Avoidance of Major Complications

To ensure functional ROM and ultimate knee stability, the surgeon must carefully examine the injured knee and correlate findings to preoperative imaging; use anatomic landmarks and imaging as necessary to ensure adequate tunnel placement; harvest grafts in a meticulous fashion; tension grafts appropriately; and use sterile technique and trusted donor graft sources to minimize infection.

Detection and Treatment of Major Complications

Concomitant injuries must be recognized and surgically treated if necessary (eg, reconstruction of the posterolateral corner, meniscus repair, etc). Misplaced femoral and tibial tunnels should be revised to their anatomic position, fractures should be anatomically reduced and early ROM begun, knee stiffness should be treated with aggressive rehabilitation or lysis of adhesions when necessary, and infection should be treated with irrigation and debridement with or without preservation of the graft.

Summary

Rupture of the ACL, once a devastating and career-ending injury for athletes, is now amenable to surgical reconstruction so refined that the injured athlete often returns to high-level performance. Nonetheless, there are many pitfalls and potential problems associated with ACL reconstruction. In this article, the problems associated with diagnosis and judgment (Table 1; Fig. 1); graft harvest (Table 2), graft sizing (Table 3), graft placement and fixation (Table 4; Figs. 2 and 3); and postoperative care are presented (Table 5). The goal of ACL reconstruction is to offer the patient a functional, pain-free, and stable joint. With attention to the issues presented here, the surgeon is more apt to deliver on that promise.

Table 1 Complications related to errors in diagnosis and judgment
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Fig. 1
figure 1

The posterior horn and root attachment of the medial meniscus are seen with the arthroscope positioned under the posteromedial bundle of the PCL, along the lateral aspect of the medial femoral condyle in this Gillquist view [10]. Meniscal root tears and far posterior horn tears can be missed if a detailed arthroscopic examination is not performed. (MFC = medial femoral condyle; MM = posterior horn attachment of medial meniscus).

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Table 2 Complications related to graft harvest
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Table 3 Complications related to graft sizing
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Table 4 Complications related to graft placement and fixation
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Fig. 2
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An arthroscopic view shows the intercondylar notch during an ACL reconstruction with the knee positioned in full extension. An intercondylar notch is evident after a tunnel dilator (unseen) is placed in the tibial tunnel. Because the dilator is in the position of the ACL graft, a frontal view such as this one can be used to determine if the tunnel is well placed. Positioned correctly, the dilator (and therefore the graft) is not seen when the knee is in full extension. In this view, only the tibia and femur are seen with the knee in full extension; the tunnel dilator (position marked by *) is obscured by the distal femur, indicating proper tibial tunnel placement and absence of graft impingement. (F = femoral trochlea; ACL = ACL stump).

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Fig. 3
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An arthroscopic view shows the intercondylar notch during a left ACL reconstruction with the knee positioned in flexion. The arthroscope is in the anterolateral portal. The femoral tunnel in this left knee was drilled via a medial portal and is in the correct 2 o’clock position. By contrast, the point selected by a transtibial guide would orient the graft too vertically. (T = femoral tunnel; TT = transtibial guide).

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Table 5 Postoperative complications
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