Revision ACL Surgery: Getting Better Results

Revision anterior cruciate ligament (ACL) reconstruction patients treated at Shelbourne Knee Center had a higher return to sport rate and a lower re-injury rate than primary ACL reconstruction patients at most orthopedic practices, according to a study published in the American Journal of Sports Medicine (1).

Researchers studied 259 competitive high school and college athletes and recreational athletes who underwent revision ACL reconstruction at Shelbourne Knee Center between 1994 and 2007. All patients completed pre-operative rehabilitation before revision ACL reconstruction, in which surgeons used patellar tendon grafts (PTGs).

Return to Sport and Re-injury Rates

Nationally, return to sport rates after primary ACL reconstruction range from 50% to 75%, according to the literature (1). The return to sport rate for revision ACL reconstruction in the Shelbourne Knee Center study was:

  • 74% for high school and college athletes (at the pre-injury level)
  • 62% for recreational adults (1).

The re-injury rate in the first 5 years after revision surgery ranged from 2% to 5% (1), which is lower than what has been reported in the literature for young competitive athletes after primary surgery. Other research on Shelbourne Knee Center patients found a re-injury rate after primary ACL reconstruction for either knee of 9.6% (2).

“Many people believe that revision ACL surgery results are quite a bit worse than primary ACL reconstruction results, and that other grafts are better than or equal to patellar tendon grafts. Our study shows this isn’t true,” says Rodney Benner, MD, an orthopedic surgeon at Shelbourne Knee Center. Dr. Benner is one of the study authors, along with K. Donald Shelbourne, MD, orthopedic surgeon, and Tinker Gray, MA ELS, research manager and medical writer.

Prospective Study

Subjects in the Shelbourne Knee Center study were primarily basketball, soccer, football and volleyball players. They were grouped by:

  • Competitive sport levels:
    • School age (mean age, 16.6 ± 0.9 years; n = 84)
    • College (19.6 ± 1.2 years; n = 58)
  • Recreational adult (27.6 ± 4.1 years; n = 117).

Researchers used an activity survey to determine the sport and sport level patients participated in before and after surgery. They also obtained responses from the International Knee Documentation Committee (IKDC) knee survey and the Cincinnati Knee Rating System (CKRS) survey.

The patellar tendon graft came from the contralateral knee for 134 patients and the ipsulateral knee for 122 patients. All patients completed the SKelbourne Knee Center pre-op rehab program.

Study Results

The rate of return to the same sport at the same level was:

  • 62 of 84 school-age athletes (74%)
  • 43 of 58 college athletes (74%)
  • 73 of 117 recreational athletes (62%) (P = .1065).

The rates of subsequent ACL injury to either knee were:

Subsequent ACL graft knee tear:

  • 2 of 84 (2.3%) in the high school group
  • 3 of 58 (5.1%) in the college group
  • 4 of 117 (3.4%) in the recreational group (P = .6706).

Subsequent ACL tear in the contralateral knee:

  • 1 of 84 (1.1%) in the school-age group
  • 1 of 58 (1.7%) in the college group
  • 2 of 117 (1.7%) in the recreational group (P = .9501).

At two years postoperatively, the mean survey scores were:

  • IKDC subjective total score: 86.1 ± 11.7 points
  • CKRS total score was 89.7 ± 11.1 points.

Rehab, PTG and Surgeon Experience Matter

Factors contributing to the higher return to sport rate and lower re-injury rate at Shelbourne Knee Center include:

  • The pre-op rehab program, which emphasized symmetry, early return of full range of motion without immobilization, and progression to activities
  • Use of a PTG, which allows for unrestricted rehabilitation and is stronger than allografts and hamstring grafts.

“The most important factor is use of PTGs by surgeons who specialize in knee problems and have done a high volume of complicated revision ACL surgeries,” says Dr. Benner.

Patients also completed postop rehab that emphasized limiting a hemarthrosis, obtaining full range of motion and achieving good quadriceps muscle control before participating in an aggressive strengthening and functional progression program.

Study Results Help Patients Make Decisions  

Study results are useful in counseling patients about return to sport and risk of subsequent injury after ACL reconstruction. “We want to make sure our patients understand what they’re up against should they choose to return to sport after ACL revision surgery,” says Dr. Benner. The results are also useful to other orthopedic surgeons in choosing a graft and rehabilitation program and as benchmarks against other surgical and rehab treatments.

For more information about revision ACL reconstruction, call 888-FIX-KNEE.


  1. Shelbourne KD, Benner RW, Gray T. Return to Sports and Subsequent Injury Rates After Revision Anterior Cruciate Ligament Reconstruction With Patellar Tendon Autograft. Am J Sports Med. 2014 Jun;42(6):1395-400.
  2. Shelbourne KD1, Gray T, Haro M. Incidence of subsequent injury to either knee within 5 years after anterior cruciate ligament reconstruction with patellar tendon autograft. Am J Sports Med. 2009 Feb;37(2):246-51.