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

Handout - Avoiding Contemporary ACL Technical Mistakes

Pdf Summary

This presentation by Dr. Aaron J. Krych from Mayo Clinic discusses common technical errors in anterior cruciate ligament (ACL) reconstruction and how to avoid them, focusing on improving surgical outcomes and reducing the risk of graft failure.<br /><br />ACL reconstruction is a common orthopedic surgery, but failures—defined as recurrent instability or post-op complications like arthrofibrosis, infection, and arthritis—still occur in 5-10% of cases. The predominant cause of recurrent instability after ACL revision surgery is poor tunnel or socket placement during the initial operation.<br /><br />The presentation highlights the impact of surgeon volume on outcomes. High-volume surgeons (performing ≥50 ACL reconstructions per year) generally have better results and shorter operative times than low-volume surgeons (≤10 per year), who tend to take longer and show specific technical weaknesses, such as tendon harvesting and tunnel accuracy. However, volume alone doesn't fully predict surgical quality.<br /><br />Iatrogenic injuries, notably tunnel malpositioning, are common during ACL surgery. Research from Denmark (31,326 reconstructions) shows better femoral tunnel positioning with anteromedial techniques and recommends concentrating ACL surgeries in high-volume centers to reduce complications.<br /><br />Key technical areas for improvement include graft harvest—specifically patellar tendon (PT) harvesting and closure techniques to prevent rupture, fractures, and contractures—and socket creation. For the femoral socket, ideal placement per the I.D.E.A.L. method, careful visualization, marking, and use of appropriate guides and reamers can minimize malposition and cartilage damage. For the tibial tunnel, surgeons must accurately identify anatomic landmarks to avoid graft-tunnel mismatch and protect nearby structures like the lateral meniscus; placing the tibial tunnel more medially may help prevent meniscal injury.<br /><br />Overall, meticulous attention to surgical technique, anatomical details, and potentially concentrating surgeries in high-volume centers is advocated to lower ACL reconstruction failure rates.

Keywords

ACL reconstruction

anterior cruciate ligament

surgical outcomes

graft failure

tunnel malpositioning

high-volume surgeons

patellar tendon harvesting

I.D.E.A.L. method

femoral socket placement

tibial tunnel anatomy