Anterior cruciate ligament reconstruction: principles of treatment

Abstract

Anterior cruciate ligament (ACL) reconstruction is one of the most common procedures in sports medicine. Several areas of controversy exist in ACL tear management which have engaged surgeons and researchers in debates towards identifying an ideal approach for these patients.This instructional review discusses the principles of ACL reconstruction in an attempt to provide guidelines and initiate a critical thinking approach on the most common areas of controversy regarding ACL reconstruction.Using high-level evidence from the literature, as presented in randomised controlled trials, systematic reviews, and meta-analyses, operative versus conservative treatment, timing of surgery, and rehabilitation are discussed. Also, the advantages and disadvantages of the most common types of autografts, such as patellar tendon and hamstrings as well as allografts are presented.Key considerations for the anatomical, histological, biomechanical and clinical data ('IDEAL') graft positioning are reviewed. Cite this article: Paschos NK, Howell SM. Anterior cruciate ligament reconstruction: principles of treatment. EFORT Open Rev 2016;398-408. DOI: 10.1302/2058-5241.1.160032.

Keywords: ACL tear; allograft; anterior cruciate ligament; autograft; reconstruction; rehabilitation; timing; tunnel position.

Fig. 1

Topographies at the femoral footprint that ensure isometric, eccentric, direct placement of the graft at a low-tension location.

Fig. 2

The correct or IDEAL location for the femoral tunnel (see black circle) is shown superimposed on the topographic outline of the five characteristics that should be fulfilled when judging where to position the femoral tunnel.