Revision Anterior Cruciate Ligament Reconstruction: Tibial Tunnel-First Graft-Sizing Technique

Revision anterior cruciate ligament reconstruction (R-ACLR) has become more common as the number of failed primary ACLRs increase. Although increasingly common, R-ACLR has a greater failure rate than a primary reconstruction. Technical errors, particularly in tunnel placement, account for a large proportion of graft failure in R-ACLR as well as re-revision cases. Tunnel placement and trajectory is particularly important in R-ACLR and becomes more challenging with each additional revision attempt. This is in part because any tunnels created for revision may converge with formerly drilled tunnels or face interference hardware creating, complicating proper graft fixation. While there are many approaches to revision ACL surgery, our technique describes a simple, tibial tunnel-first graft-sizing method initially reaming tunnels with very small diameters and sequentially working your way up to more anatomic diameters.
Technique Video Video 1 Revision anterior cruciate ligament (ACL) reconstruction using the tibial tunnel sizing technique. Diagnostic arthroscopy showing few fibers of the remnant ACL. An electrocautery wand is used to clean the back wall. The lateral femoral condyle notch is clear. The tibial tunnel sizing technique is accomplished by firing a guide pin using a tip aiming guide to confirm a good guide pin trajectory for the new tibial tunnel. Once the position and trajectory of the pin is satisfactory, the smallest reamer available, size 6-mm reamer, is used to ream the new tibial tunnel. An arthroscope is then used to confirm a sufficient bony wall throughout the tibial tunnel before proceeding. The next size up reamer, a size 7-mm reamer, is reinserted into the same tibial tunnel that is created using the size 6-mm reamer and is positioned using a straight clamp from the anteromedial portal. This process is repeated until the size 10-mm reamer is inserted while each time looking up the tibial tunnel to confirm a sufficient bony circumferential wall. At the graft preparation station, the Achilles tendon is cut down to a size 10, loaded on the TightRope (Arthrex), and confirmed with a sizing block. The TightRope button with Achilles allograft is passed up the femoral socket and flipped in the cortex. The Achilles allograft is cinched up, the FastThread Biocomposite Interference Screw (Arthrex) is used, and graft is probed to check for proper tension. The graft is retensioned and then a final check is completed.