Abstract
The Dutch Orthopaedic Association has a long tradition of development of practical clinical guidelines. Here we present the recommendations from the multidisciplinary clinical guideline working group for anterior cruciate ligament injury.
The following 8 clinical questions were formulated by a steering group of the Dutch Orthopaedic Association.
What is the role of physical examination and additional diagnostic tools?
Which patient-related outcome measures should be used?
What are the relevant parameters that influence the indication for an ACL reconstruction?
Which findings or complaints are predictive of a bad result of an ACL injury treatment?
What is the optimal timing for surgery for an ACL injury?
What is the outcome of different conservative treatment modalities?
Which kind of graft gives the best result in an ACL reconstruction?
What is the optimal postoperative treatment concerning rehabilitation, resumption of sports, and physiotherapy?
These 8 questions were answered and recommendations were made, using the “Appraisal of Guidelines for Research and Evaluation” instrument. This instrument seeks to improve the quality and effectiveness of clinical practical guidelines by establishing a shared framework to develop, report, and assess. The steering group has also developed 7 internal indicators to aid in measuring and enhancing the quality of the treatment of patients with an ACL injury, for use in a hospital or practice.
Anterior cruciate ligament injury is a common sports injury with a worldwide reconstruction rate of more than 200,000 per year (CitationMeuffels et al. 2011). Clinically practical guidelines have been used for a long time; the Dutch Orthopaedic Association has a long experience of guideline development, since the 1980s. This is the recommendation from the multidisciplinary clinical guideline “anterior cruciate ligament injury”, set up and aimed at all the members of the medical disciplines concerned with diagnosis and treatment of anterior cruciate ligament injury. This injury is seen by a large number of diverse medical caregivers, and the importance of a team approach to injury treatment with a view to reintegration in sport has been established. This guideline was set up using the “Appraisal of Guidelines for Research and Evaluation (AGREE)” instrument (www.agreecollaboration.org).
Methods
The process started with the formulation of 8 clinical questions by a steering group of the Dutch Orthopaedic Association.
Literature search
The guideline was meant to cover fully-grown adolescents up to active patients of middle-age. A general search was performed for existing guidelines in the databases of National Guideline Clearinghouse (http://www.guideline.gov/), NICE (http://www.nice.org.uk/), SIGN (http://www.sign.ac.uk/), CBO (http://www.cbo.nl/thema/Richtlijnen/), and using the search machine SUMSearch (http://sumsearch.uthscsa.edu/). We also searched for systematic reviews in the Cochrane Library (http://www.cochrane.org). For each question, the bibliographic database Medline (OVID) (1950-2010) was searched for specific terms (Table 1, see supplementary data). We searched for randomized trials and systematic reviews or meta-analyses. If none were found, a broader search of studies of a lower level of evidence was performed, including case-control studies and cohort studies (both prospective and retrospective). Afterwards, a hand search was performed using the reference lists of the previously found articles.
Grading of study quality
After selection of the relevant literature, the members of the steering group and a methodologist graded the studies for levels of evidence and quality (). For each query, the scientific level of evidence was graded and the conclusion was summarized ().
Table 2. Level of evidence of the conclusion
Table 3. Level of evidence of the conclusion
Table 4. Internal indicators for ACL injury
Recommendations
The recommendations given are influenced by many considerations apart from the scientific evidence—such as patient preferences, availability of facilities, or organizational aspects. The recommendations for each question have been based on the scientific evidence, combined with the most important considerations, such as input from the patient focus group and feedback from the participating medical societies.
Questions addressed in the guideline
What is the role of physical examination and additional diagnostic tools?
Scientific evidence
Level 1:
The Lachman test is the most valid stability test at the physical examination of the knee, with a sensitivity of 85% and a specificity of 95% (Solomon et al. Citation2001, Scholten et al. Citation2003, Benjaminse et al. Citation2006).
Performance of a complete physical examination of the knee (Lachman test, pivot shift, anterior drawer test) has a higher sensitivity and specificity than a partial investigation (Solomon et al. Citation2001).
MRI is a valid and safe non-invasive diagnostic tool for diagnosing anterior cruciate ligament injury, with a high sensitivity and specificity (both 94%) (Oei et al. Citation2003, Crawford et al. Citation2007).
Level 2:
It is likely that, when physical examination is conducted well, an MRI has no added value, since it will seldom change the diagnosis or the treatment strategy (Liu et al. Citation1995, Gelb et al. Citation1996, Kocabey et al. Citation2004).
Recommendation. In order to maximise the diagnostic accuracy for an anterior cruciate ligament injury, it is recommended that the Lachman test, pivot shift test, and anterior drawer test of the knee be performed. Having an experienced investigator enhances the reliability of this physical examination.
MRI has no additional value when physical examination has shown anterior-posterior or rotational instability of the knee, suggesting an anterior cruciate ligament injury. However, MRI is a reliable additional investigation to establish other intraarticular lesions.
Which patient-related outcome measures should be used for the evaluation and follow-up of patients with anterior cruciate ligament injury?
Scientific evidence
Level 1:
Performance of a complete physical examination of the knee (Lachman, pivot shift, and anterior drawer test) has a higher sensitivity and specificity than performing a partial examination (Solomon et al. Citation2001, Scholten et al. Citation2003, Benjaminse et al. Citation2006).
Level 2:
The IKDC and KOOS are validated (in Dutch) (Haverkamp et al. Citation2006, de Groot et al. Citation2008) as patient-related outcome scores. These knee-related scores are probably well-suited for patients with an ACL rupture (Roos et al. Citation1998, Irrgang et al. Citation2001).
The Tegner score is an accepted activity score (Briggs et al. Citation2009); it is has not, however, been validated in Dutch.
Recommendation. We recommend the combination of the Lachman test, pivot shift test, and anterior drawer test as a clinical outcome measurement. We recommend use of the IKDC subjective and the KOOS as patient-related outcome measures. It can be useful to adopt the Tegner score as an outcome measurement for activity.
What are the relevant parameters that influence the indication for an anterior cruciate ligament reconstruction?
Scientific evidence
Level 1:
Actual age is not a factor of importance for the decision to perform an ACL reconstruction (Barber et al. Citation1996, Sloane et al. Citation2002).
Younger patients are entitled to an ACL reconstruction earlier because of their higher activity level (Barber et al. Citation1996, Ferrari and Bach Citation2001, Sloane et al. Citation2002, Dunn et al. Citation2004).
Level 3:
The activity level of the patient is probably the most important predictor for the necessity to perform an ACL reconstruction. The more the patient is active in pivoting sports, the greater the chance that an operation is necessary to reach an acceptable activity level (Daniel and Fithian Citation1994).
Reconstruction of the ruptured ACL might reduce the chance of further meniscal and/or cartilage damage (Dunn et al. Citation2004).
Consideration. Timing of the operative procedure is an important issue. The reconstruction should be performed at the time that the knee function has been optimized, and the synovial reaction has quietened down. Other considerations such as cartilage damage or degeneration can influence the choice of an operative procedure. From a patient’s point of view, other non-medical motives can play an important role. Professional or upcoming talented sports people may have different expectations and wishes considering operative or conservative treatment of an ACL rupture.
Recommendation. If symptomatic instability of the knee, as a result of an anterior cruciate ligament injury, is not reduced after physiotherapy nor after adjustment of activity, anterior cruciate ligament reconstruction is recommended. This might prevent multiple interventions because of further meniscal and cartilage damage.
In adults, when deciding between nonoperative or operative treatment, age should not be weighed as an important factor.
In children, it may be preferable to await surgery until the growth plates are (almost) closed.
An anterior cruciate ligament reconstruction should only be performed in a “quiet” knee with a normal range of motion.
Which findings or complaints are predictive of a bad result of an anterior cruciate ligament injury treatment?
Scientific evidence
Level 2:
A longer period between the occurrence of the ACL rupture and the reconstruction could increase the risk of meniscal and/or cartilage damage (Fithian et al. Citation2005, Gregory and Landreau Citation2008, Joseph et al. Citation2008, Slauterbeck et al. Citation2009).
Level 3:
Persistent subjective knee instability has a negative influence on the outcome of both nonoperative and operative treatment. Treatment outcome is negatively influenced by undergoing multiple knee interventions of any kind (Meunier et al. Citation2007).
An extension deficit before the operation can have a negative effect on the outcome of an ACL reconstruction (Mauro et al. Citation2008).
A strength deficit of more than 20% of the hamstring and quadriceps muscles compared to the uninjured side can have a negative effect on the outcome of an ACL reconstruction (Citationde Jong et al. 2007, Eitzen et al. Citation2009).
Cartilage and/or meniscal damage can have a negative effect on the functional result of the treatment of an ACL injury (Williams et al. Citation2000, Meunier et al. Citation2007, Kowalchuck et al. Citation2009).
Continued participation in “high-risk sports” predisposes the knee for injury of the cartilage, the meniscus, and the possibly reconstructed ACL—increasing the risk of re-rupture, secondary surgery, and knee osteoarthritis (Fink et al. Citation2001, Salmon et al. Citation2005, Meuffels et al. Citation2009). There is insufficient evidence to prove the protective effect of an ACL reconstruction against knee osteoarthritis (Fithian et al. Citation2005, Gregory et al. Citation2008, Joseph et al. Citation2008, Meuffels et al Citation2009, Slauterbeck et al. Citation2009).
Leg malalignment could have a negative influence on the outcome of an ACL reconstruction. Combining an ACL reconstruction and a correcting osteotomy could make the outcome of the ACL reconstruction more predictable (Williams et al. Citation2000).
There is no clear evidence to show that the patient’s gender influences the outcome of an ACL reconstruction (Salmon et al. Citation2005, Heijne et al. Citation2008, Slauterbeck et al Citation2009).
Consideration. From a patient’s point of view, the definition of a “bad result” may differ from the specific medical-technical definition. It is important to give clear counseling about the expected activity level in both the short and long term. The uncertainty of a nonoperative treatment can be more difficult to accept for a sports person at a high level than for a person who is more interested in sport for recreation, or an elderly patient. One should also take the working circumstances of the person involved into consideration.
Recommendation. An anterior cruciate ligament reconstruction should be performed only when a full extension of the knee is possible and the synovial reaction is minimal.
During the preoperative preparations, a possible muscle strength deficit of the injured leg should be treated.
In the presence of knee malalignment and anterior cruciate ligament insufficiency, correction of the leg alignment should be considered, possibly in combination with an anterior cruciate ligament reconstruction.
It is recommended that the patient be informed that participation in high-risk sports or heavy knee labor increases the risk of cartilage damage, meniscal damage, and damage to the reconstructed anterior cruciate ligament, which could result in a re-rupture, secondary surgery, or knee osteoarthritis.
What is the optimal timing for surgery for an anterior cruciate ligament injury?
Scientific evidence
Level 2:
The increase in time between the injury and reconstruction of the ACL is a risk factor for meniscal and cartilage damage (Church and Keating Citation2005, Foster et al. Citation2005, Kim et al. Citation2005, Vasara et al. Citation2005. Seon et al. Citation2006, Ohly et al. Citation2007, Papagasteriou et al. Citation2007, Granan et al. Citation2009, Tayton et al. Citation2009 Vasara et al. Citation2005).
Level 3:
At long-term follow-up (7 years) of a subacute reconstruction (within 6 weeks) gave better outcome for range of motion, work participation, and degenerative change than late reconstruction (Järvelä et al. Citation1999).
Recommendation. The indication for a reconstruction is persistent instability of the knee with complaints of giving way. This diagnosis is difficult to make in an acute situation. We therefore recommend that anterior cruciate ligament reconstruction should not be performed in the first weeks after trauma, in order to minimize the risk of operating on an asymptomatic patient.
If the indication for anterior cruciate ligament reconstruction has been defined, we recommend performing the reconstruction in a timely manner in order to minimize the risk of additional damage to the cartilage and/or meniscus.
The patient with a delayed reconstruction (6 weeks to 3 months post-trauma) can resume his or her physical activity sooner—with a greater chance of obtaining higher activity scores—than a patient with a late reconstruction (more than 3 months after trauma).
In the long term, delayed reconstruction gives a better range of motion and less degenerative changes than a late reconstruction.
What is the outcome of different non-operative treatment modalities?
Scientific evidence
Level 1:
Balance and proprioception training has a positive effect on joint position sense, muscle strength, experienced knee function, outcome of functional capacity, and return to full activity (Fitzgerald et al. Citation2000, Cooper et al. Citation2005, Trees et al. Citation2005, Citation2007).
Level 2:
Addition of open-chain strength training to an ACL rehabilitation program has a positive effect on muscle strength of quadriceps and hamstring muscles and on functional recovery (Zatterstrom et al. Citation2000, Perry et al. Citation2005, Tagesson et al. Citation2008).
Supervised training has more value than non-supervised training concerning muscle strength of the quadriceps and hamstring muscles, and on functional recovery (Zatterstrom et al. Citation1998, Citation2000).
Level 3:
The sensation of instability is reduced for ACL-injured individuals by wearing a knee brace, but initially, the use of a brace can also lead to more complaints in activities of daily living (Swirtun et al. Citation2005).
Recommendation. It is advisable to rehabilitate patients with an anterior cruciate ligament injury using a physiotherapy exercise program that trains multiple ground-motoric abilities.
We strongly recommend incorporating senso-motoric training (balance and proprioception) into the rehabilitation program.
It is preferable to incorporate both open- and closed-chain strength training into the rehabilitation program after an anterior cruciate ligament injury.
There are no indications for use of a brace in the standard treatment of an ACL injury.
A brace could be considered for patients with instability, who do not qualify or who do not want to qualify for operative treatment.
Surgical treatment— which kind of graft gives the best result in an anterior cruciate ligament reconstruction?
Scientific evidence
Level 1:
Bone-patella-tendon-bone and hamstring grafts both give similar degrees of stability when used in conjunction with modern (extra-cortical) fixation techniques (Schultz and Carr Citation2002, Goldblatt et al. Citation2005, Prodromos et al. Citation2005, Thompson et al. Citation2005).
The use of a bone-patella-tendon-bone autograft has a greater chance of giving anterior knee pain than the use of a hamstring autograft. There is no substantial difference between hamstring or bone-patella-tendon-bone reconstruction, in muscle strength of the flexors and extensors of the knee 2 years after surgery (Freedman et al. Citation2003, Dauty et al. Citation2005, Forster and Forster Citation2005, Goldblatt et al. Citation2005).
Level 2:
There is no significant clinical difference between allograft and autograft ACL reconstruction in IKDC, activity scores, and stability (Carey et al. Citation2009, Krych et al. Citation2008, Sun et al. Citation2009).
Radiating the allograft can give higher failure rates. Pre-tensioning of the allograft before the reconstruction has no additional value (Ejerhed et al. Citation2001, Gorschewski et al. Citation2005, Rappe et al. Citation2007, Sun et al. Citation2009).
At short-term follow-up (2 years), there is no difference in patient-related outcome between single- and double-bundle ACL reconstruction. At short-term follow-up, there is a better recovery of the rotational stability when performing a double-bundle reconstruction (Kondo et al. Citation2008, Meredick et al. Citation2008, Seon et al. 2008, Siebold and Zantop Citation2008, Streich et al. Citation2008, Tsuda et al. Citation2009, Wang et al. Citation2009).
Suturing of ACL ruptures does not lead to good results; there is an increased chance of knee osteoarthritis and many patients report knee instability and ruptures (25–30% after 5 years) (Engebretsen et al. Citation1989).
Enhancement of the graft with, for example, a Kennedy LAD does not increase stability, diminish ruptures, or improve function, but it does lead to more side effects (swelling, infection, and need for revision) (Grontvedt et al. 1995, Drogset and Grontvedt Citation2002, Muren et al. Citation2003).
Use of a synthetic graft (Leeds-Keio, Gore-Tex) leads to more instability, more ruptures, more pain, and lower activity scores (Engebretsen et al. Citation1989, Engstrom et al. Citation1993, Grontvedt et al. 1995, Citation1996, Drogset and Grontvedt Citation2002, Muren et al. Citation2003).
Level 3:
In different modern methods using metal or resorbable screws, graft fixation strength is similar (Brand et al. Citation2000, Harvey et al. Citation2005).
Recommendation. Considering clinical outcome measurement, there is no direct preference for the use of either autograft or allograft for anterior cruciate ligament reconstruction. Both graft types lead to good clinical results.
Radiated allografts fail more often than non-radiated allografts.
Stretching of allografts before the reconstruction is unnecessary.
Bone-patellar-tendon-bone and hamstring reconstructions give good results, stability, and low complication rates. Hamstring reconstruction results in significantly less anterior knee pain. Both single- and double-bundle hamstring reconstruction give good functional results. With our current scientific knowledge, there is no preference for either technique. Double-bundle reconstruction is a more time consuming and technically more demanding procedure than single-bundle reconstruction.
Use of synthetic graft or ligament augmentation is not recommended because of inferior results and increased complications in long-term follow-up.
There is no scientific basis for making recommendations as to the choice of type of fixation device for the different grafts.
What is the optimal postoperative treatment (after the first postoperative check-up, concerning rehabilitation, resumption of sports, and physiotherapy)?
Scientific evidence
Level 1:
Wearing of a knee brace has no additional treatment value after an ACL reconstruction (Wright and Fetzer Citation2007, Anderson et al. 2009).
In the early phase of rehabilitation, closed-chain exercise therapy is likely to give fewer patello-femoral complaints and less laxity than open-chain exercises (Trees et al. Citation2005, Wright et al. Citation2008, Anderson et al. 2009).
Level 2:
Addition of neuromuscular training to the rehabilitation program will have a better outcome than strength training alone (Risberg et al. Citation2007).
An exercise program with early open-chain exercises (4 weeks postoperatively) will lead to more laxity with hamstring grafts than late open-chain exercises (12 weeks postoperatively) (Heijne and Werner Citation2007).
Consideration. The literature retrieved gives insufficient scientific information for us to be able to give advice concerning work, daily living, and resumption of sports that can be applied to every patient. On every occasion of the rehabilitation program, the treatment team should be aware of signals such as knee pain, swelling, feeling of warmth, and range of motion. With this information, an individual schedule can be implemented concerning daily living, work, and sports to ensure a swift and safe rehabilitation.
Recommendation. We recommend combining strength with neuromuscular training in the postoperative treatment.
It is recommended that only closed-chain exercises be used in the early rehabilitation phase.
There is no reason for the use of a brace in the postoperative treatment period after an anterior cruciate ligament reconstruction.
Heavy physical activity in labor or sports should not be resumed within 3 months of surgery.
Indicators
The steering group has developed 7 internal indicators to aid in measuring and enhancing the quality of the treatment of patients with an ACL injury, for use in a hospital or medical practice. They are summarized in . These indicators were not developed for use as an external quality control (external indicators).
www.actaorthop.org
Download PDF (122.3 KB)- Andersson D, Samuelsson K, Karlsson J. Treatment of anterior cruciate ligament injuries with special reference to surgical technique and rehabilitation: an assessment of randomized controlled trials. Arthroscopy 2009; 25 (6):653–85.
- Barber FA, Elrod BF, McGuire DA, Paulos LE. Is an anterior cruciate ligament reconstruction outcome age dependent? Arthroscopy 1996; 12: 720-5.
- Benjaminse A, Gokeler A, Schans C P van der. Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis. J Orthop Sports Phys Ther 2006; 36: 267-88.
- J Jr, HJr, BrandWeiler A, Caborn DN, Brown CJohnson DL. Graft fixation in cruciate ligament reconstruction. Am J Sports Med 2000; 28 (5): 761–74.
- Briggs KK, Lysholm J, Tegner Y, Rodkey WG, Kocher MS, Steadman JR. The reliability, validity, and responsiveness of the Lysholm score and Tegner activity scale for anterior cruciate ligament injuries of the knee: 25 years later. Am J Sports Med 2009; 37: 890-7.
- Carey JL, Dunn WR, Dahm DL, Zeger SL, Spindler KP. A systematic review of anterior cruciate ligament reconstruction with autograft compared with allograft. J Bone Joint Surg (Am) 2009; 91 (9): 2242–50.
- Church S. Keating JF. Reconstruction of the anterior cruciate ligament: timing of surgery and the incidence of meniscal tears and degenerative change. J Bone Joint Surg (Br) 2005; 87 (12): 1639–42.
- Cooper RL, Taylor NF, Feller JA. A systematic review of the effect of proprioceptive and balance exercises on people with an injured or reconstructed anterior cruciate ligament. Res Sports Med 2005; 13 (2): 163–78.
- Crawford R, Walley G, Bridgman S, Maffulli N. Magnetic resonance imaging versus arthroscopy in the diagnosis of knee pathology, concentrating on meniscal lesions and ACL tears: a systematic review. Br Med Bull 2007; 84: 5-23.
- Daniel DM, Fithian DC. Indications for ACL surgery. Arthroscopy 1994; 10 (4): 434–41.
- Dauty M, Tortellier L, Rochcongar P. Isokinetic and anterior cruciate ligament reconstruction with hamstrings or patella tendon graft: analysis of literature. Int J Sports Med 2005; 26 (7): 599–606.
- de Groot, IB, Favejee, MM, Reijman M, Verhaar J AN Terwee CB. The Dutch version of the Knee Injury and Osteoarthritis Outcome Score: a validation study. Health Qual Life Outcomes 2008;26 (6): 16.
- Drogset JO, Grontvedt T. Anterior cruciate ligament reconstruction with and without a ligament augmentation device : results at 8-Year follow-up. Am J Sports Med 2002; 30 (6): 851–6.
- Dunn WR, Lyman S, Lincoln AE, Amoroso PJ, Wickiewicz T, Marx RG. The effect of anterior cruciate ligament reconstruction on the risk of knee reinjury. Am J Sports Med 2004; 32 (8): 1906–14.
- Eitzen I, Holm I, Risberg MA. Preoperative quadriceps strength is a significant predictor of knee function two years after anterior cruciate ligament reconstruction. Br J Sports Med 2009; 43 (5): 371–6.
- Ejerhed L, Kartus J, Köhler K, Sernert N, Brandsson S, Karlsson J. Preconditioning patellar tendon autografts in arthroscopic anterior cruciate ligament reconstruction: a prospective randomized study. Knee Surg Sports Traumatol Arthrosc 2001; 9 (1): 6–11.
- Engebretsen L, Benum P, Sundalsvoll S. Primary suture of the anterior cruciate ligament. A 6-year follow-up of 74 cases. Acta Orthop Scand 1989; 60 (5): 561–4.
- Engstrom B, Wredmark T, Westblad P. Patellar tendon or Leeds-Keio graft in the surgical treatment of anterior cruciate ligament ruptures. Intermediate results. Clin Orthop 1993; (295): 190-7.
- Ferrari J D, Bach B R. Isolated anterior cruciate ligament injury. In: Chapman M W, ed. Chapman’s Orthopedic Surgery 2001; Philadelphia:Pa: Lippincott, Williams & Wilkins2347–59.
- Fink C, Hoser C, Hackl W, Navarro RA, Benedetto KP. Long-term outcome of operative or nonoperative treatment of anterior cruciate ligament rupture--is sports activity a determining variable? Int J Sports Med 2001; 22 (4): 304–9.
- Fithian DC, Paxton EW, Stone ML, Luetzow WF, Csintalan RP, Phelan D, Daniel DM. Prospective trial of a treatment algorithm for the management of the anterior cruciate ligament-injured knee. Am J Sports Med 2005; 33 (3): 335–46.
- Fitzgerald GK, Axe MJ, Snyder-Mackler L. The efficacy of perturbation training in nonoperative anterior cruciate ligament rehabilitation programs for physical active individuals. Phys Ther 2000; 80 (2): 128–40.
- Forster MC, Forster IW. Patellar tendon or four-strand hamstring? A systematic review of autografts for anterior cruciate ligament reconstruction. Knee 2005; 12 (3): 225–30.
- Foster A, Butcher C, Turner PG. Changes in arthroscopic findings in the anterior cruciate ligament deficient knee prior to reconstructive surgery. Knee 2005; 12 (1): 33–5.
- Freedman KB, D’Amato MJ, Nedeff DD, Kaz A, Bach B, R Jr. Arthroscopic anterior cruciate ligament reconstruction: a metaanalysis comparing patellar tendon and hamstring tendon autografts. Am J Sports Med 2003; 31 (1):2–11.
- Gelb HJ, Glasgow SG, Sapega AA, Torg JS. Magnetic resonance imaging of knee disorders. Clinical value and cost-effectiveness in a sports medicine practice. Am J Sports Med 1996; 24 (1): 99–103.
- Goldblatt JP, Fitzsimmons SE, Balk E, Richmond JC. Reconstruction of the anterior cruciate ligament: meta-analysis of patellar tendon versus hamstring tendon autograft. Arthroscopy 2005; 21 (7): 791–803.
- Gorschewsky O, Klakow A, Riechert K, Pitzl M, Becker R. Clinical comparison of the Tutoplast allograft and autologous patellar tendon (bone-patellar tendon-bone) for the reconstruction of the anterior cruciate ligament: 2- and 6-year results. Am J Sports Med 2005; 33 (8): 1202–9.
- Granan LP, Bahr R, Lie SA, Engebretsen L. Timing of anterior cruciate ligament reconstructive surgery and risk of cartilage lesions and meniscal tears: a cohort study based on the Norwegian National Knee Ligament Registry. Am J Sports Med 2009; 37 (5): 955–61.
- Gregory T. Landreau P. Meniscus and cartilaginous lesions. Influence of the delay between ACL injury and ligament reconstruction in 40-year-old patients. Rev Chir Orthop Reparatrice Appar Mot 2008; 94 (6): 566–72.
- Grontvedt T, Engebretsen L, Bredland T. Arthroscopic reconstruction of the anterior cruciate ligament using bone-patellar tendon-bone grafts with and without augmentation. A prospective randomised study. J Bone Joint Surg (Br) 1996; 78 (5): 817–22.
- Harvey A, Thomas NP, Amis AA. Fixation of the graft in reconstruction of the anterior cruciate ligament. J Bone Joint Surg (Br) 2005; 87 (5): 593–603.
- Haverkamp D, Sierevelt IN, Breugem S JM, Lohuis K, Blankevoort L, van Dijk CN. Translation and validation of the Dutch version of the International Knee Documentation. Am J Sports Med 2006; 34 (10): 1680–4.
- Heijne A, Werner S. Early versus late start of open kinetic chain quadriceps exercises after ACL reconstruction with patellar tendon or hamstring grafts: a prospective randomized outcome study. Knee Surg Sports Traumatol Arthrosc 2007; 15 (4): 402–14.
- Heijne A, Ang BO, Werner S. Predictive factors for 12-month outcome after anterior cruciate ligament reconstruction. Scand J Med Sci Sports 2008;5: (e-pub)
- Irrgang JJ, Anderson AF, Boland AL, Harner CD, Kurosaka M, Neyret P, Richmond JC, Shelborne KD. Development and validation of the international knee documentation committee subjective knee form. Am J Sports Med 2001; 29: 600-13.
- Järvelä T, Nyyssönen M, Kannus P, Paakkala T, Järvinen M. Bone- patellar tendon-bone reconstruction of the anterior cruciate ligament. A long-term comparison of early and late repair. Int Orthop 1999; 23 (4): 227–31.
- Jong S N de, Caspel D R van, Haeff M J van, Saris DB. Functional assessment and muscle strength before and after reconstruction of chronic anterior cruciate ligament lesions. Arthroscopy 2007; 23 (1): 21–8, 28.
- Joseph C, Pathak SS, Aravinda M, Rajan D. Is ACL reconstruction only for athletes? A study of the incidence of meniscal and cartilage injuries in an ACL- deficient athlete and non-athlete population: an Indian experience. Int Orthop 2008; 32 (1): 57–61.
- Kim SG, Kurosawa H, Sakuraba K, Ikeda H, Takazawa S, Seto H, Ishijima M. Analysis of the risk factors regarding anterior cruciate ligament reconstruction using multiple-looped semitendinosus tendon. Knee 2005; 12 (5): 366–9.
- Kocabey Y, Tetik O, Isbell WM, Atay OA, Johnson DL. The value of clinical examination versus magnetic resonance imaging in the diagnosis of meniscal tears and anterior cruciate ligament rupture. Arthroscopy 2004; 20 (7): 696–700.
- Kondo E, Yasuda K, Azuma H, Tanabe Y, Yagi T. Prospective clinical comparisons of anatomic double-bundle versus single-bundle anterior cruciate ligament reconstruction procedures in 328 consecutive patients. Am J Sports Med 2008; 36 (9):1675-87.
- Kowalchuk, DA, Harner CD, Fu FH, Irrgang JJ. Prediction of patient- reported outcome after single-bundle anterior cruciate ligament reconstruction. Arthroscopy 2009; 25 (5): 457-63.
- Krych AJ, Jackson JD, Hoskin, TL, Dahm DL. A meta-analysis of patellar tendon autograft versus patellar tendon allograft in anterior cruciate ligament reconstruction. Arthroscopy 2008; 24 (3): 292–8.
- Liu SH, Osti L, Henry M, Bocchi L. The diagnosis of acute complete tears of the anterior cruciate ligament. Comparison of MRI, arthrometry and clinical examination. J Bone Joint Surg (Br) 1995; 77 (4): 586–8.
- Mauro CS, Irrgang JJ, Williams BA, Harner CD. Loss of extension following anterior cruciate ligament reconstruction: analysis of incidence and etiology using IKDC criteria. Arthroscopy 2008; 24 (2): 146–53.
- Meredick RB, Vance KJ, Appleby D, Lubowitz JH. Outcome of single-bundle versus double-bundle reconstruction of the anterior cruciate ligament: a meta-analysis. Am J Sports Med 2008; 36 (7): 1414–21.
- Meuffels DE, Favejee M, Vissers M, Heijboer R, Reijman M, Verhaar J. Ten year follow-up study comparing conservative versus operative treatment of anterior cruciate ligament ruptures. A matched control study. Br J Sports Med 2009; 43: 347-51.
- Meuffels DE, Reijman M, Scholten RJ, Verhaar JA. Computer assisted surgery for knee ligament reconstruction. Cochrane Database Syst Rev 2011;15(6):CD007601.
- Meunier A, Odensten M, Good L. Long-term results after primary repair or non-surgical treatment of anterior cruciate ligament rupture: a randomized study with a 15-year follow-up. Scand J Med Sci Sports 2007; 17 (3): 230–7.
- Muren O, Dahlstedt L, Dalen N. Reconstruction of acute anterior cruciate ligament injuries: a prospective, randomised study of 40 patients with 7-year follow- up. No advantage of synthetic augmentation compared to a traditional patellar tendon graft. Arch Orthop Trauma Surg 2003; 123 (4): 144–7.
- Oei EH, Nikken JJ, Verstijnen AC, Ginai AZ, Hunink MG. MR imaging of the menisci and cruciate ligaments: a systematic review. Radiology 2003; 226: 837-48.
- Ohly NE, Murray IR, Keating JF. Revision anterior cruciate ligament reconstruction: timing of surgery and the incidence of meniscal tears and degenerative change. J Bone Joint Surg (Br) 2007; 89 (8): 1051–4.
- Papastergiou SG, Koukoulias NE, Mikalef P, Ziogas E, Voulgaropoulos H. Meniscal tears in the ACL-deficient knee: correlation between meniscal tears 58 and the timing of ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2007; 15 (12): 1438–44.
- Perry MC, Morrissey MC, King JB, Morrissey D, Earnshaw P. Effects of closed versus open kinetic chain knee extensor resistance training on knee laxity and leg function in patients during the 8- to 14-week post-operative period after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2005; 13 (5): 357–69.
- Prodromos CC, Joyce BT, Shi K, Keller BL. A meta-analysis of stability after anterior cruciate ligament reconstruction as a function of hamstring versus patellar tendon graft and fixation type. Arthroscopy 2005; 21: 1202.
- Rappe M, Horodyski M, Meister K, Indelicato PA. Nonirradiated versus irradiated Achilles allograft: in vivo failure comparison. Am J Sports Med 2007; 35 (10): 1653–8.
- Risberg MA, Holm I, Myklebust G, Engebretsen L. Neuromuscular training versus strength training during first 6 months after anterior cruciate ligament reconstruction: a randomized clinical trial. Physical Therapy 2007; 87 (6): 737–50.
- Roos EM, Roos HP, Lohmander LS, Ekdahl C, Beynnon BD. Knee Injury and Osteoarthritis Outcome Score (KOOS)--development of a self- administered outcome measure. J Orthop Sports Phys Ther 1998; 28: 88-96.
- Salmon L, Russell V, Musgrove T, Pinczewski L, Refshauge K. Incidence and risk factors for graft rupture and contralateral rupture after anterior cruciate ligament reconstruction. Arthroscopy 2005; 21 (8): 948–57.
- Scholten R J PM, Opstelten W, Plas C G van der, Bijl D, Deville W L JM, Bouter, LM. Accuracy of physical diagnostic tests for assessing ruptures of the anterior cruciate ligament: a meta-analysis. J Fam Pract 2003; 52: 689-94.
- Schultz WR, Carr CF. Comparison of clinical outcomes of reconstruction of the anterior cruciate ligament: autogenous patellar tendon and hamstring grafts. Am J Orthop 2002; 31 (11): 613–20.
- Seon JK, Song EK, Park SJ. Osteoarthritis after anterior cruciate ligament reconstruction using a patellar tendon autograft. Int Orthop 2006; 30 (2): 94-8.
- Seon JK, Park SJ, Lee KB, Yoon TR, Seo HY, Song EK. Stability comparison of anterior cruciate ligament between double- and single-bundle reconstructions. Int Orthop 2009; 33 (2): 425–9.
- Siebold R, Zantop T. Anatomic double-bundle ACL reconstruction: a call for indications. Knee Surg Sports Traumatol Arthrosc 2008; 17 (3): 211–2.
- Slauterbeck JR, Kousa P, Clifton BC, Naud S, Tourville TW, Johnson RJ, Beynnon BD. Geographic mapping of meniscus and cartilage lesions associated with anterior cruciate ligament injuries. J Bone Joint Surg (Am) 2009; 91 (9): 2094–103.
- Sloane PA, Brazier H, Murphy AW, Collins T. Evidence based medicine in clinical practice: how to advise patients on the influence of age on the outcome of surgical anterior cruciate ligament reconstruction: a review of the literature. Br J Sports Med 2002; 36 (3): 200–3.
- Solomon DH, Simel DL, Bates DW, Katz JN, Schaffer JL. The rational clinical examination. Does this patient have a torn meniscus or ligament of the knee? Value of the physical examination. JAMA 2001; 286: 1610-20.
- Streich NA, Friedrich K, Gotterbarm T, Schmitt H. Reconstruction of the ACL with a semitendinosus tendon graft: a prospective randomized single blinded comparison of double-bundle versus single-bundle technique in male athletes. Knee Surg Sports Traumatol Arthrosc 2008; 16 (3): 232–8.
- Sun K, Tian SQ, Zhang JH, Xia CS, Zhang, CL, Yu TB. Anterior cruciate ligament reconstruction with BPTB autograft, irradiated versus non- irradiated allograft: a prospective randomized clinical study. Knee Surg Sports Trauma Arthrosc 2009; 17 (5): 464–74.
- Swirtun LR, Jansson A, Renstrom P. The effects of a functional knee brace during early treatment of patients with a nonoperated acute anterior cruciate ligament tear: a prospective randomized study. Clin J Sport Med 2005; 15 (5): 299–304.
- Tagesson S, Oberg B, Good L, Kvist J. A comprehensive rehabilitation program with quadriceps strengthening in closed versus open kinetic chain exercise in patients with anterior cruciate ligament deficiency: a randomized clinical trial evaluating dynamic tibial translation and muscle function. Am J Sports Med 2008; 36 (2): 298–307.
- Tayton E, Verma R, Higgins B, Gosal H. A correlation of time with meniscal tears in anterior cruciate ligament deficiency: stratifying the risk of surgical delay. Knee Surg Sports Trauma Arthrosc 2009; 17 (1): 30–4.
- Thompson J, Harris M, Grana, WA. Patellofemoral pain and functional outcome after anterior cruciate ligament reconstruction: an analysis of the literature. Am J Orthop 2005; 34 (8): 396–9.
- Trees AH, Howe TE, Dixon J, White L. Exercise for treating isolated anterior cruciate ligament injuries in adults. Cochrane Database Syst Rev 2005;(4):CD005316.
- Trees AH, Howe TE, Grant M, Gray HG. Exercise for treating anterior cruciate ligament injuries in combination with collateral ligament and 64 meniscal damage of the knee in adults. Cochrane Database Syst Rev 2007;(3):CD005961.
- Tsuda E, Ishibashi Y, Fukuda A, Tsukada H, Toh S. Comparable results between lateralized single- and double-bundle ACL reconstructions. Clin Orthop 2009; 467 (4): 1042–55.
- Vasara AI, Jurvelin JS, Peterson L, Kiviranta I. Arthroscopic cartilage indentation and cartilage lesions of anterior cruciate ligament-deficient knees. Am J Sports Med 2005; 33 (3): 408–14.
- Wang JQ, Ao YF, Yu CL, Liu P, Xu Y, Chen LX. Clinical evaluation of double-bundle anterior cruciate ligament reconstruction procedure using hamstring tendon grafts: a prospective, randomized and controlled study. Chin Med J (Engl) 2009;122 (6): 706–11.
- Williams R J III, Wickiewicz TL, Warren RF. Management of unicompartmental arthritis in the anterior cruciate ligament-deficient knee. Am J Sports Med 2000; 28 (5): 749–60.
- Wright RW, Fetzer GB. Bracing after ACL reconstruction: a systematic review. Clin Orthop 2007; (455): 162-8.
- Wright RW, Preston E, Fleming BC, Amendola A, Andrish JT, Bergfeld JA, Dunn WR, Kaeding C, Kuhn JE, Marx RG, McCarty EC, Parker RC, Spindler KP, Wolcott M, Wolf BR, Williams GN. 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; 21 (3): 225–34.
- Zatterstrom R, Friden, T, Lindstrand A, Moritz U. Early rehabilitation of acute anterior cruciate ligament injury--a randomized clinical trial. Scand J Med Sci Sports 1998; 8 (3): 154–9.
- Zatterstrom R, Friden T, Lindstrand A, Moritz U. Rehabilitation following acute anterior cruciate ligament injuries--a 12-month follow-up of a randomized clinical trial. Scand J Med Sci Sports 2000; 10 (3): 156–63.