Dr. Mandelbaum Discusses with Medscape Orthopedics New Approaches to ACL Repair

A Renowned Surgeon Discusses New Approaches to ACL Repair

Bert R. Mandelbaum, MD, DHL (Hon)

|January 06, 2016

Reviewing the Video Evidence

The field of anterior cruciate ligament (ACL) repair is rapidly changing. The more we learn about the knee and the more we experiment with new techniques, the better we are able to tailor our treatment to the individual athlete. In my practice, one size definitely doesn't fit all.

Among other factors, the widespread availability of video and new findings concerning the anterolateral ligament have changed the way I proceed.

I always start with trying to understand how the injury occurred. Was it perturbation, contact, full contact, or noncontact? There are videos where I can tell exactly what type of injury occurred.

I search aggressively for video of the injury. It's amazing how many people have videos of games, all the way down to games in the under-14-year-old age bracket. Someone's got one—if not a broadcaster or a trainer, maybe a spectator or even someone who works with the opposing team.

Once I obtain a video, I slow it down, take a look at what happened, and review it with the patient. It's a good way to partner with the patient and the patient's family. I ask the patient and other witnesses what happened. Did the patient feel or hear a "pop"? How was the patient moving and interacting with other players when the injury occurred? The answers to these questions give me clues about what type of damage has occurred. And they tell me whether there are instability patterns that need to be addressed.

The Importance of Imaging

Imaging techniques help me confirm or discard these ideas about what has happened inside the knee. One of the questions I need to answer with radiographs is whether there is a Segond fracture.[1] I fix them all. The recent work of Steven Claes, MD, of the University of Leuven in Belgium[2] has shown that the anterolateral ligament is attached to that piece of bone and has an important role in stabilizing the joint.

Next I get to the MRI, which can tell me something about the extent of the ACL damage. ACL tears are scalable; some are incomplete; and some could be in anteromedial bundle, the posterolateral bundle, or both.

Anatomical Assessment of Injury

It's also important to assess associated damage to the meniscus and the articular cartilage, because they are associated with greater risk for osteoarthritis later on.[3] If I see this type of damage, I plan to manage it at the time of surgery.

Lastly are the associated ligaments. I find it helpful to locate the anterolateral ligament and study it, starting on the lateral side between the femur and tibia, looking for injuries. There are surgeons who will routinely bolster this ligament with graft material even if it's not ruptured, on the theory that they can reduce the risk for reinjury. Dr Bertrand Sonnery-Cottet, of the Centre Orthopedique Santy in Lyon, France, has popularized this belt-and-suspenders approach.[4]

I perform this procedure in the course of a revision situation and in those individuals who have the most instability. When I do, most of the time I perform a concurrent tenodesis of the iliotibial band.

I also look for injuries to the iliotibial band, the fibular collateral ligament, the biceps tendon, and the capsule on the lateral side.

In addition, I try to identify bone marrow lesions. These lesions are common in ACL injuries, are associated with increased amounts of cytokines, and may be associated with the potential for osteoarthritis later on. There is nothing we can do about them during the ACL reconstruction, but it's important to keep an eye on these lesions in the coming months. Most will heal on their own, but some will cause ongoing pain and even collapse of the joint cartilage if not eventually treated.

Next, I search for injuries to the medial column, which includes the deep and superficial medial collateral ligaments, the posterior oblique ligament, and the capsule. Bigger injuries on the medial and lateral side can be repaired either at the same time as the ACL or in stages. Where there is significant damage to the collateral ligaments and medial or lateral column, I repair these in one procedure, then later reconstruct the ACL arthroscopically.

Conducting the Physical Exam

With the information from the MRI, I move on to the physical exam to see how the picture I have formed of the interior of the knee is affecting the patient's range of motion and pain.

The physical examination includes the Lachman test, anterior drawer test, and pivot shift for the ACL, and then an assessment of medial or lateral laxity to check for damage to the collateral ligaments.[5] After I've assessed the knee, I review my findings with the patient and the patient's support team. In the case of a youth athlete, that typically includes a parent, a coach, and sometimes a trainer. In the case of a professional athlete, an agent may also be involved.

In the case of a college athlete, I discuss such issues as whether we can "redshirt" the athlete. I discuss the status of athletic scholarships. A high school athlete may be a candidate for a scholarship, or hopeful of signing with a top college team.

Risks With ACL Reconstruction

Of course, there are risks with ACL reconstruction, as with any surgery, and not everyone with a torn ACL should have it reconstructed. A patient who is a cyclist or who practices yoga and has mild to moderate deficiency from the injury won't need reconstruction. A patient who has high instability that interferes with daily living is a candidate for reconstruction. There are some patients who can't walk to the bathroom after their ACL is torn.

An athlete who does pivoting and landing—as in football, basketball, or soccer—must have the stability to the knee to perform those activities. For these athletes, a torn ACL is like having loose bindings for a skier.

Then I get into issues of timing. Do I operate right away, or wait 3 weeks? I find that delaying is not as critical for most young athletes. But for the older athlete, it's important to let the swelling go down and let them get range of motion back.

The patient's age and athletic plans factor into the choice of graft materials, whether to use platelet-rich protein, and the approach to rehabilitation, all of which I'll discuss in my next column.


1.Gottsegen CJ, Eyer BA, White EA, Learch TJ, Forrester D. Avulsion fractures of the knee: imaging findings and clinical significance. Radiographics. 2008;28:1755-1770. Abstract

2.Claes S, Vereecke E, Maes M, Victor J, Verdonk P, Bellemans J. Anatomy of the anterolateral ligament of the knee. J Anat. 2013;223:321-328. Abstract

3.Englund M, Guermazi A, Lohmander SL. The role of the meniscus in knee osteoarthritis: a cause or consequence? Radiol Clin North Am. 2009;47:703-712. Abstract

4.Sonnery-Cottet B, Thaunat M, Freychet B, Pupim BH, Murphy CG, Claes S. Outcome of a combined anterior cruciate ligament and anterolateral ligament reconstruction technique with a minimum 2-year follow-up. Am J Sports Med. 2015;43:1598-1605. Abstract

5.Benjaminse A, Gokeler A, van der Schans CP. Clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis. J Orthop Sports Phys Ther. 2006;36:267-288. Abstract

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