Technical Causes of ACL Graft Failure

Revision anterior cruciate ligament reconstruction has a higher failure rate and worse clinical outcomes than primary reconstruction. A number of technical factors can contribute to these results. Proper tunnel positioning on the femoral and tibial sides is critically important, and tunnel malposition is the most common technical cause of graft failure. Recognizing tunnel enlargement and properly preparing the tunnels are likewise important. Graft-related factors that may contribute to failure include improper graft choice, as well as inadequate graft fixation or tensioning. Failure to address limb malalignment and concomitant ligamentous injuries may also contribute to ACL graft failure. Errors in notchplasty can lead to graft failure, as well. Each of these factors should be addressed in the planning and execution of revision ACL reconstructions.