The common cause of failure in ACL reconstruction surgery

Posted: 08/01/2019

The anterior cruciate ligament (ACL) is a band of fibrous tissue that runs diagonally through the inside of the knee and gives the joint stability. It also helps to control the back-and-forth movement of the lower leg. The ACL can be torn during sudden movements of the knee, which will cause the joint to feel unstable. A torn ACL is one of the most common knee injuries and, in seven out of ten cases, occurs when playing sports. Injury to the ACL usually happens when landing incorrectly from a jump, stopping suddenly, quickly changing direction, or experiencing a collision, such as a football tackle. Some sports that are particularly prone to causing ACL injury are basketball, netball, rugby, football and skiing.

There is often a perception that a torn ACL requires surgical treatment. This is not always the case and not everyone is suitable for reconstructive surgery. When a patient with a torn ACL is examined, the surgeon will suggest the options suitable to that patient based on their individual circumstances:

• The patient may be advised not to have surgery at all and to wait and see how the knee recovers through a combination of patience and physiotherapy. Although the ACL provides stability to the knee joint, strengthening of the surrounding muscles within the joint can compensate for loss of stability previously provided by the ACL. Many patients who do not undergo surgery go on to lead normal lives without complication.
• The alternative option is to surgically reconstruct the ACL. Surgery is usually recommended if the knee is very unstable (ie gives way) and affects quality of life, or if the patient previously played a significant amount of sport / has an active job. If ACL reconstruction is the preferred approach, the torn ACL cannot simply be sewn back together - the surgery involves replacing the ligament with a graft which is commonly taken from either the back of the thigh (hamstring) or the front of the thigh (patella tendon). The surgeon will then harvest the ACL graft via a small incision on the inside of the knee before continuing the operation via two keyhole incisions. Holes are drilled into the tibia (shin bone) and femur (thigh bone), and then the ACL graft is screwed into place using metal screws. After surgery, patients will need to undergo regular physiotherapy. They can typically return to work within two to six weeks of surgery and to sport between nine and twelve months of surgery.

Arran Macleod, an associate in the clinical negligence team at Penningtons Manches LLP who specialises in orthopaedic claims, said: “ACL reconstruction is one of the most common surgical procedures in orthopaedic surgery. It is successful in the vast majority of cases, however 10% of reconstructions do fail and a large majority of these do so because the ACL graft has been incorrectly positioned.

“When a surgeon reconstructs the ACL, it is incredibly important that the graft is implanted in the correct position so as to restore the natural mechanics of the patient’s knee. It is often said that the drill holes securing the graft should be positioned within the anatomical footprint of the natural ACL. If the graft is implanted in the incorrect position – either too far back or forward - the patient is more likely to experience post-operative problems such as grinding and clunking of the knee, pain and instability that causes the knee to give way. Such post-operative symptoms are unlikely to be improved without revision surgery.

“The clinical negligence team at Penningtons Manches often speaks to clients who have experienced problems after ACL reconstruction, which are commonly associated with a poorly positioned graft. If you have any concerns about ACL reconstruction surgery that you or a family member has undergone, then please do get in touch and we will be happy to advise you of your options.”

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