Current concepts of management of anterior cruciate ligament revision in adults

Anterior cruciate ligament revision (ACLRev) remains a complex and demanding procedure. Although an increasing number of studies identified factors associated with graft failure and revision outcomes, clear and practical guidelines are still limited. To address these gaps, the European Society for Sports Traumatology, Knee Surgery and Arthroscopy developed a consensus aimed at standardizing indications for ACLRev. Although this initiative provided important guidance, some questions remain unresolved, such as the optimal graft choice and the management of associated procedures. The aim of this review is to provide an updated overview of current literature regarding preoperative planning, surgical techniques and ACLRev management. ACLRev is currently indicated after previous anterior cruciate ligament reconstruction resulting in knee instability, particularly in younger patients with high-functional demands. ACLRev may be performed as a one- or two-stage procedure. A two-stage approach is appropriate in case of infection, arthrofibrosis or insufficient bone stock that precludes secure and anatomical graft fixation. Autografts are generally preferred, particularly in young active patients, due to lower reported failure rates. Increasing attention has been directed to treatment of associated pathologies, such as ramp and root lesions, associated ligamentous instabilities (medial and lateral) or bony malalignment. Additional extraarticular anterolateral procedures are frequently used to reduce failure rates and improve rotational stability. Conversely, the role of slope-reducing osteotomies in ACLRev remains less defined, with good outcomes reported in small case series. Despite the growing body of clinical research, several issues remain unresolved, including the optimal individualized graft selection and indications for combined procedures. This manuscript summarizes the most recent evidence on ACLRev management, with emphasis on graft selection, indications for extraarticular anterolateral procedures, management of medial instability and principles of slope correction. Future high-level studies are needed, particularly addressing peripheral soft-tissue management and osseous corrections, to establish guidelines and enhance clinical outcomes for patients undergoing ACLRev. LEVEL OF EVIDENCE: Level V, expert opinion.