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American Academy of Orthopaedic SurgeonsOrthopaedic Surgery2022advanced

Management of Anterior Cruciate Ligament Injuries

Published by American Academy of Orthopaedic Surgeons · Level of Evidence (High, Moderate, Low, Very Low, Consensus) and Strength of Recommendation (Strong, Moderate, Limited, Consensus)

15Recommendations
342References
2Tables
1Figures
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Summary

AI-generated

This clinical practice guideline evaluates the management of anterior cruciate ligament injuries based on a systematic review of published studies in skeletally mature and immature patients, offering practice recommendations while highlighting gaps in the literature.

anterior cruciate ligament injuryACL tearAAOSorthopaedic surgeryguidelinesrecommendationsknee injuryskeletally immature

Key Recommendations

HISTORY AND PHYSICAL

  • 1

    A relevant history should be obtained, and a focused musculoskeletal exam of the lower extremities should be performed when assessing for an ACL injury.

    StrongEvidence: HighRecommendation

SURGICAL TIMING

  • 2

    When surgical treatment is indicated for an acute isolated ACL tear, early reconstruction is preferred because the risk of additional cartilage and meniscal injury starts to increase within 3 months.

    StrongEvidence: HighRecommendation

SINGLE OR DOUBLE BUNDLE ACL RECONSTRUCTION

  • 3

    In patients undergoing intraarticular ACL reconstruction single or double bundle techniques can be considered because measured outcomes are similar.

    StrongEvidence: HighRecommendation

AUTOGRAFT VS. ALLOGRAFT

  • 4

    When performing an ACL reconstruction, surgeons should consider autograft over allograft to improve patient outcomes and decrease ACL graft failure rate, particularly in young and/or active patients.

    StrongEvidence: HighRecommendation

AUTOGRAFT SOURCE

  • 5

    When performing an ACL reconstruction with autograft for skeletally mature patients, surgeons may favor BTB to reduce the risk of graft failure or infection, or hamstring to reduce the risk of anterior or kneeling pain.

    ModerateEvidence: HighRecommendation

ACL TRAINING PROGRAMS

  • 6

    Training programs designed to prevent injury can be used to reduce the risk of primary ACL injuries in athletes participating in high-risk sports.

    ModerateEvidence: ModerateRecommendation

ANTEROLATERAL LIGAMENT / LATERAL EXTRAARTICULAR TENODESIS

  • 7

    ALL Reconstruction / LET could be considered when performing hamstring autograft reconstruction in select patients to reduce graft failure and improve short-term function, although long-term outcomes are yet unclear.

    ModerateEvidence: HighRecommendation

REPAIR VS. RECONSTRUCTION

  • 8

    ACL tears indicated for surgery should be treated with ACL reconstruction rather than repair because of the lower risk of revision surgery.

    StrongEvidence: HighRecommendation

ASPIRATION OF THE KNEE

  • 9

    In the absence of reliable evidence, it is the opinion of the workgroup that physicians may consider aspirating painful, tense effusions after knee injury.

    ConsensusEvidence: ConsensusOption

ACL SURGICAL RECONSTRUCTION

  • 10

    ACL reconstruction can be considered in order to lower the risk of future meniscus pathology or procedures, particularly in younger and/or more active patients. ACL reconstruction may be considered to improve long term pain and function.

    LimitedEvidence: LowOption

MENISCAL REPAIR

  • 11

    In patients with ACL tear and meniscal tear, meniscal preservation should be considered to optimize joint health and function.

    LimitedEvidence: LowOption

COMBINED ACL / MCL TEAR

  • 12

    In patients with combined ACL and MCL tears, non-operative treatment of the MCL injury results in good patient outcomes, although operative treatment of the MCL may be considered in select cases.

    LimitedEvidence: ModerateOption

PROPHYLACTIC KNEE BRACING

  • 13

    Prophylactic bracing is not a preferred option to prevent ACL injury.

    LimitedEvidence: LowOption

RETURN TO SPORT

  • 14

    Functional evaluation, such as the hop test, may be considered as one factor to determine return to sport after ACL reconstruction.

    LimitedEvidence: LowOption

RETURN TO ACTIVITY FUNCTIONAL BRACING

  • 15

    Functional knee braces are not recommended for routine use in patients who have received isolated primary ACL reconstruction, as they confer no clinical benefit.

    LimitedEvidence: HighOption

Scope & Objectives

Clinical Topic

Anterior Cruciate Ligament Injuries

Objectives

To help improve treatment based on the current best evidence.

Target Patient Population

Skeletally immature and skeletally mature patients who have been diagnosed with an ACL injury of the knee.

Diagnostic Criteria

History of mechanism/date of injury, popping sensation, ability to bear weight. Physical exam including neurovascular exam, assessment of varus/valgus laxity at 0 and 30 degrees flexion, dial testing, Lachman's, anterior drawer, pivot shift, and active buckling sign tests.

Target Providers

Orthopaedic surgeonsPhysiciansPhysical therapistsOccupational therapistsNurse practitionersAthletic trainersEmergency room physiciansPrimary care physiciansPhysiatristsPhysician assistants

Patient Criteria & Setting

Therapeutic Area

Musculoskeletal Care

Guideline Scope

DiagnosisTreatmentPrevention

Inclusion Criteria

  • Study must be of an Anterior Cruciate Ligament injury or prevention thereof
  • Article must be a full article report of a clinical study
  • Study must appear in a peer-reviewed publication
  • Study should have 10 or more patients per group
  • Study must be of humans
  • Study must be published in English

Exclusion Criteria

  • Retrospective non-comparative case series, medical records review, meeting abstracts, historical articles, editorials, letters, and commentaries
  • Confounded studies
  • Case series studies that have non-consecutive enrollment of patients
  • All studies of 'Very Weak' strength of evidence
  • All studies evaluated as Level V
  • In vitro studies
  • Biomechanical studies
  • Cadaver studies

Care Settings

Various practice settings

Special Populations

Skeletally mature patientsSkeletally immature patientsYoung and/or active patientsFemale athletes

Evidence Grading

System: Level of Evidence (High, Moderate, Low, Very Low, Consensus) and Strength of Recommendation (Strong, Moderate, Limited, Consensus)

Evidence Levels

LowEvidence from two or more 'Low' quality studies with consistent findings or evidence from a single 'Moderate' quality study recommending for or against the intervention.
HighEvidence from two or more 'High' quality studies with consistent findings recommending for or against the intervention.
ModerateEvidence from two or more 'Moderate' quality studies with consistent findings or evidence from a single 'High' quality study recommending for or against the intervention.
ConsensusEvidence from one 'Low' quality study, no supporting evidence, or Rec is downgraded using the EtD framework. Work group is making a statement based on clinical opinion.

Recommendation Strength

StrongEvidence from two or more 'High' quality studies with consistent findings for recommending for or against the intervention.
LimitedOptions are formed when there is little or no evidence on a topic. Defined as low quality evidence or a single moderate quality study.
ModerateEvidence from two or more 'Moderate' quality studies with consistent findings, or evidence from a single 'High' quality study for recommending for or against the intervention.
ConsensusOptions are formed when there is little or no evidence on a topic, or only conflicting evidence.

Safety & Contraindications

Contraindications

  • Contraindications vary widely based on the treatment administered.

Authors & Contributors

American Orthopaedic Society for Sports MedicineAmerican Medical Society for Sports MedicineAmerican Academy of Physical Medicine and RehabilitationPediatric Orthopaedic Society of North AmericaAmerican College of Emergency Physicians

Guideline Features

Flowcharts includedBased on systematic reviewMultidisciplinary

Learning Context

Difficulty

advanced

Exam Relevance

Orthopaedic SurgerySports Medicine