Total Knee Arthroplasty After Anterior Cruciate Ligament Reconstruction

Rodrigo Torres, MD, CHILE Sebastián Ruidíaz, MD, CHILE Gabriel Carlos Baron, MD, CHILE

ISAKOS eNewsletters   Current Perspective 2025   Not yet rated

Introduction

Over the past two decades, there has been a substantial increase in the number of procedures performed for both anterior cruciate ligament (ACL) reconstruction and knee arthroplasty globally. The relationship between ACL injury and subsequent osteoarthritic changes in the knee has been extensively documented in various case-control studies. Despite reconstruction, approximately 20% of patients who undergo ACL reconstruction ultimately develop moderate to severe osteoarthritis (OA) after a mean follow-up of 10 years. However, limited data exist regarding (1) whether ACL reconstruction (ACLR) increases the risk of requiring knee replacement and (2) which specific patient characteristics may elevate the likelihood of secondary arthroplasty due to degenerative changes in the knee joint.

Abram et al., in a longitudinal cohort study utilizing NHS data on 112,241 patients who were followed for 2 decades after undergoing ACLR, reported an increased risk of subsequent knee arthroplasty as compared with that in the general population. Although the absolute rate of arthroplasty remained low, the risk was notably elevated in younger patients. While the rate of arthroplasty is modest overall, the increased risk among younger patients is a major concern.

Patients with a history of ACLR present unique challenges during total knee arthroplasty (TKA) that can lead to intraoperative or postoperative complications such as instability, stiffness and disruption of the extensor mechanism. The aim of the present article is to describe specific surgical consideration related to TKA after ACLR.

Preoperative Evaluation

A thorough preoperative assessment is essential and should include a detailed history of the prior ACLR, including graft selection, hardware used, any history of infection, postoperative outcomes, the presence of residual anterior or combined instability, and any additional procedures. Scar tissue and skin condition, particularly over the previous incision sites, should be carefully examined to guide surgical planning.

Assessment of the range of motion (ROM) of the knee, dynamic gait analysis, and evaluation for anterior or multidirectional laxity, stiffness, and instability are critical components of the clinical examination.

Radiological evaluations, including standard and long-standing radiographs, should be performed to assess the severity of osteoarthritic changes, bone loss, and any deformities caused by prior surgical procedures (e.g., enlarged tunnels that could affect implant fixation or increase the risk of fractures). Patellar height and potential defects from graft harvesting should also be evaluated. Chronic anterior instability typically results in posteromedial tibial wear, whereas primary osteoarthritis is more often associated with anteromedial wear.

It is imperative to identify the hardware retained from the prior ACLR as its presence can impact the success of the TKA procedure. In cases in which hardware removal is necessary, the surgeon must ensure that the appropriate tools are available as some hardware may be embedded in bone and require additional time for removal.

Stress radiographs are useful for evaluating multidirectional instability, recurvatum, or posterior cruciate ligament (PCL) laxity. In such cases, a higher degree of constraint during TKA may be required to achieve joint stability. CT imaging can also be beneficial for identifying substantial osseous defects or the enlargement of bone tunnels, allowing for tailored grafting or more-robust metaphyseal or diaphyseal fixation techniques.

Surgical Considerations to perform a TKA after ACLR, Risk of Complications, and Expected Outcomes

Exposure and Surgical Approach

Previous skin incisions and tissue scarring following ACLR must be considered when planning the approach for TKA. ACLR may result in skin retraction, especially on the medial aspect of the tibia, and may lead to complications such as loss of extension, joint stiffness, and soft-tissue compromise at the donor site.

The use of a patellar tendon-bone graft during the original ACLR can increase the risk of patellar fractures if resurfacing is performed and also can increase the risk of patellar tendon rupture, particularly if the donor side defect is left unaddressed.

Retained Hardware

Retained hardware from the ACLR, including interference screws or other fixation devices, should be recognized during the preoperative evaluation. In approximately 45%-50% of cases, hardware removal is necessary, particularly if the hardware interferes with cutting guides or final prosthetic alignment. The use of appropriate extraction tools, such as screwdrivers for interference screws or staple extractors, is crucial. Metal implants, in particular, may be covered by bone, increasing operative time. Bioabsorbable or biocomposite devices typically present fewer challenges during TKA (Figs. 1 and 2).

Constraint

Wilson et al. (2023), in a study including 160 patients (165 TKA) who underwent TKA after ACLR, reported 10-year survivorship free of any revision or reoperation of 92% and 88% respectively1. The main reason for revision was instability (7 patients), followed by infection (4 patients). The authors also showed an increased rate of manipulation and flexion instability. They concluded that TKA patients after ACLR achieved lower survivorship compared to the primary TKA group, finding instability the most common reason for revision

James et al. (2019) in a matched-cohort study of patients undergoing TKA reported an increased use of constraint in the group who had a previous ligament reconstruction (34.1% [76 of 223]) compared to primary TKA (17.9% [40 of 223]). Hardware removal was performed in 69.5%. Operative and tourniquet time were longer in patients with a previous ACLR in comparison with the control group.

The same group described an increased use of bone-grafting, metaphyseal augmentation devices as cones or sleeves, and stemmed implants related to bone defects associated to bone tunnels enlargment.

Operative Time

Several studies have shown longer operative times for patients undergoing TKA following a history of ACLR as compared with those undergoing primary TKA. Alessio-Mazzola et al. (2023), in a systematic review and meta-analysis, reported an average operative time of 95.2 minutes for post-ACLR TKA, compared with 84.0 minutes for primary TKA.

Infection Risk

Increased infection risk is a concern in patients undergoing TKA following ACLR. The previously mentioned meta-analysis3 showed no significant difference in infection rates comparing post-ACLR and primary TKA groups (2.3% vs. 1.2%), nevertheless different cohort studies have shown higher infection rates in TKA after ACLR.

Surgeons should remain vigilant for signs of infection and take appropriate preventive measures.

Functional Outcomes

Clinical and functional outcomes following TKA after ACLR are comparable to primary osteoarthritic patients. Postoperative ROM, extension and flexion contractures are similar between groups, nevertheless Magnussen et al, 2012 reported 23% of manipulation in the post ACLR cohort. [1]

Complications Risk

The risk of complications is elevated in patients undergoing TKA following ACLR, as confirmed by the previously discussed systematic review and meta-analysis3. Common complications include donor-site morbidity from the original ACLR, wound dehiscence, the need for hardware removal, and revisions or reoperations for the treatment of instability. Instability is particularly common in patients managed with non-constrained TKA following ACLR.

Conclusion

TKA following ACLR should not be considered a routine primary knee replacement. When planning surgery, surgeons must account for previous incisions, donor-site morbidity, the need for hardware removal, and the potential for increased instability. The likelihood of requiring more-constrained implants and enhanced fixation strategies, alongside the extended operative time and increased risk of complications, necessitates thorough preoperative preparation. Surgeons without access to revision and extraction instrumentation should plan accordingly for these challenging cases.

Figure 1. TKA after ACLR retaining previous hardware.

Figure 2. Conversion TKA after Distal Femoral Osteotomy and ACLR extracting osteotomy hardware.

References

1. Wilson JM, Markos JR, Krych AJ, Berry DJ, Trousdale RT, Abdel MP. Total Knee Arthroplasty in Patients Who had a Prior Anterior Cruciate Ligament Reconstruction: Balancing Remains the Issue. J Arthroplasty. 2023 Jun;38(6S):S71-S76. doi: 10.1016/j.arth.2023.02.037. Epub 2023 Feb 18. PMID: 36801476; PMCID: PMC10461606.
2. Abram SGF, Judge A, Khan T, Beard DJ, Price AJ. Rates of knee arthroplasty in anterior cruciate ligament reconstructed patients: a longitudinal cohort study of 111,212 procedures over 20 years. Acta Orthop. 2019 Dec;90(6):568-574. doi: 10.1080/17453674.2019.1639360. Epub 2019 Jul 10. PMID: 31288595; PMCID: PMC6844427.
3. Alessio-Mazzola M, Placella G, Zagra L, Leone O, Di Fabio N, Moharamzadeh D, Salini V. Previous anterior cruciate ligament reconstruction influences the complication rate of total knee arthroplasty: a systematic review and meta-analysis. EFORT Open Rev. 2023 Nov 1;8(11):854-864. doi: 10.1530/EOR-23-0069. PMID: 37909702; PMCID: PMC10646514.
4. Best MJ, Amin RM, Raad M, Kreulen RT, Musharbash F, Valaik D, Wilckens JH. Total Knee Arthroplasty after Anterior Cruciate Ligament Reconstruction. J Knee Surg. 2022 Jul;35(8):844-848. doi: 10.1055/s-0040-1721423. Epub 2020 Nov 26. PMID: 33242906.
5. James EW, Blevins JL, Gausden EB, Turcan S, Denova TA, Satalich JR, Ranawat AS, Warren RF, Ranawat AS. Increased utilization of constraint in total knee arthroplasty following anterior cruciate ligament and multiligament knee reconstruction. Bone Joint J. 2019 Jul;101-B(7_Supple_C):77-83. doi: 10.1302/0301-620X.101B7.BJJ-2018-1492.R1. PMID: 31256640.

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