 A new study suggests that after failure of revision ACL reconstruction, a second revision surgery results in better knee function than non-surgical management, although both treatment strategies are associated with a high rate of return to sport. The findings are published in the American Journal of Sports Medicine. Tearing of the anterior cruciate ligament, or ACL, is a common sports injury. It's usually treated with ACL reconstruction surgery. However, in some patients, particularly young and active patients, the surgical graft ruptures and requires revision ACL reconstruction. And a subset of these patients experience another rupture after the revision. It has remained unclear whether a second revision ACL reconstruction or non-surgical management results in better outcomes for these patients. To find out, the new study followed 41 patients with a failed first revision ACL reconstruction, 31 of whom underwent a second revision surgery and 10 of whom chose non-surgical management. The researchers compared the rate of return to sport and various functional outcomes between the groups using clinical data, responses from a standardized telephone interview, and patient-reported outcome scores. Both groups had a high rate of return to sport, but the second revision group had significantly better scores than the non-surgical management group for four of the patient-reported outcome measures suggesting better knee function. In addition, more patients in the surgical group than in the non-surgical group achieved a patient-acceptable symptom state on the COOS Sport and Recreation Scale. In contrast, non-surgical management was the only significant predictor of failure to achieve a good or excellent lease home score at the final follow-up. This predictive link was likely related to inferior knee stability in the non-surgical group versus the surgical group. Notably, this study was retrospective in nature, so the groupings weren't controlled and the sample size was small. In addition, some data on the first ACL repair surgeries was missing. Finally, some instances of graft failure may have been missed if patients were asymptomatic as imaging and physical exams weren't performed at the final follow-up visit. Despite these limitations, the findings suggest that both a second revision ACL reconstruction and non-surgical management of a failed first revision ACL reconstruction support a high rate of return to sport. However, a second revision surgery may yield better functional outcomes in the eyes of patients.