Management of an ACL graft failure in a high-level pivoting sport athlete

Lateral tenodesis
Sport related injury
Management of an ACL graft failure in a high-level pivoting sport athlete

What are the treatment options in case of ACL graft failure? Dive into this clinical case, find out an innovative technique and understand the reasons for the failure of the first surgery!​

CHU Toulouse, FRANCE
Course Director

I am an orthopedic surgeon specialized in knee surgery. I practice at the University Hospital of Toulouse in the University Sports Clinic located in the Pierre Paul Riquet Hospital.
In addition to teaching at the Faculty of Medicine, I participate in courses for the professional societies to which I belong such as the SFA, ESSKA and SOFCOT.
My clinical activity (more than 800 surgeries per year) is exclusively focused on knee surgery. An important part of my surgeries is related to sports traumatology, in particular anterior cruciate ligament injuries (350+ ACL reconstructions per year).
My research activity is also focused on the knee. I have contributed to more than 110 publications in international journals. I am developing an à la carte approach in order to propose a personalized surgery to the patient. In the context of degenerative activity, the aim is to better analyze the variability of the anatomy in order to be able to propose prostheses adapted to the patient's anatomy. In the context of sports traumatology, it is a question of improving the dismemberment of all the lesions in order to propose an adequate therapy.
Since May 2022, I am a member of the board of ESSKA (European Society of Sports Traumatology Knee Surgery and Arthroscopy) as treasurer.

Escaldes, ANDORRA
Hospital Nostra senyora de Meritxell
Part one
Clinical presentation
  • 24 Y.O male
  • Professional freestyle skier
  • ACL reconstruction with harmstrings 18 months ago
  • Knee torsional trauma skiing
  • On physical examination, he presents a positive Lachman test and a grade 3 pivot shift test
Video 1
Video 2
Video 3

Powered by Quiz Maker

Part two
Final strategy decision

In this case, our choice was to perform a one-time ACL revision with a hybrid graft composed by the iliotibial band left attached and a gracilis allograft. An outside-in femoral tunnel has been performed, and the same tibial tunnel has been used as it was well positioned. This technique is easy to perform and allows to do a lateral tenodesis and an ACL reconstruction with the same graft, and to avoid a femoral tunnel convergence. A meniscal ramp lesion and a lateral meniscal tear have been sutured at the same time.

Performing a lateral tenodesis (anterolateral ligament reconstruction or lemaire modified procedure) at the time of the first surgery would have been wiser according to the anterolateral ligament experts' group, since the patient is a high-level athlete performing a pivoting sport.


  • Marot V, Valette A, Courtot L, Lucena T, Reina N, Cavaignac E. Outside-In Anterior Cruciate Ligament Revision With Lateral Tenodesis and High-Strength Suture Augmentation Is Easy to Perform With the Iliotibial Band. Arthrosc Tech. 2021 Apr 18;10(5):e1321-e1326. doi: 10.1016/j.eats.2021.01.032. PMID: 34141548; PMCID: PMC8185809.
  • Lucena T, Cavaignac M, Marot V, Courtot L, Lutz C, Bérard E, Cavaignac E. Iliotibial band autograft is a suitable alternative graft for anterior cruciate ligament reconstruction: a systematic review and meta-analysis of outcomes. Knee Surg Sports Traumatol Arthrosc. 2022 May;30(5):1679-1690. doi: 10.1007/s00167-021-06701-w. Epub 2021 Aug 24. PMID: 34431012.
  • Haidar IM, Billières J, Saithna A, Rayes JE, Fradin T, Ngbilo C, Vieira TD, Cavaignac E, Sonnery-Cottet B. Outside-In Drilling Allows Avoidance of Two-Stage Surgery in Revision Anterior Cruciate Ligament Reconstruction. Arthrosc Tech. 2021 Feb 8;10(3):e691-e696. doi: 10.1016/j.eats.2020.10.057. PMID: 33738203; PMCID: PMC7953166.
  • Li N, Xue X, Tu H, Zhang M, He C. Anterior Cruciate Ligament Reconstruction with Hybrid Graft versus Autograft: A Systematic Review and Meta-Analysis. J Healthc Eng. 2021 Oct 6;2021:7562649. doi: 10.1155/2021/7562649. PMID: 34659692; PMCID: PMC8514892.
  • Sonnery-Cottet B, Daggett M, Fayard JM, Ferretti A, Helito CP, Lind M, Monaco E, de Pádua VBC, Thaunat M, Wilson A, Zaffagnini S, Zijl J, Claes S. Anterolateral Ligament Expert Group consensus paper on the management of internal rotation and instability of the anterior cruciate ligament - deficient knee. J Orthop Traumatol. 2017 Jun;18(2):91-106. doi: 10.1007/s10195-017-0449-8. PMID: 28220268; PMCID: PMC5429259.

Login or register to post comments.