Skip to main content
SpringerLink
Log in

Anatomic anterior cruciate ligament (ACL) reconstruction: a global perspective. Part 1

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

In August 2011, orthopaedic surgeons from more than 20 countries attended a summit on anatomic anterior cruciate ligament (ACL) reconstruction. The summit offered a unique opportunity to discuss current concepts, approaches, and techniques in the field of ACL reconstruction among leading surgeons in the field.

Methods

Five panels (with 36 panellists) were conducted on key issues in ACL surgery: anatomic ACL reconstruction, rehabilitation and return to activity following anatomic ACL reconstruction, failure after ACL reconstruction, revision anatomic ACL reconstruction, and partial ACL injuries and ACL augmentation. Panellists’ responses were secondarily collected using an online survey.

Results

Thirty-six panellists (35 surgeons and 1 physical therapist) sat on at least one panel. Of the 35 surgeons surveyed, 22 reported performing “anatomic” ACL reconstructions. The preferred graft choice was hamstring tendon autograft (53.1 %) followed by bone-patellar tendon-bone autograft (22.8 %), allograft (13.5 %), and quadriceps tendon autograft (10.6 %). Patients generally returned to play after an average of 6 months, with return to full competition after an average of 8 months. ACL reconstruction “failure” was defined by 12 surgeons as instability and pathological laxity on examination, a need for revision, and/or evidence of tear on magnetic resonance imaging. The average percentage of patients meeting the criteria for “failure” was 8.2 %.

Conclusions

These data summarize the results of five panels on anatomic ACL reconstruction. The most popular graft choice among surgeons for primary ACL reconstructions is hamstring tendon autograft, with allograft being used most frequently employed in revision cases. Nearly half of the surgeons surveyed performed both single- and double-bundle ACL reconstructions depending on certain criteria. Regardless of the technique regularly employed, there was unanimous support among surgeons for the use of “anatomic” reconstructions using bony and soft tissue remnant landmarks.

Level of evidence

V.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8

Similar content being viewed by others

References

  1. Adachi N, Ochi M, Uchio Y, Sumen Y (2000) Anterior cruciate ligament augmentation under arthroscopy. A minimum 2-year follow-up in 40 patients. Arch Orthop Trauma Surg 120(3–4):128–133

    Article  CAS  PubMed  Google Scholar 

  2. Ahlden M, Samuelsson K, Sernert N, Forssblad M, Karlsson J, Kartus J (2013) The Swedish national anterior cruciate ligament register: a report on baseline variables and outcomes of surgery for almost 18,000 patients. Am J Sports Med 40(10):2230–2235

    Article  Google Scholar 

  3. Ahlden M, Sernert N, Karlsson J, Kartus J (2013) A prospective randomized study comparing double- and single-bundle techniques for anterior cruciate ligament reconstruction. Am J Sports Med 41(11):2484–2491

    Article  PubMed  Google Scholar 

  4. Ardern CL, Taylor NF, Feller JA, Whitehead TS, Webster KE (2013) Psychological responses matter in returning to pre-injury level of sport after anterior cruciate ligament reconstruction surgery. Am J Sports Med 41(7):1549–1558

    Article  PubMed  Google Scholar 

  5. Ardern CL, Webster KE, Taylor NF, Feller JA (2011) Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med 45(7):596–606

    Article  PubMed  Google Scholar 

  6. Borbon CA, Mouzopoulos G, Siebold R (2012) Why perform an ACL augmentation? Knee Surg Sports Traumatol Arthrosc 20(2):245–251

    Article  PubMed  Google Scholar 

  7. Bray RC, Leonard CA, Salo PT (2002) Vascular physiology and long-term healing of partial ligament tears. J Orthop Res 20(5):984–989

    Article  PubMed  Google Scholar 

  8. Brown CH Jr, Spalding T, Robb C (2013) Medial portal technique for single-bundle anatomical anterior cruciate ligament (ACL) reconstruction. Int Orthop 37(2):253–269

    Article  PubMed Central  PubMed  Google Scholar 

  9. Buoncristiani AM, Tjoumakaris FP, Starman JS, Ferretti M, Fu FH (2006) Anatomic double-bundle anterior cruciate ligament reconstruction. Arthroscopy 22(9):1000–1006

    Article  PubMed  Google Scholar 

  10. Gianotti SM, Marshall SW, Hume PA, Bunt L (2009) Incidence of anterior cruciate ligament injury and other knee ligament injuries: a national population based study. J Sci Med Sport 12(6):622–627

    Article  PubMed  Google Scholar 

  11. Gifstad T, Drogset JO, Viset A, Grontvedt T, Hortemo GS (2013) Inferior results after revision ACL reconstructions: a comparison with primary ACL reconstructions. Knee Surg Sports Traumatol Arthrosc 21(9):2011–2018

    Article  PubMed  Google Scholar 

  12. Hussein M, van Eck CF, Cretnik A, Dinevski D, Fu FH (2012) Prospective randomized clinical evaluation of conventional single-bundle, anatomic single-bundle, and anatomic double-bundle anterior cruciate ligament reconstruction: 281 cases with 3- to 5-year follow-up. Am J Sports Med 40(3):512–520

    Article  PubMed  Google Scholar 

  13. Illingworth KD, Hensler D, Working ZM, Macalena JA, Tashman S, Fu FH (2011) A simple evaluation of anterior cruciate ligament femoral tunnel position: the inclination angle and femoral tunnel angle. Am J Sports Med 39(12):2611–2618

    Article  PubMed  Google Scholar 

  14. Iriuchishima T, Horaguchi T, Kubomura T, Morimoto Y, Fu FH (2011) Evaluation of the intercondylar roof impingement after anatomical double-bundle anterior cruciate ligament reconstruction using 3D-CT. Knee Surg Sports Traumatol Arthrosc 19(4):674–679

    Article  PubMed  Google Scholar 

  15. Iriuchishima T, Tajima G, Ingham SJ, Shen W, Smolinski P, Fu FH (2010) Impingement pressure in the anatomical and non-anatomical anterior cruciate ligament reconstruction: a cadaver study. Am J Sports Med 38(8):1611–1617

    Article  PubMed  Google Scholar 

  16. Kazusa H, Nakamae A, Ochi M (2013) Augmentation technique for anterior cruciate ligament injury. Clin Sports Med 32(1):127–140

    Article  PubMed  Google Scholar 

  17. Lee BI, Min KD, Choi HS, Kwon SW, Chun DI, Yun ES, Lee DW, Jin SY, Yoo JH (2009) Immunohistochemical study of mechanoreceptors in the tibial remnant of the ruptured anterior cruciate ligament in human knees. Knee Surg Sports Traumatol Arthrosc 17(9):1095–1101

    Article  PubMed  Google Scholar 

  18. Magnussen RA, Lawrence JT, West RL, Toth AP, Taylor DC, Garrett WE (2012) Graft size and patient age are predictors of early revision after anterior cruciate ligament reconstruction with hamstring autograft. Arthroscopy 28(4):526–531

    Article  PubMed  Google Scholar 

  19. Marquass B, Engel T, Hepp P, Theopold JD, Josten C (2007) One- and two-stage procedure for revision after failure of anterior cruciate ligament reconstruction. Z Orthop Unfall 145(6):712–718

    CAS  PubMed  Google Scholar 

  20. Matsubara H, Okazaki K, Tashiro Y, Toyoda K, Uemura M, Hashizume M, Iwamoto Y (2013) Intercondylar roof impingement after anatomic double-bundle anterior cruciate ligament reconstruction in patients with knee hyperextension. Am J Sports Med 41(12):2819–2827

    Article  PubMed  Google Scholar 

  21. Murray MM, Martin SD, Martin TL, Spector M (2000) Histological changes in the human anterior cruciate ligament after rupture. J Bone Joint Surg Am 82-A(10):1387–1397

    CAS  PubMed  Google Scholar 

  22. Ochi M, Adachi N, Deie M, Kanaya A (2006) Anterior cruciate ligament augmentation procedure with a 1 incision technique: anteromedial bundle or posterolateral bundle reconstruction. Arthroscopy 22(4):e461–e465

    Google Scholar 

  23. Papalia R, Franceschi F, Vasta S, Di Martino A, Maffulli N, Denaro V (2012) Sparing the anterior cruciate ligament remnant: is it worth the hassle? Br Med Bull 104:91–111

    Article  PubMed  Google Scholar 

  24. Park SY, Oh H, Park S, Lee JH, Lee SH, Yoon KH (2012) Factors predicting hamstring tendon autograft diameters and resulting failure rates after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc

  25. Siebold R (2011) The concept of complete footprint restoration with guidelines for single- and double-bundle ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 19(5):699–706

    Article  PubMed  Google Scholar 

  26. Song EK, Seon JK, Yim JH, Woo SH, Seo HY, Lee KB (2013) Progression of osteoarthritis after double- and single-bundle anterior cruciate ligament reconstruction. Am J Sports Med 41(10):2340–2346

    Article  PubMed  Google Scholar 

  27. Sonnery-Cottet B, Barth J, Graveleau N, Fournier Y, Hager JP, Chambat P (2009) Arthroscopic identification of isolated tear of the posterolateral bundle of the anterior cruciate ligament. Arthroscopy 25(7):728–732

    Article  PubMed  Google Scholar 

  28. Survey monkey (1999–2012). http://www.surveymonkey.com. Accessed 9 Sep 2012

  29. van Eck CF, Lesniak BP, Schreiber VM, Fu FH (2010) Anatomic single- and double-bundle anterior cruciate ligament reconstruction flowchart. Arthroscopy 26(2):258–268

    PubMed  Google Scholar 

  30. van Eck CF, Schreiber VM, Liu TT, Fu FH (2010) The anatomic approach to primary, revision and augmentation anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 18(9):1154–1163

    Article  PubMed  Google Scholar 

  31. Weiler A, Schmeling A, Stohr I, Kaab MJ, Wagner M (2007) Primary versus single-stage revision anterior cruciate ligament reconstruction using autologous hamstring tendon grafts: a prospective matched-group analysis. Am J Sports Med 35(10):1643–1652

    Article  PubMed  Google Scholar 

  32. Wu B, Zhao Z, Li S, Sun L (2013) Preservation of remnant attachment improves graft healing in a rabbit model of anterior cruciate ligament reconstruction. Arthroscopy 29(8):1362–1371

    Article  PubMed  Google Scholar 

  33. Zantop T, Brucker PU, Vidal A, Zelle BA, Fu FH (2007) Intraarticular rupture pattern of the ACL. Clin Orthop Relat Res 454:48–53

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

We gratefully acknowledge each and every panellist for their participation in this endeavour, including their participation at the Panther Global Summit and their verification of the data presented in this article. We would also like to acknowledge the efforts of all University of Pittsburgh Sports Medicine research fellows who assisted in data collection and Sara Herold for her assistance with statistics. Finally, we would like to thank Dr. Pau Golanó for the femoral and tibial ACL insertion site dissections.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Kaufman Medical Building, Suite 1011, 3941 Fifth Avenue, Pittsburgh, PA, 15203, USA

    K. K. Middleton, T. Hamilton, J. J. Irrgang, C. D. Harner & F. H. Fu

  2. Department of Orthopaedics, Götenborg University, Göteborg, Sweden

    J. Karlsson

Authors
  1. K. K. Middleton
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. T. Hamilton
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. J. J. Irrgang
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. J. Karlsson
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. C. D. Harner
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. F. H. Fu
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to F. H. Fu.

Appendix: Panel and survey questions

Appendix: Panel and survey questions

All responses were open ended unless specified.

General information

Demographic survey

  1. 1.

    Surgeon information:

    1. a.

      Name

    2. b.

      Company

    3. c.

      City/Town

    4. d.

      State/Province

    5. e.

      Country

    6. f.

      E-mail address

  2. 2.

    Total years of experience?

  3. 3.

    Total years of experience with primary ACL reconstructions?

  4. 4.

    Total number of ACL reconstruction performed over career?

  5. 5.

    Total number of ACL reconstructions performed per year?

  6. 6.

    Total number of anatomic single-bundle ACL reconstructions performed per year?

  7. 7.

    Total number of anatomic double-bundle ACL reconstructions performed per year?

  8. 8.

    Patient demographic characteristics:

    1. a.

      Age: percent in each of the following categories. (total 100 %)

      1. i.

        <14 years

      2. ii.

        14–18 years

      3. iii.

        19–24 years

      4. iv.

        25–34 years

      5. v.

        35–50 years

      6. vi.

        >50 years

    2. b.

      Gender: percent in each of the following categories. (total 100 %)

      1. i.

        Female

      2. ii.

        Male

    3. c.

      Level of sports participation: percent in each of the following categories. (total 100 %)

      1. i.

        High school athlete

      2. ii.

        College athlete

      3. iii.

        Professional athlete

      4. iv.

        Recreational athlete

      5. v.

        Non-athlete

    4. d.

      List specific criteria for single-bundle ACL reconstruction

    5. e.

      List specific criteria for double-bundle ACL reconstruction

Panel I: Anatomic ACL reconstruction

  1. 1.

    List specific indications for anatomic single and double-bundle ACL reconstruction.

  2. 2.

    Preferred technique:

    1. a.

      List specific criteria for location of femoral tunnel(s).

    2. b.

      List specific criteria for location of tibial tunnel(s).

    3. c.

      Do you perform the following intraoperative measurements?

      1. i.

        ACL mid-substance size? Yes/no

      2. ii.

        ACL insertion site size? Yes/no

      3. iii.

        Intercondylar notch width? Yes/no

      4. iv.

        Tunnel aperture? Yes/no

      5. v.

        I do not perform any intraoperative measurements.

    4. d.

      Do you preserve ACL remnants? Yes/no

    5. e.

      Do you use the following methods to create your femoral tunnel:

      1. i.

        Accessory medial portal? Yes/no

      2. ii.

        Transtibial drilling? Yes/no

      3. iii.

        Both techniques? Yes/no

    6. f.

      Do you use the following methods to document femoral tunnel location:

      1. i.

        Intraoperative pictures/video? Yes/no

      2. ii.

        Intraoperative radiographs/fluoroscopy? Yes/no

      3. iii.

        Intraoperative measurements? Yes/no

      4. iv.

        Navigation? Yes/no

      5. v.

        Post-operative radiographs? Yes/no

      6. vi.

        Post-operative MRI? Yes/no

      7. vii.

        Post-operative CT scan? Yes/no

    7. g.

      Do you use the following methods to document tibial tunnel location:

      1. i.

        Intraoperative pictures/video? Yes/no

      2. ii.

        Intraoperative radiographs/fluoroscopy? Yes/no

      3. iii.

        Intraoperative measurements? Yes/no

      4. iv.

        Navigation? Yes/no

      5. v.

        Post-operative radiographs? Yes/no

      6. vi.

        Post-operative MRI? Yes/no

      7. vii.

        Post-operative CT scan? Yes/no

    8. h.

      What percentage of the time do you use: (total 100 %)

      1. i.

        Allograft?

        1. 1

          Please specify type.

      2. ii.

        Autograft bone patellar tendon bone?

      3. iii.

        Autograft hamstring?

      4. iv.

        Autograft quad tendon?

    9. i.

      What is a typical graft size you use?

    10. j.

      How do you fix the graft on the femoral side?

    11. k.

      How you fix the graft on the tibial side?

    12. l.

      What biological methods do you use to enhance graft healing?

      1. i.

        None.

      2. ii.

        PRP.

      3. iii.

        Fibrin clot.

      4. iv.

        Other. Please specify.

  3. 3.

    Results:

    1. a.

      How often and when do you routinely see patients for follow-up? List the time from surgery for all office visits.

    2. b.

      Of all surgical complications, what percentage is due to: (total 100 %)

      1. i.

        Infection.

      2. ii

        DVT.

      3. iii.

        Stiffness or arthrofibrosis.

      4. iv.

        Graft failure at a time point less than 6 months.

      5. v.

        Graft failure at a time point greater than 6 months.

      6. vi.

        Other. Please specify.

      7. vii.

        Percent of surgeries without complications.

    3. c.

      Do you use the following methods to assess outcome?

      1. i.

        Range of motion? Yes/no

      2. ii.

        Manual/instrumented laxity? Yes/no

      3. iii.

        Radiographs? Yes/no

      4. iv.

        MRI? Yes/no

      5. v.

        CT scan? Yes/no

      6. vi.

        Patient reported outcomes? Yes/no

      7. vii.

        Other? Please specify.

Panel II: Rehabilitation and return to activity: When do you allow your athletes to return to sports?

  1. 1.

    Do you use the following criteria to determine readiness for return to sports activity?

    1. a.

      Time from surgery? Yes/no

    2. b.

      Absence of pain and swelling? Yes/no

    3. c.

      Range of motion? Yes/no

    4. d.

      Laxity upon examination? Yes/no

    5. e.

      Strength? Yes/no

    6. f.

      Functional testing? Yes/no

    7. g.

      Other. Please specify.

  2. 2.

    Do you consider graft healing when making the return to play decision? Yes/no

  3. 3.

    If yes, how do you determine graft healing? Check all that apply.

    1. a.

      Time from surgery.

    2. b.

      Laxity.

    3. c.

      Graft appearance on MRI.

    4. d.

      Other. Please specify.

  4. 4.

    When do you allow your athletes to return to the following activities? Respond in months.

    1. a.

      Running?

    2. b.

      Jumping, cutting, and pivoting?

    3. c.

      Practice?

    4. d.

      Competition?

    5. e.

      Physical work/labor?

  5. 5.

    At 12 months after surgery, what percentage of your patients return to: (total 100 %)

    1. a.

      Full participation?

    2. b.

      Partial participation?

    3. c.

      No participation at 12 months?

  6. 6.

    For those patients who do not return to full activity, what is the reason? (total 100 %)

    1. a.

      Problems related to the knee?

    2. b.

      Fear of re-injury/lack of confidence?

    3. c.

      Personal choice: changes in lifestyle due to family or work obligations?

    4. d.

      Other. Please specify.

Panel III: Failure after anatomic ACL reconstruction

  1. 1.

    Do you use the methods below to follow your patient’s to evaluate your rate of failure after primary anatomic ACL reconstruction?

    1. a.

      Yearly survey or phone call? Yes/no

    2. b.

      Yearly office visit? Yes/no

    3. c.

      Recommendations to return to the office as needed? Yes/no

  2. 2.

    Do you use the following criteria to identify failure after anatomic ACL reconstruction?

    1. a.

      Complaints of instability? Yes/No

    2. b.

      Pathological laxity? Yes/No

    3. c.

      MRI evidence of graft failure? Yes/No

    4. d.

      Need for revision? Yes/No

    5. e.

      Other. Please specify.

  3. 3.

    What is your definition of ACL reconstruction “failure?” Please be specific.

  4. 4.

    What percentage of your own anatomic ACL reconstructions meets your definition of failure?

  5. 5.

    What percentage of your own anatomic ACL reconstructions do you revise?

  6. 6.

    Of all failure cases that you see, what percentage is due to: (total 100 %)

    1. a.

      Technical error?

    2. b.

      Trauma or re-injury?

    3. c.

      Failure of graft healing/incorporation?

    4. d.

      Combination of above factors?

Panel IV: Revision anatomic ACL reconstruction

  1. 1.

    Do you consider the following factors in preoperative planning?

    1. a.

      History and physical exam? Yes/no

    2. b.

      Prior operative report? Yes/no

    3. c.

      Radiographs? Yes/no

    4. d.

      MRI? Yes/no

    5. e.

      CT Scan? Yes/no

    6. f.

      Other. Please specify.

  2. 2.

    What percentage of your revisions is: (total 100 %)

    1. a.

      One staged?

    2. b.

      Two staged?

  3. 3.

    What percentage of the time do you use: (total 100 %)

    1. a.

      Allograft?

      1. i.

        Please specify type.

    2. b.

      Autograft bone patellar tendon bone?

    3. c.

      Autograft hamstring?

    4. d.

      Autograft quad tendon?

  4. 4.

    What percent of revisions are: (total 100 %)

    1. a.

      Single-bundle?

    2. b.

      Double-bundle?

  5. 5.

    What percent of your ACL reconstruction require: (total does not have to be 100 %)

    1. a.

      Meniscectomy?

    2. b.

      Meniscus repair?

    3. c.

      Meniscal transplant?

    4. d.

      Collateral ligament surgery?

    5. e.

      Posterolateral corner surgery?

    6. f.

      Articular cartilage procedure?

    7. g.

      Osteotomy?

    8. h.

      Other: please specify.

  6. 6.

    What complications have you observed with revision ACL reconstruction?

  7. 7.

    How would you qualify your outcomes? (total 100 %)

    1. a.

      Very good (like pre-primary injury condition)?

    2. b.

      Good (same as pre-re-injury condition)?

    3. c.

      Fair?

    4. d.

      Poor (no change from re-injury condition)?

    5. e.

      Very poor (worse than re-injury condition)?

Panel V: Partial ACL injuries and ACL augmentation

  1. 1.

    What is your definition of a partial ACL injury?

  2. 2.

    Explain how you make your diagnosis using each of the modalities below:

    1. a.

      History and Physical exam.

    2. b.

      MRI.

    3. c.

      Arthroscopy.

  3. 3.

    What percentage of patients undergoing ACL surgery has a partial ACL injury?

  4. 4.

    How many of the following ACL augmentation types do you perform a year?

    1. a.

      Primary augmentation of the AM bundle (PL reconstruction)?

    2. b.

      Primary augmentation of the PL bundle (AM reconstruction)?

    3. c.

      Revision augmentation of the AM bundle (PL reconstruction)?

    4. d.

      Revision augmentation of the PL bundle (AM reconstruction)?

  5. 5.

    List your specific criteria for location of femoral tunnel(s).

  6. 6.

    List your specific criteria for location of tibial tunnel(s).

  7. 7.

    Do you use the following intraoperative measurements?

    1. a.

      ACL mid-substand size? Yes/no

    2. b.

      ACL insertion site size? Yes/no

    3. c.

      Intercondylar notch width? Yes/no

    4. d.

      Tunnel aperture? Yes/no

    5. e.

      I do not use intraoperative measurements.

  8. 8.

    Do you preserve ACL remnants? Yes/no

  9. 9.

    Do you preserve the ACL stump? Yes/no

  10. 10.

    Do you use the following methods to create the femoral tunnel?

    1. a.

      Accessory medial portal? Yes/no

    2. b.

      Transtibial drilling? Yes/no

    3. c.

      Both techniques? Yes/no

  11. 11.

    Do you use the following methods to document femoral tunnel location:

    1. a.

      Intraoperative pictures/video? Yes/no

    2. b.

      Intraoperative radiographs/fluoroscopy? Yes/no

    3. c.

      Intraoperative measurements? Yes/no

    4. d.

      Navigation? Yes/no

    5. e.

      Post-operative radiographs? Yes/no

    6. f.

      Post-operative MRI? Yes/no

    7. g.

      Post-operative CT scan? Yes/no

  12. 12.

    Do you use the following methods to document tibial tunnel location:

    1. a.

      Intraoperative pictures/video? Yes/no

    2. b.

      Intraoperative radiographs/fluoroscopy? Yes/no

    3. c.

      Intraoperative measurements? Yes/no

    4. d.

      Navigation? Yes/no

    5. e.

      Post-operative radiographs? Yes/no

    6. f.

      Post-operative MRI? Yes/no

    7. g.

      Post-operative CT scan? Yes/no

  13. 13.

    Please specify your tunnel location and method for creating tunnels.

  14. 14.

    What percentage of the time do you use: (total 100 %)

    1. a.

      Allograft?

      1. i.

        Please specify type.

    2. b.

      Autograft bone patellar tendon bone?

    3. c.

      Autograft hamstring?

    4. d.

      Autograft quad tendon?

  15. 15.

    What complications have you encountered?

  16. 16.

    How would you qualify your outcomes? (total 100 %)

    1. a.

      Very good (like pre-primary injury condition)?

    2. b.

      Good (same as pre-re-injury condition)?

    3. c.

      Fair?

    4. d.

      Poor (no change from re-injury condition)?

    5. e.

      Very poor (worse than re-injury condition)?

Rights and permissions

Reprints and permissions

About this article

Cite this article

Middleton, K.K., Hamilton, T., Irrgang, J.J. et al. Anatomic anterior cruciate ligament (ACL) reconstruction: a global perspective. Part 1 . Knee Surg Sports Traumatol Arthrosc 22, 1467–1482 (2014). https://doi.org/10.1007/s00167-014-2846-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-014-2846-3

Keywords

Search

Navigation