Complications in primary anterior cruciate ligament reconstruction surgery: rates of occurrence, prevention, and management

Abstract

In anterior cruciate ligament (ACL) reconstruction surgery a graft is used to replace the torn ligament. Understanding the complications of ACL reconstruction surgery is vital for the surgeon to help guide clinical practice.

This synoptic commentary presents eight articles the overall aim of which was to explore complications of ACL reconstruction surgery consider how their occurrence may be
minimised through preventive measures and how they can be managed once they occur.

The stage was set out by a narrative review which looked at the spectrum of intraoperative complications encountered in ACL reconstruction surgery as well as their causes and
management. Following this, an article presented a narrative over view of hamstring tendon harvesting and the substantial variability that exists in the anatomy of these tendons that are frequently used as ACL reconstruction grafts. Subsequently, a third article reported a clinical study on the rate of inadequate hamstring graft harvesting whilst a fourth article reported on a cadaveric study that showed that the hamstring tendon graft quality is related to the type of tendon harvester utilised to obtain the graft. Two systematic reviews and meta analyses were conducted to assess infection in ACL reconstruction surgery. One reported on the rate of infection in ACL reconstruction, its relation to graft type as well as its relation to vancomycin presoaking. This article demonstrated a higher risk of infection associated with hamstring grafts as compared to other graft types and showed that vancomycin graft presoaking minimise d this infection risk. The other article analysed the effectiveness of arthroscopic washout and antibiotic treatment with graft salvage and showed this to be a successful option in most cases of bacterial infection post ACL reconstruction. The seventh article of this commentary reported a systematic review of complications of femoral suture button fixation of the ACL graft It showed the potential for misplacement of the femoral suture button and the need to consider additional intraoperative measures such as radiological screening or arthroscopic inspection of the button to try and avoid this. The final article reported a study which used artificial bones and looked at the relation between the type of reamer used to create the tibial tunnel in ACL reconstruction and tunnel morphology. It showed that misdirection of the reamer may influence the morphology of the outer aperture of the tibial tunnel and that such change in aperture morphology is reamer type dependent.

In conclusion, the articles of this commentary provided knowledge to enhance the ability of the surgeon to obtain a graft of adequate dimensions, minimise the risk of infection and enhance the graft fixation to the femur and tibia. This knowledge may also improve the ability of the surgeon to manage postoperative infection once encountered. The commentary ’s articles also emphasise the need to recognise that surgical complications occur and that by discussing these and sharing experiences in a n open and transparent way, surgeons and other professionals can learn and develop further.