Total knee arthroplasty after anterior cruciate ligament reconstruction: a narrative review

Background and Objective: Knee replacement following anterior cruciate ligament (ACL) reconstruction can be demanding due to altered anatomy, soft tissue scars, bone loss, extensor mechanism complications, and knee instability. This narrative review summarizes the strategies and approaches to managing operative challenges in total knee arthroplasty (TKA) following ACL reconstruction. Methods: Studies reporting outcomes of patients who underwent TKA after ACL reconstruction were retrieved and assessed to be included in this review that synthesizes the available evidence highlighting the pitfalls encountered during surgery, the intraoperative challenges posed by ligament balancing and exposure, and the leading role of modular and retained implants. Key Content and Findings: TKA following ACL reconstruction has a high rate of intra-operative complications such as instability, bone loss, difficult exposure and demanding soft tissue balancing, representing a revision surgery rather than routine primary knee arthroplasty and a revision-oriented skill set and modular components are recommended to significantly optimize both surgical strategy and patient outcomes. With a rising incidence of ACL injuries and growing reconstructions, anticipating an increase in TKA procedures, this review aims to provide a call for rethinking clinical approaches to ensure effective and patient-centric care. Conclusions: This narrative review seems to indicate that TKA after ACL reconstruction should be considered as revision surgery and modular components should be used. However, future prospective and high-quality studies are required to better clarify risk factors and give strong recommendations for this complex surgery.