ISAKOS: 2019 Congress in Cancun, Mexico

2019 ISAKOS Biennial Congress ePoster #776


The Revision Using Imaging to Guide Staging and Evaluation (REVISE) of Tunnel Placement in ACL Reconstruction Classification

Bryson P. Lesniak, MD, Pittsburgh, PA UNITED STATES
Darren L. de SA, MBA(c), MD, FRCSC, Hannon, ON CANADA
Raphael Crum, BS, Pittsburgh, PA UNITED STATES
Alan Getgood, MD, FRCS(Tr&Orth), DipSEM, London, ON CANADA
Dharmesh Vyas, MD, PhD, Pittsburgh, PA UNITED STATES
Scott Kaar, MD, Beachwood, OH UNITED STATES
Eric J. Kropf, MD, Charlotte, NC UNITED STATES
Devin Clarke Peterson, MD, FRCSC, Dip Sport Med, Ancaster, Ontario CANADA
Craig S. Mauro, MD, Pittsburgh, PA UNITED STATES
Olufemi R. Ayeni, MD, PhD, MSc, FRCSC, Hamilton, ON CANADA
Asheesh Bedi, MD, Ann Arbor, MI UNITED STATES
Volker Musahl, MD, Pittsburgh, Pennsylvania UNITED STATES

University of Pittsburgh Medical Center, Pittsburgh, PA, UNITED STATES

FDA Status Not Applicable


The REVISE classification is presented as a reliable and straightforward method to classify fail ACL reconstruction tunnel placement and predict revision operative strategies.



Revision anterior cruciate ligament (ACL) procedures are increasing in incidence and possess markedly inferior clinical outcomes (76% satisfaction) and return-to-sports (57%) rates than their primary counterparts. Given their complexity, a universal language is required to identify and communicate the technical challenges faced with revision procedures and guide treatment strategies.

Hypothesis/Purpose: The proposed REVISE ACL Classification can serve as the foundation for this universal language, functioning as a system that is both feasible and practical with acceptable inter-rater agreement.


A focus group of sports medicine fellowship-trained orthopaedic surgeons was assembled to develop a classification to assess femoral/tibial tunnel “usability” (i.e. placement, widening, overlap) and guide the revision reconstruction strategy (i.e. one- versus two-stage) post-failed ACL reconstruction. Twelve board-certified sports medicine orthopaedic surgeons independently applied the classification to the de-identified computed tomography (CT) scan data of ten patients who failed ACL reconstruction. An Inter-class Correlation Coefficient (ICC) was calculated (with 95% Confidence Intervals) to assess the level of agreement amongst the reviewers concerning the three major classifications of the proposed system.


Across the twelve surgeons, and on an individual patient-basis, there was high internal validity and observed agreement on treatment strategy (i.e. one- versus two-stage revision). Reliability testing of the classification using CT scan data demonstrated an ICC [95% CI] of 0.92 [0.80, 0.98] suggesting “substantial” agreement between the twelve surgeons across all ten patients for all elements of the classification.


The proposed REVISE ACL Classification, which employs CT scan analysis to both identify the technical issues and guide the revision ACL treatment strategy (i.e. one- or two-stage) constitutes a feasible and highly practical system with high internal validity, high observed agreement and substantial inter-rater agreement. Increased adoption of this classification, both clinically and in research, will help provide a universal language for orthopaedic surgeons to discuss these complex clinical presentations, and in doing so, help standardize an approach to diagnosis and treatment to improve patient outcomes.