Acute Phase
Rehabilitation program
Physical therapy
Before any treatment, encourage strengthening of the quadriceps and hamstrings, as well as range of motion (ROM) exercises. Performance of ROM helps reduce the amount of effusion and helps the patient regain motion and strength.
Surgical intervention
When deciding whether to perform reconstructive surgery, the physician should consider the following factors:
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Preinjury activity level
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Desire to return to high-demand sports (eg, basketball, football, soccer)
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Associated injuries
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Abnormal laxity
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Patient's expectations
Generally, the recommendation is that surgical intervention be delayed at least 3 weeks following injury to prevent the complication of arthrofibrosis. However, the results of one study noted that increased time to surgery (6-12 mo and >12 mo) is strongly associated with a higher risk of medial meniscus injury and decreased repair rate. While females experienced a lower risk of cartilage injury, increasing age and increasing time to surgery (>12 mo) in male patients realized a greater risk. [20]
The methods of surgical repair may be categorized into 3 groups, primary repair, extra-articular repair, and intra-articular repair.
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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.
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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.
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Intra-articular reconstruction of the ACL has become the criterion standard for treating ACL tears.
Bone-patella-bone (BTB) 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 (HT) grafts are associated with a faster recovery and less anterior knee pain. Critics believe that these are more susceptible to graft elongation; however, a recent randomized, prospective study by Wipfler et al comparing BTB autografts to HT grafts at 9 years demonstrated significantly better International Knee Documentation Committee (IKDC) scores in the HT group, with no significant differences in laxity, tunnel widening, or any other parameters. [7]
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.
The results of a 2-year randomized trial noted that the double-bundle technique resulted in fewer graft failures and significantly lower revision rates than the single-bundle technique in anterior cruciate ligament reconstruction. [21]
After a 3-year follow up, the data from one study showed that patients with combined lesions of the ACL and MCL who had undergone an arthroscopic double-bundle ACL reconstruction showed a significantly greater mean medial joint opening (1.7 mm) compared with uninjured knees (0.9 mm). However, no significant difference was noted between the anteroposterior laxity and other clinical parameters. Because the data showed that residual valgus laxity did not affect anteroposterior laxity significantly, these results suggest that no additional surgical procedure is necessary for the medial collateral ligament in combined lesions. [22]
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.
Recovery Phase
Rehabilitation program
Physical therapy
Postoperative treatment is discussed.
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Closed-chain exercises are used to emphasize early and long-term maintenance of full extension.
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Therapy protocols may be divided into the following 4 categories per Shelbourne and Nitz [23] :
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.
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Proper technique for the Lachman test.
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Anterior drawer test: Note the anterior excursion of the tibia in relationship to the femur.
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The pivot shift test.
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MRI displaying a ruptured anterior cruciate ligament.
