acl reconstruction (1)

Running head: ANTERIOR COLLATERAL LIGAMNET RECONSTRUCTION 1

Anterior Collateral Ligament Reconstruction

“How to Choose the Graft Meant for You”

Ramon Valdez

Barry University

ANTERIOR COLLATERAL LIGAMENT RECONSTRUCTION 2

Anterior Collateral Ligament Reconstruction

The anterior collateral ligament is the main supporting structure in the knee joint when

preventing anterior displacement of the lower leg and internal rotation. The Anterior Collateral

Ligament (ACL) originates in the medial anterior aspect of the tibia, it then extends upwards

laterally and posteriorly to its insertion in the lateral condyle of the femur.

The ACL is the most commonly injured ligament of the knee. Injury to the ACL can

occur from numerous bodily motions, but is mainly associated with a hard hit from the side of

the knee, overextension of the knee, or an extreme twisting motion of the knee usually seen when

quickly changing positions during running. Individuals may feel a sudden pop or unstable feeling

in the knee followed by extreme pain and swelling within six hours of the time of injury. The

ACL injury is usually accompanied with a Medial Collateral Ligament (MCL) injury or a medial

meniscus injury, or even all three, commonly referred to as the unhappy triad; this correlation of

injury between these three structures of the knee is caused by a common chance of injury for

each negative force applied to the knee (Vorvick, 2015).

There are many ways to diagnose an ACL injury. In regards to ligaments, there is a high

level of blood supplied to the ACL; therefore, increased swelling soon after the injury is a sign of

ACL injury. Seventy-two percent of subjects with increased swelling soon after the injury were

confirmed to have injured their ACL. In only 15% of these cases was an isolated meniscal injury

diagnosed (Manning, Sloan, Draycott, & Barron, 2008). There are two anterior displacement

tests used to determine the laxity or lack of ACL support in the knee. The Lachman’s Test is


when the subject’s knee is placed at a 30-degree angle and the tibia is checked for anterior

displacement. The Anterior Drawer Test is the same as the Lachman’s Test, However, the knee

is placed at a 90-degree angle. Swelling usually prevents the subject from positioning his or her

knee to 90 degrees; therefore, the Lachman’s Test is a more viable method for clinical testing.

Even though these clinical methods of determining ACL injuries are helpful to develop a

basis for an accurate diagnosis, they are not always the most efficient method for doing so. Four

electronic databases (PubMed, MEDLINE, EMBASE, CINAHL) were analyzed to find Clinical

ACL tests and their results. A QUADAS-2 checklist was used to exclude cases with a high

chance of bias for the reasoning of the diagnosis. Of the four databases, a total of 285 articles

were extracted for analyzing. Of those, 14 were used for the review. Of those, nine were

diagnosed by physical symptoms (hearing a popping sound, swelling, pain, giving way, and

ability to continue activity) and 3 were diagnosed using clinical tests (Anterior Drawer Test,

Lachman’s Test, Prone Lachman’s Test and Pivot Shift Test). These clinical diagnostics were

analyzed using a positive negative likelihood ratio, and results showed that none of the tests

provided accurate information regarding a clinical diagnosis. Bias of injury was the number one

issue for providing an accurate and precise diagnosis (Swain, et al, 2014). The clinical post-

injury assessment of the ACL is unreliable; therefore, the importance of the MRI is paramount. It

provides adequate non-invasive imaging in all three planes (sagittal, coronal, and axial) to allow

medical examiners to create an accurate diagnosis and pre-surgical mapping of the injury

(Nissman, Hobbs, Pope, Geier, & Conway, 2008).

A partial tear of the ACL can sometimes heal on its own with the help of minimal

anterior, and internal rotational stress of the lower leg. Individuals have also been known to

continue daily life with a completely torn ACL. However, other injuries and extreme pain tend to


follow due to over compensation of surrounding structures. Once a complete tear is determined

and reconstruction is requested by the patient and deemed necessary by a physician, the process

of selecting the graft can begin. The patient’s lifestyle should be the ultimate guideline when

selecting a graft. There are three main methods: the bone-patella-bone (BPB) autograft, the

hamstring autograft, and the cadaver allograft. An autograft is a graft that comes from the

patient’s body. The bone-patellar tendon-bone method is the utilization of the central third of the

patellar tendon along with an attached block of bone from the patella and the tibia. Advantages

are that it is approximately the same length as the original ACL and the bone to bone healing

method is much quicker and durable. Disadvantages of the BPB method are that the patella now

has a greater risk of fracturing, as well as an increased chance of anterior knee pain where the

donor ligament was extracted (Cluett, 2014). Two tendons are extracted from the back of the leg

when using the hamstring method. They are then folded over to make a stronger ligament.

Advantages are that there is less pain experienced in the front of the knee post-surgery.

Disadvantages are that it takes longer for the graft to fuse to the insertion points on the tibia and

femur because it is not a bone top bone connection (Cluett, 2014). An allograft is a graft

selection that comes from another source other than the individual’s body such as a cadaver.

Advantages are that they do not cause any additional injury to another part of the body.

Disadvantages are that they are not as strong as the autograft and have a potential possibility of

carrying diseases during the transfer (Cluett, 2014).

BPB autograft is considered the gold standard because of the bone to bone healing. This

creates a stronger bond to the femur and the tibia four weeks faster than a soft tissue to bone

bond such as the hamstring graft method. However, they are both very effective, and when time

is not a factor, they can both perform to the same extent when becoming the subject’s new ACL


(Adhya, Dhillon, & Dhillon, 2014). The reason why the BPB method is so valuable is because

the bone to bone healing process decreases the time it takes for the graft to fully heal to the

patient, in turn decreasing opportunities for it to slip out of place. Out of 153 BPB graft

reconstructions there were 11 failures accounting for a 7.2% failure rate, but in a 165 hamstring

graft reconstructions, there were 26 failures accounting for a 15.8% failure rate. More athletes

have been recorded to return back to their level of play when having used the BPB graft method

(Poulsen & Johnson, 2010). This is attributed to the shorter healing process due to the bone-to-

bone connection. The comparison of autografts and allografts have shown that athletes who have

used allografts have taken longer to return to the playing field, and have had a 2 to 3 times higher

rate of failure than an autograft (Poulsen & Johnson, 2010). The graft recommendation from the

physician to the patient is usually based on the individual’s lifestyle. The BPB method and the

hamstring method both possess the possible risk of permanently injuring another part of the

body, although they both have a high level return rate. Whereas the allograft possesses minimal

risk to additional body parts; however, there is a high chance of increased graft failure. The BPB

graft is recommended for high level athletes because of the strength and high return rate of the

graft. Active patients younger than 40 years are advised to use the hamstring autograft due to it

having greater stability than the allograft. Active patients over 40 are advised to utilize the

hamstring option whereas non active patients are advised to have the allograft to prevent

unnecessary non-donor site morbidity (Poulsen & Johnson, 2010).

In order to insert the graft, the remains of the ruptured ACL must be shave off. Then,

three holes are drilled. One hole originates on the superior posterior part of the lateral femoral

condyle that angles downward and medially into the medial anterior plateau of the tibia. This is

where the graft will be fitted. Then, the second and third holes are drilled to insert the


arthroscopic camera and light source, and the arthroscopic instrument. The graft is pulled

through into the newly formed canal, and then wedged into place with screws. The security of

the new graft is tested by violently flexing and extending the leg at the knee joint. Once the graft

is deemed secure and of adequate tension, the skin is stitched together and the rehabilitation

process begins. The biggest factor determining a successful ACL surgery has been the different

methods of placement of the graft on the femoral condyle. Subjects with grafts placed too

anteriorly on the femur have lost range of motion in the knee which has resulted in permanent

stretching of the graft. It has also been observed that subjects with a vertically inserted graft have

experienced decreased stability in the knee and little resistance against internal rotation of the

knee as opposed to the more resistant weight bearing oblique style insertion (Markatos, Kaseta,

Lallos, Korres, & Efstathopoulos, 2013). This is why choosing the right surgeon is an extremely

important part of an ACL reconstruction because graft placement and attachment style have a

direct correlation to the level of success of the joint after surgery.

The rehabilitation process begins shortly after surgery has ended. Most of the

improvements were complete in respect to pain and range of motion by the 12-week mark

(Cupido, Peterson, Sutherland, Ayeni, & Stratford 2014). Once most of the extreme pain has

subsided, and the range of motion has been regained, major rehabilitation can begin. Most of the

support to the ACL is from the surrounding larger muscles around the knee. This is one of the

major reasons, along with other anatomical and hormonal differences, that ACL injuries tend to

be more prevalent in women than men. This is due to women naturally having less muscle mass

than men. In soccer ACL injuries are two to three times more common, and in basketball four

times more common in women than men. In general, women have a two to eight time’s greater

chance of an ACL injury, 70% of these occurring from non-contact (Rodenberg, Cayce, & Hall,


2006). Many people tend to take their physicians recommendation for graft selections. This is

why it is important for people to make informed decisions from detailed research and

contemplating the positives and negatives before agreeing to certain methods of reconstruction.


References

Adhya, B., Dhillon, M. S., & Dhillon, H. S. (2014). Rehabilitation Techniques after Anterior

Cruciate Ligament (ACL) Reconstruction the Indian Approach. Indian Journal Of

Physiotherapy & Occupational Therapy, 8(2), 236-243. doi:10.5958/j.0973-5674.8.2.092

Cluett, J. (2014, December 15). ACL Surgery Graft Options. Retrieved February 6, 2015, from

About Health website: http://orthopedics.about.com/cs/aclrepain/a/aclgrafts.htm

Cupido, C., Peterson, D., Sutherland, M. S., Ayeni, O., & Stratford, P. W. (2014). Tracking

Patient Outcomes after Anterior Cruciate Ligament Reconstruction. Physiotherapy

Canada, 66(2), 199-205. doi:10.3138/ptc.2013-19BC

Manning, M., Sloan, J., Draycott, S., & Barron, D. (2008). Soft tissue injuries: 5 The knee.

Emergency Medicine Journal, 25(12), 832-838. doi:10.1136/emj.2008.062927

Markatos, K., Kaseta, M., Lallos, S., Korres, D., & Efstathopoulos, N. (2013). The anatomy of

the ACL and its importance in ACL reconstruction. European Journal Of Orthopaedic

Surgery & Traumatology, 23(7), 747-752. doi:10.1007/s00590-012-1079-8

Nissman, D., Hobbs, R., Pope, T., Geier, C. J., & Conway, W. (2008). Imaging the knee:

ligaments. Applied Radiology, 37(12), 25.

Poulsen, M. R., & Johnson, D. L. (2010). Sports medicine update. Graft selection in anterior

cruciate ligament surgery. Orthopedics, 33(11), 832-835. doi:10.3928/01477447-

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Rodenberg, R., Cayce, K. I., & Hall, S. (2006). Your guide to a dreaded injury: the ACL tear.

Contemporary Pediatrics, 23(7), 26-26-8, 31-4, 36 passim.

Swain, M. S., Henschke, N., Kamper, S. J., Downie, A. S., Koes, B. W., & Maher, C. G. (2014).

Accuracy of clinical tests in the diagnosis of anterior cruciate ligament injury: a

http://orthopedics.about.com/cs/aclrepain/a/aclgrafts.htm


systematic review. Chiropractic & Manual Therapies, 22(1), 1-19. doi:10.1186/s12998-

014-0025-8

Vorvick, L. J. (2015, January 12). Anterior cruciate ligament (ACL) injury. Retrieved February

6, 2015, from Medline Plus website:

http://www.nlm.nih.gov/medlineplus/ency/article/001074.htm

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