ACL Revisions & Multiple Surgeries

July 3, 2025

ACL Revisions & Multiple Surgeries

Anterior Cruciate Ligament (ACL) injuries are among the most common and debilitating knee injuries, especially in athletes and active individuals. While many people recover well after a primary ACL reconstruction, sometimes the outcome isn’t as expected leading to the need for a revision surgery or even multiple procedures.

Any kind of failure is likely top among the fears of ACL patient candidates. And such concerns may weigh heavily upon those who may be considering whether or not they want or need such surgery. It’s challenging to suggest what a failure rate might be. While some studies may say 5%, others might say 10%, however there is a great deal of nuance in these findings. There are differences in graft types, patient activity types, the biology of different situations and so on. For example, one study says those who have had an ACL injury are 6 times more likely than others to have another injury. This may seem like a large number. And yet other studies show failure rates under 2% for most graft types. Meanwhile, we need to consider that often ACL injuries are among highly active populations. In any case, the need for a revision is not necessarily the same as a fresh injury. Higher rates have also been reported for athletes. And also for younger athletes, which stands to reason. (Younger athletes are likely much more active and might be at much higher intensities than older recreational athletes.)

Here’s some things to consider in this general area of concern.

Why ACL Reconstructions Fail

Primary ACL reconstruction has a high success rate, but failures can occur. Causes include:

Graft Failure: The reconstructed ligament may re-tear, often due to trauma or inadequate healing.
Technical Errors: Improper tunnel placement or fixation during the initial surgery can compromise joint mechanics.
Biological Factors: Poor healing or graft incorporation may occur, especially in smokers or those with poor vascular supply.
Reinjury: Return to high-risk activities too soon or without adequate rehab can cause a second tear.
Poor Rehabilitation: If a patient doesn’t recovery as well as possible, it’s conceivable that other knee structures are less than they otherwise could be and could cause additional wear at various places in the knee joint. This can lead to additional problems of the ACL, meniscus or other structures.

What Is an ACL Revision?

An ACL revision is a second surgery to reconstruct the ACL after a failed initial reconstruction. This procedure is typically more complex because:

There may be scar tissue, tunnel widening, or hardware that must be addressed first.
Bone grafting might be needed if old tunnels were improperly placed or too large.
The choice of graft: autograft (your tissue), allograft (donor tissue), or synthetic. The choice may differ from your first surgery. This could simply be due to age. If you went 10, 15 or more years with a reconstructed ACL and tore it again, it could be you’re now in your late 30s or 40s and a recommendation might be for an allograft vs. using your own, (now older), tissue. However, for a young person, a different autograft option may be chosen.

Evaluation Before a Revision

A thorough evaluation is critical before deciding on revision surgery. This usually includes:

MRI and CT scans to assess the integrity of the graft, hardware, and tunnel placement.
Physical examination for instability, alignment issues, and range of motion deficits.
Functional assessments to understand your activity level and goals.

The unfortunate reality though, is just as with an initial surgery there’s no way to really tell for sure what’s going on until a surgeon can look at the knee arthroscopically.

Recovery Expectations After Revision

Rehabilitation after an ACL revision often takes longer than after the initial surgery. At least 9 to 12 months, but quite possibly longer. Expect:

Slower return to sport or high-impact activity due to healing time and more extensive soft tissue disruption.
Physical therapy tailored to address compensatory movement patterns and lingering muscle imbalances.
Close monitoring to reduce risk of complications such as joint stiffness or graft failure.
Emotional aspects may be more significant. Painful injuries and the long term efforts involved in rehabilitation require not only mental and emotional strength to get through, but along the way there has likely been loss of some sort. Or fear of loss, from simple ability to play for a recreational athlete vs. collegiate or career impacts.

Multiple Surgeries: When Is It Too Much?

Some patients require more than one revision, especially if there’s significant damage to the surrounding cartilage, meniscus, or other ligaments. In these cases:

Multiligament reconstruction or osteotomy (bone realignment) may be necessary.
Joint preservation strategies like cartilage restoration procedures might be needed.
In rare, severe cases, knee replacement could be considered, especially if osteoarthritis develops.

Psychological and Lifestyle Considerations

Undergoing multiple surgeries can be emotionally and physically draining. It’s important to:

Set realistic goals and timelines for recovery.
Consider counseling or support groups if motivation or mental health becomes a challenge.
Work with a multidisciplinary team: surgeon, physical therapist, and possibly a sports psychologist.

Patients may also be re-considering things like if they want yet more surgery. Or whether and how long to wait. And then of course, if they want to make lifestyle changes afterwards. Some high profile athletes have returned to sport after repeated injuries. But these are typically top-tier professional athletes. Besides the fact that this is their career, their entire identities are likely deeply wrapped up in their sport. The 50+ year old beer league hockey player on the other hand, might consider some other sports options. And then there’s everyone one and every sport in between.

Preventing Another ACL Injury

Whether you’re recovering from a revision or a third surgery, prevention is clearly a goal.

Neuromuscular training and sports-specific drills can reduce the risk of reinjury.
Activity modification may be necessary for high-risk sports.
Ensure full strength, proprioception, and confidence before returning to sport.
Perhaps obviously, consider whether return to a particular sport, or at least to certain intensity levels, is still desired. Injuries can certainly happen from just happening to turn the wrong way or one bad landing. It is, however, also somewhat sensible to consider there’s a difference between a high intensity competitive sports league vs. more casual recreational play.