Management of anterior cruciate ligament revision in adults: the 2022 ESSKA consensus part III—indications for different clinical scenarios using the RAND/UCLA appropriateness method

Thomas Tischer, Luca Andriolo, Philippe Beaufils, Sufian S. Ahmad, Corrado Bait, Marco Bonomo, Etienne Cavaignac, Riccardo Cristiani, Matthias J. Feucht, Markas Fiodorovas, Alberto Grassi, Gijs Helmerhorst, Christian Hoser, Mustafa Karahan, George Komnos, Koen Carl Lagae, Vincenzo Madonna, Edoardo Monaco, Juan Carlos Monllau, Matthieu OllivierMikko Ovaska, Wolf Petersen, Tomasz Piontek, James Robinson, Kristian Samuelsson, Sven Scheffler, Bertrand Sonnery-Cottet, Giuseppe Filardo, Vincenzo Condello

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3 Citations (Scopus)


Purpose: The aim of the ESSKA 2022 consensus Part III was to develop patient-focused, contemporary, evidence-based, guidelines on the indications for revision anterior cruciate ligament surgery (ACLRev). Methods: The RAND/UCLA Appropriateness Method (RAM) was used to provide recommendations on the appropriateness of surgical treatment versus conservative treatment in different clinical scenarios based on current scientific evidence in conjunction with expert opinion. A core panel defined the clinical scenarios with a moderator and then guided a panel of 17 voting experts through the RAM tasks. Through a two-step voting process, the panel established a consensus as to the appropriateness of ACLRev for each scenario based on a nine-point Likert scale (in which a score in the range 1–3 was considered ‘inappropriate’, 4–6 ‘uncertain’, and 7–9 ‘appropriate’). Results: The criteria used to define the scenarios were: age (18–35 years vs 36–50 years vs 51–60 years), sports activity and expectation (Tegner 0–3 vs 4–6 vs 7–10), instability symptoms (yes vs no), meniscus status (functional vs repairable vs non-functional meniscus), and osteoarthritis (OA) (Kellgren–Lawrence [KL] grade 0–I–II vs grade III). Based on these variables, a set of 108 clinical scenarios was developed. ACLRev was considered appropriate in 58%, inappropriate in 12% (meaning conservative treatment is indicated), and uncertain in 30%. Experts considered ACLRev appropriate for patients with instability symptoms, aged ≤ 50 years, regardless of sports activity level, meniscus status, and OA grade. Results were much more controversial in patients without instability symptoms, while higher inappropriateness was related to scenarios with older age (51–60 years), low sporting expectation, non-functional meniscus, and knee OA (KL III). Conclusion: This expert consensus establishes guidelines as to the appropriateness of ACLRev based on defined criteria and provides a useful reference for clinical practice in determining treatment indications. Level of evidence: II.
Original languageEnglish
Pages (from-to)4662-4672
Number of pages11
JournalKnee surgery, sports traumatology, arthroscopy
Issue number11
Early online date2023
Publication statusPublished - Nov 2023
Externally publishedYes


  • Anterior cruciate ligament
  • Consensus
  • Guidelines
  • Knee
  • Revision

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