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Review
. 2015 Oct;3(4):220-40.

Failure of Anterior Cruciate Ligament Reconstruction

Gonzalo Samitier  1 , Alejandro I Marcano  1 , Eduard Alentorn-Geli  1 , Ramon Cugat  1 , Kevin W Farmer  1 , Michael W Moser  1
Affiliations
Review

Failure of Anterior Cruciate Ligament Reconstruction

Gonzalo Samitier et al. Arch Bone Jt Surg. 2015 Oct.

Abstract

The present review classifies and describes the multifactorial causes of anterior cruciate ligament (ACL) surgery failure, concentrating on preventing and resolving such situations. The article particularly focuses on those causes that require ACL revision due to recurrent instability, without neglecting those that affect function or produce persistent pain. Although primary ACL reconstruction has satisfactory outcome rates as high as 97%, it is important to identify the causes of failure, because satisfactory outcomes in revision surgery can drop to as much as 76%. It is often possible to identify a primary or secondary cause of ACL surgery failure; even the most meticulous planning can give rise to unexpected findings during the intervention. The adopted protocol should therefore be sufficiently flexible to adapt to the course of surgery. Preoperative patient counseling is essential. The surgeon should limit the patient's expectations for the outcome by explaining the complexity of this kind of procedure. With adequate preoperative planning, close attention to details and realistic patient expectations, ACL revision surgery may offer beneficial and satisfactory results for the patient.

Keywords: ACL reconstruction; ACL revision; Allografts; Autografts; Failure of ACL reconstruction; Instability; Pain; Review.

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Figures

Figure 1
Figure 1
Etiologic factors of the failure of ACL reconstruction.
Figure 2
Figure 2
Excessive anterior femoral tunnel location (MRI sagittal view).
Figure 3
Figure 3
Suitable femoral tunnel positioning leaving 2 mm of posterior wall (arthroscopic intraoperative view).
Figure 4
Figure 4
Posterior location of the tibial tunnel showing ACL reconstructed fibers non-parallel to the Blumensaat line.
Figure 5
Figure 5
Intraarticular guide pin exiting at the anteromedial aspect of the ACL tibial footprint (arthroscopic intraoperative view from AL portal).
Figure 6
Figure 6
Verticalized femoral tunnel using transtibial technique for ACL reconstruction (coronal sequence on MRI). Special consideration: Double-bundle ACL reconstruction technique.
Figure 7
Figure 7
A. Guide pins showing anatomic insertion points during MCL reconstruction with Achilles tendon allograft. B. Tibial tunnel drilling during MCL reconstruction with Achilles tendon allograft. C. Final fixation and tensioning at 30ª angle for MCL reconstruction with Achilles tendon allograft. The flexible guide is used for interference screw insertion. Anteriorly, the other half of the Achilles tendon allograft is shown exiting from the tibial tunnel created during the ACL concomitant reconstruction.
Figure 8
Figure 8
Posterolateral corner reconstruction using Achilles tendon allograft. The distal graft is seen exiting through the anterolateral aspect of the proximal tibia.
Figure 9
Figure 9
Arthroscopic intraoperative view of a monofascicular reconstructed PCL using Achilles tendon allograft.
Figure 10
Figure 10
AP view Xray showing different fixation methods in a patient with a previous history of multiple ACL reconstructions. In the femur, a metallic interference screw and a variation of suspensory cortical device is demonstrated. Fixation devices visualized on the tibia are a metal staple and a screw-post system with a spiked head.
Figure 11
Figure 11
Autologous hamstrings tendons prior to preparation and inmediately after extraction.
Figure 12
Figure 12
Achilles tendon allograft exiting through the tibial tunnel during ACL reconstruction. Tibial fixation was achieved using two 8-mm metal staples.
Figure 13
Figure 13
Intraoperative view during excision of bone-tendon-bone patellar tendon.
Figure 14
Figure 14
Anatomic positioning of the femoral tunnel (MRI coronal view).
Figure 15
Figure 15
External intraoperative view showing a guide pin through the accessory anteromedial portal used for femoral drilling. An expanding tunnel device is shown inferiorly positioned and exiting from the tibial tunnel.
Figure 16
Figure 16
Widened tibial and femoral tunnel (MRI sagittal view).
Figure 17
Figure 17
Tibial tunnel filled with allograft cancellous bone chips
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