Anterior Cruciate Ligament Pathology

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The anterior cruciate ligament (ACL) is one of the most commonly injured ligaments of the knee. Injuries occur predominantly in a young and sports-active population. Many patients are left with significant disability following injury to the ACL. The injury leads to alteration in the mechanics of the knee. This mechanical deficit can lead to an increased risk of meniscal injury. The incidence of osteoarthritis rises sharply when the meniscus is injured. 

Understanding and preventing associated meniscal pathology is the key to management of this condition. Treatment aims to protect the meniscus by modifying activity levels or reconstructing the ACL. This article endeavors to explain the complex nature of the ligament and its injuries and aid the reader in making informed management decisions.

Bonnet first discussed ACL injury in the medical literature in 1845. Further discussion was made by Segond in 1879. Stark made the first reports in the English literature in 1850. In 1900, Battle described surgical intervention when he attempted repair of the ACL. Subsequent operative descriptions include those by Groves and Jones in 1913.

In 1917, Groves described a reconstructive procedure. He used the iliotibial band (ITB) as the graft. In 1918, Smith detailed combined intra-articular and extra-articular procedures. Zur Verth first used the patellar tendon graft in 1933. Campbell used this same donor tissue in 1936. In 1966, Bruckner reported using the patellar tendon as a free graft. Since that time, numerous entries have been made in the literature describing natural history, operative reports, and surgical series.

Future research in the field of ACL surgery will attempt to address a number of features, including the following:

Problems of abnormal kinematics and early osteoarthritis continue, despite excellent surgery. Which of the emerging technologies will allow continued gains to be made remains to be seen. Until many of these problems are addressed, physicians can only continue to inform patients and allow them to choose the best management course.

For patient education resources, see Knee Injury and Knee Pain.

The anatomy of the ACL is highly complex. The ligament is intra-articular but extrasynovial. It is described as being composed of the following three main bundles:

The ACL really functions as a continuum, with a portion being tight through all ranges of knee flexion.

The ligament courses obliquely, running from the tibia anteriorly and medially to the femur posteriorly, superiorly, and laterally. The broad tibial footprint lies at a point one third to one half the distance between the medial and lateral tibial spines, 5-7 mm anterior to the posterior cruciate ligament (PCL).

On the femoral side, the attachment lies on the medial aspect of the lateral femoral condyle, just anterior to the posterior aspect of the intercondylar notch. An intercruciate ligament joins the ACL to the PCL. This intercruciate ligament may have some role in proprioception and coupling of the two ligaments.

The microstructure of the ligament is composed of collagen fiber bundles, grouped into fascicles. Type I collagen is the predominant collagen type, accounting for more than 90% of total collagen. Types III and VI also are found. Elastin is found in significant amounts and provides some of the elastic properties of the ligament.

The major blood supply for the ACL comes from the synovium and fat pads. The middle geniculate and terminal branches of the inferior medial and lateral geniculate vessels are the vessels involved.

Sensory receptors and nerve fibers have been identified in the ligament and associated feeding blood vessels. This suggests some sensory role and possible proprioceptive function.

The ACL acts as the primary restraint to anterior tibial translation and guides the screw-home mechanism associated with knee extension. It acts secondarily to prevent varus and valgus, particularly in the extended knee. Injury leads to abnormal kinematics of the knee. Subluxation episodes occur, creating abnormal shear forces on the meniscus and articular cartilage. Subsequent meniscal injury therefore is increased significantly.

The authors have found a significant increase in this meniscal pathology when ACL reconstruction is delayed. Associated with this meniscal pathology is an increased incidence of osteoarthritis. A series conducted by the authors demonstrated a 15% incidence of ACL tears in patients undergoing total knee replacement (TKR). This incidence is at least three times the incidence of ACL tears found in the general population.

Approximately 70% of ACL injuries occur through noncontact mechanisms. Patients experience giving way of the knee when attempting to rapidly change direction. This involves deceleration, coupled with a cutting, pivoting, or sidestepping maneuver. The remainder of cases tend to occur through direct contact and often are associated with other ligament injury.

The incidence of ACL injury in the United States is estimated to approach 1 case per 3000 individuals. In the United States alone, more than100,000 injuries occur from snow skiing each year. The estimated cost of management is on the order of 2 billion dollars annually, which is a significant problem. The authors’ series demonstrated an incidence of 1.5% of the population of New South Wales, Australia, with males affected twice as often as females.

Females are at higher risk of ACL injury when sports participation numbers are taken into account. This higher risk is believed to be related to both intrinsic factors (increased Q angle, decreased notch width, increased joint laxity, hormonal influences) and extrinsic factors (less muscle strength, different muscle activation patterns, altered cutting and landing patterns). Further investigation is required to fully identify which of these factors are the most important and determine whether any alterations to ACL injury patterns can be made as a result of intervention.

The natural history of ACL injury is an interesting topic. Meniscal preservation and activity levels are the key points to consider. Multiple studies demonstrate an increased incidence of osteoarthritis following meniscectomy. Nonoperative management with adequate rehabilitation can be undertaken in those patients with sedentary lifestyles. Castelyn et al have demonstrated this finding. ^[6]  In 228 low-demand patients, long-term risk of requiring meniscal surgery or ACL reconstruction was low.

Patients that remain active should undergo reconstruction. Daniel states that more than 50 hours of high-level sports per year is significant. Incidence of meniscal injury increases with time, and therefore, there is an increased incidence of osteoarthritis. The authors’ series of over 1000 cases confirms these findings; meniscal injury is time-dependent in those with ACL injury.

ACL reconstruction decreases the incidence of meniscal injury that requires meniscectomy. Normal kinematics are not restored. Osteoarthritis levels are thus reduced by the meniscal preservation associated with the reconstruction; however, these levels of osteoarthritis are not eliminated. Bone bruising may also play some role in the ongoing incidence of osteoarthritis following reconstruction.

Hunt JA, Callaghan JT. Polymer-hydroxyapatite composite versus polymer interference screws in anterior cruciate ligament reconstruction in a large animal model. Knee Surg Sports Traumatol Arthrosc. 2008 Jul. 16(7):655-60. [Medline].

Spalazzi JP, Dagher E, Doty SB, Guo XE, Rodeo SA, Lu HH. In vivo evaluation of a multiphased scaffold designed for orthopaedic interface tissue engineering and soft tissue-to-bone integration. J Biomed Mater Res A. 2008 Jul. 86(1):1-12. [Medline].

Altman GH, Horan RL, Weitzel P, Richmond JC. The use of long-term bioresorbable scaffolds for anterior cruciate ligament repair. J Am Acad Orthop Surg. 2008 Apr. 16(4):177-87. [Medline].

Kimura Y, Hokugo A, Takamoto T, Tabata Y, Kurosawa H. Regeneration of anterior cruciate ligament by biodegradable scaffold combined with local controlled release of basic fibroblast growth factor and collagen wrapping. Tissue Eng Part C Methods. 2008 Mar. 14(1):47-57. [Medline].

Sasaki K, Kuroda R, Ishida K, Kubo S, Matsumoto T, Mifune Y, et al. Enhancement of tendon-bone osteointegration of anterior cruciate ligament graft using granulocyte colony-stimulating factor. Am J Sports Med. 2008 Aug. 36(8):1519-27. [Medline].

Casteleyn PP, Handelberg F. Non-operative management of anterior cruciate ligament injuries in the general population. J Bone Joint Surg Br. 1996 May. 78(3):446-51. [Medline].

Farshad-Amacker NA, Potter HG. MRI of knee ligament injury and reconstruction. J Magn Reson Imaging. 2013 Oct. 38(4):757-73. [Medline].

Draghi F, Torresi M, Urciuoli L, Gitto S. Magnetic Resonance Signal Abnormalities Within the Pericruciate Fat Pad: A Possible Secondary Sign for Acute Anterior Cruciate Ligament Tears. Can Assoc Radiol J. 2017 Nov. 68 (4):438-444. [Medline].

Daniel DM, Fithian DC. Indications for ACL surgery. Arthroscopy. 1994 Aug. 10(4):434-41. [Medline].

Daniel DM, Stone ML, Dobson BE. Fate of the ACL-injured patient. A prospective outcome study. Am J Sports Med. 1994 Sep-Oct. 22(5):632-44. [Medline].

Miller CJ, Christensen JC, Burns RD. Influence of Demographics and Utilization of Physical Therapy Interventions on Clinical Outcomes and Revision Rates Following Anterior Cruciate Ligament Reconstruction. J Orthop Sports Phys Ther. 2017 Nov. 47 (11):834-844. [Medline].

Gerber JP, Marcus RL, Dibble LE, Greis PE, Burks RT, LaStayo PC. Effects of early progressive eccentric exercise on muscle size and function after anterior cruciate ligament reconstruction: a 1-year follow-up study of a randomized clinical trial. Phys Ther. 2009 Jan. 89(1):51-9. [Medline].

Shelbourne KD, Nitz P. Accelerated rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med. 1990 May-Jun. 18(3):292-9. [Medline].

Swenson TM, Harner CD. Knee ligament and meniscal injuries. Current concepts. Orthop Clin North Am. 1995 Jul. 26(3):529-46. [Medline].

Bedi A, Musahl V, Steuber V, et al. Transtibial versus anteromedial portal reaming in anterior cruciate ligament reconstruction: an anatomic and biomechanical evaluation of surgical technique. Arthroscopy. 2011 Mar. 27(3):380-90. [Medline].

Mohtadi NG, Chan DS, Dainty KN, Whelan DB. Patellar tendon versus hamstring tendon autograft for anterior cruciate ligament rupture in adults. Cochrane Database Syst Rev. 2011 Sep 7. 9:CD005960. [Medline].

Calvo R, Figueroa D, Figueroa F, Vaisman A, Schmidt-Hebbel A, Morales N, et al. Five-Strand Hamstring Autograft Versus Quadruple Hamstring Autograft With Graft Diameters 8.0 Millimeters or More in Anterior Cruciate Ligament Reconstruction: Clinical Outcomes With a Minimum 2-Year Follow-Up. Arthroscopy. 2017 May. 33 (5):1007-1013. [Medline].

Reid JS, Hanks GA, Kalenak A. The Ellison iliotibial-band transfer for a torn anterior cruciate ligament of the knee. Long-term follow-up. J Bone Joint Surg Am. 1992 Oct. 74(9):1392-402. [Medline].

Leys T, Salmon L, Waller A, Linklater J, Pinczewski L. Clinical results and risk factors for reinjury 15 years after anterior cruciate ligament reconstruction: a prospective study of hamstring and patellar tendon grafts. Am J Sports Med. 2012 Mar. 40(3):595-605. [Medline].

Shelbourne KD, Wilckens JH, Mollabashy A. Arthrofibrosis in acute anterior cruciate ligament reconstruction. The effect of timing of reconstruction and rehabilitation. Am J Sports Med. 1991 Jul-Aug. 19(4):332-6. [Medline].

Chhadia AM, Inacio MC, Maletis GB, Csintalan RP, Davis BR, Funahashi TT. Are meniscus and cartilage injuries related to time to anterior cruciate ligament reconstruction?. Am J Sports Med. 2011 Sep. 39(9):1894-9. [Medline].

Zaffagnini S, Bonanzinga T, Marcheggiani Muccioli GM, Giordano G, Bruni D, Bignozzi S, et al. Does chronic medial collateral ligament laxity influence the outcome of anterior cruciate ligament reconstruction?: a prospective evaluation with a minimum three-year follow-up. J Bone Joint Surg Br. 2011 Aug. 93(8):1060-4. [Medline].

Shea KG, Grimm NL, Belzer JS. Volumetric Injury of the Distal Femoral Physis During Double-Bundle ACL Reconstruction in Children: A Three-Dimensional Study with Use of Magnetic Resonance Imaging. J Bone Joint Surg Am. 2011 Jun 1. 93(11):1033-8. [Medline].

Arneja S, McConkey MO, Mulpuri K, Chin P, Gilbart MK, Regan WD, et al. Graft tensioning in anterior cruciate ligament reconstruction: a systematic review of randomized controlled trials. Arthroscopy. 2009 Feb. 25(2):200-7. [Medline].

Bushnell BD, Sakryd G, Noonan TJ. Hamstring donor-site block: evaluation of pain control after anterior cruciate ligament reconstruction. Arthroscopy. 2010 Jul. 26(7):894-900. [Medline].

Järvelä T, Moisala AS, Paakkala T, Paakkala A. Tunnel enlargement after double-bundle anterior cruciate ligament reconstruction: a prospective, randomized study. Arthroscopy. 2008 Dec. 24(12):1349-57. [Medline].

Arnoczky SP. Biology of ACL reconstructions: what happens to the graft?. Instr Course Lect. 1996. 45:229-33. [Medline].

Scheffler SU, Unterhauser FN, Weiler A. Graft remodeling and ligamentization after cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2008 Sep. 16(9):834-42. [Medline].

John Maguire, MBBS, MSc, FRACS Partner, Townsville Orthopaedics and Sports Surgery, Australia

Disclosure: Nothing to disclose.

Mervyn J Cross, MBBS, FRACS, MD Director of the Australian Institute of Musculoskeletal Research, Department of Orthopedic Surgery, North Sydney Orthopedic/Sports Medicine Center, Crows Nest, Australia

Mervyn J Cross, MBBS, FRACS, MD is a member of the following medical societies: American Orthopaedic Society for Sports Medicine, Australasian College of Sports Physicians, Australian Association of Surgeons, Australian Medical Association, Australian Orthopaedic Association, Hughston Society, Royal Australasian College of Surgeons

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Thomas M DeBerardino, MD Orthopedic Surgeon, The San Antonio Orthopaedic Group; Professor of Orthopedic Surgery, Baylor College of Medicine as Co-Director, Combined Baylor College of Medicine-The San Antonio Orthopaedic Group, Texas Sports Medicine Fellowship; Medical Director, Burkhart Research Institute for Orthopaedics (BRIO) of the San Antonio Orthopaedic Group; Consulting Surgeon, Sports Medicine, Arthroscopy and Reconstruction of the Knee, Hip and Shoulder

Thomas M DeBerardino, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Herodicus Society, International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Arthrex, Inc.; MTF; Aesculap; The Foundry, Cotera; ABMT; Conmed; <br/>Received research grant from: Histogenics; Cotera; Arthrex.

Robert D Bronstein, MD Associate Professor, Department of Orthopedics, Division of Athletic Medicine, University of Rochester School of Medicine

Robert D Bronstein, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Medical Society of the State of New York

Disclosure: Nothing to disclose.

Anterior Cruciate Ligament Pathology

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