Anterior Cruciate Ligament Reconstruction

Indications for Surgery

Although there are no rigid criteria for patient selection, the most frequently cited indications for
ACL reconstruction include the following.
 Disabling instability of the knee due to ACL deficiency caused by a complete or partial
acute tear or chronic laxity
 Frequent episodes of the knee giving way (buckling) during routine ADL as the result of
significantly impaired dynamic knee stability despite a course of non-operative
management
 A positive pivot-shift test because an ACL deficit is often associated with a lesion of
other structures of the knee, such as the MCL, resulting in rotatory instability of the joint
 Injury of the MCL at the time of ACL injury to prevent lax healing of the MCL
 High risk of reinjury because of participation in high demand, high joint-load activities
related to work, sports, or recreational activities

Relative Contraindications to ACL Reconstruction

 Relatively inactive individual with little to no exposure to work, sport, and recreational
activities that place high demands on the knee
 Ability to make lifestyle modifications to eliminate high-risk activities
 Ability to cope with infrequent episodes of instability
 Advanced arthritis of the knee
 Poor likelihood of complying with postoperative restrictions and adhering to a
rehabilitation program

Advantages and Disadvantages/ Complications of the Bone-Patellar Tendon-Bone Autograft

Advantages
 High tensile strength/stiffness, similar or greater than the ACL
 Secure and reliable bone-to-bone graft fixation with interference screws
 Rapid revascularization/biological fixation (6 weeks) at the bone-to-bone interface permitting
safe, accelerated rehabilitation
 Ability to return to pre-injury, high-demand activities safely

Disadvantages/Potential Complications
 Anterior knee pain in area of graft harvest site
 Pain during kneeling
 Extensor mechanism/patellofemoral dysfunction
 Long-term quadriceps muscle weakness
 Patellar fracture during graft harvest (rare, but significant adverse effects)
 Patellar tendon rupture (rare)

Advantages and Disadvantages/ Complications of the Semitendinosus-Gracilis Autograft Advantages

 High tensile strength/stiffness greater than ACL with quadrupled graft
 No disturbance of epiphyseal plate in skeletally immature patient
 Evidence of hamstring tendon regeneration at donor site
 Loss of knee flexor muscle strength remediated by 2 years postoperatively
Disadvantages/Potential Complications
 Tendon-to-bone fixation devices (particularly tibial fixation) not as reliable as bone-to-bone
fixation
 Longer healing time (12 weeks) at tendon-bone interface
 Hamstring muscle strain during early rehabilitation
 Short- and long-term knee flexor muscle weakness (not associated with functional limitation)
 Possible increased anterior knee translation (not associated with functional limitations)

ACL Reconstruction: Interventions for Accelerated Postoperative Rehabilitation