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Anterior Cruciate Ligament Reconstruction–Related Bone Contusions: Association with Intra-Articular Injury, Pain, and Outcomes

Introduction Bone contusions of the knee refer to bone injuries seen on magnetic resonance imaging (MRI) and are also referred to as bone bruising and bone marrow edema. These lesions likely depict hemorrhage, edema, or infarction resulting from trabecular microfractures. The prevalence of bone contusions has been reported to be as high as 80% in anterior cruciate ligament (ACL)-injured patients, and is primarily found on the…

The Treatment of Combined Posterolateral Knee Injuries and Anterior Cruciate Ligament Tears

Introduction Posterolateral knee injuries have been noted to be some of the most difficult knee injuries to diagnose and treat due to the multiple different structures, the intricate anatomical relationships, and the fact that there is no one specific clinical test to diagnose these injuries. In addition, the majority of posterolateral knee injuries occur in combination with cruciate ligament injuries and can often be overlooked. Thus…

Anterior Cruciate Ligament Deficiency in the Varus-Angulated Knee: Diagnosis, Surgical Techniques, and Clinical Outcomes

Authors’ note: This chapter represents a condensed version of a previously published work: Noyes FR, Barber-Westin SD. Tibial and Femoral Osteotomy for Varus and Valgus Knee Syndromes: Diagnosis, Operative Techniques, and Clinical Outcomes. In: Noyes’s Knee Disorders: Surgery, Rehabilitation, Clinical Outcomes . 2nd ed. Philadelphia: Elsevier; 2017;773–847. Introduction High tibial osteotomy (HTO) is a widely accepted operation for medial tibiofemoral osteoarthritis and varus deformity of the…

Anterior Cruciate Ligament Reconstruction Combined with High-Tibial Osteotomy, Autologous Chondrocyte Implantation, Microfracture, Osteochondral, and/or Meniscal Allograft Transplantation

Introduction Knees with chronic anterior cruciate ligament (ACL) tears often have degenerative changes. If these changes are severe, cartilage restorative procedures may be necessary in addition to ACL reconstruction (ACLR). The question in such cases is whether to perform the restorative procedures simultaneously with the ACLR. If they are not done simultaneously, the question becomes one of proper sequencing and the necessary time interval between procedures.…

Meniscal Repair with Anterior Cruciate Ligament Reconstruction

Introduction Meniscus tears are commonly encountered in the setting of anterior cruciate ligament (ACL) injury. For decades, the importance of the meniscus was not recognized. Previously the standard treatment for meniscus tears was excision. While we have improved on returning patients to high-level activities after ACL injuries, posttraumatic osteoarthritis in the decades that follow reconstruction continues to be problematic. The meniscus is becoming increasingly recognized for…

Treatment of Meniscus Tears with Anterior Cruciate Ligament Reconstruction

Introduction The treatment of meniscus tears in conjunction with anterior cruciate ligament (ACL) reconstruction requires a thorough understanding of the different types of meniscus tears and their capacity for healing. The factors to consider are whether the tear is medial or lateral, degenerative or nondegenerative, or stable or unstable, as well as the vascular zone of the meniscus. The treatment choices are to remove, repair, or…

Anterior Cruciate Ligament Injury Combined with Medial Collateral Ligament, Posterior Cruciate Ligament, and/or Lateral Collateral Ligament Injury

Introduction A knee dislocation injury is a rare but potentially devastating injury. The definition of knee dislocation includes the grossly unstable knee, with a minimum of two of the four major knee ligaments injured, regardless of a reduced joint line. Some authors suggest that any combined anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries be considered a knee dislocation, although knee dislocations have been…

Isolated Single-Bundle Reconstruction

Acknowledgments We acknowledge Fotios Paul Tjoumakaris, Anthony Buoncristiani, and James S. Starman, the authors of the previous edition, for their great contribution to this chapter. Introduction Restoration of the native anatomy and performing individualized anterior cruciate ligament (ACL) surgery are critical to a successful outcome after ACL reconstruction. The surgeon needs to consider multiple anatomic factors, such as size and shape of the tibial and femoral…

Acute Anterior Cruciate Ligament Rupture: A Biological Approach through Primary Anterior Cruciate Ligament Repair, Augmentation with Bone Marrow Stimulation, and Growth Factor Injection

Introduction Anterior cruciate ligament (ACL) injuries are common in recreational and competitive sporting activities. According to an ongoing study in the United States, an estimated 200,000 ACL reconstructions (ACLRs) are performed annually, and the incidence of ACL injury is roughly 1 in 3000 per year. The treatment of ACL injury is an area of considerable controversy, despite advances in sports medicine literature. The current gold standard…

Partial Tear of the Anterior Cruciate Ligament: Management with One-Bundle Augmentation Technique

Introduction The anterior cruciate ligament (ACL) consists of two distinct bundles, termed anteromedial (AM) and posterolateral (PL), based on their tibial insertions. Biomechanical studies have shown that both bundles contribute synergistically to knee stability throughout the joint’s range of motion. However, their function is distinctively diverse because the AM fibers are primarily tense in flexion, whereas the PL fibers are more tense in extension. Injuries of…

Operative Versus Nonoperative Treatment and Timing of Surgery in Skeletally Immature Patients with Anterior Cruciate Ligament Tear

Introduction As the percentage of the pediatric population engaged in organized athletic activity continues to climb, rates of sports-related injuries have increased commensurately. In particular, the rate of anterior cruciate ligament (ACL) reconstruction in skeletally immature patients has increased steadily over the past 20 years, with ACL tears now representing a large percentage of total knee injury claims in young athletes. Multiple factors have likely contributed…

An Overview of the Diagnosis and Treatment of the Torn Anterior Cruciate Ligament in the Skeletally Immature Athlete

Introduction Intrasubstance tears of the anterior cruciate ligament (ACL) were once considered a rare injury in skeletally immature athletes; however, they are now observed with increasing frequency. A dramatic rise in youth competitive athletic activity, early sport specialization, year-round training and competition, and lack of free play, along with increased awareness of ACL injuries in children, have contributed to a commensurate increase in the frequency of…

Techniques and Complications of Transphyseal Anterior Cruciate Ligament Reconstruction in the Skeletally Immature Patient

Introduction In general, the treatment of anterior cruciate ligament (ACL) injuries in adults has been extensively analyzed. However, this does not stand true for skeletally immature patients. The increasing incidence of such injuries, as well as the substantial spectrum and gravity of secondary complications, highlights the necessity for more in-depth research in this field. Injuries in pediatric and adolescent athletes have dramatically increased. Midsubstance ACL tears…

Revision Anterior Cruciate Ligament Reconstruction: Management of Femoral Tunnel Malposition

Introduction Revision anterior cruciate ligament (ACL) surgery represents a salvage procedure, and the patient should be counseled that the outcome is not likely to be as good as a primary procedure. The goal of surgery is to provide a stable pain-free knee joint. Return to sport is another goal, but is less predictable. In many cases, the status of the articular cartilage and meniscus are major…

Revision Anterior Cruciate Ligament Reconstruction with Bone–Patellar Tendon–Bone Autograft

Introduction Anterior cruciate ligament (ACL) reconstruction is a common procedure, with over 100,000 procedures performed annually in patients who have an active lifestyle and who are unable to continue with their activities because of instability. Yet the success rate of surgery varies widely, which results in some patients wanting or needing to undergo revision ACL surgery if they want to remain active and prevent knee instability.…

Hamstring Four- to Six-Strand Double-Bundle Graft for Revision or High-Risk Primary Anterior Cruciate Ligament Reconstruction

Introduction This chapter will describe a technique that provides the highest strength known graft for use in revision and high-risk primary anterior cruciate ligament reconstruction (ACLR), while allowing flexibility for femoral tunnel creation in the revision setting. Autograft has consistently shown better results than allograft and should be used whenever possible for ACL revision. Hamstring (HS), bone–patellar tendon–bone (BPTB), and quadriceps tendon (QT) are the only…

Graft Length in the Tunnel in Anterior Cruciate Ligament Reconstruction

Introduction The nature of anterior cruciate ligament (ACL) reconstruction is to create new graft-bone connections. Although in native ACL the ligament fibers attach to the bone surface of the femur and tibia, in ACL reconstruction, no one has been reported trying to attach the graft directly to the bone surface. It is hard to believe that a strong tendon-bone connection can be realized through tendon-bone surface…

Graft-Tunnel Healing

Introduction Graft healing within the bone tunnel and the intra-articular ligamentization process represent together the two main sites of biological incorporation after anterior cruciate ligament (ACL) reconstruction, since they contribute to the determination of the mechanical behavior of the femur-ACL graft-tibia complex. Graft-tunnel healing is a complex process influenced by several surgical and postoperative variables, and most of our knowledge on the physiology of graft-tunnel healing…