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Mend It Like Beckham – Anterior Cruciate Ligament (ACL) Reconstruction

By Mr David Griffiths MA (Cantab), MBBS (London), FRCS (England), FRCS (Orth)

David Griffiths is a consultant orthopaedic and trauma surgeon with over 20 years experience of preparing medical reports and appearing as an expert witness in court.

Issue 1

The ACL is a band of dense connective tissue which runs diagonally in the knee and contributes significantly to stability, particularly during twisting and turning activities. It is often injured in sports such as football or skiing and, in my experience, is an increasing area for alleged medical negligence.

Many patients describe feeling a “pop” following a non-contact injury with pain and a variable amount of swelling. The first issue is that ACL rupture is seldom recognised in A&E departments and many patients wait a frustratingly long time before being diagnosed.

Ruptured ACLs do not heal and, particularly in young sporting individuals, a reconstruction may be necessary. The patient’s own tissues (hamstring tendons or patella tendon) are used to reconstruct the ligament in most cases although cadaveric tissues (allografts) are an option. Synthetic ligaments have largely fallen out of favour. The operation is now almost exclusively performed arthroscopically and frequently as a day case procedure. The graft is pulled through tunnels drilled in the femur and tibia with the aim being to replicate the normal ACL attachments and anatomy. It is successful in restoring knee stability in about 80-90 per cent of cases.

It is fair to say that success is generally more dependent on the skill of the surgeon than the graft used or particular technique employed – again leaving the way open for potential allegations of negligence.

The most frequent indication of failure is recurrent instability and this occurs in about 10 per cent of cases. There are several possible reasons for this but the commonest is technical error and, specifically, non-anatomical tunnel placement, usually on the femoral side.

If the femoral tunnel is too far forward then movement of the knee may be affected but the commonest error that I see regularly in failed ACL surgery is placement of the femoral tunnel too vertically (the “high noon” position as it is called in the US). When this occurs the normal obliquity of the ligament is not restored and it does not therefore act as a restraint to rotation. The ligament reconstructed in this way cannot be expected to restore pivotal stability, which is the primary purpose of the surgery.

It is by no means rare to see patients whose ACL reconstructions have failed and find that the femoral tunnel (and also occasionally the tibial one) are so misplaced that they can be ignored and fresh tunnels drilled at the time of revision.

The commonest causes of complaint (and litigation) that I see in this field are a failure to diagnose the injury and misplacement of the reconstructed ligament leading to early recurrent instability and the need for revisional surgery.

I see about 10-15 cases of alleged clinical negligence per year related to ACL reconstruction, most are in young sporting individuals. I have dealt with a case in a professional footballer who had a substandard reconstruction which ended his career. He was successful in his claim.