TREATMENTS FOR ANTERIOR CRUCIATE LIGAMENT INJURY

Treatment
. Acute
. Establish diagnosis
. Ice, resolution of swelling, closed-chain quadmotion recovery
. Avoid immobilization
. Physical therapy
. Consider MRI
. Treatment considerations
. Age
. Activity level
. Category I sports (e.g., basketball, football, soccer, volleyball)
. Associated injuries (e.g., meniscus,MCL)
. Amount of pathologic laxity (e.g., Grade 2 or 3 pivot)
. Sports participation
. Expectation
. KT-1000 maximummanual (>6mmSSD, poor prognosis)
. Treatment options
. Nonsurgical
. Activity modificationmandatory
. ACL brace – Low-level activities
. Does not prevent instability
. Reduces severity and frequency of instability
. May require arthroscopy for meniscal pathology
. Surgical: tissue options
. Patellar tendon autograft
. Hamstrings
. Quadriceps tendon
. Allograft
. Irradiated vs. nonirradiated
. Patellar tendon vs. Achilles tendon
Disposition
N/A
Prognosis
. Nonsurgical treatment
. Low probability of high-level sports participation
. High likelihood of recurrent injuries –meniscal, articular
. Subjective satisfaction generally low
. 50% function due to ACL functional brace
. Surgical treatment
. Preferred for most individuals
. Stability success 85–90%
. Patient satisfaction 95%
. Patellar pain testing variable (10–40%)
. Side-to-side functional testing: 40–90% normal
. Return to play
. Nonoperative
. Should be braced
. Usually 4–6 weeks
. Caution that reinjury common
. Reconstructive
. Graft and sport dependent
. 4–6monthsmost surgeons; others recommend 6–9months
. Criteria – Normal stability, motion functional testing within
10–15%
. Complications of surgical treatment
. Infection (1%)
. Deep venous thrombosis, pulmonary embolus (1%)
. Patellar fracture, patellar tendon rupture (1%)
. Loss ofmotor (extension and/or flexion)
. Recurrent laxity (micro/macrotraumatic)
. Reinjury (5–10%) – Time-dependent
. Opposite side ACL injury –More common than graft disruption
Caveats and Pearls
. Suspect ACL injury in athlete with hemarthrosis.
. A patient with a displaced bucket handle meniscal tear (locked
knee) has an ACL injury until proven otherwise.
. “Partial” ACL injuries are extremely uncommon (<5%); athlete has
an ACL-deficient knee until proven otherwise.
. ACL diagnosis is established by history and exam; MRI should not
be used to establish diagnosis.
. ACL reconstructive surgery is not a surgical emergency.
. Postop motion complications reduced with delayed surgical treatment
. Beware of associated MCL injury, which may contribute to delayed
motion recovery.
. Medial meniscal tears more common in chronic ACL knees; lateral
meniscal tearsmore common in acute injuries
. Postoperative ACL bracing controversial
. ACL injuries three to four times more common in females (multifactorial)
. Accelerated rehab programs for patellar tendon graft current standard
. Surgical results similar for patellar tendon vs. hamstring autograft
. Surgical results of single- vs. double-incision arthroscopic techniques
similar
. Current graft choices: patellar tendon autograft, hamstring, quadriceps
tendon, nonirradiated patellar tendon allograft
. Outpatient ACL reconstruction feasible
. Postop continuous passive motion is longer standard of care
. Avoid open-chain quad extension exercises during rehab.