Review Question - QID 298

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.