The ACL Dilemma

T he more we learn, the more we often realize how much we don't know. Twenty-five years ago, I thought we had the anterior cruciate ligament (ACL) dilemma all figured out: arthroscopic technique, patellar tendon grafts, meniscus repair, and immediate motion. Everything looked good clinically until we started seeing the results of long-term outcome studies. 2 I must admit I've been missing some of the warning signs. While arthritic changes were not unusual in many of the knees of patients showing up 10 to 12 years after ACL surgery in my clinic, there were many who were out that long who were still active and doing pretty well. Consequently, I'm still not sure where the truth lies on the success of our current ACL techniques. Unfortunately, nothing changes perceived good results more than long-term follow-up. A close look at some of the best known clinical reviews reveals some interesting regional differences in treatment that may factor into the reported outcomes. For instance, in the review by Oiestad et al, in 2009, 6 a cohort study with an evidence level of II, there were 127 partial meniscectomies in 106 patients with only 8 meniscal repairs. The mean time from injury to ACL reconstruction was 28 months. The delay to reconstruction and the low number of meniscus repairs may reflect the Scandinavian approach, which may not be representative of clinical trends elsewhere and may explain some of the less-than-optimal clinical results. One of the difficulties in tracking results of specific ACL techniques is the rapidly changing ACL technique carousal. No doubt, the recent emphasis on a more anatomic reconstruction results in better surgeries and is a step in the right direction. Whether 1 bundle or 2, placing the graft in the anatomic femoral and tibial footprint while producing a more horizontal (and less vertical) graft will pay dividends. It's very interesting how technology drove us to the more vertical position and what we have done recently as surgeons to correct those errors. Being aware of how we went awry should help steer our efforts in the future as we more critically evaluate emerging technologies. Now that we are doing a better job placing the ACL graft in the femoral and tibial footprint, thinking more about the soft tissue mechanics of the graft itself appears worthwhile. 4 Most techniques use a strong, well-fixed construct, which will allow immediate motion, accelerated rehabilitation, and, consequently, …