Treatment of anterior cruciate ligament injuries with special reference to surgical technique and rehabilitation: an assessment of randomized controlled trials

Arthroscopy. 2009 Jun;25(6):653-85. doi: 10.1016/j.arthro.2009.04.066.


Purpose: The primary aim was to investigate and assess the current evidence of randomized controlled trials (RCTs) on anterior cruciate ligament (ACL) injuries, with special reference to the choice of surgical techniques and aspects of rehabilitation. A secondary aim was to clarify relative strengths and weaknesses of the selected studies, resolve literature conflicts, and finally, evaluate the need for further studies.

Methods: A PubMed database search using the key words "anterior cruciate ligament" was performed. The search was limited to only RCTs published in English during the period of January 1995 to March 2009. Articles concerning surgical technique and rehabilitation were obtained. After initial screening and subsequent quality appraisal based on the CONSORT (Consolidated Standards of Reporting Trials) Statement, a total of 70 articles were included in this review.

Results: Initial graft tension and the use of a ligament augmentation device do not affect clinical outcome. Bioabsorbable screws and titanium screws produced equal clinical outcome, regardless of graft type. Radiographic signs of osteoarthritis develop in 50% of ACL-injured patients, regardless of treatment. Meniscectomy further increases the risk. Furthermore, the use of a postoperative knee brace does not affect the clinical outcome after ACL reconstruction. Closed kinetic chain exercises produced less pain and laxity while promoting better subjective outcome than open kinetic chain exercises after patellar tendon reconstruction.

Conclusions: In terms of quality assessment, several weaknesses pertaining to study design were discovered among the included RCTs, which intelligibly stress the need for further high-quality studies.

Level of evidence: Level II, systematic review of RCTs.

Publication types

  • Review
  • Systematic Review

MeSH terms

  • Absorbable Implants
  • Anterior Cruciate Ligament / surgery*
  • Anterior Cruciate Ligament Injuries
  • Arthroscopy / methods*
  • Bone Nails
  • Bone Screws
  • Braces
  • Equipment Design
  • Evidence-Based Medicine
  • Humans
  • Knee Injuries / complications
  • Knee Injuries / rehabilitation
  • Menisci, Tibial / surgery
  • Osteoarthritis, Knee / epidemiology
  • Osteoarthritis, Knee / etiology
  • Patellar Ligament / surgery
  • Patellar Ligament / transplantation
  • Physical Therapy Modalities
  • Plastic Surgery Procedures / instrumentation
  • Plastic Surgery Procedures / methods
  • Postoperative Complications / epidemiology
  • Postoperative Complications / etiology
  • Prostheses and Implants
  • Randomized Controlled Trials as Topic / statistics & numerical data*
  • Tendons / transplantation
  • Time Factors
  • Transplantation, Autologous
  • Treatment Outcome