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Objectives and questions: The aim of this study was to evaluate the morphological changes and their implications resulting from the utilization of foreign material during anterior cruciate ligament (ACL) reconstruction. It was hypothesized that suture material remnants act as a pathological factor, directly provoking regression phenomena in both ligamentous and bony compartments of the knee joint.

Material and methods: In this prospective study, a total of 43 consecutive patients undergoing revision surgery for graft failure after autologous ACL reconstruction were analyzed. The specimens were redrilled with a hollow drilling machine to obtain the entire drill canal and then examined histopathologically after staining with haematoxylin and eosin (HE), Masson-Goldner and Elastika-Gieson stains to characterize morphological changes due to the presence of foreign material, both qualitatively and quantitatively by light microscopy.

Results: A total of 68 bone blocks were harvested from 43 patients (9 female, 34 male) with a mean age of 29.7 years, standard deviation: 9.02 (8–58 years). Histomorphological analysis revealed significant degenerative changes in the area of residual suture materials. The degenerative changes observed included intense inflammatory reactions, necrotic alterations, fissure defects and cyst formation. In certain instances, the degradation of the graft was almost total, manifesting as severe cystic changes. The qualitative characteristics of the foreign body reactions demonstrate that direct reactions to the underlying foreign material were observed in 92.6% of the specimens analyzed.

Discussion and conclusions: The findings confirm that residual suture materials are associated with severe histomorphological changes in failed ACL grafts. These changes may weaken or compromise graft resilience, contributing to graft failure. The observed pathology was characterized by inflammatory reactions, osteonecrosis, and cyst formation. The results suggest that residual suture material plays a critical role in pathological regression and destructive alterations of autologous tendon grafts following ACL reconstruction. These findings support the recommendation to minimize excessive suture material use in future surgical procedures to reduce the risk of graft failure.