The document discusses potential complications from ACL reconstruction surgery, noting that surgical technical errors during graft harvest, tunnel preparation, or fixation are most common causes of failure. Five possible causes of reconstruction failure are identified as graft discontinuity, inappropriate tunnel positioning, hardware failure, infection, or arthrofibrosis. Proper surgical technique and avoidance of tunnel malpositioning are emphasized to prevent complications.

1. DR DHANANJAYA SABAT MS, DNB, MNAMS
Assistant Professor
DEPARTMENT OF ORTHOPAEDICS
COMPLICATIONS
IN A C L
RECONSTRUCTION

2. No one likes to experience complications,
but the surgeon who is prepared to deal
with the potential complications will rise
above the rest. Remember:
"It's not if,
but when,
and how bad."

3. Presentation of failure of
ACLR
 Persistent pain (most consistent patient complaint)
 Instability
 Joint swelling
 Infection
 Stiff knee

4. Five possible causes of reconstruction
failure and patient complication
 Graft discontinuity (a tear or impingement in the graft)
 Inappropriate position of the femoral
and/or tibial tunnel (graft will not function properly
without proper tunnel positioning)
 Hardware failure (screws may not be in the right
position)
 Infection
 Arthrofibrosis (affecting movement of the joint).

5. POINTS TO NOTE>>>>
 Surgical technical error is most common
cause
 Tunnel placement error is the cause of
revision surgery in 70% cases
 Missed diagnosis of associated MCL or
PLC injury is common.

6. COMPLICATIONS
TECHNICAL
 During graft harvest
 During tunnel
preparation
 During fixation of
graft
NONTECHNICAL
 Implant and
instrument breakage
 Specific complications -
Related to graft

7. TECHNICAL COMPLICATIONS
Patellar Tendon Harvest
 Patellar fracture
 Small thin bone plug
 Use saw like a cast saw - 90* to cut cortex, 45*
to depth of 6-7 mm
 Avoid deep V - 6-7 mm in depth
 Gently lift out with osteotome - make a flat base
to bone plug.

8. Hamstring Graft Harvest
 MCL injury
 Premature amputation Use opposite side or PTB
 Saphenous nerve injury Use oblique incision
 Sciatic nerve injury
 Identify both ST & G before harvest at pes anserinus
 Dilate with finger to the depth of index finger
 Detach all attachments of ST to medial gastrocnemius
 Beaware of anomalous connections

9. Dropped Graft
 Prevent by keeping the graft
wrapped in a mop and clip it.
 Always pass with a tray under it.
Solution
 Change graft option
 Cleanse graft with 4%
chlorohexidine soln. for 30 min.
f/b triple antibiotic soln. for 30
min.

10. Tibial Tunnel Preparation
 Transportal (AM or Accesory AM)
 Injury to cartilage of MFC
 Short tunnel length
 Limited visualization

11. Tibial Tunnel Malposition
 Anterior – Notch/ roof impingement
 Posterior – PCL impingement
Solution
 Re-position.
 Use anatomic landmarks

12. Femoral Tunnel Malposition
 Anterior: Graft failure in flexion
 Posterior: Blow out
 Vertical graft: rotational instability
Solution
 Re-position.
 Use anatomic landmarks
 Use cotical suspensory
fixation when there is blow
out

13. GRAFT PASSAGE COMPLICATIONS
 Knot failure: use continuous loop
(Endobutton CL)
 Graft laceration: mismatch betn.
graft & tunnel
 Loose graft in tunnel

14. GRAFT FIXATION PROBLEM
 Posterior slippage of the
screw –possible vascular
injury
 Use of malleable guide wire for screw
placement
 Use notcher before screw insertion
 May require formal arthrotomy for screw
retrieval

15. Screw protrusion into Joint:
 Can cause cartilage injury
 Bioscrew may break in joint
Prevention
 Always verify screw protrusion by
probing after fixation while using screw
longer than 30 mm.

16.  Graft rotation during screw
insertion:
Pull both ends of graft while putting the
screw
 Graft laceration by screw: screw
tunnel mismatch
 Bioscrew breakage during
insertion: screw tunnel mismatch

17. • Graft screw divergence –
Screw insertion at an angle to
graft.
 Screw divergence of <30º
does not seem to have a
significant effect on the clinical
outcome if the fixation
strength at time of operation is
tested and found to be
adequate. Dworsky et al.

18. Loose tibial side fixation
 Use cortical fixation
- with suture disc / suture post
or direct cortical fixation

19. LATE MIGRATION OF SCREW
 Re-injury
 Overdrilling of tibial tunnel
 Bone resorption
 Tunnel widening
 Poor bone quality
 Partial hydrolysis of bioscrew
 Fissuring of bioscrew during
insertion
 Tibial screw more migration:
pull in the same line of ACL
graft

20. Button flip outside
quadriceps:
 Cause: improper calculation
 Flip outside quadriceps more with
Tightrope.
 Open – split quadriceps – push
button onto bone
Button flip inside tunnel:
 Cause: improper calculation
 Pull the leading thread to reverse
the flip and pull the graft down.

21.  IT band friction
 Dislodged crosspin

22. Anatomic aimer Technique:
 If first tunnel is nonanatomic; the
second will be also nonanatomic
 PL tunnel can be more anterior
Free hand Technique:
 More chance of tunnel confluence
or wide separation of tunnels
DOUBLE BUNDLE:
DOUBLE TROUBLE

23. Technical:
1. AM Tibial tunnel anterior
blow out
2. Graft misplacement :
inversion of bands
3. PL tunnel can lacerate
LCL
AM
PL
PL

24.  AM graft anterior
placement on tibial
side
 Roof impingement
 More loss of extension

25. NONTECHNICAL COMPLICATIONS
Related to B-PT-B graft
 Patellofemoral pain
 Anterior knee pain
 Kneeling pain
 Patellar tendinitis
 Patella baja
 Late patellar fracture
 Patellar tendon rupture
 Quadriceps weakness

26. Related to ST_G graft
 Sensory loss along IPSBN & SBSN:
least with oblique incision
 Hamstring weakness

27. Related to implant
Bioscrew
• Persistent discharge at tibial
site : PLLA screw
• Tunnel dilatation
• Cyst formation within
osseous tunnel.
Martinek, friedrich, Arthroscopy 1999

28. Not related to graft
 Aseptic Effusion
 Infection
 Thromboembolic disease
 Arthrofibrosis
 Reflex sympathetic dystrophy
 Early osteoarthritic changes
 Fracture through tunnels

29. Aseptic Effusion
 Common; usually due to aggressive rehab.
presentation
Pain, swelling
Investigation
TLC, DLC, ESR, CRP
Joint aspiration: gram stain and cultures
Treatment
Theraputic aspiration, compression bandage,
ice packs
Observation
Slow rehabilitation

30. Infection
(Septic arthritis)
The rate of deep infection is reported at 0.3%.
Staph aureus most common
presentation
Pain, swelling, erythema, and increased WBC
at 2-14 days postop
Investigation
immediate joint aspiration: gram stain and
cultures
Treatment
Immediate arthroscopic washout & antibiotics
If no improvement: removal of graft & implant

31. Arthrofibrosis/ Loss of motion
 More with acute ACLR: ensure full ROM and
subsidence of swelling before surgery
 Proper tunnel placement
 Aggressive cryotherapy in post-op
Treatment
 < 3 mo: Aggressive physiotherapy, CPM
 > 3 mo: arthroscopic arthrolysis, cyclops
excission

32. Cyclops lesion
fibroproliferative tissue
blocks extension; "click"
heard at terminal extension
 Treatment: arthroscopic
excision

33. Generalyzed arthrofibrosis
 Reconstructed ligament
encased with fibrovascular
proliferative tissue that
extend to infra &
suprapatellar area
 Treatment: arthrolysis

34.  Incidence 18%
 Related to status of menisci at the
time of surgery – Kaiser & Dameron
Early osteoarthritic changes

35. REHABILLITATION ONLY
ENSURES WETHER YOU END UP
WITH
THIS OR THIS

36. WORK UP FOR A FAILED
ACL
 Clinical: ROM, manual laxity tests,
arthrometer
 Radiographic: Xray, stress view, MRI
 Others: Hematologic, joint aspiration
analysis
 Diagnostic Arthroscopy

37. Conclusions
 ACL reconstruction is a procedure that
has a long learning curve.
 Various perioperative considerations
determine the final outcome
 Meticulous technique prevents
complications

38.  Familiarity with use of different grafts &
different modes of fixation might save a lot
of sweat on the operating table.
 Failed cases need to be thoroughly worked
up to find the cause of failure.