Navigation for Revision ACL Reconstruction

  • Stefano Zaffagnini
  • Tommaso Bonanzinga
  • Bharat Sharma
  • Nicola Lopomo
  • Cecilia Signorelli
  • Giulio Maria Marcheggiani Muccioli
  • Maurilio Marcacci


Revision reconstruction of the anterior cruciate ligament (ACL) is becoming more frequent due to the increasing number of ACL primary reconstruction combined with the high level of activity expected by the patients. In the revision ACL reconstruction, there are many technical issues, like bone tunnel defects or incorrect tunnel placement, that influence negatively the result compared with primary procedures. Computer-aided surgery (CAS) can enable the surgeon to improve the outcome and to detect causes for failure of the primary reconstruction. The purpose of this chapter is to describe an approach to ACL revision surgery using a commercial navigation system (BLU-IGS, Orthokey LLC, Lewes, De, USA) to intra-operatively measure joint laxity, graft elongations, isometry maps, and previous tunnel placement. This technique allows to evaluate joint kinematics and laxities before performing the ACL revision, to check the placement and the isometry of the new tunnels. Further, navigated surgery allows to test in real-time the efficacy of the reconstruction and to search for any possible associated secondary laxity. Advantages of CAS are especially important for complex scenarios as ACL revision surgery, due to the improvement of the accuracy that may potentially allow to customize the surgery for each patient to reduce the failures.


  1. 1.
    Eberhardt C, Kurth AH, Hailer N, Jäger A. Revision ACL reconstruction using autogenous patellar tendon graft. Knee Surg Sports Traumatol Arthrosc. 2000; 8(5):290–5.PubMedCrossRefGoogle Scholar
  2. 2.
    Grossman MG, ElAttrache NS, Shields CL, Glousman RE. Revision anterior cruciate ligament reconstruction: three- to nine-year follow-up. Arthroscopy. 2005;21(4):418–23.PubMedCrossRefGoogle Scholar
  3. 3.
    Noyes FR, Barber-Westin SD. Revision anterior cruciate surgery with use of bone-patellar tendon-bone autogenous grafts. J Bone Joint Surg Am. 2001; 83-A(8):1131–43.PubMedGoogle Scholar
  4. 4.
    Uribe JW, Hechtman KS, Zvijac JE, Tjin-A-Tsoi EW. Revision anterior cruciate ligament surgery: experience from Miami. Clin Orthop Relat Res. 1996;325: 91–9.PubMedCrossRefGoogle Scholar
  5. 5.
    Yagi M, Kuroda R, Nagamune K, Yoshiya S, Kurosaka M. Double-bundle ACL reconstruction can improve rotational stability. Clin Orthop Relat Res. 2007;454: 100–7.PubMedCrossRefGoogle Scholar
  6. 6.
    Carson EW, Anisko EM, Restrepo C, et al. Revision anterior cruciate ligament reconstruction: etiology of failures and clinical results. J Knee Surg. 2004;17(3): 127–32.PubMedGoogle Scholar
  7. 7.
    Johnson DL, Swenson TM, Irrgang JJ, Fu FH, Harner CD. Revision anterior cruciate ligament surgery: experience from Pittsburgh. Clin Orthop Relat Res. 1996;325:100–9.PubMedCrossRefGoogle Scholar
  8. 8.
    Noyes FR, Barber-Westin SD. Revision anterior cruciate ligament surgery: experience from Cincinnati. Clin Orthop Relat Res. 1996;325:116–29.PubMedCrossRefGoogle Scholar
  9. 9.
    Taggart TF, Kumar A, Bickerstaff DR. Revision anterior cruciate ligament reconstruction: a midterm patient assessment. Knee. 2004;11(1):29–36.PubMedCrossRefGoogle Scholar
  10. 10.
    Texier A, Hulet C, Acquitter Y, et al. [Arthroscopy-assisted revision in failed reconstruction of anterior cruciate ligament: 32 cases]. Rev Chir Orthop Reparatrice Appar Mot. 2001;87(7):653–60.PubMedGoogle Scholar
  11. 11.
    Dennis DA, Mahfouz MR, Komistek RD, Hoff W. In vivo determination of normal and anterior cruciate ligament-deficient knee kinematics. J Biomech. 2005;38(2):241–53.PubMedCrossRefGoogle Scholar
  12. 12.
    Fu FH, Harner CD, Johnson DL, Miller MD, Woo SL. Biomechanics of knee ligaments: basic concepts and clinical application. Instr Course Lect. 1994;43: 137–48.PubMedGoogle Scholar
  13. 13.
    Jackson DW, Simon TM. History of computer-assisted orthopedic surgery (CAOS) in sports medicine. Sports Med Arthrosc. 2008;16(2):62–6.PubMedCrossRefGoogle Scholar
  14. 14.
    Schep NWL, Broeders IAMJ, van der Werken C. Computer assisted orthopaedic and trauma surgery. State of the art and future perspectives. Injury. 2003;34(4):299–306.PubMedCrossRefGoogle Scholar
  15. 15.
    Koh JL. The future of computer-assisted surgery (CAS) in sports medicine. Sports Med Arthrosc. 2008;16(2):108–10.PubMedCrossRefGoogle Scholar
  16. 16.
    Sikorski JM, Chauhan S. Computer-assisted orthopaedic surgery: do we need CAOS? J Bone Joint Surg Br. 2003;85(3):319–23.PubMedCrossRefGoogle Scholar
  17. 17.
    Kodali P, Yang S, Koh J. Computer-assisted surgery for anterior cruciate ligament reconstruction. Sports Med Arthrosc. 2008;16(2):67–76.PubMedCrossRefGoogle Scholar
  18. 18.
    Nakagawa T, Hiraoka H, Fukuda A, et al. Fluoroscopic-based navigation-assisted placement of the tibial tunnel in revision anterior cruciate ligament reconstruction. Arthroscopy. 2007;23(4):443.e1–e4.CrossRefGoogle Scholar
  19. 19.
    Marcacci M, Zaffagnini S, Bonanzinga T, et al. Over-the-top double-bundle revision ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2012;20: 1404–8. Available at: Scholar
  20. 20.
    Martelli S, Lopomo N, Bignozzi S, Zaffagnini S, Visani A. Validation of a new protocol for navigated intraoperative assessment of knee kinematics. Comput Biol Med. 2007;37(6):872–8.PubMedCrossRefGoogle Scholar
  21. 21.
    Martelli S, Lopomo N, Greggio S, Ferretti E, Visani A. Development and applications of a software tool for diarthrodial joint analysis. Comput Methods Programs Biomed. 2006;83(1):50–6.PubMedCrossRefGoogle Scholar
  22. 22.
    Zaffagnini S, Bignozzi S, Martelli S, et al. New intraoperative protocol for kinematic evaluation of ACL reconstruction: preliminary results. Knee Surg Sports Traumatol Arthrosc. 2006;14(9):811–6.PubMedCrossRefGoogle Scholar
  23. 23.
    Zaffagnini S, Bignozzi S, Martelli S, Lopomo N, Marcacci M. Does ACL reconstruction restore knee stability in combined lesions?: an in vivo study. Clin Orthop Relat Res. 2007;454:95–9.PubMedCrossRefGoogle Scholar
  24. 24.
    Lopomo N, Zaffagnini S, Bignozzi S, Visani A, Marcacci M. Pivot-shift test: analysis and quantification of knee laxity parameters using a navigation system. J Orthop Res. 2010;28(2):164–9.PubMedGoogle Scholar
  25. 25.
    Martelli S, Zaffagnini S, Falcioni B, Motta M. Determination of an optimal kinematic protocol for computer-assisted evaluation of anterior cruciate ligament deficiency. Ann Biomed Eng. 2001;29(12):1112–21.PubMedCrossRefGoogle Scholar
  26. 26.
    Zaffagnini S, Martelli S, Falcioni B, Motta M, Marcacci M. Rotational laxity after anterior cruciate ligament injury by kinematic evaluation of clinical tests. J Med Eng Technol. 2000;24(5):230–6.PubMedCrossRefGoogle Scholar
  27. 27.
    Marcacci M, Zaffagnini S, Iacono F, et al. Arthroscopic intra- and extra-articular anterior cruciate ligament reconstruction with gracilis and semitendinosus tendons. Knee Surg Sports Traumatol Arthrosc. 1998; 6(2):68–75.PubMedCrossRefGoogle Scholar
  28. 28.
    Daniel DM, Malcom LL, Losse G, et al. Instrumented measurement of anterior laxity of the knee. J Bone Joint Surg Am. 1985;67(5):720–6.PubMedGoogle Scholar
  29. 29.
    Colombet P. Knee laxity control in revision anterior cruciate ligament reconstruction versus anterior cruciate ligament reconstruction and lateral tenodesis: clinical assessment using computer-assisted navigation. Am J Sports Med. 2011;39(6):1248–54.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Stefano Zaffagnini
    • 1
  • Tommaso Bonanzinga
    • 1
  • Bharat Sharma
    • 2
  • Nicola Lopomo
    • 3
  • Cecilia Signorelli
    • 4
    • 5
  • Giulio Maria Marcheggiani Muccioli
    • 1
  • Maurilio Marcacci
    • 1
  1. 1.Clinica Ortopedica e Traumatologica III/Laboratorio di Biomeccanica e Innovazione TecnologicaIstituto Ortopedico RizzoliBolognaItaly
  2. 2.Department of OrthopedicsSingapore General HospitalOutram ParkSingapore
  3. 3.Laboratorio di Biomeccanica ed Innovazione TecnologicaIstituto Ortopedico RizzoliBolognaItaly
  4. 4.Laboratorio di Biomeccanica e Innovazione TecnologiaIstituto Ortopedico RizzoliBolognaItaly
  5. 5.Dipartimento di Elettronica, Informazione e BioingegneriaPolitecnico di MilanoMilanoItaly

Personalised recommendations