Revision ACL Reconstruction (Redo ACL Surgery) in Bristol & Bath

Revision ACL reconstruction (sometimes called redo ACL surgery) is an operation to restore knee stability after a previous ACL reconstruction has failed, stretched, or the knee remains unstable. Revision surgery is more complex than first-time (primary) ACL reconstruction because the surgeon must understand why the first graft failed and tailor the plan to your anatomy, sport goals, and any associated knee damage.

Mr Simon Abram, Consultant Specialist Knee Surgeon, is frequently referred patients following an unsuccessful or failed ACL reconstruction and offers specialist assessment and treatment planning for revision ACL reconstruction in Bath and Bristol. Your plan is personalised and may involve graft selection, tunnel strategy (including staged surgery when needed), and addressing meniscus, cartilage, alignment, or rotational instability factors that can increase re-injury risk.

What is revision ACL reconstruction?

Revision ACL reconstruction replaces or rebuilds the ACL again after a previous reconstruction. It aims to restore stability for walking, work, and sport–especially pivoting activities such as football, rugby, netball, skiing, and court sports.

Revision surgery may be performed as a single-stage operation (all done in one procedure) or as a two-stage process if the bone tunnels from the previous surgery need to heal or be rebuilt first.

Why does an ACL reconstruction fail?

There are several reasons an ACL graft may fail or the knee may still feel unstable. Common contributors include:

New injury (a further twist, contact injury, or return to sport too early)
Technical factors (for example, tunnel position or graft fixation issues)
Biological factors (graft incorporation/healing problems)
Meniscus deficiency (loss of meniscus support increases instability and graft load)
Rotational instability not fully addressed (in selected cases, additional lateral procedures may help)
Alignment factors (bow-leg/knock-knee or slope-related factors that increase forces on the graft)
Rehabilitation and return-to-sport factors (strength deficits, poor movement control, or high-risk return)

Revision planning starts by identifying the most likely drivers in your specific case.

Symptoms that may suggest ACL graft failure

Recurrent giving way or “shifting” during turning or pivoting
Loss of confidence in the knee during sport or uneven ground
Swelling after twisting events
Difficulty decelerating or changing direction
Feeling that the knee is unstable or 'just not right' despite rehabilitation

Assessment and diagnosis (Bath & Bristol)

Revision ACL surgery should never be “one-size-fits-all”. Mr Simon Abram offers specialist revision ACL assessment in Bath and Bristol, focusing on understanding the reason for failure and building a plan that reduces the chance of repeat failure.

Assessment typically includes:

History: when symptoms returned, any new injury, sport demands, previous graft type
Examination: stability tests (including rotational stability), movement patterns, hypermobility
X-rays: to assess tunnel position, fixation hardware, and arthritis changes
MRI scan: to assess graft integrity, meniscus tears, cartilage injury, and associated ligament injury
CT scan: to accurately assess tunnel size/position and bone quality for planning
Alignment assessment (selected cases): especially if overload or malalignment may be contributing

The aim is to confirm what needs correcting: the ACL itself, the tunnels, the meniscus/cartilage environment, and any additional stabilisers.

Single-stage vs two-stage revision ACL reconstruction

Single-stage revision

A single-stage revision may be possible when the previous tunnels are in acceptable positions and not excessively widened, and when fixation and graft placement can be achieved reliably in one operation.

Two-stage revision

A two-stage approach is considered when the existing bone tunnels are too large, poorly positioned, or overlapping the new ideal tunnel positions. Stage 1 may involve removing old hardware and bone grafting to rebuild tunnel bone stock. Stage 2 is the definitive revision ACL reconstruction once healing has occurred.

This staged approach is sometimes the safest way to achieve a durable result.

Graft choices in revision ACL reconstruction

Choosing the right graft is a key decision in revision ACL surgery. The best option depends on what graft you had before, your anatomy, your sport, your preferences, and whether additional procedures are planned. Options can include grafts from your own tissue (autograft) or donor tissue (allograft) in selected cases.

Autograft options (your own tissue)

BTB (Bone-Patellar Tendon-Bone) graft

BTB uses the middle third of the patellar tendon with small bone blocks. It can provide strong fixation and is commonly considered for high-demand athletes and revision settings, particularly if the previous graft was not BTB or if strong bone fixation is desirable. It is typically the first choice for a revision ACL reconstruction.

Hamstring tendon graft

Hamstring graft uses tendon tissue from the inner side of the knee. It is widely used in ACL surgery. In revision cases, hamstring graft can be an excellent option depending on what was used previously and the overall reconstruction plan. In some cases, this graft can be taken from the other leg (contralateral graft) and this is a good option in selected patients.

Quads Tendon or Rectus femoris graft (quadriceps mechanism option)

The central quads tendon and rectus femoris are part of the quadriceps mechanism. In some revision cases, a graft option from the quadriceps/rectus femoris region may be considered, particularly when previous graft harvest limits options or when a robust graft is needed. This is planned carefully to balance graft strength with donor-site recovery. Good physiotherapy is essential as it can take time for the quadriceps to regain their function.

Key point: In revision surgery, graft choice is often influenced by what has already been used, what remains available, and which choice best fits your sport and stability needs.

Contralateral grafts (using the other leg)

In some revision cases, the best graft option may come from the other (contralateral) knee. This can be considered when:

The previously operated knee has limited remaining graft options due to prior harvest
A strong autograft is preferred for your sport goals
Using the other side allows better graft choice and avoids re-harvesting from a previously operated area

Contralateral graft harvest means you may have some temporary symptoms in the donor knee during early rehabilitation. This is discussed carefully in clinic so you understand the trade-offs and what recovery typically involves.

Additional procedures that may improve revision success

Revision ACL reconstruction works best when contributing factors are addressed at the same time. Depending on your knee, this may include:

Meniscus treatment (repair, root repair, or meniscus preservation strategies)
Cartilage treatment for focal defects
Lateral extra-articular tenodesis (LET) / ALL reconstruction for additional rotational stability in selected high-risk cases
Osteotomy if alignment is increasing load on the graft or causing compartment overload
Management of other ligament injuries (MCL, LCL/PLC, PCL) where relevant

The goal is not only to “replace the ACL”, but to create a stable, durable knee environment.

Recovery and rehabilitation

Rehabilitation after revision ACL reconstruction is structured and criteria-based. In general, recovery can be slower than after a first-time ACL reconstruction because of the complexity of the surgery and the need to protect additional repairs.

Rehabilitation priorities include:

Swelling control and regaining full extension early
Progressive strength rebuilding (quads, hamstrings, hips)
Movement retraining and neuromuscular control
Gradual return to running and sport-specific change-of-direction work when criteria are met
Return to sport based on objective testing and confidence, not dates alone

If you have additional procedures (meniscus repair, LET/ALL, cartilage surgery, osteotomy), your early rehabilitation may be modified to protect healing tissues.

Risks and considerations

All surgery carries risks. Revision ACL reconstruction has additional complexity and may carry higher risks of stiffness, ongoing instability, and further surgery. Potential risks include:

Infection, blood clots, wound issues
Stiffness or prolonged swelling
Persistent instability or graft failure
Ongoing pain, including donor-site discomfort depending on graft choice
Meniscus or cartilage problems that continue to influence symptoms

Your consultation will cover the specific risks that apply to you, your expected outcomes, and how we minimise risk through planning and rehabilitation.

Frequently asked questions

Is revision ACL reconstruction always needed if the graft fails?

Not always. Some people can manage with rehabilitation and activity modification, especially if they do not do pivoting sport. Revision surgery is usually considered when instability affects daily life, work, or sport goals, or when the knee is at risk of further damage.

How do you choose the best graft for revision ACL surgery?

Graft choice depends on your previous graft, your sport goals, tunnel strategy, and what graft options are available. Options may include BTB, hamstrings, or quadriceps/rectus femoris region grafts, and in some cases a graft from the other knee (contralateral).

Will I recover more slowly than after my first ACL reconstruction?

Often, yes. Revision surgery can involve more complex work and sometimes additional procedures. Return-to-sport decisions are criteria-based, with objective strength and function targets to reduce re-injury risk.

Can I be assessed for revision ACL reconstruction in Bath or Bristol?

Yes. Mr Simon Abram offers specialist assessment and treatment planning for revision ACL reconstruction in Bath and Bristol, including imaging-led diagnosis, graft selection planning, and combined procedures when needed to improve stability and reduce repeat failure risk.