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Anterior Cruciate Ligament Injury: Treatment & Medication
Updated: Mar 7, 2006
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Acute Phase
Rehabilitation Program
Physical Therapy
Before any treatment, encourage strengthening of the quadriceps and hamstrings, as well as ROM exercises. Performance of ROM helps reduce the amount of effusion and regain motion and strength.
Surgical Intervention
When deciding whether to perform reconstructive surgery, the physician should consider the following factors:
- Preinjury activity level
- Desire to return to high-demand sports (eg, basketball, football, soccer)
- Associated injuries
- Abnormal laxity
- Patient's expectations
Generally, the recommendation is that surgical intervention be delayed at least 3 weeks following injury to prevent the complication of arthrofibrosis. The methods of surgical repair may be categorized into 3 groups, primary repair, extra-articular repair, and intra-articular repair.
- Primary repair is not recommended except for bony avulsions, which are mostly seen in adolescents. Because the ACL is intra-articular, the ligamentous ends are subjected to synovial fluid, which does not support ligamentous healing.
- Extra-articular repair generally involves a tenodesis of the iliotibial tract. This may prevent a pivot shift but has not been shown to decrease anterior tibial translation.
- Intra-articular reconstruction of the ACL has become the criterion standard for treating ACL tears.
- Bone-patella-bone autografts are currently popular because they yield a significantly higher percentage of stable knees with a higher rate of return to preinjury sports. The major pitfall of these grafts is their association with postoperative anterior knee pain (10-40%).
- Hamstring tendon grafts are associated with a faster recovery and less anterior knee pain. Critics believe that these are more susceptible to graft elongation.
- Recent literature has supported a greater tensile strength with the use of braided quadruple hamstring grafts. However, this finding has not been confirmed in vivo, and the graft may be limited by the type of fixation.
- Allografts have also been very popular because of their efficiency, their ability to provide bony fixation, and the lack of associated patella morbidity. However, they are associated with a risk of viral transmission. Allografts are best used in revisions. These have also fallen out of favor by some because several deaths linked to clostridial infections from inadequate sterilization techniques have been reported, which led to increased research into sterilization techniques to ensure safety. In addition, concerns exist regarding what effects the immunologic response and delayed revascularization and remodeling may have on clinical outcomes. Although allografts are generally accepted as having less associated morbidity, no proof of this is present in the literature.
- Synthetic grafts and ligament augmentation devices have also been used. Synthetic grafts are no longer acceptable, because of their high rate of complications, including failure and aseptic effusions.
- Intra-articular reconstruction may be performed through a 2-incision technique or a single-incision endoscopic technique; the latter is currently more popular. This procedure requires graft stabilization with some type of fixation hardware for all of the graft options. The stabilization may be performed with metal interference screws, bioabsorbable screws, endobuttons, and cross pins. Each device has its own benefits.
- Double-tunnel ACL reconstructions attempt to reproduce stability in internal rotation and valgus torque applied to the knee. Investigations into the benefits of such surgical treatment versus the increased level of difficulty and operative time are currently ongoing. Studies at this time have been limited to animal models.
Other Treatment
Nonoperative treatment may be considered in elderly patients or in less active athletes who may not be participating in any pivoting type of sports (eg, running, cycling). The goal is to obtain a full ROM and strength compared with the uninjured knee. This modality of treatment requires modification of activity levels and avoidance of physically demanding occupations. Arthroscopy may also be considered for persons who are poor candidates for reconstruction but have a mechanical block to ROM. The goal of this procedure is to debride the remaining stump to increase motion. Patients with significant arthritis are also thought to be poor candidates unless they are experiencing recurrent instability. See below for bracing information.
Recovery Phase
Rehabilitation Program
Physical Therapy
Postoperative treatment is discussed.
- Closed-chain exercises are used to emphasize early and long-term maintenance of full extension.
- Therapy protocols may be divided into the following 4 categories per Shelbourne and Nitz:
- Phase I: This is the preoperative period when the goal is to maintain full ROM.
- Phase II (0-2 wk): The goal is to achieve full extension, maintain quadriceps control, minimize swelling, and achieve flexion to 90o.
- Phase III (3-5 wk): Maintain full extension and increase flexion up to full ROM. Stair-climbers and bicycles may be used.
- Phase IV (6 wk): Increase strength and agility, progressive return to sports. Return to all sports without activity may take 6-9 months and should be closely monitored by the surgeon and physical therapist.
Other Treatment (Injection, manipulation, etc.)
The use of knee braces remains a highly controversial topic; braces are well accepted by patients, but most biomechanical studies do not support their use. Studies have shown that functional bracing can limit anterior translation of the tibia at low loads. Furthermore, most braces have been found to decrease the reaction time of the hamstring muscles.
Maintenance Phase
Rehabilitation Program
Physical Therapy
Open-chain exercises are initiated. The patient's timeframe for returning to sports depends on his/her strength, ROM, and the type of fixation that was performed.
Medication
Medication for ACL injuries mainly consists of analgesics. Preoperative drugs may include cyclooxygenase-2 (COX-2) inhibitors and opioid analgesic agents. Postoperatively, the patient may obtain pain relief through nonsteroidal anti-inflammatory drugs (NSAIDs) and opioid analgesics. NSAIDS have been shown to decrease bone formation in spine fusions and rotator cuff surgery. Although this has not been seen clinically in ACL reconstructions with bone-patella tendon-bone grafts, it is plausible to think that this may be the case. Therefore, long-term postoperative use may not be beneficial.
Nonsteroidal anti-inflammatory drugs
Have analgesic and anti-inflammatory activities. Their mechanism of action is not known, but may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation and various cell membrane functions.
Ketorolac (Toradol)
Inhibits prostaglandin synthesis by decreasing the activity of the enzyme, cyclo-oxygenase, which results in decreased formation of prostaglandin precursors. Used in postoperative pain control.
Adult
10 mg PO q6h for 5 d (requires IM/IV loading dose)
Alternatively, 15-30 mg IM/IV q6h for 5 d
Pediatric
Not established
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding; do not administer into CNS
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Category D in third trimester of pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low WBC counts (rare) usually return to normal during ongoing therapy; discontinue therapy if persistent leukopenia, granulocytopenia, or thrombocytopenia occur
Cyclooxygenase-2 inhibitors
Although increased cost can be a negative factor, the incidence of costly and potentially fatal GI bleeds is clearly less with COX-2 inhibitors than with traditional NSAIDs. Ongoing analysis of cost avoidance of GI bleeds will further define the populations that will find COX-2 inhibitors the most beneficial.
Celecoxib (Celebrex)
Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited thus GI toxicity may be decreased. Seek lowest dose of celecoxib for each patient. Used for postoperative pain control.
Adult
100 mg PO bid or 200 mg PO qd
Pediatric
Not established
Coadministration with fluconazole may cause increase in celecoxib plasma concentrations because of inhibition of celecoxib metabolism; coadministration of celecoxib with rifampin may decrease celecoxib plasma concentrations
Documented hypersensitivity to drug or sulfa
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
May cause fluid retention and peripheral edema; caution in compromised cardiac function, hypertension, conditions predisposing to fluid retention; severe heart failure and hyponatremia, because may deteriorate circulatory hemodynamics; NSAIDs may mask usual signs of infection; caution in the presence of existing controlled infections; evaluate symptoms and signs suggesting liver dysfunction, or in abnormal liver lab results
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
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Further Reading
Keywords
ACL injury, knee injury, knee ligament injury, sprained knee, twisted knee, ACL injuries, anterior cruciate ligament injuries
