An overview of complications in anterior cruciate ligament reconstruction

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.