After ACL Reconstruction | Complications and knee instability

Prolotherapy Knee articular cartilage repair without surgery

Ross Hauser, MD

In this article we will discuss problems of knee instability following anterior cruciate ligament reconstruction and review various non-surgical treatment suggestions including Prolotherapy.

How often does ACL reconstruction complication occur? In a recent paper from Johns Hopkins University listing the Top 100 Cited Articles in Clinical Orthopedic Sports Medicine, 15 of the 100 ( a very heavy influence) dealt with injury to the ACL.

Why is so much attention given to the ACL?

Because ACL reconstruction surgery is a popular procedure. More than 120,000 a year are performed in the United States. Secondly, it’s because of the high number of complications that can lead to the patient needing a revision surgery to repair what the first surgery did not, or what the first surgery made worse.

Let’s examine a October 2017 study in the medical journal Arthroscopy led by the Minnesota Orthopedic Sports Medicine Institute and Department of Orthopedics, University of Michigan MedSport.

The title of the paper should say it all: Generalized Hypermobility, Knee Hyperextension, and Outcomes After Anterior Cruciate Ligament Reconstruction

Here are the summary findings:

Knee Hypermobility – instability

Clearly we have a problem of knee instability following ACL reconstruction that leads to knee joint degeneration.

The appeal and enthusiasm for ACL reconstruction, is this misguided?


The problem of instability after ACL manifested in need for revision surgery and knee joint failure.

Using tissue from cadavers (allograft) or from a patient’s own tissue (autograft) is used for ACL reconstruction because it sounds promising to a patient in pain who is looking for repair, and is necessary in the instance of grade III (complete) tears.

Here are points to consider:

It is important to consider that the findings above are considered excellent ACL reconstruction patient results. We ask, do these findings really merit an excellent? Here is more research to review:

Tunnel placement complications

ACL tunnel complications

During the ACL reconstruction surgery a hole is drilled in the thigh bone and the shin bone, the donor tendon that is being used as the graft  is then threaded through the holes, through the knee and fixed or screwed into place.

Image: Erickson B, et al. ORTHOPEDICS. 2016; 39: e456-e464.

A well documented summary of ACL complications can be found in the abstract of a classic lecture presentation from Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh. This lecture was delivered in 2001. Compare it to the research from 2017 we cited above – little has changed.

From 2001: “Many factors influence the overall success or failure of anterior cruciate ligament reconstruction, including the integrity of the secondary restraints (that is the supporting structures of the knee, the collateral ligaments, the mid-third capsular ligaments, the meniscus, and the iliotibial band), the preoperative laxity of the knee, the status of the articular and meniscal cartilage, the selection of the graft material, the surgical technique, the postoperative rehabilitation, and the motivation and expectations of the patient. (As discussed above).“12

As we noted in the research above untreated associated ligaments insufficiencies, in other words the other knee ligaments were too weak to support the new ACL, this caused failure.

In the American Journal of Sports Medicine, researchers suggest that there are many factors that doctors have explored including over-rehabbing one leg and creating an imbalance. Younger athletes under the age of 20 and female athletes are especially susceptible to this injury.14

This article continues with non-surgical options > Is ACL reconstruction the only option?

If you have questions about ACL reconstruction options, you can get help and information from our Caring Medical Staff


References for this article

1. Nayar SK, Dein EJ, Spiker AM, Bernard JA, Zikria BA.  The Top 100 Cited Articles in Clinical Orthopedic Sports Medicine. Am J Orthop (Belle Mead NJ). 2015 Aug;44(8):E252-61.
2. Larson CM, Bedi A, Dietrich ME, Swaringen JC, Wulf CA, Rowley DM, Giveans MR. Generalized Hypermobility, Knee Hyperextension, and Outcomes After Anterior Cruciate Ligament Reconstruction: Prospective, Case-Control Study With Mean 6 Years Follow-up. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2017 Jun 7.
3. Lind M, Menhert F, Pedersen AB. Incidence and Outcome After Revision Anterior Cruciate Ligament Reconstruction. Am J Sports Med July 2012 vol. 40 no. 7 1551-1557
4. Reinhardt KR, Hammoud S, Bowers AL, Umunna BP, Cordasco FA. Revision ACL reconstruction in skeletally mature athletes younger than 18 years. Clin Orthop Relat Res. 2012 Mar;470(3):835-42.
5. Wegrzyn J, Chouteau J, Philippot R, Fessy MH, Moyen B. Repeat revision of anterior cruciate ligament reconstruction: a retrospective review of management and outcome of 10 patients with an average 3-year follow-up. Am J Sports Med. 2009 Apr;37(4):776-85.
6. Noyes FR, Barber-Westin SD. Treatment of meniscus tears during anterior cruciate ligament reconstruction.  Arthroscopy. 2012 Jan;28(1):123-30. doi: 10.1016/j.arthro.2011.08.292. Epub 2011 Nov 9.
7. Grassi A, Ardern CL, Marcheggiani Muccioli GM, Neri MP, Marcacci M, Zaffagnini S. Does revision ACL reconstruction measure up to primary surgery? A meta-analysis comparing patient-reported and clinician-reported outcomes, and radiographic results. Br J Sports Med. 2016 Jan 25.
8. Watters TS, Zhen Y, Martin JR, Levy DL, Jennings JM, Dennis DA. Total Knee Arthroplasty After Anterior Cruciate Ligament Reconstruction: Not Just a Routine Primary Arthroplasty. J Bone Joint Surg Am. 2017 Feb 1;99(3):185-189.
9. Lind M, Menhert F, Pedersen AB. Incidence and outcome after revision anterior cruciate ligament reconstruction: results from the Danish registry for knee ligament reconstructions. Am J Sports Med. 2012 Jul;40(7):1551-7.
10. Kraeutler MJ, Welton KL, McCarty EC, Bravman JT. Revision Anterior Cruciate Ligament Reconstruction. JBJS. 2017 Oct 4;99(19):1689-96.
11. Gifstad T, Drogset JO, Viset A, Grontvedt T, Hortemo GS. Inferior results after revision ACL reconstructions: a comparison with primary ACL reconstructions. Knee Surg Sports Traumatol Arthrosc. 2012 Dec 14
12 Harner CD, Giffin JR, Dunteman RC, Annunziata CC, Friedman MJ. Evaluation and treatment of recurrent instability after anterior cruciate ligament reconstruction. Instr Course Lect. 2001;50:463-74.
13. Culvenor AG, Schache AG, Vicenzino B. Are knee biomechanics different in those with and without patellofemoral osteoarthritis after anterior cruciate ligament reconstruction? Arthritis Care Res (Hoboken). 2014 Oct;66(10):1566-70.
14. Kaeding CC, Pedroza AD, Reinke EK, Huston LJ; MOON Consortium, Spindler KP. Risk Factors and Predictors of Subsequent ACL Injury in Either Knee After ACL Reconstruction: Prospective Analysis of 2488

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