ACL Deficient Knee, an Approach to Patient Selection and Reconstruction.

Rupture of the anterior cruciate ligament (ACL) is one of the most common injuries of the knee in the athletes and other group of patients who present to the knee clinics each year . Near to 250000 ACL ruptures occur in the Unites State each year. Almost 100000 ACL reconstructions are performed in the USA annually (1). This means that not all the patients with an ACL injury need operation. So, patient selection is an important step towards surgical treatment of ACL injury. Reconstruction of the anterior cruciate ligament is one of the most commonly performed orthopedic procedures in developed countries of the world. The goal of anatomic reconstruction is to restore normal motion and stability to the knee and thereby, presumably, to restore its function and allow the patient to return to normal activities, including sports. Another goal is to prevent early degenerative changes. In order to achieve these goals, the immediate objective of the operation is to reduce abnormal laxity by substituting the injured anterior cruciate ligament with a graft (2). We know about the natural history of a knee with an ACL rupture and the consequences of such an injury to the knee. This might include meniscal injury, stretching of other ligaments and degenerative changes in the knee joint. On the other hand not all patients with ACL injury are suitable or good candidates for reconstruction. We know that having an operation needs considerations such as social and work status of the patient, availability of skillful surgeon and well equipped operating room. One should balance the risks and benefits of a major reconstruction surgery with potential risks and complications. The patient usually needs general or regional anesthesia for his /her operation. They need to be off work for a couple of months and need extensive rehabilitation. Looking at all these points and problems encountered in surgical and non-surgical treatment of an ACL deficient knee we need to have a method of classification and criteria to choose the best means of treatment which suits each patient. Most of the patients with an ACL injury of the knee are in the young and active age group who might be keen to pursue their sport activities. They usually present with the chief complain of giving way. The main indication for reconstruction surgery is instability presenting as giving way. Some patients present to the knee clinic with a locked knee. They usually give a history of knee injury a couple of years ago and subsequent instability which was left untreated. A recent injury and giving way has damaged the meniscus, usually a bucket handle tear of medial meniscus with a typical pattern of image on the MRI scan. They need to be operated on as soon as possible for a meniscal repair or menisectomy and ACL reconstruction at the same time. An important issue in the treatment of an ACL deficient knee is patient selection. The technical issues such as graft selection, graft harvest and preparation, proximal fixation, tensioning and distal fixation with the knee in extension are also important. A period of rehabilitation before surgery and early range of motion and extensive physiotherapy and rehabilitation after surgery will complete the procedure. At our referral Knee and Shoulder center, Ghaem Hspital Medical Center, Mashhad, Iran, preferred method of reconstruction of ACL is BPB tendon autograft as the gold standard technique. Over 2000 patients have been operated on by the same technique in our center in the last 15 years. Overall results are satisfactory. Anterior knee pain and pain on kneeling is not as common as been previously