c l i n i c a l f o l i o s : d i s c u s s i o n

Anterior Cruciate Ligament Repair



Related narratives: Anterior Cruciate Ligament Repair,
Arthroscopic ACL Repair Using a Hamstring Graft and Transfix Femoral Fixation

Insufficiency of the anterior cruciate ligament (ACL) is an extremely common injury and its incidence has been increasing in recent years as more and more people are remaining active as they age. Women seem to have a higher risk of ACL injury and although basketball, soccer and rugby are sports with the highest incidence of ACL injury, most occur in non-contact situations when the leg is rotated or extended over a planted foot. Medial collateral ligament (MCL) injury is extremely common as are meniscal injuries which occur in approximately 50% of ACL tears, usually involving the lateral meniscus.

Patients often present with a classic story of a valgus rotation injury to the leg with the foot planted, an audible "pop" and a large hemarthrosis developing within a few hours after the injury. Initial assessment is often difficult unless patients are examined prior to the development of the hemarthrosis. If there is no evidence of a knee dislocation, fracture or displaced meniscus tear and the patient has normal neurologic function, normal lower extremity pulses and can achieve full extension, the knee is iced and placed in a knee immobilizer. The knee is reexamined at weekly intervals and all ligament injuries are assessed. Abnormal excessive anterior translation of the tibia with respect to the femur is indicative of an ACL injury. The injury may range from a stable partial injury to a complete, unstable tear or rupture. X-rays are usually normal. MRI has become increasingly essential in evaluation of ligament and cartilage injuries in the knee as well as assessing micro-fractures and bone contusions.

Urgent surgical repair and/or reconstruction have fallen out of favor unless the injury involves a knee dislocation, a displaced "bucket-handle" meniscus tear limiting full extension or the occurrence of a tibial spine avulsion injury in the juvenile population. Initial treatment includes progressive return to weight bearing in an ACL brace with aggressive maintenance of motion and thigh strength. Most surgeons advocate reconstruction for active individuals after 4-6 weeks to allow for stabilization of other injuries and maximization of motion and conditioning.

Reconstruction using a portion of the patients own patellar tendon harvested with small bone plugs at either end is the most common technique and is the benchmark by which other techniques are measured. The use of the patients own hamstring tendons for graft reconstruction is also proven to be successful and has some distinct advantages. Graft selection, fixation techniques and rehabilitation are all debated among the experts and there are many different successful techniques.

Post-operative early emphasis on return of full knee extension, bracing, a regimented physical therapy protocol involving specialized "closed-chain kinetic exercises", proprioceptive reeducation and progressive return to "sports-specific" training all have contributed to overall success rates approaching 95%.


Adalberth T et al. MRI, Scintigraphy and Arthroscopic Evaluation of Traumatic Hemarthrosis of the Knee. Am J Sports Med 1997; 25:231-237.

Beaty JH (ed). AAOS Orthopaedic Knowledge Update 6: Knee and Leg-Soft Tissue Trauma. 1999; p 533-539.

Daniel DM et al. Fate of the ACL-Injured Patient: A Prospective Outcome Study. Am J Sports Med 1994;22:632-644.

O'Neill DB. Arthroscopically Assisted Reconstruction of the ACL: A Prospective Randomized Analysis of Three Techniques. J Bone Joint Surg 1996;78A:803-813.

Shelbourne KD, Foulk DA. Timing of Surgery in ACL Tears on the Return of Quadriceps Muscle Strength after Reconstruction using an Autogenous Patellar Tendon Graft. Am J Sports Med 1995; 23:686-689.

Wojtys EM et al. ACL Functional Brace Use in Sports. Am J Sports Med 1996;24:539-546.

This page was last modified on 12-Dec-2000.