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Case Study

AAOS Clinical Practice Guideline

Management of Anterior Cruciate Ligament Injuries

Evidence-Based Guideline

Carey, James L. MD, MPH; Shea, Kevin G. MD

Author Information
Journal of the American Academy of Orthopaedic Surgeons: May 2015 - Volume 23 - Issue 5 - p e6-e8
doi: 10.5435/JAAOS-D-15-00095
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The AAOS Clinical Practice Guideline Management of Anterior Cruciate Ligament Injuries is a summary of the available high-quality research designed to help guide the clinician on the evaluation and management of these injuries. The following case presentation is designed to highlight how the guideline supports the clinician throughout the care of a patient.

History

The patient is a 24-year-old male finance specialist who sustained a right knee injury while playing basketball approximately 10 days ago. The patient described the mechanism of injury as twisting on a planted foot. He felt a pop at the time of injury. At that point, the knee pain localized primarily laterally. The pain was associated with immediate swelling.

Physical Examination

The patient ambulates with minimal antalgia. The skin about the knee is intact. Right knee range of motion is zero to 110°. There is no point tenderness. There is a moderate effusion. Lachman testing is positive. Posterior drawer testing is negative. The application of a varus stress to the knee reproduces no pain and no appreciable laxity. Similarly, the application of a valgus stress to the knee reproduces no pain and no appreciable laxity.

The recommendation in the AAOS Clinical Practice Guideline is that strong evidence supports that the practitioner obtain a relevant history and perform a musculoskeletal examination of the lower extremities because these are effective diagnostic tools for anterior cruciate ligament (ACL) injury.

Imaging

Radiographs of the right knee are reviewed and are normal (Figure 1).

Figure 1
Figure 1:
A PA weight-bearing radiograph made with the knee in 45° of flexion was reviewed and was normal. This radiograph (along with lateral and axial patellar radiographs) indicates no evidence of fracture or dislocation requiring emergent care.

The recommendation in the AAOS Clinical Practice Guideline is that there is consensus of the work group that in the initial evaluation of a person with a knee injury and associated symptoms (giving way, pain, locking, catching) and signs (effusion, inability to bear weight, bone tenderness, loss of motion, and/or pathological laxity) that the practitioner obtain AP and lateral knee radiographs to identify fractures or dislocations requiring emergent care.

An MRI of the right knee from November 12, 2014, is reviewed, which demonstrates an ACL rupture (Figure 2, A) with archetypal bone bruise pattern of the lateral femoral condyle and lateral tibial plateau (Figure 2, B).

Figure 2
Figure 2:
Sagittal T2-weighted views selected from the right knee MRI demonstrate an anterior cruciate ligament rupture (A) with the archetypal bone bruise pattern of the lateral femoral condyle and lateral tibial plateau (B).

The recommendation in the AAOS Clinical Practice Guideline is that strong evidence supports that the MRI can provide confirmation of ACL injury and assist in identifying concomitant knee pathology, such as other ligament, meniscal, or articular cartilage injury.

Shared Decision Making

Consequently, the risks, benefits, and alternatives to surgical arthroscopy of the right knee with ACL reconstruction are reviewed with the patient. Specifically, the surgeon reviews the ACL reconstruction postoperative protocol as well as the advantages and disadvantages of ACL reconstruction with autograft and with allograft tissue. The patient clearly communicates that these issues are understood. The patient wishes to proceed with a treatment course using bone–patellar tendon–bone autograft.

The recommendation in the AAOS Clinical Practice Guideline is that moderate evidence supports performing surgical reconstruction in active young adult patients (those aged 18 to 35 years) with an ACL tear. Further, another recommendation in the AAOS Clinical Practice Guideline is that moderate evidence supports performing reconstruction within 5 months of injury to protect the articular cartilage and menisci.

Treatment

In the interim until surgery, the patient is advised to continue ambulation with crutches until he can walk without a limp. The patient is advised to apply ice to the knee twice daily. He is provided with a prescription for formal rehabilitation so that he can work on range-of-motion exercises, gait training, and quadriceps strengthening according to the ACL reconstruction prehabilitation protocol.

Subsequently, about 3 weeks following injury, the patient undergoes surgical arthroscopy of the right knee with ACL reconstruction using bone–patellar tendon–bone autograft. The ACL is found to be ruptured (Figure 3, A). A targeting guide is oriented carefully (Figure 3, B), so that the aperture of the femoral tunnel is located at the anatomic attachment site of the ACL (Figure 3, C). The tibial tunnel is similarly established (Figure 3, D).

Figure 3
Figure 3:
A, Arthroscopic evaluation confirms that the anterior cruciate ligament rupture (ACL) is ruptured. Additional arthroscopic images illustrate the careful positioning of the targeting guide (B), so that the aperture of the femoral tunnel is located at the anatomic attachment site of the ACL (C). D, A subsequent arthroscopic image shows that the tibial tunnel is similarly established.

The bone–patellar tendon–bone autograft is harvested from the central one third of the patellar tendon (Figure 4, A). This autograft tissue is shuttled into the knee (Figure 4, B) and secured with interference screws.

Figure 4
Figure 4:
A, An intraoperative photograph of the bone–patellar tendon–bone autograft that was harvested from the central one third of the patellar tendon. B, A final arthroscopic image demonstrates the position and orientation of the reconstructed anterior cruciate ligament rupture, after this autograft tissue was shuttled into the knee.

The recommendation in the AAOS Clinical Practice Guideline is that strong evidence supports that in patients undergoing ACL reconstructions, the practitioner should use either autograft or appropriately processed allograft tissue because the measured outcomes are similar, although these results may not be generalizable to all allografts or all patients, such as young patients or highly active patients.

Postoperative Protocol

A knee immobilizer is used for the first 24 hours following surgery because the patient underwent a femoral nerve block. Subsequently, no immobilizer or brace is used.

The patient attends physical therapy for several months postoperatively. Crutches are discontinued when the patient demonstrates a normal gait pattern and the ability to use stairs safely without pain. He works on range of motion and strengthening as well as neuromuscular retraining on a graduated protocol, which is individualized to meet patient-specific demands. Progression is based on achieving functional criteria rather than only measuring elapsed time since surgery.

The recommendation in the AAOS Clinical Practice Guideline is that moderate evidence does not support the routine use of functional knee bracing after isolated ACL reconstruction because there is no demonstrated efficacy.

Ultimately, the patient has no functional complaints and no pain. He reports confidence when running, cutting, and jumping at full speed. He resumes all activities without limitation.

Summary

The AAOS Clinical Practice Guideline on ACL injuries presents several recommendations that can help guide the evaluation and treat ment of these injuries. This guideline also outlines areas for further investigation into this condition.

© 2015 by American Academy of Orthopaedic Surgeons