European Journal of Orthopaedic Surgery & Traumatology (2023) 33:3125–3133 https://doi.org/10.1007/s00590-023-03544-8 ORIGINAL ARTICLE Good rates of return‑to‑sport in athletes after revision anterior cruciate ligament reconstruction using autologous patellar tendon and lateral extra‑articular tenodesis: a 2‑year follow‑up prospective study Felipe Moreira Borim1,2,4 · Nayana Joshi Jubert1,2,3 · Maria Mercedes Revertè Vinaixa1,2,3,5 · Irene Portas‑Torres2 · Joan Pijoan Bueno1,2,3,5 · Raquel Sevil Mayayo2,5 · José Vicente Andrés Peiró1,3,5 · Enric Castellet Feliu1,2,3 · Joan Minguell Monyart1,2,3,5 Received: 27 February 2023 / Accepted: 3 April 2023 / Published online: 11 April 2023 © The Author(s) 2023 Abstract Background Most athletes who undergo revision of the anterior cruciate ligament reconstruction (ACLR) aim to return to their preinjury sport at a similar level of performance while minimizing the risk for reinjury. Additional lateral extra-articular tenodesis (LET) has recently been correlated with improved outcomes and low complication rate. Yet, there are few series evaluating return-to-sport (RTS) and clinical outcomes after revision ACLR using bone-patellar tendon-bone (BPTB) and LET in athletes. Methods The study cohort consisted of 19 eligible athletes who had undergone their first revision ACLR using BPTB and LET (modified Lemaire) between January 2019 and 2020. Patients were prospectively followed and interviewed in a sports activity survey during a 2-year follow-up. Results Despite all patients returning to sports after revision ACLR surgery, 52.6% resumed playing at their preinjury level. Furthermore, patient-reported functional outcomes improved significantly following revision surgery, as evidenced by improvements in IKDC [64.4 (± 12) to 87.8 (± 6)], Lysholm [71.27 (± 12) to 84.2 (± 9.7)], and SF-12 scales [Physical: 53.3 (± 3) 57 (± 1.2); Mental: 50.2 (± 3.3) to 52.7 (± 2.4)]. One case (5.3%) experienced persistent pain and underwent reoperation for a partial meniscectomy. Conclusion After revision ACLR using autologous BPTB and LET, all active individuals are expected to RTS, similar to primary ACLR. The difference comes down to returning to the preinjury level, where the levels are lower depending on the sport and initial level of play. Good mid-term functional outcomes with a low complication rate can be expected in most cases. Study design Case series; Level of evidence IV. Ethical Committee Approval Number PR(ATR)79/2021 and HCB/2023/0173. Keywords Anterior cruciate ligament · Autografts · Tenodesis · Revision · Knee 3 * Felipe Moreira Borim Reconstructive Surgery of Locomotor System Group ‑ VHIR, dr.moreiraborim@gmail.com Hospital Universitari Vall d’Hebron, Passeig de la Vall d’Hebron 119‑129, 08035 Barcelona, Spain * Joan Minguell Monyart 4 minguell.traumatologia@gmail.com Bioengineering, Cell Therapy and Surgery in Congenital Malformations ‑ VHIR, Hospital Universitari Vall d’Hebron, 1 Surgery and Morphological Sciences, Universitat Autónoma Passeig de la Vall d’Hebron 119‑129, 08035 Barcelona, de Barcelona (UAB), 08193 Bellaterra, Barcelona, Spain Spain 2 5 Orthopaedic Surgery Department; Knee Surgery Unit, Knee Surgery Unit, Clínica Corachan, Carrer de Buïgas, 19, Hospital Universitari Vall d’Hebron, Passeig Vall d’Hebron 08017 Barcelona, Spain 119‑129, 08035 Barcelona, Spain 13 Vol.:(0123456789) 3126 European Journal of Orthopaedic Surgery & Traumatology (2023) 33:3125–3133 Introduction Material and methods Reconstruction of the anterior cruciate ligament (ACLR) is Patients recruitment and follow‑up assessment one of the most common surgical procedures, with a reported failure rate of 3–14% [1]. Patient outcomes are less favourable This study was approved by Hospital Universitari Vall when failures occur, and they undergo revision procedures. d'Hebron and Hospital Clínic de Barcelona Ethics Com- These procedures have higher failure rates, complications, and mittee, and patients signed informed consent before being poor functional outcomes [2, 3]. Most athletes who undergo included. All patients who underwent revision ACLR revision ACLR aim to return to their preinjury sport at a simi- using autologous BPTB and modified Lemaire LET lar level of performance while minimizing the risk of rein- between January 2019 and January 2020 were screened jury. However, for many, these goals are not always attained. for eligibility for this prospective study. Inclusion criteria Return-to-sport (RTS) rates after revision ACLR have a rela- were (1) age above 16 years and capable of giving consent tively high rate of RTS at any level (56–100%) but a relatively for study participation; (2) patients with ACLR graft rup- low rate of RTS at the preinjury level of play (13–69%) [4, 5]. ture diagnosed by clinical symptoms and physical exam, Several factors, including recurrent instability, stiffness, confirmed by magnetic resonance images (MRI); (3) Teg- and pain, may lead to less-than-expected results and prevent ner Activity Scale Level ≥ 6 before primary ACL rupture athletes from RTS [5]. Although the cause of rotational insta- and before primary ACLR. Exclusion criteria included (1) bility after revision ACLR is multifactorial, adding an extra- concomitant ligament injuries or coronal plane deformity; articular procedure is based on its ability to restrict rotational (2) incomplete follow-up and clinical data. laxity [6]. Patient satisfaction, overall knee function, RTS, and Patients' demographic, clinical and radiological data functional scores appear to correlate more with the restoration were collected preoperatively, postoperatively, and dur- of rotational stability than with translational stability, making ing the follow-up period until 24 months postoperatively. it a critical short-term to mid-term goal [7, 8]. The limited Patients were asked to complete a sports activity survey. body of evidence has shown that adding soft tissue proce- The assessment included Tegner Activity Scale (TAS), dures may lower the risk of graft re-rupture rates and improve International Knee Documentation Committee (IKDC) overall outcomes [9]. Furthermore, compared to allografts, score, Lysholm Knee Score, and Short-Form Health Sur- autografts have improved sports function, patient-reported vey (SF-12) Physical and Mental. Concomitant lesions outcome measures, and decreased graft re-rupture rate at a were recorded in radiological (radiographs, CT and MRI) 2-year follow-up [3, 10]. and arthroscopic evaluation during the primary and revi- In recent years, several studies [8, 11–22] have empha- sion surgery. sized the crucial role of simultaneous revision ACLR using A total of 23 consecutive patients were initially an autologous graft and LET in improving rotational stability screened; three were excluded for failing to meet the and graft protection. Despite these findings, the scientific evi- inclusion criteria; one case had an incomplete follow-up. dence remains highly heterogenous, with variations in patient At 24 months follow-up, 19 patients (men, n = 9; women, selection, graft type, and surgical technique. To date, no study n = 10; mean age 27.7 years; SD 7.2) were available for has specifically examined the RTS of athletes following revi- follow-up. Two patients underwent a 2-stage revision and sion ACL using concomitant autologous bone-patellar tendon- were also included. bone (BPTB) and LET (modified Lemaire), with a minimum Twenty-four-month outcome data for the cohort are follow-up of 2 years. Therefore, it is imperative to conduct a available in the Appendix. thorough analysis that primarily examines the assessment of RTS while also taking into account the clinical outcomes and potential complications that may arise in athletes who undergo Surgical technique this procedure. Our hypothesis suggests that by adopting this approach, we can anticipate positive outcomes in the short to Combined spinal anaesthesia with regional nerve blockade mid-term, with good rates of RTS and minimal complications. was used. All patients were assessed under anaesthesia for ROM, Lachman, Pivot Shift, LCL, MCL, and pulse exams. A preliminary arthroscopic inspection was performed to help diagnose and treat associated meniscal and chon- dral injuries. Furthermore, the size of the intercondylar fossa is evaluated, and notchplasty is done if needed to avoid impingement. Progressive drilling of the tibial and femoral tunnels with cannulated drills of different sizes 13 European Journal of Orthopaedic Surgery & Traumatology (2023) 33:3125–3133 3127 until completing the debridement of the previous graft procedure and LET. Then an incorporation phase of site was done. BPTB autografts were prepared, usually 20–24 weeks, allowing the bone graft to heal before the 10 × 25 mm bone plugs; suspension systems were used for subsequent second stage; a CT scan at 3–4 months was per- femoral fixation (TightRope® RT; Arthrex, Naples, FL), formed to confirm correct incorporation. interferential screw (Biocomposite®; Arthrex, Naples, FL) and ligament staple were used for a hybrid fixation on the Rehabilitation tibia (see Fig. 1). Lastly, a modified Lemaire LET was performed [23]. For the first 4–6 weeks, walking with partial weight bearing Patients were offered a two-stage surgery (1) if tunnel was allowed using two crutches. Patients were encouraged to widening was so significant on both the tibia and femur that perform complete knee flexion and extension. Closed kinetic one-stage bone grafting is not feasible, usually enlarged over chain exercises and the use of a balance board to regain 14–16 mm; (2) malpositioned, which could result in tunnel proprioception were performed for the first three months, overlapping; (3) arthrofibrosis or (4) local infection. The and after that, open kinetic chain exercises were started. two-stage procedure involved an initial bone-allografting To authorize RTS, we considered physical and psychologi- cal aspects. In general, sports activities are allowed after a period of 9 months, but it is important to prioritize func- tional criteria when deciding to engage in them. Statistical analysis Performed with Statistics STATA/IC 15.1 (StataCorp®). Categorical variables were described with their absolute val- ues and percentages. Quantitative variables were presented by their measures of central tendency (mean and standard deviation). Preoperative and postoperative tests were com- pared using paired Mann–Whitney U tests. Differences with p values < 0.05 were considered statistically significant. Results Table 1 provides a summary of the demographic data for the cohort of athletes who underwent revision ACLR using autologous BPTB and LET. Although all patients were able to return to some level of sports activity, the rate of return to preinjury level of sport was lower after the revision pro- cedure. Out of the nineteen athletes, only ten (52.6%) were able to return to their preinjury level of sport, which is in contrast to the fifteen (79%) who were able to do so after primary reconstruction. The majority of athletes (79%) participated in contact sports such as basketball and football, with only a few (15.8%) participating in noncontact sports like cycling and athletics, and one athlete (5.3%) involved in collision sports (rugby). Two professional athletes (10.5%) were included in the cohort, one of them did return to her pre- injury level after the primary procedure, but not after the Fig. 1  Schematic drawing of the lateral aspect of a right knee demon- revision. The majority of patients (68.4%) were affiliated strating a revision anterior cruciate ligament reconstruction (ACLR) with a player's federation and engaged in regular sport. using a bone–patellar tendon–bone autograft and a lateral extra- Age did not appear to have a significant influence on the articular tenodesis procedure (modified Lemaire), with the iliotibial return-to-sport (RTS) rate. Interestingly, the RTS rate for band autograft passed deep to the fibular collateral ligament (FCL), oriented with a 30° anterior angle in the axial plane and 30° proximal women was slightly higher (77.8%) than for men (55.6%). in the coronal plane When selecting sports to participate in after revision 13 3128 European Journal of Orthopaedic Surgery & Traumatology (2023) 33:3125–3133 Table 1  Demographic data and concomitant lesions of the included patients (n = 19) Patient data Sex, n (%) 10 (52.6%) 9 (47.4%) Female/male Side, n (%) 14 (73.7%) 5 (26.3%) Right/left (%) Age, y (SD)* 29.8 (± 7.5) Number of Stages, n (%) One-/two-stages 17 (89.5%) 2 (10.5%) Concomitant lesions Primary ACLR Revision ACLR n % n % Chondral lesion (medial, lateral and femoropatellar) 1 5.3 2 10.5 Meniscus lesion (medial, lateral) 6 31.6 9 47.4 Chondral or meniscal (any lesion) 7 36.9 11 57.9 No chondral nor meniscus lesion 12 63.1 8 42.1 Expressed as the n and (percentage). *Expressed in mean and (± SD) ACLR anterior cruciate ligament reconstruction ACLR, most patients opted for noncontact sports like Pivot-Shift tests) or reported by the patients. There was one padel (42.1%) and cycling (26.1%), with all of them also case of contralateral primary ACL rupture. attending a gym for general fitness. Additionally, patients were asked to indicate the main reason why they did not return to their previous level of sport from among four cat- Discussion egories, with knee-related reasons, such as pain or insta- bility, only corresponding to 26.3% of the cases. Table 2 The main finding of this cohort was that the addition of provides an overview of the RTS results. The mean time a LET to an autologous BTPB revision ACLR provides to return to sport was 10.3 months (as shown in Fig. 2). improved rates of RTS, patient-reported functional out- The functional improvement of patients was assessed comes and minimal complications. Although all athletes did using various scales. The IKDC score increased from 64.4 return to some level of play, only ten out of nineteen athletes (± 12) to 87.8 (± 6), while the Lysholm score increased from (52.6%) could return to their preinjury level after a 2-year 71.27 (± 12) to 84.2 (± 9.7). The SF-12 scale also showed follow-up. Significant improvements were seen on Lysholm, significant improvement in both the Physical (from 53.3 ± 3 IKDC and SF-12 Physical and Mental scales. When compar- to 57 ± 1.2) and Mental (from 50.2 ± 3.3 to 52.7 ± 2.4) ing the revision to the primary reconstruction, there was a domains. However, the Tegner Activity Scale demonstrated notable increase in the prevalence of meniscus and osteo- a significant decrease in activity level from 7.2 (± 1) to 6.6 chondral injuries, with the percentage rising from 36.9 to (± 1.1). An overview of these results can be found in Table 3. 57.9%. The rate of complications remained low, with only In addition, 57.9% of patients had concomitant lesions, one case (5.3%) experiencing residual pain and reoperation which is a higher proportion than the 36.8% observed in for a partial menisectomy. To date, few studies have analysed the same group of patients who underwent primary ACLR. the results of revision ACLR and LET [12–22], with dif- Table 1 provides a summary of the associated lesions. ferences in graft type and surgical technique. Furthermore, Notchplasty was performed in 6 cases (31.6%) due to inter- selecting a uniform group of patients presents a challenge. condylar notch impingement. In an effort to achieve homogeneity, we carefully established Major complications accounted for one case (5.3%) of our inclusion criteria. residual pain, where a partial meniscectomy was later per- This study presents some limitations. First, it is non- formed. Minor complications accounted for 3 cases (15.8%), comparative, with the inherent biases of this type of study. which included one case of hemarthrosis and two cases of Second, our cohort is small despite no consistent losses, material discomfort (see Table 1). Despite this, patient sat- and it has limited statistical power and, therefore, generaliz- isfaction and functional outcomes remained high, and no ability of the results. Third, the outcomes are not evaluated savage procedure was necessary. There were no cases of with objective radiological measurements, but with subjec- anteroposterior and rotational laxity detected (Lachman and tive tests and scales, with 24-month follow-up. However, our study provides information on using a single type of 13 European Journal of Orthopaedic Surgery & Traumatology (2023) 33:3125–3133 3129 Table 2  Return to sport (RTS) outcomes summary and comparison (n = 19) Tegner Activity Score (TAS)* Before ACLR 7.4 (± 1) (6–10) After ACLR 7.1 (± 1) (6–10) Revision ACLR 6.4 (± 1) (5–10) List of sports After primary ACLR After revision ACLR Basketball 10 (52.6%) 6 (31.6%) Football 6 (31.6%) 2 (10.5%) Tenis/Padel 1 (5.3%) 7 (36.8%) Athletics 1 (5.3%) 1 (5.3%) Rugby 1 (5.3%) 1 (5.3%) Cycling – – 2 (10.5%) Level of return to sport Same sport, same level Same sport, lower level Another sport, lower level Total 10 (52.6%) 6 (31.6%) 3 (15.8%) < 25 y 4 (57.1%) 2 (28.6%) 1 (14.3%) ≥ 25 y 6 (50%) 4 (33.3%) 2 (16.7%) Reasons for changing or stopping the preinjury sport played Job-relateda Personal ­reasonsb Knee-relatedc Medical ­reasonsd 5 (26.3%) 6 (31.6%) 5 (26.3%) 2 (10.5%) Values for outcomes are expressed expressed as n and (%). *Expressed in mean and (± SD) ACLR anterior cruciate ligament reconstruction a Job-related included work-related constraints b Personal reasons included personal preferences or interests that might have changed c Knee-related included those directly related to the limitations after the surgery, such as pain or instability d Medical reasons included other conditions or indications that could prohibit the return Fig. 2  The proportion of patients that return-to-sport (RTS), measured in time in months 13 3130 European Journal of Orthopaedic Surgery & Traumatology (2023) 33:3125–3133 Table 3  Patient-reported outcomes summary and comparison (n = 19) Many authors [6, 8, 9, 11–22] already advocate the criti- Patient-reported Preoperative 24 month follow-up p value cal role of adding an extra-articular procedure due to its outcome scales ability to restrict rotational laxity [6]. Getgood et al. have recently found that adding LET to primary ACLR in young Lysholma 64.4 (± 12) 87.8 (± 6) 0.0001 patients at high risk of failure results in a statistically signifi- IKDCb 71.27 (± 12) 84.2 (± 9.7) 0.0005 cant reduction in graft rupture and persistent rotatory laxity SF-12 ­Physicalc 53.3 (± 3) 57 (± 1.2) 0.0002 two years after surgery. Some studies have looked into RTS SF-12 ­Mentalc 50.2 (± 3.3) 52.7 (± 2.4) 0.0025 after revision ACLR and LET [8, 11–22, 24], finding good TAS 7.2 (± 1) 6.6 (± 1.1) 0.0005 functional outcomes, low rates of residual rotatory laxity, re- Expressed in mean and (± SD) ruptures or complications. Louis et al. stated that combining TAS Tegner Activity Scale ALL stabilization with revision ACLR improves functional a Lysholm Knee Scoring System outcomes by improving rotational stability without increas- b International Knee Documentation Committee subjective knee form ing the risk of early or late complications [24]. Alessio- c Short Form (12) Health Survey Mazzola et al. [13] reported a RTS rate at preinjury level of 91.7% in professional soccer players and a mean time of return of 9.2 months. Similarly, we reported a 10.2 months autograft combined with LET for revision ACLR in a very mean time of return. homogenous cohort. There are concerns about overtightening the lateral com- There is a discrepancy between the rate of RTS at any partment during different LET techniques, which subse- level and the rate of return to sport to the preinjury level, quently may lead to osteoarthritis [6, 9]. However, accord- which is more pronounced following revision ACLR [4, 5, ing to Declercq et al.'s comparison of modified Lemaire and 11]. Lefevre et al. (BTB/HS + extra-articular tenodesis with Cocker-Arnold procedures, the choice of LET technique tensor fasciae latae tendon) compared RTS rates between appears to have minimal impact on both clinical and radio- patients who underwent primary ACLR and revision ACLR graphic outcomes [25]. In our series, we did not see any and found no significant difference in the rates of return to signs of overtightening or osteoarthritis. sport at any level between the two groups. However, the There are inconsistent results in the literature regarding authors also found that athletes returned to their preinjury the impact of graft type on RTS outcomes [4, 11]. How- sport at a significantly higher rate after primary ACLR ever, some reasons for favoring autografts are their improved (64%) than after revision (49%) [12]. Similarly, in two recent patient-reported outcomes, RTS, and decreased graft re- systematic reviews, Grassi et al. reported that 53.4% (CI rupture rate compared to allografts [3, 10]. Keizer et al. 37.8–68.7), and Glogovac et al. a range from 13 to 69%, of [26] retrospectively compared outcomes between patients patients following revision ACLR had returned to the same with patellar tendon autografts and allografts, and after a sport at a preinjury level [4, 11]. Likewise, the rate of RTS follow-up of 2 years, the rate of RTS was 75% versus 43%, at a preinjury level we saw in our cohort remained within respectively. Shorter RTS times have also been reported [4, that range at 52.3%. Table 4 summarises the results from 11]. Moreover, Glogovac et al. [4] found that the studies the most important published studies on the subject to date. that reported strictly patellar or hamstring tendon autografts There is undoubtedly significant heterogeneity in the demonstrated some of the highest rates of return to sport at results found in different studies [4, 11–22]. The reason for preinjury levels (67–69%). In our case, unharvested BPTB this is multifactorial but we believe it has a lot to do with has been our first choice for young and active patients, the athletes' age, type of sport and initial level of play (elite, reserving contralateral grafts or allografts only in case of professional, or semi-professional). Our series was com- repeated revision, combined ligament reconstruction, or posed of professional and semi-professional athletes, and other particular extraordinary circumstances. at a young age (median age 27.7 years). Younger age was Revision ACLR procedures are known to be signifi- associated with a higher rate of return to sport following cantly more challenging and to present meniscal and carti- revision ACLR in multiple studies [13–15]. When asked for lage injury in nearly 90% of patients [2]. In our case, 57.9% reasons why they did not RTS at preinjury level only 26,3% had some concomitant lesions. Minguell et al. has reported attributed it “to the knee” and that it did not behave as well that a higher rate of concomitant lesions detected in revi- as before. Other reasons included personal reasons (31.6%), sion ACLR was associated with reduced RTS at follow-up since the sport played did not represent the same importance [27]. In addition, The rate of ACL re-rupture after a revi- in these patients' lives, professional reasons (26.3%) where sion surgery is higher than the re-rupture rate after primary work–life balance prohibited returning to the same training reconstruction [5]. Shelbourne et al. found a reinjury rate in routines and 10.5% attributed to other medical conditions. the first 5 years after revision surgery that ranged from 2 to 13 Table 4  Summary from published studies on revisions ACLR using autologous grafts and LET: return to sport (RTS) and patient-reported functional outcomes Authors Year Number of Patients Autologous Graft, (%) LET Technique RTS Any RTS Time to Return, m TAS IKDC Lysholm Level, % Same Level, % Lefervre et al. [12] 2017 47 (n = 55) HT (32.7%)/BPTB (52.7%)/ Lemaire 87.3 49.1 7.4 (± 4.9) – – – CFL (14.6%) – 78.4 (16.6) 87.5 (12.9) Alessio et al. [13] 2018 24 BPTB (79.9%)/HT (20.1%) Coker–Arnold 100 91.7 9.2 (± 2.2) 9.5 (± 0.5) 69.5 (± 11.1) 58.1 (± 11.7) 9.2 (± 1) 88.4 (± 8.9) 97.4 (± 3.2) Redler et al. [14] 2018 118 HT Coker–Arnold 100 41.5 – 3.6 (± 1.8) 70.3 (± 8.4) 67 (± 19.8) 5.7 (± 1.9) 85.7 (± 12.3) 90 (± 7.2) Legnani et al. [15] 2019 9 HT Coker–Arnold – 78 – 6 (± 2.8) 40.2 (± 4.2) 62.2 (± 3.4) 6 (± 3.2) 85.6 (± 4.8) 87.9 (± 7) Legnani et al. [16] 2019 12 HT Coker–Arnold – 58 6 35.7 (± 2.4) 60.8 (± 4.7) 6 84.8 (± 6) 88.7 (± 6.1) Alm et al. [17] 2020 59 HT/BPTB/QT Lemaire – – – – 60 ± 23 – 7 ± 1.3 95 ± 10.8 90 ± 10.7 European Journal of Orthopaedic Surgery & Traumatology (2023) 33:3125–3133 Ventura et al. [18] 2021 12 HT Coker–Arnold – – – 6 35.7 (SD: 2.4) 60.8 (SD: 4.7) 6 84.8 (SD: 6.0) 88.7 (SD: 6.1) Eggeling et al. [19] 2021 23 HT (39.2%)/BPTB (30.4%)/ Lemaire 47.8 – – – – 49.2 ± 28.1 QT (30.4%) 5.7 ± 1.3 77.5 ± 16.2 81.9 ± 14.2 Zanna et al. [20] 2022 17 BPTB Coker–Arnold 94.1 58.8 – – 71.4 (± 9.03) 58.3 (± 19.3) – 92 (± 6.9) 66.8 (± 27.7) Rayes et al. [21] 2022 36 BPTB Lemaire 86.1 61.1 – – 54.4 (± 17.5) 64.8 (± 12.3) 7.3 86.7 (± 10.6) 92.8 (± 10.5) Keizer et al. [22] 2022 42 BPTB Lemaire 52.3 30.9 – – – – 6 81.7 (± 13.4) – Case series (for comparison) 2023 19 BPTB Lemaire 100 52.6 10.3 7.1 (± 1) 71.3 (± 12) 64.4 (± 12) 6.4 (± 1) 84.2 (± 9.7) 87.8 (± 6) Values for outcomes are expressed as mean and (SD). Studies that didn’t report on the use of autologous grafts and extra-articular augmentation (individually or by groups) were not included for comparison TAS Tegner’s Activity Scale, IKDC International Knee Documentation Committee, Lysholm Lysholm Knee Score, LET lateral extra-articular tenodesis, HT hamstrings tendon, BPTB bone– patellar tendon–bone, CFL combined fasciae latae 13 3131 3132 European Journal of Orthopaedic Surgery & Traumatology (2023) 33:3125–3133 5% [28]. Our case series did not have any re-ruptures at the (2020) Anterior cruciate ligament reconstruction in high school 2-year follow-up. and college-aged athletes: does autograft choice influence anterior cruciate ligament revision rates? Am J Sports Med 48(2):298–309. https://​doi.​org/​10.​1177/​03635​46519​892991 2. MARS Group (2019) Reoperation and failure rate at six years following revision ACL reconstruction: a MARS cohort study. Conclusions Orthop J Sports Med 7(7 suppl5):2325967119S00292. https://d​ oi.​ org/​10.​1177/​23259​67119​S00292 In conclusion, the rates of RTS at the preinjury level follow- 3. MARS Group (2014) Effect of graft choice on the outcome of ing revision ACLR using autologous BPTB and modified revision anterior cruciate ligament reconstruction in the Multi- center ACL Revision Study (MARS) Cohort. Am J Sports Med Lemaire LET are lower than those observed after primary 42(10):2301–2310. https://​doi.​org/​10.​1177/​03635​46514​549005 ACLR. Nevertheless, it is important to note that the major- 4. Glogovac G, Schumaier AP, Grawe BM (2019) Return to sport ity, if not all, of the patients can still expect to RTS at some following revision anterior cruciate ligament reconstruction in level. Furthermore, patients can expect significant improve- athletes: a systematic review. Arthroscopy 35(7):2222–2230. https://​doi.​org/​10.​1016/j.​arthro.​2019.​01.​045 ments in their patient-reported functional scales, including 5. Ardern CL, Taylor NF, Feller JA, Webster KE (2014) Fifty-five the IKDC, Lysholm, and SF-12; with a low complications per cent return to competitive sport following anterior cruciate rate. ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and Supplementary Information The online version contains supplemen- contextual factors. Br J Sports Med 48(21):1543–1552. https://​ tary material available at https://d​ oi.o​ rg/1​ 0.1​ 007/s​ 00590-0​ 23-0​ 3544-8. doi.​org/​10.​1136/​bjspo​r ts-​2013-​093398 6. Musahl V, Getgood A, Neyret P, Claes S, Burnham JM, Batailler Author contributions JMM, MRV, JPB, and JVAP were responsible C, Sonnery-Cottet B, Williams A, Amis A, Zaffagnini S, Karls- for surgical operations and for the revision of the final manuscript for son J (2017) Contributions of the anterolateral complex and publication. FMB was responsible for maintaining the database, com- the anterolateral ligament to rotatory knee stability in the set- piling information, and writing and revising the manuscript. MRV and ting of ACL injury: a roundtable discussion. Knee Surg Sports JPB were also responsible for the statistical analysis. All authors read Traumatol Arthrosc 25(4):997–1008. https://​doi.​org/​10.​1007/​ and approved the final manuscript. s00167-​017-​4436-7 7. Ayeni OR, Chahal M, Tran MN, Sprague S (2012) Pivot shift Funding Open Access Funding provided by Universitat Autonoma de as an outcome measure for ACL reconstruction: a systematic Barcelona. This work was carried out as part of the Doctorate in Sur- review. Knee Surg Sports Traumatol Arthrosc 20(4):767–777. gery and Morphological Sciences of the Autonomous University of https://​doi.​org/​10.​1007/​s00167-​011-​1860-y Barcelona. The “Post-FSE Carles Margarit” grant was awarded by the 8. Grassi A, Zicaro JP, Costa-Paz M, Samuelsson K, Wilson VHIR—Vall d'Hebron Institut de Investigación to one of the authors A, Zaffagnini S, Condello V, ESSKA Arthroscopy Commit- (FMB). tee (2020) Good mid-term outcomes and low rates of residual rotatory laxity, complications and failures after revision ante- Declarations rior cruciate ligament reconstruction (ACL) and lateral extra- articular tenodesis (LET). Knee Surg Sports Traumatol Arthrosc Conflict of interest The authors declare no conflicts of interest. 28(2):418–431. https://​doi.​org/​10.​1007/​s00167-​019-​05625-w 9. Riediger MD, Stride D, Coke SE, Kurz AZ, Duong A, Ayeni Informed consent Every patient has signed an informed consent to OR (2019) ACL reconstruction with augmentation: a scoping participate in this study. review. Curr Rev Musculoskelet Med 12(2):166–172. https://​ doi.​org/​10.​1007/​s12178-​019-​09548-4 10. Maletis GB, Inacio MC, Desmond JL, Funahashi TT (2013) Open Access This article is licensed under a Creative Commons Attri- Reconstruction of the anterior cruciate ligament: association bution 4.0 International License, which permits use, sharing, adapta- of graft choice with increased risk of early revision. Bone Jt tion, distribution and reproduction in any medium or format, as long J 95-B(5):623–628. https://​doi.​org/​10.​1302/​0301-​620X.​95B5.​ as you give appropriate credit to the original author(s) and the source, 30872 provide a link to the Creative Commons licence, and indicate if changes 11. Grassi A, Zaffagnini S, Marcheggiani Muccioli GM, Neri MP, were made. The images or other third party material in this article are Della Villa S, Marcacci M (2015) After revision anterior cruci- included in the article's Creative Commons licence, unless indicated ate ligament reconstruction, who returns to sport? A systematic otherwise in a credit line to the material. If material is not included in review and meta-analysis. Br J Sports Med 49(20):1295–1304. the article's Creative Commons licence and your intended use is not https://​doi.​org/​10.​1136/​bjspo​r ts-​2014-​094089 permitted by statutory regulation or exceeds the permitted use, you will 12. Lefevre N, Klouche S, Mirouse G, Herman S, Gerometta A, need to obtain permission directly from the copyright holder. To view a Bohu Y (2017) Return to sport after primary and revision ante- copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. rior cruciate ligament reconstruction: a prospective comparative study of 552 patients from the FAST cohort. 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Shelbourne KD, Benner RW, Gray T (2014) Return to sports and patellar tendon autograft combined with lateral extra-articular subsequent injury rates after revision anterior cruciate ligament tenodesis. Eur J Orthop Surg Traumatol. https://​doi.​org/​10.​1007/​ reconstruction with patellar tendon autograft. Am J Sports Med s00590-​022-​03352-6 42(6):1395–1400. https://​doi.​org/​10.​1177/​03635​46514​524921 21. Rayes J, Ouanezar H, Haidar IM, Ngbilo C, Fradin T, Vieira TD, Freychet B, Sonnery-Cottet B (2022) Revision anterior cruciate Publisher's Note Springer Nature remains neutral with regard to ligament reconstruction using bone-patellar tendon-bone graft jurisdictional claims in published maps and institutional affiliations. combined with modified Lemaire technique versus hamstring graft combined with anterolateral ligament reconstruction: a clinical comparative matched study with a mean follow-up of 5 years from the SANTI study group. 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