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:

  • Doctors looked at 183  (knees) patients two years removed from ACL reconstruction
  • Patients underwent ACLR with either bone-patellar-tendon autograft, quadrupled hamstring autograft or allograft tissue.

Knee Hypermobility – instability

  • Of the 183 patients: Forty-one of 183 consecutive patients were categorized as hypermobile.
    • The remaining 142 non-hypermobile.
  • ACL reconstruction failure was higher in the Hypermobile group (24.4% failure rate) compared with the Non-hypermobile group (7.7% failure rate)
  • The overall ACL injury rate (ACL graft injury, excessive graft laxity, plus contralateral (the other knee) ACL tear) was higher in the Hypermobile group (34.1%) compared with the Non-hypermobile group (12.0%)2

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:

  • Doctors writing in the American Journal of Sports Medicine suggest that  younger patients had a higher risk of revision ACL reconstruction than older patients and that subjective clinical outcome was worse after revision ACL reconstruction compared to primary ACL reconstruction. They report that nearly 9% of patients under 20 need a second anterior cruciate ligament (ACL) Reconstruction Therapy.3
  • Doctors reporting in the journal Clinical orthopaedics and related research also suggest that young, active, skeletally mature patients have higher failure rates after various surgical procedures, including primary ACL reconstruction. While a single-stage transosseous revision (ACL tunnel repair surgery) restores knee stability, only 52% of these patients return to their prior level of activity or sport.4
  • How good was the stability? In another study published in the American Journal of Sports Medicine, doctors in France reported that while the second ACL reconstruction was excellent or good in 70% of the cases, HOWEVER knee degeneration continued to occur because of stress and damage to the meniscus and articular cartilage. Meniscus tears were more frequent and more severe with recurrent laxity and knee instability.5

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:

  • In the medical journal Arthroscopy, doctors wrote: “Meniscectomy was performed in 65% of ACL tear procedures. This is concerning because studies have shown that, regardless of knee stability obtained after ACL reconstruction, meniscectomy accelerates degenerative joint changes.6
  • Doctors writing in the journal Arthritis care & research, note that Patellofemoral osteoarthritis is common following anterior cruciate ligament reconstruction and that post surgical lack of knee rotation may be sufficient to initiate or accelerate patellofemoral cartilage degeneration.12
  • Researchers writing in the British Journal of Sports Medicine found that if you had to have a revision or secondary ACL reconstruction surgery you were at advanced risk for osteoarthritis, ligament damage and weakness, and loss of knee function. 7
    • In fact doctors writing in the Journal of Bone and Joint Surgery wrote: “Despite the success of restoring joint stability and improving early functional outcomes after anterior cruciate ligament reconstruction, the long-term risk of developing symptomatic osteoarthritis requiring total knee replacement is higher than that in the uninjured population.” 8
    • Even worse, Danish doctors report in the American Journal of Sports Medicine that ACL injury following surgical repair results in worse patient outcomes in secondary repair.9  
      • Revision – Revision – the Third ACL surgery
        Doctors writing in The Journal of bone and joint surgery suggest that it is important for orthopaedic surgeons to attempt to restore proper anatomy and biomechanics during revision (the second ACL surgery) ACLR to minimize the rate of re-revision. (The third ACL surgery). Here are the surgeon’s checklist of guidelines.
      • They write that: Technical errors such as nonanatomic tunnel placement are some of the most common causes of graft failure after primary anterior cruciate ligament reconstruction.
      •  When considering a revision ACLR in a patient with ACL graft failure, it is crucial to perform preoperative imaging, which should include an initial radiographic series, magnetic resonance imaging, and possibly computed tomography for further assessment of tunnel locations.
      • Revision ACLR may be performed in a 1 or 2-stage procedure depending on the size and location of the existing tunnels, bone stock, existing hardware, and infection status.
      • Use of autograft (patient) ligament tissue for revision ACLR has been shown to correlate with higher patient-reported outcomes and a significantly lower risk of subsequent graft rupture in comparison with allograft (donor) use.
      • Multiple studies have shown that the rate of return to the preinjury level of sport is significantly lower following revision ACLR than following primary ACLR procedures.10
    • Why doctors want to avoid a revision was pointed out in a study out of Norway in the journal Knee surgery, sports traumatology, arthroscopy:
      • researchers compared 56 patients undergoing a revision reconstruction to 52 patients undergoing a primary reconstruction surgery. The results showed that the patients who had the second surgery had inferior results in almost every category of observation, including greater laxity, less muscle strength, and more severe radiological osteoarthritis.11

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.

  • Tunnel widening (the hole gets bigger),
  • and tunnel misplacement (the tunnel was put in the wrong place),
  • and fracture (the tunnel hole was too wide and caused a fracture of the bone) are the more common complications.

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

Prolotherapy can save your joints!


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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