March 14, 2019
10 min read

One approach does not fit all in ACL reconstruction

Age, activity level, type of sport should be matched to an appropriate ACL injury treatment.

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The ACL is reportedly one of the most commonly injured knee ligaments among professional- and recreational-level athletes, with a high risk for primary and secondary ACL injuries found with participation in pivoting and cutting sports, such as football, basketball, skiing and soccer.

“Multiple investigators have demonstrated second ACL injury rates [in adolescent athletes] ranging from 25% to 40%, which is certainly unacceptable. The causes are multifactorial and have been identified as modifiable or extrinsic and non-modifiable or intrinsic risk factors,” Frank A. Cordasco, MD, MS, professor of orthopedic surgery at Weill Cornell Medical College and attending orthopedic surgeon in the sports medicine and shoulder service and senior scientist in the research division at Hospital for Special Surgery, told Orthopedics Today. “The impact is significant given that these are structural knee injuries in adolescent athletes who have their whole lives ahead of them.”

As research of the ACL anatomy, physiology, histology, structural properties and function continues to identify appropriate treatment methods, orthopedic surgeons have found many patient and injury factors play a role in treatment choice and there is no “one-size-fits-all” solution.

Volker Musahl, MD
Volker Musahl, MD, said to personalize the care of a patient with an ACL tear requires an in-depth understanding of the ACL and the many factors that play a role in its injury.

Source: Volker Musahl, MD

“Specifically to personalizing their care, I think it is important to understand with the ACL there are so many factors that play a role that all need to be taken into account that already make every ACL different,” Volker Musahl, MD, chief of the division of sports medicine at University of Pittsburgh Medical Center and Freddie Fu Sports Complex, said. “You may tear your [ACL] and I tear mine, and we are looking at a different spectrum of injury.”

According to Darren L. Johnson, MD, director and chief sports medicine and professor of orthopedic surgery at University of Kentucky, choosing the most appropriate treatment for ACL injuries begins with looking at the patient’s age, activity level, knee laxity and associated injuries.

“Whether they be skeletally immature, whether they are a high school or collegiate athlete, whether they are a weekend warrior or whether they were skiing for the first time and they did something crazy and tore their ACL and they are never going to go skiing again, all of those variables are important,” Johnson, who is an Orthopedics Today Editorial Board Member, said.


Opt for nonoperative treatment

Darren L. Johnson, MD
Darren L. Johnson

By collecting patient and injury data, Matthew J. Bollier, MD, Congdon Professor in orthopedic surgery and sports medicine fellowship director at University of Iowa, said a generic algorithm can help determine timing of the surgery, the graft to use and how to perform the surgery.

An important factor when deciding the most appropriate treatment is knowing the patient’s postoperative goals, Johnson said.

“All things being equal, the most important thing is not necessarily how the patient got injured, but what do they want to do later on?” he said.

Patients with an isolated ACL tear who are sedentary and have a stable knee may benefit from nonoperative treatment, sources noted.

“There are a few people who can live nicely without their ACL,” John C. Richmond, MD, professor of orthopedic surgery at Tufts University School of Medicine, told Orthopedics Today. “It is trying to pick off first those people who do not do significant high-risk sports and are somewhat risk adverse as far as potentially going through surgery. Those I split off into at least starting the nonoperative treatment and follow them to see if they have symptoms that would warrant surgery.”

Musahl said published research has shown that “nonoperative treatment may be as good as operative treatment” as long as patients are comfortable with dropping down, on average, one level on the Tegner Activity Scale.

Furthermore, these patients may have to accept that they may eventually tear their meniscus and/or cartilage, which will make them more prone to post-traumatic osteoarthritis, following nonoperative treatment, Musahl said.

When surgery is needed

Although skeletally immature athletes were historically treated nonoperatively with bracing and avoidance of competitive sports until they reached a level of skeletal maturity at which time they could safely undergo an adult-type ACL reconstruction, Cordasco said that approach “failed at an unacceptable high rate and left many pediatric and adolescent athletes with irreparable meniscus tears or significant articular cartilage damage that changed the natural history of the knee.”

Research published in the last 15 years demonstrates that ACL reconstruction is the “preferred management to restore function of the knee in young athletes who do not wish to modify their activities and also provide them with an opportunity to join their peers and continue sports participation at a competitive level,” he said.

“Although nonoperative treatment is an option in the pediatric and adolescent athlete, it requires the athlete and her or his family to discontinue the majority of organized sports that involve lateral movements in competitive field and court athletic activities,” Cordasco said.


Surgery is also indicated in young athletes with ACL tears who present with associated pathology, such as significant meniscus tears or articular cartilage injuries, Cordasco noted.

Frank A. Cordasco, MD, MS
Frank A. Cordasco

Choose the appropriate graft

A patient’s age, activity level and the type of sport they participate in all play a role in the type of graft that is used during surgery, sources said.

“A sprinter will be upset if you take their hamstrings. A wrestler would be upset when the patellar tendon is harvested and they have anterior knee pain, so those things need to be taken into account,” Musahl said.

Because allografts have a higher re-injury rate when used for ACL reconstruction in pediatric and adolescent athletes, these grafts are generally not indicated for this cohort of young patients, Cordasco said.

“We know re-rupture rate is higher for younger, active patients with an allograft, so we want to make sure we optimize the outcome and function after ACL reconstruction,” Bollier said. “Patients who are less active or older ... do not have a higher re-rupture rate with allograft and they may benefit from some of the advantages of using allograft without increasing the re-rupture rate.”

Cordasco noted that published research has shown bone-patellar tendon-bone (BPTB) autograft to be a compelling choice for skeletally mature high school and college athletes under the age of 25 with closed growth plates.

Richmond cautioned against BPTB use in patients with open growth plates because it may impair the patient’s growth due to the bone that bridges the growth plate. Prior to the growth plate closing, he said soft tissue grafts and certain placement techniques can be advantageous in these patients.

“Once their growth plates are closed, the knee reconstructive technique ... dramatically favors the autograft over the allograft and bone-tendon-bone autograft tends to have the best results and allows the earliest return to sport,” Richmond said.

In older patients, BPTB autograft may increase anterior knee pain and are not ideal for patients who kneel on a daily basis, he said.

For people who work on their knees, such as plumbers or electricians, or pray on their knees frequently, patellar tendon grafts are an unattractive graft. “They often times will lead to permanent sensitivity from the graft donor site,” Richmond said.

Quadriceps tendon autograft has shown positive outcomes among young active patients. Surgeons can individualize its size to the patient’s needs, Musahl said.

“If you measure the ACL that is small, you can take a nice partial thickness quadriceps graft and help that patient really well with it,” Musahl told Orthopedics Today. “If you measure that ACL to be large, you can take a full-thickness quadriceps graft.”


Questions about hamstring grafts

Surgeons may also use hamstring autografts in skeletally mature young athletes younger than 25 years, but Cordasco noted there is a higher failure rate when hamstring autografts are used in young active patients, according to published results. In the skeletally immature athlete, BPTB grafts are not indicated because of the potential for growth disturbance. In skeletally immature athletes, hamstring autografts have traditionally been chosen, although quadriceps autografts have recently been used with more frequency.

John C. Richmond, MD
John C. Richmond

Cordasco and colleague Daniel W. Green, MD, MS, reviewed rates of revision ACL reconstruction and return to sport in 332 patients who participated in travel-, club- or school-level competition to evaluate the clinical outcomes of three cohorts of primary ACL reconstruction in pediatric and adolescent athletes younger than 20 years old based on skeletal age, school grade distribution and ACL reconstruction technique. The focus was on return to sport and incidence of second surgery with a minimum 2-year follow-up.

“We defined return to sport as playing one full season in the same sport in which they were injured,” Cordasco said. “To meet the criteria for successful return to sport they had to actually play a full season within that sport.”

The patients were categorized into three groups based upon skeletal age. Group 1 included prepubescent athletes with 3 to 6 years of remaining growth who underwent an all-inside, all-epiphyseal reconstruction with a hamstring autograft; group 2 included young adolescent athletes with 2 to 3 years of remaining growth who underwent an all-inside partial or complete transphyseal reconstruction with a hamstring autograft. The hamstring autografts in athletes in groups 1 and 2 were secured using suspensory fixation and an adjustable loop construct. Group 3 included skeletally mature adolescent athletes who underwent reconstruction with a BPTB autograft secured with metal interference screws. School grades were seventh grade or under for group 1; eighth and ninth grade for group 2 and 10th grade to college freshman for group 3.

“The revision ACL reconstruction rate in group 1 was 6% and in group 3 was 6%.

Cordasco said the eighth- and ninth-grade athletes in group 2 had an overall failure rate of 20%. Patients in group 2 had a statistically significant lower return-to-sport rate at 85% vs. 100% in group 1 and 94% in group 3, as well as a lower return-to-sport rate at the previous level at 74% vs. 92% in group 1 and 80% in group 3.

“Regarding contralateral ACL reconstruction, we found a 2.8 odds ratio for female compared to male [patients], and that was statistically significant,” Cordasco said.


Cordasco and colleagues believe the poor outcomes experienced by patients in group 2 are multifactorial, which may be due to the level of competition as athletes are transitioning between middle school and high school.

“The return-to-sport process averaged 12 months and included a postoperative rehabilitation and qualitative movement assessment program. By definition, these eighth-grade and ninth-grade athletes missed a year of developmental and sports-specific athletic activity and then joined a highly competitive cohort of skeletally mature high school athletes who had not lost a year of development. Although hamstring autograft in group 1 yielded excellent outcomes, in group 2 athletes it may not be up to the task,” he noted.

Matthew J. Bollier, MD
Matthew J. Bollier

Therefore, the investigators have used soft-tissue quadriceps autograft instead of hamstring autograft in this cohort of athletes for the last 3 years, and they are analyzing those results.

Delay surgery, regain range of motion

Despite reports in the media of high-performance athletes who undergo ACL reconstruction shortly after injury, Johnson noted “few ACL-injured knees are emergent or urgent.”

In most cases, sources said it may be better to delay surgery until the patient has good range of motion, with Bollier noting “range of motion before the ACL surgery is going to be a big predictor of how the range of motion is after the surgery.”

“Those high-performance athletes from college to professional have unlimited access to athletic training and physical therapy so they can go into surgery relatively early on after tearing their ACL and not have to worry about stiffness and getting their motion back,” Richmond said. “Whereas for the vast majority of high school and recreational athletes, it is best to delay surgery for several weeks to get their motion back before going into surgery.”

Patients who present with a medial collateral ligament (MCL) injury in addition to ACL injury may benefit from waiting until the MCL heals before undergoing ACL surgery, Bollier said.

In this situation, “I would also be less likely to use a hamstring graft because that can decrease stability on the medial part of the knee and more likely to use a bone-patellar-bone graft,” Bollier told Orthopedics Today.

Challenges in the OR

Musahl noted it is always important to perform a good patient history and physical and to collect appropriate imaging to avoid any surprises in the OR.

According to Richmond, graft choice would not typically change intraoperatively unless a patient has smaller hamstrings.

To get around small-diameter hamstrings, “instead of just taking the semitendinosus and the gracilis and making a four-strand graft, you can end up with a five- or six-strand graft,” Richmond said. “More strands give more bulk and will make up for the small amount of collagen that you thought you were going to get from the hamstrings,” he said.


Bollier said it is always good to have a backup plan.

“If we were doing an osteotomy to correct alignment, meniscal transplant and ACL reconstruction in the same case, I would have a plan going into surgery on the order of steps and the plan for graft choice,” Bollier said. “During surgery, we might modify our steps depending on the findings or how the case is going.”

Overall, Richmond believes individualized patient treatment after ACL injury is the best way to achieve satisfactory outcomes, and he advises orthopedic surgeons to be familiar with various management approaches.

“Every orthopedic surgeon who does a volume of ACL reconstructions needs to be familiar with multiple techniques, whether it be bone-tendon-bone autografts, hamstring autografts, quadriceps tendon autografts and allografts, and have a good skillset for doing all of them because one graft type does not fit all,” Richmond said. “I think demand matching is the way to get the most satisfactory result, giving stability to the patient’s knee while subjecting them to the least amount of risk.” – by Casey Tingle

ACL reconstruction graphic

Disclosures: Cordasco reports he receives royalties from and is a consultant for Arthrex and receives publishing royalties, financial or material support from Saunders/Mosby-Elsevier and Wolters Kluwer Health - Lippincott Williams & Wilkins. Musahl reports he is a consultant for Smith & Nephew and receives royalties from Springer and Knee Surgery, Sports Traumatology, Arthroscopy. Bollier, Johnson and Richmond report no relevant financial disclosures.

Click here to read the POINTCOUNTER, “What ACL graft is best for older active patients who are uncomfortable with receiving allograft tissue?