, 3. Methods: In a retrospective study, we included 53 patients with revision ACLR and chronic grade 2 medial knee instability to compare medial surgical techniques (MCL reconstruction [n = 17] vs repair [n = 36]). Postoperative failure of the revision ACLR (primary aim) was defined as side-to-side difference in Rolimeter testing ≥5 mm or pivot-shift grade ≥2. Clinical parameters and postoperative functional scores (secondary aim) were evaluated with a mean ± SD follow-up of 28.8 ± 9 months (range, 24-69 months). Results: Revision ACLR was performed in 53 patients with additional grade 2 medial instability (men, n = 33; women, n = 20; mean age, 31.3 ± 12 years). Failure occurred in 5.9% (n = 1) in the MCL reconstruction group, whereas 36.1% (n = 13) of patients with MCL repair showed a failed revision ACLR ( P = .02). In the postoperative assessment, the anterior side-to-side difference in Rolimeter testing was significantly reduced (1.5 ± 1.9 mm vs 2.9 ± 2.3 mm; P = .037), and medial knee instability occurred significantly less (18% vs 50%; P = .025) in the MCL reconstruction group than in the MCL repair group. In the logistic regression, patients showed a 9-times elevated risk of failure when an MCL repair was performed ( P = .043). Patient-reported outcomes were increased in the MCL reconstruction group as compared with MCL repair, but only the Lysholm score showed a significant difference (Tegner, 5.6 ± 1.9 vs 5.3 ± 1.6; International Knee Documentation Committee, 80.3 ± 16.6 vs 73.6 ± 16.4; Lysholm, 82.9 ± 13.6 vs 75.1 ± 21.1 [ P = .047]). Conclusion: MCL reconstruction led to lower failure rates in patients with combined revision ACLR and chronic medial instability as compared with MCL repair. MCL reconstruction was superior to MCL repair, as lower postoperative anterior instability, an increased Lysholm score, and less medial instability were present after revision ACLR. MCL repair was associated with a 9-times greater risk of failure.

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Percutaneous MCL reconstruction technique in acute anterior medial knee instability using cadaveric grafts

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967114s00258 ◽

2014 ◽

Vol 2 (12_suppl4) ◽

pp. 2325967114S0025

Author(s):

Jorge Batista ◽

Rodrigo Maestu ◽

Sebastián Teper ◽

Manuel Ocampo ◽

German Antúnez ◽

...

Keyword(s):

Acl Reconstruction ◽

Cruciate Ligament ◽

Functional Results ◽

Lysholm Score ◽

High Rate ◽

Knee Instability ◽

Reconstruction Technique ◽

Medial Knee ◽

Acute Injuries ◽

Anterior Cruciate

Purpose: There are several alternatives described for the treatment of acute injuries of the anterior cruciate ligament (ACL ) and the medial collateral ligament (MCL) of the knee. We present the result of the combined ACL reconstruction and MCL in the same surgical procedure using only percutaneous cadaveric graft in the reconstruction of the MCL ligament. Methods: We retrospectively analyzed 30 patients with acute anterior and medial knee instability surgically treated between August 2007 and September 2013. 27 men and 3 women , mean age 30.53 years (range 18-46 ) The level of pre and post surgical activity was determined by the Tegner score , while the function was evaluated using the Lysholm score and IKDC grade Results: The average follow-up was 43 months (range 12-84 months). The mean Lysholm score was 91 (R, 61-100 ) . Only 19 of 30 (63.3 %) patients returned and kept the pre -injury level sports ; 26 patients IKDC : A (normal knee ), 3 patients IKDC : B (slightly abnormal knee ) and 1 patient IKDC C ( Knee abnormal) with limitation of 15 degrees of extension that had to be reoperated. Conclusion: The use of cadaveric tendons for reconstruction of MCL in combination with ACL reconstruction surgeries resulted in less postoperative pain, good functional results, and a high rate of return to competitive sport. The result of this study shows that the percutaneous reconstruction of LCM cadaveric graft is a viable option.

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Revision ACL Reconstruction - A retrospective failure analysis with a mean follow up of 35 months

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120s00305 ◽

2020 ◽

Vol 8 (5_suppl4) ◽

pp. 2325967120S0030

Author(s):

Lena Alm ◽

Matthias Krause ◽

Karl-Heinz Frosch ◽

Ralph Akoto

Keyword(s):

Acl Reconstruction ◽

Pivot Shift ◽

Cruciate Ligament ◽

Knee Laxity ◽

Knee Instability ◽

Medial Knee ◽

Risk Of Failure ◽

Anterior Knee Laxity ◽

Anterior Cruciate ◽

Anterior Knee

Aims and Objectives: While patients following primary anterior cruciate ligament (ACL) surgery show satisfying results, the outcome after revision ACL reconstruction (ACLR) seems to be less favourable. The purpose of this study was to evaluate the outcome of patients after revision ACLR. We hypothesize that peripheral knee instabilities and further concomitant lesions are risk factors for failure of revision ACLR. Furthermore, we hypothesize that peripheral stabilisation will reduce the risk of failure. Materials and Methods: Between 2013 and 2016, 111 patients with revision ACLR (revision surgery after primary ACL reconstruction) were included in the retrospective study. All patients were clinically examined with a minimum of 2 years after revision surgery (mean 35 months) and identified as “failed revision ACLR” (side-to-side difference greater than 5mm and/or pivot-shift grade 2/3) and “stable revision ACLR”. Multiple logistic regression modeling was used to evaluate whether certain predisposing factors were associated with increased odds of failure of the revision ACLR. Results: Failure after revision ACLR occurred in 14.5% (n=16) of the cases. Preoperative medial knee instability (n=36) was associated with failure of revision ACLR, thus patients had a 17 times greater risk of failure when medial knee instability was diagnosed preoperatively. Also, the risk of failure was reduced when patients had peripheral medial (n=24) and/ or antero-lateral stabilisation (n=51). Increased posterior tibial slope (PTS, n=11 greater than 12°) and high-grade anterior knee laxity (side-to-side-difference greater than 5 mm and/or pivot-shift grade 3, n=41) were associated with failed revision ACLR. Furthermore, patients had a 9 times greater risk of failure when they were obese (BMI greater than 30 kg/m2, n=30). Also, postoperative functional scores in comparison to preoperative scores were shown to be significantly higher (Lysholm 85±27 vs. 51±31.9, p=0.024; Tegner 6.5± 1.3 vs. 4± 2.6, p=0.015). Conclusion: Results following revision anterior cruciate ligament reconstruction (ACLR) are less favourable than primary ACLR. Peripheral medial knee instability, high-grade anterior knee laxity, increased PTS and high BMI are risk factors for failure in revision ACLR while additional medial and/or antero-lateral stabilisation reduces the risk of failure.

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Performance of the PROMIS in Patients After Anterior Cruciate Ligament Reconstruction

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967118774509 ◽

2018 ◽

Vol 6 (5) ◽

pp. 232596711877450 ◽

Cited By ~ 16

Author(s):

Elizabeth J. Scott ◽

Robert Westermann ◽

Nathalie A. Glass ◽

Carolyn Hettrich ◽

Brian R. Wolf ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Physical Function ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Sf 36 ◽

Significant Difference ◽

Patient Reported ◽

Floor Effects ◽

Anterior Cruciate ◽

Pro Instruments

Background: The Patient-Reported Outcomes Measurement Information System (PROMIS) is designed to advance patient-reported outcome (PRO) instruments by utilizing question banks for major health domains. Purpose: To compare the responsiveness and construct validity of the PROMIS physical function computer adaptive test (PF CAT) with current PRO instruments for patients before and up to 2 years after anterior cruciate ligament (ACL) reconstruction. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: Initially, 157 patients completed the PROMIS PF CAT, Short Form–36 Health Survey (SF-36 physical function [PF] and general health [GH]), Marx Activity Rating Scale (MARS), Knee injury and Osteoarthritis Outcome Score (KOOS activities of daily living [ADL], sport, and quality of life [QOL]), and EuroQol–5 dimensions questionnaire (EQ-5D) at 6 weeks, 6 months, and 2 years after ACL reconstruction. Correlations between instruments, ceiling and floor effects, effect sizes (Cohen d), and standardized response means to describe responsiveness were evaluated. Subgroup analyses compared participants with and without additional arthroscopic procedures using linear mixed models. Results: At baseline, 6 weeks, and 6 months, the PROMIS PF CAT showed excellent or excellent-good correlations with the SF-36 PF ( r = 0.75-0.80, P < .01), KOOS-ADL ( r = 0.63-0.70, P < .01), and KOOS-sport ( r = 0.32-0.69, P < .01); excellent-good correlation with the EQ-5D ( r = 0.60-0.71, P < .01); and good correlation with the KOOS-QOL ( r = 0.52-0.58, P < .01). As expected, there were poor correlations with the MARS ( r = 0.00-0.24, P < .01) and SF-36 GH ( r = 0.16-0.34, P < .01 ). At 2 years, the PROMIS PF CAT showed good to excellent correlations with all PRO instruments ( r = 0.42-0.72, P < .01), including the MARS ( r = 0.42, P < .01), indicating frequent return to preinjury function. The PROMIS PF CAT had the fewest ceiling or floor effects of all instruments tested, and patients answered, on average, 4 questions. There was no significant difference in baseline physical function scores between subgroups; at follow-up, all groups showed improvements in scores that were not statistically different. Conclusion: The PROMIS PF CAT is a valid tool to assess outcomes after ACL reconstruction up to 2 years after surgery, demonstrating the highest responsiveness to change with the fewest ceiling and floor effects and a low time burden among all instruments tested. The PROMIS PF CAT is a beneficial alternative for assessing physical function in adults before and after ACL reconstruction.

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PATIENT REPORTED KNEE FUNCTION AND STABILITY IN PATIENTS WITH FIBULAR DEFICIENCY

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967119s00158 ◽

2019 ◽

Vol 7 (3_suppl) ◽

pp. 2325967119S0015

Author(s):

Matthew J. Brown ◽

Lauren Agatstein ◽

Brian Haus ◽

Joel Lerman

Keyword(s):

Standard Deviation ◽

Physical Function ◽

Normal Population ◽

Lysholm Score ◽

Knee Function ◽

Average Score ◽

T Score ◽

Significant Difference ◽

Patient Reported ◽

The Mean

BACKGROUND Fibular deficiency is a common long-bone deficiency with an estimated incidence of 7.4-20 cases per million live births. Absence or hypoplasia of the cruciate ligaments is present in most patients with fibular deficiency. In one series, the anterior cruciate ligament (ACL) was deficient in 95% while the posterior cruciate ligament (PCL) was deficient in 60% of patients with fibular deficiency. Symptomatic instability of the knee is variably present in patients with congenital absence of the ACL including fibular deficiency, with a reported incidence of between 3% and 50%. Despite this reported incidence, limited literature assessing the perceived knee stability in patients with fibular deficiency exists. METHODS Patients diagnosed with fibular hemimelia with congenital absence of the ACL were identified retrospectively at a pediatric hospital. Of the identified patients over the age of 16, 28 agreed to be part of the study and were sent an online survey. They completed Lysholm and Patient-Reported Outcomes Measurement Information System (PROMIS) surveys on knee problems, physical function, pain intensity, and overall health. The PROMIS raw score responses were converted to a T-score, scaled to a mean of 50 points (representative of the mean of the reference population), with a standard deviation of 10 points. Any response more than one standard deviation away from 50 was considered worthy of further review. 18 patients returned surveys, and these individuals comprise the final study group. RESULTS Of the study patients, the average age was 19.8 years (16-24 years), with 7 females and 11 males. 9 patients are amputees and 9 are non-amputees. On the Lysholm Knee Scoring Scale, the highest possible score is 100 points, which relates to normal knee function. Our average Lysholm score was 79.94, with a wide range in scores from 25-100 points, in comparison to the average adult knee score of 94 (Briggs et al). The amputee average Lysholm score was 77.8 and the non-amputee average Lysholm score was 74.1, with no statistically significant difference. For our cohort, the mean Physical Function T-score was 52 (range 27.5-60.1), with a higher score relating to better physical function. The amputee average score was 53.1 and the non-amputee average score was 45.8, with no statistically significant difference. 12 respondents reported normal physical function compared to the general population, with 8 more than 1 standard deviation (SD) above a T-score of 50. Of the 6 respondents with a physical function score lower than 50, 4 reported mild functional impairment (.5 – 1.0 SD), 1 moderate impairment (1.6 SD), and 1 severe impairment (2.25 SD). The severe impairment was reported by an amputee and the moderate physical impairment reported by a non-amputee. For the PROMIS Global Physical Health domain, the mean T-score was 52.6 (range 29 -63.3). There was no significant difference between the average scores of the amputee (54.8) and non-amputee (50.3) groups. 13 respondents had no difference or had better health than the normal population mean, with 8 being amputees and 5 being non-amputees. 5 respondents had the highest possible score of 63.3, which is 1.33 standard deviations better than the normal average (2 non-amputees and 3 amputees). Of the 5 patients (4 non-amputees and 1 amputee) reporting worse health, only 1 respondent reported severe health impairments (2.1 SD). All PROMIS subject areas measure whether more of the domain occurs. For Physical Function and Global Health, a higher score indicates improved function. In the Pain Intensity realm, a higher score relates to more pain. In this study population, the mean pain T-score was 40.15 (range 30.7 – 60.5). The amputee average score was 38.98 and the non-amputee average score was 41.3, with no significant difference between them. 16 patients had less pain or normal pain levels compared to the population mean. Of the two patients reporting worse pain than the normal population, the amputee patient had mild pain (within 1 SD of 50) and the non-amputee had moderate pain (1.05 SD). CONCLUSIONS The only previously published report on knee function in adults with fibular deficiency contained 11 patients; our 18 patients substantially expands data available on knee function in these patients. Previously, Crawford, et al, obtained Lysholm and Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) scores on nine patients treated since 1928. Their data demonstrated an average Lysholm score of 90.2, compared to ours of 79.94. The majority of our patients demonstrated excellent PROMIS responses, with 12-15 demonstrating average or above pain, physical function, and global health scores. Amputees tended to self-report better health than the non-amputees. Overall, in the young adult cohort, we demonstrate that the majority of patients with fibular deficiency function well and have a stable knee, although a small subset of patients do have challenges with knee function.

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Reoperation and Failure Rate at Six Years Following Revision ACL Reconstruction: A MARS Cohort Study

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967119s00292 ◽

2019 ◽

Vol 7 (7_suppl5) ◽

pp. 2325967119S0029

Author(s):

Keyword(s):

Acl Reconstruction ◽

Cruciate Ligament ◽

Reoperation Rate ◽

Patient Reported Outcome ◽

Young Cohort ◽

Revision Procedure ◽

Revision Acl Reconstruction ◽

Patient Reported ◽

Surgical Data

Objectives: Revision anterior cruciate ligament (ACL) reconstruction remains a challenge for orthopaedic surgeons, as results are persistently inferior to those of primary reconstructions. There is very limited data regarding outcomes at 6 years following revision ACL surgery. The purpose of this study was to report the rate of reoperation, further revision, and conversion to total knee arthroplasty (TKA) in a large cohort of revision ACL reconstructions Methods: Patients undergoing revision ACL reconstructions were identified and prospectively enrolled between 2006 and 2011. Data collected included baseline demographics, intraoperative surgical technique, and a series of validated patient-reported outcome instruments. Patients were followed up by questionnaire and telephone at 6 years following index revision surgery and asked if they had undergone any further surgical procedures to either knee. If a patient reported having undergone subsequent surgery, operative reports detailing the subsequent procedure(s) were obtained and categorized. Results: Six-year follow-up subsequent surgical data was available for 951/1234 patients (77%). In this available cohort, 556 (58%) were male, mean age was 28 years (range 12-61 years) and mean BMI was 26.1 (range 17.1-47.5). Allograft was used in 510 (54%) cases, BTB autograft in 234 (25%), soft tissue autograft in 174 (18%) and other grafts were used in the remaining 33 (3%). Their index surgery was their first revision ACL reconstruction in 822 (86.4%), in 108 (11.4%) it was their second, and in 21 (2.2%) it was their third or greater. This revision procedure was a mean of 5.7 years (range 0.1-26 years) from their prior ACL reconstruction. At six years following the index revision procedure, 16.2% of the cohort underwent at least 1 subsequent surgical procedure on their index knee. Of the reoperations, 29% were meniscal procedures (71% meniscectomy, 18% repair), 21% were articular cartilage procedures (79% chondroplasty, 15% microfracture, 3% OATS, 3% ACI), 11% were for arthrofibrosis, 9% for hardware removal, and 6% were for a subsequent revision ACL reconstruction. Surprisingly, only 5% reported having undergone a subsequent TKA on their ipsilateral knee. During this same 6-year follow-up period, 6% of the cohort (n=53 patients) underwent a subsequent surgery on their contralateral knee, of which 36 were ACL reconstructions. Conclusion: Our data shows that there is a reoperation rate of greater than 15% following ACL revision, which is an important point of discussion between surgeons and their patients. Of particular interest is that there was a 6% rate of recurrent ACL failure and 5% rate of subsequent TKA in this young cohort 6 years following a revision ACL reconstruction.

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Platelet-Rich Plasma Augmentation for Isolated Arthroscopic Meniscal Repairs Leads to Significantly Lower Failure Rates: A Systematic Review of Comparative Studies

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120964534 ◽

2020 ◽

Vol 8 (11) ◽

pp. 232596712096453

Author(s):

Kyle R. Sochacki ◽

Marc R. Safran ◽

Geoffrey D. Abrams ◽

Joseph Donahue ◽

Constance Chu ◽

...

Keyword(s):

Systematic Review ◽

Odds Ratio ◽

Patient Reported Outcomes ◽

Platelet Rich Plasma ◽

Meniscal Repair ◽

Activity Level ◽

Failure Rates ◽

Significant Difference ◽

Patient Reported ◽

Variable Data

Background: Studies have reported relatively high failure rates of isolated meniscal repairs. Platelet-rich plasma (PRP) has been suggested as a way to increase growth factors that enhance healing. Purpose: To compare (1) meniscal repair failures and (2) patient-reported outcomes after isolated arthroscopic meniscal repair augmented with and without PRP. Study Design: Systematic review; Level of evidence, 3. Methods: A systematic review was performed using the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines. Multiple databases were searched for studies that compared outcomes of isolated arthroscopic meniscal repair augmented with PRP versus without PRP in human patients. Failures and patient-reported outcome scores were reported for each study and compared between groups. Study heterogeneity was assessed using I 2 for each outcome measure before meta-analysis. Study methodological quality was analyzed. Continuous variable data were reported as mean and standard deviation from the mean. Categorical variable data were reported as frequency with percentage. All P values were reported with significance set at P < .05. Results: Five articles were analyzed (274 patients [110 with PRP and 164 without PRP]; 65.8% male; mean age, 29.1 ± 4.6 years; mean follow-up, 29.2 ± 22.1 months). The risk of meniscal repair failure ranged from 4.4% to 26.7% for PRP-augmented repairs and 13.3% to 50.0% for repairs without PRP. Meniscal repairs augmented with PRP had significantly lower failure rates than repairs without PRP (odds ratio, 0.32; 95% CI, 0.12-0.90; P = .03). One of the 5 studies reported significantly higher outcomes in the PRP-augmented group versus the no-PRP group for the International Knee Documentation Committee (IKDC), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Knee injury and Osteoarthritis Outcome Score (KOOS) ( P < .05 for all). The remaining 4 studies reported no significant difference between groups with regard to outcomes for the IKDC, Lysholm knee scale, visual analog scale for pain, or Tegner activity level. Conclusion: Although the studies were of mostly of low quality, isolated arthroscopic meniscal repairs augmented with PRP led to significantly lower failure rates (10.8% vs 27.0%; odds ratio, 0.32; P = .03) as compared with repairs without PRP. However, most studies reported no significant differences in patient-reported outcomes.

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Clinical Outcome of Fixed Versus Adjustable Loop Cortical Suspension Devices in Arthroscopic Anterior Cruciate Ligament Reconstruction

Ortopedia Traumatologia Rehabilitacja ◽

10.5604/01.3001.0014.3234 ◽

2020 ◽

Vol 22 (3) ◽

pp. 181-185

Author(s):

Ramy Said Assaad Ahmed Mohamed ◽

Mohamed Hossam El-Din El-Shafie ◽

Mohamed Ahmed El-Sheikh

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Ligament Reconstruction ◽

Cruciate Ligament ◽

Loop Group ◽

Lysholm Score ◽

Graft Fixation ◽

Cruciate Ligament Reconstruction ◽

Significant Difference ◽

Anterior Cruciate

Background. Anterior cruciate ligament (ACL) reconstruction has remained the gold standard for ACL injuries, especially for young individuals and athletes exposed to high level sporting activities aiming to return to their preinjury level of activity. Cortical suspensory femoral fixation is commonly performed for graft fixation to the femur in anterior cruciate ligament reconstruction using hamstring tendons. The aim of this study was to compare the clinical results of using fixed and adjustable loop cortical suspension devices in arthroscopic ACL reconstruction using the Lysholm Knee Scoring Scale after 12 months postoperatively. Material and methods. This study included a total of sixty patients who underwent transportal arthroscopic ACL reconstruction using a hamstring tendon autograft from November 2016 to December 2017. For femoral graft fixation, a fixed-length loop device was used in 30 patients (fixed-loop group) and an adjustable-length loop device was used in 30 patients (adjustable-loop group) randomly.For tibial graft fixation, interference screw was used for all patients. Results. The present study shows that there was no statistically significant difference between the two groups regarding the Lysholm score with highly statistically significant difference between preoperative and postoperative Lysholm score in each group separately. Conclusion. Both fixed loop and adjustable loop devices in ACL reconstruction provided good clinical outcomes but without significant statistical difference between both groups from the clinical point of view postoperatively using the Lysholm score.

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Revision Anterior Cruciate Ligament Reconstruction

Sports Health A Multidisciplinary Approach ◽

10.1177/1941738113500910 ◽

2013 ◽

Vol 6 (6) ◽

pp. 504-518 ◽

Cited By ~ 34

Author(s):

Jeffrey Wilde ◽

Asheesh Bedi ◽

David W. Altchek

Keyword(s):

Anterior Cruciate Ligament ◽

Clinical Outcomes ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Knee Instability ◽

Return To Play ◽

Revision Acl Reconstruction ◽

Pubmed Database ◽

Anterior Cruciate ◽

Primary Acl Reconstruction

Context: Reconstruction of the anterior cruciate ligament (ACL) is one of the most common surgical procedures, with more than 200,000 ACL tears occurring annually. Although primary ACL reconstruction is a successful operation, success rates still range from 75% to 97%. Consequently, several thousand revision ACL reconstructions are performed annually and are unfortunately associated with inferior clinical outcomes when compared with primary reconstructions. Evidence Acquisition: Data were obtained from peer-reviewed literature through a search of the PubMed database (1988-2013) as well as from textbook chapters and surgical technique papers. Study Design: Clinical review. Level of Evidence: Level 4. Results: The clinical outcomes after revision ACL reconstruction are largely based on level IV case series. Much of the existing literature is heterogenous with regard to patient populations, primary and revision surgical techniques, concomitant ligamentous injuries, and additional procedures performed at the time of the revision, which limits generalizability. Nevertheless, there is a general consensus that the outcomes for revision ACL reconstruction are inferior to primary reconstruction. Conclusion: Excellent results can be achieved with regard to graft stability, return to play, and functional knee instability but are generally inferior to primary ACL reconstruction. A staged approach with autograft reconstruction is recommended in any circumstance in which a single-stage approach results in suboptimal graft selection, tunnel position, graft fixation, or biological milieu for tendon-bone healing. Strength-of-Recommendation Taxonomy (SORT): Good results may still be achieved with regard to graft stability, return to play, and functional knee instability, but results are generally inferior to primary ACL reconstruction: Level B.

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