Review Article
Management of Intraoperative Graft-related
Challenges in Anterior Cruciate
Ligament Reconstruction
Todd C. Battaglia, MD, MS,
FAAOS, FAANA
From the Department of Sports Medicine,
Syracuse Orthopedic Specialists, PC, Syracuse,
NY, and Team Orthopedist, Syracuse University
Athletics, Syracuse, NY.
Neither Battaglia nor any immediate family
member has received anything of value from or
has stock or stock options held in a commercial
company or institution related directly or
indirectly to the subject of this article.
J Am Acad Orthop Surg 2022;30:448-456
DOI: 10.5435/JAAOS-D-21-00350
Copyright 2022 by the American Academy of
Orthopaedic Surgeons.
448
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Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
ABSTRACT
Anterior cruciate ligament reconstruction (ACLR) is one of the most
frequently performed procedures in orthopaedic sports medicine.
Intraoperative challenges related to graft procurement, graft
preparation, and graft placement are common. Frequently
encountered difficulties include insufficient graft diameter and graft-
tunnel length mismatches, whereas less frequent challenges may be
encountered during graft harvest and handling. This article
discusses these possible complications and the strategies for
their prevention and management. For successful ACLR, clinicians
must be prepared to address each of these potential sources of
difficulty.
A
nterior cruciate ligament reconstruction (ACLR) is one of the most
commonly performed orthopaedic surgeries, with up to 200,000
occurring annually in the United States. Despite this, failure
rates remain disappointingly high, especially in younger athletes.1,2 One
particular set of complications that may compromise outcomes includes
graft-associated issues that arise during the procedure itself. These
may involve difficulties related to graft harvest, to insufficient graft diameter
or suboptimal length, and to graft handling and passage. It is critical
that surgeons be sufficiently prepared to address these issues when they
occur.
Harvest-related Complications
Few publications specifically focus on intraoperative harvest-related com-
plication rates, and there appear to be no randomized studies focused on the
harvest technique. Hardy et al,3 summarizing 36 expert-opinion articles,
focused on the occurrence and prevention of harvest-related complications
related to bone-patellar tendon-bone (BPTB) and hamstring (HT) auto-
grafts, but primarily discussed postoperatively issues, including anterior
knee pain (occurring in up to 46%, with both BPTB and HT), nerve injury,
patellar fracture, patellar tendon (PT) rupture, and postoperative strength
deficits.
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Specific complications occurring during HT harvest
include saphenous nerve branch injury, premature
tendon amputation, and iatrogenic medial collateral
ligament injury. Although statistical analysis of such
events is lacking, strategies described below clearly
lessen the likelihood of occurrence. As described by
Frank et al,4 it is typically easier to palpate the pes
insertion without gloves; thus, marking the incision
before skin preparation may allow a smaller incision
and minimize cutaneous nerve injury. An oblique or
vertical incision also seems to lessen chances of nerve
injury.3
To avoid premature amputation, surgeons should
sequentially release each desired tendon, assess for
tethers, and complete harvest before moving on to the
second tendon. It is recommended that at least 10 to
12 cm of tendon be free of any tethers before harvest.
Furthermore, any anomalous tendon insertions must be
released; a study of 123 children undergoing ACLR
with autograft HT found an anomalous insertion in the
form of low-lying muscle and/or accessory tendon in
2.4%.5 This was typically identifiable by the presence
of muscle tissue within 6 cm of tendon insertion. If all
vincula are appropriately released, no movement or
contraction of the medial gastrocnemius should occur
during traction on the tendon. Ultimately, if premature
amputation results in insufficient specimens, surgeons
must be prepared to respond using other techniques
discussed in this article, including the use of secondary
graft options.
Lanternier et al6 nicely demonstrated safe hamstring
harvest using an anterior approach in a surgical video.
Alternatively, a posterior harvest approach may limit
risks of saphenous branch injury and premature
amputation and allow better identification of accessory
attachments. Khanna et al7 used this approach on 214
pediatric and adolescent patients and reported suc-
cessful tendon identification and harvest in all cases,
with no cases of premature transection, no wound
complications, and no pain or cosmetic complaints
related to scar. It is unclear whether this approach af-
fects the incidence of anterior knee pain.
Patellar Tendon Harvest
Anterior knee pain and cutaneous saphenous branch
injury are more common with BPTB harvest, with rates of
both exceeding 50% in many studies.8 Regarding
patellar fracture, Stein et al9 reported an incidence of
1.3% during 618 consecutive BPTB ACLRs, but none
occurred intraoperatively; in fact, occurrence was at a
mean of 57 days after surgery. It is suggested that
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Todd C. Battaglia, MD, MS, FAAOS, FAANA
Review Article
limiting bone plug length to 20 to 25 mm or less, and
specifically avoiding harvest above the patellar equator,
may lessen fracture risk. Packing the patellar defect with
cancellous graft, or using platelet-rich plasma, may also
reduce the rate of subsequent fracture.3
Frank et al10 also advised strategies for safe BPTB
harvest. These include exposure of full tendon width to
ensure central-third harvest, leaving less than 10 mm of
tendon medially may increase rupture risk. To lessen
patellar stresses, a trapezoidal plug (narrowing more
deeply) no more than 1 cm deep should be harvested,
marking the saw blade can decrease over-penetration.
Furthermore, when making the horizontal cut, angling
the saw 45
obliquely can avoid extension beyond the
longitudinal cuts. Finally, minimal mallet use and
avoidance of levering the osteotome should minimize
fracture risk during plug extraction.10
Wilding et al,11 in a technical note, endorsed har-
vesting bone-tendon autograft (BTA)—that is, tendon
with tibial, but no patellar, bone plug—and presented
the technique in a video.12 This technique eliminates the
risk of patella fracture and lessens harvest time. It may
also lessen graft-tunnel mismatch issues; however, if
using such an approach, surgeons must use caution to
ensure adequate graft length and consider including
patellar bone plug if the graft would otherwise be
shorter than 70 mm. No clinical studies are available on
outcomes or complications of BTA grafts.
Quadriceps Tendon Harvest
Although the use of quadriceps tendon (QT) is increas-
ing, minimal data currently exist regarding harvest
complications. Theoretical advantages include a lower
likelihood of anterior knee pain, numbness, and kneeling
pain. Likely, the most common issue encountered with
QT harvest is that of a short graft. It is recommended
that, if using QT graft without a bone plug, harvest
should cheat toward the lateral (and longer) side of the
quad tendon.8,13 But if harvesting with the bone plug,
this approach will typically position the plug precari-
ously close to the lateral patella. In such cases, align
the plug and tendon harvest to lie just medial to the
medial tendon border and use similar precautions to
plug harvest for BPTB. QT can also be harvested with
endoscopic assistance, aiding harvest trajectory and
minimizing joint capsule violation.14
Insufficient Graft Diameter
Copious literature has demonstrated the importance of
graft diameter on both patient-reported outcome
449
Management of Intraoperative Graft-related Challenges
measures and objective measures of knee stability and
graft failure. Insufficient graft diameter is rarely an issue
when using BPTB or QT, which can nearly always be
harvested to obtain desired diameter. HT autograft, on
the other hand, has a much greater inherent variability in
diameter,15 with quadrupled diameter most commonly
falling between 7 and 8 mm.16
Unfortunately, such small diameters are associated
with greater failure rates. Numerous studies from large
ACLR registries have consistently shown an approxi-
mately 0.85· lower rate of graft revision for every
0.5 mm increase in graft diameter above 7 mm.17-19
These studies demonstrate that, for example, 9 mm HT
grafts seem 55% less likely to require revision compared
with a 7 mm, with a relative risk of 1.25 for revision
within the first 2 years for patients with grafts smaller
than 8 mm compared with those with grafts greater than
or equal to 8 mm.17
This relationship appears to be even more dramatic
for younger patients. Magnussen et al16 followed a series
of 256 patients who underwent quadrupled HT ACLR.
For those younger than 20 years, the 1-year revision rate
was 4.5% when the graft was 8.5 mm or greater, but
16.5% when the graft was 8 mm or smaller. Even more
impressively, failure was 24.1% when the graft was
7 mm or less. It is concerning that, overall, 90% of
women and 66% of men fell into this “highest risk”
group. Interestingly, no relationship was found between
failure rate and the ratio of graft diameter to patient size,
suggesting that, even in smaller individuals, small graft
diameter is not well tolerated.
Thus, it seems that achieving an HT autograft with
diameter of at least 8 to 8.5 mm is critical to minimize
odds of graft failure and revision, especially in young
patients. Surgeons must therefore be comfortable with
strategies to increase graft size when confronted with
insufficient HT diameter (Table 1)
5-Strand Graft Creation
Perhaps the most popular adjustment when faced with
insufficient HT diameter is the creation of a 5-strand,
Table 1. Summary of Options to Manage Insufficient
Hamstring Autograft Diameter
5-strand (or 6-strand) graft creation
Augmentation with allograft (hybridization)
Augmentation with autograft
Synthetic augmentation
Graft manipulation (braiding)
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rather than a standard 4-strand, construct. This strategy,
which usually entails tripling the semitendinosus (ST)
and combining with a doubled gracilis (G), may allow the
creation of a graft larger than 8 mm in most cases but
does require the ST to be a minimum of 22 to 23 cm, thus
allowing a 7 cm length when tripled. Carredano et al20
provided a surgical video demonstrating this 5-strand
graft technique.
Krishna et al21 randomized 64 patients to either
quadrupled or 5-strand HT autograft use. The 5-strand
technique increased average graft diameter by 1.4 mm
and created a graft greater than 8 mm in 75% of the
patients (compared with 28% with quadrupled HT). No
clinical outcomes were reported, although additional
studies suggest that a 5-string HT graft does not behave
differently from an equivalently sized 4-strand graft.
Calvo et al15 studied 33 patients with 4-strand grafts
larger than 8 mm and compared them with 37 patients
who required a 5-strand configuration to achieve similar
size. Over an average follow-up of 2.5 years, no sta-
tistical differences in rerupture rates or outcome scores
were found.
Krishna et al22 also published outcomes of 25 patients
in whom a 5-strand configuration was required to
achieve a graft larger than 8 mm, in comparison with 20
patients in whom the 4-strand graft achieved this size,
finding no notable differences in Knee injury and
Osteoarthritis Outcome Score or Short Form-36 scores.
There is question as to whether the use of a femoral
interference screw with 5-strand constructs is more
appropriate than suspensory fixation. In theory, an
interference screw ensures that all strands are secured,
whereas suspensory fixation might allow elongation
and reduced stress in the “tripled strand,” which is not
directly secured to the suspension device. No litera-
ture exists examining this concern. It is also con-
ceivable that if both ST and G tendons are sufficiently
long, both could be tripled and provide an even larger
graft through a 6-strand construct. Currently, no
literature exists assessing the outcomes of 6-strand
autografts.
Hybridization
Another method to increase the diameter of smaller au-
tografts is through augmentation with allograft tissue.
This combination is termed a “hybrid” graft. Although it
would seem that adding tissue should improve biome-
chanical properties and lower failure likelihood, allo-
graft has slower incorporation and maturation than
does autograft, rendering the ultimate behavior of
hybrid grafts unclear.
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Numerous studies have looked at this issue over the
past half-decade. Burrus et al,23 in 2015, compared pa-
tients receiving pure HT autograft with those receiving
hybrids (used when autograft measured ,7.5 mm). In
these matched groups, 13.8% of the hybrids failed (and
another 27.6% appeared partially ruptured on arthros-
copy or MRI), whereas the pure autograft group had a
3.4% failure rate (and 3.4% partially ruptured).
Pennock et al24 published dramatic results from a
2016 retrospective chart review focused on young pa-
tients with a 4-strand autograft HT of diameter less than
7 mm. Based on surgeon preference, some grafts were
used at this smaller size, whereas others were augmented
with a low-dose irradiated allograft ST. Ultimately,
these groups had an average graft diameter of 6.4 versus
8.9 mm, respectively. Despite this discrepancy, the
overall failure rates in these groups were 5% and 30%,
respectively, indicating that hybrid augmentation actu-
ally resulted in a higher failure rate than did smaller
autografts.
Perkins et al,25 in 2019, published a retrospective study
of 354 patients younger than 19 years. This study com-
pared 4-strand autograft HT (with diameter $7.5 mm),
5-strand HT autograft (to achieve diameter $7.5 mm), or
6-strand hybrid graft (consisting of a 4-strand autograft
plus a low-level irradiated allograft). This single-center
study used consistent fixation techniques and rehab
protocols for all groups. The authors found that, while no
statistical difference was found in failure rates between
the 4- and 5-strand autograft groups, the 6-strand hybrid
group had overall failure rate of 20%, 2.6· that of the
4-strand autograft group.
Conversely, in a 2019 systemic review, Sochacki
et al26 included six articles comparing pure HT auto-
graft versus HT hybrid with soft-tissue allograft. The
most common indication for hybridization was HT
diameter of ,7.5 to 8 mm, but among these 6 studies,
there was a mix of irradiated and nonirradiated grafts,
and a mix of techniques, including transtibial and
independent femoral drilling. Follow-up in these studies
ranged from 2 to 5 years, with similar outcomes, sta-
bility measures, and revision surgery rates noted overall
for hybrid and nonhybrid groups.
Similarly, Belk et al27 performed a systemic review of
12 ACLR studies, including a mix of pure HT autograft,
HT augmented with irradiated allograft, and HT aug-
mented with nonirradiated allograft. Unsurprisingly, a
wide range of failure rates was noted, with no clear
pattern favoring autografts versus hybrids (although a
trend was noted toward lower failure rates with HT
autograft versus hybrids using irradiated allograft).
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Todd C. Battaglia, MD, MS, FAAOS, FAANA
Review Article
Thus, the current literature provides a mixed picture
regarding hybrid grafts. This is likely because numerous
factors, including allograft sterilization methods, com-
bination techniques, and rehabilitation protocols, play a
role in failure rates. Overall, there does seem to be suffi-
cient evidence to warrant caution regarding the use of
hybrid grafts, particularly in young patients. When pos-
sible, it seems preferable to use an alternate autograft or
augment the autograft with additional ipsilateral or
contralateral autograft tissue. Finally, if hybridization is
necessary, surgeons should select low-irradiated or
nonirradiated tissue.
Graft Braiding
Another proposal to increase graft strength when faced
with smaller HT tendons is the technique of interweav-
ing, or “braiding,” the separate tendon strands. Whereas
previous studies have found notable decreases in both
strength and stiffness after such braiding,28 a more
recent study has described a more uniform weaving
method, and suggests that previous studies may have
been compromised by the technique and by graft age
and preparation.29,30 Still, there are no convincing
biomechanical studies that support this opinion, and
currently, there seems to be insufficient evidence to
support braiding as a method to increase overall
strength of multistrand soft-tissue grafts.
Synthetic Augmentation
In theory, using artificial materials to fully replace an
injured ACL would not only avoid donor site morbidity,
but also avoid complications related to insufficient
length, diameter, and strength. In fact, the use of syn-
thetics for ACLR dates back more than 100 years, when a
German surgeon used silk sutures to stabilize ACL-
deficient knees. In recent decades, trialed materials have
included polyester, polypropylene, nylon, and carbon
fiber. Unfortunately, these attempts have proved uni-
versally unsuccessful, marked by high rates of laxity and
frequent postoperative complications, including synovi-
tis, effusion, foreign body reaction, and graft rupture.31
More recently, however, surgeons have considered
graft reinforcement with a nonresorbable suture.
Typically, a standard ACLR is done, and a wide (2 to
3 mm), high-strength suture is also independently ten-
sioned and secured as an “internal splint”—acting, in
theory, in a load-sharing manner. This may add to the
overall construct strength, protect the graft during early
phases of graft remodeling, and may particularly rein-
force small-diameter grafts, lessening the chances of
irreversible stretch during early phases of healing and
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Management of Intraoperative Graft-related Challenges
rehabilitation.32 The limited in vitro research available
at this time does show reduced graft elongation and
notable increases in ultimate failure load. These effects
were particularly pronounced for smaller diameter
grafts, with suture reinforcement decreasing the total
elongation of tripled porcine extensor tendons by 56%
in load to failure testing and increasing ultimate failure
load by 30%.1,33 To date, however, no long-term ani-
mal (or human) studies have quantified the effects of
such augmentation on graft maturation, graft organi-
zation, final graft strength, nor on ultimate stability or
other clinical outcomes,34 and this method should be
considered an intriguing strategy with only early sup-
portive data.
Graft-tunnel Length Mismatch
The issue of graft-tunnel length mismatch (GTM) pri-
marily occurs with the use of BPTB when the total graft
length exceeds the combined intra-articular and tunnel
lengths. As a result, graft extends beyond the tibial tun-
nel. There is likely to be greater risk of GTM when the
femoral tunnel is drilled using an anteromedial approach
because this often results in a shorter tunnel and,
therefore, a relatively longer graft; however, the true
incidence with anteromedial drilling is unknown.35
GTM can affect the choice of fixation and ultimate graft
incorporation, and a number of intraoperative strategies
exist to avoid or manage this complication (Table 2).
Tunnel Adjustments
Historically, guidelines to avoid GTM, including the
N17 and N110 rules, have centered on the adjustment
of tibial drilling angle and tibial tunnel length based on
the harvested PT length.35 Because a relatively steeper
drilling angle is used, a longer tibial tunnel can be cre-
ated to accommodate longer grafts. These strategies
were developed and intended for use with a transtibial
drilling technique, but are then limited because steeper
Table 2. Summary of Options to Manage Graft-Tunnel
Length Mismatch
Adjustment of femoral tunnel length (recession)
Adjustment of tibial tunnel length (drilling angle)
Graft manipulation
Folding
Rotation
Alternative fixation techniques
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angles place the femoral tunnel more vertical and further
from the anatomic femoral footprint. This becomes
particularly true as drilling angles approach and exceed
60
. Such concern obviously does not exist when using
an independent drilling technique, either through an
accessory medial portal or an outside-in technique, and
thus a steeper (and, therefore, longer) tibial tunnel can
be created with no effect on femoral tunnel position.
When an overly long BPTB is recognized before dril-
ling, the technique of “femoral recession” may be used,
assuming adequate femoral space is available—this
technique simply involves drilling a deeper femoral
tunnel so that the femoral bone plug is recessed further
into the femur. Saltzman et al36 recently polled 260
orthopaedic sports medicine specialists, and recession
was named the most frequent technique for “lower
levels” of GTM. Fears that plug recession might allow
increased abrasion of the soft-tissue portion of the graft
on the tunnel edge appear unfounded; in 100 consecu-
tive patients with grafts recessed up to 15 mm, no
correlation with graft laxity or failure was found.37
Dwyer et al35 proposed creation of the tibial tunnel
first, followed by measurement of the tibial length and
intra-articular distance. In theory, this would allow final
determination and creation of femoral tunnel depth as
needed. Unfortunately, the authors found that, while the
tibial tunnel measurement has a high degree of reli-
ability, intra-articular distance measurements were less
reliable, and highly influenced by the obliquity of the
tunnel apertures and the angle of knee flexion at the time
of measurement, thus making it difficult to accurately
determine the necessary femoral tunnel length.
Graft Manipulation
Rather than adjusting the tunnel positions or lengths, the
graft itself may be manipulated to address GTM. One
such described technique is bone block “flipping,” in
which the tibial bone plug is doubled back on the soft-
tissue portion, thus shortening the graft by the length of
the bone block. This typically requires a larger tibial
tunnel diameter to accommodate.38 In addition, one
should flip the plug such that the cancellous portion
remains facing away from the graft to maintain the
benefits of bone-to-bone healing. A similar approach
uses free bone block placement, in which the bone plug
is detached from the soft-tissue portion and inserted into
the tibial tunnel alongside the tendinous portion. No
biomechanical or outcome studies of these techniques
exist.
Another approach to deal with GTM is to rotate, and
thereby shorten, the graft. External, rather than internal,
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rotation is typically recommended because it better
mimics native ACL bundle orientation. Verma et al39
tested 40 porcine tendons, rotated 0, 90, 180, or 540
.
With 540
rotation, graft shortening of up to 10%
(average 5.41 mm), could be achieved. Ninety and 180

rotations resulted in minimal shortening. No difference
in failure load was found between any of the groups. The
authors also acknowledge that long-term effects on graft
remodeling and revascularization are still unknown.
Subsequently, de Olivero et al40 assessed 40 porcine
ligaments at larger degrees of rotation. Progressive graft
shortening occurred up to 720
, with no effect on ulti-
mate load to failure found at 540, 720, or 900
.
Overall, it is unclear what biomechanical effects result
from graft rotation. Verma et al39 found slightly
decreased graft stiffness at all rotations when compared
with 0
. Hame et al,41 using fresh-frozen human knee
specimens, found that both internal and external graft
rotations had minor effects on graft tension and laxity
noted for all degrees of rotation. Although statistically
significant, these changes were on an order thought to
be of minimal clinical importance, with the authors
concluding “clinicians who chose to rotate their. . .grafts
can expect that the biomechanical changes. . .will have
little clinical importance.”
Alternative Fixations
Perhaps the simplest method to accommodate small de-
grees of GTM is through the use of alternate tibial fixa-
tion methods. Removal of any (or all) of the tibial-sided
bone plug and the use of a soft-tissue interference screw is
straightforward, but do forgo the potential advantages of
bone-to-bone healing. Conversely, creation of a bone
trough in the tibia for any prominent plug, with use of
staples or a post, will maintain such bony healing. It is
recommended that ACL surgeons have access to mul-
tiple fixation devices. In fact, for expert respondents
in Saltzman’s survey, the addition of a screw and post
on the tibia was the most common approach to manage
larger amounts of GTM.36
Hamstring-related Length Issues
Whereas GTM that occurs when using BPTB typically
involves a too-long graft, the opposite issue can be
encountered when using an autograft HT. Here, a shorter-
than-desired graft may result, particularly whether the
surgeon is confronted with a low musculotendinous
junction, premature graft amputation, or insufficient graft
diameter requiring creation of a 5-strand graft.
If faced with a relatively short HT graft, it is appro-
priate to ask what is the minimum amount of graft
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Todd C. Battaglia, MD, MS, FAAOS, FAANA
Review Article
needed to contact the bony tunnels to achieve sufficient
integration. Mariscalco, with the MOON group,42 re-
viewed 181 consecutive HT ACLRs with suspensory
femoral fixation, using a 4-strand graft, and a range of
femoral tunnel lengths from 14 to 35 mm. No difference
was found in IKDC scores when comparing femoral
tunnel lengths .25 versus ,25 mm. Two failures did
occur in the “short” tunnel group, but both were rec-
ognized as intrasubstance failures, implying that tunnel
length as short as 14 mm may be sufficient. It is also
important to recognize that this may limit the choice of
fixation. Specifically, interference screw fixation may be
inappropriate or impossible and alternate fixation,
particularly suspensory devices, may be needed on the
femoral or tibial sides.
Graft Contamination
Graft contamination is, unfortunately, not an infrequent
occurrence. In fact, in a survey of academic sports med-
icine program directors and sports fellowship graduates,
25% of nearly 200 respondents reported at least 1 epi-
sode of intraoperative graft contamination, with the graft
either falling on the floor or contacting a nonsterile
object.43 These were not inexperienced surgeons; the
great majority of the surgeons experiencing contami-
nation events reported performing more than 40 ACLRs
per year.
When contamination occurs, options include substi-
tution of an allograft, harvest of an alternate autograft, or
disinfection with reimplantation of the original graft. The
appropriateness of the former two options obviously
depends on other factors, including whether the patient
has had previously harvested autografts, availability of
allograft tissue, and patient consent. Concerns over
additional harvest morbidity and appropriateness of
autograft versus allograft for a given patient also influ-
ence the decision. However, for surgeons who wish to
still use the compromised graft, existing literature in-
dicates that decontamination and implantation can be
reasonable and low risk.
In the Izquierdo survey, 75% of contamination epi-
sodes were managed with cleansing and subsequent use
of the original graft. (Furthermore, of the high-volume
surgeons who had never experienced a contamination
event, 58% reported that in a hypothetical episode, they
would likely choose to cleanse and reuse the original
graft.) Despite the fact that there were a large variety of
cleansing agents used, no cases of septic arthrosis were
reported. The most common decontamination protocol
453
Management of Intraoperative Graft-related Challenges
used was chlorhexidine alone (30%). Others included
antibiotic solution, povidone-iodine, and various com-
binations of multiple agents.43
A number of studies have attempted to determine the
most effective decontamination agents. Khan et al,44 in a
systemic review of in vitro investigations, identified 6 such
studies done between 1991 and 2012, assessing a total of
495 samples and a wide variety of cleaning methods.
Overall, the most effective protocols for decontamination
included chlorhexidine (either pulsatile irrigation with 2%
solution for 7 to 8 minutes or 90-second soak in 4%
solution) and polymyxin B-bacitracin solutions (serial
dilution with mechanical agitation), with both typically
achieving sterilization rates close to 100%. Conversely, the
use of povidone-iodine alone typically resulted in sterili-
zation rates of less than 50%.
Although it is difficult to determine an ideal protocol
because of the heterogeneity of methods used in existing
studies, from the current literature it seems most rea-
sonable and efficacious to select a multistep decontami-
nation process, including obligatory treatment in 2%
chlorhexidine, plus additional treatments with antibiotic
and/or povidone-iodine, followed by saline rinse. This
should be done after the removal of all suture materials
from the graft, and soaks should be a minimum of
15 minutes each.45 Such an approach should allow the
reuse of a contaminated graft with minimal increased
risk of postoperative infection.
Allograft Quality
It occasionally occurs that an allograft, when opened,
seems to be of suboptimal quality. This may be grossly
obvious, such as cases where the allograft is damaged,
torn, or incorrectly sized, or it may be more subtle, such
as cases where the tissue color or consistency seems
atypical. There are no studies specifically describing the
incidence of damaged or compromised allografts.
One specific issue related to allograft quality that has
been investigated, however, is whether donor age affects
allograft quality and, therefore, ACL outcomes. Swank
et al,46 using tibialis posterior tendons, correlated donor
age with numerous structural and mechanical proper-
ties, including ultimate tensile force, stiffness, ultimate
strength, strain, and modulus. Although all parameters
demonstrated a weak correlation with age, the strongest
was only R = 0.063, suggesting that age explained, at
most, 6% of the variation in these biomechanical
properties. This was borne out in a clinical study of PT
allograft, finding no notable effects of donor age on
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Lysholm and Tegner scores after ACLR.47 Yet, Zaf-
fagnini et al48 recommended the use of allografts from
young donors (,45 years), finding that older donor
age for Achilles allografts, when used in revision
ACLR, was associated with lower postoperative out-
come scores.
Thus, effect of donor age on allograft quality remains
unclear. Still, surgeons—when faced with what seems to
be an inferior allograft—must be prepared to use a back-
up graft either through the harvest of autograft or
availability of other allograft.
A separate issue, also related to allograft quality, is the
possibility of contaminated donor tissue. Concerningly,
routine culture of ACL allografts before implantation has
produced positive results in up to 13.25% of cases.49
However, multiple studies have found that positive
cultures do not seem to correlate with the development
of clinical infection. Thus, routine intraoperative
allograft culture is not recommended, nor is routine
antibiotic treatment in cases of positive allograft
culture.49-51
Graft Passage Complications
Very little has been written about complications occur-
ring during the process of graft passage into and through
the bony tunnels. Assuming the graft has been sized
appropriately, and corresponding tunnels drilled, one is
unlikely to encounter challenges when passing a soft-
tissue graft. However, two potential hurdles may occur
when passing a graft with a femoral-sided bone plug.
The first relates to graft incarceration within the joint
and/or femoral tunnel aperture. This is of particular
concern when using an independent technique for fem-
oral drilling because this creates nonlinear tibial and
femoral tunnels. Accordingly, the bone plug must now
“turn” within the joint to align with the femoral tunnel.
The most important strategy to avoid incarceration is to
avoid excessively long bone plugs. It is recommended
that the femoral plug be no longer than 25 mm, and in
fact, harvesting a plug approximately 18 to 20 mm
will greatly facilitate passage through the joint and into
the femoral tunnel. Using a shaver to gently chamfer
the tunnel aperture will also assist plug engagement with
the tunnel, as will steering the plug with probe or clamp
as it passes through the joint.
A second, related complication can occur with allo-
graft with a femoral bone plug (allograft BPTB or
Achilles). Because of the decreased strength of allograft
bone, if resistance is encountered during passage, the
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May 15, 2022, Vol 30, No 10 © American Academy of Orthopaedic Surgeons

passing suture (or adjustable suspension device) may
fracture through the bone plug. This results, at best, in a
graft that must be removed and now has a compromised
plug. Worse, the graft may become stuck and difficult to
remove. Accordingly, when using an allograft with bone
plug, it is recommended to place an additional passing
suture that traverses the bone plug but also captures the
proximal 1 to 1.5 cm of the soft-tissue portion of the
graft. In this way, the suture will still steer the bone plug
appropriately, but tensile forces bypass the plug and are
instead applied to the soft-tissue portion. Once the bone
plug is fully seated in the femur, fixation may be com-
pleted with an interference screw or final tightening of the
adjustable suspension device.
Summary
Despite the frequency with which ACLR is performed
today, it remains a technically challenging operation.
Numerous opportunities exist during the procedure for
significant complications to occur, including those
related to graft harvest, handling, and sizing. Ortho-
paedic surgeons who perform this surgery must have at
their disposal a multitude of approaches to handle and
overcome such complications. This particularly should
include abilities to manage insufficient graft diameter and
mismatched graft length. Surgeons must also be com-
fortable with harvest techniques for multiple graft op-
tions. Armed with such skills, surgeons can be confident
in overcoming such challenges when encountered.
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Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
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