Anterior Cruciate Ligament Injury

D espite more than 40 years of clinical focus on the anterior cruciate ligament (ACL)–injured knee, a complete understanding of the injury mechanism, the optimal treatment plan (including reconstruction), and the best protocol for rehabilitation continue to stimulate much debate. Prevention efforts focused on ACL injuries have been laudable, but unfortunately, far too many young athletes still fall victim to this injury and are denied the opportunity to reach their full athletic potential. Besides the deleterious effects on an athletic career, many lifestyles are sadly altered as the knee deteriorates, and physical limitations are realized as osteoarthrosis becomes a reality. All too often, this occurs at a very young age. Consequently, ACL research remains a booming business whose results occupy a large portion of our scientific journals and sports medicine meeting programs. But as this issue of Sports Health demonstrates, progress is being made in the search for the best medical evidence to guide injury prevention programs, reconstructive techniques, rehabilitation efforts, and guidelines for return to sport. The review of 55 ACL injury soccer videos by Brophy et al 2 suggests that it is safer for your knees to play an offensive position—70% of those ACL injuries occurred while defending (87% in females). Tackling was the most problematic skill, with 51% of injuries occurring during those maneuvers, most with contact. Not surprising! Cutting was the second most problematic skill, producing 15% of ACL tears. The take-home message for parents is try to convince your son's or daughter's coach that your kids belong on the offensive side of the ball because of their goal-scoring potential, and if they do end up on defense, teach them good tackling skills over and over and over again. If, however, your efforts at prevention are unsuccessful and an ACL tear occurs, find a surgeon who is willing to do an autograft reconstruction for your youngster, as emphasized by Wasserstein et al. 4 Although the level of evidence of this study (level 3) is not the highest due to the available studies, the numbers presented are pretty convincing. In 1016 ACL-injured patients with 2-to 4-year follow-up, the pooled failure prevalence was 9.6% (76 of 788) for autografts and 25% (57 of 228) for allografts. The number needed to benefit to prevent 1 failure by using autografts was only 7 patients (95% CI, 5-10). Disappointing is the almost 10% failure rate even in ACL autografts in this …