Rupture of the anterior cruciate ligament is a common injury. Correct diagnosis and patient selection, along with proper surgical technique, with careful attention to anatomic graft placement, followed by attention to proper rehabilitation, leads to predictably good to excellent results. This article reviews the recognition and avoidance of complications associated with bone–patellar tendon–bone contructs of anterior cruciate ligament reconstruction.
AlfordJWBachBRJr. Arthrometric aspects of anterior cruciate ligament surgery before and after reconstruction with patellar tendon grafts. Techniques in Orthopaedics. 2005;20:421–438.
2.
American Academy of Orthopaedic Surgeons. Advisory statement #1011: Use of musculoskeletal tissue allografts. Available at http://www.aaos.org/about/papers/advistmt/1011.asp. Accessed 12 December 2007.
3.
ArcieroRA. Endoscopic anterior cruciate ligament reconstruction: Complication of graft rupture and a method of salvage. Am J Knee Surg. 1996;9:27–31.
4.
AustinJCPhomphutkulCWojtysEM. Loss of knee extension after anterior cruciate ligament reconstruction: Effects of knee position and graft tensioning. J Bone Joint Surg Am. 2007;89:1565–1574.
5.
BachBRJr. Patellar tendon autograft for ACL reconstruction. In: MillerMDColeBJ, eds. Textbook of Arthroscopy. Philadelphia: Elsevier; 2004.
6.
BachBRJr. Potential pitfalls of Kurosaka screw interference fixation for ACL surgery. Am J Knee Surg. 1989;2:76–82.
7.
BachBRJr. Revision ACL reconstruction: Indications and technique. In: MillerMDColeBJ, eds. Textbook of Arthroscopy. Philadelphia: Elsevier; 2004.
8.
BachBRJrAadalenKJDennisMG. Primary anterior cruciate ligament reconstruction using fresh-frozen, nonirradiated patellar tendon allograft: Minimum 2-year follow-up. Am J Sports Med. 2005;33:284–292.
9.
BachBRJrNhoSJ. Anterior cruciate ligament: Diagnosis and decision making. In: MillerMDColeBJ, eds. Textbook of Arthroscopy. Philadelphia: Elsevier; 2004.
10.
BachBRJr.TradonskySBojchukJLevyMEBush-JosephCAKhanNH. Arthroscopically assisted anterior cruciate ligament reconstruction using patellar tendon autograft: Five- to nine-year follow-up evaluation. Am J Sports Med. 1998;26:20–29.
11.
BachBRJrWarrenRFFlynnWMKrollMWickiewiczTL. Arthrometic evaluation of knees that have a torn anterior cruciate ligament. J Bone Joint Surg Am. 1990;72:1299–1306.
12.
BachBRJrWarrenRFWickiewiczTL. The pivot shift phenomenon: Results and description of a modified clinical test for anterior cruciate ligament insufficiency. Am J Sports Med. 1988;16:571–576.
BarrackRLBrucknerJDKneislJInmanWSAlexanderAH. The outcome of non-operatively treated complete tears of the anterior cruciate ligament in active young adults. Clin Orthop Relat Res. 1990;259:192–199.
BearBJCohenSBBowenMKSiegelJMoormanCTIWarrenRF. Fractures of the patella following anterior cruciate ligament reconstructions with the central one-third of the patella tendon. Presented at the Annual Meeting of the American Academy of Orthopaedic Surgeons, 1996, Atlanta, Ga.
17.
BellabarbaCBush-JosephCABachBRJr. Patterns of meniscal injury in the anterior cruciate ligament-deficient knee: A review of the literature. Am J Orthop. 1997;26:18–23.
18.
BergE.Autograft bone-patella tendon-bone plug comminution with loss of ligament fixation and stability. Arthroscopy. 1996;12:232–235.
19.
BergEE. Management of patella fractures associated with central third bone-patella tendon-bone autograft ACL reconstructions. Arthroscopy. 1996;12:756–759.
20.
BerksonELeeGHKumarAVermaNBachBJHallabN.The effect of cyclic loading on rotated bone-tendon-bone anterior cruciate ligament graft constructs. Am J Sports Med. 2006;34:1442–1449.
21.
BeynnonBDUhBSJohnsonRJ. Rehabilitation after anterior cruciate ligament reconstruction: A prospective, randomized, double-blind comparison of programs administered over 2 different time intervals. Am J Sports Med. 2005;33:347–359.
22.
BrownCHJrHeckerATHippJAMyersERHayesWC. The biomechanics of interference screw fixation of patellar tendon anterior cruciate ligament grafts. Am J Sports Med. 1993;21:880–886.
23.
BurksRTFriederichsMGFinkBLukerMGWestHSGreisPE. Treatment of postoperative anterior cruciate ligament infections with graft removal and early reimplantation. Am J Sports Med. 2003;31:414–418.
24.
BusamMLEstherRJObremskeyWT. Hardware removal: Indications and expectations. J Am Acad Orthop Surg. 2006;14:113–120.
25.
Bush-JosephCABachBRJrBryanJ.Posterior cortical violation of the femoral tunnel during endoscopic anterior cruciate ligament reconstruction. Am J Knee Surg. 1995;8:130–133.
26.
BussDDWarrenRFWickiewiczTLGalinatBJPananelloRA. Arthroscopically assisted reconstruction of the anterior cruciate ligament with use of autogenous patellar-ligament grafts: Results after twenty-four to forty-two months. J Bone Joint Surg Am. 1993;75:1346–1355.
27.
Bylski-AustrowDIGroodESHefzyMSHoldenJPButlerDL. Anterior cruciate ligament replacements: A mechanical study of femoral attachment location, flexion angle at tensioning and initial tension. J Orthop Res. 1990;8:522–531.
28.
CainELGilloglySDAndrewsJR. Management of intraoperative complications associated with autogenous patellar tendon graft anterior cruciate ligament reconstruction. Instr Course Lect. 2003;52:359–367.
29.
CarpenterJEKasmanRAPatelNLeeMLGoldsteinSA. Biomechanical evaluation of current patella fracture fixation techniques. J Orthop Trauma. 1997;11:351–356.
30.
CDC. Septic arthritis following anterior cruciate ligament reconstruction using tendon allografts: Florida and Louisiana, 2000. MMWR. 2001;50:1081–1083.
31.
CDC. Update: Allograft-associated bacterial infections: United States, 2002. MMWR. 2002;51:201–210.
32.
CiccottiMGLombardoSJNonweilerBPinkW.Non-operative treatment of ruptures of the anterior cruciate ligament in middle aged patients. J Bone Joint Surg Am. 1994;76:1315–1321.
33.
CosgareaAJSebastianelliWJDeHavenKE. Prevention of arthrofibrosis after anterior cruciate ligament reconstruction using the central third patellar tendon autograft. Am J Sports Med. 1995;23:87–92.
34.
CreightonRABachBRJ. Arthrofibrosis: Evaluation, prevention, and treatment. Techniques in Knee Surgery. 2005;4:163–172.
35.
CullisonTRMuldoonMPGormanJDGoffWB. The incidence of deep venous thrombosis in anterior cruciate ligament reconstruction. Arthroscopy. 1996;12:657–659.
36.
DanielDMStoneMLDobsonBEFithianDCRossmanDJKaufmanKR. Fate of the ACL-injured patient: A prospective outcome study. Am J Sports Med. 1994;22:632–644.
37.
DeehanDJSalmonLJWebbVJDaviesAPinczewskiLA. Endoscopic reconstruction of the anterior cruciate ligament with an ipsilateral patellar tendon autograft: A prospective longitudinal five-year study. J Bone Joint Surg Br. 2000;82:984–991.
38.
DoerrALCohnBTRuoffMJMcInerneyVK. A complication of interference screw fixation in anterior cruciate ligament reconstruction. Orthop Rev. 1990;19:997–1000.
FerrariJDBachBRJr. Bone graft procurement for patellar defect grafting in anterior cruciate ligament reconstruction. Arthroscopy. 1998;15:543–545.
41.
FerrariJDBachBRJrBush-JosephCAWangTBojchukJ.Anterior cruciate ligament reconstruction in men and women: An outcome analysis comparing gender. Arthroscopy. 2001;17:588–596.
42.
FettoJFMarshallJL. Injury to the anterior cruciate ligament producing the pivot-shift sign. J Bone Joint Surg Am. 1979;61:710–714.
43.
FidelerBMVangsnessCTJrMooreTLiZRasheedS.Effects of gamma irradiation on the human immunodeficiency virus: A study in frozen human bone-patellar ligament-bone grafts obtained from infected cadavera. J Bone Joint Surg Am. 1994;76:1032–1035.
44.
FuFHBennettCHLattermanCMaCB. Current trends in anterior cruciate ligament reconstruction. Am J Sports Med. 1999:27:821–830.
45.
GalawayRDBeaupreAMacIntoshDL. Pivot shift: A clinical sign of symptomatic anterior cruciate ligament insufficiency. J Bone Joint Surg Br. 1972:54:763.
46.
GeorgeMSDunnWRSpindlerKP. Current concepts review: Revision anterior cruciate ligament reconstruction. Am J Sports Med. 2006;34:2026–2037.
47.
GerichTGCassimALattermanCLobenhofferHP. Pullout strength of tibial graft fixation in anterior cruciate ligament replacement with a patellar tendon graft: Interference screw versus staple fixation in human knees. Knee Surg Sports Traumatol Arthrosc. 1997;5:84–88.
48.
GibbonsMJButlerDLGroodESBylski-AustrowDILevyMSNoyesFR. Effects of gamma irradiation on the initial mechanical and material properties of goat bone-patellar tendon-bone allografts. J Orthop Res. 1988;6:95–102.
49.
GoebelMEDrezDJrHeckSBStomaMK. Contaminated rabbit patellar tendon grafts: In vitro analysis of disinfecting methods. Am J Sports Med. 1994;22:387–391.
50.
GrafBCookDDeSmetAKeeneJ.“Bone bruises” on magnetic resonance imaging evaluation of anterior cruciate ligament injuries. Am J Sports Med. 1993;21:220–223.
51.
GrantJAMohtadiNGMaitlandMEZernickeRF. Comparison of home versus physical therapy-supervised rehabilitation programs after anterior cruciate ligament reconstruction: A randomized clinical trial. Am J Sports Med. 2005;33:1288–1297.
52.
GreulichWPyleS.Radiographic Atlas of Skeletal Development of the Hand and Wrist. Stanford, CA: Stanford University Press; 1959.
53.
HarrisIMulfordJSolomonMvan GelderJMYoungJ.Association between compensation status and outcome after surgery: A meta-analysis. JAMA. 2005;293:1644–1652.
54.
HassanSSSaleemABachBRJBush-JosephCABojchukJ.Results of arthroscopic treatment of symptomatic loss of extension following anterior cruciate ligament reconstruction. Am J Knee Surg. 2000;13:201–210.
55.
HawkinsRJMisamoreGWMerrittTR. Followup of the acute nonoperated isolated anterior cruciate ligament tear. Am J Sports Med. 1986;14:205–210.
56.
HeisFTPaulosLE. Tensioning of the anterior cruciate ligament graft. Orthop Clin North Am. 2002;33:697–700.
57.
HessTRuppSHopfTGleitzMLieblerJ.Lateral tibial avulsion fractures and disruptions to the anterior cruciate ligament. Clin Orthop Relat Res. 1994;303:193–197.
58.
HopkinsJTIngersollCDKrauseBAEdwardsJECordovaML. Effect of knee joint effusion on quadriceps and soleus motoneuron pool excitability. Med Sci Sports Exerc. 2001;33:123–126.
59.
HowellSMTaylorMA. Brace-free rehabilitation, with early return to activity, for knees reconstructed with a double-looped semitendinosus and gracilis graft. J Bone Joint Surg Am. 1996;78:814–825.
60.
HunterREMastrangeloJFreemanJRPurnellMLJonesRH. The impact of surgical timing on postoperative motion and stability following anterior cruciate ligament reconstruction. Arthroscopy. 1996;12:667–674.
IzquierdoRJrCadetERBauerRStanwoodWLevineWNAhmadCS. A survey of sports medicine specialists investigating the preferred management of contaminated anterior cruciate ligament grafts. Arthroscopy. 2005;21:1348–1353.
63.
JacksonDWSchaeferRK. Tibial tunnel placement in ACL reconstruction. Arthroscopy. 1990;10:124–131.
JomhaNMRasoVJLeungP.Effect of varying angles on the pullout strength of interference screw fixation. Arthroscopy. 1993;9:580–583.
67.
JonnsonTAlthoffBPetersonLRenstromP.Clinical diagnosis of ruptures of the anterior cruciate ligament: A comparative study of the Lachman test and the anterior drawer sign. Am J Sports Med. 1982;10:100–102.
68.
KocabeyYTetikOIsbellWMAtayOAJohnsonDL. The value of clinical examination versus magnetic resonance imaging in the diagnosis of meniscal tears and anterior cruciate ligament rupture. Arthroscopy. 2004;20:696–700.
69.
LaPradeRFResigSWentorfFLewisJL. The effects of grade III posterolateral knee complex injuries on anterior cruciate ligament graft force. Am J Sports Med. 1999;27:469–475.
70.
LaPradeRFWentorfF.Diagnosis and treatment of posterolateral knee injuries. Clin Orthop Relat Res. 2002;402:110–121.
71.
LarsonRLTaillonM.Anterior cruciate ligament insufficiency: Principles of treatment. J Am Acad Orthop Surg. 1994;2:26–35.
72.
LemosMJAlbertJSimonTJacksonDW. Radiographic analysis of femoral interference screw placement during ACL reconstruction: Endoscopic vs open technique. Arthroscopy. 1993;9:154–158.
73.
LemosMJJacksonDWLeeTQSimonTM. Assessment of initial fixation of endoscopic interference femoral screws with divergent and parallel placement. Arthroscopy. 1995;11:37–41.
74.
MartinRPGallowayMTDiagneaultJ.Patellofemoral pain following ACL reconstruction: Bone grafting the patellar defect. Orthop Trans. 1996:20:9.
75.
MatavaMLEvansTAWrightRWShivelyRA. Septic arthritis of the knee following anterior cruciate ligament reconstruction: Results of a survey of sports medicine fellowship directors. Arthroscopy. 1998;14:717–725.
76.
MatthewsLSLawrenceSJYahiroMASinclairMR. Fixation strengths of patellar tendon-bone grafts. Arthroscopy. 1993;9:76–81.
77.
MatthewsLSSofferSR. Pitfalls in the use of interference screws for anterior cruciate ligament reconstruction. Arthroscopy. 1989;5:225–226.
78.
McAllisterDRParkerRDCooperAERechtMPAbateJ.Outcomes of postoperative septic arthritis after anterior cruciate ligament reconstruction. Am J Sports Med. 1999;27:562–570.
79.
McCarrollJRShelbourneKDPatelDV. Anterior cruciate ligament reconstruction in athletes with an ossicle associated with Osgood-Schlatter's disease. Arthroscopy. 1996;12:556–560.
McDevittERTaylorDCMillerMD. Functional bracing after anterior cruciate ligament reconstruction: A prospective, randomized, multicenter study. Am J Sports Med. 2004;32:1887–1892.
82.
McMahonPJDettlingJRYocumLAGlousmanRE. The cyclops lesion: A cause of diminished knee extension after rupture of the anterior cruciate ligament. Arthroscopy. 1999;15:757–761.
83.
MeadeTDDicksonTB. Technical pitfalls of single incision arthroscopic-assisted ACL reconstruction. Am J Arthritis. 1992;2:15–19.
84.
MillerMDHinkinDT. The “N + 7 rule” for tibial tunnel placement in endoscopic anterior cruciate ligament reconstruction. Arthroscopy. 1996;12:124–126.
85.
MillsWJRobertsCSMirandaMA. Knee injuries. In: BaumgaertnerMTomettaP, eds. Orthopaedic Knowledge Update: Trauma 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2005.
86.
MolinaMENonweillerDEEvansJADeLeeJD. Contaminated anterior cruciate ligament grafts: The efficacy of 3 sterilization agents. Arthroscopy. 2000;16:373–378.
87.
NaborsEDRichmondJCVannahWMMcConvilleOR. Anterior cruciate ligament graft tensioning in full extension. Am J Sports Med. 1995;23:488–492.
88.
NovakPJBachBRJrHagerCA. Clinical and functional outcome of anterior cruciate ligament reconstruction in the recreational athlete over the age of 35. Am J Knee Surg. 1996;9:111–116.
89.
NovakPJWexlerGMWilliamsJSBachBRJrBush-JosephCA. Comparison of screw post fixation and free bone block interference for anterior cruciate ligament soft tissue grafts: Biomechanical considerations. Arthroscopy. 1996;12:470–473.
90.
NoyesFRBarber-WestinSDHewettTE. High tibial osteotomy and ligament reconstruction for varus angulated anterior cruciate ligament-deficient knees. Am J Sports Med. 2000;28:282–296.
91.
NoyesFRMangineREBarberS.Early knee motion after open and arthroscopic anterior cruciate ligament reconstruction. Am J Sports Med. 1987;15:149–160.
92.
NoyesFRMooarPAMatthewsDSButlerDL. The symptomatic anterior cruciate deficient knee: Part I: The long term functional disability in athletically active individuals. J Bone Joint Surg Am. 1983;65:154–162.
93.
NoyesFRSchippleinODAndriacchiTPSaddemiSRWeiseM.The anterior cruciate ligament-deficient knee with varus alignment: An analysis of gait adaptations and dynamic joint loadings. Am J Sports Med. 1992;20:707–716.
94.
O'ConnorDPLaughlinMSWoodsGW. Factors related to additional knee injuries after anterior cruciate ligament injury. Arthroscopy. 2005;21:431–438.
95.
OttoDDPinczewskiLAClingelefferAJOdellR.Five-year results of single-incision arthroscopic anterior cruciate ligament reconstruction with patellar tendon autograft. Am J Sports Med. 1998;26:181–188.
96.
PatelJVChurchJSHallAJ. Central third bone-patellar tendon-bone anterior cruciate ligament reconstruction: A 5-year follow-up. Arthroscopy. 2000;16:67–70.
97.
PaulosLPWnorowskiDCGreenwaldAE. Infrapatellar contracture syndrome: Diagnosis, treatment, and long-term followup. Am J Sports Med. 1994;22:440–449.
98.
PierzKBaltzMFulkersonJP. The effect of Kurosaka screw divergence on the holding strength of bone-tendon-bone grafts. Am J Sports Med. 1995;23:332–335.
99.
PlancherKDSteadmanJRBriggsKKHuttonKS. Reconstruction of the anterior cruciate ligament in patients who are at least forty years old: A long-term follow-up and outcome study. J Bone Joint Surg Am. 1998;80:184–197.
100.
PoolmanRWAboualiJAKConterHJBhandariM.Overlapping systematic reviews of anterior cruciate ligament reconstruction comparing hamstring autograft with bone-patellar tendon-bone autograft: Why are they different?J Bone Joint Surg Am. 2007;89:142–152.
101.
RisbergMAHolmISteenHErikssonJEkelandA.The effect of knee bracing after anterior cruciate ligament reconstruction: A prospective, randomized study with two years’ follow-up. Am J Sports Med. 1999;27:76–83.
102.
RisingerRJVermaNNBachBRJr. Graft fixation alternatives. Techniques in Orthopaedics. 2005;20:382–390.
103.
RobinsAJNewmanAPBurksRT. Postoperative return of motion in anterior cruciate ligament and medial collateral ligament injuries: The effect of medial collateral ligament rupture location. Am J Sports Med. 1993;21:20–25.
104.
RoseNEGoldSM. A comparison of accuracy between clinical examination and magnetic resonance imaging in the diagnosis of meniscal and anterior cruciate ligament tears. Arthroscopy. 1996;12:398–405.
105.
RuppSSeilRKraussPWKohnDM. Cortical versus cancellous interference fixation for bone-patellar tendon-bone grafts. Arthroscopy. 1998;14:484–488.
106.
SekiyaJKOngBCBradleyJP. Complications in anterior cruciate ligament surgery. Orthop Clin North Am. 2003;34:99–105.
107.
ShelbourneKDGrayT.Anterior cruciate ligament reconstruction with autogenous patellar tendon graft followed by accelerated rehabilitation: A two- to nine- year followup. Am J Sports Med. 1997;25:786–795.
108.
ShelbourneKDPatelDVMartiniDJ. Classification and management of arthrofibrosis of the knee after anterior cruciate ligament reconstruction. Am J Sports Med. 1996;24:857–862.
109.
SmithSTCramerKEKargesDEWatsonJTMoedBR. Early complications in the operative treatment of patella fractures. J Orthop Trauma. 1997;11:183–187.
110.
Snyder-MacklerLDelittoAStralkaSWBaileySL. Use of electrical stimulation to enhance recovery of quadriceps femoris muscle force production in patients following anterior cruciate ligament reconstruction. Phys Ther. 1994;74:901–907.
111.
SolomonDHSimelDLBatesDWKatzJNSchafferJL. Does this patient have a torn meniscus or ligament of the knee? Value of physical examination. JAMA. 2001;286:1610–1620.
112.
SvenssonMKartusJEjerhedLLindahlSKarlssonJ.Does the patellar tendon normalize after harvesting its central third? A prospective long-term MRI study. Am J Sports Med. 2004;32:34–38.
113.
Van HuyssteenALBraceyDJ. Chlorhexadine and chondrolysis in the knee. J Bone Joint Surg Br. 1999;81:995–996.
114.
van KampenAWymengaABvan der HeideHJLBakensHJAM. The effect of different graft tensioning in anterior cruciate ligament reconstruction: A prospective randomized study. Arthroscopy. 1998;14:845–850.
VermaNNoerdlingerMAHallabNBush-JosephCABachBRJr. Effects of graft rotation on initial biomechanical failure characteristics of bone-patellar tendon-bone constructs. Am J Sports Med. 2003;31:708–713.
117.
VermaNNDennisMGCarreiraDSBojchukJHaydenJKBachBRJr. Preliminary clinical results of two techniques for addressing graft tunnel mismatch in endoscopic anterior cruciate ligament reconstruction. J Knee Surg. 2005;18:1–9.
118.
ViolaRVianelloR.Three cases of patella fracture in 1,320 anterior cruciate ligament reconstructions with bone-patellar tendon-bone autograft. Arthroscopy. 1999;15:93–97.
119.
WebbJMCorryISClingelefferAJPinczewskiLA. Endoscopic reconstruction for isolated anterior cruciate ligament rupture. J Bone Joint Surg Br. 1998;80:288–294.
120.
WexlerGBachBRJrBush-JosephCASminkDFerrariJDBojchukJ.Outcomes of anterior cruciate ligament reconstruction in patients with workers’ compensation claims. Arthroscopy. 2000;16:49–58.
121.
WilliamsJSHulstynMFadalePD. Incidence of deep vein thrombosis after arthroscopic knee surgery: A prospective study. Arthroscopy. 1995;11:701–705.
122.
WilliamsRJLaurencinCTWarrenRFSpecialeACBrauseBDO'BrienS.Septic arthritis after arthroscopic anterior cruciate ligament reconstruction: Diagnosis and management. Am J Sports Med. 1997;25:261–267.
123.
WilsonTCKantarasAAtayAJohnsonDL. Tunnel enlargement after anterior cruciate ligament surgery. Am J Sports Med. 2004;32:543–549.
