Between July 2015 and May 2022, 10 patients (3 males and 7 females, median age 28 years, range 18–52 years) referred to our institution for failure of primary ACL repair with DIS underwent surgery. In four patients, a single-stage ACLR was performed following the removal of the tibial monoblock. In six patients, due to arthrofibrosis and excessive tibial tunnel enlargement following the removal of the monoblock, arthroscopic arthrolysis and tunnel bone grafting were performed as a first-stage revision procedure. Patient characteristics and preoperative radiographic measurements are reported in Table 1. A brief description of each case is given below.

Table 1 Patient characteristics and preoperative radiographic measurements

Patient 1

A 32-year-old male twisted his knee while playing rugby about six months prior to presentation. Four years before, he underwent ACL repair with DIS. At the clinical examination, he had full range of motion (ROM) and positive Lachman and pivot-shift tests. The patient wished to return to his previous sport (rugby) and ACLR was therefore recommended. Preoperative anteroposterior and lateral X-rays showed the correct position of the femoral and tibial tunnels (Fig. 1). He underwent single-stage ACLR with a quadriceps tendon-bone autograft and medial meniscus resection. Diffuse synovitis was found during arthroscopic examination. Due to the large (11 mm) tibial bone defect following the removal of the monoblock, the tendinous part of the graft was inserted in the femoral tunnel and the bone plug was inserted in the tibial tunnel. The graft was fixed on both sides with bioabsorbable interference screws.

Fig. 1
figure 1

Preoperative anteroposterior (a) and lateral (b) X-rays before implant removal

Patient 2

A 27-year-old male presented with persistent knee pain and activity limitation about 10 months after he underwent ACL repair with DIS. He had a five-degree extension deficit, a negative Lachman test but a positive pivot-shift test. Due to activity limitations and a wish to return to football, ACLR was recommended. Arthroscopy revealed femoral tunnel malposition (anterior placement). Arthroscopic arthrolysis was performed and the tibial monoblock was removed. The patient underwent single-stage anatomical ACLR with a quadriceps tendon-bone autograft and lateral meniscus repair.

Patient 3

A 23-year-old male presented with effusion, pain and instability following a knee injury that occurred a few days before while playing football. He underwent ACL repair with DIS 1.5 years before presentation. At the clinical examination, he had positive Lachman and pivot-shift tests. The tibial monoblock was removed and the patient underwent single-stage bone-patellar-tendon-bone autograft ACLR and repair of a medial meniscus ramp lesion.

Patient 4

A 47-year-old female who injured her ACL and underwent ACL repair with DIS one year before presentation. She complained of knee pain and instability. At the clinical examination, she had a severe (30 degrees) extension deficit and a positive Lachman test. The patient underwent arthroscopic arthrolysis due to generalised synovitis and arthrofibrosis (Fig. 2 a-b) and the removal of the tibial monoblock. The large tibial bone defect, which measured 15 mm in diameter, was bone grafted with a femoral head allograft. At the end of the procedure, the patient had an ROM of 0–140 degrees. A computed tomography scan performed four months after surgery showed the osteointegration of the bone graft within the tibial tunnel. She was scheduled for an ACLR in a second stage, but, due to other medical issues, she did not undergo surgery.

Fig. 2
figure 2

ab Intraoperative arthroscopic pictures showing arthrofibrosis in the anterior compartment

Patient 5

A 33-year-old female who underwent ACL repair with DIS six months before and presented with knee pain and functional impairment. She had severely restricted ROM (10–60 degrees) and swelling. A synovial fluid examination showed no sign of infection. The patient underwent arthroscopic arthrolysis due to pronounced arthrofibrosis and removal of the tibial monoblock. The large tibial bone defect (12 mm diameter) was bone grafted with a femoral head allograft. The patient had an ROM of 0–140 degrees at the end of the procedure. She complained of persistent instability at the follow-up appointments (4, 7 and 12 months postoperatively) and an ACLR was recommended. However, the patient moved abroad and continued her treatment elsewhere.

Patient 6

A 20-year-old female presented with knee pain and significant functional impairment. She underwent ACL repair with DIS seven months before presentation. She had knee effusion, significant muscle atrophy and restricted ROM (10–100 degrees). Preoperative X-rays showed a significant malposition of the femoral tunnel. Moreover, the endobutton had not flipped over the femoral cortex (Fig. 3). The patient underwent two-stage ACLR. An arthroscopic arthrolysis due to generalised synovitis and arthrofibrosis and the removal of the tibial monoblock was performed in the first stage. Arthroscopy confirmed femoral tunnel malposition. The large tibial bone defect, which measured 15 mm in diameter, was bone grafted with a femoral head allograft. At the end of the procedure, the patient had an ROM of 0–140 degrees. An ACLR with hamstring tendons was performed seven months later, following the complete osteointegration of the bone allograft.

Fig. 3
figure 3

Preoperative anteroposterior (a) and lateral (b) X-rays before implant removal showing significant malposition of the femoral tunnel and improper position of the endobutton which had not flipped over the femoral cortex

Patient 7

A 29-year-old female presented with knee pain and instability. She underwent ACL repair with DIS 2.5 years before presentation. She had an ROM of 0–90 degrees and a positive Lachman test. During arthroscopic examination, scar tissue formation in the intercondylar notch was found and debrided. Following the removal of the tibial monoblock, the patient underwent single-stage quadriceps tendon-bone autograft ACLR. A concomitant lateral meniscus root repair and medial meniscus ramp lesion repair were performed.

Patient 8

An 18-year-old female presented with knee pain and swelling. She underwent ACL repair with DIS about four months before presentation and had an ROM of 15–80 degrees. Arthroscopy revealed a rupture of the ACL and generalised arthrofibrosis. The femoral tunnel was located in a non-anatomic, anterior position. The removal of the tibial monoblock left a large (12 mm diameter) bone defect (Fig. 4), which was bone grafted with a femoral head allograft. The patient is under follow-up to evaluate ACLR in a second stage.

Fig. 4
figure 4

Intraoperative picture showing measurement of the enlarged (12 mm diameter) tibial tunnel after removal of the monoblock

Patient 9

A 27-year-old female who underwent ACL repair with DIS prior to presentation. She had knee pain, a positive Lachman test and an ROM of 0–50 degrees. At arthroscopy, the ACL was partially torn and generalised arthrofibrosis was present. Extensive arthrolysis was performed. The removal of the tibial monoblock left a bone defect of 10–11 mm, which was bone grafted with a femoral head allograft. The patient was followed up for about four years. At the latest follow-up, she complained of subjective instability and had positive Lachman and pivot-shift tests. An ACLR was recommended, but the patient refused treatment due to her inability to pause her work as a cleaner.

Patient 10

A 52-year-old female presented with pain in her knee such that normal walking was significantly limited. She underwent ACL repair with DIS about four months prior to presentation. Her ROM was 30–80 degrees. Arthroscopic arthrolysis due to generalised arthrofibrosis was performed. Arthroscopy also revealed a cyclops lesion, which was debrided together with the ACL remnant and the polyethylene wire. The removal of the tibial monoblock left a bone defect of 12 mm, which was bone grafted with a femoral head allograft. At the end of the procedure, the patient achieved an ROM of 0–110 degrees. She is under follow-up to evaluate a possible ACLR in a second stage.

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