Central quadriceps free tendon for anterior cruciate ligament reconstruction

Central quadriceps free tendon provides an outstanding autograft alternative for routine anterior cruciate ligament (ACL) reconstruction, allowing preservation of hamstring tendons and eliminating the morbidity of bone plug harvest from the patella. Correct graft harvest technique, proper tunnel/graft sizing, accurate fixation, and adherence to the methods described will permit excellent ACL reconstruction with low morbidity.     

The mid- to long-term results of the anterior cruciate ligament reconstruction with hamstring tendons using Transfix technique

In this study, mid to long-term results of anterior cruciate ligament reconstruction with hamstring tendons and Transfix technique were evaluated. Anterior cruciate ligament (ACL) reconstruction with four-strand hamstring tendon was performed with Transfix technique on 271 (198 males, 73 females; mean age 25.7; 17–52) patients with anterior cruciate ligament ruptures. The patients were followed up with clinical examination, Lysholm and Tegner activity scales, IKDC scoring system, KT-1000 test and radiological examination. The mean follow-up period was 82 (48–100) months; 204 (75%) patients had no subjective complaints. According to the KT-1000 test, only 14 (5%) patients had more than 5 mm laxity postoperatively, whereas, 161 (59%) patients had more than 5 mm laxity preoperatively. In addition to this, only 19 (7%) patients had Lysholm scores less than 80 postoperatively, whereas 154 (57%) patients scored less than 80 preoperatively. When compared with Tegner activity scale, 189 (70%) patients scored <6 preoperatively and only 24 (8%) postoperatively; 78 (29%) patients scored D preoperatively and only 5 (2%) patients scored D postoperatively on the basis of the IKDC scoring system. Our functional results were found to be satisfactory in more than 90% of patients. Commonly seen problems in ACL reconstruction such as inaccurate graft placement and tunnel widening were found to be consistent with the values in relevant literature. However, we demonstrated that the functional results and the stability of the knee were not related with tunnel widening. This study concludes that the reconstruction of ACL with hamstring tendons and the Transfix technique is reasonably successful, safe and causes low morbidity. Furthermore, we believe that proper graft preparation, accurate tunnel placement, notch-plasty, fixation and rehabilitation program are all as important as the choice of graft and fixation material.     

A pitfall of transfix fixation during anterior cruciate ligament reconstruction

While attempting femoral fixation during anterior cruciate ligament (ACL) reconstruction using Bio-TransFix (Arthrex, Naples, FL), we experienced failure of complete insertion of a hamstring graft into the femoral tunnel. A passing wire was twisted in the femoral tunnel during insertion of the ACL graft. The cause and methods of prevention of this complication are discussed.     

Anterior cruciate ligament reconstruction using hamstrings for a two-incision technique

Anterior cruciate ligament (ACL) reconstructions are most commonly performed through a single incision, using either a patellar tendon or a hamstring graft. This technique, however, may be problematic in circumstances such as revision ACL reconstructions or reconstructions in patients with open growth plates. In these cases, a second incision may be needed to avoid existing tunnels or an open physis. The two-incision ACL reconstruction technique described in this article incorporates a four-stranded, gracilis-semitendinosus graft. The four free tendon ends are fixed proximally in a figure-of eight fashion with two bicortical screws and soft tissue washers. The distal looped end is secured with three No. 5 sutures tied to a screw and post. This construct provides graft (2800–4500 N) and fixation (821 N) strengths exceeding that of a 10 mm patellar tendon graft with interference screw fixation. This technique allows for an accelerated rehabilitation program, has low graft harvest morbidity, and provides the freedom necessary for tunnel placement and orientation in complicated reconstructions. For these reasons, this technique should be familiar to surgeons specializing in knee ligament reconstruction.     

Measurement of the graft angles for the anterior cruciate ligament reconstruction with transtibial technique using postoperative magnetic resonance imaging in comparative study

The aims of this study were to quantify the angle and placement of an anterior cruciate ligament (ACL) grafted with a single incision ACL reconstruction technique using postoperative magnetic resonance imaging (MRI), and to compare the results with those with a native ACL. Between February 1996 and May 2004, 96 consecutive patients, who had undergone postoperative MRI of the knee followed by an arthroscopically assisted ACL reconstruction with either a hamstring tendon or bone-patellar tendon-bone (BTB) autograft, were enrolled in this study. The femoral tunnel was drilled using the transtibial technique. The patients were divided into two groups; the hamstring tendon graft group (group H; 50 patients) and the BTB graft group (group B; 46 patients). All the patients including both groups in this study underwent postoperative MRI and were followed up for a minimum of 2 years. The control group (group C) consisted of 50 patients whose meniscus tear had been operated on by arthroscopy and whose ACL was intact. The orientation of the ACL ligament or graft was measured using three different methods: the sagittal ACL angle, the ACL-Blumensaat line angle, and the coronal ACL angle. The mean sagittal ACL angle in group C (58.7 ± 3.8°) was significantly lower than in groups H (64.6 ± 4.2°) and B (71.3 ± 6.0°). The mean ACL-Blumensaat line angle in group C (8.6 ± 3.6°) was also significantly lower than in groups H (12.8 ± 5.2°) and B (18.0 ± 5.3°). The mean coronal ACL angle in group C (65.9 ± 4.4°) was lower than that in groups H (73.5 ± 2.4°) and B (75.2 ± 2.9°). The grafted ACL of the hamstring tendon and BTB grafts on the postoperative MRI showed a significant vertical angle in the coronal and sagittal plane compared with the native ACL. In the sagittal plane, the hamstring tendon graft was positioned more obliquely than the BTB graft, which had a larger angle of the tibial tunnel, in an attempt to prevent a graft-tunnel mismatch. The postoperative MRI study showed that the more horizontally the angle of the tibial tunnel can be placed in a single incision ACL reconstruction, the more efficiently it can produce a graft closer to the native ACL.     

Consideration of growth factors and bio-scaffolds for treatment of combined grade II MCL and ACL injury

The literature suggests that a Grade II medial collateral ligament (MCL) injury in combination with anterior cruciate ligament (ACL) injury will heal naturally and not compromise patient outcome following ACL reconstruction. Evidence based on bone-patella tendon-bone autograft use is stronger than evidence supporting anatomically placed soft tissue graft use. Current ACL reconstruction practices make greater use of soft tissue grafts, differing fixation methods, and anatomically lower placement on the inner wall of the lateral femoral condyle. Anatomical graft placement aligns the femoral bone tunnel more directly with valgus knee loading forces. Differences in the soft tissue graft-bone tunnel integration and ligamentization timetable following ACL reconstruction also increase concerns regarding residual Grade II MCL laxity and functional deficiency during accelerated functional rehabilitation. MCL dysfunction may increase susceptibility to early ACL graft slippage, elongation, outright failure, and medial femoral condyle lift-off with valgus knee loading. This concept paper discusses the potential role of growth factors and bio-scaffolds for improving Grade II MCL injury healing and mechanical integrity when the injury occurs in combination with an ACL injury that is reconstructed with a soft tissue graft and an anatomical surgical approach.     

Importance of femoral tunnel placement in double-bundle posterior cruciate ligament reconstruction: biomechanical analysis using a robotic/universal force-moment sensor testing system

BACKGROUND: Previous studies have identified the femoral attachment of the posterior cruciate ligament fibers as one of the primary determinants of fiber tension behavior. In addition, a double-bundle posterior cruciate ligament reconstruction has been shown to restore the intact knee kinematics more closely than does a single-bundle reconstruction. HYPOTHESIS: An anterior tunnel position in double-bundle posterior cruciate ligament reconstruction restores the biomechanics of the normal knee more closely than does a posterior tunnel position. STUDY DESIGN: Controlled laboratory study. METHODS: Kinematics and in situ forces of human knees after double-bundle posterior cruciate ligament reconstruction with 2 different femoral tunnel positions (anterior vs posterior) were evaluated using a robotic/universal force-moment sensor testing system. Within the same specimen, the resulting knee kinematics and in situ forces were compared. For statistical analysis, 2-way analysis of variance repeated measures were performed. RESULTS: The femoral tunnel position of the double-bundle hamstring graft had significant effect on the resulting posterior tibial displacement and in situ forces of the hamstring grafts. The anterior femoral tunnel position provided significantly less posterior tibial translation than did the posterior tunnel position. There was a tendency toward higher in situ forces of grafts fixed in the anterior tunnel when compared to the posterior position, but this difference was statistically not significant. CONCLUSION: An anterior position of the bone tunnels in double-bundle posterior cruciate ligament reconstruction restores the normal knee kinematics more closely than does a posterior position of the tunnels. CLINICAL RELEVANCE: In double-bundle posterior cruciate ligament reconstruction, posterior placement of the tunnel should be avoided.     

Graft impingement in anterior cruciate ligament reconstruction

Anterior cruciate ligament (ACL) graft impingement is one of the most troubling complications in ACL reconstruction. In the previous strategy of isometric “non-anatomical” ACL reconstruction, posterior tibial tunnel placement and notchplasty were recommended to avoid graft impingement. Recently, the strategy of ACL reconstruction is shifting towards “anatomical” reconstruction. In anatomical ACL reconstruction, the potential risk of graft impingement is higher than in non-anatomical reconstruction because the tibial tunnel is placed at a more anterior portion on the tibia. However, there have been few studies reporting on graft impingement in anatomical ACL reconstruction. This study will provide a review of graft impingement status in both non-anatomical and the more recent anatomical ACL reconstruction techniques. In conclusion, with the accurate creation of bone tunnels within ACL native footprint, the graft impingement might not happen in anatomical ACL reconstruction. For the clinical relevance, to prevent graft impingement, surgeons should pay attention of creating correct anatomical tunnels when they perform ACL reconstruction. Level of evidence IV.     

Revision anterior cruciate ligamentsurgery: Etiology of failures

Anterior cruciate ligament (ACL) reconstruction has gained wide acceptance as the treatment of choice for the functionally unstable ACL-deficient knee. Long-term good or excellent results of primary ACL reconstructions with respect to functional stability, relief of symptoms, and return to activity is between 75% and 95%. As much as 8% of the unsatisfactory results after primary ACL reconstructions are secondary to recurrent instability and graft failure. Failed ACL reconstruction with recurrent instability can be classified into the following three categories based on the primary reason for failure: technical errors, biological failure, and traumatic failure. These causes of failure are not mutually exclusive, and more than one may contribute to failure. Technical reasons are the most common cause of failure, and anterior femoral tunnel placement is by far the most prevalent cause of graft failure and recurrent instability after ACL reconstruction. This article reviews the possible causes of recurrent instability after ACL reconstruction to enable the surgeon to thoroughly delineate the cause of failure before proceeding with revision ACL surgery.     

Tunnel enlargement after anterior cruciate ligament surgery

Bone tunnel enlargement has been reported after anterior cruciate ligament (ACL) reconstruction surgery. Although the long-term outcome of this phenomenon is not yet known, tunnel lysis or expansion may be clinically significant in revision surgery because the enlarged tunnels may complicate graft placement and fixation. There any many proposed theories for tunnel lysis. The most accurate statement is that this condition has a multifactorial etiology. Mechanical and biological causes have been reported, and both contribute to enlarged graft tunnels. This article describes the multiple causes of bone tunnel enlargement after ACL surgery. Future techniques and advances in primary ACL surgery must seek to eliminate this phenomenon.     

Quadriceps tendon--a reliable alternative for reconstruction of the anterior cruciate ligament

Anterior cruciate ligament (ACL) reconstruction surgery with the central third quadriceps tendon can yield a stable, high-functioning knee with little associated morbidity. Both the quadriceps tendon-patellar bone graft and the free tendon graft are reported to produce good to excellent outcomes at more than 2 years of follow-up. The decreased donor-site morbidity and absence of anterior knee pain suggest that the quadriceps free tendon autograft offers a reliable, pain-free, low-morbidity autograft alternative in ACL reconstruction. Recent data suggest that this graft may be the least morbid of the currently used ACL autograft reconstruction alternatives.     

Interactive effects of tunnel dilation on the mechanical properties of hamstring grafts fixed in the tibia with interference screws

The effect of dilation of the tibial tunnel on the strength of hamstring graft fixation using interference screws was evaluated. In all, 28 RCI screws were tested in male human tibia-hamstring constructs with tibial tunnels reamed or dilated to the respective size of the graft diameter. Dilation of the tibial tunnel failed to significantly enhance hamstring fixation. Grafts secured in dilated tunnels displayed an 11% greater resistance to the initiation of graft slippage (174+/-112 N) compared to their undilated controls (156+/-77 N, P=0.63). Dilation of the tibial tunnel increased the failure load by an average of 4%, independent of screw diameter (dilated specimens: 360+/-120 N, controls: 345+/-88 N, P=0.74). Biomechanical research on the effect of tibial tunnel dilation in hamstring fixation has not provided satisfactory evidence as to the benefits of this additional surgical step during anterior cruciate ligament (ACL) reconstruction.     

自体骨-髌腱-骨和腘绳肌腱单束重建陈旧性断裂前交叉韧带后移植物愈合形态学和前向稳定性比较

目的:探讨陈旧性前交叉韧带(anterior cruciate ligament,ACL)断裂患者,采用自体骨-髌腱-骨(bone-patellar tendon-bone,B-PT-B)和自体腘绳肌腱(hamstring tendon,HT)单束重建后移植物愈合的形态学表现以及前向稳定性是否存在差异。方法:2000年12月～2003年8月,我所77例受伤病史>12个月的ACL断裂患者,分别采用自体B-PT-B和HT作为移植物,接受了膝关节镜下ACL单束重建,因去除金属内固定进行二次手术,并接受关节镜探查(术后10～32个月,平均14.7个月)。根据移植物种类将其分为B-PT-B组(n=27)和HT组(n=50)两组,比较关节镜下移植物愈合形态学表现,采用膝关节韧带位移测量仪(KT-2000),分别在屈膝30°和90°时测量前向松弛度。结果:B-PT-B组和HT组移植物愈合形态学表现分别为:①韧带完整的分别占96.3%(26/27)和98.0%(49/50),部分断裂占3.7%(1/27)和2.0%(1/50)(χ2=0.000,P=1.000);②滑膜完整的分别占77.8%(21/27)和82.0%(41/50)(χ2=0.119,P=0.655);③滑膜内有明显血管形成的分别占63.0%(17/27)和76.0%(38/50)(χ2=1.460,P=0.227);④有分股表现的分别占22.2%(6/27,此6例均无完整滑膜覆盖)和32.0%(16/50)。屈膝30°时,两组前向松弛度分别为1.5±1.8 mm和2.2±1.3 mm(t=1.949,P=0.055),90°时分别为1.1±1.4mm和1.4±0.9 mm(t=1.467,P=0.147)。结论:采用自体B-PT-B和HT单束重建陈旧性ACL断裂,术后短期肉眼观察移植物愈合形态学表现无显著性差异,前向稳定性均满意,且无显著性差异。     

Femoral fixation of hamstring grafts in posterior cruciate ligament reconstruction: biomechanical evaluation of different fixation techniques: is there an acute angle effect?

BACKGROUND: The literature provides little biomechanical data about femoral fixation of hamstring grafts in posterior cruciate ligament reconstruction. HYPOTHESIS: A hybrid fixation technique with use of an undersized screw has sufficient strength to provide secure fixation of posterior cruciate ligament grafts. Additional aperture fixation with a biodegradable interference screw can prevent graft damage that might be caused by an acute angle on the edge of the femoral tunnel. STUDY DESIGN: Controlled laboratory study. METHODS: In part 1, extracortical fixation of posterior cruciate ligament reconstructions with quadrupled porcine flexor digitorum grafts to simulate human hamstring grafts was compared with hybrid fixation methods using 6-, 7-, and 8-mm screws. Groups were tested in cycling loading with the load applied in line with the bone tunnel. In part 2, extracortical fixation was compared with hybrid fixation using a 1-mm undersized screw anterior and posterior to the graft. Structural properties and graft abrasion were evaluated after cyclic loading with the load applied at 90 degrees to the tunnel. In each group, 8 porcine knees were tested. RESULTS: In part 1, stiffness, maximum load, and yield load were significantly higher for hybrid fixation than for extracortical fixation. Hybrid fixation with an 8-mm screw resulted in higher yield load than with a 7-mm screw. In part 2, graft laceration was more pronounced in specimens with extracortical fixation than with hybrid fixation. Posterior screw placement was superior to the anterior position. CONCLUSION: For all parameters, hybrid fixation with an interference screw provided superior structural results. No relevant disadvantages of undersized screws could be found. Graft damage due to abrasion at the edge of the femoral bone tunnel was reduced by use of an interference screw. The posterior screw placement seems favorable. CLINICAL RELEVANCE: Hybrid fixation of hamstring grafts in posterior cruciate ligament reconstruction is superior to extracortical fixation alone with no relevant disadvantages of undersized screws. The results raise the suspicion of an acute angle effect of the femoral bone tunnel.     

Posterior cruciate ligament: anatomy, biomechanics, and outcomes

The optimal treatment of posterior cruciate ligament ruptures remains controversial despite numerous recent basic science advances on the topic. The current literature on the anatomy, biomechanics, and clinical outcomes of posterior cruciate ligament reconstruction is reviewed. Recent studies have quantified the anatomic location and biomechanical contribution of each of the 2 posterior cruciate ligament bundles on tunnel placement and knee kinematics during reconstruction. Additional laboratory and cadaveric studies have suggested double-bundle reconstructions of the posterior cruciate ligament may better restore normal knee kinematics than single-bundle reconstructions although clinical outcomes have not revealed such a difference. Tibial inlay posterior cruciate ligament reconstructions (either open or arthroscopic) are preferred by many authors to avoid the "killer turn" and graft laxity with cyclic loading. Posterior cruciate ligament reconstruction improves subjective patient outcomes and return to sport although stability and knee kinematics may not return to normal.     

Synovial healing in reconstructed cruciate ligaments. Our personal experience compared in single interventions and combined reconstructions

INTRODUCTION: The healing process of tendon grafts used in cruciate ligament reconstruction is called ligamentization. The tendon structural architecture changes progressively into the histological appearance of normal ligament. Amiel and Clancy have demonstrated that this process is time-dependent in anterior cruciate ligament (ACL) reconstruction, the tendon graft taking one year to become similar to a normal cruciate ligament. Three different maturation phases of anterior cruciate graft ligamentization can be seen at MRI: periligamentous proliferation, intraligamentous proliferation and definitive healing. We report our MR findings in the reconstruction of single ACL, posterior cruciate ligament (PCL), and of both ACL and PCL. MATERIAL AND METHODS: January 1995 to January 1999 we selected 60 patients submitted to arthroscopic cruciate ligament reconstruction. The ACL was reconstructed with the patellar tendon in 22 cases and the PCL in 23; fifteen patients underwent double reconstruction of ACL, with hamstring tendons, and PCL, with patellar tendons. Fifty-five patients were followed-up with MRI: 45 with a dedicated permanent magnet (Artroscan, Esaote Biomedica, Genoa, Italy) and 10 with a permanent low-field unit (AIRIS, Hitachi, Japan); the same technical parameters were used in all cases. Forty of 55 patients were examined at 1, 3, 6, 9 and 12 postoperative months, while 15 were followed-up longer (12 to 36 months postoperatively). At the first follow-up MR examination, 5 patients (2 ACL and 3 PCL) were excluded for incorrect tunnel position (1 case), hypertrophic scarring (2 cases) and new trauma (2 cases). MR findings were compared with clinical data of joint stability. RESULTS: MRI showed the different stages of the healing process in 20 ACL patients: proliferating soft tissue around the graft with the low signal intensity typical of tendons (stage I, 1-3 months postoperatively), the graft becomes progressively hyperintense (stage II, 3-9 months postoperatively), and finally the low signal intensity indicating completed ligamentization (stage III, 12 months postoperatively). As for PCL reconstructions, MR findings were similar but the process took longer, even 24 months. Finally, in the 15 cases of double reconstruction, both grafts were difficult to distinguish on T1-weighted images for a very long time (24-36 months postoperatively). DISCUSSION AND CONCLUSIONS: Relative to the ACL, ligamentization takes longer for PCL and combined ACL and PCL reconstructions, probably because the morphological changes in PCL and double grafts may be impaired by many factors, such as gravity, long bone tunnels, hemarthrosis, hyperplastic synovial reaction in the intercondylar notch; also, rehabilitation protocols differ in ACL from PCL patients. No signs of instability were found at physical or arthrometric examinations. MRI demonstrates the different stages of ligamentization and thus proves a useful tool for postoperative follow-up in cruciate ligament reconstructions. Contrast-enhanced (Gd) studies are reserved to the cases of graft impingement or if other abnormalities are suspected.     

同种异体胫前肌腱和自体腘绳肌腱重建前交叉韧带临床研究

目的:探讨关节镜下同种异体胫前肌腱与自体腘绳肌腱重建前交叉韧带(ACL)的临床疗效。方法:回顾了60例陈旧性前交叉韧带损伤重建病例,分为A组30例,B组30例。分别应用同种异体胫前肌腱(A组)和自体半腱肌、股薄肌腱(B组)重建ACL,A组平均随访29.4个月,B组平均随访31.6月。采用Lysholm、Tegner、IKDC、KT2000对患者进行术前和术后膝关节功能测试、评分,并用等速测试仪测量各组术后伸膝、屈膝、内旋和外旋肌力。结果:两组手术前后Lysholm、TegnerI、KDC、KT2000测试结果均有显著性差异(P<0.01);但两组间术后评分无显著性差异(P>0.05)。等速肌力测试结果显示术后B组内旋、屈膝肌力较术前下降(P<0.05),而A组术后肌力较术前无明显下降(P>0.05)。结论:关节镜下采用同种异体胫前肌腱重建前交叉韧带疗效满意,不良反应发生率低。     

Anterior cruciate ligament anatomy and function relating to anatomical reconstruction

Recently, the interest in surgical techniques that reconstruct the anteromedial (AM) and the posterolateral (PL) bundles of the anterior cruciate ligament (ACL) has risen. This review focuses on the structural as well as the mechanical properties of the ACL and the anatomical details of the femoral origin, midsubstance, and tibial insertion of AM and PL bundles of the ACL. The terminology of AM and PL bundles is chosen according to the tibial insertion and determined by their functional tensioning pattern throughout knee flexion. Close to extension the AM is moderately loose and the PL is tight. As the knee is flexed, the femoral attachment of the ACL becomes more horizontally oriented, causing the AM bundle to tighten and the PM bundle to loosen up. The ACL has been described to be restraint to anterior tibial displacement and internal tibial rotation. The rotational component might be represented by the PL bundle. The femoral origin has an oval shape with the center of the AM close to over-the-top position and the center of the PL close to the anterior and inferior cartilage margin. Tibial and femoral insertions of the ACL are over 3.5 times larger when compared to the midsubstance and tunnel placement is more challenging because of the limited size of potential grafts selection of tunnel site placement. For reconstruction, both bone–patellar tendon–bone (BPTB) and quadrupled hamstring grafts are used. Structural properties of a 10 mm wide BPTB or quadrupled hamstring graft have been reported to be comparable with those of the native ACL.     

Avoiding pitfalls in anatomic ACL reconstruction

As interest in double-bundle anterior cruciate ligament (ACL) reconstruction grows, we continue to refine our technique to perform the most anatomic reconstruction possible. Our experience has brought to our attention the potential mistakes that should be avoided when performing an anatomic double-bundle ACL reconstruction. These mistakes include (1) failure to visualize the femoral insertion completely, (2) use of the clock face to reference femoral tunnel positioning, (3) nonanatomic tunnel placement leading to graft impingement, (4) mismatching tibial and femoral tunnels, and (5) failure to restore the native tension pattern of the ACL. It is also important to recognize that a double-bundle ACL reconstruction is not necessarily equivalent to an anatomic double-bundle reconstruction. This article reviews potential mistakes in DB ACL reconstruction and describes our way of avoiding them.     

Revision anterior cruciate ligament reconstruction with hamstring tendon autograft: 5- to 9-year follow-up

BACKGROUND: The results of revision anterior cruciate ligament reconstruction are limited in the current literature, and no studies have previously documented the outcome of revision anterior cruciate ligament reconstruction using solely hamstring tendon grafts. HYPOTHESIS: Revision anterior cruciate ligament reconstruction with 4-strand hamstring tendon graft affords acceptable results and is comparable to reported outcomes with the bone-patellar tendon-bone graft. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Fifty-seven consecutive revision anterior cruciate ligament reconstructions with the hamstring tendon graft and interference screw fixation were assessed a mean time of 89 months (range, 60-109 months) after surgery. Assessment included the International Knee Documentation Committee knee ligament evaluation, instrumented laxity testing, and radiologic examination. RESULTS: Of the 50 knees reviewed, 5 (10%) had objective failure of the revision anterior cruciate ligament reconstruction. Of the 45 patients with functional grafts, knee function was normal or nearly normal in 33 patients (73%). An overall grade of normal or nearly normal was found in 56% of patients. The mean side-to-side difference on manual maximum testing was 2.5 mm (range, -1 to 4 mm). Degenerative changes on radiographs were identified in 23% of patients at the time of surgery, increasing to 56% of patients at review. The status of the articular cartilage at the time of revision surgery was the most significant contributor to successful outcome. CONCLUSION: Revision anterior cruciate ligament reconstruction with hamstring tendon graft and interference screw fixation affords acceptable results at a minimum of 5 years' follow-up. Good objective results can be obtained, but subjectively, the results appear inferior to those of primary anterior cruciate ligament reconstruction in the literature, which may be related to the high incidence of articular surface damage in this patient population. We recommend that, when available, hamstring tendon autografts should be considered for revision anterior cruciate ligament reconstruction.