u/greatindianortho

Posted a clip of a moment from an ACL reconstruction today.
Guide wire comes out. Surgeon steps back. Knee is closed.
But something got left inside that joint, something that’ll hold the new graft in place and then vanish on its own over the next several months.

What do you think it is?
And does the idea of something dissolving inside your knee freak you out or fascinate you?
Genuinely curious what u think when u see this moment.

One of the most important lessons in knee surgery: if the alignment is wrong, your ACL graft will fail.

She came to us with a painful, unstable left knee.
The diagnosis? A combination that’s more common than people realize — genu valgum (knock knee deformity) with a ACL tear.

This put me into a dilemma of what should I do the deformity or the ligament because both are related to each other

The problem with just doing ACL reconstruction In a knock knee, the mechanical axis passes lateral to the knee centre. This means every time the patient walks, runs, or lands from a jump, the forces on that ACL graft are skewed. Studies consistently show that uncorrected valgus malalignment dramatically increases graft failure rates. You’re essentially rebuilding a rope and then hanging it at the wrong angle.

The plan: staged correction
We performed a Distal Femoral Osteotomy (DFO) — a lateral closing wedge — to correct the valgus deformity, fixed with a distal femoral locking plate. Simultaneously, ACL reconstruction was completed. The alignment is now corrected. The graft has a fighting chance.
Key takeaways for anyone reading this:

Alignment always trumps ligament reconstruction. Fix the bone first, or alongside.
Young active patients with valgus + ACL tears are not straightforward ACL cases.
Skipping the osteotomy is a shortcut to revision surgery.

She is now 7 weeks post-op, full weight bearing, and starting rehab. 💪

happy to discuss DFO indications, the combined vs staged approach debate, and rehab timelines.​​​​​​​​​​​​​​​​

Uploading a short intraoperative clip from today’s ACL reconstruction.
What you’re seeing is a bioabsorbable interference screw being driven in to secure the graft inside the tibial tunnel. This is one of those moments that patients never get to see, and have I decided to share so that it fulfil is your thirst of knowledge.
A few things to note.
A] The screw is bioabsorbable, meaning it gradually dissolves and is replaced by bone over 12–18 months

B] Proper screw placement is critical , too proud or too deep and you risk graft impingement or poor fixation strength

C] The tactile feedback as it seats flush is something you learn to trust over hundreds of cases

For those post-op and curious: This tiny screw is doing a lot of the heavy lifting in your early rehab weeks while the graft is still integrating.

Respect the timeline we as surgeons give u ..
Happy to answer questions .

Sever varus deformity,the classic bow-legged collapse that happens when the medial compartment gives up over years of untreated osteoarthritis.

Joint space nearly gone.Every single step she took, bone was meeting bone with nothing meaningful in between.
The mechanical axis was so far off that her gait had reorganised itself entirely around the pain — which is exactly why she limped, and exactly why she thought the limp was just her now.

We talked through the options . At this stage, there were no half-measures left. Injections would have been a temporary kindness at best. The only real answer was bilateral total knee replacement, and we went ahead.

N three months later.
She walked into my OPD for her follow-up. And I watched her come through the door ,and she wasn’t limping. She just walked in. Normally.
Like it was nothing. She sat down, told me her pain was gone,

She didn’t make a big deal of it.

He walked into my OPD two weeks ago — a referral, a second opinion, someone who’d been through something difficult and was looking for a way forward.

Before he sat down, he placed something on my desk.

A bioabsorbable interference screw. Intact. The kind used to fix ACL grafts.

“This came out of my knee,” he said. “On its own.”

Then he told me his story.

Six months ago he had ACL reconstruction surgery — done elsewhere. Shortly after, he developed a post-operative infection. It was managed. Antibiotics, intervention, the standard protocol.

But here he was. Six months later. In my clinic. Holding hardware that his body had decided it no longer wanted.

As a surgeon receiving a case like this, your mind does several things simultaneously.

You’re clinically assessing — is the joint stable, is there active infection, is the skin intact, what’s the neurovascular status.

You’re also reconstructing a story from fragments — incomplete records, a patient’s memory of what he was told, an X-ray that tells you some but not everything.

And somewhere in the back of your mind you’re thinking — never has someone take out their ACL implant themselves.

Here’s what spontaneous screw extrusion after infection actually means biologically —

When infection sets in post-ACL surgery, bacteria form a biofilm on the implant surface. Antibiotics can suppress it but struggle to eliminate it completely while the foreign body remains.

The body’s response — wall it off. Push it out. Find the path of least resistance toward the skin surface and slowly, over months, eject it.

It’s called spontaneous implant extrusion. It’s documented. It’s rare. And it’s the body essentially performing the surgery that nobody scheduled.

Now — what’s the plan for this patient going forward?

This is the part I want people in this community to understand — because if you’ve had an ACL infection, or know someone who has, this matters.

Step 1 — Rule out active infection first. Everything else waits.

Before we even talk about revision ACL surgery, we need to confirm the joint is clean. That means blood markers — CRP, ESR, Procalcitonin. It means an MRI. It means possibly a joint aspiration to culture the fluid.

You do not put a new graft into a knee that still has active infection. Full stop.

Step 2 — Let the biology settle.

Even if markers are normal, we typically wait. The knee needs a quiet period — inflammation down, swelling resolved, full range of motion restored. Rushing a revision is how you end up with a second failure.

Step 3 — Counsel the patient honestly.

Revision ACL is a bigger surgery than primary. Graft options may be different. Outcomes are good but recovery is longer. The patient needs to understand exactly what they’re signing up for — not a repeat of the first surgery, but something more complex.

Step 4 — Rebuild trust.

This patient didn’t come to me originally. He came because something went wrong elsewhere and he needed someone to look at him fresh — without defensiveness, without politics, without ego.

That’s actually a privilege. And a responsibility.

For anyone reading this who is post-ACL infection and anxious —

•	Spontaneous extrusion is the body winning, not failing

•	It does not mean revision is impossible

•	It means the timeline shifts and the workplan changes

•	Find a surgeon who will look at your knee — not their own reputation

This patient’s revision journey is just beginning.

But he walked in holding proof that his body is a fighter.

I plan to make sure the next chapter is better than the last one.

AMA