Current Trends in Anterior Cruciate Ligament Reconstruction Part 2

Surgical management of the anterior cruciate ligamentdeficient knee has evolved from primary repair to extracapsular augmentation to anterior cruciate ligament reconstruction using biologic tissue grafts. The technique of anterior cruciate ligament reconstruction has improved over the last few decades with the aid of knowledge gained from basic science and clinical research. The biology and biomechanics of anterior cruciate ligament reconstruction were analyzed in the previously published first part of this article. In this second part, current operative concepts of anterior cruciate ligament reconstruction as well as clinical correlations are discussed. The latest information regarding anterior cruciate ligament reconstruction is presented with a goal of demonstrating the correlation between the application of basic science knowledge and the improvement of clinical outcomes. Surgical options for treatment of the ACL-deficient knee include primary repair, augmented primary repair, prosthetic replacement, and ACL reconstruction using various types of graft material. Anterior cruciate ligament-deficient knees are currently treated with reconstruction procedures that use biologic tissue grafts, as other types of surgical procedures have been performed with less success. A brief review of previously performed surgical procedures will be presented, followed by a focus on the current concepts of ACL tissue graft reconstructions. Pertinent clinical studies that review the results of various components of the operative procedure will be discussed, as well as a few key basic science principles. ACL SURGERY—TREATMENT PERSPECTIVES Primary suturing of the ruptured ACL is no longer recommended as a treatment option, as both retrospective and prospective data suggest that isolated primary repairs become functionally inadequate in a high proportion of patients. Although primary repair can be augmented with lateral extraarticular procedures, these procedures consist of placing a tissue weaker than the ACL in a nonanatomic position. Most extraarticular procedures have failed to restore satisfactory stability to the knee. An additional means of augmenting a primarily sutured ACL is with an artificial strut. This technique uses an artificial ligament-augmentation device placed in the over-the-top position on the lateral femoral condyle to provide some additional stability. However, a recent prospective, randomized study did not find that such augmentation improved the results achieved with primary repair alone. Prosthetic ligaments are not currently recommended for the reconstruction of the ACL. A recent review found that between 40% and 78% of 855 prosthetic ACL ligaments failed when assessed over a 15-year period. Another report found that 83% (46) of 55 knees that had been reconstructed with a Dacron prosthesis had significant osteoarthritic changes at 9-year follow-up. Synthetic grafts appear to cause more complications than biologic grafts. This may partly be the result of increased wear debris. The solution may come from tissue-engineered collagen scaffolds, enriched with growth factors. These materials may be sufficiently strong to allow the achievement * Address correspondence and reprint requests to Freddie H. Fu, MD, DSc, Chairman, Department of Orthopaedic Surgery, 1011 Kaufmann Building, 3471 Fifth Avenue, Pittsburgh, PA 15213. No author or related institution has received financial benefit from research in this study. 0363-5465/100/2828-0124$02.00/0 THE AMERICAN JOURNAL OF SPORTS MEDICINE, Vol. 28, No. 1 © 2000 American Orthopaedic Society for Sports Medicine