What is the latest treatment guideline for a patient with an anterior cruciate ligament (ACL) tear?

Management of Anterior Cruciate Ligament Tear

For patients with acute ACL tears, the American Academy of Orthopaedic Surgeons (AAOS) 2023 guidelines strongly recommend early ACL reconstruction within 3 months for most active patients, as this reduces the risk of additional cartilage and meniscal injury. 1

Initial Management

• Aspirate painful, tense knee effusions after injury for symptom relief in the acute setting 2
• Obtain MRI for definitive diagnosis, which has 96% sensitivity and 97% specificity on 3T equipment 2
• Plain radiographs should be obtained to evaluate for bony injuries 3

Treatment Decision Algorithm

Surgical Candidates (ACL Reconstruction Recommended):

• Younger patients (<30 years) with vigorous physical activity 2
• Any active patient wanting to return to jumping, cutting, or pivoting sports 4
• Patients with physically demanding occupations 4
• Patients who fail conservative management 4
• Goal: Prevent future meniscus pathology and improve long-term pain and function 1, 2

Conservative Management Candidates:

• Less active patients with sedentary jobs 4
• Older patients (>40 years) with lower activity demands 4
• Treatment consists of physical therapy, bracing, and activity modification 4

Important caveat: Recent high-quality evidence from an 11-year randomized trial showed no difference in patient-reported outcomes between early reconstruction and initial exercise therapy with optional delayed reconstruction 5. However, this conflicts with the AAOS strong recommendation for early surgery, which is based on preventing secondary meniscal and cartilage damage.

Surgical Technique Recommendations

Timing:

• Perform reconstruction within 3 months to minimize risk of additional cartilage and meniscal injury (Strong recommendation) 1, 2

Reconstruction vs. Repair:

• Always perform reconstruction rather than repair due to lower revision surgery rates 1, 2

Graft Selection:

• Bone-patellar tendon-bone (BTB) autograft reduces risk of graft failure or infection 1, 2
• Hamstring tendon autograft reduces risk of anterior knee pain or kneeling pain 1, 2
• Autograft is preferred over allograft in younger athletes 4
• Allograft is reasonable in patients >40 years with lower activity levels 4

Surgical Approach:

• Single-bundle or double-bundle techniques can be used as outcomes are similar (Strong recommendation) 1, 2

Management of Concomitant Injuries

Combined ACL/MCL Tears:

• Treat the MCL non-surgically as this results in good patient outcomes 1, 2
• Surgical MCL treatment may be considered in select cases 1, 2

Meniscal Injuries:

• Perform meniscal repair whenever technically possible rather than meniscectomy, as repair results in similar clinical outcomes to isolated ACL injuries 2

Rehabilitation Protocol

• Include both open and closed kinetic chain exercises for quadriceps strength recovery 2
• Combine strength training with motor control training 2
• Adequate rehabilitation is fundamental to successful outcomes 2

Return to Sport Criteria

• Use functional evaluation (hop test) as one factor to determine return to sport readiness 1, 2
• This is a Limited recommendation, so clinical judgment should guide the decision 1

Post-Treatment Considerations

Bracing:

• Do not routinely use functional knee braces after isolated primary ACL reconstruction as they provide no clinical benefit 1

Long-Term Monitoring:

• Counsel patients about increased osteoarthritis risk even with successful surgical treatment 2
• Approximately 44% develop radiographic osteoarthritis by 11 years post-injury 5
• Address modifiable risk factors: weight control and quadriceps strengthening 2

Prevention Strategies

• Implement ACL injury prevention training programs for athletes in high-risk sports (Moderate recommendation) 1, 2
• These programs reduce the risk of primary ACL injuries 1, 2
• Do not use prophylactic knee bracing as it is not effective for preventing ACL injury 1

Common Pitfall:

The most recent high-quality 11-year RCT 5 challenges the AAOS strong recommendation for early surgery, showing equivalent patient-reported outcomes between early reconstruction and delayed optional reconstruction (with only 52% ultimately requiring surgery). However, the early reconstruction group had higher radiographic osteoarthritis scores. This creates a clinical dilemma: prioritize the AAOS guideline for active patients wanting to return to high-level sports, but consider initial conservative management with optional delayed reconstruction for less demanding activity goals.