Trauma and femoral tunnel position are the most common failure modes of anterior cruciate ligament reconstruction: a systematic review

Abstract

Purpose To improve outcomes of anterior cruciate ligament reconstruction (ACLR), it is important to understand the reasons for failure of this procedure. This systematic review was performed to identify current failure modes of ACLR. Methods A systematic search was performed using PubMed, EMBASE, Cochrane, and annual registries for ACLR failures. Studies were included when failure modes were reported (I) of ≥ 10 patients and (II) at a minimum of two-year followup. Modes of failure were also compared between different graft types and in femoral tunnel positions. Results This review included 24 cohort studies and 4 registry-based studies (1 level I, 1 level II, 10 level III, and 16 level IV studies). Overall, a total of 3657 failures were identified. The most common single failure mode of ACLR was new trauma (38%), followed by technical errors (22%), combined causes (i.e. multiple failure mechanisms; 19%), and biological failures (i.e. failure due to infection or laxity without traumatic or technical considerations; 8%). Technical causes also played a contributing role in 17% of all failures. Femoral tunnel malposition was the most common cause of technical failure (63%). When specifically looking at the bone-patellar tendon-bone (BPTB) or hamstring (HT) autografts, trauma was the most common failure mode in both, whereas biological failure was more pronounced in the HT group (4% vs. 22%, respectively). Technical errors were more common following transtibial as compared to anteromedial portal techniques (49% vs. 26%). Conclusion Trauma is the single leading cause of ACLR failure, followed by technical errors, and combined causes. Technical errors seemed to play a major or contributing role in large part of reported failures, with femoral tunnel malposition being the leading cause of failure. Trauma was also the most common failure mode in both BPTB and HT grafts. Technical errors were a more common failure mode following transtibial than anteromedial portal technique. Level of evidence IV.

Effect of Demineralized Bone Matrix, Bone Marrow Mesenchymal Stromal Cells, and Platelet-Rich Plasma on Bone Tunnel Healing After Anterior Cruciate Ligament Reconstruction: A Comparative Micro-Computed Tomography Study in a Tendon Allograft Sheep Model

“…24 Bone tunnel healing varies depending on the position in the tunnel, with healing at the aperture (the intra-articular opening) reported to be lower than that at the midportion and exit (the segment farthest from the intra-articular space). 3 The propensity for tendon-bone healing depends on the graft; hamstring tendon grafts are associated with a higher incidence of biological failures 43 and greater tunnel widening, 46 while tendon allografts have the advantage of avoiding donor-site morbidity but have delayed graft healing compared with autografts. 38 Therefore, strategies to enhance bone tunnel healing might be particularly advantageous for allogenic-free tendon grafts.…”

Editorial Commentary: Independent Femoral Tunnel Drilling Avoids Anterior Cruciate Ligament Graft Malpositioning: Advice From a Transtibial Convert

“…[1][2][3] Not to suggest that the tibial position is not important, as it is, but malpositioning of the femoral tunnel has been found to be a leading cause of technical failure in ACL reconstructions. 4 So, the issue is how we best make our ACL femoral socket? Certainly, this topic has been well researched, 5 but now authors Moorthy, Sayampanathan, and Tan in their article "Superior Postoperative Stability and Functional Outcomes With Anteromedial Versus Transtibial Technique of Single-Bundle Autologous Hamstring Anterior Cruciate Ligament Reconstruction: A Meta-analysis of Prospective Randomized Controlled Trials" have provided us with further evidence of the benefit of anteromedial (AM) portal drilling.…”

Ideal Combination of Anatomic Tibial and Femoral Tunnel Positions for Single-Bundle ACL Reconstruction

“…6,18,30 The annual reported incidence of ACL tears is 68.6 per 100,000 person-years and peaks between 19 and 25 years in male patients and between 14 and 18 years in female patients. 30 Many studies 6,7,9,24,31,37 have identified factors that affect the outcomes of ACLR. Some studies 8,16,26 have suggested that anatomic ACLR is preferred over nonanatomic ACLR (isometric).…”