Surgical Management of Anterior Cruciate Ligament Injuries

  • Mark E. Steiner

An anterior cruciate ligament (ACL) injury produces an athletic disability that is the most common knee injury to require a ligament reconstruction. Recent research has contributed to a better understanding of all aspects of this injury, but it is particularly in the areas of kinematics, graft placement, and graft fixation that the greatest improvements have occurred. Controversy abounds in the treatment of this injury, partly due to the difficulty in assessing results of treatment, but an understanding of the controversies is necessary in order to make informed treatment plans. This chapter will address the most current methodologies for ACL injury care relevant to the surgeon and team physician


Anterior Cruciate Ligament Anterior Cruciate Ligament Reconstruction Posterior Cruciate Ligament Patellar Tendon Anterior Cruciate Ligament Injury 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Odensten M, Gillquist J. Functional anatomy of the anterior cruciate ligament and a rational for reconstruction. J Bone Joint Surg 1985;67A:257–262.Google Scholar
  2. 2.
    Girgis FG, Marshall JL, Monajem A. The cruciate ligaments of the knee joint. Clin Orthop Relat Res 1975;106:216–231.PubMedCrossRefGoogle Scholar
  3. 3.
    Cha PS, Brucker PU, West RV, Zelle BA, Yagi M, Kurosaka M, Fu FH. Arthroscopic double-bundle anterior cruciate ligament reconstruction: an anatomic approach. J Arthrosc 2005;21:1275e1–1275e8.Google Scholar
  4. 4.
    Harner CD, Baek GHB, Vogrin TM, Carlin GJ, Kashiwaguchi S, Woo SL. Quantitative analysis of human cruciate ligament insertions. J Arthrosc 1999;15:741–749.CrossRefGoogle Scholar
  5. 5.
    Steckel H, Vadala G, Davis D, Fu FH. 2D and 3D 3-tesla magnetic resonance imaging of the double bundle structure in anaterior cruciate ligament anatomy. Knee Surg Sports Traum Arthrosc 2006;14:1151–1158.CrossRefGoogle Scholar
  6. 6.
    Howell SM, Gittins ME, Gottlieb JE, Traina SM, Zoellner TM. The relationship between the angle of the tibial tunnel in the coronal plane and loss of flexion and anterior laxity after anterior cruciate ligament reconstruction. Am J Sports Med 2001;29:567–574.PubMedGoogle Scholar
  7. 7.
    Mellado J, Calmet J, Olona M, Gine J, Sauri A. Magnetic resonance imaging of anterior cruciate ligament tears: reevaluation of quantitative parameters and imaging findings including a simpolified method for measurirng the anterior cruciate ligament angle. Knee Surg Sports Traumatol Arthrosc 2004;12:217–224.PubMedCrossRefGoogle Scholar
  8. 8.
    Heming JF, Rand J, Steiner ME. Anatomic limitations of transtibial drilling in ACL reconstruction. Am J Sports Med 2007;35: 1708–1715.PubMedCrossRefGoogle Scholar
  9. 9.
    O’Connor J, Shercliff T, FitzPatrick D, et al. Geometry of the knee. In Daniel D, Akeson W, O’Connor J (eds.), Knee Ligaments: Structure, Function, Injury and Repair. New York: Raven Press, 1990, p. 194.Google Scholar
  10. 10.
    Khalfayan EE, Sharkey PF, Alexander AH, Bruckner JD, Bynum EB. The relationship between tunnel placement and clinical results after anterior cruciate ligament reconstruction. Am J Sports Med 1996;24:335–341.PubMedCrossRefGoogle Scholar
  11. 11.
    Yagi M, Wong EK, Kanamori A, Debski RE, Fu FH, Woo SL. Biomechanical analysis of an anatomic anterior cruciate ligament reconstruction. Am J Sports Med 2002;30:660–665.PubMedGoogle Scholar
  12. 12.
    Yasuda K, Kondo E, Ichiyama H, Kitamura N, Tanabe Y, Tohyama J, Minami A. Anatomic reconstruction of the anteromedial and posterolateral bundles of the anterior cruciate ligament using hamstring tendon grafts. J Arthrosc 2004;20:1015–1025.CrossRefGoogle Scholar
  13. 13.
    Zavras TD, Race A, Bull AMJ, Amis AA. A comparative study of ‘isometric’ points for anterior cruciate ligament graft attachment. Knee Surg Sports Traumatol Arthrosc 2001;9:28–33.PubMedCrossRefGoogle Scholar
  14. 14.
    Mochizuki T, Muneta T, Nagase T, Shirawawa S, Akita K, Sekiya I. Cadaveric knee observation study for describing anatomic femoral tunnel placement for two-bundle anterior cruciate ligament reconstruction. J Arthrosc 2006;22:356–361.CrossRefGoogle Scholar
  15. 15.
    Hutchinson M, Bae T. Reproducibility of anatomic tibial landmarks for anterior cruciate ligament reconstructions. Am J Sports Med 2001;29:777–780.PubMedGoogle Scholar
  16. 16.
    Stäubli HU, Rauschning W. Tibial attachment area of the anterior cruciate ligament in the extended knee position. Knee Surg Sports Traumatol Arthrosc 1994;2:138–146.PubMedCrossRefGoogle Scholar
  17. 17.
    Morgan CD, Kalman KR, Grawl DM. Definitive landmarks for reproducible tibial tunnel placement in anaterior cruciate ligmanent reconstruction. J Arthrosc 1995;11:275–288.CrossRefGoogle Scholar
  18. 18.
    Colombet P, Robinson J, Christel P, Franceschi JP, Djian P, Bellier G, Sbihi A. Morphology of anterior cruciate ligament attachments for anatomic reconstruction: a cadaveric dissection and radiographic study. J Arthrosc 2006;22:984–992.CrossRefGoogle Scholar
  19. 19.
    Clancy WG, Nelson DA, Reider B, Narechania RG. Anterior cruciate ligament reconstruction using one-third of the patellar ligament, augmented by extra-articular tendon transfers. J Bone Joint Surg 1982;64A:352–359.Google Scholar
  20. 20.
    Amis AA, Jakob RP. Anterior cruciate ligament graft positioning, tensioning and twisting. Knee Surg Sports Traumatol Arthrosc 1998;6(Suppl 1):S2–S12.PubMedCrossRefGoogle Scholar
  21. 21.
    Takahashi M, Doi M, Abe M, Suzuki D, Nagano A. Anatomical study of the femoral and tibial insertions of the anteromedial and posterolateral bundles of human anterior cruciate ligament. Am J Sports Med 2006;34:787–792.PubMedCrossRefGoogle Scholar
  22. 22.
    Howell SM, Barad SJ. Knee extension and its relationship to the slope of the intercondylar roof: implications for positioning the tibial tunnel in anterior cruciate ligament reconstructions. Am J Sports Med 1995;23:288–294.PubMedCrossRefGoogle Scholar
  23. 23.
    Loh JC, Fukuda Y, Tsuda E, Steadman RJ, Fu FH, Woo SL. Knee stability and graft function following anterior cruciate ligament reconstruction: comparison between 11 o’clock and 10 o’clock femoral tunnel placement. J Arthrosc 2003;19:297–304.CrossRefGoogle Scholar
  24. 24.
    Yamamoto Y, Hsu WH, Woo SL, Van Scyoc AH, Takakura Y, Debski RE. Knee stability and graft function after anterior cruciate ligament reconstruction: a comparison of a lateral and an anatomical femoral tunnel placement. Am J Sports Med 2004;32: 1825–1832.PubMedCrossRefGoogle Scholar
  25. 25.
    Berg EE. Intrinsic healing of a patellar tendon donor site defect after anterior cruciate ligament reconstruction. Clin Orthop 1992;278:160–163.PubMedGoogle Scholar
  26. 26.
    Bernard M, Hertel P, Hornung H, Cierpinski T. Femoral insertion of the ACL radiographic quadrant method. Am J Knee Surg 1997;10:14–22.PubMedGoogle Scholar
  27. 27.
    Kohn D, Busche T, Caris J. Drill hole position in endoscopic anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 1998;6(Suppl 1):S13–S15.PubMedCrossRefGoogle Scholar
  28. 28.
    Woo S, Hollis J, Adams D, Lyon R, Takai S. Tensile properties of the human femur-anterior cruciate ligament-tibia complex. Am J Sports Med 1991;19:217–225.PubMedCrossRefGoogle Scholar
  29. 29.
    Woo SL, Kanamori A, Zeminski J, Yagi M, Papageorgiou C, Fu JG. The effectiveness of reconstruction of the anterior cruciate ligament with hamstrings and patellar tendon: a cadaveric study comparing anterior tibial and rotational loads. J Bone Joint Surg 2002;84A:907–914.Google Scholar
  30. 30.
    Zantop T, Herbort M, Raschke M, Fu FH, Petersen W. The role of the anteromedial and posterolateral bundles of the anterior cruciate ligament in anterior tibial translation and internal rotation. Am Sports Med 2007;35:223–227.CrossRefGoogle Scholar
  31. 31.
    Steiner M, Brown C, Zarins B, Brownstein B, Koval BS, Stone P. Measurement of anterior-posterior knee displacement: comparison of instrumented devices and clinical examination. J Bone Joint Surg 1990;72A:1307–1315.Google Scholar
  32. 32.
    Hamada M, Shino K, Horibe S, Mitsuoka R, Miyama T, Shiozaki Y, Mae T. Single versus bi-socket anterior cruciate ligament reconstruction using autogenous multiple-stranded hamstring tendons with endobutton femoral fixation: a prospective study. J Arthrosc 2001;17:801–807.Google Scholar
  33. 33.
    Battaglia TC, Rand JD, Festa A, Steiner ME. Tunnel placement and knee kinematics after standard versus computer-assisted ACL reconstruction. Presented at: AOSSM Annual Meeting; June 29--July 2, 2006; Hershey, PA.Google Scholar
  34. 34.
    Scopp JM, Jasper LE, Belkoff SM, Moorman CT. The effect of oblique femoral tunnel placement on rotational constraint of the knee reconstructed using patellar tendon autografts. J Arthrosc 2004;20:294–299.CrossRefGoogle Scholar
  35. 35.
    Georgoulis AD, Papadonikolakis A, Papageorgiou CD, Mitsou A, Stergiiou N. Three-dimensional tibiofemoral kinematics of the anterior cruciate ligament-deficient and reconstructed knee during walking. Am J Sports Med 2003;31:75–79.PubMedGoogle Scholar
  36. 36.
    Logan M, Dunstan E, Robinson J, Williams A, Gedroyc W, Freeman M. Tibiofemoral kinematics of the anterior cruciate ligament (ACL)-deficient weightbearing living knee employing vertical access open “interventional” multiple resonance imaging. Am J Sports Med 2004;32:720–726.PubMedCrossRefGoogle Scholar
  37. 37.
    Mahfouz MR, Komistek RD, Dennis DA, Hoff W. In vivo assessment of the kinematics in normal and anterior cruicate ligament-deficient knees. J Bone Joint Surg 2004;86A(Suppl 2):56–61.Google Scholar
  38. 38.
    Ristanis S, Stergiou N, Patras K, Vasiliadis JS, Giakas G, Georgoulis AD. Excessive tibial rotation during high-demand activities is not restrored by anterior cruciate ligament reconstruction. J Arthrosc 2005;21:1323–1329.CrossRefGoogle Scholar
  39. 39.
    Tashman S, Collon D, Anderson K, Kolowich P, Anderst W. Abnormal rotational knee motion during running after anterior cruciate ligment reconstruction. Am J Sports Med 2004;32: 975–983.PubMedCrossRefGoogle Scholar
  40. 40.
    Muneta T, Koga H, Morito T, Yagishita K, Sekiya I. A retrospective study of the midterm outcome of two-bundle anterior cruciate ligament reconstruction using quadrupled semitendinosus tendon in comparison with one-bundle reconstruction. J Arthrosc 2006;22:252–258.CrossRefGoogle Scholar
  41. 41.
    Steiner M, Koskinen S, Winalski C, et al. Dynamic lateral patellar tilt in the ACL deficient knee. Am J Sports Med 2001;29: 593–599.PubMedGoogle Scholar
  42. 42.
    Hsieh Y-F, Draganich L, Ho S, Reider B. The effects of removal and reconstruction of the anterior cruciate ligament on the contact characteristics of the patellofemoral joint. Am J Sports Med 2002;30:121–127.PubMedGoogle Scholar
  43. 43.
    DeMorat G, Weinhold P, Blackburn T, Chudik S, Garrett W. Aggressive quadriceps loading can induce noncontact anterior cruciate ligament injury. Am J Sports Med 2004;32:477–483.PubMedCrossRefGoogle Scholar
  44. 44.
    Adler G, Hoekman R, Beach D. Drop leg Lachman test: a new test of anterior knee laxity. Am J Sports Med 1995;23:320–323.PubMedCrossRefGoogle Scholar
  45. 45.
    Costa-Paz M, Muscolo D, Ayerza M, Makino A, Aponte-Tinao L. Magnetic resonance imaging follow-up study of bone bruises associated with anterior cruciate ligament ruptures. Arthroscopy 2001;17:445–449.PubMedCrossRefGoogle Scholar
  46. 46.
    Nakamae A, Engebretsen L, Bahr R, Krosshaug T, Ochi M. Natural history of bone bruises after acute knee injury: clinical outcome and histopathological findings. Knee Surg Sports Traumatol Sports 2006;14:1252–1258.CrossRefGoogle Scholar
  47. 47.
    Graf B, Cook D, De Smet A, Keene JS. “Bone bruises" on magnetic resonance imaging evaluation of anterior cruciate ligament injuries. Am J Sports Med 1993;21:220–223.PubMedCrossRefGoogle Scholar
  48. 48.
    Johnson D, Urban W, Caborn D, Vanarthos WJ, Carlson CS. Articular cartilage changes seen with magnetic resonance imaging-detected bone bruises associated with acute anterior cruciate ligament rupture. Am J Sports Med 1998;26:409–414.PubMedGoogle Scholar
  49. 49.
    Daniel D, Stone M, Dobson B, Fithian DC, Rossman DJ, Kaufman KR. Fate of the ACL-injured patient: a prospective outcome study. Am J Sports Med 1994;22:632–644.PubMedCrossRefGoogle Scholar
  50. 50.
    Fitzgibbons R, Shelbourne KD. “Aggressive" nontreatment of lateral meniscal tears seen during anterior cruciate ligament reconstruction. Am J Sports Med 1995;23:156–159.PubMedCrossRefGoogle Scholar
  51. 51.
    Beynnon B, Johnson R, Abate J, Fleming BC, Nichols CE. Treatment of anterior cruciate ligament injuries, Part 2. Am J Sports Med 2005;33:1751–1767.PubMedCrossRefGoogle Scholar
  52. 52.
    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;32: 629–634.PubMedCrossRefGoogle Scholar
  53. 53.
    Fithian D, Paxton E, Stone M, 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;33:335–346.PubMedCrossRefGoogle Scholar
  54. 54.
    Feagin JA Jr, Curl WW. Isolated tear of the anterior cruciate ligament: 5-year follow-up study. Am J Sports Med 1976;4:95–100.PubMedCrossRefGoogle Scholar
  55. 55.
    Shelton W, Barrett G, Dukes A. Early season anterior cruciate ligament tears: a treatment dilemma. Am J Sports Med 1997;25: 656–658.PubMedCrossRefGoogle Scholar
  56. 56.
    Wojtys E, Huston L. Neuromuscular performance in normal and anterior cruciate ligament-deficient lower extremities. Am J Sports Med 1994;22:89–104.PubMedCrossRefGoogle Scholar
  57. 57.
    Shelbourne KD, Wilckens JH, Mollasbashy A, DeCarlo M. Arthrofibrosis in acute anterior cruciate ligament reconstruction. Am J Sports Med 1991;19:332–336.PubMedCrossRefGoogle Scholar
  58. 58.
    Hey Groves WE. The crucial ligaments of the knee joint: their function, rupture, and the operative treatment of the same. Br J Surg 1920;7:505–515.CrossRefGoogle Scholar
  59. 59.
    Pinczewski P, Lyman J, Salmon L, 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;35:564–574.PubMedCrossRefGoogle Scholar
  60. 60.
    Armour T, Forwell L, Litchfield R, Kirkley A, Amendola N, Fowler PJ. Isokinetic evaluation of internal/external tibial rotation strength after the use of hamstring tendons for anterior cruciate ligament reconstruction. Am J Sports Med 2004;32:1639–1643.PubMedCrossRefGoogle Scholar
  61. 61.
    Adachi N, Ochi M, Uchio Y, Iwasa J, Kuriwaka M, Ito Y. Reconstruction of the anterior cruciate ligament single versus double bundle multistranded hamstring tendons. J Bone Joint Surg 2004;86B:515–520.Google Scholar
  62. 62.
    Hamner D, Brown C, Steiner M, Hecker AT, Hayes WC. Hamstring tendon grafts for reconstruction of the anterior cruciate liagament: biomechanical evaluation of multiple strands and tensioning techniques. J Bone Joint Surg 1999;81A:549–557.Google Scholar
  63. 63.
    Tuman J, Diduch D, Rubino L, Baumfeld JA, Nguyen HS, Hart JM. Predictors for hamstring graft diameter in anterior cruciate ligament reconstruction. Am J Sports Med 2007; Nov; 35(11): 1945–9.Google Scholar
  64. 64.
    Adriani E, Mariani PP, Maresca G, Santori N. Healing of the patellar tendon after harvesting of its mid-third for anterior cruciate ligament reconstruction and evolution of the unclosed donor site defect. Knee Surg Sports Traumatol Arthrosc 1995;3:138–143.PubMedCrossRefGoogle Scholar
  65. 65.
    Shelbourne KD, Urch SE. Primary anterior cruciate ligament reconstruction using the contralateral autogenous patellar tendon. Am J Sports Med 2000;28:651–658.PubMedGoogle Scholar
  66. 66.
    Adams D, Mazzocca A, Fulkerson J. Residual strength of the quadriceps versus patellar tendon after harvesting a central free tendon graft. J Arthrosc 2006;22:76–79.CrossRefGoogle Scholar
  67. 67.
    Curran A, Adams D, Gill J, Steiner M, Scheller A. The biomechanical effects of low-dose irradiation on bone-patellar tendon-bone allografts. Am J Sports Med 2004 July-Aug; 32(5):1131–1135.Google Scholar
  68. 68.
    Daniel D, Lumkong G, Stone M, Pedowitz, R. Effects of tourniquet use in anterior cruciate ligament reconstruction. J Arthrosc 1995;11:307–311.CrossRefGoogle Scholar
  69. 69.
    Muneta T, Yamamoto H, Ishibashi R, Asahina S, Murakami S, Furuya K. The effects of tibial tunnel placement and roofplasty on reconstructed anterior cruciate ligament knees. J Arthrosc 1995;11:57–62.CrossRefGoogle Scholar
  70. 70.
    Tanzer M, Lenczner E. The relationship of intercondylar notch size and content to notchplasty requirement in anterior cruciate ligament surgery. J Arthrosc 1990;6:89–93.CrossRefGoogle Scholar
  71. 71.
    Cooper DE, Small J, Urrea L. Factors affecting graft excursion patterns in endoscopic anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 1998;6(Suppl 1):S20–S24.PubMedCrossRefGoogle Scholar
  72. 72.
    Hefzy MS, Grood ES, Noyes FR. Factors affecting the region of most isometric femoral attachments. part II the anterior cruciate ligament. Am J Sports Med 1989;17:208–216.PubMedCrossRefGoogle Scholar
  73. 73.
    Howell SM, Deutsch ML. Comparison of endoscopic and two-incision techniques for reconstructing a torn anterior cruciate ligament using hamstring tendons. J Arthrosc 1999;15:594–606.CrossRefGoogle Scholar
  74. 74.
    Jackson DW, Gasser SI. Tibial tunnel placement in ACL reconstruction. J Arthrosc 1994;10:124–131.CrossRefGoogle Scholar
  75. 75.
    Panni AS, Milano G, Tartarone M, Demontis A, Fabbriciani C. Clinical radiographic results of ACL reconstruction: a 5- to 7- year follow-up study of outside-in versus inside-out reconstruction techniques. Knee Surg Sports Traumatol Arthrosc 2001;9: 77–85.PubMedCrossRefGoogle Scholar
  76. 76.
    Paessler H, Rossis J, Mastrokalos D, Kotsovolos I. Anteromedial vs. transtibial technique for correct femoral tunnel placement during arthroscopic ACL reconstruction with hamstrings: an in vivo study. J Bone Joint Surg Br. 2004; 86(Suppl III):234.Google Scholar
  77. 77.
    Arnold MP, Kooloos J, van Kampen A. Single-incision technique misses the anatomical femoral anterior cruciate ligament insertion: a cadaver study. Knee Surg Sports Traumatol Arthrosc 2001;9:194–199.PubMedGoogle Scholar
  78. 78.
    Romano VM, Graf BK, Keene JS, Lange RH. Anterior cruciate ligament reconstruction the effect of tibial tunnel placment on range of motion. Am J Sports Med 1993;21:415–418.PubMedCrossRefGoogle Scholar
  79. 79.
    Hantes M, Zachos V, Basdekis G, Zibis A, Dailiana Z, Malizos K. Differences in graft orientation using the transtibial and anteromedial portal technique in ACL reconstruction: an MRI prospective study. J Bone Joint Surg Br. 2006; 88(Suppl I):93.Google Scholar
  80. 80.
    Chhabra A, Diduch DR, Blessey PB, Miller MD. Recreating an acceptable angle of the tibial tunnel in the coronal plane in anterior cruciate ligament reconstruction using external landmarks. J Arthrosc 2004;20:328–330.CrossRefGoogle Scholar
  81. 81.
    Miller M, Hinkin D. The “N + 7 Rule” for tibial tunnel placement in endoscopic anterior cruciate ligament reconstruction. J Arthrosc 1996;12:124–126.CrossRefGoogle Scholar
  82. 82.
    Burks R, Friederichs M, Fink B, Luker MG, West HS, Gries PE. Treatment of postoperative anterior cruciate ligament infections with graft removal and early reimplantation. Am J Sports Med 2003;31:414–418.PubMedGoogle Scholar
  83. 83.
    Sommer C, Friederich NF, Müller W. Improperly placed anterior cruciate ligament grafts: correlation between radiological parameters and clinical results. Knee Surg Sports Traumatol Arthrosc 2000;8:207–213.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  • Mark E. Steiner
    • 1
  1. 1.Orthopaedic Sports Medicine, Department of Orthopaedic SurgeryNew England Baptist Hospital, Harvard Medical School, Tufts Medical SchoolBoston

Personalised recommendations