Reasons for Failed ACL Surgery
The Sanders Clinic regularly sees athletes who have had failed Anterior Cruciate Ligament (ACL) surgery. Such surgery may fail
for many reasons. The principle reasons for failure are permanent stiffness of the knee manifested by lack of full extension,
and recurrent instability or giving way.
The most common failure is the failure to regain Range of Motion, particularly the loss of full knee extension. This will lead
to pain and grinding at the patellofemoral joint. When this occurs, it is nearly impossible for an athlete to live a normal
sedentary life, much less one allowing for successful competition in sports.
Reasons for Failed ACL Surgery
Failure of an ACL surgery can occur when the surgery is done too soon following an injury, and before normal range of motion is achieved.
Other reasons for failed results include the use of a postoperative brace or cast, which prevents full extension.
Often times it is a misplacement of the graft, or a graft that is properly placed, though too tight, which limits range of motion. This
occurs when two interference bone screws are used. The last common cause of a failed ACL surgery lies in the rehabilitation - either a
poorly designed program or the lack of motivation on the athletes' part to do the necessary rehabilitation.
But, most often, the cause of failure is a combination of the above. When it occurs, the condition is called arthrofibrosis. Left alone,
it will lead to posttraumatic arthritis. The best treatment for this problem is prevention. The Sanders Clinic protocol for knee
rehabilitation is designed for exactly that.
Salvaging a Previously Failed ACL Surgery
Unfortunately, not all surgeons performing ACL surgery have the same philosophy - resulting in stiff knees following ligament
reconstruction. If the knee lacks only a small amount of extension, then redirecting the rehabilitation to include the use of the
Elite Seat will be successful. If a large amount of extension or flexion is lost, then arthroscopic surgery
is necessary to cut scar tissue, release abnormal adhesions between the moving parts, and sometimes resect part or all of the cruciate
graft - which has now become the problem rather than the solution to the overall problem.
Following this procedure to salvage a previously failed ACL surgery, a cast with the knee at hyperextension is applied and
maintained for the first night. In the morning, rehabilitation begins for gait training, strengthening and knee flexion. Work on knee
extension is rarely needed, as that is accomplished during surgery and maintained in the cast - which, when carefully removed, is used
at night for six weeks in order to prevent recurrence of the flexion contracture.
Athletes must take responsibility for the maintenance of their knee Range of Motion. Exercises must be continued indefinitely in
these cases. The surgeon's work takes place over a one-hour period in the operating room. Following that, it is the athlete's
responsibility to get those exercises done. Period.
Unfortunately, this decade has become the decade of the Allografts and the hamstring tendons. More than one half of the ACL
reconstructions performed in the United States include tissue from cadavers, or tendons from the hamstrings.
When a graft tissue from the patient is used, the body recognizes it as its own and embraces it. And while the body may not
reject an Allograft outright, it, like a kidney, creates an uncertainty with regard to the body's willingness to accept or reject it.
The best we can expect is that the body will tolerate it.
Problems with Allograft Tissue
At the Sanders Clinic, we use a rule of thumb regarding ACL graft choices. This rule is based on excellent scientific research done
by Drs. Frank Noyes and Sue Barber-Westin. They have shown that the survival rate of an athlete’s own tissue as an ACL is approximately
93 percent and the survival rate of allograft tissue as an ACL approximately 70 percent. Stated another way, an athlete who has an
allograft reconstruction is at four-times greater risk of needing a revision. For this reason, Dr. Sanders does not perform allograft
reconstructions on any athlete, regardless of age. Nor does he perform them on any patient under the age of forty.
An allograft tissue is dead. It is frozen and then thawed and installed as a graft. This dead tissue must then be revascularized -
prompting new cells to move into the place where the dead cells existed. This rarely happens in allografts, and many rupture before
they can revascularize. This process takes nearly a year at best. And athletes must remain on the sidelines during this time. Since most
young athletes do not want, or cannot afford, to miss a year of competition, they return to their sport too for this type of graft early.
For this reason many of the allografts put into serious young athletes FAIL!
Unfortunately, failed allograft surgery often causes comprise and resorption of the bone of the lower femur and upper tibia. Many
surgeons believe that in order to remedy the problem, a two-stage procedure is necessary - the first stage involves bone grafting
the defects and the second is performing the ACL reconstruction. At the Sanders Clinic, results show that this is almost never
necessary, as a standard reconstruction using the athlete's opposite patella tendon can be done in a single procedure - avoiding a
second surgery. Unfortunately, while Dr. Sanders can repair the knee of a previously failed reconstruction, he is unable to return
the lost years of a sport to the athlete, which is why he encourages young athletes to fully understand the differences between
the graft choices before having their first surgery.
Problems with Hamstring Tendons
Hamstring tendons are live tendons taken from the back of the injured athlete's knee. Because it is technically easy for the surgeon
to harvest them, they have become popular graft sources.
By themselves they are alive and strong. Unfortunately, they have no bone attached to them - and the healing of these tendons,
installed into the knee as an ACL, must occur by the tendon healing to the bone. This is at best an uncertain process and is
not complete before nearly one year. Furthermore, as these tendons heal to the bone, significant stretching can occur -
which can lead to a loose knee.
During this first year, just like those who have had allograft reconstructions, an athlete must restrict him or herself
to working out at the health club or gym, rather than the field of play.
Another major problem with the hamstring tendon repair is that the harvest of the hamstring tendons ablates two important
muscle tendon units that serve with the ACL and hold the tibia backward. Removing these important tendons means that the nascent
hamstring ACL graft has to "go it alone." This is another common reason for failure.
