ACL Reconstruction

Mark arrived at my door today to announce that he wanted to join the ACL surgery club and had therefor gone and torn his ACL during a rousing game of football (that's soccer to the ignorant Americans). So, in light of this I went to look for the review articles I had read on ACL reconstruction and found that since my surgery a complete review issue was released by Clinics in Sports Medicine. I've included the important articles from that first, as it's the most recent source. But I will start by pointing out that it is clear from my reading that surgeons have their preferred methods and sometimes the conclusions drawn form the data are, by and large, opinion applied to completely inconclusive results. While I did not read any outright contradictions of the data—there was considerable wiggle room used in interpretation.

I will summarize my reading of the articles here and then group the articles by topic and relevance. I haven't read all of these articles as I couldn't find my original list and I read a bunch of them on paper hand haven't confirmed which was which.

First, Bone-Patellar-Bone autograft reconstructions are the oldest and probably the best under most valid statistical measures of knee function recovery but have the highest rate of associated long term post-surgery (anterior) knee pain. This anterior knee pain can also slow recovery as the time to full knee mobility is highly correlated with recovery time and the extra pain associated with the BPB autograft increases this time. Further, all the recent reviews I read suggested that the current generation of alternative allo and auto grafts had statistically indistinguishable results from the BPB autograft, though at least two meta-analyses showed at least one measure that was statistical better for each of the primary auto-grafts (PBP and hamstring) and the allograft comparisons appear to be the same. The primary worry cited in the allograft comparisons is the small (order ~1:400,000 chance) that you will receive an infection from the allograft and in one report I found the median surgical infection rate for this category is 0.36% suggesting that this should probably not be a primary concern (Am J Infect Control 31 (2003)). The other concern is a very small rate of rejection due to improper treatment but the rates were similarly very low (~1:100,000 if I remember correctly). There is a major advantage to the allograft as it allows for faster transition into recovery (less additional trauma) and it can be harvested to maximize match between the grafts bio-physical characteristics and that of the native ACL. A recent class of surgeries appears to be destined to be the new gold standard: the double bundle reconstruction. This actually locates two separate graft attachment points on the femur and tibia. These dual bundle reconstructions appear to be capable of both better duplicating the natural ACLs construction and reducing rotational laxity—a problem with current grafts (but least with the BPB graft).

Below I am grouping and categorizing the reviews. I would remember that the graft comparison reviews (especially the conclusion/discussions) appear to be slightly biased towards the particular surgeons favorite technique.

Clinics in Sports Medicine Review Issue

• Clinical outcomes of allograft versus autograft in anterior cruciate ligament reconstruction
• Allograft safety in anterior cruciate ligament reconstruction
• Soft tissue allograft and double-bundle reconstruction
• Primary anterior cruciate ligament reconstruction using contralateral patellar tendon autograft
• Bone-patella tendon-bone autograft anterior cruciate ligament reconstruction
• Biology of autograft and allograft healing in anterior cruciate ligament reconstruction

Allo vs Auto Graft

• Allografts in the treatment of anterior cruciate ligament injuries
• Should allografts be used for routine anterior cruciate ligament reconstructions?
• Anterior cruciate ligament reconstruction: allograft versus autograft

Additional ACL Surgery Procedures

• Cryotherapy after ACL reconstruction: a meta-analysis
• Bracing after ACL reconstruction: a systematic review

ACL Graft Comparisions

(Orrin Sherman's review first)

• Anterior cruciate ligament reconstruction: which graft is best?
• A comparison of autogenous patellar tendon and hamstring tendon grafts for anterior cruciate ligament reconstruction
• Hamstring tendon autograft better than bone patellar-tendon bone autograft in ACL reconstruction: a cumulative meta-analysis and clinically relevant sensitivity analysis applied to a previously published analysis
• Anterior cruciate ligament reconstruction, hamstring versus bone-patella tendon-bone grafts: a systematic literature review of outcome from surgery
• ACL reconstruction: a meta-analysis of functional scores
• Reconstruction of the anterior cruciate ligament: meta-analysis of patellar tendon versus hamstring tendon autograft
• Hamstring tendon autograft better than bone patellar-tendon bone autograft in ACL reconstruction: a cumulative meta-analysis and clinically relevant sensitivity analysis applied to a previously published analysis

Structure, Double Strand and Partial Tear

• Partial rupture of the anterior cruciate ligament
• Review article: anatomic double bundle anterior cruciate ligament reconstruction
• Anterior cruciate ligament anatomy and function relating to anatomical reconstruction

One Nasty Complication of BPB Grafts

• Indirect patella fractures following ACL reconstruction: a review

Injury Fate and Recovery Rates

• Fate of the anterior cruciate ligament-injured knee
• Return to play after anterior cruciate ligament reconstruction
• A review of ski injuries resulting in combined injury to the anterior cruciate ligament and medial collateral ligaments