Clinical Pearls & Morning Reports
Published June 12, 2019
Patients with anterior cruciate ligament (ACL) tears typically present with acute injury, sometimes with an associated “pop,” a sensation of tearing, the immediate onset of effusion, or any combination thereof. Read the latest Clinical Practice Article here.
Q: Who is at risk for ACL tear?
A: Young persons participating at high levels of competition are at particular risk of ACL tear; 40% of injuries are attributed to noncontact mechanisms involving pivoting, cutting, or jumping. ACL injuries are associated with several modifiable and nonmodifiable risk factors, including female sex (with risk three times as high as that associated with male sex), young age (with a peak at 16 to 18 years), and earlier, more intense, and more frequent participation in sports.
Q: What additional knee injuries often complicate an ACL tear?
A: ACL injuries are often complicated by concomitant injury of the medial collateral ligament (19 to 38%) and lateral (20 to 45%) or medial (0 to 28%) meniscal tears.
A: Randomized trials of primary ACL reconstruction have shown that autografts of the hamstrings (the tendons of the semitendinosus and gracilis muscles) and the patellar tendon have similar results, patient-reported outcomes, and incidences of postoperative osteoarthritis on radiography. The quadriceps tendon is another potential source for grafting and is associated with less damage at the site of tendon harvest than grafts of the patellar tendon and with similar patient-reported outcomes. As compared with autografts, allografts have higher costs and higher rates of graft failure and repeat rupture of the ACL, particularly in young athletes. As such, autografts remain the preferred source.
A: Whatever the approach to therapy, the patient’s activity level may decline after an ACL tear. The athlete’s goal after ACL injury is to return to the same level of play achieved before surgery. Data suggest that only 40 to 55% of patients return to the same level of activity or higher after undergoing ACL surgery. According to the findings in one randomized trial, the activity level on return to play was on average two Tegner levels (scores range from 0 to 10, with a score of 0 indicating sick leave or disability, a score of 5 indicating participation in recreational sports, and a score of 10 indicating participation in competitive sports on a professional level) below that before injury, independent of treatment choice. However, in a study assessing return to play among European professional soccer players after ACL reconstruction (who presumably had high motivation to return to play and excellent resources for rehabilitation), the rate of return to play was 93%, with 65% of players returning at the same level reported before injury. Although data from randomized trials to guide the timing of return to sports are lacking, it is generally accepted that return should be delayed for a minimum of 9 months from surgery to optimize biologic graft incorporation and clinical outcomes.