2323-E JE ACL 11 Low

JointEvidence 5/2009 Lit. No.
2323-e
Anterior cruciate ligament

Table of contents
Executive summary 3 VII Recommendations and future research 22

I Introduction 4 VIII References 23
II Clinical questions 10 APPENDIX A: Ovid Medline and EMBASE search results 25
III Data sources and search strategy 11 APPENDIX B: Articles by level of evidence 44
IV Quality of the literature for this topic 12 APPENDIX C: Detailed data of diagnostic studies 47
V Results 13 APPENDIX D: Detailed data of treatment studies 50
VI Area of uncertainty 22
JointEvidence 5/2009 page – 2
AUTHORS
Juliana Kraeva, BA (cand.)
Cheryl Wylie, BSc
Sarah Elliot, BSc
Sheila Sprague, MSc
Mohit Bhandari, MD, MSc, FRCSC
Published March 2009, Copyright © 2009 by

KLEOS, Erlenstrasse 4a, 6343 Rotkreuz, Switzerland
Phone +41 41 798 41 11, Fax +41 41 798 41 00
kleos@smith-nephew.com
Lit. No. 2323-e Ed. 5/09
LIST OF TABLES
Table 1: The search strategy for ovid medline 11
Table 2: Levels of evidence for primary research question 12
Table 3: Incidence of ACL tears by gender and sport 13
Table 4: Methods of calculations 14
Table 5: Sensitivity and specificity of three physical tests 15
Table 6: Diagnostic efficacy of primary and secondary ACL tear signs on MRI 16
Table 7: Outcomes of autograft versus allograft pcl reconstructions 17
Table 8: Possible causes of increased allograft clinical laxity 17
Table 9: Outcomes of type of graft for ACL reconstruction 18
Disclaimer Great care has been taken to Table 10: Summary of outcomes of high level studies comparing hamstring and patellar tendons in ACLR 18
maintain the accuracy of the information contained Table 11: List of complications reported in the literature 20
in the publication. However, neither KLEOS, nor Table C-1: Detailed data from individual studies 47
the authors can be held responsible for errors
or any consequences arising from the use of the
Table D-1: Level I detailed data from individual studies 50
information contained in this publication. The Table D-2: Level II detailed data from individual studies 57
statements or opinions contained in editorials
and articles in this journal are solely those of the
authors thereof and not of KLEOS. The products, LIST OF FIGURES
procedures, and therapies described are only
to be applied by certified and trained medical Figure 1: Location of the ACL in the flexed knee joint 4
professionals in environments specially designed
for such procedures. No suggested test or Figure 2: ACL bundles; AM = Anteromedial, PL = Posterolateral 4
procedure should be carried out unless, in the Figure 3: ACL bundles in extension (left) show posteromedial bundle tight and anterolateral
reader’s professional judgment, its risk is justified. moderately lax. ACL bundles in flexion (right) show the opposite relationship 5
Because of rapid advances in the medical
sciences, we recommend that independent
Figure 4: Twisting mechanism of ACL injury 5
verification of diagnosis, drugs dosages, and Figure 5: At-risk position for ACL injury 6
operating methods should be made before any Figure 6: The female Q angle is typically larger than that of males, thus females experience different
action is taken. Although all advertising material biomechanical forces on the ACL 6
is expected to conform to ethical (medical)
standards, inclusion in this publication does Figure 7: Clinical diagnostic tests for ACL injury 7
not constitute a guarantee or endorsement of
the quality or value of such product or of the LIST OF ABBREVIATIONS
claims made of it by its manufacturer. Some of
the products, names, instruments, treatments,
logos, designs, etc. referred to in this journal 4HT Four-strand Hamstring Tendon
are also protected by patents and trademarks ACL Anterior Cruciate Ligament
or by other intellectual property protection ACLR Anterior Cruciate Ligament Reconstruction
laws even though specific reference to this fact
is not always made in the text. Therefore, the ADLS Activities of Daily Living Scale
appearance of a name, instrument, etc. without AP Anteroposterior
designation as proprietary is not to be construed BPB Bone-Patellar Tendon-Bone
as a representation by the publisher that it is in
the public domain. This publication, including all
F/U Follow-up
parts thereof, is legally protected by copyright. HA Hydroxyapatite
Any use, exploitation or commercialization HT Hamstring Tendon
outside the narrow limits of copyrights legislation, MCL Medial Collateral Ligament
without the publisher’s consent, is illegal and
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to photostat reproduction, copying, scanning or NMES Neuromuscular Electrical Stimulation
duplication of any kind, translating, preparation NPV Negative Predictive Value
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and storage. Institutions’ subscriptions allow
PCL Posterior Cruciate Ligament
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address indicated.
Executive summary
The anterior cruciate ligament (ACL) is one of four major ligaments that are important
in stabilizing the knee joint. The main function of the ACL is to prevent anterior tibial
displacement on the femur, increasing stability of the knee. It also stabilizes the knee during
rotation. ACL injuries are common in some sports, particularly soccer and basketball. This
literature review seeks to examine the incidence of ACL injuries, the methods for diagnosis,
and the various treatment techniques.
Injury to the ACL tends to occur when there is a sudden displacement of the tibia in
relation to the femur, and occurs more frequently in females than in males. The ACL can be
partially or completely ruptured. The patient often experiences an audible “pop” at the time
of injury, followed by severe pain, swelling, and a feeling of instability. Three physical tests,
the Lachman, anterior drawer, and pivot shift tests, are commonly used in diagnosing ACL
tears. These tests rely on assessing the movement of the tibia when force is applied, with the
contralateral knee serving as baseline. MR imaging can be used to detect tears of the ACL and
secondary signs of ACL rupture in the surrounding tissues. An arthrometer, a calibrated device
used to measure the arc or range of motion of a joint, can be used to objectively quantify
sagittal translation and to overcome the subjectivity of the physical evaluation. The most
common arthrometer used in ACL diagnosis is the KT-1000 arthrometer.
ACL ruptures are most commonly treated with the use of grafts. The size, cross-sectional
area and bony fixations at the ends of the graft are all important factors to consider when
selecting the most appropriate graft. Autografts, taken from a donor site within the patient,
and allografts, using transplanted tissue, are both used in ACL reconstruction. Autografts can
be harvested from either the patellar or the hamstring tendon. Both involve drilling a tibial
tunnel through to the ACL footprint as well as a femoral tunnel to accept the origin of the graft.
The graft is then inserted into the femoral tunnel and secured with a screw, and fixated to the
tibial tunnel with appropriate tension. The most common form of fixation is via interference
screws used on both the tibial and femoral side. Until now, metal screws have been used in
ACL reconstruction for graft fixation; bioabsorbable screws have recently become an option
for ACL graft fixation and have several advantages, the most important being the eventual
absorption of the screw into the bone.
In this literature review, we found that the Lachman and KT-1000 tests are very sensitive
and specific at diagnosing ACL tears. With some exceptions, MRI is generally viewed as a very
effective technique for diagnosing complete ACL tears and less effective for partial ACL tears.
Secondary signs of ACL tears are very useful when combined with primary signs on MR images.
Allograft ACLR was found to have an overall significantly lower stability rate when
compared to autografts and it is recommended that autograft remain the graft selection of
choice for ACL reconstruction. Overall, four-strand hamstring autograft is now considered to
produce increased stability compared to patellar grafts. Both grafts, however, produce good
results, and either can be used by surgeons to produce excellent outcomes.
Bioabsorbable screws have shown to be just as effective as traditional titanium interference
screws, without the additional disadvantages, and are recommended in ACL reconstruction.
The new allograft interference screw has shown excellent results and surpasses the
composite screws in terms of bony replacement. It is recommended that the new allograft
interference screws be evaluated more thoroughly.
JointEvidence Anterior cruciate ligament

I Introduction
1.1 Pathophysiology and etiology
1.1.2 Anatomy
The anterior cruciate ligament (ACL) is one of four major ligaments that are important in
stabilizing the knee joint. The ACL originates from the posteromedial part of the lateral femoral
condyle on the intercondylar notch, posterior to the longitudinal axis. The ligament extends
anteriorly to insert on an interspinous area on the proximal tibia, in a fossa in front of and
lateral to the anterior spine (Figure 1).
Figure 1: Location of the ACL in the flexed knee joint [1].

The average ACL has a width of about 10 mm and a length of approximately 38 mm.
Innervation is provided by the tibial nerve, while the middle genicular artery, a branch of the
popliteal artery, supplies blood to the ACL [2]. The ACL consists of two main bands: a large
posterolateral band and a smaller anteromedial band (Figure 2).
Figure 2: ACL bundles; AM = anteromedial, PL = Posterolateral [3].

1.1.2 Biomechanics and function

The knee joint has six degrees of freedom in three rotational and three translational
planes. The ACL’s main function is to prevent anterior tibial displacement on the femur, thus
adding stability to the knee. It also stabilizes the knee during rotation. The medial collateral
ligament (MCL) assists the ACL in resisting anterior tibial translation. The ACL is a dynamic
ligament that changes in tension and laxity according to knee position, and the two ACL
bundles work together, each contributing to stability during different parts of the knee’s range
of motion. The posterolateral bundle is tight in extension, while the anteromedial bundle is
more lax. In flexion, however, the roles are reversed as the femoral origin becomes more
horizontal; the anteromedial bundle tightens and the posterolateral bundle has more
slack (Figure 3).
Figure 3: ACL bundles in extension (left) show posteromedial bundle tight and anterolateral moderately lax. ACL
bundles in flexion (right) show the opposite relationship [3]
1.1.3 Mechanism of injury: rupture

Injury to the ACL tends to occur when there is a sudden displacement of the tibia in
relation to the femur. Sex also appears to be associated with ACL rupture.
Noncontact vs contact
ACL injuries are frequently caused by noncontact mechanisms. Twisting is one mechanism
commonly responsible for ACL injury and can result from either internal or external rotation.
This may occur when the foot is planted and the femur twists in a different direction, as shown
in Figure 4. Anterior shear force in the sagittal plane, valgus force in the coronal plane, or
internal/external rotation in the transverse plane are all mechanisms of ACL injury [4].
Figure 4: Twisting mechanism of ACL injury [5]

In sports, this may be the result of a quick change of direction to avoid an opponent
while running, planting the foot and pushing off, pivoting while slowing down from a sprint,
or landing from a jump with great force. Ireland has identified a “position of no return” for
ACL injuries in which the body is flexed forward, the hip is abducted, the knee is internally or
externally rotated with valgus stress, and the foot is pronated (Figure 5) [6].
Figure 5: At-risk position for ACL injury [4]
Forceful hyperextension or hyperflexion can also result in an ACL tear. Another less
common mechanism is direct contact. Tackling, for example, can result in excessive tibial
translation that results in ACL damage.
Gender
Studies have shown that ACL injury is more common in females. Hewett et al states that
there is a 4- to 6-fold increase in ACL injuries in female athletes compared to males playing
the same sports (4). There are various hypotheses to explain the differences, including
anatomical differences in limb alignment (Figure 6), hormonal differences, amount of training,
strength-to-weight ratios, and joint laxity, among others.
Figure 6: The female Q angle is typically larger than that of males, thus females experience
different biomechanical forces on the ACL [7]

1.2 Diagnosis
1.2.1 History and physical signs and symptoms
As with any orthopedic examination, a thorough history should be taken initially. The
patient often experiences an audible “pop” at the time of injury, followed by severe pain,
swelling within 4–12 hours, and a feeling of instability while weight bearing.
1.2.2 Tests: anterior drawer, Lachman, pivot shift test

Anterior drawer test
The anterior drawer test is done while the patient is supine, the knee is flexed to 80–90°
with foot flat and secure on the table and thigh muscles relaxed. The examiner grips the proximal
tibia and applies anterior force while palpating and assessing tibial translation (Figure 7). The
contralateral healthy knee should be used as a baseline for normal tibial movement and
endpoint.
Figure 7: Clinical diagnostic tests for ACL injury [8]
Lachman test
The Lachman test requires the patient to lie supine with the knee flexed 20–30°. The
examiner holds the femur in place with one hand and uses the other to apply anterior force to
the proximal tibia (Figure 7). Using the contralateral healthy knee as a point of reference, the
amount of tibial translation and the integrity of the endpoint is assessed.
Pivot shift test
The pivot shift test involves applying valgus force on an extended knee while internally
rotating the tibia (Figure 7). While these forces are being applied, the knee is taken through
approximately 40° of flexion. A positive test is found when the knee is subluxed in full
extension, then reduces at approximately 30° of flexion.

1.2.3 Imaging: MRI

The literature yields mixed verdicts on the value of MRI as a diagnostic method of ACL
injury detection. Advantages of using MRI for diagnosis of ACL injury include a clear picture
of the joint angles and soft tissues (including ACL), as well as the ability to assess damage
to surrounding structures, which is beneficial in complicated or more severe cases. However,
the static picture of an MRI does not indicate the dynamic properties that can be evaluated in
clinical exam.
1.3 Treatment
1.3.1 Surgical reconstruction
The size, cross-sectional area and bony fixations at the ends of the graft are all important
factors to consider when selecting the most appropriate graft for a patient requiring ACL
reconstruction. The literature is undecided on which graft is the best choice overall; the graft
that can best simulate the normal anatomy should produce the most consistent results [9].
Allograft vs autograft
Autografts, taken from a donor site within the patient, and allografts, using transplanted
tissue, are both used in ACL reconstruction. The advantages of autografts include better graft
source, no rejection or disease transmission, and availability. Disadvantages include extra
incision, prolonged surgical time, and complications (including infection, donor site pain,
and limitation in graft size). Alternatively, a surgeon can use an allograft technique. Allograft
PCL reconstruction is usually selected for complex ligament injuries, revision surgery or
generalized ligamentous laxity [9]. The advantages of allograft include a smaller incision, less
surgical time, and versatility in graft size. The disadvantages, however, include additional cost,
limited availability, potential risk of disease transmission and graft failure or rejection. Some
sources have found that allografts result in more residual laxity than autografts [10].
Bone-patellar tendon-bone vs hamstring grafts
The patellar tendon graft is harvested from the central third of the tendon and includes
bone plugs from the patella and the tibial tubercle. The bone-patellar tendon-bone graft
involves drilling a tibial tunnel through to the ACL footprint, as well as a femoral tunnel to
accept the origin of the graft. The graft is then inserted into the femoral tunnel and secured
with a screw, and fixated to the tibial tunnel with appropriate tension [11].
The hamstring graft technique also requires a femoral and tibial tunnel to be drilled to
fit the graft. The graft is then inserted, tensioned appropriately and secured with a suitable
fixation device.
Both grafts are generally done arthroscopically. The literature tends to suggest that bone-
patellar tendon-bone grafts and four-strand hamstring grafts yield comparable results. Two-
strand hamstring grafts are becoming obsolete due to inferior outcomes in several studies.
Some smaller studies have shown that bone-patellar tendon-bone grafts result in better
stability, but these studies have low statistical power [12].
Mechanism of fixation
Methods of mechanical fixation depend on whether the graft used is a BPB or a hamstring
graft. BPB fixation can be categorized as either direct or indirect. Direct methods include
interference screws, staples, and spiked washers. These compress the graft against the outer
surface of the bone or the wall of the bone tunnel [13]. Indirect methods include cross-pin
fixation and endobuttons.

These methods suspend the graft within the bone tunnel. Direct methods of fixation for
hamstring grafts include interference screws and a claw washer-screw. Indirect methods include
endobutton, transverse pin fixation, and anchors within the tunnel with graft loop suspension [13].
The most common form of fixation is via interference screws used on both the tibial and
femoral side. Interference screws stabilize the graft close to the joint line as well as the sites
of attachment of the active ACL. These screws also compress the bone block of the graft
against the tunnel wall, allowing direct graft-tunnel healing [13]. So far, metal screws have
been used in ACL reconstruction for graft fixation; however, issues have been raised about
the possible long-term effects of metal implants. There is also the inconvenience of revision
surgery to remove the metallic screws. Bioabsorbable screws have recently become an option
for ACL graft fixation and have several advantages, the most important being the eventual
absorption of the screw into the bone.

II Clinical questions
This report will attempt to answer the following clinical questions:
2.1 Clinical outcomes of incidence of ACL injuries

2.1.1 What are the clinical outcomes regarding the incidence of ACL injuries?
2.2 Clinical outcomes of diagnostic technique

2.2.1 What are the clinical outcomes regarding physical examination?
2.2.2 What are the clinical outcomes regarding the imaging techniques for the evaluation
of ACL tears?
2.3 Clinical outcomes of treatment techniques

2.3.1 What are the clinical outcomes regarding ACL reconstruction for:
2.3.1.1 Graft selection
2.3.1.2 Graft type
2.3.1.3 Surgical technique – screws
2.3.2 What are the complications associated with PCL treatment?
2.4 Summary of clinical outcomes

III Data sources and search strategy
We searched Ovid Medline from 1966 to January 2008 to identify studies that described
the clinical outcomes of incidence, diagnosis, and treatment of ACL injuries. Specifically, the
inclusion criteria were:
1) reported clinical (human) data,
2) isolated ACL injuries,
3) adults (over the age of 18 years), and
4) levels of evidence I, II, III, and IV (case series) (Table 2).
We excluded articles on:

1) biomechanics,
2) those done in vitro,
3) case studies,
4) reports focusing on elite athletes,
5) articles not reported in English,
6) ACL damage not resulting from acute injury (eg, chronic injury or deficiency), and
7) letters to the editor/editorials (Level-V evidence).
The search strategy is summarized in Table 1.
Table 1: The search strategy for Ovid Medline

# Search History Results
1 Exp anterior cruciate ligaments/in [injuries] 3749
2 Exp diagnosis/ 4400288
3 1 and 2 2398
4 Exp incidence/ 113019
5 1 and 4 93
6 Magnetic resonance imaging/ 181407
7 1 and 6 461
8 Exp radiography/ 467633
9 1 and 8 103
10 Exp surgical procedures, operative/ 1712612
11 1 and 10 1977
12 Exp Rehabilitation/ 103141
13 1 and 12 189
14 Exercise therapy/ 17224
15 1 and 14 117
16 2 or 4 or 6 or 8 or 10 or 12 or 14 5441004
17 1 and 16 2952
18 Limit 17 to (English language and humans) 2332

We identified 2332 possible articles from Ovid Medline. We also conducted an EMBASE
search, which yielded 1867 articles. Of these 4199 articles, 450 were potentially relevant
(Appendix A). From these searches, 31 clinical articles met the criteria for this review
(11 diagnosis articles and 21 treatment articles) (Appendix B).
IV Quality of the literature for this topic

Due to the vast amount of literature available, we only included randomized controlled
trials and prospective studies in the treatment section, and only Level I and II studies and
Level III and IV studies with more than 50 patients in the diagnosis section. There are
11 diagnosis articles included, 14 Level-I treatment articles, and 7 Level-II treatment articles.
Clinical articles on therapy will be evaluated for the strength of evidence following
the criteria set below (Table 2). Articles with the highest level of evidence will be given the
most attention.
Table 2: Levels of evidence for primary research question

Levels of Evidence for Therapeutic Studies – Investigating the Results of Treatment 1
– High-quality randomized controlled trial with statistically significant difference or no

statistically significant difference but narrow confidence intervals
Level I
– Systematic review2 of Level-I randomized controlled trials (and study results were
homogeneous3)
– Lesser-quality randomized controlled trial (eg, <80% follow-up, no blinding, or improper
randomization)
Level II
– Prospective4 comparative study5
– Systematic review2 of Level-II studies or Level-I studies with inconsistent results
– Case-control study7
Level III – Retrospective6 comparative study5
– Systematic review2 of Level-III studies
Level IV Case series8
Level V Expert opinion
1. A complete assessment of the quality of individual studies requires critical appraisal of all aspects of the study
design.
2. A combination of results from two or more prior studies.
3. Studies provided consistent results.
4. Study was started before the first patient enrolled.
5.Patients treated one way (eg, with cemented hip arthroplasty) compared with patients treated another way (eg,
with cementless hip arthroplasty) at the same institution.
6. Study was started after the first patient enrolled.
7. Patients identified for the study on the basis of their outcome (eg, failed total hip arthroplasty), called “cases,” are
compared with those who did not have the outcome (eg, had a successful total hip arthroplasty), called “controls.”
8. Patients treated one way with no comparison group of patients treated another way.
This chart was adapted from material published by the Centre for Evidence-Based Medicine, Oxford, UK. For more
information, please see www.cebm.net.

V Results
5.1 Clinical outcomes of incidence of ACL injuries

The literature has shown that ACL tears vary based on gender and sport. One
meta-analysis evaluating the incidence of ACL tears is reviewed and conclusions are made.
Prodromos et al conducted a meta-analysis that looked at the incidence of ACL tears by
gender and by sports [14]. The results of his study can be seen in Table 3.
Table 3: Incidence of ACL tears by gender and by sport [14]

Sports Female Male Female-Male Ratio
Basketball
Highschool 0.09 0.02 4.5
Collegiate 0.29 0.08 3.63
Professional 0.20 0.21 0.95
Soccer
Collegiate 0.32 0.12 2.67
Indoor 5.21 1.88 2.77
Alpine skiing
Ski lodge employees (no gender difference) 0.03 0.03 1.00
General population (no gender difference) 0.52 0.52 1.00
Lacrosse 0.18 0.17 1.06
Football (all male) 0.08
Handball
Study 1 0.86 0.24 3.59
Study 2 0.56 0.11 5.01
Australian-Rules Football (all male) 0.04
Rugby 0.36 0.18 2

Wrestling 0.77 0.19 4.1
Females showed more injuries than males in nearly every sport they participated in. In
descending order, the female-male ratios are as follows: wrestling (4.05), basketball (3.5),
indoor soccer (2.77), soccer (2.67), rugby (1.94), lacrosse (1.18), and alpine skiing (1.00). In
general, female athletes have a, roughly, three times higher incidence of ACL tears in soccer
and basketball than their male counterparts. Recreational alpine skiers had the highest
incidence of ACL tears, whereas experts had the lowest incidences. Volleyball was also
included in this study; however, no ACL tears were found, suggesting that volleyball may
actually have the lowest incidence of all sports reviewed.
Overall, females showed a higher incidence of ACL tears than males in sporting activities,
and the sports with the most frequently reported ACL tears were basketball and soccer,
with a particularly high rate in indoor soccer. It was also shown that the level of experience,
specifically in terms of skiing, affected the risk of ACL tears.

5.2 Clinical outcomes of diagnostic techniques

The parameters for evaluating diagnostic techniques are derived from the correlation of
the “gold standard” and the predictive test (Table 4).
Table 4: Methods of calculations
Gold Standard
Positive Negative
Positive True Positive (TP) False Negative (FN)

Predictive Test
Negative False Positive (FP) True Negative (TN)
Diagnostic techniques are typically evaluated in terms of the following parameters:
1. Accuracy: identifies how well the diagnostic method correctly identifies or excludes
an ACL tear.
(True negative + True positive)
Accuracy =
Total Cases
2. Sensitivity: is how good the diagnostic test is at detecting ACL tears. It is the number
of ACL injuries correctly diagnosed by the respective diagnostic method divided by the total
number of ACL tears.
True positive
Sensitivity =
(True positive + False negative)
3. Specificity: is how good the diagnostic test is at identifying a normal knee. It is the
number of correctly diagnosed intact ACLs divided by the total number of intact ACLs.
True negative
Specificity =
(True negative + False positive)
4. Positive Predictive Value (PPV): the relative probability that an ACL labeled
“pathological” by the respective diagnostic method is indeed pathological.
True positive
PPV =
(True positive + False positive)
5. Negative Predictive Value (NPV): the relative probability that an ACL labeled “not
pathological” by the respective diagnostic method is indeed intact.
True negative
NPV =
(True negative + False negative)

Due to the nature of the diagnostic data regarding ACL injuries, poolable results were not
obtainable. Therefore, referral to specific high-level articles that compare different diagnostic
techniques will be used to determine conclusions.

5.2.1 Physical tests

Scholten et al conducted a meta-analysis of the accuracy of physical diagnostic tests
in ACL diagnosis [15]. This study pooled data from 17 studies examining the accuracy of the
Lachman, anterior drawer and pivot shift tests; the results can be seen in Table 5.
Table 5: Sensitivity and specificity of three physical tests [15]

Test Sensitivity Specificity
Lachman 86% 91%
Anterior drawer 62% 88%
Pivot shift 18–48% 97–99%
The Lachman test was found to have both the greatest sensitivity and the greatest
specificity; the anterior drawer test scored slightly lower in both categories, and the pivot shift
test, while very specific, was found to be much less sensitive. Only one other study examined
the sensitivity of these three tests, and similarly found the Lachman to be the most sensitive,
at 95%, and the anterior drawer test to be 61% sensitive; the sensitivity of the pivot shift test,
however, was much higher than the range found by Scholten et al, at 71% [15, 16].
A study by Mitsou et al that examined the effect of anaesthesia on Lachman and anterior
drawer test results found that when patients were examined under general anaesthesia, the
ability of the anterior drawer test to diagnose a tear correctly was dramatically improved [17].
The outcome of physical tests is affected by the state of the surrounding tissues, and relaxing
the relevant muscles with anesthesia could improve diagnostic accuracy, especially in acute
ruptures; these findings need to be replicated.
Arthrometry was developed to objectively quantify sagittal translation and to overcome
the subjectivity of the physical evaluation. It is a calibrated device used to measure the arc
or range of motion of a joint. The most common arthrometer used in ACL diagnosis is the
KT-1000 arthrometer. Only two studies evaluated the diagnostic accuracy of the KT-1000
arthrometer, and both found it to have fairly high sensitivity: Liu et al found KT-1000 results to
be comparable to Lachman test results, and significantly better than all other tests; Rijke et
al found 80% sensitivity and 100% specificity for the KT-1000 in the diagnosis of complete or
partial ACL tears [16, 18].
5.2.2 Imaging
A common technique used for the diagnosis of ACL tears is magnetic resonance imaging;
although uncommon, sonography has also been found to be an effective tool [19]. Magnetic
resonance imaging can be a very useful tool in evaluating the presence of ACL injuries. It is a
well-established diagnostic method for the knee, and is referred to frequently in the literature.
Of the diagnostic studies examined, the majority focused on various MRI techniques, and
found a wide range of sensitivity and specificity. In addition to assessing primary signs of ACL
tear, MRI can be used to assess secondary signs, such as bone contusion and femoral sulcus
depth; a number of studies found that assessing secondary signs of ACL tear greatly improved
diagnostic accuracy [20–26]. Table 6 shows the accuracy, sensitivity and specificity of the
most common primary and secondary signs of ACL tear seen in MRI.

Table 6: Diagnostic efficacy of primary and secondary ACL tear signs on MRI
Accuracy Sensitivity Specificity
Conventional MRI criteria 90 82 89
Primary
Direct signs of ACL tear 93 97
Fiber discontinuity 93 98
Secondary
Anterior tibial subluxation 86 99
Bone contusion, anterior tibial translation 82 90
Bone bruise 69 89.5
Posterior lateral tibial plateau bruise 48 97
Posterior lateral tibial plateau and condyle bruise 34.5 100

Posterior displacement of posterior horn of lateral
41 98.5
meniscus
Deep femoral sulcus 60 9 100
Angle of PCL 79 82.5
ACL angle 87
AT angle 87.4 93.3 84.2
Primary signs are better for diagnosing tears than are secondary signs; secondary signs
should not be used alone, and are useful primarily in cases where the MR appearance of the
ligament itself is equivocal [20, 23]. Secondary signs are seen in both partial and complete
tears, and should not be used alone to distinguish between complete and partial tears [23].
In general, MRI was found to be less sensitive for partial than for complete tears; Umans et al
found MRI alone to be insufficient in the diagnosis of partial tears [24, 27]. Vellet et al found
that field strength had no effect on diagnostic accuracy [28].
Sonography is an ultrasound-based medical imaging technique used to visualize internal
structures of the body. In a prospective study of 37 patients, Ptasznik et al evaluated the
efficacy of sonography in the diagnosis of ACL injuries in the presence of a recent traumatic
hemarthrosis [19]. This study found a sensitivity of 91%, a specificity of 100%, and positive and
negative predictive values of 100% and 63%, respectively, suggesting that sonography may be
a promising method for ACL tear diagnosis. However, this study had a relatively small sample
size, and few other studies have been conducted on the use of sonography for this purpose.
Very few high-quality studies have been conducted on the diagnostic accuracy of physical
tests and imaging in the diagnosis of ACL tears, and there is no standard protocol for their
diagnosis. Hartnett et al report that, of 70 patients with ACL tears, only 16% were diagnosed
correctly at their first doctor visit, and 36% visited three or more doctors before an accurate
diagnosis was made [29]. ACL injury is very common in a variety of sports, and can be quite
debilitating; early, accurate diagnosis is crucial to patient recovery, and it is important to focus
on the development of simple and accurate diagnostic techniques.

5.3 Clinical outcomes of treatment techniques
The treatment of ACL tears is typically ACL reconstruction, and will be the focus of the
results for the treatment section. Data was collected on the various treatment options for ACL
reconstruction and weighted means were formulated to compare outcomes.
5.3.1 ACL reconstruction
5.3.1.1 Graft selection – autograft or allograft

ACL reconstruction is a complex procedure that involves replacing the ACL ligament
with another graft. There are a number of areas in the ACL reconstruction that can vary, the
first being the type of graft. Two options are available: autograft and allograft. The traditional
method used is autografts; however, allografts have gained popularity in recent years, despite
high failure rates [30]. Prodromos and colleagues conducted a meta-analysis reviewing the
effectiveness of autografts and allografts for ACL reconstruction. Based on previous reported
literature, the authors predicted that allografts would demonstrate overall lower objective
stability rates compared to autografts [30]. The results of their study are in Table 7.
Table 7: Outcomes of autograft versus allograft PCL reconstructions [30]

Autograft Allograft
Overall normal stability rate 72% 59%
BPB 66% 57%
Hamstring 77% 64%
Overall abnormal stability rates 5.3% 14%
BPB 5.9% 16%

Hamstring 4.7% 12%
The results of this study show that allograft ACL reconstruction produces a significantly
lower level of stability than autograft ACL reconstruction. Abnormal stability, which the authors
report usually represents a failed graft, was 2–3 times higher for allografts than for autografts.
Prodromos also reported possible causes for the decreased rates of stability for allograft ACL
reconstruction. The results of this can be seen in Table 8.
Table 8: Possible causes of increased allograft clinical laxity [30]

Resource
Immunological response [31, 32]
Freezing Cryolife
Lack of cryopreservation Cryolife
Increased donor age [33]
Subclinical infection [34]

Radiation sterilization [35, 36]

Freezing of the allografts can pose a problem, since the tendon is typically frozen twice
and thawed twice, which can cause damage to the tissue. An immunological response can
also be seen, which may result in weakening of the graft or inhibition of cellular ingrowth. The
age of the donor can also have an effect, with a trend towards more failure in older donors.
A high waiting time between harvesting the graft and the ACL reconstruction has also been
correlated with an increased ACL graft failure. Infection can also occur readily, even after
low-level irradiation. Lastly, allografts can use radiation to sterilize the graft, which can weaken
the graft [30].
Overall, Prodromos’ meta-analysis reports that allograft ACLR has an overall significantly
lower stability rate when compared to autografts [30]. It is recommended that autograft remain
the graft selection of choice for ACL reconstruction.
5.3.1.2 Graft location

Two graft tendons are currently used in the medical field for ACL reconstruction: the
hamstring tendon and the patellar tendon. Much debate exists over which tendon yields the
best results. Data was pooled on high-level studies and the results can be seen in Table 9.
Table 9: Outcomes of type of graft for ACL reconstruction

Hamstring Patellar
Lysholm score 92.1 95.2
Loss of flexion (deg) 3.3 2.6
Loss of extension (deg) 1.4 2.9
Side-to-side difference (mm) 2.0 1.4
Complications (% of pts) 6.6 15.6
The patellar tendon shows higher Lysholm scores, and less loss of flexion, but greater
loss of extension than the hamstring tendon. The side-to-side difference is greater in the
hamstring tendon groups, where more complications were reported in the patellar groups.
Overall, the pooled data appears to be split between hamstring and patellar tendons for ACL
reconstruction. Numerous meta-analysis studies were done comparing hamstring tendon with
patellar tendon for ACL reconstruction. The results of each of these articles are summarized
in Table 10.
Table 10: Summary of outcomes of high-level studies comparing hamstring and patellar tendons in ACLR
Number
Type of
of Studies Author Results
study
Included
Meta- Biau et al, Patients with 4HT autografts report fewer anterior knee symptoms
24
analysis 2006 and extension deficits than patients with BPB autografts.
The incidence of instability is not significantly different between
Meta- Goldblatt et BPB and 3–4HT grafts, however, BPB was more likely to result in
11
analysis al, 2005 reconstruction with normal Lachman, pivot shift, KT-1000, and SSD,
and fewer results with significant flexion loss.
Meta- Prodromos, 4HT showed lower morbidity and high stability rates over BPB,
64
analysis Joyce, 2006 making it the “gold standard” graft for ACLR.

The general consensus amongst the meta-analyses is that hamstring tendon autograft
produces increased stability over patellar tendon autograft, if the hamstring tendon is 4
strands. Hamstring tendons that were 2 or 3 strands did not appear to produce these results
[38]. Each of the meta-analyses included in Table 10 is described here in more detail.
Biau et al compared BPB autografts with hamstring autografts for ACL reconstruction
(ACLR) [37]. A literature search was done through Medline as well as other databases to
produce 1494 articles, of which 24 studies (1512 patients) were useable in the meta-analysis.
The inclusion criteria were RCT reporting one or more outcomes related to stability and
morbidity. The weighted mean difference of knee laxity was 0.36. The relative risk of a positive
Lachman test was 1.22, of anterior knee pain 0.57, of positive kneeling test 0.26, and of loss of
extension 0.52. Overall, morbidity was lower for HT autografts than for BPB autografts [37].
Goldblatt et al conducted a systematic meta-analysis review comparing BPB and
hamstring autograft for ACLR [38]. A literature search was done through Medline database,
where studies with follow-up periods of greater than 2 years, and identical rehabilitation
protocols were followed were included. Eleven reports were included. The patellar tendon was
favored in the results: normal Lachman test (RR 0.91), normal pivot shift test (RR 0.94), KT-1000
SSD difference of < 3 mm (RR 0.75), and fewer reconstructions resulting in flexion loss >5˚
(RR1.41). Outcomes that favored the hamstring tendon (HT) were absence of patellofemoral
crepitance (RR 1.08), fewer results with extension loss >5˚ (RR 0.56), and kneeling pain.
Instability was not significantly different between the two groups [38].
Prodromos and Joyce compared 4-strand hamstring tendon (4HT) to BPB grafts for ACLR
in a meta-analysis [39]. Studies with at least 2 years’ follow-up that reported stability results
and that used at least 30 lb of arthrometric force were used. Sixty-four articles were included.
The results show that 4HT had significantly higher normal stability than BPB (77% to 69%
respectively) and lower abnormal stability (4.7% to 5.9% respectively). Overall, Prodromos and
Joyce consider 4-strand hamstring graft the “gold standard” graft for ACLR [39].
Overall, four-strand hamstring autograft can be a reliable method for ACL reconstruction,
and is now considered to produce increased stability compared to patellar grafts. Both
grafts, however, produce good results, and either can be used by surgeons to produce
excellent outcomes.
5.3.1.3 Surgical technique – screws

Two varieties of screws exist for the attachment of the graft in ACL reconstruction: metallic
interference screws and bioabsorbable interference screws. The interference screw is the
traditional method of fixation, and still remains the most frequently used technique [40]. It
provides high internal fixation strength, but can cause potential problems such as hardware
removal during revision surgery and distorted postoperative MRI evaluations [40]. In recent
years bioabsorbable screws have become an option and have typically shown good results;
however, it is associated with a number of complications, such as reduced failure strength,
osteolysis, resorption, and inflammatory response [40, 41]. From the literature search, two high
level studies were identified and are discussed.
Fink et al conducted a prospective randomized study of 40 patients undergoing ACL
reconstruction to compare the two different screw techniques: bioabsorbale polyglyconate
interference screws and titanium interference screws [40]. The clinical results between the
two groups did not show significant differences, and no additional complications were seen
in the group who received the bioabsorbable polyglyconate interference screws. The authors
conclude that the new bioabsorbable screws are just as effective as the traditional screws,
and the typical time for degradation for the bioabsorbable screws was 12 months. The major
downfall for the bioabsorbable screws was that bone replacement was not seen until up to 3
years after surgery [40].

Tecklenburg et al conducted a study that looked at the issues raised by Fink et al [40, 41].
Bioabsorbable screws are safe and provide good fixation, but degradation times are highly
variable and bony replacement of the screws may be delayed (as in Fink et al’s study) or may
not even occur. Tecklenburg, thus, decided to look at the newly introduced composite screws
that enhance bony integration by adding osteconductive substances to the bioabsorbable
screws. Two different composite interference screws exist: poly-L-lactid acid/hydroxyapatite
composite screws (group A), poly-L-lactic acid/β-tricalcium phosphate composite screws
(group B). These were compared to new allograft interference screws, made out of bone. All
three screw types provided adequate graft fixation and were associated with excellent clinical
results and no inflammatory responses on MRI evaluation. Bony allograft screws, however,
were the only screws that showed complete bony integration after 24 months [41].
Overall, bioabsorbable screws have shown to be just as effective as traditional
titanium interference screws, without the additional disadvantages. The major downside of
bioabsorbable screws, however, is the delayed bony replacement. This can be accounted for
when osteoconductive substances are added to the screw. The new allograft interference
screw, though, has shown excellent results and surpasses the composite screws in terms
of bony replacement. It is recommended that bioabsorbable screws be used in ACL
reconstruction, and that the new allograft interference screws be evaluated more thoroughly.
5.3.2 Complications
There were quite a number of complications reported from ACL reconstruction. Table 11
is a list of the complications associated with ACL treatment and the frequency of each in the
literature review.
Table 11: List of complications reported in the literature

Complications Number
Crepitus 64
Revision surgery 10
Infection 6
Screw breakage during insertion 2
Arthrofibrosis 1
Cyclops lesion 1
Deep vein thrombosis 1
Graft rupture 1
Intraoperative patellar fracture 1

Reflex sympathetic dystrophy 1
The most frequently reported complication is crepitus, which is the term used to describe
the grating and cracking sounds and sensations in the knee joint. Revision surgery was also
reported, with 10 cases found in the literature. Generally, however, complications were not
frequently reported, limiting our conclusions.

5.4 Summary of clinical outcomes
The final conclusions to the results section are summarized below:
Incidence
−− F emales show a higher incidence of ACL tear than males in sporting activities, and the
sports with the most reported ACL tears are soccer and basketball.
Diagnosis
−− T he Lachman and KT-1000 tests are very sensitive and specific at diagnosing ACL
tears.
−− With some exceptions, MRI is generally viewed as a very effective technique for
diagnosing complete ACL tears and less effective for partial ACL tears.
−− S econdary signs of ACL tear are very useful when combined with primary signs on MR
images.
−− Sonography may be a promising method for ACL tear diagnosis.
Treatment
−− A llograft ACLR has an overall significantly lower stability rate when compared to
autografts and it is recommended that autograft remain the graft selection of choice
for ACL reconstruction.
−− O verall, 4-strand hamstring autograft can be a reliable method for ACL reconstruction,
and is now considered to produce increased stability compared to patellar grafts.
Both grafts, however, produce good results, and either can be used by surgeons to
produce excellent outcomes.
−− B ioabsorbable screws have shown to be just as effective as traditional titanium
interference screws, without the additional disadvantages, and are recommended in
ACL reconstruction.
−− T he new allograft interference screw has shown excellent results and surpasses the
composite screws in terms of bony replacement. It is recommended that the new
allograft interference screws be evaluated more thoroughly.
−− Complications were not frequently reported, limiting our conclusions.

VI Area of uncertainty
Despite the large number of ACL injury, diagnosis and treatment studies available, few
were high-quality studies, particularly on the topics of incidence and diagnosis. Since the
diagnosis of this injury has been shown to be difficult, more high-quality studies are needed.
Studies have reported a difference in acute and chronic ACL injuries, but many articles do
not separate the two in their results. Outcomes can vary depending on whether the ACL tear
is acute or chronic. Therefore, the duration of injury should be separated when determining
the outcomes of ACL treatment. Since this was not done in most cases, the results are
affected and less reliable. In the studies examined, the results reported could not be pooled
as a variety of measuring standards were used; a standardized battery of tests for diagnosis
efficacy or treatment effectiveness would be useful in future studies.
Generally, only a limited number of high-level studies were found, and more research is
needed before definite recommendations can be made.
VII Recommendations and future research

Additional high-quality research is needed in order to determine the best diagnostic tests
and treatment techniques for ACL injuries. Multiple research initiatives have been completed
on ACL treatment; however, it is difficult to make definitive recommendations on the optimal
diagnostic tests and treatment techniques due to the small amount of high-level evidence
available. High-quality studies that use validated, patient-centered outcome measures are
needed in order to determine the best techniques.

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APPENDIX A: Ovid Medline and EMBASE search

results
Database: Ovid Medline and EMBASE
Relevant Articles: 450
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Pereira, ER, Ryu, KN, Ahn, JM, et al (1998). Evaluation of the anterior cruciate ligament of the knee: Comparison
between partial flexion true sagittal and extension sagittal oblique positions during MR imaging. Clinical
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Perko, MMJ, Cross, MJ, Ruske, D, et al (1992). Anterior cruciate ligament injuries. Clues for diagnosis. Medical
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Perry, MC, Morrissey, MC, King, JB, et al (2005). Effects of closed versus open kinetic chain knee extensor
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Petersen, W, Zantop, T (2006). Partial rupture of the anterior cruciate ligament. Arthroscopy; 22(11):1143–1145.
Pfeiffer, RP, Shea, KG, Roberts, D, et al (2006). Lack of effect of a knee ligament injury prevention program on
the incidence of noncontact anterior cruciate ligament injury. Journal of Bone & Joint Surgery – American Volume;
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Plaweski, S, Julliard, R, Rosell, P (2006). Navigation in anterior cruciate ligament reconstruction. Techniques in
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Prodromos, C, Joyce, B, Shi, K (2007). A meta-analysis of stability of autografts compared to allografts after
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Prodromos, CC, Joyce, BT, Shi, K, et al (2005). A meta-analysis of stability after anterior cruciate ligament
reconstruction as a function of hamstring versus patellar tendon graft and fixation type. Arthroscopy; 21(10):1202.

Prokopis, PM, Schepsis, AA (1999). Allograft use in ACL reconstruction. Knee; 6(2):75–85.
Ptasznik, R, Feller, J, Bartlett, J, et al (1995). The value of sonography in the diagnosis of traumatic rupture of
the anterior cruciate ligament of the knee. American Journal of Roentgenology; 164(6):1461–1463.
Puddu, G, Cipolla, M, Cerullo, G, et al (1993). Anterior cruciate ligament reconstruction and augmentation with
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Rijke, AM, Perrin, DH, Goitz, HT, et al (1994). Instrumented arthrometry for diagnosing partial versus complete
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Snyder-Mackler, L (1995). Fate of the ACL-injured patient: A prospective outcome study. American Journal of
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Solomon, DH, Simel, DL, Bates, DW, et al (2001). Does this patient have a torn meniscus or ligament of the
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Svensson, M, Sernert, N, Ejerhed, L, (2006). A prospective comparison of bone-patellar tendon-bone
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Tow, BP, Chang, PC, Mitra, AK, et al (2005). Comparing 2-year outcomes of anterior cruciate ligament
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Trieshmann, HW Jr, Mosure, J (1997). A comparison of accuracy between clinical examination and magnetic
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Tyler, TF, McHugh, MP, Gleim, GW, et al (1998). The effect of immediate weightbearing after anterior cruciate
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Tyler, TF, Nicholas, SJ, Hershman, EB, et al (2004). The effect of creatine supplementation on strength recovery
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Umans, H, Wimpfheimer, O, Haramati, N, et al (1995). Diagnosis of partial tears of the anterior cruciate
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Warden, WH, Friedman, R, Teresi, LM, et al (1999). Magnetic resonance imaging of bioabsorbable polylactic
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Webster, KE, Feller, JA, Hameister, KA (2001). Bone tunnel enlargement following anterior cruciate ligament
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West, RV, Harner, CD (2005). Graft selection in anterior cruciate ligament reconstruction. Journal of the
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Williams, RJ 3rd, Hyman, J, Petrigliano, F, et al (2005). Anterior cruciate ligament reconstruction with a four-
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Wilson, JB, Wittstein, JR, Moorman III, CT (2006). Patella fractures with bone-patella tendon-bone autografts
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Woods, GA, Indelicato, PA, Prevot, TJ (1991). The gore-tex anterior cruciate ligament prosthesis: Two- versus
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Wright, RW, Fetzer, GB (2007). Bracing after ACL reconstruction: A systematic review. Clinical Orthopaedics &
Related Research; 455:162–168.
Yao, L, Gentili, A, Petrus, L, et al (1995). Partial ACL rupture: An MR diagnosis? Skeletal Radiology; 24(4):247–251.
Yasuda, K, Kondo, E, Ichiyama, H, et al (2006). Clinical evaluation of anatomic double-bundle anterior cruciate
ligament reconstruction procedure using hamstring tendon grafts: Comparisons among 3 different procedures.
Arthroscopy - Journal of Arthroscopic and Related Surgery; 22(3):240–251.
Yasuda, K, Tsujino, J, Tanabe, Y, et al (1997). Effects of initial graft tension on clinical outcome after anterior
cruciate ligament reconstruction. Autogenous doubled hamstring tendons connected in series with polyester
tapes. American Journal of Sports Medicine; 25(1):99–106.
Yerys, P (2007). Anterior cruciate ligament reconstruction using allograft: Single tunnel technique. Sports
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Yoshiya, S, Kurosaka, M, Ouchi, K, et al (2002). Graft tension and knee stability after anterior cruciate ligament
reconstruction. Clinical Orthopaedics and Related Research; (394):154–160.
Yu, JS, Bosch, E, Pathria, MN, et al (1995). Deep lateral femoral sulcus: Study of 124 patients with anterior
Zaffagnini, S, Marcacci, M, Lo Presti, M, et al (2006). Prospective and randomized evaluation of ACL
reconstruction with three techniques: A clinical and radiographic evaluation at 5 years follow-up. Knee Surgery,
Zatterstrom, R, Friden, T, Lindstrand, A, (2000). Rehabilitation following acute anterior cruciate ligament injuries
– a 12-month follow-up of a randomized clinical trial. Scandinavian Journal of Medicine & Science in Sports;
10(3):156–163.
Zatterstrom, R, Friden, T, Lindstrand, A, (1998). Early rehabilitation of acute anterior cruciate ligament injury – a
randomized clinical trial. Scandinavian Journal of Medicine & Science in Sports, 8(3):154–159.
Zelle, BA, Brucker, PU, Feng, MT, (2006). Anatomical double-bundle anterior cruciate ligament reconstruction.
Zelle, BA, Herzka, AS, Harner, CD, et al (2005). Evaluation of clinical outcomes in anterior cruciate ligament
surgery. Operative Techniques in Orthopaedics; 15(1):76–84.
Zhao, J, He, Y, Wang, J (2007). Double-bundle anterior cruciate ligament reconstruction: Four versus eight
strands of hamstring tendon graft. Arthroscopy; 23(7):766–770.
APPENDIX B: Articles by level of evidence

Diagnosis
Brandser, EA, Riley, MA, Berbaum, KS, et al (1996). MR imaging of anterior cruciate ligament injury:
Independent value of primary and secondary signs. American Journal of Roentgenology; 167(1):121–126.
Chan, WP, Peterfy, C, Fritz, RC, et al (1994). MR diagnosis of complete tears of the anterior cruciate ligament of
the knee: Importance of anterior subluxation of the tibia. American Journal of Roentgenology; 162(2):355–360.

Liu, SH, Osti, L, Henry, M, et al (1995). The diagnosis of acute complete tears of the anterior cruciate ligament.
comparison of MRI, arthrometry and clinical examination. Journal of Bone & Joint Surgery – British Volume;
77(4):586–588.
McCauley, TR, Moses, M, Kier, R, et al (1994). MR diagnosis of tears of anterior cruciate ligament of the knee:
Importance of ancillary findings. American Journal of Roentgenology; 162(1):115–119.
Mitsou, A, Vallianatos, P (1988). Clinical diagnosis of ruptures of the anterior cruciate ligament: A comparison
between the Lachman test and the anterior drawer sign. Injury; 19(6):427–428.
Murao, H, Morishita, S, Nakajima, M, et al (1998). Magnetic resonance imaging of anterior cruciate ligament
(ACL) tears: Diagnostic value of ACL-tibial plateau angle. Journal of Orthopaedic Science; 3(1):10–17.
Ptasznik, R, Feller, J, Bartlett, J, et al (1995). The value of sonography in the diagnosis of traumatic rupture of
the anterior cruciate ligament of the knee. American Journal of Roentgenology; 164(6):1461–1463.
Rijke, AM, Perrin, DH, Goitz, HT, et al (1994). Instrumented arthrometry for diagnosing partial versus complete
anterior cruciate ligament tears. American Journal of Sports Medicine; 22(2):294–298.
Siwinski, D, Ziemianski, A (1998). Value of posterior cruciate ligament index in the diagnosis of anterior cruciate
ligament injuries. Archives of Orthopaedic and Trauma Surgery; 118(1/2):116–118.
Umans, H, Wimpfheimer, O, Haramati, N, et al (1995). Diagnosis of partial tears of the anterior cruciate
ligament of the knee: Value of MR imaging. American Journal of Roentgenology; 165(4):893–897.
Yao, L, Gentili, A, Petrus, L, et al (1995). Partial ACL rupture: An MR diagnosis? Skeletal Radiology; 24(4):247–251.
Yu, JS, Bosch, E, Pathria, MN, et al (1995). Deep lateral femoral sulcus: Study of 124 patients with anterior
Treatment
Level I evidence (randomized controlled trials)
Almekinders, LC, de Castro, D (2001). Fixed tibial subluxation after successful anterior cruciate ligament
reconstruction. American Journal of Sports Medicine; 29(3):280–283.
Ejerhed, L, Kartus, J, Kohler, K, et al (2001). Preconditioning patellar tendon autografts in arthroscopic
anterior cruciate ligament reconstruction: A prospective randomized study. Knee Surgery, Sports Traumatology,
Engebretsen, L, Benum, P, Fasting, O, et al (1990). A prospective, randomized study of three surgical
techniques for treatment of acute ruptures of the anterior cruciate ligament. American Journal of Sports Medicine;
18(6):585–590.
Feller, JA, Webster, KE (2003). A randomized comparison of patellar tendon and hamstring tendon anterior
cruciate ligament reconstruction. American Journal of Sports Medicine; 31(4):564–573.
Fitzgerald, GK, Piva, SR, Irrgang, JJ (2003). A modified neuromuscular electrical stimulation protocol for
quadriceps strength training following anterior cruciate ligament reconstruction. Journal of Orthopaedic & Sports
Gobbi, A, Mahajan, S, Zanazzo, M, et al (2003). Patellar tendon versus quadrupled bone-semitendinosus
anterior cruciate ligament reconstruction: A prospective clinical investigation in athletes. Arthroscopy; 19(6):592–601.
Hess, T, Duchow, J, Roland, S, et al (2002). Single- versus two-incision technique in anterior cruciate ligament
replacement: Influence on postoperative muscle function. American Journal of Sports Medicine; 30(1):27–31.
Jepsen, CF, Lundberg-Jensen, AK, Faunoe, P (2007). Does the position of the femoral tunnel affect the laxity
or clinical outcome of the anterior cruciate ligament-reconstructed knee? A clinical, prospective, randomized,
double-blind study. Arthroscopy; 23(12):1326–1333.
Joseph, M, Fulkerson, J, Nissen, C, et al (2006). Short-term recovery after anterior cruciate ligament
reconstruction: A prospective comparison of three autografts. Orthopedics; 29(3):243–248.
McCormack, RG, Greenhow, RJ, Fogagnolo, F, et al (2006). Intra-articular drain versus no drain after
arthroscopic anterior cruciate ligament reconstruction: A randomized, prospective clinical trial. Arthroscopy;
22(8):889–893.
Meighan, AA, Keating, JF, Will, E (2003). Outcome after reconstruction of the anterior cruciate ligament in
athletic patients. A comparison of early versus delayed surgery. Journal of Bone & Joint Surgery – British Volume;
85(4):521–524.

Ohta, H, Kurosawa, H, Ikeda, H, et al (2003). Low-load resistance muscular training with moderate restriction
of blood flow after anterior cruciate ligament reconstruction. Acta Orthopaedica Scandinavica; 74(1):62–68.
Shaw, T, Williams, MT, Chipchase, LS (2005). Do early quadriceps exercises affect the outcome of ACL
reconstruction? A randomised controlled trial. Australian Journal of Physiotherapy; 51(1):9–17.
Webster, KE, Feller, JA, Hameister, KA (2001). Bone tunnel enlargement following anterior cruciate ligament
reconstruction: A randomised comparison of hamstring and patellar tendon grafts with 2-year follow-up. Knee
Level II evidence (prospective comparative studies)
Fink, C, Benedetto, KP, Hackl, W, et al (2000). Bioabsorbable polyglyconate interference screw fixation in
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Interference Screws. The Journal of Arhtroscopic and Related Surgery; 22(9)(Sept):993–999.

APPENDIX C: Detailed data of diagnostic studies
Table C-1: Detailed data from individual studies

Author
Population ACL Tear Diagnosis Method Results Conclusions
JointEvidence
(year)
N = 38 Acute complete ACL Clinical and physical Sensitivity: There were no significant differences found
M = 27 tear examination, MRI – MRI: 82% between the results from the Lachman test and
F = 11 – Lachman: 95% the KT-1000 manual maximum test, and these
Age = 26 years – Pivot shift: 71% were significantly better than all other tests.
Time from injury = 3 days – Anterior drawer: 61% The diagnosis of a complete ACL rupture can
– KT-1000 15 lb: 84% be reliably made clinically without the added
Liu et al (1995)
5/2009
– KT-1000 20 lb: 87% expense of a preoperative MRI.

– Active displacement: 95%
– Manual maximum: 97%
N = 68 ACL tear MRI Sensitivity : Ancillary MR imaging findings may be helpful
M = 44 – Bruise of any bone: 59.5% for diagnosing tears of the ACL when diagnosis
F = 24 – Bruise of posterior lateral tibial plateau: 48% based on the MR appearance of the ligament
Age = 31 years – Bruise of posterior lateral tibial plateau and is equivocal. Ancillary findings cannot be used
condyle: 34.5% to differentiate partial from complete ACl tears,
– Posterior displacement of posterior horn of as these findings were seen in both groups of
lateral meniscus: 56% patients.
– Angle of posterior cruciate ligament <105°: 73%
Specificity :
– Bruise of any bone: 89.5%
– Bruise of posterior lateral tibial plateau: 97%
McCauley et al (1993)
– Bruise of posterior lateral tibial plateau and
condyle: 100%
– Posterior displacement of posterior horn of
lateral meniscus: 98.5%
– Angle of posterior cruciate ligament <105°:
82.5%
N = 60 Acute ACL rupture Clinical and physical Positive rupture of ACL without anesthesia: The diagnostic accuracy of the Lachman test in
Age = examination – Anterior drawer test: 40% recent ruptures when the patient is examined
Time from injury = 3 days – Lachman test: 80% without anesthesia is superior to the anterior
Positive rupture of ACL with anesthesia: drawer test. The Lachman test is a highly
– Anterior drawer test: 93.33% accurate test in diagnosing anterior cruciate
– Lachman test: 96.66% ligament ruptures in the emergency room
with the knee examined in only 20° of flexion
Mitsou et al (1988)
comfortably accepted by the patient instead of
the 90° required for the anterior drawer test.
N = 105 ACL tear MRI, AT angle Sensitivity : When an AT angle of 45° or less was set as
M = 65 measurement – AT angle measurement: 93.3% the criterion defining a tear of the ACL, the
F = 40 Specificity : diagnostic accuracy of the AT angle method was
(1997)
Age = 27.4 years – AT angle measurement: 84.2% 87.4%; sensitivity was 93.3%, and specificity,
Murao et al
Time from injury = 24 months Accuracy : 84.2%.
– AT angle measurement: 87.4%
page – 47
JointEvidence
Author
(year)
N = 37 Acute ACL injury Sonography Sensitivity: Sonography is a useful and inexpensive
with presence −− Sonography: 91% method of detecting the presence of rupture
5/2009
of traumatic Specificity: of the ACL in the clinical setting of a traumatic

hemarthrosis −− Sonography: 100% hemarthrosis.
Positive predictive value:
−− Sonography: 100%
Negative predictive value:
Ptasznik et al (1995)
−− Sonography: 63%
N = 19 Partial or complete KT-1000 arthrometry Sensitivity: A diagnostic distinction between partial and
M=6 ACL tear −− Arthroscopy: 80% complete tears can be made with a satisfactory
F = 13 Specificity: degree of sensitivity and specificity using
Age = 22 −− Arthroscopy: 100% arthrometry. Graded arthrometry with x-y
recording of the force-displacement relationship
that allows for the viscoelastic qualities of
Rijke et al (1994)
ligament further extends the capabilities of
instrumented arthrometry.
N = 170 ACL injury MRI, knee joint arthroscopy PCL index: Injury to the ACL changes the PCL index
Age = 36 −− Intact knee: 5.01 markedly. In diagnostically unreliable MR
−− Total ACL rupture: 2.88 images, deterioration of the PCL index could
(1996)
−− Partial ACL rupture: 3.09 help in the diagnosis of ACL injury.
Siwiñski et al
N = 39 Complete or partial MRI, arthroscopy Sensitivity diagnosing complete ACL tear with partial tear This study reaffirms MR imaging as a sensitive
M = 25 ACL tear scored as tear: and specific noninvasive diagnostic tool for
F = 14 −− MRI: 91% detecting complete ACL rupture. However, MR
Age = 36 Specificity diagnosing complete ACL tear with partial tear evaluation of partial ACL tears is not sufficiently
scored as tear: sensitive to establish the diagnosis without
−− MRI: 68% arthroscopy.
Sensitivity diagnosing complete ACL tear with partial tear
scored as intact:
−− MRI: 77%
Specificity diagnosing complete ACL tear with partial tear
scored as intact:
Umans et al (1995)
−− MRI: 99%
Sensitivity diagnosing partial ACL tear:
−− MRI: 56%
Specificity diagnosing partial ACL tear:
−− MRI: 75%
page – 48
Author
(year)
N = 88 Complete or partial MRI Detection of partial ACL ruptures: The majority of partial ACL ruptures are shown
Age = 30 ACL tear −− Only primary MRI signs: 71% by MR, but MR is less sensitive for partial

Time from injury = 7.5 days −− Primary and secondary MRI signs: 81% than for complete ACL rupture. The distinction
JointEvidence
Detection of complete ACL ruptures: of partial from complete ACL rupture on MR

−− Only primary MRI signs: 97% examination, while problematic, is slightly
−− Primary and secondary MRI signs: 100% improved by assessment of secondary signs.
Presence in partial ACL rupture:
−− Abnormal ACL axis: 48%
−− Tibial collateral ligament injury: 24%
−− Popliteus injury: 5%
5/2009
−− Posteriorly displaced lateral meniscus: 0%
Yao et al (1995)
−− Abnormal PCL index: 43%
Presence in partial ACL rupture:
−− Abnormal ACL axis: 52%
−− Tibial collateral ligament injury: 58%
−− Popliteus injury: 32%
−− Posteriorly displaced lateral meniscus: 52%
−− Abnormal PCL index: 55%
N = 150 Complete or partial MRI, evaluation of lateral Sensitivity for complete ACL tear: Although the sensitivity is low, an abnormally
ACL tear femoral sulcus −− Femoral lateral sulcus >2.0 mm: 3.2% deepened lateral femoral sulcus is a highly
Specificity for complete ACL tear: specific indicator of ACL deficiency when
−− Femoral lateral sulcus >2.0 mm: 100% present on radiographs of the knee after an
Accuracy for complete ACL tear: acute injury.
−− Femoral lateral sulcus >2.0 mm: 60%
Yu et al (1995)
Positive predictive value for complete ACL tear:
−− Femoral lateral sulcus >2.0 mm: 100%
N = 74 Complete ACL tear MRI, arthroscopy Area under receiver operating characteristic curve: Primary signs are better for predicting tears than
Time from injury = 6 weeks −− Primary signs only: 0.96 secondary signs. Some secondary signs can
−− Secondary signs only: 0.80 be used to predict a significant number of ACL
−− Both primary and secondary signs: 0.96 tears, but on the practical level of the clinical
Sensitivity: setting, both primary and secondary signs are
−− Bone contusion and anterior studied, and it is the primary signs that form the
tibial translation: 82% basis for diagnosing the status of the ACL.
−− Fiber discontinuity: 93%
Specificity:
Brandser et al (1996)
−− Bone contusion and anterior
tibial translation: 90%
−− Fiber discontinuity: 98%
N = 120 Complete or partial MRI, arthroscopy Sensitivity: The presence of anterior subluxation of the
M = 74 ACL tear −− Anterior tibial subluxation >5 mm: 86% tibia >5 mm relative to the femur on MR images
F = 46 −− Conventional MRI criteria: 90% of the knee is a helpful adjunctive sign of a
Age = 37 Specificity: complete tear of the ACL, provides a sensitivity
−− Anterior tibial subluxation >5 mm: 99% comparable to that of conventional MRI criteria
−− Conventional MRI criteria: 94% and offers improved discrimination between
Chan et al (1994)
partial and complete ACL tears.
page – 49
APPENDIX D: Detailed data of treatment studies

JointEvidence
Table D-1: Level I detailed data from individual studies

Author
CoE Population ACL Tear Treatment Device Results Complications Conclusions
(year)
BTB Unilateral ACL Bone-patellar Not reported. Pre-op Lysholm score None reported. The semitendinosus
N = 32 rupture tendon-bone −− BTB: 70 tendon graft is at
Male = 21 graft (BTB) = 32 −− ST: 68 least an equivalent
5/2009
Female = 11 Lysholm score at F/U option to the bone-

Mean age = 26 Tripled or −− BTB: 95 patellar tendon-bone
F/U = 2 years quadrupled −− ST: 90 graft for anterior
semitendinosus Pre-op “difficult” or “impossible” knee walking ability cruciate ligament
ST tendon graft (ST) −− BTB: 6 reconstruction, and
N = 34 = 34 −− ST: 4 we recommend its
Male = 25 “Difficult” or “impossible” knee walking ability at F/U use.
I Female = 9 −− BTB: 17
Mean age = 29 −− ST: 8
F/U = 2 years Pre-op ++ or +++ Lachman test
Ejerhed et al (2003)
−− BTB: 30
−− ST: 27
++ or +++ Lachman test at F/U
−− BTB: 2
−− ST: 0
Side-to-side difference with KT-1000 at 89 N
−− BTB: 2.0 mm
−− ST: 2.25 mm
QE ACL rupture Straight Not reported. Active knee flexion ROM at F/U None reported. Isometric quad
N = 55 leg raises, −− QE: 141.6º exerciser and straight
Male = 41 quadriceps −− NE: 142.6º leg raises can be
Female = 14 contractions (QE) Active knee extension ROM at F/U safely prescribed
Mean age = 28.8 = 48 −− QE: 5.7º during the first two
F/U = 6 months −− NE: 4.9º post-op weeks and
No quadriceps Passive knee extension relative to neutral at F/U confer advantages
NE exercise (NE) −− QE: 3.1º for faster recovery
N = 48 = 55 −− NE: 2.3º of knee range of
I
Male = 34 Pain at rest 1 day post-op (cm on 10 cm VAS) motion and stability.
Female = 14 −− QE: 3.1 It remains to be
Shaw et al (2005)
Mean age = 28.4 −− NE: 2.6 proven whether
F/U = 6 months Pain at rest at F/U (cm on 10 cm VAS) the magnitude of
−− QE: 0.3 differences between
−− NE: 0.3 groups is clinically
Single hop (LSI %) at F/U significant.
−− QE: 81.7
−− NE: 83.8
page – 50
JointEvidence
Author
(year)
5/2009
AR ACL injury ACL Not reported. Mean Lysholm score None reported. ACL reconstruction
N = 15 reconstruction −− AR: 94 resulted in
F/U = 2 years (AR) = 15 −− HC: not reported anteroposterior tibial
Mean side-to-side difference translation that was
HC Age-matched −− AR: 2.2 mm within 2 to 3 mm of
N = 14 healthy controls −− HC: not reported the tibial translation in
I
F/U = 2 years (HC) = 14 Mean maximum anterior tibial position normal knees.
−− AR: +4.8 mm
−− HC: +0.9 mm
Almekinders et al (2001)
Mean maximum posterior tibial position
−− AR: -1.2 mm
−− HC: -4.0 mm
HT ACL injury Hamstring Not reported. Anterior knee pain at F/U Graft rupture due to fall This study confirms
N = 34 tendon (HT) = 34 −− HT: 33 −− HT: 0 that there is little
Male = 24 −− PT: 43 −− PT: 1 or no difference
Female = 10 Patellar tendon Extension deficit at F/U Additional procedure on between bone-
Mean age = 26.3 (PT) = 31 −− HT: 1.2° affected knee patellar tendon-bone
F/U = 3 years −− PT: 2.7° −− HT: 4 and combined
Active flexion deficit at F/U −− PT: 6 semitendinosus and
PT −− HT: 3.3° gracilis hamstring
N = 31 −− PT: 2.6° tendon grafts in terms
Male = 23 Passive flexion deficit at F/U of functional outcome,
Female = 8 −− HT: 2.2° despite greater laxity
I Mean age = 25.8 −− PT: 4.0° measurements in
F/U = 3 years 0-2 mm side-to-side difference at 134N at F/U hamstring tendon
−− HT: 85% patients.
Feller et al (2003)
−− PT: 95%
Quad muscle strength deficit as % of normal knee at
1 year at 60°/s
−− HT: 11.1
−− PT: 22.7
Hamstring muscle strength deficit as % of normal knee
at 1 year at 60°/s
−− HT: 8.7
−− PT: 1.7
page – 51
JointEvidence
5/2009
Author
(year)
PR ACL rupture Primary repair Not reported. Pre-op activity level of 7–10 Deep vein thrombosis Patellar tendon
N = 50 (PR) = 50 −− PR: 62% −− PR: 1 augmented repair
Male = 29 −− PT: 56% −− PT: 0 was found to
Female = 21 Patellar tendon −− KT: 48.9% −− KT: 0 be superior to
Mean age = 29 technique (PT) Activity level of 7–10 at 2 years Infection direct repair and
F/U = 2 years = 50 −− PR: 30% −− PR: 0 augmentation with
−− PT: 38.9% −− PT: 2 Kennedy ligament
PT Kennedy LAD −− KT: 32.4% −− KT: 2 augmentation device,
N = 50 technique (KT) Pre-op Lysholm functional level of 84–100 Crepitation in based on Lachman
Male = 29 = 50 −− PR: 74% patellofemoral joint test, pivot shift test,
I −− PT: 86% −− PR: 17
Female = 21 and KT-1000 testing.
Mean age = 29 −− KT: 81% −− PT: 27
F/U = 2 years Lysholm functional level of 84–100 at 2 years −− KT: 20
−− PR: 73%
Engelbretsen et al (1990)
KT −− PT: 97%
N = 50 −− KT: 78%
Male = 24 KT-1000 score at 20 lb of <3 mm at 2 years
Female = 26 −− PR: 29%
Mean age = 28 −− PT: 79%
F/U = 2 years −− KT: 59%
DG ACL injury ACL Intra-articular VAS pain score at F/U None reported. Routine use of
N = 60 reconstruction drain (DG) = 60 −− DG: 0.3 intra-articular drains
Male = 29 −− ND: 0.3 after uncomplicated
Female = 31 No drain (ND) Extension loss at F/U ACL surgery is not
Mean age = 25.4 = 58 −− DG: 1.6° supported by this
F/U = 8 weeks −− ND: 1.5° study. Avoiding drains
I Flexion loss at F/U will reduce costs and
ND −− DG: 5.7° eliminate potential
N = 58 −− ND: 5.6° complications of their
Male = 40 Difference in thigh circumference at F/U use.
McCormack et al (2006)
Female = 18 −− DG: 0.6 cm
Mean age = 29.5 −− ND: 0.5 cm
F/U = 8 weeks
page – 52
Author
(year)

JointEvidence
SG ACL injury Semitendinosus Not reported. Noyes score Infection No important

N = 50 graft (SG) = 50 −− SG: 84.5 −− SG: 2 differences were
Male = 31 −− SGG: 82.3 −− SGG: 0 found with the final
Female = 19 Semitendinosus Lysholm score Removal of painful outcome. However,
Mean age = 31 and gracilis graft −− SG: 92.2 hardware isokinetic tests
F/U = 1 year (SGG) = 47 −− SGG: 93.6 −− SG: 4 did reveal internal
Tegner score pre-op −− SGG: 4 rotation weakness
−− SG: 6.2
5/2009
SGG in the SG group. It is

N = 47 −− SGG: 6.2 recommended that
Male = 26 Tegner score post-op only 1 tendon be used
I Female = 21 −− SG: 5.6 whenever possible.
Mean age = 28.8 −− SGG: 6
F/U = 1 year <10° flexion loss
Gobbi et al (2000)
−− SG: 3
−− SGG: 2
Peak torque deficit of internal rotation at F/U
−− SG: 2%
−− SGG: 10%
1-leg vertical jump test as % of normal leg at F/U
−− SG: 0.93
−− SGG: 0.93
SI ACL tear, Single-incision Not reported. Mean flexion at F/U None reported. No differences in the
N = 10 replacement ACL replacement −− SI: 141° early postoperative
F/U = 1 year with BPTB (SI) = 10 −− TI: 145° phase can be found
autograft Mean extension at F/U between the two
TI Two-incision ACL −− SI: 2° operative procedures.
N = 10 replacement (TI) −− TI: 1.8° The dynamic
F/U = 1 year = 10 Mean KT-1000 at manual maximal force, 30° flexion muscular function
at F/U of the extensor
−− SI: 9.27 mm as well as flexor
−− TI: 8.86 mm muscles, measured
Mean Lysholm score at F/U by peak torque during
I −− SI: 94 isokinetic evaluation,
−− TI: 97 was markedly
Hess et al (2002)
Peak torque of extensor muscles as % of normal leg, at reduced after both
60°/s concentric at F/U procedures during
−− SI: 87.7 the first postoperative
−− TI: 87 year. After the single-
Peak torque of flexor muscles as % of normal leg, at incision technique,
60°/s concentric at F/U peak torques of both
−− SI: 102.6 flexor and extensor
−− TI: 101.6 muscles recovered
significantly faster.
page – 53
JointEvidence
Author
(year)
HT ACL rupture Hamstring Not reported. Femoral tunnel widening at F/U, AP view None reported. Femoral bone tunnel
−− HT: 47.4%
5/2009
N = 33 tendon (HT) = 33 enlargement following

Male = 23 −− PT: 15.6% ACL reconstruction
Female = 10 Patellar tendon Femoral tunnel widening at F/U, lateral view was shown to be
Mean age = 27 (PT) = 28 −− HT: 35.9% more frequent
F/U = 2 years −− PT: 10.5% and greater with
Mean KT-1000 side-to-side difference at 15 lb at F/U hamstring grafts than
PT −− HT: 1.4 mm in patellar tendon
I −− PT: 0.7 mm
N = 28 grafts. Whatever its
Male = 20 Mean extension deficit at F/U cause, in the short-
Female = 8 −− HT: 1.7° term bone tunnel
Webster et al (2001)
Mean age = 26 −− PT: 3.1° enlargement appears
F/U = 2 years to have no effect on
the clinical outcome
of ACL reconstruction
surgery.
CQ ACL injury Central Not reported. Mean time to full extension (weeks) None reported. Central quadriceps
N = 18 quadriceps free −− CQ: 3.9 free tendon and
tendon (CQ) = 18 −− PT: 7.5 semitendinosus/
PT −− ST: 6.4 gracilis tendon
N = 25 Bone-patellar Mean time to 120° prone flexion (weeks) autografts allow
tendon-bone (PT) −− CQ: 4.7 an earlier return to
ST = 25 −− PT: 5.4 non-strenuous daily
N = 21 −− ST: 5.4 activities in a safe
Semitendinosus/ Mean time to straight leg raise, no lag (weeks) manner. Patients
gracilis tendon −− CQ: 3.7 with a CQ graft used
I (ST) = 21 −− PT: 4.3 significantly less post-
−− ST: 3.7 op pain medication
Mean time of assistive device use (weeks) than the other
Joseph et al (2006)
−− CQ: 2.7 patients.
−− PT: 3.1
−− ST: 2.1
Mean days on pain medication
−− CQ: 5.4
−− PT: 22.6
−− ST: 19
page – 54
Author
(year)
LP ACL injury ACL Low-positioned Difference in Lachman score from healthy knee at 25° Cyclops lesion at A significant
N = 26 reconstruction tibial tunnel (LP) −− LP: 1.62 mm 2 months post-op in difference was
Male = 15 = 26 −− HP: 0.96 mm one group found in subjective

Female = 11 Difference in Lachman score from healthy knee at 70° IKDC scores only,
JointEvidence
Mean age = 33.8 High-positioned −− LP: 0.27 mm suggesting that it is

F/U = 334 days tibial tunnel (HP) −− HP: 0.0 4 mm possible to improve
= 25 Tibial angle post-op the clinical result by
I HP −− LP: 58.96° lowering the tibial
N = 25 −− HP: 63.36° tunnel angle and
Male = 15 Tibial angle at F/U thereby lowering the
Jepsen et al (2007)
Female = 10 −− LP: 58.52° femoral tunnel toward
−− HP: 63.77°
5/2009
Mean age = 33.1 the 2-o’clock position.

F/U = 341 days Femoral angle at F/U
−− LP: 41.67°
−− HP: 46.86°
RB ACL rupture, Restriction of Pre-op flexion Slight discomfort Training during
N = 22 reconstructed bloodflow (RB) −− NT: 144º and dull pain due moderate restriction
Male = 13 = 22 −− ST: 146º to tourniquet use in of blood flow
Female = 9 Post-op flexion restricted patients is effective in
Mean age = 28 No restriction −− NT: 140º rehabilitation, but
(NR) = 22 −− ST: 143º further attention to
NR Pre-op extension the safety of this
N = 22 −− NT: 3.1º training is required.
Male = 20 −− ST: 0.7º
I
Female = 14 Post-op extension
Mean age = 30 −− NT: 1.9º
Ohta et al (2002)
−− ST: 3.1º
Pre-op KT-2000 (133 N)
−− NT: 5.3 mm
−− ST: 5.3 mm
Post-op KT-2000 (133 N)
−− NT: 1.2 mm
−− ST: 1.2 mm
N = 31 ACL tear Early Mean tourniquet time Painful tibial fixation There is no advantage
Male = 28 reconstruction −− ER: 67 min screw in early reconstruction
Female = 3 (ER) = 13 −− DR: 74 min −− ER: 1 for isolated tears
Mean age = 21 Work deficit as % of normal leg at 12 weeks −− DR: 0 of the ACL, and
F/U = 1 year Delayed −− ER: 36 Knee stiffness it is associated
reconstruction −− DR: 22 −− ER: 1 with increased
(DR) = 18 Quad power deficit as % of normal leg at 12 weeks −− DR: 1 complication rates.
I
−− ER: 36 Re-injury
−− DR: 23 −− ER: 0
Peak torque deficit as % of normal leg at 12 weeks −− DR: 1
Meighan et al (2003)
−− ER: 35 Subjective instability
−− DR: 24 −− ER: 0
−− DR: 1
page – 55
JointEvidence
5/2009
Author
(year)
NT ACL injury, NMES-treated Not reported. Quad index at F/U None reported. Use of the modified
N = 21 reconstructed (NT) = 21 −− NT: 83.1 NMES protocol
Male = 12 −− NNT: 75.0 as an adjunct to
Female = 9 Not treated (NNT) ADLS at F/U rehabilitation resulted
Mean age = 29.2 = 22 −− NT: 91.5 in modest increases
F/U = 16 weeks −− NNT: 86.4 in quadriceps torque
I Knee pain rating at F/U output after 12 weeks
NNT −− NT: 0.9 of rehabilitation and
N = 22 −− NNT: 1.1 in self-reported
Fitzgerald et al (2003)
Male = 14 knee function at
Female = 8 12 and 16 weeks
Mean age = 31.9 of rehabilitation
F/U = 16 weeks compared to controls.
page – 56
Table D-2: Level II detailed data from individual studies

Author
JointEvidence
(year)
TRS Isolated rupture Transfix/ Not reported. Tunnel aperture on AP view before 3 months None reported. There was a
N = 20 of the ACL resorbable −− TRS: 10.28% significant reduction
Male = 17 screw (TRS) −− TPF: 29.83% of enlargement at
Female = 3 = 20 Tunnel aperture on AP view after 6 months the outlet of the
Mean age = 23.5 −− TRS: 18.97% tunnel with the use
F/U = 11.6 mos Transfix/ −− TPF: 37.38% of a periosteal flap
5/2009
II periosteal flap Side-to-side difference with KT-1000 at 133 N but widening was
TPF (TPF) = 21 −− TRS: 1.9 mm constant.
N = 21 −− TPF: 2.1 mm
Robert et al (2004)
Male = 18
Female = 3
Mean age = 29
F/U = 13.7 mos
BTB Unilateral ACL Bone-tendon- Not reported. Anterior tibial translation at 0º knee flexion None reported. The methods yield
N = 49 injury bone graft (BTB) −− BTB: 8.9 mm similar results at 0º
Male = 21 = 49 −− HT: 10.6 mm and 20º; with the
Female = 28 Anterior tibial translation at 20º knee flexion HT method, joint
Mean age = 25.4 Hamstring −− BTB: 13.5 mm instability is observed
F/U = 20 mos tendon graft (HT) −− HT: 13.9 mm during isokinetic
II = 30 concentric contraction
ST exercise between 30
N = 30 and 50º.
Sato et al (2005)
Male = 17
Female = 13
Mean age = 27.2
F/U = 18 mos
BTB Unilateral ACL Bone-patellar Not reported. Good or excellent Lysholm score at F/U Reflex sympathetic Data show a very
N = 33 injury tendon-bone −− BTB: 82% dystrophy high satisfaction
Male = 26 graft (BTB) = 33 −− HT: 89% −− BTB: 1 rate in patients
Female = 7 Patellofemoral pain at F/U −− HT: 0 with single-incision
Mean age = 32 Hamstring −− BTB: 42% Tibial interference screw ACL reconstruction,
F/U = 2 years tendon graft (HT) −− HT: 20% infection regardless of whether
= 37 Mean loss of flexion at F/U −− BTB: 1 the autograft was
II HT −− BTB: 3.4º −− HT: 0 patellar or hamstring
N = 37 −− HT: 0.97º Arthrofibrosis tendon.
Male = 21 Side-to-side difference with KT-1000 at 134 N −− BTB: 1
Shaieb et al (2002)
Female = 16 −− BTB: 1.8 mm −− HT: 0
Mean age = 30 −− HT: 2.8 mm
F/U = 2 years Side-to-side difference with KT-1000 at 89 N
−− BTB: 1.4 mm
−− HT: 2.4 mm
page – 57
JointEvidence
Author
5/2009

(year)
A Unilateral ACL ACL Composite Bone block incorporation at stage III 3 months post-op Screw breakage during All 3 screw types
N = 20 injury reconstruction screw made −− A: 20 insertion provide adequate
Male = 14 from 70–80% −− B: 20 −− A: 1 graft fixation.
Female = 6 PLLA and −− C: 20 −− B: 1 Formation of sclerotic
Mean age = 32.2 20–30% HA (A) Screw easily outlined at 24 months post-op −− C: 0 rim in type B makes
F/U = 2 years = 20 A: 20 later necessary bone
B: 20 formation unlikely.
B Composite C: 0 Only allograft screws
N = 20 screw made Sclerotic rim around screw at 24 months post-op showed complete
Male = 15 from 75% PLLA −− A: 0 bony integration at 24
II −− B: 20
Female = 5 and 25% ß-TCP months.
Mean age = 32.3 (B) = 20 −− C: 0
F/U = 2 years
Tecklenburg et al (2006)
Allograft screw
C (C) = 20
N = 20
Male = 13
Female = 7
Mean age = 31.1
F/U = 2 years
SB ACL injury Bone-patellar Straight brace Loss of knee extension 1 at F/U None reported. The use of a
N = 22 tendon-bone (SB) = 22 −− SB: 12 Hypex brace set
Male = 21 graft −− HB: 2 in hyperextension
Female = 1 Hyperextension Median post-op pain (mm VAS) for at least three
Mean age = 28 brace (HB) = 22 −− SB: 49.5 weeks after ACL-
F/U = 3 months −− HB: 44 reconstruction
Knee flexion at F/U seems to be an easy
II
HB −− SB: 141˚ way of preventing
N = 22 −− HB: 145˚ a cumbersome
Male = 19 Sagittal knee laxity at F/U extension deficit of
Mikkelsen et al (2003)
Female = 3 −− SB: 3.0 mm the knee joint.
Mean age = 24 −− HB: 3.6 mm
F/U = 3 months
1 Greater than or equal to 2°
page – 58
JointEvidence
Author
(year)
5/2009
CS ACL injury ACL Clinical None reported. None reported. A significant, linear
N = 31 reconstruction stimulator (CS) correlation was
Mean age = 24.7 = 31 found between
training intensity and
PS Portable quadriceps femoris
N = 21 stimulator (PS) muscle torque.
Mean age = 25.2 = 21 Subjects training
with console, clinical
II generators trained at
higher intensities than
those training with
portable, battery-
operated generators;
Snyder-Mackler et al≠ (1994)

such training resulted
in higher quadriceps
femoris muscle
torque.
BT ACL injury ACL Femoral Lysholm score pre-op Deep infection Polyglyconate
N = 20 reconstruction fixation with −− BT: 60.6 −− BT: 0 interference screw
Male = 14 bioabsorbable −− TT: 55.0 −− TT: 1 has not been found
Female = 6 screw, tibial Lysholm score at F/U Intraoperative patellar to be associated with
Mean age = 26.8 fixation with −− BT: 98.1 fracture during graft increased clinical
F/U = 2 years titanium screw −− TT: 97.7 harvest complications or
(BT) = 20 Tegner score pre-op −− BT: 1 major bony reactions.
TT −− BT: 8.0 −− TT: 0 It provided equivalent
N = 20 Femoral fixation −− TT: 8.0 fixation and clinical
II Male = 15 with titanium Tegner score at F/U results compared
Female = 5 screw, tibial −− BT: 7.4 with titanium screws.
Mean age = 29.6 fixation with −− TT: 7.5 However, the cost
Fink et al (2000)
F/U = 2 years titanium screw KT-1000 pre-op of bioabsorbable
(TT) = 20 −− BT: 4.9 mm screws is about
−− TT: 5.3 mm double, and it is at
KT-1000 at F/U least questionable
−− BT: 1.5 mm whether the use of
−− TT: 1.6 mm these screws can be
justified.
page – 59
Smith & Nephew Orthopaedics AG
KLEOS Global
6343 Rotkreuz
Switzerland
+41 41 798 41 11
kleos-global@smith-nephew.com
www.kleos.md

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JointEvidence 5/2009 Lit. No.

Anterior cruciate ligament

Executive summary 3 VII Recommendations and future research 22

Published March 2009, Copyright © 2009 by

JointEvidence Anterior cruciate ligament

Figure 1: Location of the ACL in the flexed knee joint [1].

Figure 2: ACL bundles; AM = anteromedial, PL = Posterolateral [3].

JointEvidence Anterior cruciate ligament

1.1.2 Biomechanics and function

1.1.3 Mechanism of injury: rupture

Figure 4: Twisting mechanism of ACL injury [5]

JointEvidence Anterior cruciate ligament

Figure 5: At-risk position for ACL injury [4]

JointEvidence Anterior cruciate ligament

1.2.2 Tests: anterior drawer, Lachman, pivot shift test

Figure 7: Clinical diagnostic tests for ACL injury [8]

JointEvidence Anterior cruciate ligament

1.2.3 Imaging: MRI

JointEvidence Anterior cruciate ligament

JointEvidence Anterior cruciate ligament

This report will attempt to answer the following clinical questions:

2.1 Clinical outcomes of incidence of ACL injuries

2.2 Clinical outcomes of diagnostic technique

2.3 Clinical outcomes of treatment techniques

2.4 Summary of clinical outcomes

JointEvidence Anterior cruciate ligament

III Data sources and search strategy

We excluded articles on:

The search strategy is summarized in Table 1.

Table 1: The search strategy for Ovid Medline

1 Exp anterior cruciate ligaments/in [injuries] 3749

2 Exp diagnosis/ 4400288

4 Exp incidence/ 113019

6 Magnetic resonance imaging/ 181407

8 Exp radiography/ 467633

10 Exp surgical procedures, operative/ 1712612

12 Exp Rehabilitation/ 103141

14 Exercise therapy/ 17224

18 Limit 17 to (English language and humans) 2332

JointEvidence Anterior cruciate ligament

IV Quality of the literature for this topic

Table 2: Levels of evidence for primary research question

– High-quality randomized controlled trial with statistically significant difference or no

Level V Expert opinion

JointEvidence Anterior cruciate ligament

5.1 Clinical outcomes of incidence of ACL injuries

Table 3: Incidence of ACL tears by gender and by sport [14]

Highschool 0.09 0.02 4.5

Collegiate 0.29 0.08 3.63

Professional 0.20 0.21 0.95

Collegiate 0.32 0.12 2.67

Indoor 5.21 1.88 2.77

Ski lodge employees (no gender difference) 0.03 0.03 1.00

General population (no gender difference) 0.52 0.52 1.00

Lacrosse 0.18 0.17 1.06

Football (all male) 0.08

Study 1 0.86 0.24 3.59

Study 2 0.56 0.11 5.01

Australian-Rules Football (all male) 0.04

Rugby 0.36 0.18 2

JointEvidence Anterior cruciate ligament

5.2 Clinical outcomes of diagnostic techniques

Table 4: Methods of calculations

– High-quality randomized controlled trial with statistically significant difference or no