Statement
This clinical practice guideline was developed and published by the AAOS Multidisciplinary Volunteer Working Group based on a systematic review of current scientific clinical research and prevailing diagnostic and therapeutic approaches. The guidelines are not intended to be a one-size-fits-all treatment plan, but should be adapted to the patient’s specific situation. Patients in clinical practice are not necessarily the same as those in clinical trials, and physicians should make independent judgments about the diagnosis and treatment of each patient on an individual basis.
Overview
This guideline was developed based on a systematic review of published research on adult and adolescent ACL injuries. In addition to providing recommendations for treatment, the guidelines suggest gaps in the literature and directions for future research.
The guidelines can be read by all practicing physicians and trained surgeons who treat ACL injuries, as well as by policy makers and other practice guideline developers.
History and Examination of Anterior Cruciate Ligament Injuries
Strong evidence supports that medical personnel should perform a skeletal muscle examination of the lower extremities along with a thorough history of the condition in question to help make an accurate diagnosis of an ACL injury.
Recommended intensity: strong
Radiological examination of the anterior cruciate ligament
Although reliable evidence is still lacking, the working group believes that in those cases of knee injury where initial examination reveals relevant symptoms (weakness, pain, interlocking) and signs (joint effusion, joint instability on weight bearing, localized pressure pain, limitation of motion, pathological joint laxity), a positive and lateral X-ray of the knee should be performed to clarify the presence of a fracture dislocation that requires emergency management.
Recommended intensity: consensus
Magnetic resonance examination of the anterior cruciate ligament
Strong evidence supports that MRI can clarify the diagnosis of ACL injury and further detect combined injuries of other ligaments, menisci, or articular cartilage.
Recommended intensity: Strong
Anterior cruciate ligament in children
Limited evidence supports the need for surgical reconstruction of ACL injuries in skeletally developing minors, which may reduce functional limitations and recurrent joint instability during activity that might otherwise result in further injury.
Recommended intensity: limited
ACL in young adults with high activity levels
Moderate intensity evidence supports that surgical reconstruction should be performed in young patients (18-35 years of age) with high activity ACL tears.
Recommended strength: moderate
ACL and meniscus repair
Limited evidence supports that in patients with combined ACL tears and repairable meniscus injuries, ACL reconstruction should be performed in conjunction with meniscal repair, which may result in improved patient function.
Recommended strength: limited
Recurrent instability of the joint due to ACL
Limited evidence comparing nonsurgical treatment of recurrent joint instability with ACL reconstruction has shown that ACL reconstruction can reduce pathological laxity of the joint.
Recommended strength: limited
Conservative treatment of the anterior cruciate ligament
Limited evidence supports the option of non-surgical treatment for patients with low activity and insignificant joint laxity.
Recommended intensity: limited
Timing of surgery for the anterior cruciate ligament
Moderate strength evidence supports that surgery should be performed within 5 months of injury for cases requiring ACL reconstruction to preserve articular cartilage and meniscus.
Recommended Strength: Moderate
Combined medial collateral ligament injury of the anterior cruciate ligament
Limited evidence supports that ACL reconstruction should be performed in cases with both ACL and medial collateral ligament tears, while non-surgical treatment of medial collateral ligament tears is an option.
Recommended strength: limited
Anterior cruciate ligament and interlocking knee
Although there is no reliable clinical evidence, the Working Group believes that patients with ACL tears that result in interlocking joints due to displaced meniscus tears should be treated immediately with “unlocking” of the knee to avoid fixed knee flexion contractures.
Recommended strength: consensus
Single or double bundle reconstruction of the anterior cruciate ligament
There is strong evidence to support that intra-articular ACL reconstruction can be performed with either single or double bundle reconstruction, with comparable outcomes.
Recommended strength: strong
Anterior cruciate ligament autograft source
Strong evidence supports that intra-articular ACL reconstruction can be performed with either a bone-patellar tendon-bone graft or an N-cord tendon graft, both of which have comparable postoperative outcomes.
Recommended strength: strong
ACL autograft or allograft
Strong evidence supports that ACL reconstruction can be performed with either an autograft or a properly treated allograft, with comparable postoperative outcomes. However, this conclusion cannot be extrapolated to all allografts or to all patients, such as younger patients or those with high activity levels.
Recommended intensity: strong
Femoral tunnel technique for the anterior cruciate ligament
Moderate strength evidence supports that intra-articular ACL reconstruction can be performed with either an anteromedial or a transtibial approach when establishing a femoral tunnel, with comparable results for both.
Recommended strength: medium
Postoperative functional bracing of the ACL
Moderate strength evidence supports that functional knee bracing should not be routinely used after ACL reconstruction alone, and there is no evidence to support its effectiveness.
Recommended strength: moderate
Prophylactic bracing of the anterior cruciate ligament
There is limited evidence to support that prophylactic bracing should not be used to prevent ACL injury and that it does not reduce ACL injury.
Recommended intensity: limited
ACL and Neuromuscular Training
Moderate intensity evidence from a small sample (109 cases) supports that neuromuscular training can reduce ACL injury.
Recommended intensity: moderate
Post-operative physiotherapy for the ACL
Moderate strength evidence supports that early rehabilitation programs, accelerated rehabilitation programs, and non-accelerated rehabilitation programs are available after ACL reconstruction, with all three having comparable outcomes.
Recommended Intensity: Moderate
ACL recovery exercises
Limited evidence supports that there is no need to wait a specific amount of time or gain a specific function to return to sports after ACL injury or reconstruction.