KOMPLIKASI

• Compartment Syndrome-a very rare complication where the fluid that is used to irrigate the
knee joint goes into the muscular compartments of the calf. Increased pressure in the calf can
compromise the blood supply of the lower leg and also the nerve and may require emergency
surgery to decompress the at risk leg.

• Deep Venous Thrombosis (DVT)-occurs when blood clots form in the deep veins of the leg and
can happen after any operation but is more probably after surgery with knees, pelvis and hips. It
may cause the leg to swell, become warm to the touch, and become painful. If the blood clot
breaks off-it travels to the lungs-this is called Pulmonary Embolus. Pulmonary Embolus is rare
but a very life threatening complication and the patient can die from it. Treatment is
anticoagulation for 3-6 months for both DVT and Pulmonary Embolus. Preventative measure for
DVT also include encouragement of movement of leg to reduce the chances of clot formation
and pressure stockings on legs that keep blood in the legs moving.

• Graft Problems:

-Graft Impingement-if the drill holes in the bone are placed incorrectly, the new graft may rub
against the bone as the knee bends and straightens and thus impede the movement of the
knee. Usually, it becomes impossible to full straighten the knee. This problem may be resolved
with physical therapy but usually another arthroscopic surgery is required to shave away the
obstructing part of the bone to allow more room for the graft. However, this may not solve the
problem and thus further surgery may be necessary and required to drill new tunnels in order to
place the graft in the correct position in the joint.
-Graft Fixation Screws-local irritation can arise from the screws that are used to secure the graft
and provide tension. If necessary, the screws are removed.
-Graft Failure-Bone-Patellar Tendon-Bone graft reconstructions have great stability and fixation
initially. In the long run, the graft relies on revascularization to allow and encourage bone
growth that would be permanent and formation of new ligament. This process takes around six
months but is possible that it will continue for up to two years post-surgery. Failure to
revascularize can cause the weakening of the graft and lead to recurrent symptoms of
instability.

• Haemarthrosis-any surgical procedure is complicated by bleeding around and within the knee
joint. Haemarthrosis can be treated with ice, rest, and physiotherapy but can also lead to
delayed recovery and stiffness of the joint in question.

• Infection-chances are very law but precautions are taken before, during, and after the
procedure to prevent this complication from forming. Antibiotics are given intravenously both
pre and post surgery. Proper care of the surgical items and careful work by the surgeon are also
other factors in preventing infection. Yet despite sterile conditions, infection can still happen.
Two different types are superficial and deep. Superficial infections are wounds only and usually
settle with antibiotics. Deep infections involve the joint. These require further surgery to
washout the joints with intravenous antibiotics. However, this may lead to stiffness and early
degeneration of the joint.

• Meniscus-more easily torn in reconstructed knee-60% of meniscus tear occur with an ACL tear
but the tear is sometimes missed and seen only if the surgery is unsuccessful and there is a
reoperation. If a reoperation does not occur and the athlete continues on with a meniscus tear,
this could develop into osteoarthritis as the femur, without the meniscus, rubs against the
cartilage and wears it down so it connects and impacts against the tibia. One third of patients
have a torn meniscus when reconstruction is finished and five years later only one patient is
lucky enough to have both meniscus intact. This can be dealt with arthroscopic surgery.

• Nerve injury-small areas of numbness can occur around the incision area. Usually such
numbness is not permanent. Sometimes wounds can become painfully sensitive but normally
settles with time. Nerve complications are very rare and account for 0.01% to 0.06% compared
to other complications. Further neurovascular risks are reduced with proper position of the
patient on the operating table, padding on the leg holders to reduce pressure, and careful use of
the infusion pump system so as not to cause compartment syndrome from extravasation of
fluid.

• Patellar Complications:

-Patellar Fracture-Use of the bone-patellar tendon-bone graft may result in fraction of the
patella and can occur either at the time of harvest or during rehabilitation. Such fracture may
require operative reduction and fixation and also can result in chronic patello-femoral pain.
-Patellar Tendon Rupture-if surgery is done improperly, the patellar tendon can rupture-this
would lead to another surgery with the probably use of an allograft instead or use of a
hamstring graft.
-Patellar tendonitis & calcification-patellar tendonitis can occur during the rehabilitation time.
Symptoms are treated with rest, anti-inflammatory drugs, and physiotherapy. Local calcification
may occur in the patellar tendon from the location of graft harvest and produce local irritation.

• Reflex Sympathetic Dystrophy-a condition that is not understood very well and can
complicate any operation. It consists of swelling, sweating, regional pain, and stiffness due to
overactivity of the sympathetic nerves in the area that were accidentally triggered by the
surgery.

• Stiffness-loss of motion in the joint-even though it is rare, if there is excessive scarring within
the knee joint after ligament surgery, this can lead to an increasingly stiff knee. What is most
important and needed immediately after surgery are range-of-motion exercises to prevent knee
stiffness. Physical therapy thus beings sooner rather than later. Stiffness can occur if the surgery
is done too prematurely-too soon after the injury when the knee is not strengthened enough to
bend through its normal proper range of motion. A surgeon should not construct a torn ACL
unless the knee can move well. Other causes of stiffness include prolonged immobilization,
infection, reflex sympathetic dystrophy, and pain. Also problems that are related to the
technicality of graft placement may lead to loss of flexion or extension. Contracture of the
anterior soft tissue of the knee after taking the BPTB-Bone-Patellar Tendon-Bone graft can limit
the range of motion. Extra fibrous/scar tissue formation or new bone formation around the
graft can also produce stiffness by acting as a mechanical block to extension.

Sources:
http://www.yourmedicalsource.com/library/acltears/ACL_have.html
http://www.kneeclinic.com.au/papers/ACLcomp.htm
American Journal of Sports Medicine. July-August 2002 by Tae Kyun Kim & associates