ACL Reconstruction: Problems, History and Future. Part II


anterior cruciate ligament, arthroscopy, reconstruction, treatment.

How to Cite

Zazirnyi, I., & Kostrub, O. (2020). ACL Reconstruction: Problems, History and Future. Part II. TERRA ORTHOPAEDICA, (3(106), 63-70.


Summary. Anterior cruciate ligament (ACL) injury is one of the most commonly seen injuries in sport and has a devastating influence on patients’ activity levels and quality of life. For patients, whose history and results of physical examination suggest an ACL injury, MRI is indicated to confirm the diagnosis and to determine whether there are concomitant injuries. There are limited data of the need for immediate ACL reconstruction. Surgeons need to discuss with the patient the option of a structured accelerated course of rehabilitation as an alternative to immediate reconstruction. If an initial strategy of rehabilitation was chosen, serial evaluation of knee function and functional recovery in the first 3 months after the injury would recommend. If there is residual instability (greater than grade 2) at the time of subsequent assessment, the surgery is necessary to avoid further damage to the articular cartilage and meniscus. When reconstruction is advised as the correct management of an ACL injury, there are various options. The type of a graft, single-bundle or double-bundle reconstruction, graft placement, and whether to use the transtibial, far anteromedial portal, or tibial tunnel–independent technique are choices that must be made. Each option has its own advantages and disadvantages, with single- or double-bundle strategy, proper placement of grafts, and the use of autografts affect the clinical outcome and quality of life of patients. The selection of the best autograft tissue type remains controversial, with the patellar tendon (PT), the hamstring (HS) tendon, and the quadriceps tendon each having their proponents.


Krosshaug T, Nakamae A, Boden BP. Mechanisms of anterior cruciate ligament injury in basketball video analysis of 39 cases. Am J Sports Med. 2007; 35:359–367.

Boden BP, Torg JS, Knowles DB. Video analysis of anterior cruciate ligament injury: abnormalities in hip and ankle kinematics. Am J Sports Med. 2009; 37:252–259.

Beynnon BD, Fleming BC. Anterior cruciate ligament strain in-vivo: a review of previous work. J Biomech. 1998; 31:519–525.

Benjaminse A, Gokeler A, Vand der Schans CP. Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis. J Orthop Sports Phys Ther. 2006; 36:267–288.

Solomon DH, Simel DK, Bates DW. The rational clinical examination. Does this patient have a torn meniscus or ligament of the knee? Value of the physical examination. JAMA. 2001; 286:1610–1620.

Galway HR, MacIntosh DL. The lateral pivot shift: a symptom and sign of anterior cruciate ligament insufficiency. Clin Orthop. 1980; 147:45–50.

Ostrowski JA. Accuracy of 3 diagnostic test for anterior cruciate ligament tears. J Athl Train. 2006; 41:120–121.

Noyes FR, Mooar PA, Matthew DS. The symptomatic anterior cruciate-deficient knee, part I. J Bone Joint Surg Am. 1983;65:154–162.

Sherman MF, Warren RF, Marshall JL. A clinical and radiographical analysis of 127 anterior cruciate insufficient knees. Clin Orthop. 1988; 227:229–237.

Spindler KP, Wright RW. Clinical practice. Anterior cruciate ligament tear. N Engl J Med. 2008; 359:2135–2142.

Chhabra A, Starman JS, Ferretti M. Anatomic, radiographic, biomechanical, and kinematic evaluation of the anterior cruciate ligament and its two functional bundles. J Bone Joint Surg Am. 2006; 88(suppl 4):2–10.

Steckel H, Vadala G, Davis D. 2D and 3D 3-Tesla magnetic resonance imaging of the double bundle structure in anterior cruciate ligament anatomy. Knee Surg Sports Traumatol Arthrosc. 2006;14: 1151–1158.

Starman JS, Vanbeek C, Armfield DR. Assessment of normal ACL double bundle anatomy in standard viewing planes by magnetic resonance imaging. Knee Surg Sports Traumatol Arthrosc. 2007; 15:493–499.

Fithian DC, Paxton EW, Stone ML. Prospective trial of a treatment algorithm for the management of the anterior cruciate ligament-injured knee. Am J Sports Med. 2005; 33:335–346.

Barrack RL, Bruckner JD, Kneisl J. The outcome of nonoperatively treated complete tears of the anterior cruciate ligament in active young adults. Clin Orthop Relat Res. 1990; 259:192–199.

Noyes FR, Barber SD, Mooar LA. A rationale for assessing sports activity levels and limitations in knee disorders. Clin Orthop Relat Res. 1989; 246:238–249.

Scavenius M, Bak K, Hansen S. Isolated total ruptures of the anterior cruciate ligament: a clinical study with long-term follow-up of 7 year. Scand J Med Sci Sports. 1999; 9: 114–119.

Wittenberg RH, Oxfort HU, Plafki C. A comparison of conservative and delayed surgical treatment of anterior cruciate ligament ruptures: a matched pair analysis. Int Orthop. 1998; 22:145–148.

Andernord D, Karlsson J, Fu FH, Samuelsson K. Timing of surgery of the anterior cruciate ligament. Arthroscopy 2013;29:1863-71.

Magnussen RA, Pedroza AD, Donaldson CT. Time from ACL injury to reconstruction and the prevalence of additional intraarticular pathology: is patient age an important factor? Knee Surg Sports Traumatol Arthrosc 2013;21:2029-34.

Sri-Ram K, Salmon LJ, Pinczewski LA.. The incidence of secondary pathology after anterior cruciate ligament rupture in 5086 patients requiring ligament reconstruction. Bone Joint J 2013; 95-B:59-64.

SheaKG, CareyJ L, Richmond J. The American Academy of Orthopaedic Surgeons evidence-based guideline on management of anterior cruciate ligament injuries. J Bone Joint Surg Am 2015; 97:672-4.

Maletis GB, Chen J, Funahashi TT. Age-related risk factors for revision anterior cruciatе ligament reconstruction: a cohort study of 21,304 patients from the Kaiser Permanente Anterior Cruciate Ligament Registry. Am J Sports Med 2016;44:331-6.

Recht MP, Piraino DW, Cohen MA, et al. Localized anterior arthrofibrosis (cyclops lesion) after reconstruction of the anterior cruciate ligament: MR imaging findings. Am J Roentgenol. 1995; 165:383–385.

Aune AK, Holm I, Risberg MA. Four-strand hamstring tendon autograft compared with patellar tendon-bone autograft for anterior cruciate ligament reconstruction: a randomized study with two-year follow-up. Am J Sports Med. 2001; 29:722–728.

Tuman JM, Diduch DR, Rubino LJ. Predictors for hamstring graft diameter in anterior cruciate ligament reconstruction. Am J Sports Med. 2007; 35:1945–1949.

DeAngelis JP, Fulkerson JP. Quadriceps tendon—a reliable alternative for reconstruction of the anterior cruciate ligament. Clin Sports Med. 2007; 26:587–596.

Lee S, Seong SC, Jo H. Anterior cruciate ligament reconstruction using quadriceps tendon autograft. J Bone Joint Surg Am. 2007;89 (suppl 3): 116–126.

Prodromos C, Joyce B, Shi K. A meta-analysis of stability of autografts compared to allografts after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2007; 15:851–856.

Krych AJ, Jackson JD, Hoskin TL. A meta-analysis of patellar tendon autograft versus patellar tendon allograft in anterior cruciate ligament reconstruction. Arthroscopy. 2008; 24:292–298.

Sun K, Tian S, Zhang J. Anterior cruciate ligament reconstruction with BPTB autograft, irradiated versus non-irradiated allograft: a prospective randomized clinical study. Knee Surg Sports Traumatol Arthrosc. 2009; 17:464–474.

Ristanis S, Stergiou N, Patras K. Excessive tibial rotation during high-demand activities is not restored by anterior cruciate ligament reconstruction. Arthroscopy. 2005; 21:1323–1329.

Tashman S, Collon D, Anderson K. Abnormal rotational knee motion during running after anterior cruciate ligament reconstruction. Am J Sports Med. 2004; 32:975–983.

Adachi N, Ochi M, Uchio Y. Reconstruction of the anterior cruciate ligament: single versus double-bundle multistranded hamstring tendons. J Bone Joint Surg Br. 2004; 86:515–520.

Hamada M, Shino K, Horibe S. Single- versus bi-socket anterior cruciate ligament reconstruction using autogenous multiple-stranded hamstring tendons with endoButton femoral fixation: a prospective study. Arthroscopy. 2001; 17:801–807.

Yasuda K, Kondo E, Ichiyama H. Anatomic reconstruction of the anteromedial and posterolateral bundles of the anterior cruciate ligament using hamstring tendon grafts. Arthroscopy. 2004; 20:1015–1025.

Mae T, Shino K, Miyama T. Single- versus two-femoral socket anterior cruciate ligament reconstruction technique: biomechanical analysis using a robotic simulator. Arthroscopy. 2001; 17:708–716.

Nishimoto K, Kuroda R, Mizuno K. Analysis of the graft bending angle at the femoral tunnel aperture in anatomic double bundle anterior cruciate ligament reconstruction: a comparison of the transtibial and the far anteromedial portal technique. Knee Surg Sports Traumatol Arthrosc. 2009; 17:270–276.

Yagi M, Wong EK, Kanamori A. Biomechanical analysis of an anatomic anterior cruciate ligament reconstruction. Am J Sports Med. 2002; 30:660–666.

Yamamoto Y, Hsu WH, Woo SL. Knee stability and graft function after anterior cruciate ligament reconstruction: a comparison of a lateral and an anatomical femoral tunnel placement. Am J Sports Med. 2004;32: 1825–1832.

Abebe ES, Moorman CT III, Dziedzic TS. Femoral tunnel placement during anterior cruciate ligament reconstruction: an in vivo imaging analysis comparing transtibial and 2-incision tibial tunnel-independent techniques. Am J Sports Med. 2009; 37:1904–1911.

Abebe ES, Kim JP, Utturkar GM. The effect of femoral tunnel placement on ACL graft orientation and length during in vivo knee flexion. J Biomechanics. 2011; 44:1914–1920.

Shelbourne KD, Klotz C. What I have learned about the ACL: utilizing a progressive rehabilitation scheme to achieve total knee symmetry after anterior cruciate ligament reconstruction. J Orthop Sci. 2006; 11:318–325.

Wright RW, Preston E, Fleming BC. A systematic review of anterior cruciate ligament reconstruction rehabilitation: part II: open versus closed kinetic chain exercises, neuromuscular electrical stimulation, accelerated rehabilitation, and miscellaneous topics. J Knee Surg. 2008; 21:225–234.

Risberg MA, Holm I, Myklebust G. Neuromuscular training versus strength training during first 6 months after anterior cruciate ligament reconstruction: a randomized clinical trial. Phys Ther. 2007; 87:737–750.

Moffat KL, Wang IN, Rodeo SA. Orthopedic interface tissue engineering for the biological fixation of soft tissue grafts. Clin Sports Med. 2009; 28:157–176.

Mahirogullari M, Ferguson CM, Whitlock PW. Freeze-dried allografts for anterior cruciate ligament reconstruction. Clin Sports Med. 2007; 26:625–637.

Lopez-Vidriero E, Goulding KA, Simon DA. The use of platelet-rich plasma in arthroscopy and sports medicine: optimizing the healing environment. Arthroscopy. 2010; 26:269–278.

Weitzel PP, Richmond JC, Altman GH. Future direction of the treatment of ACL ruptures. Orthop Clin North Am. 2002; 33:653–661.

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