The document discusses anterior cruciate ligament (ACL) reconstruction and graft selection. It describes the anatomy of the ACL and common causes of injury. Diagnosis involves clinical tests and MRI imaging. Three main graft options exist - bone-patellar tendon-bone autograft, hamstring autograft, and allograft. The bone-patellar tendon-bone autograft integrates more quickly but risks anterior knee pain, while the hamstring autograft has less donor site morbidity but slower healing. Rehabilitation begins shortly after surgery, focusing on regaining range of motion and strengthening muscles around the knee. Graft selection depends on factors like activity level and age.

1. Running head: ANTERIOR COLLATERAL LIGAMNET RECONSTRUCTION 1
Anterior Collateral Ligament Reconstruction
“How to Choose the Graft Meant for You”
Ramon Valdez
Barry University

2. ANTERIOR COLLATERAL LIGAMENT RECONSTRUCTION 2
Anterior Collateral Ligament Reconstruction
The anterior collateral ligament is the main supporting structure in the knee joint when
preventing anterior displacement of the lower leg and internal rotation. The Anterior Collateral
Ligament (ACL) originates in the medial anterior aspect of the tibia, it then extends upwards
laterally and posteriorly to its insertion in the lateral condyle of the femur.
The ACL is the most commonly injured ligament of the knee. Injury to the ACL can
occur from numerous bodily motions, but is mainly associated with a hard hit from the side of
the knee, overextension of the knee, or an extreme twisting motion of the knee usually seen when
quickly changing positions during running. Individuals may feel a sudden pop or unstable feeling
in the knee followed by extreme pain and swelling within six hours of the time of injury. The
ACL injury is usually accompanied with a Medial Collateral Ligament (MCL) injury or a medial
meniscus injury, or even all three, commonly referred to as the unhappy triad; this correlation of
injury between these three structures of the knee is caused by a common chance of injury for
each negative force applied to the knee (Vorvick, 2015).
There are many ways to diagnose an ACL injury. In regards to ligaments, there is a high
level of blood supplied to the ACL; therefore, increased swelling soon after the injury is a sign of
ACL injury. Seventy-two percent of subjects with increased swelling soon after the injury were
confirmed to have injured their ACL. In only 15% of these cases was an isolated meniscal injury
diagnosed (Manning, Sloan, Draycott, & Barron, 2008). There are two anterior displacement
tests used to determine the laxity or lack of ACL support in the knee. The Lachman’s Test is

3. ANTERIOR COLLATERAL LIGAMENT RECONSTRUCTION 3
when the subject’s knee is placed at a 30-degree angle and the tibia is checked for anterior
displacement. The Anterior Drawer Test is the same as the Lachman’s Test, However, the knee
is placed at a 90-degree angle. Swelling usually prevents the subject from positioning his or her
knee to 90 degrees; therefore, the Lachman’s Test is a more viable method for clinical testing.
Even though these clinical methods of determining ACL injuries are helpful to develop a
basis for an accurate diagnosis, they are not always the most efficient method for doing so. Four
electronic databases (PubMed, MEDLINE, EMBASE, CINAHL) were analyzed to find Clinical
ACL tests and their results. A QUADAS-2 checklist was used to exclude cases with a high
chance of bias for the reasoning of the diagnosis. Of the four databases, a total of 285 articles
were extracted for analyzing. Of those, 14 were used for the review. Of those, nine were
diagnosed by physical symptoms (hearing a popping sound, swelling, pain, giving way, and
ability to continue activity) and 3 were diagnosed using clinical tests (Anterior Drawer Test,
Lachman’s Test, Prone Lachman’s Test and Pivot Shift Test). These clinical diagnostics were
analyzed using a positive negative likelihood ratio, and results showed that none of the tests
provided accurate information regarding a clinical diagnosis. Bias of injury was the number one
issue for providing an accurate and precise diagnosis (Swain, et al, 2014). The clinical post-
injury assessment of the ACL is unreliable; therefore, the importance of the MRI is paramount. It
provides adequate non-invasive imaging in all three planes (sagittal, coronal, and axial) to allow
medical examiners to create an accurate diagnosis and pre-surgical mapping of the injury
(Nissman, Hobbs, Pope, Geier, & Conway, 2008).
A partial tear of the ACL can sometimes heal on its own with the help of minimal
anterior, and internal rotational stress of the lower leg. Individuals have also been known to
continue daily life with a completely torn ACL. However, other injuries and extreme pain tend to

4. ANTERIOR COLLATERAL LIGAMENT RECONSTRUCTION 4
follow due to over compensation of surrounding structures. Once a complete tear is determined
and reconstruction is requested by the patient and deemed necessary by a physician, the process
of selecting the graft can begin. The patient’s lifestyle should be the ultimate guideline when
selecting a graft. There are three main methods: the bone-patella-bone (BPB) autograft, the
hamstring autograft, and the cadaver allograft. An autograft is a graft that comes from the
patient’s body. The bone-patellar tendon-bone method is the utilization of the central third of the
patellar tendon along with an attached block of bone from the patella and the tibia. Advantages
are that it is approximately the same length as the original ACL and the bone to bone healing
method is much quicker and durable. Disadvantages of the BPB method are that the patella now
has a greater risk of fracturing, as well as an increased chance of anterior knee pain where the
donor ligament was extracted (Cluett, 2014). Two tendons are extracted from the back of the leg
when using the hamstring method. They are then folded over to make a stronger ligament.
Advantages are that there is less pain experienced in the front of the knee post-surgery.
Disadvantages are that it takes longer for the graft to fuse to the insertion points on the tibia and
femur because it is not a bone top bone connection (Cluett, 2014). An allograft is a graft
selection that comes from another source other than the individual’s body such as a cadaver.
Advantages are that they do not cause any additional injury to another part of the body.
Disadvantages are that they are not as strong as the autograft and have a potential possibility of
carrying diseases during the transfer (Cluett, 2014).
BPB autograft is considered the gold standard because of the bone to bone healing. This
creates a stronger bond to the femur and the tibia four weeks faster than a soft tissue to bone
bond such as the hamstring graft method. However, they are both very effective, and when time
is not a factor, they can both perform to the same extent when becoming the subject’s new ACL

5. ANTERIOR COLLATERAL LIGAMENT RECONSTRUCTION 5
(Adhya, Dhillon, & Dhillon, 2014). The reason why the BPB method is so valuable is because
the bone to bone healing process decreases the time it takes for the graft to fully heal to the
patient, in turn decreasing opportunities for it to slip out of place. Out of 153 BPB graft
reconstructions there were 11 failures accounting for a 7.2% failure rate, but in a 165 hamstring
graft reconstructions, there were 26 failures accounting for a 15.8% failure rate. More athletes
have been recorded to return back to their level of play when having used the BPB graft method
(Poulsen & Johnson, 2010). This is attributed to the shorter healing process due to the bone-to-
bone connection. The comparison of autografts and allografts have shown that athletes who have
used allografts have taken longer to return to the playing field, and have had a 2 to 3 times higher
rate of failure than an autograft (Poulsen & Johnson, 2010). The graft recommendation from the
physician to the patient is usually based on the individual’s lifestyle. The BPB method and the
hamstring method both possess the possible risk of permanently injuring another part of the
body, although they both have a high level return rate. Whereas the allograft possesses minimal
risk to additional body parts; however, there is a high chance of increased graft failure. The BPB
graft is recommended for high level athletes because of the strength and high return rate of the
graft. Active patients younger than 40 years are advised to use the hamstring autograft due to it
having greater stability than the allograft. Active patients over 40 are advised to utilize the
hamstring option whereas non active patients are advised to have the allograft to prevent
unnecessary non-donor site morbidity (Poulsen & Johnson, 2010).
In order to insert the graft, the remains of the ruptured ACL must be shave off. Then,
three holes are drilled. One hole originates on the superior posterior part of the lateral femoral
condyle that angles downward and medially into the medial anterior plateau of the tibia. This is
where the graft will be fitted. Then, the second and third holes are drilled to insert the

6. ANTERIOR COLLATERAL LIGAMENT RECONSTRUCTION 6
arthroscopic camera and light source, and the arthroscopic instrument. The graft is pulled
through into the newly formed canal, and then wedged into place with screws. The security of
the new graft is tested by violently flexing and extending the leg at the knee joint. Once the graft
is deemed secure and of adequate tension, the skin is stitched together and the rehabilitation
process begins. The biggest factor determining a successful ACL surgery has been the different
methods of placement of the graft on the femoral condyle. Subjects with grafts placed too
anteriorly on the femur have lost range of motion in the knee which has resulted in permanent
stretching of the graft. It has also been observed that subjects with a vertically inserted graft have
experienced decreased stability in the knee and little resistance against internal rotation of the
knee as opposed to the more resistant weight bearing oblique style insertion (Markatos, Kaseta,
Lallos, Korres, & Efstathopoulos, 2013). This is why choosing the right surgeon is an extremely
important part of an ACL reconstruction because graft placement and attachment style have a
direct correlation to the level of success of the joint after surgery.
The rehabilitation process begins shortly after surgery has ended. Most of the
improvements were complete in respect to pain and range of motion by the 12-week mark
(Cupido, Peterson, Sutherland, Ayeni, & Stratford 2014). Once most of the extreme pain has
subsided, and the range of motion has been regained, major rehabilitation can begin. Most of the
support to the ACL is from the surrounding larger muscles around the knee. This is one of the
major reasons, along with other anatomical and hormonal differences, that ACL injuries tend to
be more prevalent in women than men. This is due to women naturally having less muscle mass
than men. In soccer ACL injuries are two to three times more common, and in basketball four
times more common in women than men. In general, women have a two to eight time’s greater
chance of an ACL injury, 70% of these occurring from non-contact (Rodenberg, Cayce, & Hall,

7. ANTERIOR COLLATERAL LIGAMENT RECONSTRUCTION 7
2006). Many people tend to take their physicians recommendation for graft selections. This is
why it is important for people to make informed decisions from detailed research and
contemplating the positives and negatives before agreeing to certain methods of reconstruction.

8. ANTERIOR COLLATERAL LIGAMENT RECONSTRUCTION 8
References
Adhya, B., Dhillon, M. S., & Dhillon, H. S. (2014). Rehabilitation Techniques after Anterior
Cruciate Ligament (ACL) Reconstruction the Indian Approach. Indian Journal Of
Physiotherapy & Occupational Therapy, 8(2), 236-243. doi:10.5958/j.0973-5674.8.2.092
Cluett, J. (2014, December 15). ACL Surgery Graft Options. Retrieved February 6, 2015, from
About Health website: http://orthopedics.about.com/cs/aclrepain/a/aclgrafts.htm
Cupido, C., Peterson, D., Sutherland, M. S., Ayeni, O., & Stratford, P. W. (2014). Tracking
Patient Outcomes after Anterior Cruciate Ligament Reconstruction. Physiotherapy
Canada, 66(2), 199-205. doi:10.3138/ptc.2013-19BC
Manning, M., Sloan, J., Draycott, S., & Barron, D. (2008). Soft tissue injuries: 5 The knee.
Emergency Medicine Journal, 25(12), 832-838. doi:10.1136/emj.2008.062927
Markatos, K., Kaseta, M., Lallos, S., Korres, D., & Efstathopoulos, N. (2013). The anatomy of
the ACL and its importance in ACL reconstruction. European Journal Of Orthopaedic
Surgery & Traumatology, 23(7), 747-752. doi:10.1007/s00590-012-1079-8
Nissman, D., Hobbs, R., Pope, T., Geier, C. J., & Conway, W. (2008). Imaging the knee:
ligaments. Applied Radiology, 37(12), 25.
Poulsen, M. R., & Johnson, D. L. (2010). Sports medicine update. Graft selection in anterior
cruciate ligament surgery. Orthopedics, 33(11), 832-835. doi:10.3928/01477447-
20100924-20
Rodenberg, R., Cayce, K. I., & Hall, S. (2006). Your guide to a dreaded injury: the ACL tear.
Contemporary Pediatrics, 23(7), 26-26-8, 31-4, 36 passim.
Swain, M. S., Henschke, N., Kamper, S. J., Downie, A. S., Koes, B. W., & Maher, C. G. (2014).
Accuracy of clinical tests in the diagnosis of anterior cruciate ligament injury: a

9. ANTERIOR COLLATERAL LIGAMENT RECONSTRUCTION 9
systematic review. Chiropractic & Manual Therapies, 22(1), 1-19. doi:10.1186/s12998-
014-0025-8
Vorvick, L. J. (2015, January 12). Anterior cruciate ligament (ACL) injury. Retrieved February
6, 2015, from Medline Plus website:
http://www.nlm.nih.gov/medlineplus/ency/article/001074.htm