ACL Tear

Author: Patrick McCulloch

Topic updated on 05/04/13 3:32pm

Introduction
Incidence ~400,000 ACL reconstructions / year Mechanism is a non-contact pivoting injury video showing ACL tear in elite athlete Often associated with a meniscal tear lateral meniscal tears in up to 50% of acute ACL tears Chronic ACL deficient knees associated with chondral injuries complex unrepairable meniscal tears relation with arthritis is controversial ACL injury more common in female athlete (4.5 :1 ratio) due to neuromuscular forces and control (more quadriceps dominant) landing biomechanics (conditioning and strength) play biggest role females land in more extension, higher vaglus moment smaller notches genetic factors related to collagen production a specific allelle within the COL5A1 gene is associated with a reduced risk of ACL tears in women smaller ligaments hormone levels valgus leg alignment
Anatomy
ACL Function provides 85% of the stability to prevent anterior translation of the tibia relative to the femur acts as secondary restraint to tibial rotation and varus/valgus rotation ACL Anatomy 33mm x 11mm in size goes from LFC to anterior tibia (tibial insertion is broad and irregular and inserts just anterior and between the intercondylar eminences of the tibia) two bundles anteromedial bundle more isometric tight in flexion posterolateral bundle tightest in extension (where it likely contributes greatest to rotational stability) ACL Blood supply middle geniculate artery ACL Innervation posterior articular nerve (branch of tibial nerve) ACL Composition 90% Type I collagen 10% Type III collagen ACL Strength: 2200 N (anterior)
Presentation
Presentation felt a "pop" pain deep in knee immediate swelling (70%) / hemarthrosis Physical exam effusion quadricep avoidance gait (does not actively extend knee) Lachman's test most sensitive exam test grading A= firm endpoint, B= no endpoint Grade 1: < 5 mm translation Grade 2 A/B: 5-10mm translation Grade 3 A/B: > 10mm translation PCL tear may give "false" Lachman due to posterior subluxation Pivot shift extension to flexion: reduces at 20-30° of flexion patient must be completely relaxed (easier to elicit under anesthesia) mimics the actual giving way event KT-1000 useful to quantify anterior laxity measured with knee in slight flexion and externally rotated 10-30°
Imaging
Radiographs usually normal Segond fracture (avulsion fracture of the proximal lateral tibia) is pathognomonic for an ACL tear MRI ACL tear best seen on sagittal view bone bruising occurs in more than half of acute ACL tears middle 1/3 of LFC (sulcus terminalis) posterior 1/3 of lateral tibial plateau subchondral changes on MRI can persist years after injury
Treatment
Nonoperative physical therapy & lifestyle modifications low demand patients with decreased laxity increased meniscal/cartilage damage linked to loss of meniscal integrity frequency of buckling episodes level I and II activity (e.g. jumping, cutting, side-to-side sports, heavy manual labor) Operative ACL reconstruction indications younger, more active patients (reduces incidence of mensical or chondral injury) children (strongly consider operative as activity limitation is not realistic) older active patients (age >40 is not contraindication if high demand athlete) prior ACL reconstruction failure associated injuries MCL injury allow MCL to heal (varus/valgus stability) and then perform ACL reconstruction varus/valgus instability can jeopardize graft meniscal tear perform meniscal repair at same time as ACL reconstruction increased healing rate when repaired at the same time as ACL posterolateral corner injury reconstruct at the same time as ACL or as first-stage of two stage reconstruction ligament "repair" has high failure rate revision ACL reconstruction indications failure of prior ACL reconstruction
Surgical Techniques
Femoral tunnel placement proper placement 1-2 mm rim of bone between tunnel and posterior cortex of femur anterior misplacement leads to a knee that is tight in flexion and loose in extension occurs from failure to clear "residents ridge" posterior misplacement (over-the-top) leads to a knee that is lax in flexion and tight in extension Tibial tunnel placement proper placement center of tunnel entrance into joint should be 10-11mm in front of anterior border of PCL insertion tunnel trajectory of < 75° from horizontal obtain by moving tibial starting point halfway between tibial tubercle and posterior medial edge of tibia. anterior misplacement leads to knee that is tight in flexion with impingement in extension posterior misplacement leads to an ACL that will impinge with the PCL Graft placement graft preconditioning can reduce stress relaxation up to 50% graft tensioning graft tensioning at 20N or 40N had no clinical outcome effects in a level 1 study High tibial osteotomy limb malalignment in both the coronal and sagittal plane must be addressed before or at the same time as ligament reconstruction
Graft Selection
Bone patellar bone autograft advantage of autograft using patient's own tissue most common source of graft faster incorporation less immune reaction no chance of acquiring someone else's infection pros and cons of bone-patella-bone longest history of use, considered the "gold standard" bone to bone healing ability to rigidly fix at the joint line (screws) highest incidence of anterior knee pain (up to 10-30%) maximum load to failure is 2600 Newtons (intact ACL is 1725 Newtons) complications patella fracture (usually postop during rehab), patellar tendon rupture Quadruple hamstring autograft technique may be taken from contralateral side in revision situation when allograft is not desirable or available pros and cons smaller incision, less periop pain, less anterior knee pain fixation strength may be less than Bone-PT-Bone maximum load to failure is approximately 4000 Newtons decreased peak flexion strength at 3 years compared to Bone-PT-Bone concern about hamstring weakness in female athletes leading to increased risk of re-rupture complications "windshield wiper" effect (suspensory fixation away from joint line causes tunnel abrasion and expansion with flexion/extension of knee) residual hamstring weakness Allograft pros & cons useful in revisions longer incorporation time risk of disease transmission (HIV is < 1:1 million, hepatitis is even greater) possible increased risk of re-rupture in athletes graft processing radiation: > 3 Mrads is required to kill HIV (this however decreases the structural and mechanical properties of the graft) freezing: destroys cells but does not affect strength of graft Quadriceps tendon autograft taken with patella bone plug much less common
Pediatric Considerations
Physis < 14 yrs with open physis onset of menarche is best determinant of skeletal maturity in females Graft Selection transphyseal soft tissue grafts rarely lead to growth disturbances Instrumentation avoid transphyseal interference screw fixation
Revision ACL Reconstruction
Technique use high strength grafts (quad tendon, hamstring, allograft) use dual fixation (suspension + interference screws) bone grafting (tunnel dilation, decreased bone stock, staged prn) reharvesting BTB contraindicated Postoperative conservative rehab
Rehabilitation
Early postoperative aggressive cryotherapy (ice) immediate weight bearing (shown to reduce patellofemoral pain) emphasize early full passive extension (especicially if associated with MCL injury or patella dislocation) focus rehab on exercises that do not place excess stress on graft isometric hamstring contractions at any angle isometric quadriceps, or simultaneous quadriceps and hamstrings contraction active knee motion between 35 degrees and 90 degrees of flexion emphasize closed chain (foot planted) exercises avoid isokinetic quadricep strengthening (15-30°) during early rehab open chain quadriceps strengthening Injury prevention female athlete neuromuscular training / plyometrics (jump training) land from jumping in less valgus and more knee flexion increasing hamstring strength to decrease quadriceps dominance ratio skier training teach skiers how to fall ACL bracing no proven efficacy except for ACL-deficient skiers
Complications
Failures causes surgical technical error is the most common cause of ACL failure improper tunnel placement causes failure in 70% vertical femoral tunnel will cause continued rotational instability and positive pivot shift inadequate fixation can be caused by graft-screw divergence >30 degrees missed diagnosis in combined ACL and PLC injuries, failure to treat the PLC will lead to failure of ACL reconstruction overaggressive rehab evaluation obtain X-ray, CT, and MRI to help with surgical planning treatment revision ACL Surgery Cyclops lesion fibroproliferative tissue blocks extension "click" heard at terminal extension Infection septic arthritis Staph aureus most common presentation pain, swelling, erythema, and increased WBC at 2-14 days postop treatment perform immediate joint aspiration with gram stain and cultures treatment immediate arthroscopic I&D often can retain graft with multiple I&Ds and abx (6 weeks minimum) Loss of motion preop be sure patient has regained full ROM before you operate ("pre-hab") wait until swelling (inflammatory phase) has gone down to reduce incidence of arthrofibrosis operative proper tunnel placement is critical to have full range of motion postop prevention aggressive cryotherapy (ice) treatment < 12 weeks than treat with aggressive PT and serial splinting > 12 weeks than treat with lysis of adhesions / manipulation under anesthesia Patella Tendon Rupture will see patella alta on lateral radiograph RSD (complex regional pain syndrome) Patella fracture (most fx occur 8-12 weeks postop) Hardware failure Tunnel osteolysis (treat with observation) Late arthritis (related to meniscal integrity) Local nerve irritation (saphenous nerve)

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Qbank (36 Questions)

TAG

(SBQ07.14) During anterior cruciate ligament (ACL) reconstruction divergence between the graft and screw fixation within the bone tunnel can lead to complications. Which of the following statements regarding graft-screw divergence is true? Topic

Review Topic

1. Risk of failure is eliminated using an accessory anteromedial drilling portal
2. Complications occur more commonly with soft tissue grafts
3. Loss of fixation becomes a greater risk if the graft-screw divergence is >30 degrees
4. Excessive graft-screw divergence more commonly occurs during tibial fixation
5. Graft-screw divergence is a common cause of late failure of ACL reconstructions

PREFERRED RESPONSE ▶

DISCUSSION: Graft-screw divergence greater than 15-30 degrees from the trajectory of the femoral tunnel may lead to failure of fixation and early ACL failure. Technical tips to avoid this complication include: inserting the screw and drill from the same portal (no divergence at all), hyperflexing the knee when inserting the screw if the femoral tunnel was drilled through the tibial tunnel, and using a guide wire to help gauge mismatch. Suspicion should be raised if there is difficulty inserting the screw. Intraoperative and postoperative radiographs can also help detect divergence.

Lemos et al performed a bovine biomechanical study which noted that parallell placed screws failed in 1/12 pigs, while 4/12 pigs failed with 15 degree divergent screws. Because their results were not statistically significant, they concluded that the pullout strength is still high even with divergence of up to 15 degrees.

Dworsky et al reviewed 73 consecutive ACL reconstructions using interference screw fixation. They concluded that with proper intraoperative testing, femoral screws with under 30 degrees of divergence did not lead to early clinical failure.

REFERENCES:

1. Lemos MJ, Jackson DW, Lee TO, et al: Assessment of initial fixation of endoscopic interference femoral screws with divergent and parallel placement. Arthroscopy 1995;11:37-41. PMID:7727010 (Link to Abstract)

2. Dworsky BD, Jewell BF, Bach BR Jr. Interference screw divergence in endoscopic anterior cruciate ligament reconstruction. Arthroscopy. 1996 Feb;12(1):45-9. PMID:8838728 (Link to Abstract)

Question Authors:

David Abbasi MD, John Badylak MD, Patrick McCulloch MD,

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(SBQ07.37) You are considering performing an anterior cruciate ligament reconstruction on an adolescent female athlete but are concerned about the possibility of a resultant leg length discrepency. Which of the following history or physical findings is most reliable at predicting the amount of growth remaining? Topic

Review Topic

1. Cessation of changes in shoe size
2. Onset of menarche
3. Secondary sex characteristics
4. Doubling the child’s height when she was 2 years of age to determine final height
5. Age at which patellar ossification began

PREFERRED RESPONSE ▶

DISCUSSION: Age of menarche is the most accurate clinical factor to assess the degree of skeletal maturity in the female athlete.Skeletal maturity is usually within 2 years from menarche with approximately 9mm of distal femoral and 6mm of proximal tibial growth per year.

Stanitski presents a Level 5 review of ACL tears and tibial eminence fractures in the pediatric patient. Familial height and recent change in shoe size are only moderately useful in predicting final growth, and hence, skeletal maturity. The presence of secondary sex characteristics as determined by Tanner staging is a good predictor of skeletal maturity however it is worth noting that menarche may be delayed in high performance female athletes.

REFERENCES:

1. Stanitski CL: Anterior cruciate ligament injury in the skeletally immature patient: Diagnosis and treatment. J Am Acad Orthop Surg 1995;3:146-158 PMID:10790663 (Link to Abstract)

2. Fowler PJ: Anterior cruciate ligament injuries in the child, in Drez D, DeLee JD, Miller MD (eds): Orthopaedic Sports Medicine Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, pp 2067-2074

Question Authors:

Michael Hughes MD, John Badylak MD, Patrick McCulloch MD, Eric Shirley MD,

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(SBQ07.46) A 28-year-old male presents with persistent knee symptoms 6 months following ACL reconstruction. Current radiographs are shown in Figure A. Based on the location of his femoral tunnel, which of the following physical exam findings is likely present? Topic

Review Topic

FIGURES: A

1. Positive Lachman's exam
2. Positive external rotation dial test at 30 degrees
3. Positive anterior drawer sign
4. Positive posterior drawer sign
5. Positive pivot shift sign

PREFERRED RESPONSE ▶

DISCUSSION: The clinical presentation is consistent with a ACL reconstruction with a malpositioned femoral tunnel at the "12 o'clock" position. ACL reconstruction with 12 o'clock femoral fixation would lead to a vertically placed graft and result in continued instability with cutting activities, and a positive pivot shift exam due to failure to reconstruct the posterolateral bundle of the ACL.

Current standards for anatomic ACL reconstruction stress the importance of more horizontal graft placement (10:30 in a right knee vs 1:30 in the left knee. This attempts to reconstruct both the anteromedial bundle, which provides anterior-posterior stability, and the posterolateral bundle, which provides rotational stability. Improper femoral graft placement is one of the most common reasons for ACL revision surgery.

Scopp et al studied the effect of ACL femoral fixation in the coronal plane for patellar tendon autografts in a biomechanical model. In their study, they review that non-anatomic tunnel positioning of the femoral tunnel accounts for most of all technical failures and continued knee rotational instability. Their results supported that oblique femoral fixation as opposed to vertical femoral fixation of the ACL lead to more normal knee rotational stability.

Incorrect Answers:
Answers 1 and 3: A positive Lachman or anterior drawer would not be present with a vertically placed femoral tunnel since the graft would still provide resistance to anterior-posterior translation .
Answer 2: A positive external rotation dial test at 30 degrees would be present with a posterolateral corner injury.
Answer 4: A positive posterior drawer sign would be present with a PCL injury.

REFERENCES:

1. Scopp JM, Jasper LE, Belkoff SM, et al: The effect of oblique femoral tunnel placement on rotational constraint of the knee reconstructed using patellar tendon autografts. Arthroscopy 2004;20:294-299 PMID:15007318 (Link to Abstract)

2. Carson EW, Simonian PT, Wickiewicz TL, et al: Revision anterior cruciate ligament reconstruction. Instr Course Lect 1998;47:361-368 PMID:9571438 (Link to Abstract)

Question Authors:

David Abbasi MD, Michael Hughes MD, Robert Boykin MD,

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(SBQ04.32) In biomechanical testing, which of the following tissues has the highest maximum load to failure? Topic

Review Topic

1. Quadruple semitendinosus and gracilis tendons
2. Bone-patellar tendon-bone with a width of 10 mm
3. Bone-quadriceps tendon with a width on 10mm
4. Tibialis tendon allograft
5. Native anterior cruciate ligament (ACL)

PREFERRED RESPONSE ▶

DISCUSSION: Biomechanical studies show that the quadruple semitendinosus and gracilis tendons are the strongest of the tissues on maximal load to failure testing. All of the potential ACL grafts mentioned are stronger than native ACL.

Wilson et al looked at cadaveric specimens (mean age 40) and found average load to failure for the patellar tendon grafts was 1784 +/- 580 N compared with 2422 +/- 538 N for the quadrupled hamstring tendon grafts, which was significantly different.

Woo et al tested native ACL ultimate load in cadavers and reported a mean of 2160 +/- 157 N in young patients tested in the anatomical orientation, which was higher than previous reports.

Staubli et al compared preconditioned quad to patellar tendon grafts and found ultimate failure at 2353 +/- 495 N for QT-B complexes and 2376 +/- 152 N for B-PL complexes. However, all of these grafts are reasonable and other structural properties such as graft size, stiffness, creep, and strength of fixation are also important considerations.

REFERENCES:

1. Woo SL, Hollis JM, Adams DJ, Lyon RM, Takai S. Tensile properties of the human femur-anterior cruciate ligament-tibia complex: The effects of specimen age and orientation. Am J Sports Med 1991;19:217-225. PMID:1867330 (Link to Abstract)

2. Stäubli HU, Schatzmann L, Brunner P, Rincón L, Nolte LP. Quadriceps tendon and patellar ligament cryosectional anatomy and structural properties in young adults. Knee Surg Sports Traumatol Arthrosc 1996;4:100-110. PMID:8884731 (Link to Abstract)

3. Wilson TW, Zafuta MP, Zobitz M. A biomechanical analysis of matched bone-patellar tendon-bone and doubled looped semitendinosus and gracilis tendon grafts. Am J Sports Med 1999;27:202-207. PMID:10102102 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Michael Hughes MD, John Badylak MD, Eric Shirley MD,

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(OBQ11.129) A patient develops infrapatellar contracture syndrome after undergoing ACL surgery. All of the following findings are consistent with this diagnosis EXCEPT? Topic

Review Topic

1. Patella infera
2. Decreased patellar mobility
3. Loss of active but not passive flexion
4. Loss of active extension
5. Loss of passive flexion

PREFERRED RESPONSE ▶

DISCUSSION: Infrapatellar contracture syndrome is an uncommon complication following knee surgery or injury which results in knee stiffness. The resulting stiffness limits both active and passive range of motion (ROM) and usually results in loss of flexion, extension, and patellar mobility. The development of patella infera (baja) on lateral radiographs is a common sequela and also a poor prognostic sign.

Paulos et al. describe the risk factors and their results of treatment. ACL surgery is a risk factor, as is the use of a patellar tendon autograft, multiple knee surgeries, and non-isometric tunnel placement. In patients with this condition, the use of closed manipulation and the development of patella infera are negative prognostic factors. Surgical releases are recommended to improve motion, but residual functional impairment and only fair subjective scores should be expected.

REFERENCES:

1. Paulos LE, Wnorowski DC, Greenwald AE. Infrapatellar contracture syndrome. Diagnosis, treatment, and long-term followup. Am J Sports Med. 1994 Jul-Aug;22(4):440-9. PMID:7943507 (Link to Abstract)

2. Paine R. Section A: Language of exercise and rehabilitation. In: DeLee JC, Drez D, Miller MD, eds. Rehabilitation and Therapeutic Modalities: Orthopaedic Sports Medicine. Vol 2. 3rd ed. Philadelphia, PA: Saunders-Elsevier; 2010:221-237.

Question Authors:

Patrick McCulloch MD, Ben Taylor MD, Dave Marcu MD,

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(OBQ11.215) A 25-year-old male is one year status post anterior cruciate ligament (ACL) reconstruction using patellar bone-tendon-bone (BTB) autograft. He complains of persistent instability with certain activities. His operative dictation notes excellent stability intra-operatively with femoral fixation at the 12 o'clock position. Based on his femoral tunnel position, his history and examination are most likely to reveal which of the following? Topic

Review Topic

1. Positive pivot shift test and instability with cutting activities due to failure to reconstruct the posterolateral bundle of the ACL
2. Positive Lachman's test and instability with forward running activites due to failure to reconstruct the anteromedial bundle of the ACL
3. Positive pivot shift test and instability with cutting activities due to failure to reconstruct the anterolateral bundle of the ACL
4. Positive Lachman's test and instability with forward activites due to failure to reconstruct the posteromedial bundle of the ACL
5. Positive pivot shift test and instability with forward running activities due to failure to reconstruct the posterolateral bundle of the ACL

PREFERRED RESPONSE ▶

DISCUSSION: ACL reconstruction with 12 o'clock femoral fixation would lead to a vertically placed graft and result in continued instability with cutting activities, and a positive pivot shift exam due to failure to reconstruct the posterolateral bundle of the ACL. Current standards for anatomic ACL reconstruction stress the importance of more horizontal graft placement (10:30 in a right knee vs 1:30 in the left knee), to try and reconstruct both the anteromedial bundle which provides anterior-posterior stability, and the posterolateral bundle which provides the rotational stability. Improper femoral graft placement is one of the most common reasons for ACL revision surgery.

Denti et al studied results of patients undergoing ACL revision surgery and had moderate follow-up. Their results shows that patients undergoing revision ACL surgery can still have good results similar to those found in patient with primary ACL reconstruction with utilization of similar techniques in motivated patients.

Noyes et al also looked at patients undergoing revision ACL surgery with the use of patellar BTB autograft. In contrast, although functional limitations decreased and patient satisfaction improved, their results were not as good as the rate of graft failure was three times higher than their reported failure rate after primary ACL reconstructions. Additionally, they advocated correction of knee varus malalignment with high tibial osteotomy along with addressing any associated posterolateral ligament deficiencies prior to ACL surgery.

Illustrations A and B are radiographs demonstrating an appropriate femoral tunnel placement at the 1:30 position of the lateral femoral condyle on a left knee. Illustration V shows an example of a intra-operative positive pivot shift exam which would be seen after ACL reconstruction with a vertically placed graft.

Illustrations: A

REFERENCES:

1. Denti M, Lo Vetere D, Bait C, Schonhuber H, Melegati G, Volpi P. Revision anterior cruciate ligament reconstruction: causes of failure, surgical technique, and clinical results. Am J Sports Med. 2008 Oct;36(10):1896-902. PMID:18567717 (Link to Abstract)

2. Noyes FR, Barber-Westin SD. Revision anterior cruciate surgery with use of bone-patellar tendon-bone autogenous grafts. J Bone Joint Surg Am. 2001 Aug;83-A(8):1131-43. PMID:11507120 (Link to Abstract)

Question Authors:

David Abbasi MD, Patrick McCulloch MD, John Badylak MD,

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(OBQ11.271) A 23-year-old soccer player suffers an ACL rupture and undergoes reconstruction. Post-operatively she begins a rehabilitation program and her therapist develops of series of knee conditioning exercises to help her regain strength and range of motion. Which of the following exercises places the lowest strain in this patients properly placed ACL graft? Topic

Review Topic

1. Isometric hamstring contractions at 60 degrees of knee flexion
2. Isolated quadriceps contractions with the knee at 30 degrees of flexion
3. Simultaneous quadricep and hamstring contractions at 15 degrees of knee flexion
4. Isolated quadriceps contractions with the knee at 15 degrees of flexion
5. Active resisted knee motion from terminal extension to 30 degrees of flexion

PREFERRED RESPONSE ▶

DISCUSSION: Isometric hamstring contractions at 60 degrees of knee flexion will produce the lowest strain in this patient's ACL graft. Straight leg raises are also commonly used in post-ACL rehabilitation protocols as this exercise places little stress on an ACL graft. The other exercises mentioned have been shown to result in increased graft strain in patients with a reconstructed ACL.

Beynnon et al measured the strain behavior of the ACL during rehabilitation activities in vivo. They found that exercises that produce low or unstrained ligament values, and would not endanger a properly implanted graft, are either dominated by the hamstrings muscle (isometric hamstring contractions at any angle), involve quadriceps muscle activity with the knee flexed at 60 degrees or greater (isometric quadriceps, simultaneous quadriceps and hamstrings contraction), or involve active knee motion between 35 degrees and 90 degrees of flexion.

A bar graph from their study representing their findings is shown and explained in Illustration A.

Illustrations: A

REFERENCES:

1. Beynnon BD, Fleming BC, Johnson RJ, Nichols CE, Renström PA, Pope MH. Anterior cruciate ligament strain behavior during rehabilitation exercises in vivo. Am J Sports Med. 1995 Jan-Feb;23(1):24-34. PMID:7726347 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Patrick McCulloch MD, Michael Hughes MD, Mark Miller MD,

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(OBQ10.223) A collegiate men's basketball point guard undergoes ACL reconstruction with hamstring autograft. One year following reconstruction he experiences a painful pop in the knee during a cutting manuever on the court. The knee becomes acutely swollen. Lachman's exam demonstrates greater than 10 mm of laxity with no firm end point. Which of the following is the most likely cause of his injury? Topic

Review Topic

1. Improper graft selection
2. Lack of sufficient physical rehabilitation prior to return to basketball
3. Overly aggressive physical rehabilitation during the first 3 months following reconstructive surgery
4. Surgical error in graft tensioning
5. Surgical error in tunnel position

PREFERRED RESPONSE ▶

DISCUSSION: Failure following primary ACL reconstruction has been associated with surgical error in 65-75% of cases. Of these cases, tunnel malposition is the most common, accounting for 70% of the errors. Successful ACL reconstruction has been demonstrated with hamstring autograft as well as bone-patellar tendon bone autograft, quadriceps autograft and multiple allograft specimens. Appropriate rehabilitation is crucial for successful return to sport, but is not a more frequent cause of failure than surgical error. Battaglia et al review a surgical technique for revision ACL reconstruction utilizing freeze-dried allograft bone dowels to fill malpositioned tunnels. Grossman et al review 29 patients who underwent revision ACL reconstruction with bone patellar tendon bone allograft, contralateral bone-patellar tendon-bone autograft, or achilles allograft. All 29 patients reported satisfactory clinical results with an average 67 month follow-up.

REFERENCES:

1. Battaglia TC, Miller MD. Management of bony deficiency in revision anterior cruciate ligament reconstruction using allograft bone dowels: surgical technique. Arthroscopy. 2005 Jun;21(6):767 PMID:15944645 (Link to Abstract)

2. Grossman MG, ElAttrache NS, Shields CL, Glousman RE. Revision anterior cruciate ligament reconstruction: three- to nine-year follow-up. Arthroscopy. 2005 Apr;21(4):418-23. PMID:15800521 (Link to Abstract)

Question Authors:

John Badylak MD, Patrick McCulloch MD, Dave Marcu MD,

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(OBQ09.26) A 31-year-old male is 1 year status post primary anterior cruciate ligament reconstruction. Despite adequate physical therapy, he has been unable to return to sport due to recurrent instability and elects to proceed with revision surgery. What is the most common reason for failure of his primary ACL reconstruction? Topic

Review Topic

1. Unrecognized varus malalignment preop
2. Improper bone tunnel placement
3. Reconstruction with a single bundle
4. Improper graft selection
5. Meniscal injury

PREFERRED RESPONSE ▶

DISCUSSION: Battaglia et al report that "More than 75% of all cases of failed ACL reconstruction are the result of technical error and, of these, more than 70% are attributed specifically to malpositioned tunnels." Varus malalignment (answer 1) can lead to ACLR failure if not also addressed at the time of surgery, but is a less common cause of failure. Anatomic double bundle ACLR (answer #3) has been shown to be better biomechanically, but not clinically. Graft selection (answer #4) among autograft BTB, autograft hamstring, and allograft have not been shown consistently to affect revision rate. Meniscal (answer #5) and articular cartilage injury may affect the long-term satisfaction following ACLR, but are not a common cause of need for revision surgery. The study by Grossman et al reviewed 29 ACL's that underwent revision surgery with good results. All had a positive pivot shift preoperatively..

REFERENCES:

Question Authors:

Doug Nowak MD, Patrick McCulloch MD, Eric Shirley MD,

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(OBQ09.147) Tunnel malposition is thought to be a primary etiology for ACL graft failure. All of the following are true of tunnel position EXCEPT: Topic

Review Topic

1. Vertical placement of the femoral tunnel can result in rotational instability and impingement against the PCL
2. Anterior placement of the femoral tunnel can result in elongation of the graft
3. Tibial tunnel placement should be placed posterior to a line extending from Blumenstaat's line when the knee is in full extension
4. Transtibial drilling through a tibia tunnel that is too far anterior can result in a vertical (12:00) graft
5. Transtibial drilling through a tibia tunnel that is too far anterior can result in an oblique (10:30 or 1:30 position) graft

PREFERRED RESPONSE ▶

DISCUSSION: Tunnel placement is the most critical aspect of ACL reconstruction. The most common error in an ACL reconstruction is to place either the tibial or femoral tunnel too anteriorly, leading to graft impingement and failure.

If one decides to drill the femoral tunnel by way of the tibia tunnel (transtibial drilling), it is important to understand that the direction of the tibial tunnel influences femoral tunnel placement and a tibia tunnel placed too far anteriorly can lead to a vertical (12:00) graft orientation relative to the intercondylar notch. This problem can also be avoided by drilling the femoral tunnel through a medial portal.

Pinczewski et al reviewed radiographs of 200 ACL reconstructed patients over 7 years. There was an 11% rate of graft failure and they found if the tibial tunnel was placed >50% posteriorly along the length of the anterior tibial plateau, the incidence of rupture was 17% (11 of 66) vs 7% (8 of 115) if the graft was placed <50% posteriorly. They conclude that optimal results at seven years after operation are associated with the radiological orientation of the tunnels.

Illustration A is a summary of the results described by Pinczewski et al. Taking 0% as the anterior and 100% as the posterior extent, the femoral tunnel was a mean of 86% along Blumensaat’s line and the tibial tunnel was 48% along the tibial plateau. Taking 0% as the medial and 100% as the lateral extent, the tibial tunnel was 46% across the tibial plateau and the mean inclination of the graft in the coronal plane was 19°. Illustration B reinforces the concept described in Option #3 and demonstrates an ideal tibial tunnel placement, whereby it is placed posterior to a line extending from Blumenstaats line when the knee is in full extension.

Illustrations: A

REFERENCES:

1. Pinczewski LA, Salmon LJ, Jackson WF, von Bormann RB, Haslam PG, Tashiro S. Radiological landmarks for placement of the tunnels in single-bundle reconstruction of the anterior cruciate ligament. J Bone Joint Surg Br. 2008 Feb;90(2):172-9. PMID:18256083 (Link to Abstract)

Question Authors:

Michael Hughes MD, Patrick McCulloch MD, Dave Marcu MD,

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(OBQ08.120) A 25-year-old male undergoes an ACL reconstruction with an ipsilateral bone-patella tendon-bone autograft. At his two week followup he is noted to have complete loss of his extensor mechanism on exam, stable lachman and posterior drawer tests, and patella alta radiographically. Management should consist of? Topic

Review Topic

1. Continued standard ACL rehab protocol
2. Quadraceps tendon repair
3. WBAT in a cylinder cast
4. Patellar tendon reconstruction
5. Revision ACL reconstruction with hamstring autograft

PREFERRED RESPONSE ▶

DISCUSSION: Patellar tendon rupture is a rarely reported complication of using a bone-patella tendon-bone (BPTB)autograft in ACL reconstruction. Most cases have been reported in the early post-operative period and should be treated with patellar tendon reconstruction to restore the extensor mechanism. The reference from Cain et. al details management options for intraoperative complications of patella tendon grafts. The reference from Lee et.al demonstrated a 0.2% complication rate from BPTB harvest including 2 patella fractures and 1 patellar tendon rupture treated with reconstruction.

REFERENCES:

1. Cain EL Jr, Gillogly SD, Andrews JR. Management of intraoperative complications associated with autogenous patellar tendon graft anterior cruciate ligament reconstruction. Instr Course Lect. 2003;52:359-67. PMID:12690863 (Link to Abstract)

2. Lee GH, McCulloch P, Cole BJ, Bush-Joseph CA, Bach BR Jr. The incidence of acute patellar tendon harvest complications for anterior cruciate ligament reconstruction. Arthroscopy. 2008 Feb;24(2):162-6. PMID:18237699 (Link to Abstract)

3. Garrick, JG (ED): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 169-181

Question Authors:

Robert Boykin MD, Patrick McCulloch MD, Eric Shirley MD,

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(OBQ08.186) Patients may complain of numbness over the anterolateral aspect of the knee following ACL reconstruction. This is most commonly due to injury of which of the following? Topic

Review Topic

1. Suprapatellar branch of the saphenous nerve
2. Infrapatellar branch of the saphenous nerve
3. The common peroneal nerve
4. The superficial femoral nerve
5. The lateral femoral cutaneous nerve

PREFERRED RESPONSE ▶

DISCUSSION: Injury to the infrapatellar branch of the saphenous nerve (IBSN) during ACL reconstruction is common and can lead to numbness and paresthesias over the anterolateral aspect of the knee and proximal leg. It can also be a cause of anteromedial pain in the proximal stump.

The saphenous nerve arises as a division of the femoral nerve and leaves the adductor canal between the tendons of the gracilis and semitendinosus. It then divides into the main saphenous branch and the infrapatellar branch which crosses the knee below the patella. Therefore, it can be injured when making the incision for the tibial tunnel or when harvesting hamstring or patellar tendon grafts. Injury to the IBSN can result in anteromedial pain and decreased sensation over the anterolateral infra-patellar area of the knee and leg.

Portland et al noted that the IBSN is often injured with the traditional vertical incision for central patellar tendon harvest. They suggest that a horizontal incision may result in a lower injury rate but is technically more challenging.

Illustration A shows a right leg with the infrapatellar branch of the saphenous nerve tagged.

Illustrations: A

REFERENCES:

1. Portland GH, Martin D, Keene G, Menz T. Injury to the infrapatellar branch of the saphenous nerve in anterior cruciate ligament reconstruction: comparison of horizontal versus vertical harvest site incisions. Arthroscopy. 2005 Mar;21(3):281-5 PMID:15756180 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, John Badylak MD, Ben Taylor MD,

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(OBQ08.193) Strategies which focus on increasing patient neuromuscular control are most effective at preventing which of the following female sporting injuries? Topic

Review Topic

1. Shoulder dislocations
2. Concussion
3. Anterior cruciate ligament ruptures
4. Frieberg's infarction
5. Patellofemoral instability

PREFERRED RESPONSE ▶

DISCUSSION: Anterior cruciate ligament (ACL) prevention strategies currently focus on increasing patient neuromuscular control and has been shown to decrease ACL tear rates in certain populations. Women have different muscle fiber distribution, increased ratio of quadriceps to hamstring strength, electromechanical firing delay, and different knee kinematics. As described in the reference by Griffin et al., neuromuscular training reduces these factors and has been shown to decrease rates of ACL tears in women.

REFERENCES:

1. Garrick JG (ED). Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 403-410

2. Griffin LY, Agel J, Albohm MJ, Arendt EA, Dick RW, Garrett WE, Garrick JG, Hewett TE, Huston L, Ireland ML, Johnson RJ, Kibler WB, Lephart S, Lewis JL, Lindenfeld TN, Mandelbaum BR, Marchak P, Teitz CC, Wojtys EM. Noncontact anterior cruciate ligament injuries: risk factors and prevention strategies. J Am Acad Orthop Surg. 2000 May-Jun;8(3):141-50. Review. PMID:10874221 (Link to Abstract)

Question Authors:

Patrick O'Donnell MD/PhD, Patrick McCulloch MD, Eric Shirley MD,

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(OBQ08.213) When comparing autologous graft options for ACL reconstruction, a hamstring graft is associated with which of the following findings when compared to a patellar tendon graft? Topic

Review Topic

1. Decreased tunnel widening
2. Decreased pivot shift
3. Decreased incidence of anterior knee pain
4. Increased knee flexion strength on Cybex testing
5. Increased stability on KT-1000

PREFERRED RESPONSE ▶

DISCUSSION: Beynnon's randomized JBJS study compared bone-patellar tendon-bone autograft with two strand hamstring autograft for ACL reconstructions. They followed 22 subjects in each group for an average of 3 years and evaluated them in terms of clinical test findings, patient satisfaction, activity level, functional status, and isokinetic muscle strength. The patients in whom a hamstring graft had been used had significantly lower peak knee-flexion strength than those who had a bone-patellar tendon-bone graft (p = 0.039). In contrast, the two treatments produced similar outcomes in terms of patient satisfaction, activity level, and knee function (ability to perform a one-legged hop, bear weight, squat, climb stairs, run in place, and duckwalk). BTB autograft patients tend to have a higher incidence of knee pain and knee stiffness not affecting function. Hamstring autograft does not generate less tunnel widening or a smaller pivot-shift test or KT-1000 reading than patellar autograft.

REFERENCES:

1. Rodeo SA, Arnoczky SP, Torzilli PA et al. Tendon-healing in a bone tunnel. A biomechanical and histological study in the dog. J Bone Joint Surg Am. 1993 Dec;75(12):1795-803. PMID:8258550 (Link to Abstract)

2. Beynnon BD, Johnson RJ, Fleming BC et al.Tendon-Bone Grafts with Two-Strand Hamstring Grafts : A Prospective Randomized Study. J Bone Joint Surg Am. 2002;84:1503-1513. PMID:12208905 (Link to Abstract)

3. Pinczewski LA, Lyman J, Salmon LJ, et al. A 10-year comparison of anterior cruciate ligament reconstructions with hamstring tendon and patellar tendon autograft: a controlled, prospective trial. Am J Sports Med. 2007 Apr;35(4):564-74. Epub 2007 Jan 29. PMID:17261567 (Link to Abstract)

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Patrick McCulloch MD, Derek Moore, Guillem Lomas MD,

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(OBQ07.66) A 16 year old high school basketball player sustains a non-contact knee injury when she lands from a rebound. She develops immediate swelling and is noted to have a hemarthrosis. What is the most likely diagnosis? Topic

Review Topic

1. MCL tear
2. PCL tear
3. ACL tear
4. Patellar dislocation
5. Contusion

PREFERRED RESPONSE ▶

DISCUSSION: This is the classic history for an ACL tear. Women's basketball has one of the highest rates of ACL tears. While all of the answers are possible, the incidence of ACL tears in adolescents with an acute knee injury with hemarthrosis is the highest. Stanitski et al reported that 65% of adolescents with an acute knee hemarthrosis had and ACL tear compared to 45% having a meniscal tear. Likewise, Bomberg et al reported that 71% of patients with an acute hemarthrosis had sustained an ACL injury.

REFERENCES:

1. Stanitski CL, Harvell JC, Fu F: Observations on acute knee hemarthrosis in children and adolescents. JPO 1993;13:506-510 PMID:8370785 (Link to Abstract)

2. Bomberg BC, McGinty JB: Acute hemarthrosis of the knee: Indications for diagnostic arthroscopy. Arthroscopy 1990;6:221-225 PMID:2206185 (Link to Abstract)

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Patrick McCulloch MD,

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Anatomical ACL Reconstruction

Sports - Surgical Techniques - ACL Tear

Arthroscopic comparison of normal ACL to an anatomically reconstructed ACL.

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(OBQ07.87) A patient sustains a knee injury. The MRI image shown in Figure A is indicative of which of the following injuries? Topic

Review Topic

FIGURES: A

1. ACL tear
2. PCL tear
3. Medial meniscus tear
4. Lateral meniscus tear
5. Patellar tendon tear

PREFERRED RESPONSE ▶

DISCUSSION: This image shows a bone bruise pattern consistent with an ACL tear. The pattern of bone bruise on the middle 1/3 of the lateral femoral condyle and posterior 1/3 of the lateral tibial plateau is indicative of ACL tear. It makes sense because the tibia is allowed to subluxate anterior more than usual and make abnormal contact and experiences forces inappropriately. Viskontas et al. correlated the mechanism of ACL tear with the degree of bone bruising and found that a noncontact mechanism caused more severe bone bruising in both the medial and lateral compartments. In another MRI review study, Collins et al. found that the presence of bone contusions in the lateral compartment increased the specificity and positive predictive value in determining ACL injury.

REFERENCES:

1. Viskontas DG, Giuffre BM, Duggal N, Graham D, Parker D, Coolican M. Bone bruises associated with ACL rupture: correlation with injury mechanism. Am J Sports Med. 2008 May;36(5):927-33. PMID:18354139 (Link to Abstract)

2. Collins MS, Unruh KP, Bond JR, Mandrekar JN. Magnetic resonance imaging of surgically confirmed anterior cruciate ligament graft disruption. Skeletal Radiol. 2008 Mar;37(3):233-43. PMID:18092160 (Link to Abstract)

Question Authors:

Patrick McCulloch MD,

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(OBQ07.155) Increased ACL injury rates in women athletes compared to male athletes may be due to muscular imbalance and relative weakness in which of the following muscle groups? Topic

Review Topic

1. Quadriceps
2. Hamstrings
3. Gluteus muscles
4. Adductors
5. Abdominals

PREFERRED RESPONSE ▶

DISCUSSION: Imbalanced or excessive knee extensor power causes abnormal tension on the ACL. Strengthening and proprioreceptive control of the knee flexors/hamstrings protects against excessive or unopposed knee extensors which protect the ACL from excessive tensioning. The Ahmad reference states that "female athletes after menarche increase their quadriceps strength greater than their hamstring strength, putting them at risk for anterior cruciate ligament injury. Anterior cruciate ligament-prevention programs based on improving dynamic control of the knee by emphasizing hamstring strengthening should be instituted for girls after menarche." The Vescovi paper examines the effects of such a program on athletic performance. The Baratta paper looked at EMG results of quad and hamstrings and suggested exercise of the antagonist muscle to add to dynamic stability.

REFERENCES:

1. Ahmad CS, Clark AM, Heilmann N, Schoeb JS, Gardner TR, Levine WN. Effect of gender and maturity on quadriceps-to-hamstring strength ratio and anterior cruciate ligament laxity.Am J Sports Med. 2006 Mar;34(3):370-4. Epub 2005 Oct 6. PMID:16210574 (Link to Abstract)

2. Baratta R, Solomonow M, Zhou BH, Letson D, Chuinard R, D'Ambrosia R. Muscular coactivation. The role of the antagonist musculature in maintaining knee stability. Am J Sports Med. 1988 Mar-Apr;16(2):113-22. PMID:3377094 (Link to Abstract)

3. Vescovi JD, Vanheest JL. Effects of an anterior cruciate ligament injury prevention program on performance in adolescent female soccer players. Scand J Med Sci Sports. 2010 Jun;20(3):394-402. PMID:19558381 (Link to Abstract)

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Patrick McCulloch MD,

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(OBQ07.274) Which of the following risk factors is felt to contribute greatest to the higher rate of ACL rupture in female compared to male athletes? Topic

Review Topic

1. Body mass index
2. Femoral notch width
3. Generalized ligamentous laxity
4. Neuromuscular factors
5. Limb alignment

PREFERRED RESPONSE ▶

DISCUSSION: Hewett showed that increased valgus moments when jumping and landing and a relative weakness of hamstrings compared to quadriceps are present in female athetes and may contribute to higher ACL tear rates. It has subsequently been shown that neuromuscular training to address these issues can result in a reduction of ACL injuries in select groups of female athletes.

Uhorchak conducted a 4 year study on 895 US Military cadets, there were 24 noncontact ACL tears. Significant risk factors for noncontact ACL tears included small femoral notch width, generalized joint laxity, and in women, higher than normal BMI and KT-2000 arthrometer values (indicating laxity). In the second study 205 females in high-risk sports were prospectively measured for neuromuscular control during a jump-landing task. It appears that increased valgus motion and valgus moments at the knee joint during the impact phase of jump-landing tasks are key predictors of an increased potential for ACL injury in females.

The Alentorn-Geli paper reviews these risk factors in the soccer population.

REFERENCES:

1. Alentorn-Geli E, Myer GD, Silvers HJ, Samitier G, Romero D, Lázaro-Haro C, Cugat R. Prevention of non-contact anterior cruciate ligament injuries in soccer players. Part 1: Mechanisms of injury and underlying risk factors. Knee Surg Sports Traumatol Arthrosc. 2009 Jul;17(7):705-29. Epub 2009 May 19. PMID:19452139 (Link to Abstract)

2. Uhorchak JM, Scoville CR, Williams GN, Arciero RA, St Pierre P, Taylor DC. Risk factors associated with noncontact injury of the anterior cruciate ligament: a prospective four-year evaluation of 859 West Point cadets. Am J Sports Med. 2003;31(6):831-42. PMID:14623646 (Link to Abstract)

3. Hewett TE, Myer GD, Ford KR, Heidt RS Jr, Colosimo AJ, McLean SG, van den Bogert AJ, Paterno MV, Succop P. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med. 2005;33(4):492-501. PMID:15722287 (Link to Abstract)

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Patrick McCulloch MD, Eric Shirley MD, Ben Taylor MD,

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(OBQ06.112) A 25-year-old male soccer player twisted his left knee 4 days ago and developed immediate swelling and pain. On exam, he has a 2+ effusion and pain with active range of motion. Passively, he tolerates range of motion from 0-90 degrees. He has difficulty performing a straight leg raise exercise. MRI scan is shown in Figure A. What is the most appropriate initial management for his injury? Topic

Review Topic

FIGURES: A

1. Knee immobilization
2. Physical therapy for range of motion and strength
3. Acute reconstruction followed by mobilization
4. Arthrocentesis to rule out infection
5. Rest, nonsteroidal anti-inflammatories, and follow-up in 4 weeks

PREFERRED RESPONSE ▶

DISCUSSION: The clinical presentation, physical exam, and imaging are consistent with an acute anterior cruciate ligament (ACL) tear. If the patient wants to return to sports requiring twisting/pivoting, an ACL reconstruction is recommended. He currently has an acute effusion (hemarthrosis) with decreased motion. Acute ACL reconstructions in patients with limited range of motion and weakness have been shown to lead to postoperative arthrofibrosis and weakness.

Shelbourne and Patel noted several factors that go into optimizing ACL reconstruction results: Mental preparation of the patient; school, work, family, and social schedules; preoperative condition of the knee [i.e., minimal or no swelling, good strength, good leg control, and full range of motion including full hyperextension] and lack of associated ligamentous and/or meniscal injuries.

Eitzen et al. recommended waiting until the affected quadriceps was within 20% of the strength of the contralateral unaffected one in order to mitigate postoperative strength deficits.

Sterett et al found that acute reconstruction (within 3 weeks) yielded good range of motion and strength results but in patients in whom the parameters were excellent preoperatively. The other answers would not optimize postoperative results. Immobilization would promote arthrofibrosis, as would an acute reconstruction in this stiff, weak knee. Arthrocentesis is a reasonable diagnostic/therapeutic option acutely. However, it does expose the patient to a risk of infection. Furthermore, in this patient with a 4 day old injury, the hemarthrosis is likely mostly coagulated and would frustrate attempts at aspiration. Rest and NSAIDs would not help to promote range of motion and strength.

REFERENCES:

1. Shelbourne KD, Patel DV: Timing of surgery in anterior cruciate ligament-injured knees. Knee Surg Sports Traumatol Arthosc 1995;3:148-156. PMID:8821270 (Link to Abstract)

2. Sterett WI, Hutton KS, Briggs KK, Steadman JR. Decreased range of motion following acute versus chronic anterior cruciate ligament reconstruction. Orthopedics 2003;26:151-154. PMID:12597218 (Link to Abstract)

3. Eitzen I, holm I, Risberg MA. Preoperative strength is a significant predictor of knee function two years after ACL reconstruction. Br J Sports Med. 2009 May;43(5):371-6. PMID:19224907 (Link to Abstract)

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Patrick McCulloch MD, Michael Hughes MD, Dave Marcu MD, Eric Shirley MD,

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(OBQ06.138) Following ACL reconstruction, which of the following tests most closely correlates with patient satisfaction with their reconstructed knee? Topic

Review Topic

1. KT-1000 manual maximum value
2. Lachman's test
3. Anterior drawer test
4. Pivot shift test
5. Cybex testing

PREFERRED RESPONSE ▶

DISCUSSION: Kocher et al in a study looking at 202 post ACL-reconstruction patients found that the pivot shift test was the only test significantly associated with patient satisfaction, knee giving away, difficulty cutting and twisting, activity limitation, sports participation, Lysholm score, and overall knee function. KT-1000 is an instrument to measure the anterior translation of the tibia.

REFERENCES:

1. Kocher MS, Steadman JR, Briggs KK, Sterett WI, Hawkins RJ. Relationships between objective assessment of ligament stability and subjective assessment of symptoms and function after anterior cruciate ligament reconstruction. Am J Sports Med. 2004 Apr-May;32(3):629-34. PMID:15090377 (Link to Abstract)

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Patrick McCulloch MD, Jeremy Stern MD,

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(OBQ06.177) A patient develops anteromedial pain and altered sensation over the anterolateral infrapatellar region of the knee after autologous hamstring tendon harvest for an ACL reconstruction. Which of the following nerves has been injured? Topic

Review Topic

1. Medial retinacular
2. Inferior genicular
3. Saphenous
4. Superficial peroneal
5. Tibial

PREFERRED RESPONSE ▶

DISCUSSION: The saphenous nerve is at risk during hamstring harvest for ACL reconstruction both at the site of the harvest incision and more proximally as a result of the tendon harvester. The saphenous nerve arises as a division of the femoral nerve and leaves the adductor canal and pierces the fascia lata between the tendons of the gracilis and sartorius. It then divides into the main saphenous branch and the infrapatellar branch (IBSN) which crosses the knee below the patella. Injury to the IBSN can result in anteromedial pain and decreased sensation over the anterolateral infra-patellar area of the leg.

Figueroa et al reported that injury rates to the IBSN during autologous hamstring harvesting for ACL reconstruction was higher than previously reported 30-59%. They found hypoesthesia of the IBSN territory was found in 17 knees (77%) with an average area of 36 cm(2) (1-120 cm(2)). Injury to the IBSN was electrophysiologically detected in 15 knees (68%). Two patients also had an injury to the saphenous nerve more proximally (9%) likely as a result of the tendon harvester.

The Hoppenfeld and Medvecky references review the surgical approaches and relevant anatomy. The ISBN can be seen in Illustration A.

Illustrations: A

REFERENCES:

1. Hoppenfeld S, deBoer PL The Knee, in Hoppenfeld and deBoer: Surgical Exposures in Orthopaedics, the Anatomic Approach.

2. Medvecky MJ, Noyes FR: Surgical approaches to the posteromedial and posterolateral aspects of the knee. JAAOS 2005;13:121-128. PMID:15850369 (Link to Abstract)

3. Figueroa D, Calvo R, Vaisman A, Campero M, Moraga C. Injury to the infrapatellar branch of the saphenous nerve in ACL reconstruction with the hamstrings technique: clinical and electrophysiological study.Knee. 2008 Oct;15(5):360-3. PMID:18583136 (Link to Abstract)

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Patrick McCulloch MD, John Badylak MD, Dave Marcu MD,

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(OBQ05.28) At what range of motion do seated leg extension exercises place the greatest amount of stress on the anterior cruciate ligament? Topic

Review Topic

1. 0 to 30 degrees
2. 30 to 60 degrees
3. 60 to 90 degrees
4. 90 to 120 degrees
5. flexion greater than 120 degrees

PREFERRED RESPONSE ▶

DISCUSSION: Open chain leg extension exercises cause the most anterior shear stress that would affect the ACL. The Wilk article summarizes that isotonic closed kinetic chain exercises produced significantly greater compressive forces compared to the open kinetic chain knee extension. In addition, during closed kinetic chain exercises, a posterior shear force (PCL stress) was generated throughout the entire range with maximal shear occurring from 85° to 105° of flexion. During knee extension, there is an anterior shear force (ACL stress) from 38° to 0° and a posterior shear force from 40° to 101°. According to Beynnon, a closed chain program results in anteroposterior knee laxity values that are closer to normal, and earlier return to normal daily activities, compared with rehabilitation with an open chain program.

REFERENCES:

1. Beynnon BD, Johnson RJ, Fleming BC. The science of anterior cruciate ligament rehabilitation. Clin Orthop Relat Res. 2002 Sep;(402):9-20. PMID:12218469 (Link to Abstract)

2. Wilk KE, Escamilla RF, Fleisig GS, Barrentine SW, Andrews JR, Boyd ML. A comparison of tibiofemoral joint forces and electromyographic activity during open and closed kinetic chain exercises. Am J Sports Med. 1996 Jul-Aug;24(4):518-27. PMID:8827313 (Link to Abstract)

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Patrick McCulloch MD, Eric Shirley MD, John Badylak MD,

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(OBQ05.40) During anterior cruciate ligament reconstruction, a graft that is tight in flexion but lax in extension may be due to which technical error? Topic

Review Topic

1. Femoral tunnel is too posterior
2. Femoral tunnel is too anterior
3. Femoral tunnel placed at 12:00 position
4. Tibial tunnel is too anterior
5. Tibial tunnel is too medial

PREFERRED RESPONSE ▶

DISCUSSION: The majority of early ACL reconstruction failures are felt to be due to errors in surgical technique. The most common error in ACL reconstruction is aberrant tunnel placement. The femoral tunnel can be placed too anteriorly, thereby causing increased strain on the graft in flexion because of the cam effect of the femoral condyle which can result in graft stretching, laxity in extension, and subsequent failure. Chhabra et al. performed a cadaveric study to demonstrate the anatomic footprints of the anteromedial and posterolateral bundles of the ACL. Markhof et al. performed a cadaveric study analyzing the effects of aberrant placement of the femoral tunnel. Illustration A is a table demonstrating the effects of tunnel malposition. Illustrations B and C are gross anatomy illustrations of normal ACL anatomy. Illustrations D and E are radiographs demonstrating anatomic ACL tunnels. The femoral tunnel is created through an accessory medial portal technique. Illustration F is an example of aberrant tunnel placement.

Illustrations: A

REFERENCES:

1. Chhabra A, Starman JS, Ferretti M, Vidal AF, Zantop T, Fu FH. Anatomic, radiographic, biomechanical, and kinematic evaluation of the anterior cruciate ligament and its two functional bundles. J Bone Joint Surg Am. 2006 Dec;88 Suppl 4:2-10. PMID:17142430 (Link to Abstract)

2. Markolf KL, Hame S, Hunter DM, Oakes DA, Zoric B, Gause P, Finerman GA. Effects of femoral tunnel placement on knee laxity and forces in an anterior cruciate ligament graft. J Orthop Res. 2002 Sep;20(5):1016-24. PMID:12382968 (Link to Abstract)

Question Authors:

John Badylak MD, Eric Shirley MD, Patrick McCulloch MD, Mark Miller MD,

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(OBQ05.96) Which of the following exercises should be used with caution in the initial post-operative rehabilitation following ACL reconstruction? Topic

Review Topic

1. Quadriceps sets
2. Seated leg extensions
3. Straight leg raises
4. Active range of motion
5. Closed chain exercises

PREFERRED RESPONSE ▶

DISCUSSION: Seated leg extensions are open chain exercises that are generally avoided early after ACL surgery. Closed chain exercises are emphasized because it allows for physiologic contraction of the muscles around the knee. Closed chain exercises load an extremity with the most distal segment stabilized, preventing joint shear forces. This is ideal for post-operative rehab for an ACL. For open chain exercises, the foot is unsupported. Quad sets and straight leg raises are generally allowed to help regain quadriceps function. They produce less graft strain because they are isometric about the knee, compared to a seated leg extension in which the quad force is pulling the tibia anteriorly and potentially stressing the graft.

Ross et al reviewed the literature and found support both closed chain exercises and modified open chain exercises for quadriceps strengthening at different timepoints after ACL reconstruction without causing excessive ACL strain or patellofemoral joint stress.

Beutler et al examined EMG activity of the quad in normal subjects doing single-legged squats and step-ups. They found high sustained quad activity suggesting that these exercises would be effective in muscle rehabilitation and that as functional, closed chain activities, they may also be protective of anterior cruciate ligament grafts.

The study by Wright et al is a systematic review of the recent literature regarding ACL rehabilitation.

REFERENCES:

1. Ross MD, Denegar CR, Winzenried JA. Implementation of open and closed kinetic chain quadriceps strengthening exercises after anterior cruciate ligament reconstruction. J Strength Cond Res 2001;15:466-473. PMID:11726258 (Link to Abstract)

2. Beutler AI, Cooper LW, Kirkendall DT. Electromyographic analysis of single-leg, closed chain exercises: Implications for rehabilitation after anterior cruciate ligament reconstruction. J Athl Train 2002;37:13-18. PMID:12937438 (Link to Abstract)

3. Wright RW, Preston E, Fleming BC, et al. 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 Jul;21(3):225-34. PMID:18686485 (Link to Abstract)

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Patrick McCulloch MD, Eric Shirley MD, Dave Marcu MD,

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(OBQ05.174) A high school girls basketball player sustains a non-contact knee injury and develops an acute hemarthrosis. What is the likelihood that she has an ACL tear? Topic

Review Topic

1. 0-15%
2. 15-30%
3. 30-45%
4. 45-60%
5. >60%

PREFERRED RESPONSE ▶

DISCUSSION: The classic scenario is a non-contact deceleration, jumping or cutting action. The patient might hear or feel a "pop". The acute hemarthrosis is caused by bleeding from branches of the middle geniculate artery. Women's basketball has one of the highest rates of ACL injury. With the above history, the literature states that the likelihood of ACL injury is greater than 70%. The reference by Maffulli et al. prospectively evaluated 106 acute hemarthroses in athletes and found 71 had an injury to the ACL.

REFERENCES:

1. Maffulli N, Binfield PM, King JB, Good CJ. Acute haemarthrosis of the knee in athletes. A prospective study of 106 cases. J Bone Joint Surg Br. 1993 Nov;75(6):945-9. PMID:8245089 (Link to Abstract)

2. Miller RH: Knee Injuries, In Canale ST (Ed): Campbell's Operative Orthopaedics, ED 10. ST. LOUIS, MO, MOSBY, 2003, p. 2254.

Question Authors:

Patrick McCulloch MD, Derek Moore,

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(OBQ05.190) The middle genicular artery is the primary blood supply of which of the following structures? Topic

Review Topic

1. Medial collateral ligament
2. Lateral collateral ligament
3. Medial meniscus
4. Lateral meniscus
5. Anterior cruciate ligament

PREFERRED RESPONSE ▶

DISCUSSION: Contrary to popular belief, the major blood supply to the ACL does not originate from its bony attachments. The ACL is supplied mainly by the vessels that originate from the middle genicular artery which leave the popliteal artery and directly pierce the posterior capsule (Illustration A). Branches enter the synovial membrane at the junction of the joint capsule distal to the infrapatellar fat pad. The ligament is ensheathed by the synovial plexus along its entire length. Smaller connecting branches penetrate the ligament and anastomose with a network of endoligamentous vessels that are oriented in a longitudinal direction and lie parallel to the collagen bundles within the ligament.

The vascular supply to the medial and lateral menisci of the knee originates predominantly from the lateral and medial genicular arteries (both inferior and superior). The middle genicular artery, along with a few terminal branches of the medial and lateral genicular arteries, also supplies vessels to the menisci through the vascular synovial covering of the anterior and posterior horn attachments.

The referenced study by Toy et al is a cadaveric study that reported ACL vascularization arises primarily from the middle genicular artery; the artery gives rise to periligamentous vessels which form a web-like network within the synovial membrane. They also found that the extremities of the ACL seem to be better vascularized than the middle part, and the proximal portion seems to have a greater vascular density than the distal portion.

Illustrations: A

REFERENCES:

1. Toy BJ, Yeasting RA, Morse DE, McCann P. Arterial supply to the human anterior cruciate ligament. J Athl Train. 1995 Jun;30(2):149-52. PMID:16558326 (Link to Abstract)

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Ben Taylor MD, Ben Taylor MD, Patrick McCulloch MD,

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(OBQ05.214) All of the following are true regarding excessively anterior femoral tunnel placement during ACL reconstruction EXCEPT? Topic

Review Topic

1. It may cause loss of knee flexion
2. It may cause graft over-stretching and failure
3. It is the most common technical error
4. It may cause interference screw divergence
5. It is often due to poor visualization

PREFERRED RESPONSE ▶

DISCUSSION: Anterior placement of the femoral tunnel is the most common surgical error during arthroscopic ACL reconstruction. Errors in surgical technique are the most common cause of graft failure in patients who present with recurrent instability after ACL reconstruction. Technical shortcomings that result in graft failure after primary reconstruction include nonanatomic tunnel placement, graft impingement, improper tensioning of the graft, inadequate fixation of the graft in bony tunnels, graft material problems, and the failure to address insufficiency of the secondary stabilizers of the knee during ACL reconstruction. The papers by Allen and Harner et al stress the importance of determining the cause of failure prior to revision surgery. It is estimated that 70% to 80% of graft failures are caused by malpositioned tunnels. The consequences of nonanatomic tunnel placement are well described in the literature. Sommer et al note that inappropriate positioning of either the tibial or femoral tunnels results in excessive changes in graft length as the knee moves through its functional range of motion and can effect clinical results. Because biologic ACL grafts can only accommodate small changes in length before undergoing plastic deformation, a mal-positioned graft may result in either capturing of the knee or lengthening of the graft over time; this results in either a loss of motion or recurrent instability, respectively. Improper femoral tunnel placement is most often caused by the failure to adequately visualize the most posterior aspect of the notch (the “over-the-top” position). Because the femoral attachment of the ACL is closer to the center of rotation of the knee, small errors in femoral tunnel placement may have deleterious effects on knee kinematics.

REFERENCES:

1. Allen CR Giffin JR, Harner CD: Revision anterior cruciate ligament reconstruction. Orthop Clin North Am 2003:34:79-98. PMID:12735203 (Link to Abstract)

2. Sommer C, Friederich NF, Muller W; Improperly placed anterior cruciate ligament grafts: Correlation between radiological parameters and clinical results. Knee Surg Sports Traumatol Anthrosc 2000:8:207-213 PMID:10975260 (Link to Abstract)

3. Harner CD, Giffin JR, Dunteman RC, Annunziata CC, Friedman MJ. Evaluation and treatment of recurrent instability after anterior cruciate ligament reconstruction. Instr Course Lect 2001;50:463-474. PMID:11372347 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Derek Moore, Guillem Lomas MD,

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(OBQ04.9) When evaluating patients that needed revision surgery, what is the most common cause of a failed primary ACL reconstruction? Topic

Review Topic

1. Tunnel malposition
2. Obesity
3. Smoking
4. Returning to sport too early
5. Inadequate physical therapy

PREFERRED RESPONSE ▶

DISCUSSION: Many factors may be involved in the failure of ACL reconstructions, including the surgical technique, the selection of graft material, the integrity of the secondary restraints, the condition of the articular and meniscal cartilage, postoperative rehabilitation, and the motivation and expectations of the patients. Early failure, usually within the first 6 months, most often is the result of technical errors, incorrect or overly aggressive rehabilitation, premature return to sports, or failure of graft incorporation. Later failure, usually after one year, is more typically the result of recurrent injury. The most avoidable and most common cause of failure is surgical technique. These errors include improper tunnel placement (most common), and errors in graft selection, size, physiognomy or tensioning. Anterior tunnels (most common) results in a graft tight in flexion and loose in extension. The Azar paper is an instructional course of revision ACL surgery. The Wolf paper and the Allen paper review both the causes for ACL graft failure and the planning steps needed to address them during revision reconstruction.

REFERENCES:

1. Allen CR, Giffin JR, Harner CD. Revision anterior cruciate ligament reconstruction. Orthop Clin North Am. 2003 Jan;34(1):79-98. PMID:12735203 (Link to Abstract)

2. Azar FM. Revision anterior cruciate ligament reconstruction. Instr Course Lect. 2002;51:335-42. PMID:12064122 (Link to Abstract)

3. Wolf RS and Lemak LJ. Revision anterior cructiate ligament reconstruction surgery. J South Orthop Assoc. 2002 Spring;11(1):25-32. PMID:12741583 (Link to Abstract)

Question Authors:

Patrick McCulloch MD,

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(OBQ04.19) You are called by a 35-year-old male patient who had ACL reconstruction with hamstring autograft 5 days ago. He reports his knee pain and swelling have significantly increased in the last day, and now it is difficult for him to raise his leg off the bed and is having more difficulty tolerating the CPM machine. Upon questioning he denies fever, chills, or any new trauma to the knee. What is the next step in management? Topic

Review Topic

1. Ice, NSAIDS, elevation, compression wrap and restart therapy once symptoms improve
2. Go to the ER immediately for knee aspiration with gram stain and cultures
3. Increase CPM use to 10 hours a day
4. Call the office staff in the morning to schedule an appointment
5. Start physical therapy visits once daily

PREFERRED RESPONSE ▶

DISCUSSION: Any patient who presents with a sudden increase in knee effusion in a delayed manner after ACL surgery should raise suspicion for infection, whether or not a fever is present. If suspected, an aspiration should be performed immediately and fluid sent for gram stain and cultures. If positive, immediate arthroscopy is indicated.

Mangine et al recommend aspiration of all post-operative knees if there is any suspicion of infection.

Shelbourne and Gray discuss their excellent results after ACL reconstruction with autologous bone-patellar tendon-bone graft followed by an accelerated rehab protocol. They did not discuss post-operative infections.

REFERENCES:

1. Mangine RE, Noyes FR, DeMaio M. Minimal protection program: advanced weight bearing and range of motion after ACL reconstruction--weeks 1 to 5. Orthopedics. 1992 Apr;15(4):504-15. PMID:1565587 (Link to Abstract)

2. Shelbourne KD, Gray T. Anterior cruciate ligament reconstruction with autogenous patellar tendon graft followed by accelerated rehabilitation. A two- to nine-year followup. Am J Sports Med. 1997 Nov-Dec;25(6):786-95. PMID:9397266 (Link to Abstract)

Question Authors:

Aaron Bott MD, Patrick McCulloch MD, John Badylak MD,

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(OBQ04.56) An 18-year-old athlete is now 3 months out from anterior cruciate ligament reconstruction. He has been unable to obtain full extension of the knee. His range of motion is from 12° to 125° compared to 0° to 140° on the contralateral knee. He has no effusion, no pain at rest, and a stable Lachman’s test. He is having difficulty ambulating without crutches. What is the most common technical error which can account for these findings? Topic

Review Topic

1. Femoral tunnel drilled too anteriorly
2. Failure to cycle the knee prior to final tibial fixation
3. Femoral tunnel drilled too vertically
4. Tibial tunnel drilled too vertically
5. Tibial tunnel drilled too anteriorly

PREFERRED RESPONSE ▶

DISCUSSION: A tibial tunnel drilled too anteriorly will limit full extension and causes tightness in flexion.

The majority of early ACL reconstruction failures are felt to be due to errors in surgical technique. The most common error in ACL reconstruction is aberrant tunnel placement. Placing the tibial tunnel too far anterior may cause notch impingement of the graft limiting full extension. It also causes tightness in flexion. Loss of full extension of the knee prevents appropriate heel-strike and alters the normal gait cycle.

Markolf et al used cadaveric knees to evaluate the effects of different femoral tunnel placements on the stability of an ACL reconstruction. They found that anterior and posterior errors resulted in greater laxity than errors medial or lateral around the notch clockface.

Chabra et al and Zantop et al review the anatomy and biomechanics of the two bundles of the ACL. The posterolateral (PL) bundle is tight in extension, while the anteromedial (AM) bundle becomes tight with flexion. The PL bundle appears to be more prevalent in providing rotatory stability.

Illustration A is a table demonstrating how aberrant tunnel placement affects knee range of motion. Illustration B shows an example of tunnel placement with label A being correct placement, label B being anterior tibial and femoral tunnel malposition.

Incorrect Answers:
1. Femoral tunnel drilled too anterior will lead to tightness in flexion and laxity in extension.
2. Failure to cycle the knee may lead to stretching out of the ACL and residual laxity in flexion and extension.
3. Femoral tunnel drilled to vertically is associated with transtibial drilling and will result in rotational instability.
4. Tibia tunnel drilled to vertically is not typically a problem with ACL reconstruction.

Illustrations: A

REFERENCES:

1. Chhabra A, Starman JS, Ferretti M, Vidal AF, Zantop T, Fu FH. Anatomic,radiographic, biomechanical, and kinematic evaluation of the anterior cruciateligament and its two functional bundles. J Bone Joint Surg Am. 2006 Dec;88 PMID:17142430 (Link to Abstract)

2. Markolf KL, Hame S, Hunter DM, Oakes DA, Zoric B, GaEffects of femoral tunnel placement on knee laxity and forces in an anteriorcruciate ligament graft. J Orthop Res. 2002 Sep;20(5):1016-24. use P, Finerman GA. PMID:12382968 (Link to Abstract)

3. Zantop T, Petersen W, Sekiya JK, Musahl V, Fu FH. Anterior cruciate ligamentanatomy and function relating to anatomical reconstruction. Knee Surg SportsTraumatol Arthrosc. 2006 Oct;14(10):982-92. Epub 2006 Aug 5. PMID:16897068 (Link to Abstract)

Question Authors:

John Badylak MD, Patrick McCulloch MD, Dave Marcu MD, Mark Miller MD,

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(OBQ04.91) A 30 year-old tennis player sustains the injury seen in Figure A and is considering nonoperative treatment. With nonoperative treatment, which of the following additional findings correlate most closely with the development of future arthritis? Topic

Review Topic

FIGURES: A

1. Grade IIB Lachman
2. Presence of pivot shift
3. Tenderness over MCL origin without opening on valgus
4. Positive Ober test
5. Painful pop on McMurray test

PREFERRED RESPONSE ▶

DISCUSSION: Factors that have been implicated in the progression of OA in the ACL deficient knee include meniscal lesions, osteochondral lesions, malalignment, and comcomitant ligamentous pathology. The painful pop on McMurray test is indicative of a meniscal tear.

In the ACL deficient knee the posterior horn medial meniscus is felt to be a stabilizer to anterior translation of the tibia – therefore placing it under high loads with translation and leading to a high incidence of secondary meniscal tears in chronic ACL insufficiency. Rupture of the posterior horn leads to even greater anterior translation, increased instability, and ensuing arthritis. Studies have shown ACL combined with PCL rupture to increase the incidence of OA significantly; however, several studies have shown no arthritic progression with associated collateral ligament injury.

Louboutin et al reported that the risk of developing osteoarthritis is lower after ACL reconstruction (14%-26% with a normal medial meniscus, 37% with meniscectomy) to untreated ruptures (60%-100%) at 20 year follow-up.

The Gillquist paper noted that meniscus tears and subsequent repair, or ACL tears without major concomitant injuries, seem to increase the risk 10-fold (15 to 20% incidence of gonarthrosis) compared with an age-matched, uninjured population (1 to 2%).

REFERENCES:

1. Louboutin H, Debarge R, Richou J, Selmi TA, Donell ST, Neyret P, Dubrana F. Osteoarthritis in patients with anterior cruciate ligament rupture: a review of risk factors. Knee. 2009 Aug;16(4):239-44. Epub 2008 Dec 20. PMID:19097796 (Link to Abstract)

2. Gillquist J, Messner K. Anterior cruciate ligament reconstruction and the long-term incidence of gonarthrosis. Sports Med. 1999 Mar;27(3):143-56. PMID:10222538 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, John Badylak MD, Ben Taylor MD,

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(OBQ04.174) Which of the following factors concerning ACL reconstruction has demonstrated definitive evidence of adverse effect on clinical outcomes? Topic

Review Topic

1. Graft tensioning at 20 Newtons instead of 40 Newtons
2. Quadrupled hamstring graft instead of bone-patellar tendon-bone graft
3. Femoral tunnel placement anterior instead of posterior to the lateral intercondylar ridge
4. One-incision instead of two-incision technique
5. Single bundle graft instead of double bundle graft reconstruction technique

PREFERRED RESPONSE ▶

DISCUSSION: Tunnel placement has a crictical role in clinical outcomes. AAOS COR review book states "The most common error in an ACL reconstruction is to place either the tibial or femoral tunnel too anteriorly, leading to graft impingement and failure." The text also states that graft type and the number of incisions do not appear to affect outcome. It is important to note that initial graft tension decreases shortly after the anterior cruciate ligament graft is performed.

The article by van Kampen et al was a prospective study looking at 38 patients treated with bone patella bone autografts with interference screws and the tibial block secured at 20 degrees of flexion. The patients where split into two groups: One group was tensioned at 20N, the other at 40N. They found no clinically significant difference in stability in these two patient groups one year out and thus graft tensioning does not appear to be as important as graft tunnel placement. Miller's review states "Significant controversy exists regarding the double-bundle ACL reconstruction" and the literature has not shown a definitive clinical outcome benefit compared to single bundle reconstruction.

REFERENCES:

1. Van Kampen A, Wymenga AB, van der Heide HJ, Bakens HJ. The effect of different graft tensioning in anterior cruciate ligament reconstruction: a prospective randomized study. Arthroscopy. 1998 Nov-Dec;14(8):845-50. PMID:9848597 (Link to Abstract)

Question Authors:

Michael Hughes MD, Patrick McCulloch MD,

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(OBQ04.212) A 16-year-old female volleyball player presents 1 week after sustaining a knee injury while landing from a jump. There was an audible popping sound at the time of injury and she developed swelling later that evening. On physical examination, the surgeon applies a valgus force to the fully extended and internally rotated knee. As the knee is then brought into flexion, a loud clunk occurs at 30° of flexion. Which of the following patterns of bone contusion shown on MRI in Figures A-E is most likely to be evident on this patient's MRI? Topic

Review Topic

FIGURES: A

1. Figure A
2. Figure B
3. Figure C
4. Figure D
5. Figure E

PREFERRED RESPONSE ▶

DISCUSSION: This patient has most likely sustained an ACL tear. This is supported by the history and positive Pivot Shift Test on physical exam. The most common bone bruise pattern resulting from an acute tear of the ACL is the central third of the lateral femoral condyle and posterior third of the lateral tibial plateau (shown in Figure A).

The article by Graf et al found that 43% of ACL tears had an associated bone bruise on MRI if the image was taken within 6 weeks of injury. There was no correlation between the presence of a bone bruise and articular alterations or meniscal tears observed at surgery.

In a prospective study (MOON Database) Dunn et al found that 418 of 525 (80%) patients with an ACL tear had bone bruising. They found that bone bruising is not associated with symptoms/pain at the time of index anterior cruciate ligament reconstruction.

Yoon et al found that 84% of patients with ACL tears had bone bruises. The lateral femoral condyle was the most common location (68%). They found injuries of the menisci and the MCL tended to increase with the progression of bone contusion.

Incorrect Answers:
Answer 2: Figures B shows an anterior tibia contusion.
Answer 3: Figure C shows a bone contusion pattern consistent with a patellar dislocation.
Answer 4: Figure D shows an anterior femoral condyle contusion.
Answer 5: Figure E (meniscotibial ligament avulsion) show bone contustion patterns are consistent with a hyperextension injury (an example would be a PCL tear).

Illustration A is a link to a video demonstrating the Pivot Shift Test.

Illustrations: V

REFERENCES:

1. Graf BK, Cook DA, De Smet AA, Keene JS. "Bone bruises" on magnetic resonance imaging evaluation of anterior cruciate ligament injuries. Am J Sports Med. 1993 Mar-Apr;21(2):220-3. PMID:8465916 (Link to Abstract)

2. Dunn WR, Spindler KP, Amendola A, Andrish JT, Kaeding CC, Marx RG, McCarty EC,Parker RD, Harrell FE Jr, An AQ, Wright RW, Brophy RH, Matava MJ, Flanigan DC, Huston LJ, Jones MH, Wolcott ML, Vidal AF, Wolf BR; MOON ACL Investigation. Which preoperative factors, including bone bruise, are associated with knee pain/symptoms at index anterior cruciate ligament reconstruction (ACLR)? A Multicenter Orthopaedic Outcomes Network (MOON) ACLR Cohort Study. Am J Sports Med. 2010 Sep;38(9):1778-87. Epub 201 PMID:20595556 (Link to Abstract)

3. Yoon KH, Yoo JH, Kim KI. Bone contusion and associated meniscal and medial collateral ligament injury in patients with anterior cruciate ligament rupture. J Bone Joint Surg Am. 2011 Aug 17;93(16):1510-8. PMID:22204006 (Link to Abstract)

Question Authors:

Michael Hughes MD, Patrick McCulloch MD, Derek Moore, Mark Miller MD,

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(OBQ04.240) In laboratory testing of quadrupled hamstring grafts (doubled over semitendinosis and gracilis), all of the following statements are true EXCEPT: Topic

Review Topic

1. Graft tensioning by placing weights is equivalent to manual tensioning by hand
2. Single semitendinosis strand has a higher tensile strength than a single gracilis strand
3. All strands of a hamstring graft must be equally tensioned to achieve optimum biomechanical properties
4. Quadrupled grafts have tensile properties that are higher than 10mm patellar-ligament grafts
5. Quadrupled hamstring grafts have lower tensile strength than the native ACL

PREFERRED RESPONSE ▶

DISCUSSION: Quadrupled strand hamstring grafts actually have a higher tensile strength (approximately 4,000 N) than the native ACL (approximately 2,200 N).

The article by Hamner et al showed that four combined strands (2 gracilis and 2 semitendinosus) that were equally tensioned with weights and clamped were stronger and stiffer than all 10mm patellar ligament grafts and stronger than all double grafts. Graft tensioning by placing weights is equivalent to manual tensioning by hand and it is critical that each strand is equally tensioned. They also demonstrated that a single semitendinosis strand has a higher tensile strength than a single gracilis strand.

In addition, Chen et al report level 5 evidence that ACL reconstruction using a quadrupled hamstring autograft has little morbidity, a low reoperation rate, and excellent clinical results.

REFERENCES:

1. Hamner DL, Brown CH Jr, Steiner ME, Hecker AT, Hayes WC. Hamstring tendon grafts for reconstruction of the anterior cruciate ligament: biomechanical evaluation of the use of multiple strands and tensioning techniques. J Bone Joint Surg Am. 1999 Apr;81(4):549-57. PMID:10225801 (Link to Abstract)

2. Chen L, Cooley V, Rosenberg T. ACL reconstruction with hamstring tendon. Orthop Clin North Am. 2003 Jan;34(1):9-18. PMID:12735197 (Link to Abstract)

Question Authors:

Michael Hughes MD, Patrick McCulloch MD, Ben Taylor MD,

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(OBQ04.246) A 23-year-old soccer player sustains an anterior cruciate ligament (ACL) tear and is scheduled for reconstruction. He has questions regarding the use of autografts. Which of the following statements is true regarding bone-patellar tendon-bone (BTB) autograft in comparison to quadrupled hamstring autograft for ACL reconstruction? Topic

Review Topic

1. BTB autograft is biomechanically stronger than quadrupled hamstring autograft
2. BTB autograft shows less evidence of post-operative pivot shift
3. Quadrupled hamstring autograft shows lower rate of graft failure
4. BTB shows higher incidence of anterior knee pain
5. Quadrupled hamstring autograft shows lower incidence of knee hardware removal

PREFERRED RESPONSE ▶

DISCUSSION: Anterior knee pain is one of the most common concerns following ACL reconstruction using a bone- patellar tendon- bone (BTB) autograft. In 2003, Freedman et al performed a meta-analysis comparing the results of BTB vs hamstring autografts in ACL reconstructions. Their findings showed that patients with BTB reconstructions had a lower rate of graft failure, better stability on KT-1000 (<3mm difference to contralateral knee), and patient satisfaction than in the hamstring group. The hamstring group had slightly higher incidence of hardware removal. The BTB group also showed higher rate of manipulation with or without lysis of adhesions, along with increased incidence of anterior knee pain (17% vs 12%). In cases of postoperative anterior knee pain after BTB ACL reconstruction, physical therapy with a focus on muscle strengthening is recommended with the goal of reaching strength symmetric to the nonoperative side. Bone grafting the patella donor site is also thought to potentially help.

REFERENCES:

1. Freedman KB, D'Amato MJ, Nedeff DD, Kaz A, Bach BR Jr. Arthroscopic anterior cruciate ligament reconstruction: a metaanalysis comparing patellar tendon and hamstring tendon autografts. Am J Sports Med. 2003 Jan-Feb;31(1):2-11. PMID:12531750 (Link to Abstract)

2. Arendt ED (ed): Orthopaedic Knowledge Update: Sports Medicine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 307-316

Question Authors:

David Abbasi MD, John Badylak MD, Patrick McCulloch MD,

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(OBQ04.258) The saphenous nerve is most likely to be injured with which of the following steps during an anterior cruciate ligament (ACL) reconstruction with hamstring autograft? Topic

Review Topic

1. Incision for an anteromedial portal with the knee flexed
2. Incision for an anteromedial portal with the knee extended
3. Incision for an accessory medial portal the with knee flexed
4. Hamstring harvest with the knee extended
5. Tibial tunnel aperture fixation with the knee at 30 degrees of flexion

PREFERRED RESPONSE ▶

DISCUSSION: The saphenous nerve is most at risk during the hamstring harvest of an ACL reconstruction. At the joint line, the saphenous nerve is deep to the broad sartorious fascia, and superficial to the gracilis. Bertram et al describe a case report of a patient who sustained saphenous neuralgia following an ACL reconstruction utilizing a hamstring harvest. Symptoms can include paresthesias in the anteromedial region of the lower leg and tenderness at the medial side of the knee. They note that hip external rotation and knee flexion while harvesting the hamstring tendons allows the tendinous structures and saphenous nerve to relax, thus decreasing the chance of injury. Solman et al also stress the understanding of such anatomical relationships of the medial side of knee's anatomy to avoid pitfalls such as saphenous nerve injury during a hamstring harvest. Illustration A provides a depiction of the saphenous nerve with relation to the medial knee. Illustration B is an example of a cadaveric dissection showing the anatomic relationship of the saphenous nerve (black arrow) as it courses superficially along the sartorial fascia (labelled with S).

Illustrations: A

REFERENCES:

1. Solman CG Jr, Pagnani MJ. Hamstring tendon harvesting. Reviewing anatomic relationships and avoiding pitfalls. Orthop Clin North Am. 2003 Jan;34(1):1-8. PMID:12735196 (Link to Abstract)

2. Bertram C, Porsch M, Hackenbroch MH, Terhaag D. Saphenous neuralgia after arthroscopically assisted anterior cruciate ligament reconstruction with a semitendinosus and gracilis tendon graft. Arthroscopy. 2000 Oct;16(7):763-6. PMID:11027764 (Link to Abstract)

Question Authors:

David Abbasi MD, John Badylak MD, Patrick McCulloch MD,

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(OBQ04.262) Which of the following physical exam maneuvers would be MOST expected for a patient with the following radiograph? Topic

Review Topic

FIGURES: A

1. Positive Lachman's test
2. Positive McMurray's test with leg internally rotated
3. Positve McMurray's test with leg externally rotated
4. Positive external rotation dial test with knee flexed at 30 degrees
5. Positive external rotation dial test with knee flexed at 30 degrees and 90 degrees

PREFERRED RESPONSE ▶

DISCUSSION: The radiograph shows an example of a Segond fracture, most commonly caused by an anterior cruciate ligament (ACL) injury. An ACL injury would correspond best with a positive Lachman's test on physical examination. Hess et al describe the pathoanatomy of the Segond fracture which is an avulsion of the lateral tibia plateau caused by the menisco-tibial ligament. This capsular avulsion occurs during knee flexion and internal rotation of the knee, and is usually only possible after ACL injury. They found 9% of all ACL injury patients had a positive segond sign present on plain radiographs. Stallenburg et al retrospectively reviewed radiographs of 25 patients who had sustained ACL tears and showed that posterior-lateral tibial plateau avulsion fractures were the most common radiographic finding of an ACL injury. Kezdi-Rogus et al also studied the plain-film manifestations of ACL injury and in their conclusion stressed the importance of clinical recognition of these bony avulsion injuries to raise suspicion of ACL injuries (illustration A). Furthermore, they further recommended MRI as the imaging method of choice in these patients. (Illustrations B and C show examples of an ACL tear and segond sign on MRI respectively). Answers 2 through 5 represent a lateral meniscus tear, medial meniscus tear, PLC injury, and combined PLC and PCL injury, respectively.

Illustrations: A

REFERENCES:

1. Hess T, Rupp S, Hopf T, Gleitz M, Liebler J. Lateral tibial avulsion fractures and disruptions to the anterior cruciate ligament. A clinical study of their incidence and correlation. Clin Orthop Relat Res. 1994 Jun;(303):193-7. PMID:8194233 (Link to Abstract)

2. Kezdi-Rogus PC, Lomasney LM. Radiologic case study. Plain film manifestations of ACL injury. Orthopedics. 1994 Oct;17(10):967-73. PMID:7824402 (Link to Abstract)

3. Stallenberg B, Gevenois PA, Sintzoff SA Jr, Matos C, Andrianne Y, Struyven J. Fracture of the posterior aspect of the lateral tibial plateau: radiographic sign of anterior cruciate ligament tear. Radiology. 1993 Jun;187(3):821-5. PMID:8497638 (Link to Abstract)

Question Authors:

David Abbasi MD, Patrick McCulloch MD, John Badylak MD,

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(OBQ03.166) A patient undegoes an uncomplicated anterior cruciate ligament reconstruction. Which of the following activities are generally not recommended during the first 6 weeks of physical therapy? Topic

Review Topic

1. Patellar mobilizations
2. Passive extension
3. Heel slides to improve flexion
4. Isometric quadriceps strengthening
5. Isokinetic quadriceps strengthening

PREFERRED RESPONSE ▶

DISCUSSION: The initial goals of rehabilitation focus on achieving full extension, activation of the quadriceps muscles, progressive flexion, and restoring normal gait. Closed chain rehabilitation has been emphasized because it allows physiologic contraction of the musculature around the knee. Isometric exercises such as quad sets and straight leg raises are encouraged. Isokinetic exercises are generally reserved until after the graft attachment sites have healed.

The reference is a systematic review of topics related to ACL rehabilitation.

REFERENCES:

1. Wright RW, Preston E, Fleming BC, Amendola A, Andrish JT, Bergfeld JA, DunnWR, Kaeding C, Kuhn JE, Marx RG, McCarty EC, Parker RC, Spindler KP, Wolcott M,Wolf BR, Williams GN. A systematic review of anterior cruciate ligamentreconstruction rehabilitation: part II: open versus closed kinetic chain exercises, neuromuscular electrical stimulation, accelerated rehabilitation, and miscellaneous topics. J Knee Surg. 2008 Jul;21(3):225-34. PMID:18686485 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Derek Moore, John Badylak MD,

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Cases

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ACL Tibial Tunnel Placement: Is it too close to joint space?

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6/17/2011

43 responses

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Evidence & References Show References

Level of Evidence 1 (Randomized Control Trial)

Van Kampen A, Wymenga AB, van der Heide HJ, Bakens HJ. The effect of different graft tensioning in anterior cruciate ligament reconstruction: a prospective randomized study. Arthroscopy. 1998 Nov-Dec;14(8):845-50. PMID:9848597 (Link to Abstract)

Level of Evidence 2 (Prospective Cohort Study)

Padua DA, Marshall SW, Boling MC, Thigpen CA, Garrett WE Jr, Beutler AI. The Landing Error Scoring System (LESS) Is a valid and reliable clinical assessment tool of jump-landing biomechanics: The JUMP-ACL study. Am J Sports Med. 2009 Oct;37(10):1996-2002. PMID:19726623 (Link to Abstract)
Viskontas DG, Giuffre BM, Duggal N, Graham D, Parker D, Coolican M. Bone bruises associated with ACL rupture: correlation with injury mechanism. Am J Sports Med. 2008 May;36(5):927-33. Epub 2008 Mar 19. PMID:18354139 (Link to Abstract)
Dunn WR, Spindler KP, Amendola A, Andrish JT, Kaeding CC, Marx RG, McCarty EC,Parker RD, Harrell FE Jr, An AQ, Wright RW, Brophy RH, Matava MJ, Flanigan DC, Huston LJ, Jones MH, Wolcott ML, Vidal AF, Wolf BR; MOON ACL Investigation. Which preoperative factors, including bone bruise, are associated with knee pain/symptoms at index anterior cruciate ligament reconstruction (ACLR)? A Multicenter Orthopaedic Outcomes Network (MOON) ACLR Cohort Study. Am J Sports Med. 2010 Sep;38(9):1778-87. Epub 201 PMID:20595556 (Link to Abstract)
Wright RW, Preston E, Fleming BC, Amendola A, Andrish JT, Bergfeld JA, DunnWR, Kaeding C, Kuhn JE, Marx RG, McCarty EC, Parker RC, Spindler KP, Wolcott M,Wolf BR, Williams GN. A systematic review of anterior cruciate ligamentreconstruction rehabilitation: part II: open versus closed kinetic chain exercises, neuromuscular electrical stimulation, accelerated rehabilitation, and miscellaneous topics. J Knee Surg. 2008 Jul;21(3):225-34. PMID:18686485 (Link to Abstract)

Level of Evidence 3 (Retrospective Cohort Study or Case-Control Study)

Posthumus M, September AV, O'Cuinneagain D, van der Merwe W, Schwellnus MP, Collins M. The COL5A1 gene is associated with increased risk of anterior cruciate ligament ruptures in female participants. Am J Sports Med. 2009 Nov;37(11):2234-40. PMID:19654427 (Link to Abstract)

Level of Evidence 4 (Case Series)

Dworsky BD, Jewell BF, Bach BR Jr. Interference screw divergence in endoscopic anterior cruciate ligament reconstruction. Arthroscopy. 1996 Feb;12(1):45-9. PMID:8838728 (Link to Abstract)
Chappell JD, Creighton RA, Giuliani C, Yu B, Garrett WE. Kinematics and electromyography of landing preparation in vertical stop-jump: risks for noncontact anterior cruciate ligament injury. Am J Sports Med. 2007 Feb;35(2):235-41. PMID:17092926 (Link to Abstract)
Paulos LE, Wnorowski DC, Greenwald AE. Infrapatellar contracture syndrome. Diagnosis, treatment, and long-term followup. Am J Sports Med. 1994 Jul-Aug;22(4):440-9. PMID:7943507 (Link to Abstract)
Grossman MG, ElAttrache NS, Shields CL, Glousman RE. Revision anterior cruciate ligament reconstruction: three- to nine-year follow-up. Arthroscopy. 2005 Apr;21(4):418-23. PMID:15800521 (Link to Abstract)
Pinczewski LA, Salmon LJ, Jackson WF, von Bormann RB, Haslam PG, Tashiro S. Radiological landmarks for placement of the tunnels in single-bundle reconstruction of the anterior cruciate ligament. J Bone Joint Surg Br. 2008 Feb;90(2):172-9. PMID:18256083 (Link to Abstract)
Freedman KB, D'Amato MJ, Nedeff DD, Kaz A, Bach BR Jr. Arthroscopic anterior cruciate ligament reconstruction: a metaanalysis comparing patellar tendon and hamstring tendon autografts. Am J Sports Med. 2003 Jan-Feb;31(1):2-11. PMID:12531750 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Lemos MJ, Jackson DW, Lee TO, et al: Assessment of initial fixation of endoscopic interference femoral screws with divergent and parallel placement. Arthroscopy 1995;11:37-41. PMID:7727010 (Link to Abstract)
Stanitski CL: Anterior cruciate ligament injury in the skeletally immature patient: Diagnosis and treatment. J Am Acad Orthop Surg 1995;3:146-158 PMID:10790663 (Link to Abstract)
Scopp JM, Jasper LE, Belkoff SM, et al: The effect of oblique femoral tunnel placement on rotational constraint of the knee reconstructed using patellar tendon autografts. Arthroscopy 2004;20:294-299 PMID:15007318 (Link to Abstract)
Carson EW, Simonian PT, Wickiewicz TL, et al: Revision anterior cruciate ligament reconstruction. Instr Course Lect 1998;47:361-368 PMID:9571438 (Link to Abstract)
Woo SL, Hollis JM, Adams DJ, Lyon RM, Takai S. Tensile properties of the human femur-anterior cruciate ligament-tibia complex: The effects of specimen age and orientation. Am J Sports Med 1991;19:217-225. PMID:1867330 (Link to Abstract)
Stäubli HU, Schatzmann L, Brunner P, Rincón L, Nolte LP. Quadriceps tendon and patellar ligament cryosectional anatomy and structural properties in young adults. Knee Surg Sports Traumatol Arthrosc 1996;4:100-110. PMID:8884731 (Link to Abstract)
Wilson TW, Zafuta MP, Zobitz M. A biomechanical analysis of matched bone-patellar tendon-bone and doubled looped semitendinosus and gracilis tendon grafts. Am J Sports Med 1999;27:202-207. PMID:10102102 (Link to Abstract)
Battaglia TC, Miller MD. Management of bony deficiency in revision anterior cruciate ligament reconstruction using allograft bone dowels: surgical technique. Arthroscopy. 2005 Jun;21(6):767 PMID:15944645 (Link to Abstract)
Toy BJ, Yeasting RA, Morse DE, McCann P. Arterial supply to the human anterior cruciate ligament. J Athl Train. 1995 Jun;30(2):149-52. PMID:16558326 (Link to Abstract)
Chhabra A, Starman JS, Ferretti M, Vidal AF, Zantop T, Fu FH. Anatomic,radiographic, biomechanical, and kinematic evaluation of the anterior cruciateligament and its two functional bundles. J Bone Joint Surg Am. 2006 Dec;88 PMID:17142430 (Link to Abstract)
Zantop T, Petersen W, Sekiya JK, Musahl V, Fu FH. Anterior cruciate ligamentanatomy and function relating to anatomical reconstruction. Knee Surg SportsTraumatol Arthrosc. 2006 Oct;14(10):982-92. Epub 2006 Aug 5. PMID:16897068 (Link to Abstract)
Graf BK, Cook DA, De Smet AA, Keene JS. "Bone bruises" on magnetic resonance imaging evaluation of anterior cruciate ligament injuries. Am J Sports Med. 1993 Mar-Apr;21(2):220-3. PMID:8465916 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Fowler PJ: Anterior cruciate ligament injuries in the child, in Drez D, DeLee JD, Miller MD (eds): Orthopaedic Sports Medicine Principles and Practice, ed 2. Philadelphia, PA, WB Saunders, 2003, pp 2067-2074
Paine R. Section A: Language of exercise and rehabilitation. In: DeLee JC, Drez D, Miller MD, eds. Rehabilitation and Therapeutic Modalities: Orthopaedic Sports Medicine. Vol 2. 3rd ed. Philadelphia, PA: Saunders-Elsevier; 2010:221-237.
Garrick, JG (ED): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 169-181
Miller RH: Knee Injuries, In Canale ST (Ed): Campbell's Operative Orthopaedics, ED 10. ST. LOUIS, MO, MOSBY, 2003, p. 2254.
Arendt ED (ed): Orthopaedic Knowledge Update: Sports Medicine 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 307-316

Undefined

Corry IS, Webb JM, Clingeleffer AJ, Pinczewski LA: Arthroscopic reconstruction of the anterior cruciate ligament: A comparison of patellar tendon autograft and four-strand hamstring tendon autograft. Am J Sports Med 1999;27:448-454.
Hamner DL, Brown CH Jr, Steiner ME, et al: Hamstring tendon grafts for reconstruction of the anterior cruciate ligament: Biomechanical evaluation of the use of multiple strands and tensioning techniques. J Bone Joint Surg Am 1999;81:549-557.
Noyes FR, Butler DL, Grood ES, et al: Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions. J Bone Joint Surg Am 1984;66:344-352
Azar FM: Revision anterior cruciate ligament reconstruction. Instr Course Lect 2002;51:335-342.
Markolf KL, Hame S, Hunter DM, et al. Effects of femoral tunnel placement on knee laxity and forces in an anterior cruciate ligament graft. J Orthop Res. 2002;20(5):1016-24.
Zantop T, Petersen W, Sekiya JK, et al. Anterior cruciate ligament anatomy and function relating to anatomical reconstruction. Knee Surg Sports Traumatol Arthrosc. 2006;14(10):982-92.
Beynnon BD, Gleming BC, Johnson RL, Nichols CE, Renstrom PA, Pope MH: Anterior cruciate ligament strain behavior during rehabilitation exercises in vivo. Am J Sports Med 1995;23:24-34.
Beynnon BD, Johnson RJ, Fleming BC, Stankewaich CJ, Renstrom PA, Nichols CE: The strain behavior of the anterior cruciate ligament during squatting and active flexion-extension: A comparison of an open and a closed kinetic chain exercise. Am J Sports Med 1997;25:823-829.
Hutchinson MR, Bae TS: Reproducibility of anatomic tibial landmarks for anterior cruciate ligament reconstructions. Am J Sports Med 2001;29:777-780.
McGuire DA, Hendricks SD, Sanders HM: The relationship between anterior cruciate ligament reconstruction tibial tunnel location and the anterior aspect of the posterior cruciate ligament insertion. Arthroscopy 1997;13:465-473.
Yoon KH, Yoo JH, Kim KI. Bone contusion and associated meniscal and medial collateral ligament injury in patients with anterior cruciate ligament rupture. J Bone Joint Surg Am 2011;93:1510-1518. PMID:22204006 (Link to Abstract)
Denti M, Lo Vetere D, Bait C, Schonhuber H, Melegati G, Volpi P. Revision anterior cruciate ligament reconstruction: causes of failure, surgical technique, and clinical results. Am J Sports Med. 2008 Oct;36(10):1896-902. PMID:18567717 (Link to Abstract)
Noyes FR, Barber-Westin SD. Revision anterior cruciate surgery with use of bone-patellar tendon-bone autogenous grafts. J Bone Joint Surg Am. 2001 Aug;83-A(8):1131-43. PMID:11507120 (Link to Abstract)
Beynnon BD, Fleming BC, Johnson RJ, Nichols CE, Renström PA, Pope MH. Anterior cruciate ligament strain behavior during rehabilitation exercises in vivo. Am J Sports Med. 1995 Jan-Feb;23(1):24-34. PMID:7726347 (Link to Abstract)
Paine R. Section A: Language of exercise and rehabilitation. In: DeLee JC, Drez D, Miller MD, eds. Rehabilitation and Therapeutic Modalities: Orthopaedic Sports Medicine. Vol 2. 3rd ed. Philadelphia, PA: Saunders-Elsevier; 2010:221-237.
Battaglia TC, Miller MD. Management of bony deficiency in revision anterior cruciate ligament reconstruction using allograft bone dowels: surgical technique. Arthroscopy. 2005 Jun;21(6):767. PMID:15944645 (Link to Abstract)
Grossman MG, ElAttrache NS, Shields CL, Glousman RE. Revision anterior cruciate ligament reconstruction: three- to nine-year follow-up. Arthroscopy. 2005 Apr;21(4):418-23. PMID:15800521 (Link to Abstract)
Bathala EA, Bancroft LW, Ortiguera CJ, Peterson JJ. Radiologic case study. Segond fracture. Orthopedics. 2007 Sep;30(9):689, 797-8. PMID:17899907 (Link to Abstract)
DeLee JC, Drez D Jr, Miller MD (eds): Orthopaedic Sports Medicine, ed 2. Philadelphia, PA, WB Saunders, 2002, p 1643
Cain EL Jr, Gillogly SD, Andrews JR. Management of intraoperative complications associated with autogenous patellar tendon graft anterior cruciate ligament reconstruction. Instr Course Lect. 2003;52:359-67. PMID:12690863 (Link to Abstract)
Lee GH, McCulloch P, Cole BJ, Bush-Joseph CA, Bach BR Jr. The incidence of acute patellar tendon harvest complications for anterior cruciate ligament reconstruction. Arthroscopy. 2008 Feb;24(2):162-6. PMID:18237699 (Link to Abstract)
Portland GH, Martin D, Keene G, Menz T. Injury to the infrapatellar branch of the saphenous nerve in anterior cruciate ligament reconstruction: comparison of horizontal versus vertical harvest site incisions. Arthroscopy. 2005 Mar;21(3):281-5 PMID:15756180 (Link to Abstract)
Garrick JG (ED). Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, pp 403-410
Griffin LY, Agel J, Albohm MJ, Arendt EA, Dick RW, Garrett WE, Garrick JG, Hewett TE, Huston L, Ireland ML, Johnson RJ, Kibler WB, Lephart S, Lewis JL, Lindenfeld TN, Mandelbaum BR, Marchak P, Teitz CC, Wojtys EM. Noncontact anterior cruciate ligament injuries: risk factors and prevention strategies. J Am Acad Orthop Surg. 2000 May-Jun;8(3):141-50. Review. PMID:10874221 (Link to Abstract)
Rodeo SA, Arnoczky SP, Torzilli PA et al. Tendon-healing in a bone tunnel. A biomechanical and histological study in the dog. J Bone Joint Surg Am. 1993 Dec;75(12):1795-803. PMID:8258550 (Link to Abstract)
Beynnon BD, Johnson RJ, Fleming BC et al.Tendon-Bone Grafts with Two-Strand Hamstring Grafts : A Prospective Randomized Study. J Bone Joint Surg Am. 2002;84:1503-1513. PMID:12208905 (Link to Abstract)
Pinczewski LA, Lyman J, Salmon LJ, et al. A 10-year comparison of anterior cruciate ligament reconstructions with hamstring tendon and patellar tendon autograft: a controlled, prospective trial. Am J Sports Med. 2007 Apr;35(4):564-74. Epub 2007 Jan 29. PMID:17261567 (Link to Abstract)
Stanitski CL, Harvell JC, Fu F: Observations on acute knee hemarthrosis in children and adolescents. JPO 1993;13:506-510 PMID:8370785 (Link to Abstract)
Bomberg BC, McGinty JB: Acute hemarthrosis of the knee: Indications for diagnostic arthroscopy. Arthroscopy 1990;6:221-225 PMID:2206185 (Link to Abstract)
Viskontas DG, Giuffre BM, Duggal N, Graham D, Parker D, Coolican M. Bone bruises associated with ACL rupture: correlation with injury mechanism. Am J Sports Med. 2008 May;36(5):927-33. PMID:18354139 (Link to Abstract)
Collins MS, Unruh KP, Bond JR, Mandrekar JN. Magnetic resonance imaging of surgically confirmed anterior cruciate ligament graft disruption. Skeletal Radiol. 2008 Mar;37(3):233-43. PMID:18092160 (Link to Abstract)
Ahmad CS, Clark AM, Heilmann N, Schoeb JS, Gardner TR, Levine WN. Effect of gender and maturity on quadriceps-to-hamstring strength ratio and anterior cruciate ligament laxity.Am J Sports Med. 2006 Mar;34(3):370-4. Epub 2005 Oct 6. PMID:16210574 (Link to Abstract)
Baratta R, Solomonow M, Zhou BH, Letson D, Chuinard R, D'Ambrosia R. Muscular coactivation. The role of the antagonist musculature in maintaining knee stability. Am J Sports Med. 1988 Mar-Apr;16(2):113-22. PMID:3377094 (Link to Abstract)
Vescovi JD, Vanheest JL. Effects of an anterior cruciate ligament injury prevention program on performance in adolescent female soccer players. Scand J Med Sci Sports. 2010 Jun;20(3):394-402. PMID:19558381 (Link to Abstract)
Alentorn-Geli E, Myer GD, Silvers HJ, Samitier G, Romero D, Lázaro-Haro C, Cugat R. Prevention of non-contact anterior cruciate ligament injuries in soccer players. Part 1: Mechanisms of injury and underlying risk factors. Knee Surg Sports Traumatol Arthrosc. 2009 Jul;17(7):705-29. Epub 2009 May 19. PMID:19452139 (Link to Abstract)
Uhorchak JM, Scoville CR, Williams GN, Arciero RA, St Pierre P, Taylor DC. Risk factors associated with noncontact injury of the anterior cruciate ligament: a prospective four-year evaluation of 859 West Point cadets. Am J Sports Med. 2003;31(6):831-42. PMID:14623646 (Link to Abstract)
Hewett TE, Myer GD, Ford KR, Heidt RS Jr, Colosimo AJ, McLean SG, van den Bogert AJ, Paterno MV, Succop P. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med. 2005;33(4):492-501. PMID:15722287 (Link to Abstract)
Shelbourne KD, Patel DV: Timing of surgery in anterior cruciate ligament-injured knees. Knee Surg Sports Traumatol Arthosc 1995;3:148-156. PMID:8821270 (Link to Abstract)
Sterett WI, Hutton KS, Briggs KK, Steadman JR. Decreased range of motion following acute versus chronic anterior cruciate ligament reconstruction. Orthopedics 2003;26:151-154. PMID:12597218 (Link to Abstract)
Eitzen I, holm I, Risberg MA. Preoperative strength is a significant predictor of knee function two years after ACL reconstruction. Br J Sports Med. 2009 May;43(5):371-6. PMID:19224907 (Link to Abstract)
Kocher MS, Steadman JR, Briggs KK, Sterett WI, Hawkins RJ. Relationships between objective assessment of ligament stability and subjective assessment of symptoms and function after anterior cruciate ligament reconstruction. Am J Sports Med. 2004 Apr-May;32(3):629-34. PMID:15090377 (Link to Abstract)
Hoppenfeld S, deBoer PL The Knee, in Hoppenfeld and deBoer: Surgical Exposures in Orthopaedics, the Anatomic Approach.
Medvecky MJ, Noyes FR: Surgical approaches to the posteromedial and posterolateral aspects of the knee. JAAOS 2005;13:121-128. PMID:15850369 (Link to Abstract)
Figueroa D, Calvo R, Vaisman A, Campero M, Moraga C. Injury to the infrapatellar branch of the saphenous nerve in ACL reconstruction with the hamstrings technique: clinical and electrophysiological study.Knee. 2008 Oct;15(5):360-3. PMID:18583136 (Link to Abstract)
Beynnon BD, Johnson RJ, Fleming BC. The science of anterior cruciate ligament rehabilitation. Clin Orthop Relat Res. 2002 Sep;(402):9-20. PMID:12218469 (Link to Abstract)
Wilk KE, Escamilla RF, Fleisig GS, Barrentine SW, Andrews JR, Boyd ML. A comparison of tibiofemoral joint forces and electromyographic activity during open and closed kinetic chain exercises. Am J Sports Med. 1996 Jul-Aug;24(4):518-27. PMID:8827313 (Link to Abstract)
Chhabra A, Starman JS, Ferretti M, Vidal AF, Zantop T, Fu FH. Anatomic, radiographic, biomechanical, and kinematic evaluation of the anterior cruciate ligament and its two functional bundles. J Bone Joint Surg Am. 2006 Dec;88 Suppl 4:2-10. PMID:17142430 (Link to Abstract)
Markolf KL, Hame S, Hunter DM, Oakes DA, Zoric B, Gause P, Finerman GA. Effects of femoral tunnel placement on knee laxity and forces in an anterior cruciate ligament graft. J Orthop Res. 2002 Sep;20(5):1016-24. PMID:12382968 (Link to Abstract)
Ross MD, Denegar CR, Winzenried JA. Implementation of open and closed kinetic chain quadriceps strengthening exercises after anterior cruciate ligament reconstruction. J Strength Cond Res 2001;15:466-473. PMID:11726258 (Link to Abstract)
Beutler AI, Cooper LW, Kirkendall DT. Electromyographic analysis of single-leg, closed chain exercises: Implications for rehabilitation after anterior cruciate ligament reconstruction. J Athl Train 2002;37:13-18. PMID:12937438 (Link to Abstract)
Wright RW, Preston E, Fleming BC, et al. 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 Jul;21(3):225-34. PMID:18686485 (Link to Abstract)
Maffulli N, Binfield PM, King JB, Good CJ. Acute haemarthrosis of the knee in athletes. A prospective study of 106 cases. J Bone Joint Surg Br. 1993 Nov;75(6):945-9. PMID:8245089 (Link to Abstract)
Allen CR Giffin JR, Harner CD: Revision anterior cruciate ligament reconstruction. Orthop Clin North Am 2003:34:79-98. PMID:12735203 (Link to Abstract)
Sommer C, Friederich NF, Muller W; Improperly placed anterior cruciate ligament grafts: Correlation between radiological parameters and clinical results. Knee Surg Sports Traumatol Anthrosc 2000:8:207-213 PMID:10975260 (Link to Abstract)
Harner CD, Giffin JR, Dunteman RC, Annunziata CC, Friedman MJ. Evaluation and treatment of recurrent instability after anterior cruciate ligament reconstruction. Instr Course Lect 2001;50:463-474. PMID:11372347 (Link to Abstract)
Allen CR, Giffin JR, Harner CD. Revision anterior cruciate ligament reconstruction. Orthop Clin North Am. 2003 Jan;34(1):79-98. PMID:12735203 (Link to Abstract)
Azar FM. Revision anterior cruciate ligament reconstruction. Instr Course Lect. 2002;51:335-42. PMID:12064122 (Link to Abstract)
Wolf RS and Lemak LJ. Revision anterior cructiate ligament reconstruction surgery. J South Orthop Assoc. 2002 Spring;11(1):25-32. PMID:12741583 (Link to Abstract)
Mangine RE, Noyes FR, DeMaio M. Minimal protection program: advanced weight bearing and range of motion after ACL reconstruction--weeks 1 to 5. Orthopedics. 1992 Apr;15(4):504-15. PMID:1565587 (Link to Abstract)
Shelbourne KD, Gray T. Anterior cruciate ligament reconstruction with autogenous patellar tendon graft followed by accelerated rehabilitation. A two- to nine-year followup. Am J Sports Med. 1997 Nov-Dec;25(6):786-95. PMID:9397266 (Link to Abstract)
Markolf KL, Hame S, Hunter DM, Oakes DA, Zoric B, GaEffects of femoral tunnel placement on knee laxity and forces in an anteriorcruciate ligament graft. J Orthop Res. 2002 Sep;20(5):1016-24. use P, Finerman GA. PMID:12382968 (Link to Abstract)
Louboutin H, Debarge R, Richou J, Selmi TA, Donell ST, Neyret P, Dubrana F. Osteoarthritis in patients with anterior cruciate ligament rupture: a review of risk factors. Knee. 2009 Aug;16(4):239-44. Epub 2008 Dec 20. PMID:19097796 (Link to Abstract)
Gillquist J, Messner K. Anterior cruciate ligament reconstruction and the long-term incidence of gonarthrosis. Sports Med. 1999 Mar;27(3):143-56. PMID:10222538 (Link to Abstract)
Yoon KH, Yoo JH, Kim KI. Bone contusion and associated meniscal and medial collateral ligament injury in patients with anterior cruciate ligament rupture. J Bone Joint Surg Am. 2011 Aug 17;93(16):1510-8. PMID:22204006 (Link to Abstract)
Hamner DL, Brown CH Jr, Steiner ME, Hecker AT, Hayes WC. Hamstring tendon grafts for reconstruction of the anterior cruciate ligament: biomechanical evaluation of the use of multiple strands and tensioning techniques. J Bone Joint Surg Am. 1999 Apr;81(4):549-57. PMID:10225801 (Link to Abstract)
Chen L, Cooley V, Rosenberg T. ACL reconstruction with hamstring tendon. Orthop Clin North Am. 2003 Jan;34(1):9-18. PMID:12735197 (Link to Abstract)
Solman CG Jr, Pagnani MJ. Hamstring tendon harvesting. Reviewing anatomic relationships and avoiding pitfalls. Orthop Clin North Am. 2003 Jan;34(1):1-8. PMID:12735196 (Link to Abstract)
Bertram C, Porsch M, Hackenbroch MH, Terhaag D. Saphenous neuralgia after arthroscopically assisted anterior cruciate ligament reconstruction with a semitendinosus and gracilis tendon graft. Arthroscopy. 2000 Oct;16(7):763-6. PMID:11027764 (Link to Abstract)
Hess T, Rupp S, Hopf T, Gleitz M, Liebler J. Lateral tibial avulsion fractures and disruptions to the anterior cruciate ligament. A clinical study of their incidence and correlation. Clin Orthop Relat Res. 1994 Jun;(303):193-7. PMID:8194233 (Link to Abstract)
Kezdi-Rogus PC, Lomasney LM. Radiologic case study. Plain film manifestations of ACL injury. Orthopedics. 1994 Oct;17(10):967-73. PMID:7824402 (Link to Abstract)
Stallenberg B, Gevenois PA, Sintzoff SA Jr, Matos C, Andrianne Y, Struyven J. Fracture of the posterior aspect of the lateral tibial plateau: radiographic sign of anterior cruciate ligament tear. Radiology. 1993 Jun;187(3):821-5. PMID:8497638 (Link to Abstract)

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