AOSSM/AANA Specialty Day 2020-Avoiding Contemporary ACL Technical Mistakes

Avoiding Contemporary ACL Technical Mistakes

Pdf Summary

This presentation by Dr. Aaron J. Krych from Mayo Clinic Orthopedics & Sports Medicine addresses common technical errors in anterior cruciate ligament (ACL) reconstruction (ACLR) that lead to poor outcomes and graft failure.<br /><br />Key points highlight that the most frequent cause of ACL graft failure is femoral socket malposition. Studies show many ACLRs in the US are performed by surgeons doing fewer than 10 cases per year, with high-volume surgeons generally achieving better outcomes; however, volume alone does not guarantee success. Interestingly, academic hospitals have reported worse outcomes in some studies. Failure is often predictable and often stems from technical errors.<br /><br />The discussion compares bone-patellar tendon-bone (BTB) and hamstring (HS) grafts, noting that BTB autografts can cause anterior knee pain, quadriceps weakness, patella fractures, and, potentially, late osteoarthritis, while HS grafts may have inferior fixation, reduced stiffness, risk of laxity, tunnel widening, and hamstring weakness. Modern BTB techniques with meticulous tendon closure and bone grafting have reduced donor site morbidity, with low rates (3.7%) of kneeling pain reported at two years follow-up.<br /><br />Proper surgical technique is emphasized, particularly the critical importance of correct portal placement for visualization. Visualization of the lateral femoral wall via the medial portal enables accurate identification of the anatomic ACL footprint. Marking the femoral pin location under direct visualization helps prevent malposition. Correct graft passage, fixation (e.g., femoral screw placement), and final graft tension assessment are key steps.<br /><br />In conclusion, most ACL graft failures result from surgeon error. Optimizing visualization, using anatomic landmarks for tunnel preparation, and having a skilled surgical team for fixation are essential to improve ACLR outcomes and reduce revision rates.

Keywords

ACL reconstruction

graft failure

femoral socket malposition

surgeon volume

bone-patellar tendon-bone graft

hamstring graft

surgical technique

portal placement

anatomic ACL footprint

revision rates