Double-bundle anterior cruciate ligament revision after primary vertical reconstruction

Several factors can contribute to relapsed instability after anterior cruciate ligament (ACL) reconstruction. One of the main reasons may be femoral tunnel misplacement with a high noon graft. Due to the steep graft course in the intercondylar notch, the biomechanical vector of the lever arm of the reconstruction is too low to withstand the anterior tibial and rotational forces. In the case of clinical indication for ACL revision, the diagnostics should include an overlooked posterior instability at primary reconstruction. Additionally, analysis of the femoral and tibial tunnel placement and widening is crucial. The widening can be examined using CT scans. For the placement, a 3-D reconstruction is beneficial. If a high noon graft is revised, we perform a single stage double bundle revision using a two femoral and one tibial tunnel technique with an autologous semitendinosus tendon. Femoral anatomic tunnel placement is achieved with a femoral double bundle guide. To account for individual size differences, the sighting mechanism is used in 3 different sizes in a medial portal technique. A one tibial tunnel technique is used if no significant tunnel widening is noticed. In case of tunnel widening, a two-stage revision strategy using bone grafting is performed.