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 and care, the guideline also identifies gaps in the literature and directions for future research.
The guidelines can be read by all practicing physicians and surgeons trained in the treatment of ACL injuries, as well as by policy makers and other practice guideline developers.
1. History and Examination of Anterior Cruciate Ligament Injuries
Strong evidence supports that medical personnel should perform a skeletal-muscular examination of the lower extremity along with a thorough history of the condition in question to help make an accurate diagnosis of an ACL injury.
Strength of recommendation: strong
2. Radiological examination of the anterior cruciate ligament
Although there is a lack of reliable evidence, the Working Group believes that in cases of knee injury where initial examination reveals symptoms (weakness, pain, interlocking) and signs (joint effusion, joint instability with weight bearing, localized pressure, 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
3. 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
4. Anterior cruciate ligament in children
Limited evidence supports the need for surgical reconstruction of ACL injuries in minors whose bones are still developing, thereby reducing functional limitations and recurrent joint instability during activities that might otherwise cause further injury.
Recommended intensity: limited
5. ACL in young people with high activity levels
Moderate strength evidence supports that surgical reconstruction should be performed in young patients (18-35 years of age) with high activity ACL tears.
Recommended strength: moderate
6. ACL and meniscus repair
Limited evidence supports that for patients with combined ACL tears and repairable meniscus injuries, ACL reconstruction should be performed along with meniscal repair, which may result in improved patient function.
Recommended intensity: limited
7. Recurrent instability of the joint due to the ACL
Limited evidence comparing non-surgical treatment of recurrent joint instability with ACL reconstruction has shown that ACL reconstruction can reduce pathological laxity of the joint.
Recommended strength: limited
8. Conservative treatment of the anterior cruciate ligament
Limited evidence supports that non-surgical treatment is an option for patients with low activity and insignificant joint laxity.
Recommended intensity: limited
Timing of ACL surgery
Moderate strength evidence supports that for cases requiring ACL reconstruction, surgery should be performed within 5 months of injury to preserve the articular cartilage and meniscus.
Recommended intensity: moderate
9. ACL combined with medial collateral ligament injury
Limited evidence supports that ACL reconstruction should be performed in cases with both ACL and medial collateral ligament tears, while non-surgical treatment for medial collateral ligament tears is an option.
Recommended strength: limited
10. 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
11. 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
12. Anterior cruciate ligament autograft source
Strong evidence supports that both bone-patellar tendon-bone grafts and N-cord tendon grafts can be selected for intra-articular ACL reconstruction, with comparable postoperative outcomes for both.
Recommended strength: strong
13. ACL autograft or allograft
Strong evidence supports that ACL reconstruction can be performed with either autografts or properly treated allografts, 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
14. 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 intensity: medium
15. 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
16. Prophylactic bracing of the ACL
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 strength: limited
17. ACL and neuromuscular training
Moderate strength evidence from a small sample supports that neuromuscular training can reduce ACL injury.
Recommended intensity: moderate
18. Post-operative physiotherapy for the anterior cruciate ligament
Moderate strength evidence supports that early rehabilitation programs, accelerated rehabilitation programs, and non-accelerated rehabilitation programs are available after ACL reconstruction, and that all three have comparable effects.
Recommended intensity: moderate
19. ACL recovery exercises
Limited evidence supports that after ACL injury or reconstruction, there is no need to wait a specific amount of time or gain a specific function to return to sports.
Recommended intensity: limited