ACL reconstruction in challenging patient profiles: Case-Based insights and operative considerations

Anterior cruciate ligament reconstruction (ACLR) is one of the most frequently performed procedures in orthopaedic sports surgery. While ACL reconstruction is routinely performed, real-world clinical practice often necessitates operative management in patients with significant medical comorbidities or concomitant orthopaedic conditions, presenting unique technical and perioperative challenges. Although conventional ACL reconstruction is most often performed in medically fit, active individuals, clinical practice frequently demands surgical intervention in patients with complex profiles or concurrent pathologies. These include systemic comorbidities (e.g., thrombocytopenia, sickle cell trait), neuromuscular conditions (e.g., post-polio residual paralysis, paraplegia), metabolic and biomechanical risk factors (e.g., high BMI), degenerative changes in the elderly, concomitant patellar instability requiring MPFL reconstruction, and cases where ACLR coincides with fracture fixation. Decision-making in such settings requires thoughtful modification of standard surgical techniques, graft selection, implant choice, and perioperative planning. We aim to highlight the condition-specific challenges, technical modifications, and practical strategies that may assist surgeons in optimising outcomes in such challenging scenarios. ACL reconstruction in patients with challenging clinical scenarios requires a deviation from standardised protocols and a patient-specific approach. Our case series demonstrates that successful outcomes can be achieved through thoughtful graft selection, modification of tourniquet practices, strategic surgical planning, and tailored postoperative rehabilitation.