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Single-stage versus two-stage revision anterior cruciate ligament reconstruction: a systematic review
  1. Cristin J Mathew,
  2. Jeremiah E Palmer,
  3. Bradley S Lambert,
  4. Joshua D Harris,
  5. Patrick C McCulloch
  1. Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, Texas, USA
  1. Correspondence to Dr Patrick C McCulloch, Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, TX 77030, USA; pcmcculloch{at}


Importance Despite advances in surgical techniques and postoperative rehabilitation, long-term anterior cruciate ligament (ACL) graft rupture rate remains high. The increasing number of primary ACL reconstructions in an ageing population will lead to increasing revision reconstructions. Revision cases may have higher failure rates and worse patient-reported outcomes compared with primaries. While two-stage revisions may be indicated in certain complex cases, whether this is comparatively equivalent or even superior to revisions done in a single stage would assist preoperative planning.

Objective The objective of this systematic review was to analyse and compare patient-reported outcomes and failure rate of single-stage versus two-stage revision ACL reconstruction.

Evidence review Using PubMed, MEDLINE Complete and Ovid MEDLINE databases, a review was performed using Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines to identify level I–IV outcomes of revision ACL reconstruction with a minimum follow-up of 24 months.

Findings Three studies reported outcomes of two-stage revisions with mean follow-up of 61.6 months, while 21 studies reported single-stage revisions with mean follow-up of 47.4 months. Pooled rate of two-stage revisions was 3.1% compared with 6.8% in single-stage (p=0.068). Clinical failure was reported in 5.1% of 79 two-stage patients compared with 13.8% of 533 single-stage patients (p<0.05). Within the single-stage cohort, there was a greater clinical failure rate (+8.7%, p<0.05) for patients with less than 48 months follow-up. Those with > 48 months follow-up had a higher rerupture rate (+5%, p<0.05) and a significantly greater sum of squared deviations (p<0.05) compared with those with < 48 months follow-up. Patient-reported outcomes have demonstrated two-stage revision patients with higher IKDC A and B scores than single-stage.

Conclusions and relevance Although two-stage revisions may be performed in more complex cases, there are limited short-term data available regarding their outcomes. Two-stage revisions demonstrated comparable clinical outcomes and lower rate of revision surgery and clinical failure compared with single-stage revisions. Studies with shorter follow-up (24–48 months) showed higher clinical failure rates. Those with longer follow-up (>48 months) showed higher graft rerupture rates. The decision to perform staged reconstruction should made on whether adequate tunnel placement and fixation can be established in a single setting.

Level of evidence Level IV.

  • knee
  • acl / pcl
  • repair / reconstruction
  • revision acl reconstruction
  • staged acl reconstruction
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  • Contributors All the authors presently listed have made substantive intellectual contributions of this manuscript through either data collection and analysis, and manuscript production and or editing. Drs JDH and PCM have been heavily involved in the data review and manuscript revision process. Drs CJM and JEP were heavily involved in the study design, data acquisition and manuscript production. Dr BSL was involved in the data analysisand revision process.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests CJM, JEP, BSL have nothing to disclose. JDH reports other from American Academy of Orthopaedic Surgeons, other from American Orthopaedic Society for Sports Medicine, other from Arthroscopy, other from Arthroscopy Association of North America, other from DePuy, A Johnson & Johnson Company, other from Frontiers In Surgery, personal fees from NIA Magellan, personal fees from Ossur, personal fees from SLACK Incorporated, personal fees and other from Smith & Nephew, outside the submitted work. PCM reports other from Arthrex Inc., other from DePuy, A Johnson & Johnson Company, personal fees from Journal of Knee Surgery, personal fees from, personal fees from Vericel, outside the submitted work.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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