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Purpose  To determine the most common rupture patterns of previously reconstructed DB‐ACL cases, seen at the time of revision surgery, and to determine the influence of age, gender, time between the initial ACL reconstruction and re‐injury, tunnel angle and etiology of failure.    Methods  Forty patients who presented for revision surgery after previous double‐bundle ACL reconstruction were enrolled. Three orthopedic surgeons independently reviewed the arthroscopic videos and determined the rupture pattern of both the anteromedial and posterolateral grafts. The graft rupture pattern was then correlated with the previously mentioned factors.    Results  The most common injury pattern seen at the time of revision ACL surgery was mid‐substance AM and PL bundle rupture. Factors that influenced the rupture pattern (proximal vs. mid‐substance and distal rupture vs. elongated, but in continuity) were months between ACL reconstruction and re‐injury ( P  = 0.002), the etiology of failure (traumatic vs. atraumatic) ( P  = 0.025) and the measured graft tunnel angle ( P  = 0.048).    Conclusions  The most common pattern of graft re‐rupture was mid‐substance AM and mid‐substance PL. As the length of time from the initial DB‐ACL reconstruction to revision surgery increased, the pattern of injury more closely resembled that of the native ACL. Evaluation of patients who have undergone double‐bundle ACL reconstruction, with a particular focus on graft maturity, mechanism of injury and femoral tunnel angles, and graft rupture pattern assists in preoperative planning for revision surgery.

ACL graft re‐rupture after double‐bundle reconstruction: factors that influence the intra‐articular pattern of injury