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C OPYRIGHT 2014 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Current Concepts Review

Operative Treatment of Primary Anterior
Cruciate Ligament Rupture in Adults
Christopher D. Murawski, BS, Carola F. van Eck, MD, PhD, James J. Irrgang, PT, PhD, ATC, FAPTA,
Scott Tashman, PhD, and Freddie H. Fu, MD, DSc(Hon), DPs(Hon)

Investigation performed at the Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

Operative management of an acute anterior cruciate ligament (ACL) rupture may be required in young and active
patients to stabilize the knee and return patients to desired daily activities.

ACL reconstruction should be performed anatomically.

The majority of studies show no differences between anatomic single-bundle and double-bundle ACL recon-
struction with respect to patient-reported outcome scores. Double-bundle reconstruction may provide superior
knee joint laxity measurements compared with the single-bundle technique.

Following ACL reconstruction, the age and activity level of a patient are predictive of his or her time of return to
sports and reinjury.

Concomitant meniscal and/or cartilage damage at the time of surgery, in addition to a persistent knee motion
deficit, are associated with the development of osteoarthritis after ACL reconstruction.

Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor
reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or
more exchanges between the author(s) and copyeditors.

Anterior cruciate ligament (ACL) rupture is a common injury
worldwide. Estimates suggest an annual incidence for ACL rupture
of thirty-five per 100,000 people of all ages1, with an approxi-
mately two to eight-times higher risk in female athletes than in
male athletes2-7. These injuries often result in instability of the
knee, increased joint laxity, and reduced activity and partici-
pation, as well as an increased risk of knee osteoarthritis in the
long term8,9. Surgical reconstruction of the ACL is often rec-
ommended, particularly in young and active patients, to facili-
tate a return to the desired daily activities, including sports.
As the estimated annual health-care cost of ACL surgery
is $3 billion in the United States alone, providing patients with the
best potential for a successful outcome after ACL reconstruction
remains a topic of intense interest among clinicians and re-
searchers10. In this review, a critical assessment of the evidence
for operative treatment of primary ACL rupture in adults (eighteen
years of age or older) is provided, including principles for decision
making, clinical outcomes, and guidelines for return to sports.
Anatomy and Function
The ACL is composed of two functional bundles, the antero-
medial and posterolateral bundles, which are named for the lo-
cation of their respective insertion sites on the tibia11,12. The tibial
insertion site of the ACL reveals a characteristic fan-shaped foot-
print, whereas the femoral insertion site demonstrates a smaller,
oval-shaped appearance13. The femoral insertion site is identifiable

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of
any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of
this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No
author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is
written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

J Bone Joint Surg Am. 2014;96:685-94 d http://dx.doi.org/10.2106/JBJS.M.00196

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using the position of two osseous ridges on the medial wall of

the lateral femoral condyle14-18. The lateral intercondylar ridge,
or so-called residents ridge, denotes the anterior border of the
femoral insertion site. The lateral bifurcate ridge runs perpen-
dicular to the lateral intercondylar ridge, between the femoral
insertion sites of the anteromedial and posterolateral bundles19.
Functionally, the anteromedial and the posterolateral bundles
behave synergistically with knee flexion, whereby both antero-
posterior and rotational stability of the knee are provided. In-
dividually, the anteromedial bundle length remains constant
throughout the knee flexion-extension, attaining peak tension
between 45 and 60 of flexion20-22. In comparison, the postero-
lateral bundle is tight in extension and loosens with flexion,
thereby allowing axial rotation of the knee to occur. Varying
mechanical behaviors of the functional bundles of the ACL have
been reported23,24.
A thorough understanding of the anatomy and function
of the native ACL is fundamental for the treatment of ACL in-
juries. This understanding ultimately aids the surgeon in de-
termining the most appropriate treatment strategy for a partial
or complete rupture of the ACL.
Treatment of ACL Injuries
ACL injuries can be managed with nonoperative or operative
treatment. The decision to recommend operative treatment for
an acute ACL rupture is multifactorial and must be individualized
to each patient on the basis of his or her age25, desired activity
level, and presence of potential concomitant injuries. In general,
younger and more active patients are more likely to require sur-
gery to return to functionally demanding activities. In the re-
mainder of this review article, we focus on operative treatment
of ACL injuries. While rehabilitation after ACL reconstruction
is an important aspect of the ultimate success after ACL recon-
struction25-28, it is not a focus of this review.
Operative Treatment
Once the decision to proceed with operative treatment of an ACL
rupture is made, timing of the procedure becomes an important
variable to consider. Preoperative range of motion, swelling,
and quadriceps strength have been investigated as factors that
can affect the ultimate success of ACL reconstruction29,30. Preop-
erative swelling and limited range of motion have been related to
the development of arthrofibrosis after surgery 29.
Preoperative quadriceps strength deficits of >20% have
been shown to significantly affect the two-year functional out-
come of ACL reconstruction with bone-patellar tendon-bone
autograft30. Moreover, it has been reported that preoperative
quadriceps strength of >90% of that of the noninjured leg sig-
nificantly increased postoperative strength two years after sur-
gery compared with those with <75% of preoperative quadriceps
strength31. Rehabilitation prior to surgery should focus on re-
gaining range of motion, reducing swelling, and strengthening
the quadriceps.
Intraoperatively, the rupture pattern of the ACL should be
confirmed, and if a partial one-bundle rupture is evident, aug-
mentation surgery should be considered32. Partial ACL ruptures
Fig. 1
An arthroscopic ruler is used to measure the size of the tibial insertion site
in the sagittal plane, with the ACL tibial footprint shown dissected and the
anteromedial (AM) and posterolateral (PL) bundles marked with a stan-
dard, commercially available, arthroscopic radiofrequency ablation device.
have been reported to occur in approximately 5% to 35% of
patients32,33. Performing a one-bundle augmentation surgery car-
ries the theoretical advantages of maintaining proprioceptive
fibers, biomechanical strength, and biological healing potential34.
Careful dissection and preservation of the native insertion sites
can facilitate determination of the appropriate tunnel location(s).
Presently, the majority of surgeons who perform ACL re-
constructions do so using a single-bundle technique. The double-
bundle technique is more commonly utilized in Europe and
Asia than it is in the United States. Regardless, it is important to
understand the double-bundle anatomy of the ACL so that sur-
geons can perform an anatomic single-bundle or double-bundle
ACL reconstruction. In the event that a surgeon has experience
in performing double-bundle ACL reconstruction and considers
this as part of the preoperative planning process, the decision to
perform anatomic single-bundle or double-bundle ACL recon-
struction is based on several criteria. A comprehensive flowchart
to assist surgeons in this decision has been previously described35.
The variation in size of the tibial insertion site is one element to
consider36 (Fig. 1). A tibial insertion site size of <14 mm, measured
arthroscopically, makes it difficult to perform a double-bundle
reconstruction35. Furthermore, arthritic changes, multiligament
injury, severe bone bruising, open physes, and a narrow notch
width are considered indications to perform single-bundle re-
construction32. Variation in the shape of the notch can also
influence whether two femoral tunnels can be drilled safely for
double-bundle reconstruction37.
Typical graft options for ACL reconstruction include bone-
patellar tendon-bone autograft, hamstring tendon autograft, quad-
riceps tendon autograft, and allograft (Table I)38-40. Of these options,
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TABLE I Advantages and Disadvantages of Available Graft Choices for ACL Reconstruction

Graft Choice Advantages Disadvantages

Bone-patellar tendon-bone d Bone-to-bone healing in both tunnels d Not suitable for double-bundle reconstruction
d Comparable stiffness to native ACL d Risk of anterior kneeling pain
d Invasive, large incision
d Risk of patellar fracture
d Fixed length
d Weaker than native ACL
Hamstring d Ease of harvest d Soft-tissue healing
d Cosmesis d Graft size can be unpredictable
d Minimal donor site morbidity d Not suitable for certain athletes who rely
d Comparable strength to native ACL heavily on their hamstring muscles
d Less stiffness than native ACL
Quadriceps tendon d Large graft d Invasive, large incision
d Can be used for single or d Risk of patellar fracture
double-bundle reconstruction
d Option of a one-sided bone block
Allograft d No donor site morbidity d Theoretical risk of disease transmission
d Available in various types and sizes d Longer healing time
d Increased risk of rerupture, especially in younger
patients and irradiated grafts

bone-patellar tendon-bone graft is not suitable for double-bundle surgeons and found a lack of agreement in the ideal position for
reconstruction. For the purposes of preoperative planning, the single-bundle ACL tunnels55. Several intraoperative and post-
sagittal thickness of the patellar and quadriceps tendons can be operative methods have been described to evaluate tunnel place-
measured on magnetic resonance imaging (MRI) scans to pro- ment. Postoperatively, anteroposterior and lateral radiographs
vide the surgeon with an idea as to potential graft size41. Studies
have also evaluated the use of MRI in predicting hamstring graft
size and have found that, while cross-sectional area measurements
on MRI scans correlate positively with intraoperative graft size42,43,
measurements of graft diameter do not42. Magnussen et al. found
that a hamstring autograft size of 8 mm in diameter was asso-
ciated with a higher rate of early revision than were those of
>8 mm44. In patients having primary surgery, allograft may be
used when there are concerns of donor site morbidity or cos-
mesis. Fresh-frozen allografts are typically preferred over ir-
radiated, chemically processed, or preserved grafts and provide
results equal to those of autografts45-47. Recent studies have,
however, indicated higher rates of graft failure following ACL
reconstruction with varying types of allograft, particularly in
younger active individuals desiring an early return to sport48-51.
Ultimately, daily activities and patient lifestyle influence
graft choice for an individual undergoing ACL reconstruction.
For example, in a patient with daily activities that include kneeling
(e.g., wrestling or religious practices), the use of a bone-patellar
tendon-bone autograft may be contraindicated because it is asso-
ciated with a higher prevalence of anterior knee pain52.
Proper tunnel placement is critical in anatomic ACL re- Fig. 2
construction. Nonanatomic tunnel placement has been previ- A standard 45 flexion weight-bearing posteroanterior (PA) radiograph,
ously shown to decrease knee motion53 and to produce abnormal made one year after single-bundle ACL reconstruction, demonstrating a
rotational knee kinematics during dynamic loading54. A recent 45 femoral tunnel angle relative to the long axis of the femur, suggestive
41
study has evaluated the ACL tunnel positions used by twelve of anatomic tunnel placement .
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Fig. 3
Figs. 3-A, 3-B, and 3-C MRI scans of a knee that had an anatomic ACL reconstruction with bone-patellar tendon-bone autograft. Fig. 3-A Preoperative scan
showing initial measurements. The ACL length is also measured preoperatively. Figs. 3-B Sagittal scan, made three months postoperatively, showing
the tibial insertion site size and inclination angle measurements for comparison. Fig. 3-C A coronal oblique sequence, made three months postoperatively,
in the plane of the long axis of the ACL starting at the intercondylar roof of the Blumensaat line. This sequence can be used for graft evaluation after
ACL reconstruction.

can be used to evaluate tunnel angle and implant position.
Illingworth et al. described a femoral tunnel angle measure-
ment based on the long axis of the femur on an anteroposterior
radiograph, whereby an angle of <32.7 is likely to be nonan-
atomic56 (Fig. 2). Postoperative MRI measurements of the in-
sertion site, inclination angle, and length of the ACL can also
be compared with those made preoperatively (Fig. 3). A three-
dimensional computed tomography (CT) scan is presently con-
sidered the gold standard for evaluation of tunnel placement57-59
(Figs. 4 and 5). Meuffels et al. demonstrated that three-
dimensional measurements provided the highest reliability in
the evaluation of femoral and tibial tunnel placement60. More-
over, a three-dimensional CT scan can be particularly useful in
planning for knees in which revision surgery may eventually be
required.
Clinical Outcomes After ACL Reconstruction
A Level-I clinical trial by Frobell et al. randomized 121 physi-
cally active adults to a structured rehabilitation program with
early ACL reconstruction or to a rehabilitation program alone
with the option of delayed ACL reconstruction61. At the two-
year follow-up, the difference using a subscale of the Knee Injury
and Osteoarthritis Outcome Score (KOOS4) was a mean of 39.2
for the early ACL reconstruction group and a mean of 39.4
points for the rehabilitation and optional delayed reconstruc-
tion group (p = 0.96). The rehabilitation and optional delayed
reconstruction group had a higher rate of meniscal surgery than
the early reconstruction group. Similar results were also found
with recently reported five-year results of this trial62. In total, thirty
patients (51%) in the delayed reconstruction group ultimately
had ACL surgery. Therefore, nonoperative management may
be feasible in a well-defined cohort of patients with an acute ACL
tear who have been counseled accordingly.
The outcomes of single-bundle and double-bundle recon-
struction have been reported previously (Figs. 6 and 7). A recent
Cochrane review by Tiamklang et al. evaluated the effects of
single-bundle compared with double-bundle reconstructions
in adult patients in seventeen randomized and quasi-randomized
controlled trials63. The authors reported no detectable differ-
ences between single-bundle and double-bundle reconstruc-
tions in patient-reported outcomes up to five years after surgery.
The two to five-year follow-up evaluation demonstrated im-
provements in the International Knee Documentation Com-
mittee (IKDC) knee examination, pivot-shift test, and knee laxity
measurements on the KT-1000 arthrometer with double-bundle
reconstruction. Single-bundle reconstructions had a higher rate
of new meniscal injury. Importantly, methodological deficiencies
were prevalent in all trials included in the review and should be
considered when evaluating the results of this study.
In a recent Level-I randomized controlled trial by Hussein
et al., anatomic double-bundle ACL reconstruction was com-
pared with anatomic single-bundle and conventional single-
bundle ACL reconstructions with hamstring autograft64. Two
hundred and eighty-one patients were prospectively followed
for a mean of 51.15 months after surgery. The patients in the
anatomic double-bundle group had improved anteroposterior
laxity (measured with the KT-1000 arthrometer) and rotational
laxity (pivot-shift test) compared with the anatomic single-bundle
group; the anatomic single-bundle group had improved antero-
posterior and rotational laxities compared with conventional
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favoring double-bundle reconstruction. There is also some evi-

dence to suggest that individualized surgery may facilitate similar
outcomes with respect to knee joint laxity, regardless of whether
single or double-bundle reconstruction is performed. Further
investigation is needed to confirm or dispute these findings.
The outcomes after one-bundle augmentation reconstruc-
tion for partial rupture of the ACL have been reported in several
series. Sonnery-Cottet et al. reported that reconstruction of the
anteromedial bundle with preservation of the posterolateral bundle
significantly decreased anteroposterior laxity (Telos stress ra-
diography), while significantly increasing the IKDC Subjective
Knee Form and Lysholm scores at a mean follow-up of twenty-
six months66. Adachi et al. compared ACL augmentation surgery
in partial ACL tears and complete ACL reconstruction with com-
plete ACL tears at a mean follow-up of 2.6 years67. The authors
reported augmentation surgery to be superior for joint stabil-
ity and position sense. A recent systematic review found that

Fig. 4
Femoral and tibial three-dimensional CT reconstructions demonstrating
anatomic tunnel placement of a single-bundle ACL reconstruction.

single-bundle reconstruction. The only significant difference in

patient-reported outcome was a higher Lysholm score in the
anatomic double-bundle group in comparison with the con-
ventional single-bundle group. There were no significant dif-
ferences in patient-reported outcome scores in the comparison
of anatomic double-bundle with anatomic single-bundle recon-
struction. In a second prospective comparative study (Level II),
anatomic single-bundle reconstructions were compared with
anatomic double-bundle reconstructions with hamstring au-
tograft, with the procedures individualized on the basis of in-
traoperative measurements of the native ACL tibial insertion
site size65. At a mean follow-up of thirty months after surgery, no
differences between the groups were detected with respect to
the Lysholm and IKDC Subjective Knee Form scores or the results
of the KT-1000 measurements and pivot-shift tests.
The majority of published studies have shown no dif-
ferences between anatomic single-bundle and double-bundle ACL Fig. 5
reconstruction in terms of patient-reported outcomes. Differ- Femoral and tibial three-dimensional CT reconstructions demonstrating
ences may exist with regard to knee joint laxity measurements, anatomic tunnel placement of a double-bundle ACL reconstruction.
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Fig. 6
Figs. 6-A and 6-B Intraoperative arthroscopic photographs demonstrating anatomic tunnel placement for single-bundle ACL reconstruction on the femur and
tibia. Fig. 6-A A dilator is used to enlarge the tibial tunnel. Fig. 6-B A hamstring autograft is then tensioned and fixed in an anatomic position.

the available evidence to support augmentation was weak but
encouraging68.
In Vivo Biomechanics After ACL Reconstruction
In vivo kinematic studies evaluate knee biomechanics without
the time-zero limitation of in vitro studies. They also enable
serial assessment of the effects of healing on knee function after
ACL reconstruction and can involve realistic weight-bearing
activities, such as running, jumping, and stair-climbing.
Georgoulis et al. compared ACL-reconstructed and con-
tralateral, normal knees using conventional video-motion analysis
with surface markers69. While no differences were evident during
walking, greater internal tibial rotation in the reconstructed
knee was observed during more demanding pivoting tasks. Tashman
et al. used dynamic stereoradiography to assess knee kinematics
during the stance phase of downhill running, and found greater
external rotation and adduction in ACL-reconstructed knees
compared with the contralateral, uninjured limbs54. The surgical
technique used for that study incorporated nonanatomic place-
ment of the graft, demonstrating that nonanatomic ACL recon-
struction fails to restore preinjury knee function under functional
loading conditions. Abebe et al. utilized biplanar fluoroscopy
and MRI to evaluate knee function during a series of static joint
positions and reported that single-bundle reconstruction with
anatomic femoral tunnel placement resulted in knee joint kine-
matics that were more closely restored relative to the intact knee
compared with nonanatomic tunnel placement70.
In a separate study, tibiofemoral rotations and transla-
tions in knees that had anatomic double-bundle ACL recon-
struction were compared with those in the contralateral, normal
knees using a biplane radiographic system during the early to
midstance phase of running71. A model-based tracking method
was also utilized to evaluate tibiofemoral kinematics. No sig-
nificant or clinically important differences were found between
the ACL-reconstructed and contralateral limbs with regard to
kinematic variables after anatomic double-bundle reconstruction.

Fig. 7
Figs. 7-A and 7-B Intraoperative arthroscopic photographs demonstrating anatomic tunnel placement for double-bundle ACL reconstruction on the femur
and tibia. Fig. 7-A Dilators are used to enlarge the tibial tunnels. Fig. 7-B The anteromedial (AM) and posterolateral (PL) bundles are then tensioned and fixed
with allografts in anatomic positions.
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These results suggest that anatomic double-bundle reconstruc-
tion may be effective for restoring knee function compared with
the uninjured side. It is not, however, known whether anatomic
single-bundle reconstruction may produce results similar to an-
atomic double-bundle reconstruction compared with the con-
tralateral knee.
Return to Sports After ACL Reconstruction
The timing of return to sports after ACL reconstruction is mul-
tifactorial. Graft choice is an important consideration with re-
gard to whether there is bone-to-bone healing (bone-patellar
tendon-bone graft) or soft tissue-to-bone healing. In a systematic
review and meta-analysis, Ardern et al. assessed forty-eight studies
with a total of 5770 patients at a mean follow-up of 41.5 months
after ACL reconstruction72. In total, while 82% of the patients
reported returning to some level of sporting activity, 63% of the
patients returned to sports participation at the preinjury level,
and only 44% returned to competitive sports. The leading reason
given for not returning to sporting activity was fear of reinjury.
Brophy et al. evaluated the return to sports among soccer
athletes and found that younger or male athletes were more likely
to return to play than were older or female athletes73. Smith et al.,
who separately evaluated the return to the preinjury activity level
among seventy-seven competitive athletes with a mean age of
twenty-one years (range, fifteen to thirty years), found that 71%
(fifty-five) returned to preinjury activity levels by twelve months
after surgery74. Further research on return to sports should eval-
uate the rate of return to the preinjury activity in terms of the type,
frequency, intensity, and duration of participation.
Graft Failure After ACL Reconstruction
Graft failure in the ipsilateral knee after ACL reconstruction and
native ACL rupture in the contralateral knee have been inves-
tigated. A recent study from the Danish Knee Ligament Recon-
struction Register compared anteromedial with transtibial femoral
tunnel drilling during ACL reconstruction. Anteromedial dril-
ling had a higher overall rate of revision surgery (5.16%) than
transtibial drilling (3.20%), with a relative risk of 2.04 (95% con-
fidence interval, 1.39 to 2.99)75. Surgeons should use caution when
evaluating these results, given the tendency of the transtibial
technique to place the graft in a nonanatomic position. Indi-
viduals undergoing anatomic ACL reconstruction may be at higher
risk for graft failure, particularly with early return to activity,
given the higher, closer to normal, in situ forces on an anatomi-
cally placed graft76,77.
A recent study by Bourke et al. of patients undergoing ACL
reconstruction with either bone-patellar tendon-bone or ham-
string autograft found graft failure to be 11%, while contralateral
ACL rupture was 13%78. Graft choice did not affect failure rate.
Other authors have also reported a higher risk of failure in the
contralateral ACL compared with the ipsilateral graft79. Shelbourne
et al. followed 1415 patients for a minimum of five years after
ACL reconstruction with bone-patellar tendon-bone autograft
and found a lower patient age and higher activity level to be
associated with increased injury to either knee80. Returning
to activity before six months postoperatively did not appear to
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increase the risk for injury. In this particular study, the group
with an age of less than eighteen years returned at a mean 4.6
months after surgery. In a prospective analysis of failure in
anatomic ACL reconstruction with allograft, van Eck et al. found
that 48% (thirteen) of twenty-seven reruptures occurred within
nine months after surgery, before the patients had received
clearance to return to sports51. Further investigation is required
to determine factors affecting ACL graft failure, including
consideration for graft healing. On the basis of the available
evidence, a lower patient age and higher activity level, but not
time to return to sport, appear to be predictive of reinjury.
Osteoarthritis After ACL Reconstruction
The development of osteoarthritis after ACL reconstruction is a
concern. Li et al. retrospectively investigated the predictors of
radiographic knee osteoarthritis after nonanatomic single-bundle
ACL reconstruction81. Radiographic osteoarthritis, defined as Kellgren
and Lawrence grade-2 changes in at least one compartment or
grade-1 changes in at least two compartments, were demonstrated
by 39% (ninety-six) of 249 patients at a mean 7.86 years follow-
up. The most optimal set of predictors for osteoarthritis were
body mass index, length of follow-up, prior medial meniscectomy,
and medial chondrosis of grade 2 or greater. Separately, Roe
et al. investigated differences in osteoarthritis rates in a consec-
utive cohort of nonrandomized patients who underwent ACL
reconstruction with hamstring or bone-patellar tendon-bone
autograft82. At seven years of follow-up, 45% (twenty-four) of fifty-
three patients in the bone-patellar tendon-bone group and 14%
(seven) of fifty-one in the hamstring group showed signs of ra-
diographic osteoarthritis (p = 0.002).
Several studies with longer-term follow-up have also been
performed. Oiestad et al. prospectively evaluated knee function
and the prevalence of osteoarthritis in patients ten to fifteen
years after isolated ACL reconstruction and in patients who had
concomitant meniscal and/or cartilage pathology 83. Radiographic
assessment using the Kellgren and Lawrence classification system
revealed that 80% of the patients in the concomitant pathology
group had joint space narrowing of grade 2 or greater compared
with 62% in the isolated group (p = 0.008). However, differences
were not detectable between groups with respect to symptomatic
osteoarthritis. In a separate study of the same cohort, Oiestad et al.
reported that the prevalence of patellofemoral osteoarthritis was
26.5% (forty-eight of 181 patients twelve years after reconstruction)
and was associated with older age, increased symptoms, and greater
tibiofemoral osteoarthritis, as well as reduced knee function84.
Salmon et al. also reported an association between de-
generative joint changes and meniscectomy, increased knee
joint laxity, and loss of knee motion thirteen years after ACL
reconstruction with bone-patellar tendon-bone autograft85. Sim-
ilarly, Shelbourne et al. evaluated 780 patients undergoing ACL
reconstruction with bone-patellar tendon-bone autograft and,
at a minimum of five years of follow-up, found that the loss of
normal knee flexion and extension was associated with an increased
rate of radiographic osteoarthritis86. In two separate studies of
patients in whom concomitant knee pathology was absent at
the time of surgery, Shelbourne and Gray and Lebel et al. reported
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TABLE II Grades of Recommendation for Operative Treatment of
Primary Anterior Cruciate Ligament Rupture in Adults
Recommendation Grade of Evidence*
Operative treatment B construction appears to provide no difference compared with
Single-bundle reconstruction C single-bundle reconstruction in patient-reported outcomes. The
Double-bundle reconstruction C age and activity level of the patient are predictive of the return to
Autograft C sports and of reinjury. On the basis of the currently available
Allograft C data, the time to return to sports may not be predictive of reinjury
*Grade A indicates good evidence (Level-I studies with consistent
findings) for or against recommending the intervention; Grade B,
fair evidence (Level-II or III studies with consistent findings) for or
against recommending the intervention; Grade C, conflicting or
poor-quality evidence (Level-IV or V studies) not allowing a rec-
ommendation for or against the intervention; and Grade I, there is
89
insufficient evidence to make a recommendation .
that the rate of osteoarthritis was 2% and 8%, respectively, beyond
the mean follow-up time of ten years87,88.
It is the general consensus of the available evidence that
meniscal and/or cartilage damage and knee motion deficits after
surgery are associated with the development and/or progres-
sion of osteoarthritis after ACL reconstruction. Furthermore,
patients without concomitant joint pathology at the time of
ACL surgery appear to have a low rate of osteoarthritis, even at
relatively long-term follow-up. Continued investigation into the
cause and development of osteoarthritis after ACL reconstruction,
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Christopher D. Murawski, BS
Carola F. van Eck, MD, PhD
James J. Irrgang, PT, PhD, ATC, FAPTA
Scott Tashman, PhD
Freddie H. Fu, MD, DSc(Hon), DPs(Hon)
Department of Orthopaedic Surgery,
University of Pittsburgh School of Medicine,
3471 Fifth Avenue, Suite 1011,
Pittsburgh, PA 15213.
E-mail address for F.H. Fu: ffu@upmc.edu.
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