eMedicine Specialties > Sports Medicine > Knee

Anterior Cruciate Ligament Injury: Follow-up

Author: John D Hubbell, MD, Consulting Surgeon, Department of Orthopedic Surgery, Southampton Hospital
Coauthor(s): Evan Schwartz, MD, Director of Orthopedic Surgery, St John's Queens Hospital, New York Medical College; Assistant Professor, Department of Surgery, Albert Einstein School of Medicine
Contributor Information and Disclosures

Updated: Mar 7, 2006

Follow-up

Return to Play

Once quadriceps strength reaches 65% of the opposite leg, sports-specific activities may be performed; this usually occurs within 5-8 weeks postsurgery. This may be tested using a Cybex machine. The athlete may return to activity when the quadriceps strength has reached 80%, which is usually after at least 3-4 months of sports-specific therapy.

Complications

The current failure rate for ACL reconstruction is approximately 8%. The 3 major categories of failure in an ACL reconstruction are (1) arthrofibrosis (due to inflammation of the synovium and fat pad), (2) pain that limits motion, and (3) recurrent instability, secondary to significant laxity in the reconstructed ligament. These factors may be related to the surgical procedure (eg, malpositioned tibial or femoral tunnels, misplaced hardware, inadequate notchplasty).

  • Anterior placement of a tibial tunnel may result in graft impingement. If a tunnel is placed too posteriorly on the femoral side, the posterior cortex of the femur may be violated.
  • A graft also may fail due to a lack of incorporation, secondary to rejection or stress shielding.
  • Trauma from re-injury or aggressive rehabilitation also may cause graft failure. The incidence of graft re-rupture is approximately 2.5%.

Other complications include patella fractures and patella-tendon ruptures. Reflex sympathetic dystrophy, postoperative infection, and neurovascular complications are rare (each accounting for less than 1% of complications). The rate of postoperative deep venous thrombosis is approximately 0.12%.

Prognosis

Patients treated with surgical reconstruction of the ACL have long-term success rates of 82-95%. Recurrent instability and graft failure is seen in approximately 8% of patients.

Knee scores of those treated nonoperatively have fair/poor results up to 50% of the time. As many as 40% of patients treated nonoperatively had no episodes of giving way. The knee scores in this group may be too sensitive, not accurately representing the clinical situation.

Patients with ACL ruptures, even after successful reconstruction, are at risk for osteoarthrosis. The goal of surgery is to stabilize the knee, decrease the chance of future meniscal injury, and delay the arthritic process.

Miscellaneous

Special Concerns

  • ACL ruptures in the skeletally immature
    • This group presents a difficult dilemma to the orthopedic surgeon. Those who go untreated do poorly, and the current treatment options risk growth disturbances.
    • Surgical reconstruction options vary according to the injury and skeletal maturity.
      • Rare tibial eminence fractures may be fixed by open reduction internal fixation. Midsubstance tears are fixed either transphyseally or nontransphyseally, depending on the skeletal maturity of the patient.
      • If the patient is determined to have more than 1 cm of growth remaining, try to delay the surgery. If the growth plates are closing, these individuals may be treated the same as adults.
 


More on Anterior Cruciate Ligament Injury

Overview: Anterior Cruciate Ligament Injury
Differential Diagnoses & Workup: Anterior Cruciate Ligament Injury
Treatment & Medication: Anterior Cruciate Ligament Injury
Follow-up: Anterior Cruciate Ligament Injury
Multimedia: Anterior Cruciate Ligament Injury
References
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References

  1. Belanger MJ, Moore DC, Crisco JJ 3rd, Fadale PD, Hulstyn MJ, Ehrlich MG. Knee laxity does not vary with the menstrual cycle, before or after exercise. Am J Sports Med. Jul-Aug 2004;32(5):1150-7. [Medline].

  2. Beynnon BD, Johnson RJ, Abate JA, Fleming BC, Nichols CE. Treatment of anterior cruciate ligament injuries, part I. Am J Sports Med. Oct 2005;33(10):1579-602. [Medline].

  3. Cosgarea AJ, Sebastianelli WJ, DeHaven KE. Prevention of arthrofibrosis after anterior cruciate ligament reconstruction using the central third patellar tendon autograft. Am J Sports Med. Jan-Feb 1995;23(1):87-92. [Medline].

  4. Daniel DM, Malcom LL, Losse G, Stone ML, Sachs R, Burks R. Instrumented measurement of anterior laxity of the knee. J Bone Joint Surg Am. Jun 1985;67(5):720-6. [Medline].

  5. Gardner E, O'Rahilly R. The early development of the knee joint in staged human embryos. J Anat. Jan 1968;102(2):289-99. [Medline].

  6. Getelman MH, Friedman MJ. Revision anterior cruciate ligament reconstruction surgery. J Am Acad Orthop Surg. May-Jun 1999;7(3):189-98. [Medline].

  7. Hewson GF Jr, Mendini RA, Wang JB. Prophylactic knee bracing in college football. Am J Sports Med. Jul-Aug 1986;14(4):262-6. [Medline].

  8. Johnson DL, Harner CD, Maday MG. Revision anterior cruciate ligament surgery. Knee Surg. 1994;1:877-95.

  9. Kennedy JC, Alexander IJ, Hayes KC. Nerve supply of the human knee and its functional importance. Am J Sports Med. Nov-Dec 1982;10(6):329-35. [Medline].

  10. Larson RL, Tailon M. Anterior Cruciate Ligament Insufficiency: Principles of Treatment. J Am Acad Orthop Surg. Jan 1994;2(1):26-35. [Medline].

  11. Maday MG, Harner CD, Fu FH. Evaluation and Treatment. In: Feagin JA, ed. The Crucial Ligaments: Diagnosis, Treatment of Ligamentous Injuries About the Knee. 2nd. New York, NY: Churchill Livingstone; 1994:711-23.

  12. Miyasaka KC, Daniel DM, Stone ML. The incidence of knee ligament injuries in the general population. Am J of Knee Surg. 1991;4:3-8.

  13. Montgomery KD, Herschman EB, Nicholas S. Anterior cruciate ligament injuries. In: Arendt EA, ed. Orthopaedic Knowledge Update: Sports Medicine 2. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1999:307-316.

  14. Noyes FR, Bassett RW, Grood ES, Butler DL. Arthroscopy in acute traumatic hemarthrosis of the knee. Incidence of anterior cruciate tears and other injuries. J Bone Joint Surg Am. Jul 1980;62(5):687-95, 757. [Medline].

  15. Noyes FR, Butler DL, Grood ES, Zernicke RF, Hefzy MS. Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions. J Bone Joint Surg Am. Mar 1984;66(3):344-52. [Medline].

  16. Shelbourne KD, Gray T. Anterior cruciate ligament reconstruction with autogenous patellar tendon graft followed by accelerated rehabilitation. A two- to nine-year followup. Am J Sports Med. Nov-Dec 1997;25(6):786-95. [Medline].

  17. Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med. May-Jun 1990;18(3):292-9. [Medline].

  18. Stanitski CL. Anterior Cruciate Ligament Injury in the Skeletally Immature Patient: Diagnosisand Treatment. J Am Acad Orthop Surg. May 1995;3(3):146-158. [Medline].

  19. Watson JT. Knee and leg: bone trauma. In: Beaty JH, ed. Orthopaedic Knowledge Update 6. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1999:521-32.

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Further Reading

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Keywords

ACL injury, knee injury, knee ligament injury, sprained knee, twisted knee, ACL injuries, anterior cruciate ligament injuries

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Contributor Information and Disclosures

Author

John D Hubbell, MD, Consulting Surgeon, Department of Orthopedic Surgery, Southampton Hospital
John D Hubbell, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, and Medical Society of the State of New York
Disclosure: Nothing to disclose.

Coauthor(s)

Evan Schwartz, MD, Director of Orthopedic Surgery, St John's Queens Hospital, New York Medical College; Assistant Professor, Department of Surgery, Albert Einstein School of Medicine
Evan Schwartz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Society for Sports Medicine
Disclosure: Nothing to disclose.

Medical Editor

David T Bernhardt, MD, Director of Primary Care Sports Medicine Fellowship, Professor, Department of Pediatrics, University of Wisconsin
David T Bernhardt, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Sports Medicine, and American Medical Society for Sports Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Marlene DeMaio, MD, Consulting Staff, Assistant Professor, Department of Orthopedic Surgery, Bone & Joint/Sports Medicine Institute, Naval Medical Center
Marlene DeMaio, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American Orthopaedic Foot and Ankle Society, and American Orthopaedic Society for Sports Medicine
Disclosure: Nothing to disclose.

CME Editor

Jon Whitehurst, MD, Consulting Staff, Rockford Orthopedic Associates
Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

 
 
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