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Corresponding author. Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan. Fax: +81 172 36 3826.
This clinical guideline presents recommendations for the management of patients with anterior cruciate ligament (ACL) injury, endorsed by the Japanese Orthopaedic Association (JOA) and Japanese Orthopaedic Society of Knee, Arthroscopy and Sports Medicine (JOSKAS).
Methods
The JOA ACL guideline committee revised the previous guideline based on “Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014”, which proposed a desirable method for preparing clinical guidelines in Japan. Furthermore, the importance of “the balance of benefit and harm” was also emphasized. This guideline consists of 21 clinical questions (CQ) and 23 background questions (BQ). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design.
Results
We evaluated the objectives and results of each study in order to make a decision on the level of evidence so as to integrate the results with our recommendations for each CQ. For BQ, the guideline committee proposed recommendations based on the literature.
Conclusions
This guideline is intended to be used by physicians, orthopedic surgeons, physical therapists, and athletic trainers managing ACL injuries. We hope that this guideline is useful for appropriate decision-making and improved management of ACL injuries.
1. Introduction
Japanese Orthopedic Association (JOA) Guideline for the treatment of anterior cruciate ligament (ACL) injury was first published in 2006, and was revised in 2012. Following the publication of the 2nd revised edition, many new studies were published in the literature. As a result of this increase in basic and clinical information, major advances of ACL injury treatment have been made in late years. Therefore, the ACL Guidelines Committee made the decision to prepare the 3rd revised edition in accordance with the Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014 [
] (MINDS 2014). MINDS 2014 proposed preferred methods of guideline preparation in Japan based on such as The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system, Cochrane Collaboration, Agency for Healthcare Research and Quality (AHRQ) and the Oxford EBM center. In the MINDS 2014, the preparation procedures of guidelines were defined precisely, in particular, the importance of a viable body of evidence was emphasized. For clinical questions (CQ), study reports were collected by systematic method, and were evaluated by outcome data and study design. The results were evaluated in light of a viable body of evidence and were required to emphasize the balance between risk and benefit.
Since CQ in the previous guidelines target orthopedic surgeons who are experts in sports medicine and knee surgery, the propriety of previous CQ was investigated. CQ that did not fit current practice standards and those pertaining to an expert opinion were excluded. New CQ thought to be relevant to general orthopedic surgeons and to the sports medicine field were added. All CQ (https://www.aaos.org/research/guidelines/ACLGuidelineFINAL.pdf) documented in the 2014 guidelines on ACL injury by the American Academy of Orthopedic Surgeons (AAOS ACL guideline) were included. Clinical and epidemiological characteristics, such as risk factors of ACL injury, were not incorporated into CQ; therefore, a commentary on these characteristics was added as background question (BQ). The guidelines are designed to assist the clinician in easily identifying areas of concern, and also allow the clinician to quickly grasp appropriate treatments for ACL injury.
2. Results of the literature search
In preparation for the 3rd edition revision, the authors performed a MEDLINE search of the literature that included papers published from September 2008 through April 2016. This search utilized the search formula presented in Table 1 and extracted 3753 papers. In addition, a Cochrane Library search was performed that included articles published from 2008 through 2016. This search utilized the search formula presented in Table 2 and extracted 600 articles. In the initial screening, articles that did not match the CQ based on their titles and abstracts were excluded. In order to narrow the number of documents, articles for CQ, which the AAOS ACL guidelines included, were limited to those with publications dates after 2013 and later. This date was later than the article collection time for the ACL injury guidelines of AAOS. In total, 979 articles were selected.
Table 1Search formula.
Medline Search
ID
Hits
Search Criteria
Explanation
L1
1425
S ANTERIOR (2A) CRUCIATE (2A) LIGAMENT?(4A) (INJUR? OR RUPTUR?)/TI
①L1-L4: anterior cruciate ligament/injury (included in the title or main theme)
L2
4086
S *ANTERIOR CRUCIATE LIGAMENT + AUTO/CT(L)IN/CT
L3
190
S *KNEE JOINT + NT/CT(L)IN/CT AND (ANTERIOR (1W) CRUCIATE (1W) LIGAMENT? OR ACL)/TI
L4
2794
S *KNEE INJURIES + AUTO/CT AND (ANTERIOR (1W) CRUCIATE (1W) LIGAMENT? OR ACL)/TI
L5
4613
S *ANTERIOR CRUCIATE LIGAMENT + AUTO/CT(L) (SU OR TR)/CT
②L5-L7: anterior cruciate ligament/surgery, transplant, reconstruction (included in the title or main theme)
L6
1748
S *ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION + AUTO/CT
L7
4888
S ANTERIOR (2A) CRUCIATE (2A) LIGAMENT?(4A) (SURG? OR OPERAT? OR TRANSPLANT? OR GRAFT? OR AUTOGRAFT? OR ALLOGRAFT? OR RECONSTRUCT?)/TI
L8
10222
S (L1 OR L2 OR L3 OR L4 OR L5 OR L6 OR L7)
①+②
L9
9193
S L8/HUMAN OR (L8 NOT ANIMALS + NT/CT)
Limited to humans
L10
8308
S L9 AND (EN OR JA)/LA
Limited to English and Japanese
L11
4202
S L10 AND 2008–2016/PY AND 2008090120160430/UP NOT EPUB?/FS
Limited to a certain age (September 2008–April 2016).
L12
3905
S L11 NOT (LETTER OR EDITORIAL OR COMMENT?)/DT
Letter, editorial, and comments excluded
L13
3753
S L12 AND AB/FA
Limited to literature with an abstract in the Database
3. Preparation of structured abstract and evaluation of the articles
The authors selected 106 clinicians who are experts in the treatment of knee joints from Japanese Orthopaedic Society of Knee, Arthroscopy and Sports Medicine (JOSKAS) board of trustees. These individuals constituted a systematic review team (SR Team). The SR Team performed a secondary screening from the full text of 979 articles and prepared structured abstracts from the articles selected in the secondary screening. The SR Team also performed evaluations for individual reports. The structured abstracts were based on MINDS 2014 [
] recommendations. SR Team members were assigned to specific areas of the ACL injury treatment guidelines. These team members evaluated the content of the articles based on the structured abstract. As a rule, the selected articles were closely related to the various clinical questions.
4. Strength of evidence and recommendations
The selected articles were evaluated by outcome data. Risk, lack of direction, inconsistencies, inadequacies, publication bias, etc., were evaluated to formulate a viable body of evidence. The evaluation and definition of the strength of the body of evidence were decided in accordance with Table 3. Recommended text was created for each CQ, and the strength of the recommendation was decided by the committee members using a GRADE grid as described in Table 4. The opinions of at least 70% of the voters were considered to determine the recommended final decision. If a consensus of at least 70% of the voters could not be obtained, a discussion and a secondary voting were required. The recommended texts were prepared based on the current practice of orthopedic surgeons, physiotherapists, etc., as well as the various levels of treatment of ACL injury. The authors also considered that laypersons, including patients, might also read the 3rd edition to in order to understand treatment guidelines.
For the 3rd edition, each selected article was evaluated according to the CQ, the outcome data, and the final body of evidence. Unlike in the previous edition, the evidence level of each article was not evaluated. When formulating the body of evidence, the strength of the outcome data of studies, such as randomized-controlled trials (RCT), was considered from the initial evaluation (A). The strength of outcome data from observational studies was evaluated from the initial evaluation (C). Appropriate operations were performed in order to raise or lower the level of each article being evaluated.
6. JOA 2019 guideline for anterior cruciate ligament injuries
6.1 Epidemiology, natural course, and pathological condition
The risk for a cruciate ligament injury of the knee in adolescents and young adults: a population-based cohort study of 46 500 people with a 9 year follow-up.
]. A relationship between non-contact ACL injury and menstrual cycle has been reported, and female athletes in the preovulatory phase were significantly more likely to sustain an ACL injury than those in the postovulatory phase [
]. It has been reported that female athletes with ACL injuries had significantly lower concentrations of 17-β estradiol, progesterone, and testosterone than control groups [
]. In addition, when the relative risk (RR) of cases with no history of oral contraceptive use is 1.0, RR associating oral contraceptive with ACL injury was 0.82 for individuals with and without history of oral contraceptive usage [
Is the use of oral contraceptives associated with operatively treated anterior cruciate ligament injury? A case-control study from the Danish Knee Ligament Reconstruction Registry.
], suggesting that there is a relationship between sex hormones and ACL injuries. In a survey taken at a United States military academy, general joint laxity and elevated body mass index (BMI) was associated with ACL injury [
] increases the risk of ACL injury. In recent years, detailed examination of the tibial joint surface using magnetic resonance image (MRI) has also been performed. A greater lateral meniscal slope [
] and smaller tibial plateau length relative to the femur and more convex articulating surface of the proximal aspect of the tibia and of the distal aspect of the femur [
] have been associated with risk of ACL injury, and a cutoff of >4° for the posterior tibial slope of the lateral compartment showed 76% sensitivity and 75% specificity for predicting ACL injury [
]. Moreover, in a study examining ACL injury risk from multiple anatomical factors, females with both a decreased femoral notch width and an increased posterior-inferior-directed lateral compartment tibial articular cartilage slope or males with a decreased ACL volume and decreased lateral compartment posterior meniscus angle were most at risk for sustaining an ACL injury [
]. In addition to knee joints, studies have also been conducted to identify anatomical risk factors in hip joints. It has been demonstrated that the center-edge angle in radiographs of ACL injured female patients was significantly smaller than that of the control group [
High knee abduction moments are common risk factors for patellofemoral pain (PFP) and anterior cruciate ligament (ACL) injury in girls: is PFP itself a predictor for subsequent ACL injury?.
], reduced electromyography (EMG) preactivity of the semitendinosus and increased EMG preactivity of the vastus lateralis during side cutting maneuvers [
] differed between ACL injured patients and control groups. An OR of 1.95 was found for ACL injury if the patients had a parent with a history of ACL injury [
]. Women's National Basketball Association reported that the OR for ACL injury in White European American basketball players versus non-White European American basketball players was 6.55 [
], suggesting race-dependent differences in the risk of ACL injury.
Most of the literature derives from observational studies, and little literature is available with a high evidence level. Studies that showed consistent results in reporting risk factors for ACL injury were adopted for preparing this guideline, in accordance with the guidelines of the previous edition. Although there were no studies demonstrating contradictory results, it is necessary to produce results with a high level of evidence in order to identify risk factors. Therefore, the recommendation for the existence of risk factors for ACL injury is low.
ACL injury usually occurs with knee valgus and tibial internal rotation during landing or deceleration.
Previously, the context of an ACL injury was reported based on interviews with injured patients, however, video analysis to study injuries has recently been introduced. Valgus knee motion and internal tibial rotation appear to be important components of the injury mechanism. Furthermore, an internally rotated position of the hip, foot contact with the heel striking the ground, and lateral trunk bending are considered to be associated with ACL injury.
] analyzed the kinematics from videos recorded by at least 2 cameras of actual ACL injury situations of 7 handball players and 3 basketball players using the model-based image-matching (MBIM) technique. Analysis revealed that sudden knee valgus development coupled with internal rotation of the tibia occurs during the first 40 ms following initial ground contact, and then after the ACL is torn, external rotation of the tibia occurs. These results suggested that knee valgus loading applies lateral compressive load, and the tibia translates anteriorly and rotates internally due to the posterior tibial slope of the lateral tibia plateau, resulting in ACL rupture [
] assessed the knee and hip kinematics of 2 slip-catch situations representative of a series of similar injuries from World Cup alpine skiing events using the MBIM technique. The hip was internally rotated and remained unchanged from the moment in which the ski tail touched the snow surface to ACL rupture, suggesting that a fixed and internally rotated position of the hip may contribute to ACL injury.
] reported that the foot touched the ground with the heel striking or in a full flat-foot position in all cases evaluating 29 videos of injury scenes in basketball matches. On inspecting 33 videos of soccer players, Walden et al. [
Three distinct mechanisms predominate in non-contact anterior cruciate ligament injuries in male professional football. Players: a systematic video analysis of 39 cases.
] reported that 11 players touched the ground with a heel-strike position and 7 players touched the ground with a full flat-foot position on ACL injury. The authors also reported that the trunk was laterally rotated toward the injured leg in 16 of the 33 videos [
Three distinct mechanisms predominate in non-contact anterior cruciate ligament injuries in male professional football. Players: a systematic video analysis of 39 cases.
Video analysis of trunk and knee motion during noncontact anterior cruciate ligament injury in female athletes: lateral trunk motion are combined component of the injury mechanisms.
] determined the trunk position of 10 female basketball players at the time of ACL injury, and compared the videos performing similar landing and cutting tasks with those of 6 female uninjured control athletes. They reported that ACL injured athletes showed increased lateral trunk angle toward the injured leg and less forward trunk lean than controls. These results suggested that the foot touching the ground by a heel-strike and the trunk laterally rotating toward the injured leg may contribute to ACL injury. However, these studies had a relatively small sample size of videos collected as a convenience sample; therefore, the findings from these studies may not be representative of all non-contact ACL injury mechanisms. Additional research is needed to further analyze videotapes of ACL injury where the injury is captured in various playing situations or motions associated with non-contact ACL injury including male and female athletes.
The prevalence of articular cartilage injury and medial meniscus tear would increase with time. The risk of these intra-articular injuries is affected by the patient's age, sex, and physical activity level.
If patients with an ACL injury do not receive any therapeutic intervention, the prevalence of articular cartilage and medial meniscus injury would increase as time passes from the initial ACL injury. A previous report of arthroscopic findings during ACL reconstruction showed that the prevalence of articular cartilage and meniscus injury increased in patients with a long time gap between ACL injury and reconstruction surgery [
]. Similarly, even in juvenile patients (average age: 15 years old), there was a greater incidence of medial meniscus injury or the worsening of existing medial meniscus injury as the duration between the ACL injury and reconstruction surgery increased [
Increasing incidence of medial meniscal tears in nonoperatively treated anterior cruciate ligament insufficiency patients documented by serial magnetic resonance imaging studies.
], second MRI evaluations showed a higher prevalence of medial meniscus injuries than the initial evaluations (the initial MRI evaluation: mean 8.5 months from the time of ACL injury; the second MRI evaluation: mean 46.9 months from the time of ACL injury).
Specifically, the prevalence of articular cartilage injury is likely to increase in older patients and that of meniscus injury is likely to be higher among men than women. In previous reports of arthroscopic findings during ACL reconstruction [
], aging increased the OR for the prevalence of articular cartilage injury; the OR for the prevalence of both medial and lateral meniscus injury was greater among men than among women.
Although patients’ activity level temporarily decreases after ACL injury, subjective knee function evaluation and muscle strength are relatively good in the short to middle term from the time of ACL injury. A previous study [
] which investigated the efficacy of conservative treatment on patients who injured their ACL (duration of observation: 12–66 months) reported a mean Lysholm score of 87 at the final follow-up; a decrease in the Tegner activity score from 7.1 (baseline) to 5.6 (final follow-up); and the ratio of hop-for-distance between the intact and the involved knee, which was constant at 96% at the final follow-up [
The Lachman and pivot shift tests are effective for manually diagnosing ACL injury.
ACL injury is generally evaluated using three manual tests, namely the Lachman test, pivot shift test, and anterior drawer test. In a meta-analysis of 28 studies conducted prior to 2000, the Lachman test was found to have the highest sensitivity and specificity, and the pivot shift test was found to have high specificity when used to manually evaluate acute ACL injuries without anesthesia, whereas the anterior drawer test had the lowest sensitivity and specificity [
]. In another meta-analysis of 14 studies from the past 30 years, the Lachman test was found to have the highest sensitivity and specificity, and the pivot shift test was found to have high specificity when used to manually evaluate acute ACL injuries [
]. A comparison of the results of manual testing with and without anesthesia indicated that the Lachman test had the highest sensitivity without anesthesia and exhibited similar specificities across three manual tests. The Lachman test exhibited the highest sensitivity, whereas the pivot shift test showed the highest specificity with anesthesia [
]. Manual testing under anesthesia revealed the pivot shift test to be the most sensitive and specific owing to the elimination of pain and muscular tension, which in turn improved test accuracy.
Both the Lachman test and pivot shift tests require a high degree of skill but are inexpensive and have good clinical relevance. These tests should therefore be included in the decision-making process despite not being referenced in detail in other guidelines or included as a CQ.
Although radiographs may not lead to a definitive diagnosis, indirect findings are useful for diagnosis and radiographs are also necessary for differential diagnosis.
Although radiographs may not lead to a definitive diagnosis of ACL injury, indirect findings suggesting ACL injury, including Segond fracture and lateral femoral notch sign, are helpful for diagnosis. In addition, three direction (anteroposterior, lateral, and axial views) knee radiographs are needed for differential diagnosis; these lead to early diagnosis such as fracture and knee joint dislocation requiring urgent care.
The Segond fracture is an avulsion fracture of the lateral tibial plateau visualized on the anteroposterior radiograph and has been referred to as the lateral capsular sign [
]. Therefore, if a Segond fracture is observed, ACL injury is suspected, and further examination is required.
The lateral femoral notch sign is a deep depression in the lateral femoral condyle on the lateral radiograph, and it is observed in 3.2–26.4% of ACL injuries [
]. A depth of the lateral femoral notch greater than 2.0 mm had a sensitivity of 3.2%, specificity of 100%, and a positive predictive value of 100% for ACL injuries [
]; therefore, it is a useful radiographic finding suggestive of ACL injuries.
Stress radiography to assess anterior instability for diagnosis of ACL injury has been reported, however there has been no consensus on whether it is more useful than other diagnostic tools [
ACL avulsion fractures are more common in children and adolescents than adults, and most occur in the tibial attachment, so diagnosis can be made if fracture lines or dislocated bony fragments are found in the tibial eminence.
Patellar dislocation, whose injury mechanism is relatively similar to ACL injury, also requires differential diagnosis. The patella is laterally displaced, and in about 20% of cases, osteochondral fragments (sliver sign) originating from the patella or the lateral femoral condyle are recognized in the joint. As for the sliver sign, it has been reported that there are about 30% of cases that can be confirmed only by axial imaging and that axial imaging should be taken [
The use of MRI is strongly recommended because it can provide confirmation of ACL injury and assist in identifying concomitant knee pathology such as other ligament, meniscus or articular cartilage injury, although the accuracy depends on performance of the imaging device or experience of the radiologists.
It is difficult for radiologists to diagnose ACL injury by plain X-ray alone because the ACL is commonly ruptured at the mid-substance of the ligament. Thus, MRI is useful to improve sensitivity in diagnosing ACL injuries, as it is superior for imaging soft tissue injuries.
According to a systematic review of 89 studies comparing MRI and arthroscopic findings, sensitivity and specificity of MRI in diagnosing ACL injuries were 87% and 91%, respectively [
]. The accuracy of MRI for diagnosing ACL injuries is reported to be consistent for the 3 cut-off time limits: 6 weeks (82.1%), 3 months (89.4%), and 1 year (89.4%) after injury [
]. When the diagnosis based on the MRI results of the ligament is equivocal, ancillary MRI findings may be helpful for diagnosing ACL injuries, as bone bruising in the posterior aspect of the tibial plateau, angulation of posterior cruciate ligament, and posterior displacement of the posterior horn of the lateral meniscus are highly specific for a torn ACL [
]. The sensitivity and specificity of MRI to detect an ACL graft tear were reported to be 60% and 87%, respectively. In addition, there is a false positive rate ranging from 6 to 11% for diagnosing meniscus injuries concomitant with an ACL injury. It has been reported that MRI was 77% sensitive and 90% specific for diagnosing medial meniscus injuries and had a 57% sensitivity and 95% specificity for diagnosing lateral meniscus injuries [
Diagnosis of ligamentous and meniscal pathologies in patients with anterior cruciate ligament injury: comparison of magnetic resonance imaging and arthroscopic findings.
Patients may do well with conservative treatment to some degree because there is no significant difference between conservative treatment and surgical treatment in terms of return to sport and progression of knee osteoarthritis. However, we suggest not doing conservative treatment from with the objective of preventing progression of meniscal injury (Recommendation 2, Agreement ratio 85.7%, Level C).
A study with meta-analysis on return-to-play after ACL injury showed that there were no significant differences between the surgical treatment group and conservative treatment group [
Is reconstruction the best management strategy for anterior cruciate ligament rupture? A systematic review and meta-analysis comparing anterior cruciate ligament reconstruction versus non-operative treatment.
]. Conversely, a systematic review on sport level and activity after ACL injury revealed that the recovery of the Tegner activity score was significantly better in the surgical treatment group than in the conservative treatment group [
]. The selection of conservative treatment or surgical treatment as well as method of evaluation for patients differed among studies. Thus, future research should attempt to investigate return-to-sport or recovery of sports level/activity with larger populations and consistent methods to evaluate patients after ACL injury.
As for the progression of knee osteoarthritis after ACL injury, a systematic review concluded that there was no significant difference between the surgical treatment and conservative treatment groups [
]. In addition, a long-term cohort study reported that the incidence of osteoarthritis after conservative treatment was relatively low (15%), and the progression of knee osteoarthritis occurred in cases of meniscal resection [
]. It is assumed that ACL reconstruction in itself cannot prevent progression of knee osteoarthritis and that meniscectomy or meniscal injury are the main causes of progression of knee osteoarthritis. However, during conservative treatment for ACL injury, not a small number of patients ultimately seem to have meniscal injury [
Is reconstruction the best management strategy for anterior cruciate ligament rupture? A systematic review and meta-analysis comparing anterior cruciate ligament reconstruction versus non-operative treatment.
Although there is limited evidence to support the efficacy of conservative treatment for ACL injury, patients may do well with conservative treatment to some degree. However, we cannot recommend conservative treatment as an approach to prevent progression of meniscal injury. In the consensus meeting, there was a statement from a member that recent anatomic ACL reconstruction might be more efficacious than conventional non-anatomic ACL reconstruction in preventing the progression of knee osteoarthritis.
Conservative treatment is recommended for skeletally immature patients with ACL injury. However, treatment methods should be decided in each case based on age, epiphyseal condition, and activity level of the patient.
A meta-analysis study concluded that knee instability after conservative treatment for skeletally immature patients with ACL injury was worse than that after early ACL reconstruction [
A meta-analysis evaluating the clinical results of skeletally immature patients with ACL injury showed that the International Knee Documentation Committee (IKDC) scores of patients who underwent surgical treatment was significantly higher than that of those who underwent conservative treatment. The authors of the study also reported that the Lysholm score of the patients who underwent surgical treatment was higher (although not statistically significant) than those of patients who underwent conservative treatment [
With regards to return-to-sport activity, a study with meta-analysis concluded that skeletally immature patients who underwent surgical treatment for ACL injury could return to their pre-injury sports level more often than those who underwent conservative treatment. Although an observational study showed that sports level and activity after conservative treatment for ACL injury in skeletally immature patients were low [
], another observational study showed that over half of skeletally immature patients who underwent conservative treatment could return to their pre-injury activity level [
Therefore, we cannot suggest conservative treatment for skeletally immature patients with ACL injury because of the limited strength of evidence does not support conservative treatment for these patients. However, the treatment method should be decided in each case based on age, epiphyseal condition, and activity of the patients.
The evidence level of the studies on skeletally immature patients with ACL injury is low because several previous studies were observation studies and the number of the patients in each study was small. Although more studies with higher evidence level are desirable, it may be difficult to perform such high evidence level studies in skeletally immature patients with ACL injury (See CQ11 for ACL reconstruction before epiphyseal closing).
We recommend ACL reconstruction in active young adult patients because the surgical treatment improves subjective as well as objective knee instability (Recommendation 1, Agreement ratio 100%, Level B).
This guideline committee additionally selected one systematic review [
] from the studies between 2012 and 2016 investigating surgical reconstruction in active young adult patients with ACL injury. The systematic review summarized and evaluated research on factors predictive of progression to surgery after nonoperative treatment for ACL injury. The systematic review included two studies to determine whether activity before ACL injury affects progression to surgery after nonoperative treatment for ACL injury. Although one of the studies showed that high activity levels before ACL injury predicted an outcome of subsequent ACL reconstruction after nonoperative treatment, the other concluded that activity before injury did not affect progression to surgery after nonoperative treatment. In addition, the systematic review showed that neither sex nor the severity of the knee joint laxity could predict whether a patient required ACL reconstruction following nonoperative treatment [
The AAOS ACL guideline considered “ACL Young Active Adult” as a CQ and concluded that moderate evidence supported surgical reconstruction in active young adult (18–35 years old) patients with an ACL tear. The guideline indicated that ACL reconstruction decreased pathologic laxity, as measured by the Lachman, KT-1000, and pivot shift tests, and reduced episodes of instability [
Although additional studies with higher strength of evidence are necessary regarding the relationship between objective/subjective knee instability and meniscal/chondral injury, we recommend ACL reconstruction in active young adult patients.
There is no obvious evidence comparing non-operative treatment to ACL reconstruction in patients with recurrent instability.
With respect to treatment for patients with recurrent instability, one systematic review summarized and evaluated the available research on factors predictive of progression to surgery after nonoperative treatment. The study concluded that sex and knee joint laxity tests did not predict the need for ACL reconstruction soon after ACL injury [
]. This study compared two groups of interest: an ACL-unstable group that ultimately did not undergo ACL reconstruction despite persistent pathologic laxity, as well as an ACL-unstable group that ultimately did undergo late ACL reconstruction following recurrent instability. At final follow-up, 18% of the 139 non-ACL-reconstructed, unstable patients felt giving way during sports activity while only 3% of the 33 late-ACL-reconstructed patients felt giving way. Similarly, 9% of the non-ACL reconstructed, unstable patients felt giving way with daily activities, while only 3% of the late-ACL-reconstructed patients felt giving way with daily activities. Objective instrumented findings and results of physical examination paralleled these subjective findings. Eighty-four percent of the non-ACL-reconstructed, unstable patients demonstrated positive KT-1000 arthrometer measurements (>3 mm side-to-side differences with manual maximum testing) and 84% had positive pivot shift testing. Seventy percent of late-ACL-reconstructed patients demonstrated positive KT-1000 arthrometer measurements and 52% had positive pivot shift testing.
However, the above was the only study included in the AAOS ACL guideline, which was published in 1994. In addition, clinical results of the study were not satisfactory. Considering the results of the study, which was included in the ACL guideline [
There are no differences in clinical results of ACL reconstruction between middle-aged patients and young patients. Therefore, treatment method should be decided considering the patient's desire to return to sports or to another activity (Recommendation 2, Agreement ratio 71.4%, Level C).
Several studies have shown good clinical results on return to sports after ACL reconstruction in middle-aged patients [
]. On the other hand, a study (published in 2011) compared activity levels after ACL reconstruction between 20 patients aged over 50 years and 20 patients aged under 30 years. The study showed that although 18 patients (90%) in the younger group (<30 years old) could return to pre-injury activity level, only 12 patients (60%) in the older group (>50 years old) returned to their pre-injury activity level. The authors concluded that the rate of return to pre-injury activity levels in patients aged >50 years was significantly lower than that in younger group [
There is no clear evidence regarding progression of knee osteoarthritis (OA) following ACL injury. A non-RCT investigated clinical results of conservative and surgical treatment for ACL injury in middle-aged patients, and concluded that there was no significant difference in the progression of knee osteoarthritis comparing conservative and surgical treatment. However, the study included primary repair of the ACL and extra-articular reconstruction in the surgical treatment group, which are procedures that are not acceptable as current treatment methods [
Operative or conservative treatment of the acutely torn anterior cruciate ligament in middle-aged patients. A follow-up study of 133 patients between the ages of 40 and 59 years.
]. An observation study showed that there was no or little radiographic change of osteoarthritis more than 2 years after ACL reconstruction in patients aged older than 40 years [
]. For conservative treatment for ACL injury, a study showed that there was no radiographic change in osteoarthritis in 87% of the patients 5–18 years (average; 7 years) after the injury [
Many studies have reported good knee stability after ACL reconstruction in middle-aged patients. A systematic review published in 2011 showed that knee stability improved after ACL reconstruction in all of the included studies [
]. An observational study evaluated knee stability after ACL reconstruction in 30 patients aged >40 years and in 37 patients aged 20–24 years. The authors concluded that, at the final follow up, there were no significant changes in knee stability during side-to-side movements measured by a KT-1000 arthrometer between the two groups [
Most studies mentioned above were observation studies and only studied middle-aged patients who underwent ACL reconstruction. Although some studies have evaluated middle-aged patients as well as young patients subjected to ACL reconstruction, few studies have compared clinical results from surgical and conservative treatment in middle-aged patients with ACL injury. Moreover, the surgical methods used in these few studies are not compatible with current treatment methods. Therefore, in the consensus meeting, the strength of the recommendation for this clinical question was “limited”.
We recommend performing ACL reconstruction early after injury (within 3–6 months) (Recommendation 1, Agreement ratio 100%, Level B).
It is well known that arthroscopy frequently shows concomitant meniscus injury in cases with chronic ACL injury. An observation study evaluated concomitant meniscus injuries after ACL injury in 1375 patients, and showed that the risk of incidence of meniscus injury significantly increased from 26 weeks after ACL injury when compared to the incidence within 2 weeks after injury. The authors also concluded that the rate of concomitant meniscus injury after ACL injury was significantly higher in male than in female patients, and patient activity did not significantly affect concomitant meniscus injury [
We performed a meta-analysis to compare early (within 3 months after ACL injury) and late ACL reconstruction. The analysis showed that the incidence of meniscus injury was lower in the early ACL reconstruction group than in the late reconstruction group (Fig. 1) [
Prospective evaluation of patients with anterior cruciate ligament reconstruction using a patient-based health-related survey: comparison of acute and chronic cases.
]. In Fig. 1, the OR of meniscus injury was evaluated without distinguishing the medial and lateral meniscus. When evaluating only studies that reported the incidence of medial and lateral meniscus injuries separately, the incidence of medial meniscus injury was lower in the early ACL reconstruction group than in the late reconstruction group (Fig. 2) [
Prospective evaluation of patients with anterior cruciate ligament reconstruction using a patient-based health-related survey: comparison of acute and chronic cases.
Prevalence of associated lesions in anterior cruciate ligament reconstruction: correlation with surgical timing and with patient Age, sex, and body mass index.
]. Conversely, despite the incidence of lateral meniscus injury having a tendency to be lower in the early ACL reconstruction group, there was no significant difference in incidence between the early and late ACL reconstruction groups (Fig. 3) [
Prospective evaluation of patients with anterior cruciate ligament reconstruction using a patient-based health-related survey: comparison of acute and chronic cases.
Prevalence of associated lesions in anterior cruciate ligament reconstruction: correlation with surgical timing and with patient Age, sex, and body mass index.
Many investigators have reported that a longer interval between ACL injury and surgery can cause articular cartilage injury of the knee. An observation study that investigated the relationship between the incidence of articular cartilage injury and interval between injury and surgery reported that the average interval in patients without cartilage injury was 17.4 months. Conversely, the average interval between injury and surgery in patients with cartilage injury was significantly longer (37 months) than that in patients without cartilage injury. The authors also showed that the longer the interval between injury and surgery, the worse the articular cartilage conditions [
]. The meta-analysis reported in this guideline also supports early (within 3 months after injury) ACL reconstruction from the standpoint of preventing articular cartilage injury (Fig. 4) [
Prospective evaluation of patients with anterior cruciate ligament reconstruction using a patient-based health-related survey: comparison of acute and chronic cases.
A comparison of results in acute and chronic anterior cruciate ligament ruptures of arthroscopically assisted autogenous patellar tendon reconstruction.
An observation study on knee stability after ACL reconstruction found that there was no significant difference between early and late ACL reconstruction groups in terms of the knee stability [
A comparison of results in acute and chronic anterior cruciate ligament ruptures of arthroscopically assisted autogenous patellar tendon reconstruction.
An observation study investigating the return to sport activity after ACL reconstruction reported that, at the final follow-up, 83% of the patients who underwent ACL reconstruction within 3 months after injury (average; 6 weeks) returned to their sports, and 86% of the patients who underwent ACL reconstruction more than 3 months after injury (average; 54 months) returned to their sports [
A comparison of results in acute and chronic anterior cruciate ligament ruptures of arthroscopically assisted autogenous patellar tendon reconstruction.
]. An observation study investigating the activity level after ACL reconstruction showed that the average Tegner activity score was 8 in the early reconstruction group and 6 in the late reconstruction group (12–24 months after injury) [
According to the aforementioned systematic reviews and the meta-analysis presented herein, we considered the strength of evidence to be moderate in the consensus meeting, and recommend performing ACL reconstruction early after injury.
There are no significant differences between the grafts in terms of the clinical outcome of ACL reconstruction (Recommendation 1, Agreement ratio 100%, Level A).
ACL reconstruction requires bone tunnel creation to the anatomical ACL insertion and appropriate graft selection. Although bone-patellar tendon-bone (BTB) graft and hamstring tendon (HT) graft are commonly selected, the graft that is most suitable for ACL reconstruction is unclear. A systematic review of the clinical outcomes showed that there were no differences in anterior tibial translation, Lachman test, pivot shift test, IKDC objective score, re-injury rate, restriction of extension or flexion angle, and return to sports between BTB and HT reconstruction [
Increased incidence of osteoarthritis of knee joint after ACL reconstruction with bone-patellar tendon-bone autografts than hamstring autografts: a meta-analysis of 1,443 patients at a minimum of 5 years.
] (Fig. 5, Fig. 6, Fig. 7). An RCT with 150 ACL reconstruction procedures showed that the outcomes of both BTB and HT reconstruction were excellent and had no differences in clinical scores (Knee Injury and Osteoarthritis Outcome Score [KOOS] and Lysholm score) and objective scales (anterior tibial translation, pivot-shift test, and strength tests) [
Prospective randomized study of objective and subjective clinical results between double-bundle and single-bundle anterior cruciate ligament reconstruction.
A nationwide registry revealed that revision rates of HT reconstruction were 0.65% (within 1 year) and 4.45% (within 5 years) and those of BTB reconstruction were 0.16% (within 1 year) and 3.03% (within 5 years). Adjusted relative risks for revision surgery were 3.82 (95% confidence interval [CI] 1.20–12.2) within 1 year, and 1.90 (95% CI: 0.43–8.40) within 5 years, and the 1-year revision rate of HT reconstruction was higher than that of BTB reconstruction [
Comparison of hamstring tendon and patellar tendon grafts in anterior cruciate ligament reconstruction in a nationwide population-based cohort study: results from the Danish registry of knee ligament reconstruction.
Lower risk of revision with patellar tendon autografts compared with hamstring autografts: a registry study based on 45,998 primary ACL reconstructions in Scandinavia.
]. BTB reconstruction has the advantage of avoiding postoperative loss of knee flexion strength, while HT reconstruction is superior with regard to anterior knee pain and kneeling pain (Fig. 8, Fig. 9) [
The incidence of knee osteoarthritis over 15-year follow-up after HT reconstruction was 32% and that after BTB reconstruction was 26%—the difference was not statistically significant. However, a meta-analysis of 290 ACL reconstructions indicated that knee osteoarthritis incidence was significantly higher after BTB reconstruction and HT reconstruction prevented osteoarthritis progression [
Increased incidence of osteoarthritis of knee joint after ACL reconstruction with bone-patellar tendon-bone autografts than hamstring autografts: a meta-analysis of 1,443 patients at a minimum of 5 years.
Quadriceps tendon can represent a graft option for ACL reconstruction as it showed comparable results with that of patellar tendon or hamstring tendon (Recommendation 2, Agreement ratio 85.7%, Level C).
Six studies, including randomized controlled trials, non-randomized controlled trials and cohort studies, directly compared quadriceps tendon (QT) grafts with BTB grafts. Five of 6 studies found no difference in clinical outcomes between QT and BTB [
Quadriceps tendon autograft for anterior cruciate ligament reconstruction: a comprehensive review of current literature and systematic review of clinical results.
]. In contrast, only one study found that BTB was better than QT. Regarding knee stability, 4 of 6 studies found no difference, whereas 2 studies showed that QT was significantly better than BTB in some of knee stability examinations. Regarding patient satisfaction, 1 of 3 studies found that patients undergoing ACL reconstruction with BTB were more satisfied than those with QT, while the other two studies showed no differences. There was only one study comparing postoperative quadriceps strength, showing no significant differences. All 5 comparative studies comparing postoperative pain demonstrated that reduced donor-site pain could be observed in the QT group than in the BTB group. Based on these reports, the QT showed comparable results with BTB in terms of clinical outcomes, knee stability, and patient satisfaction after ACL reconstruction, and less donor-site morbidity. No study has directly compared QT and hamstring tendon. In addition, the number of cases with QT was smaller than BTB and hamstring tendon.
In the consensus meeting, there was an opinion that QT should not be recommended because of the lack of favorable biomechanical studies. However, to date QT can be suggested as a graft option for ACL reconstruction—an option that was agreed upon by 6 of the 7 committee members and was thus recommended in the consensus meeting.
The practitioner might not use allograft tissue because the occurrence of re-tear of the graft is recognized to be more frequent in allografts, especially in young patients or highly active patients, although these results may be almost similar (Recommendation 2, Agreement ratio 85.7%, Level B).
This recommendation was based upon five meta-analyses (1980–2014) [
Post-operative complications following primary ACL reconstruction using allogenic and autogenic soft tissue grafts: increased relative morbidity risk is associated with increased graft diameter.
When comparing the clinical results of autografts and allografts, the meta-analyses demonstrated no significant difference in IKDC evaluation, Lysholm score, Lachman test, pivot shift test, the KT-1000 knee arthrometer measures, and complications (Fig. 10, Fig. 11, Fig. 12, Fig. 13, Fig. 14, Fig. 15).
Fig. 10Objective IKDC score (normal and nearly normal) after ACL-R for autografts versus allografts.
However, case–control studies showed that postoperative complications occur twice as often in ACL reconstruction using an allograft rather than an autograft [
] (Fig. 16). ACL reconstruction using autografts achieved better postoperative results in the IKDC and Tegner activity scores (Fig. 17). Moreover, the time to return to sports activity was shorter in revision ACL reconstruction using an autograft rather than an allograft [
] (Fig. 18). A case–control study demonstrated that the ratio of the re-tear of the graft is significantly higher in ACL reconstruction using allografts, especially in active adolescents (aged <19 years) [
Post-operative complications following primary ACL reconstruction using allogenic and autogenic soft tissue grafts: increased relative morbidity risk is associated with increased graft diameter.
The Japan Health Insurance Association established that ACL-reconstruction using an allograft is relevant to the 2016 Revision of Medical Fees K059-3, which stipulates that allografts should be appropriately harvested, processed, and preserved in tissue banks approved by the Japanese Society of Tissue Transplantation.
No clear recommendations as there are few useful reports.
One study reported that a positive Lachman test was found in 74.5% of cases and that osteoarthritic changes were observed in all cases 19 years after ACL reconstruction with an artificial ligament [
], while another study concluded that an artificial ligament was not recommended for primary ACL reconstruction because of the high frequency of graft tears and low IKDC/Lysholm score [
]. Furthermore, the number of ACL reconstructions using artificial ligaments has decreased recently, as some cases resulted in inflammatory findings including fluid collection and synovitis. Comparing the outcomes after ACL reconstruction between artificial ligament and autografts, there were no significant differences between artificial ligament and patellar tendon autografts after over a 4-year follow-up [
]. However, these studies cannot be simply compared, as different types of autograft were used and tunnel locations were not anatomical. Further studies are warranted.
There is limited evidence to support that in patients undergoing ACL reconstructions, the practitioner should use a double bundle technique as the postoperative ratio of the pivot shift test is significantly lower than that with the single bundle technique, although results in subjective knee evaluations, the KT-1000 knee arthrometer measures, and proprioception are quite similar (Recommendation 2, Agreement ratio 71.4%, Level C).
This recommendation was based on a meta-analysis comparing five different meta-analyses (2006–2016) [
Does double-bundle anterior cruciate ligament reconstruction improve postoperative knee stability compared with single-bundle techniques? A systematic review of overlapping meta-analyses.
Comparison of single-bundle versus double-bundle anterior cruciate ligament reconstruction after a minimum of 3-year follow-up: a meta-analysis of randomized controlled trials.
Prospective randomized study of objective and subjective clinical results between double-bundle and single-bundle anterior cruciate ligament reconstruction.
A prospective randomized study of 4-strand semitendinosus tendon anterior cruciate ligament reconstruction comparing single-bundle and double-bundle techniques.
Reconstruction of the ACL with a semitendinosus tendon graft: a prospective randomized single blinded comparison of double-bundle versus single-bundle technique in male athletes.
Knee Surg Sport Traumatol Arthrosc.2008 Mar; 16: 232-238
Comparison of anatomic double- and single-bundle techniques for anterior cruciate ligament reconstruction using hamstring tendon autografts: a prospective randomized study with 5-year clinical and radiographic follow-up.
Clinical evaluation of anatomic double-bundle anterior cruciate ligament reconstruction procedure using hamstring tendon grafts: comparisons among 3 different procedures.
A retrospective study of the midterm outcome of two-bundle anterior cruciate ligament reconstruction using quadrupled semitendinosus tendon in comparison with one-bundle reconstruction.
Anatomic reconstruction of the anterior cruciate ligament using double-bundle hamstring tendons: surgical techniques, clinical outcomes, and complications.
Double-bundle anterior cruciate ligament reconstruction with split Achilles allograft and single tibia tunnel for small ACL tibial footprint : technical note with clinical results.
Clinical outcomes of second-look arthroscopic evaluation after anterior cruciate ligament augmentation: comparison with single- and double-bundle reconstruction.
Dynamic effect of quadriceps muscle activation on anterior tibial translation after single-bundle and double-bundle anterior cruciate ligament reconstruction.
When comparing the clinical results between the single- and double-bundle technique, the meta-analysis demonstrated no significant differences in the Lysholm score, KOOS (4 items), KOOS pain, KOOS sports, the KT-1000 knee arthrometer measures, and the re-tear ratios (Fig. 19, Fig. 20, Fig. 21, Fig. 22, Fig. 23, Fig. 24, Fig. 25, Fig. 26).
Fig. 19Lysholm score after ACL-R for DB versus SB (Controlled Clinical Trial).
However, several studies have shown that the postoperative ratio of the pivot shift test is significantly lower in the double bundle technique than in the single bundle approach (Fig. 27, Fig. 28) [
Does double-bundle anterior cruciate ligament reconstruction improve postoperative knee stability compared with single-bundle techniques? A systematic review of overlapping meta-analyses.
A prospective randomized study of 4-strand semitendinosus tendon anterior cruciate ligament reconstruction comparing single-bundle and double-bundle techniques.
Clinical evaluation of anatomic double-bundle anterior cruciate ligament reconstruction procedure using hamstring tendon grafts: comparisons among 3 different procedures.
Outcomes of anterior cruciate ligament reconstruction using single-bundle versus double-bundle technique: meta-analysis of 19 randomized controlled trials.
]. Although, one study demonstrated that the postoperative ratio of the pivot shift test was significantly lower in the double-bundle technique than in the single-bundle approach for up to 5 years after surgery, this difference diminished after 5 years [
Comparison of single-bundle versus double-bundle anterior cruciate ligament reconstruction after a minimum of 3-year follow-up: a meta-analysis of randomized controlled trials.
Five of seven (71.4%) committee members recommended that in patients undergoing ACL reconstructions, the surgeon may choose the double-bundle technique, whereas one (14.3%) insisted that this should be the only technique used.
Agreement to use a double-bundle technique depends on the low postoperative ratio of the pivot shift test and reconstruction to mimic the anatomy of the ACL. A lack of recommendation depends on the similarity of the postoperative clinical outcomes and cost of the surgery.
There is limited evidence supporting that in patients undergoing ACL reconstructions, the surgeon should use a tibial independent approach for femoral tunnel placement (either a trans-portal or outside-in technique), because the approach is readily accepted for the anatomy of the ACL, although clinical and measured outcomes are similar (Recommendation 2, Agreement ratio 71.4%, Level C).
This recommendation was based on three systematic reviews [
Outcome of single-bundle hamstring anterior cruciate ligament reconstruction using the anteromedial versus the transtibial technique: a systematic review and meta-analysis.
Comparison of femoral tunnel length and obliquity between transtibial, anteromedial portal, and outside-in surgical techniques in single-bundle anterior cruciate ligament reconstruction: a meta-analysis.
Femoral tunnel position on conventional magnetic resonance imaging after anterior cruciate ligament reconstruction in young men: transtibial technique versus anteromedial portal technique.
Modified transtibial versus anteromedial portal technique in anatomic single-bundle anterior cruciate ligament reconstruction: comparison of femoral tunnel position and clinical results.
Biomechanical comparison between the rectangular-tunnel and the round-tunnel anterior cruciate ligament reconstruction procedures with a bone-patellar tendon-bone graft.
Anteromedial portal versus transtibial drilling techniques in anterior cruciate ligament reconstruction: any clinical relevance? A retrospective comparative study.
Evaluation of femoral tunnel positioning using 3-dimensional computed tomography and radiographs after single bundle anterior cruciate ligament reconstruction with modified transtibial technique.
Evaluation and comparison of femoral tunnel placement during anterior cruciate ligament reconstruction using 3-dimensional computed tomography: effect of notchplasty on transtibial and medial portal drilling.
Orthop J Sports Med.2014 Mar 5; 2 (2325967114525572)
Anatomic single-bundle ACL reconstruction is possible with use of the modified transtibial technique: a comparison with the anteromedial transportal technique.
When comparing the clinical results between the trans-portal and trans-tibial technique, it was controversial which method was superior. Several studies suggested that the trans-portal procedure resulted in better postoperative clinical outcomes, a higher ratio of return to sports activities, better anterior stability, and lower postoperative ratio of the pivot shift test, than the trans-tibial technique [
Femoral tunnel position on conventional magnetic resonance imaging after anterior cruciate ligament reconstruction in young men: transtibial technique versus anteromedial portal technique.
Modified transtibial versus anteromedial portal technique in anatomic single-bundle anterior cruciate ligament reconstruction: comparison of femoral tunnel position and clinical results.
Anteromedial portal versus transtibial drilling techniques in anterior cruciate ligament reconstruction: any clinical relevance? A retrospective comparative study.
Anatomic single-bundle ACL reconstruction is possible with use of the modified transtibial technique: a comparison with the anteromedial transportal technique.
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