Considerations in revision of anterior cruciate ligament reconstruction in the high-level athlete.

Anterior cruciate ligament (ACL) graft failure following ACL reconstruction (ACLR) remains a persistent challenge, especially in the high-level athlete. This review aims to provide a comprehensive overview of the key considerations in revision ACLR, with a particular focus on the high-level athlete. ACL graft failure is multifactorial in origin, with the most common technical error being femoral tunnel malposition. Preoperative evaluation should include a thorough history, physical examination, and advanced imaging such as magnetic resonance imaging and three-dimensional (3D) computed tomography (CT) to assess tunnel position, osteolysis, and associated intra-articular pathology. Concomitant injuries, including meniscal tears and collateral ligament insufficiencies, must be identified and appropriately addressed during revision surgery. Surgical planning must consider prior ACL graft choice, ACL tunnel position, and the potential need for a staged procedure. ACL graft selection should be individualized, though autografts, particularly bone-patellar tendon-bone (BPTB) and quadriceps tendon (QT), are preferred over hamstring tendon (HT) or allograft due to superior outcomes. The decision to perform a single-stage versus two-stage revision is influenced by tunnel placement and tunnel lysis, with a CT scan aiding in preoperative planning. Adjunctive procedures such as a lateral extra-articular tenodesis (LET) or anterolateral ligament (ALL) reconstruction may be considered when certain high-risk characteristics are present, such as young age, knee hyperextension >5 degrees, high-grade pivot shift, multiple revisions, and increased posterior tibial slope (PTS) not meeting criteria for slope-correcting osteotomy. Additionally, slope-reducing or coronal alignment-correcting osteotomies may be necessary in select cases to optimize knee biomechanics and prevent further failure, but literature regarding return to high-level sport following these procedures is limited. Return to sport (RTS) following revision ACLR should be approached as a continuum, incorporating strength, neuromuscular control, and psychological readiness, with emphasis on individualized, criteria-based protocols. Delaying RTS to at least 9 months postoperatively has been associated with reduced ACL graft failure risk. Overall, revision ACLR in the high-level athlete is a complex and nuanced procedure that requires a meticulous, multifactorial approach. By tailoring surgical strategies and postoperative rehabilitation, surgeons can optimize outcomes and facilitate a safe return to competitive sport.