Table 1.
Complications related to errors in diagnosis and judgment
| Complication | Clinical effect | Prevention | Detection | Remedy |
|---|---|---|---|---|
| Performing surgery too soon after injury [20, 26] | Postoperative stiffness | Postpone surgery until full extension and 90° flexion are attained | Poor motion postoperative | Aggressive physical therapy; manipulation under anesthesia +/− arthroscopy |
| Performing surgery too late [6, 28] | Damage to the meniscus and articular cartilage may result from persistent instability | Patient education regarding limited activities; informed consent for nonoperative treatment; bracing | MRI may detect disorder if recurrent instability has occurred | Treat lesions as they arise |
| Incorrect diagnosis: MRI or preoperative examination is falsely positive [24] | Removing an intact ACL and replacing it is clearly harmful to the patient | Careful history and examination; consider differential diagnosis (ie, quadriceps insufficiency); high resolution MRI with musculoskeletal radiologist | Thorough examination under anesthesia (ie, pivot shift, Lachman test); intraoperative observation and assessment of integrity | Abort reconstruction and treat the underlying diagnosis |
| Missed additional diagnosis: MCL/medial capsule injury [30] | Persistent pain and valgus instability may result with ultimate failure of the ACL reconstruction | Careful history and examination with valgus stress at 0° and 30° flexion and anterior drawer with external rotation;scrutinize MRI | Persistent valgus laxity at 0° and 30° flexion; presence of anteromedial rotatory instability; ACL reconstruction failure | Bracing MCL injuries early to promote healing; surgical repair versus reconstruction, capsular plication |
| Missed additional diagnosis: posterolateral corner injury [23] | Persistent varus instability and development of a varus thrust with ultimate failure of the ACL reconstruction | Careful history and examination with varus stress at 0° and 30° flexion; scrutinize MRI | Varus laxity at 0° and 30° flexion; presence of posterolateral rotatory instability with dial test | Surgical repair versus reconstruction of the damaged structures |
| Missed additional diagnosis: meniscal tear [12] | Persistent posterior joint line pain after ACL reconstruction | Careful history and examination; MRI to assess coronal and sagittal sequences; posteromedial portal for complete observation and Gillquist view (Fig. 1) | Postoperatively noted by persistent joint line pain and mechanical symptoms | Meniscal repair for red-red and red-white tears versus meniscectomy for complex/ irreparable tears |
ACL = anterior cruciate ligament; MCL = medial collateral ligament.