Management of Intraoperative Graft-Related Challenges in Anterior Cruciate Ligament Reconstruction

Todd C. Battaglia, MD, MS, FAAOS, FAANA


J Am Acad Orthop Surg. 2022;30(10):448-456. 

In This Article

Abstract and Introduction


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.


Anterior 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.