From the Guidelines
The posteromedial bundle of the anterior cruciate ligament (ACL) should be addressed through a double-bundle technique during ACL reconstruction surgery to provide more anatomic restoration of knee biomechanics and improve patient outcomes, particularly in young and/or active patients, as recommended by the American Academy of Orthopaedic Surgeons clinical practice guideline summary 1.
Key Considerations
- The posteromedial bundle plays a critical role in knee stability, providing resistance to rotational forces and posterior tibial translation, especially when the knee is in flexion.
- Addressing both the anteromedial and posteromedial bundles through a double-bundle technique can provide more anatomic restoration of knee biomechanics compared to single-bundle reconstruction.
- The posteromedial bundle originates from the posterior aspect of the femoral attachment and inserts on the medial tibial plateau.
- When injured, patients may experience increased rotational instability, particularly with pivoting movements.
- Rehabilitation following reconstruction should focus on progressive strengthening, proprioception, and gradual return to rotational activities, with a transition phase from sports participation to sports performance with progressive and controlled exposure to the athlete's sport 1.
Surgical Timing and Graft Choice
- Early reconstruction is preferred when surgical treatment is indicated for an acute isolated ACL tear, as the risk of additional cartilage and meniscal injury starts to increase within 3 months 1.
- Autograft should be considered over allograft to improve patient outcomes and decrease ACL graft failure rate, particularly in young and/or active patients, with bone-tendon-bone (BTB) or hamstring autografts being favored to reduce the risk of graft failure or infection 1.
Rehabilitation Protocol
- Exercise interventions should be considered the foundation of ACLR rehabilitation, with a focus on progressive strengthening, proprioception, and gradual return to rotational activities 1.
- Strength and motor control training should be combined in the rehabilitation protocol, with neuromuscular training added to strength training to optimize self-reported outcome measurements 1.
- Psychological factors, such as fear of reinjury, should be evaluated and addressed during rehabilitation to ensure a successful return to play 1.
From the Research
ACL Posteromedial Injury
- The provided studies do not specifically discuss ACL posteromedial injuries, but rather focus on ACL injuries in general.
- According to 2, ACL tears can occur from noncontact injuries, and women experience ACL tears up to nine times more often than men.
- The diagnosis of ACL injuries is typically made with a combination of patient history, clinical examination, and magnetic resonance imaging 3.
- Treatment options for ACL injuries include conservative management or surgical intervention, with the latter being the better option for patients who want to return to a high level of activity 2.
- Rehabilitation after ACL injury is critical for successful recovery, and protocols vary greatly with little consensus among practitioners 4.
- Some studies suggest that nonsteroidal anti-inflammatory drugs (NSAIDs) may not affect tissue healing after arthroscopic ACL reconstruction 5.
- The use of NSAIDs after ACL reconstruction may decrease adverse side effects caused by opioid drugs 5.
- Ligamentous injuries of the knee, including ACL, medial collateral, posterior cruciate, and posterolateral corner injuries, can be managed with conservative or surgical treatment depending on the severity and location of the injury 6.