Revision Anterior Cruciate Ligament Reconstruction in a Patient with Generalized Joint Laxity and Previously Undiagnosed Medial Collateral Ligament Injury: A Case Report Highlighting Surgical Strategies
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Abstract
Background: Revision anterior cruciate ligament reconstruction (rACLR) remains one of the most technically demanding procedures in orthopedic sports medicine, particularly in patients with generalized joint laxity (GJL), unrecognized medial collateral ligament (MCL) injuries, and meniscal pathology. Successful outcomes require meticulous diagnostic assessment, individualized graft selection, and simultaneous management of associated ligamentous and meniscal injuries.
Case Report: We report the case of a 23-year-old man with a history of failed primary anterior cruciate ligament reconstruction (ACLR), who presented with recurrent instability, medial knee pain, and episodes of giving way. Clinical and imaging evaluation revealed GJL, a previously unrecognized MCL rupture, meniscal tears, and tibial tunnel widening. A single-stage rACLR using a quadriceps tendon (QT) autograft, combined with concurrent MCL reconstruction and meniscal repair, was performed.
Conclusion: This case highlights the importance of comprehensive evaluation of medial laxity, GJL, and meniscal pathology in all anterior cruciate ligament (ACL) injuries. rACLR in such complex cases requires anatomy-based, patient-specific planning, careful graft selection, and concurrent management of associated injuries to optimize stability and functional outcomes. Hamstring autografts should be used with caution in patients with joint laxity, and double hamstring harvest is discouraged in combined ACL- MCL reconstruction.
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2. Rayan F, Nanjayan SK, Quah C, Ramoutar D, Konan S, Haddad FS. Review of evolution of tunnel position in anterior cruciate ligament reconstruction. World J Orthop. 2015;6(2):252-62. doi: 10.5312/wjo.v6.i2.252. [PubMed: 25793165]. [PubMed Central: PMC4363807].
3. Hettrich CM, Dunn WR, Reinke EK, Spindler KP. The rate of subsequent surgery and predictors after anterior cruciate ligament reconstruction: two- and 6-year follow-up results from a multicenter cohort. Am J Sports Med. 2013;41(7):1534-40. doi: 10.1177/0363546513490277. [PubMed: 23722056]. [PubMed Central: PMC4195486].
4. Maletis GB, Inacio MCS, Funahashi TT. Analysis of 16,192 Anterior Cruciate Ligament Reconstructions From a Community-Based Registry. Am J Sports Med. 2013;41(9):2090-8. doi: 10.1177/0363546513493589. [PubMed: 23813802].
5. Aghaghazvini L, Tahmasebi MN, Gerami R, Vaziri AS, Rasuli B, Tahami M, et al. Sonography: a sensitive and specific method for detecting trochlear cartilage pathologies. J Ultrasound. 2020;23(3):259-63. doi: 10.1007/s40477-020-00488-1. [PubMed: 32524280]. [PubMed Central: PMC7441103].
6. Andrä K, Prill R, Kayaalp E, Irlenbusch L, Liesaus E, Trommer T, et al. Increase in cartilage degeneration in all knee compartments after failed ACL reconstruction at 4 years of follow-up. J Orthop Traumatol. 2021;22(1):54. doi: 10.1186/s10195-021-00618-3. [PubMed: 34914026]. [PubMed Central: PMC8677851].
7. Battaglia MJ, 2nd, Lenhoff MW, Ehteshami JR, Lyman S, Provencher MT, Wickiewicz TL, et al. Medial collateral ligament injuries and subsequent load on the anterior cruciate ligament: a biomechanical evaluation in a cadaveric model. Am J Sports Med. 2009;37(2):305-11. doi: 10.1177/0363546508324969. [PubMed: 19098154].
8. Beaufils P, Becker R, Kopf S, Englund M, Verdonk R, Ollivier M, et al. Surgical management of degenerative meniscus lesions: the 2016 ESSKA meniscus consensus. Knee Surg Sports Traumatol Arthrosc. 2017;25(2):335-46. doi: 10.1007/s00167-016-4407-4. [PubMed: 28210788]. [PubMed Central: PMC5331096].
9. Cruz AI, JR., Beck JJ, Ellington MD, Mayer SW, Pennock AT, Stinson ZS, et al. Failure Rates of Autograft and Allograft ACL Reconstruction in Patients 19 Years of Age and Younger: A Systematic Review and Meta-Analysis. JB JS Open Access. 2020;5(4):e20.00106. doi: 10.2106/jbjs.Oa.20.00106. [PubMed: 34322650]. [PubMed Central: PMC8312832].
10. Mariscalco MW, Flanigan DC, Mitchell J, Pedroza AD, Jones MH, Andrish JT, et al. The influence of hamstring autograft size on patient-reported outcomes and risk of revision after anterior cruciate ligament reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON) Cohort Study. Arthroscopy. 2013;29(12):1948-53. doi: 10.1016/j.arthro.2013.08.025. [PubMed: 24140144]. [PubMed Central: PMC3844091].
11. Perkins CA, Busch MT, Christino M, Herzog MM, Willimon SC. Allograft Augmentation of Hamstring Anterior Cruciate Ligament Autografts Is Associated With Increased Graft Failure in Children and Adolescents. Am J Sports Med. 2019;47(7):1576-82. doi: 10.1177/0363546519849607. [PubMed: 31095404].
12. Dejour D, Pungitore M, Valluy J, Nover L, Saffarini M, Demey G. Tibial slope and medial meniscectomy significantly influence short- term knee laxity following ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2019;27(11):3481-9. doi: 10.1007/s00167-019- 05435-0. [PubMed: 30809722].
13. Noyes FR, Barber-Westin SD. Anterior cruciate ligament revision reconstruction: results using a quadriceps tendon-patellar bone autograft. Am J Sports Med. 2006;34(4):553-64. doi: 10.1177/0363546505281812. [PubMed: 16365373].
14. Noyes F, Barber-Westin S. The role of high tibial osteotomy in the anterior cruciate ligament-deficient knee with varus alignment. In: DeLee J, Drez JD, Editors. Orthopaedic Sports Medicine: Principles and Practice. Phillidelphia, PA: WB Saunders; 1994.
15. Cooper DE, Dunn WR, Huston LJ, Haas AK, Spindler KP, Allen CR, et al. Physiologic Preoperative Knee Hyperextension Is a
Predictor of Failure in an Anterior Cruciate Ligament Revision Cohort: A Report From the MARS Group. Am J Sports Med. 2018;46(12):2836-41. doi: 10.1177/0363546518777732. [PubMed: 29882693]. [PubMed Central: PMC6170681].
16. Magosch A, Mouton C, Nührenbörger C, Seil R. Medial meniscus ramp and lateral meniscus posterior root lesions are present in more than a third of primary and revision ACL reconstructions. Knee Surg Sports Traumatol Arthrosc. 2021;29(9):3059-67. doi: 10.1007/s00167-020-06352-3. [PubMed: 33165632].
17. Pioger C, Saithna A, Rayes J, Haidar IM, Fradin T, Ngbilo C, et al. Influence of Preoperative Tunnel Widening On the Outcomes of a Single Stage-Only Approach to Every Revision Anterior Cruciate Ligament Reconstruction: An Analysis of 409 Consecutive Patients From the SANTI Study Group. Am J Sports Med. 2021;49(6): 1431-40. doi: 10.1177/0363546521996389. [PubMed: 33689510].
18. Keyhani S, Movahedinia M, LaPrade RF, Qoreishy M, Vosoughi F. Long-term clinical results of using a posteromedial all-inside and anteromedial inside-out approach to repair unstable or irreducible bucket-handle medial meniscal tears. J Orthop Traumatol. 2023;24(1):12. doi: 10.1186/s10195-023-00691-w. [PubMed: 37024629]. [PubMed Central: PMC10079791].
19. Keyhani S, Movahedinia M, Sherafat Vaziri A, Soleymanha M, Vosoughi F, Tahami M, et al. Is posterior knee arthroscopy using posterior portals necessary for orthopedic surgeons? The latest evidence on applications and techniques. EFORT Open Rev. 2023;8(4):189-98. doi: 10.1530/eor-22-0133. [PubMed: 37097043]. [PubMed Central: PMC10155121].
20. Tischer T, Beaufilis P, Becker R, Ahmad SS, Bonomo M, Dejour D, et al. Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus part I-diagnostics and preoperative planning. Knee Surg Sports Traumatol Arthrosc. 2023;31(11): 4642-51. doi: 10.1007/s00167-022-07214-w. [PubMed: 36322180].
21. Condello V, Beaufilis P, Becker R, Ahmad SS, Bonomo M, Dejour D, et al. Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus: part II-surgical strategy. Knee Surg Sports Traumatol Arthrosc. 2023;31(11):4652-61. doi: 10.1007/s00167-023- 07550-5. [PubMed: 37700168]. [PubMed Central: PMC10598082].
2. Rayan F, Nanjayan SK, Quah C, Ramoutar D, Konan S, Haddad FS. Review of evolution of tunnel position in anterior cruciate ligament reconstruction. World J Orthop. 2015;6(2):252-62. doi: 10.5312/wjo.v6.i2.252. [PubMed: 25793165]. [PubMed Central: PMC4363807].
3. Hettrich CM, Dunn WR, Reinke EK, Spindler KP. The rate of subsequent surgery and predictors after anterior cruciate ligament reconstruction: two- and 6-year follow-up results from a multicenter cohort. Am J Sports Med. 2013;41(7):1534-40. doi: 10.1177/0363546513490277. [PubMed: 23722056]. [PubMed Central: PMC4195486].
4. Maletis GB, Inacio MCS, Funahashi TT. Analysis of 16,192 Anterior Cruciate Ligament Reconstructions From a Community-Based Registry. Am J Sports Med. 2013;41(9):2090-8. doi: 10.1177/0363546513493589. [PubMed: 23813802].
5. Aghaghazvini L, Tahmasebi MN, Gerami R, Vaziri AS, Rasuli B, Tahami M, et al. Sonography: a sensitive and specific method for detecting trochlear cartilage pathologies. J Ultrasound. 2020;23(3):259-63. doi: 10.1007/s40477-020-00488-1. [PubMed: 32524280]. [PubMed Central: PMC7441103].
6. Andrä K, Prill R, Kayaalp E, Irlenbusch L, Liesaus E, Trommer T, et al. Increase in cartilage degeneration in all knee compartments after failed ACL reconstruction at 4 years of follow-up. J Orthop Traumatol. 2021;22(1):54. doi: 10.1186/s10195-021-00618-3. [PubMed: 34914026]. [PubMed Central: PMC8677851].
7. Battaglia MJ, 2nd, Lenhoff MW, Ehteshami JR, Lyman S, Provencher MT, Wickiewicz TL, et al. Medial collateral ligament injuries and subsequent load on the anterior cruciate ligament: a biomechanical evaluation in a cadaveric model. Am J Sports Med. 2009;37(2):305-11. doi: 10.1177/0363546508324969. [PubMed: 19098154].
8. Beaufils P, Becker R, Kopf S, Englund M, Verdonk R, Ollivier M, et al. Surgical management of degenerative meniscus lesions: the 2016 ESSKA meniscus consensus. Knee Surg Sports Traumatol Arthrosc. 2017;25(2):335-46. doi: 10.1007/s00167-016-4407-4. [PubMed: 28210788]. [PubMed Central: PMC5331096].
9. Cruz AI, JR., Beck JJ, Ellington MD, Mayer SW, Pennock AT, Stinson ZS, et al. Failure Rates of Autograft and Allograft ACL Reconstruction in Patients 19 Years of Age and Younger: A Systematic Review and Meta-Analysis. JB JS Open Access. 2020;5(4):e20.00106. doi: 10.2106/jbjs.Oa.20.00106. [PubMed: 34322650]. [PubMed Central: PMC8312832].
10. Mariscalco MW, Flanigan DC, Mitchell J, Pedroza AD, Jones MH, Andrish JT, et al. The influence of hamstring autograft size on patient-reported outcomes and risk of revision after anterior cruciate ligament reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON) Cohort Study. Arthroscopy. 2013;29(12):1948-53. doi: 10.1016/j.arthro.2013.08.025. [PubMed: 24140144]. [PubMed Central: PMC3844091].
11. Perkins CA, Busch MT, Christino M, Herzog MM, Willimon SC. Allograft Augmentation of Hamstring Anterior Cruciate Ligament Autografts Is Associated With Increased Graft Failure in Children and Adolescents. Am J Sports Med. 2019;47(7):1576-82. doi: 10.1177/0363546519849607. [PubMed: 31095404].
12. Dejour D, Pungitore M, Valluy J, Nover L, Saffarini M, Demey G. Tibial slope and medial meniscectomy significantly influence short- term knee laxity following ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2019;27(11):3481-9. doi: 10.1007/s00167-019- 05435-0. [PubMed: 30809722].
13. Noyes FR, Barber-Westin SD. Anterior cruciate ligament revision reconstruction: results using a quadriceps tendon-patellar bone autograft. Am J Sports Med. 2006;34(4):553-64. doi: 10.1177/0363546505281812. [PubMed: 16365373].
14. Noyes F, Barber-Westin S. The role of high tibial osteotomy in the anterior cruciate ligament-deficient knee with varus alignment. In: DeLee J, Drez JD, Editors. Orthopaedic Sports Medicine: Principles and Practice. Phillidelphia, PA: WB Saunders; 1994.
15. Cooper DE, Dunn WR, Huston LJ, Haas AK, Spindler KP, Allen CR, et al. Physiologic Preoperative Knee Hyperextension Is a
Predictor of Failure in an Anterior Cruciate Ligament Revision Cohort: A Report From the MARS Group. Am J Sports Med. 2018;46(12):2836-41. doi: 10.1177/0363546518777732. [PubMed: 29882693]. [PubMed Central: PMC6170681].
16. Magosch A, Mouton C, Nührenbörger C, Seil R. Medial meniscus ramp and lateral meniscus posterior root lesions are present in more than a third of primary and revision ACL reconstructions. Knee Surg Sports Traumatol Arthrosc. 2021;29(9):3059-67. doi: 10.1007/s00167-020-06352-3. [PubMed: 33165632].
17. Pioger C, Saithna A, Rayes J, Haidar IM, Fradin T, Ngbilo C, et al. Influence of Preoperative Tunnel Widening On the Outcomes of a Single Stage-Only Approach to Every Revision Anterior Cruciate Ligament Reconstruction: An Analysis of 409 Consecutive Patients From the SANTI Study Group. Am J Sports Med. 2021;49(6): 1431-40. doi: 10.1177/0363546521996389. [PubMed: 33689510].
18. Keyhani S, Movahedinia M, LaPrade RF, Qoreishy M, Vosoughi F. Long-term clinical results of using a posteromedial all-inside and anteromedial inside-out approach to repair unstable or irreducible bucket-handle medial meniscal tears. J Orthop Traumatol. 2023;24(1):12. doi: 10.1186/s10195-023-00691-w. [PubMed: 37024629]. [PubMed Central: PMC10079791].
19. Keyhani S, Movahedinia M, Sherafat Vaziri A, Soleymanha M, Vosoughi F, Tahami M, et al. Is posterior knee arthroscopy using posterior portals necessary for orthopedic surgeons? The latest evidence on applications and techniques. EFORT Open Rev. 2023;8(4):189-98. doi: 10.1530/eor-22-0133. [PubMed: 37097043]. [PubMed Central: PMC10155121].
20. Tischer T, Beaufilis P, Becker R, Ahmad SS, Bonomo M, Dejour D, et al. Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus part I-diagnostics and preoperative planning. Knee Surg Sports Traumatol Arthrosc. 2023;31(11): 4642-51. doi: 10.1007/s00167-022-07214-w. [PubMed: 36322180].
21. Condello V, Beaufilis P, Becker R, Ahmad SS, Bonomo M, Dejour D, et al. Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus: part II-surgical strategy. Knee Surg Sports Traumatol Arthrosc. 2023;31(11):4652-61. doi: 10.1007/s00167-023- 07550-5. [PubMed: 37700168]. [PubMed Central: PMC10598082].
| Files | ||
| Issue | Vol 12 No 4 (2026) | |
| Section | Case Report | |
| Keywords | ||
| Revision Surgery Collateral Ligaments Joint Instability Tendons Autografts | ||
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How to Cite
1.
Vosoughi F, Zolghadr H, Akhoondi A, Sherafatvaziri A. Revision Anterior Cruciate Ligament Reconstruction in a Patient with Generalized Joint Laxity and Previously Undiagnosed Medial Collateral Ligament Injury: A Case Report Highlighting Surgical Strategies. J Orthop Spine Trauma. 2026;12(4):215-9.
