85

Anterior Cruciate Reconstruction

Name : MBI
IC

: 710204 08 5285

RN

: 451904

Mr. MBI, a 32 year-old teacher twisted his left knee while playing sepaktakraw
following his bicycle kick and landed on his left leg. The left lower leg twisted
outward with a pop sound. He was not able to continue with the games after that.
The swelling developed within two hours to the maximum. He went to the near by
clinic and was treated with bandage and analgesic.
The pain and swelling disappeared after three weeks and he was able to work after
that. He had no locking symptoms but had difficulties in going down and up stairs
but worse on going downstairs. He tried to play sepaktakraw again but few times
his knee gave way.
Examination of the left knee revealed the quadriceps was wasted. No knee
effusion. He had tenderness at the medial joint line. The left knee has about 5 o of
fixed flexion and pain on extremen flexion beyond 135o. Lachman and anterior
drawer test were positive grade 2. Modified pivot test was positive. Mc Murray test
was negative
Diagnosis of anterior cruciate ligament was made. The option of anterior cruciate
reconstruction and conservative treatment with lifestyle modification were
discussed in lengthy with the patient and the expectation of reconstruction was
explained. He opted for reconstructive surgery using bone patellar tendon bone
autograft. The operation was done on the January 2003 without complication.
Closed chain exercise started immediate after surgery. He was follow up after 2
weeks post surgery. He was able to perform straight leg raising and sliding hip and
knee movement. He was able to walk without crutches at 4 weeks. At 10 weeks his

86

passive range of movement was 0-100o and active was 90o. He was happy with the
surgical outcome.

Discussion
Sports-related injuries involving the knee are common, with the anterior cruciate
ligament (ACL) being the most frequently injured ligament. Football, soccer,
skiing, and basketball are the sports most implicated in this injury. The anterior
cruciate ligament (ACL) ruptures occur > 200,000 in American population each
year. (Albright et al, 1999) Severities of injury vary from mild sprain to complete
disruption. Worst injury occur when the combination of medial collateral ligament,
medial meniscus and anterior cruciate ligament occur in combination known as
unhappy triad of ODonoghue (ODonoghue, 1950). Female athlete has a higher
risk to ACL injury (Mary, 2002).
Anatomically anterior cruciate ligament is an intraarticular and extrasynovial
ligament. The femoral attachment of the ACL is at the posterior part of the inner
surface of the lateral femoral condyle. The ACL fibers fan out as they approach
their tibial insertion, anterior and lateral to anterior tibial spine after passed beneath
the transverse meniscus ligament. A few fibers of the ACL may blend with the
anterior attachment of the anterior horn of the lateral meniscus as well as with the
posterior attachment of the posterior horn of the lateral meniscus.
Girgis et al (1975) divided the ACL into two parts, the anteromedial band (AMB)
and the posterolateral band (PLB) base on its tibial insertion. The fascicles of the
AMB originate at the most posterior and proximal aspect of the femoral attachment
and insert at the anteromedial aspect of the tibial attachment. Conversely, the
fascicles of the PLB originate at the distal aspect of the femoral attachment and
insert at the posterolateral aspect of the tibial attachment. The AMB is smaller than
PLB. The length and orientation of the bundles change as the knee passes through
motion. With passive flexion, the AMB tightens and the PLB is relatively lax.

87

When the knee is extended, the PLB tightens and the AMB remains fairly tight but
is not as predominant as the PLB.
ACL has limited ability to form scar tissue and to heal. Mid substance tear also
incapable to heal. The ACL has a thin, vascularized envelope formed by the
synovial lining. When this synovial sheath is torn during injury, blood dissipates
within the joint and does not form a local fibrinous mesh at the site of injury and
therefore compromise healing. Presence of free radical following the injury also
compromised healing process.
The main ACL function is to resist anterior displacement of tibia in relation to
femur in all flexion position especially at 15 to 30o of flexion. ACL help to resist
hyperextension. It is also contributed to rotational stability of fully extended knee
for both internal and external rotation. When the ACL is ruptured, the knee
depends on other structure to prevent anterior translation and internal rotation. As
the knee extend the secondary restrainer become lax and the tibia translated
forward. It reduced back when the knee flexed around 20 to 30 o.This subluxation
and reduction movement known as pivot shift. This is caused by the action of
iliotibial tract. Beynnon et al (1997) concluded the ACL functions as a major
secondary restraint to internal rotation and as a minor secondary restraint to
external rotation and varus-valgus angulation, particularly under weight-bearing
conditions.
The classic history of a person sustaining an isolated ACL injury consists of a noncontact deceleration mechanism, usually occurring with a sudden stopping, cutting,
or jumping maneuver with a pop sound and hyperextension knee. Usually patient
cannot continue with the game due to unstable joint and haemarthrosis occur
within hours. The likelihood is more than 70% that the patient has torn the ACL
(De Haven, 1980). Contact injuries are more likely to result in multiligament
injuries, as is seen with O'Donoghue's classic triad in which a direct blow valgus
load on the knee results in injury to the ACL, medial collateral ligament (MCL),
and medial meniscus such as lateral tackle of rugby player. The differential

88

diagnosis for an acute traumatic hemarthrosis includes patellar subluxation or

dislocation, osteochondral injury, peripheral meniscus tear, or intraarticular
fracture. As happened to Mr. MBI, even without examination the diagnosis of
anterior cruciate ligament rupture was apparent from history.
Patients with acute anterior cruciate ligament (ACL) injuries present frequently;
the diagnosis should be suspected in all cases of acute haemarthrosis. More than
70 percent of patients with an acute traumatic haemarthrosis have an ACL tear,
either partial or complete (Noyes et al, 1980). The first few hours before there is
gross swelling and muscle spasm, is the best time to diagnose. Diagnosis of ACL
tear can be made by clinical examination, arthrometer, MRI and arthroscopy.
The Lachman test has been reported to be the most useful clinical examination for
acute and chronic ACL tears (Zarin et al, 1986). Anterior translation of the tibia in
relation to the femur at 25-30o flexion with the absence of firm endpoint constitutes
a positive Lachman test. Anterior drawer test is another indicative of ACL
insufficiency but less sensitive as compared to Lachman because meniscus also
contribute to the stability and resists translation. Pivot test is pathognomonic
finding for ACL tear. The test is perfomed with hip slightly abducted and flexed
with neutral rotation. The valgus is applied to the knee and the knee move from
flexed position to extension with internally rotated tibia. The tibia will translate
anteriorly at 25-30o flexion. Bach et al (1990) modified the pivot test by doing it
under anaesthesia, with the tibia externally rotated and found the result was more
reliable.
Patients may demonstrate associated ligamentous laxity-related injury to the
medial, lateral collateral, posterior cruciate, or posterolateral structures. Joint line
tenderness and discomfort with rotation maneuvers or mechanical catching or
locking symptoms are highly suggestive of an associated meniscal tear.
The radiographs of the weight-bearing anteroposterior, lateral, and 45
posterioanterior views as well as a Merchant view of the patellofemoral joint are

89

important to evaluate the medial and lateral joint spaces for degeneration or
osteochondral injuries, subluxation and/or tilt of the patellafemoral joint as well as
degeneration or osteochondral injury. Standard radiograph of the knee may
demonstrate a pathognomonic sign of ACL injury, an avulsion of the lateral
meniscal capsular ligament from a lateral tibial plateau known as Segond
fracture.
The most accurate imaging for the ACL has been magnetic resonance imaging.
(MRI) MRI was 93 % accuracy in detecting ACL pathology. Negative predictive
value was 98% and positive predictive value was 76% (Fischer et al, 1991). MRI is
expensive and poorly tolerated by many patients. Advantage of preoperative MRI
is the detection of associated meniscal pathology, noninvasive and no radiation
risk.
A normal ACL is a taut, straight anterior margin with low signal intensity on all
pulse sequence. Because of fanlike configuration a gray slightly inhomogenous
signal may not be seen in its entirely on a single sagital slice. Direct signs of tear is
an amorphous edematous mass with focal increase signal T2-weighted images.
Interruption of fibres with tears seen at midsubstance or at tibial or femoral
attachment (Moore, 2003).
There are many arthrometers available and the KT-1000 is the most reliable. KT1000 arthrometer reported specificity of 90 percent to 95 percent (Bach et al, 1990)
(Daniel et al, 1985). The KT-1000 and Lachman examinations were more accurate
in predicting complete acute ACL ruptures. DeHaven et al (1980) compared the
results of arthroscopy with clinical anterior-drawer, pivot-shift, anteromedial
rotatory instability and Lachman tests. False-negative results were found in 72
percent to 84 percent of conscious patients with the first three clinical tests but in
only 16 percent with the Lachman test. Under anaesthesia, the pivot-shift test
improved to 16 percent false-negative results and the Lachman test reached 100
percent accuracy.

90

Not all patients with ACL tear will have symptoms and progress to arthrosis.
Patient who is at risk of giving way is most likely will benefit from reconstructive
surgery. The incidence and progression of osteoarthritis following an anterior
cruciate disruption is not only on the ligament tear but also on the associated injury
e.g. meniscal tears, and osteochondral lesions.
MacDaniel and Dameron et al (1983) reported an average 10-year follow-up of
untreated ACLs exhibited radiographic osteoarthritis in 16% and arthroscopic
changes in 24%. They revealed a definite relationship between osteoarthritis and a
varus deformity, medial menisectomy, and medial joint space narrowing. Sherman
et al (1988) reported that patients with chronic ACL deficient knees and a
menisectomy showed more progressive degenerative changes by radiographic
criteria. But at 10 years all knees were doing poorly regardless of meniscal status.
A higher incidence of osteoarthritis after lateral menisectomy or in knees with
abnormal alignment also been reported by Allen et al (1984).
Reconstruction of the anterior cruciate ligament is carried out for stability and
protection of the menisci and articular cartilage to alter the natural history of
osteoarthritic progression. ACL reconstructive surgery will eliminate the pivot shift
phenomenon (e.g. anterior subluxation of the tibia). In the anterior cruciate
deficient knee, the posterior horn of the medial meniscus is the primary stabilizer
to anterior translation and explains the high incidence of secondary medial
meniscal tears in chronic ACL insufficiency (Shoemaker et al, 1986). Rupture of
the posterior horn resulting in increased instability. Stabilization decreased the
progression of arthritis. Preservation of meniscus as much as possible is the best
warranty for slowing down degenerative arthritis after cruciate ligament injury
(Shoemaker et al, 1986).
De Jour et al (1994) found that in patients who underwent an ACL reconstruction 2
years after injury, medial meniscal tears occurred in 30% and lateral meniscal tears
in 7%. This increased to 60% for the medial meniscus and 15% for the lateral
meniscus 10 years from injury. Shelton et al (1997) followed 44 conservatively

91

treated ACL deficient patients prospectively who elected to return to sports with a
brace. They had a normal meniscus on MR imaging. In the 29 patients requiring
reconstruction, 23 menisci were torn in 17 patients. Finsterbush et al (1990)
reviewed 98 patients who had an isolated ACL rupture at arthroscopy and found at
a mean of 4.2 years, 71% of them has meniscal injury in repeat arthroscopy.
There is great controversy as to whether a reconstruction prevents osteoarthritis.
Shino et al (1989) contributed the most thorough evaluation of osteoarthritic
development by arthroscopically documenting the progression of articular cartilage
lesions in 49 of 201 patients who received an allograft ACL reconstruction at a
mean of 30 months after surgery. He found that patients who had pre-existing
articular cartilage deterioration, loss of the corresponding meniscus, and had
returned to strenuous activities, showed continued deterioration of the articular
cartilage. These suggest ACL reconstruction for patient who wants to continue high
level sport activity and reluctant life style modification.
Result of conservative management of ACL tears deteriorate with time. An ACL
reconstruction result in a lesser degree or slower development of degenerative joint
disease is not being proven. Even a prompt reconstruction and an excellent
rehabilitation do not alter the natural history of a major intra-articular derangement
of the knee. A recent well-controlled prospective study from Sweden has shown no
significant difference in the number of professional soccer players who had retired
from the sport and who had a similar degree of degenerative joint disease 7 years
after tearing the ACL, regardless of whether they had undergone reconstruction or
conservative management (Ross et al, 1995). Buss et al (1995) reported a good
patient satisfaction level among who is > 30 years old, sedentary lifestyle and low
athletic demand with conservative treatment. Casteleyn et al (1996) reported that
patients who are willing to avoid high demand activities can have acceptable
functional results after non-operative treatment of an ACL injury. The outcome
does not appear to deteriorate with time and includes only very limited
osteoarthritic changes.

92

Advances in surgical treatment and reconstruction of the ACL have resulted in

more aggressive treatment for this injury. General indications for ACL
reconstruction surgery (Strover, 1993). In acute ACL injury are athletically active
patient with high activity levels who wish to continue to participation cutting,
pivoting and jumping sport, active patient with acute ACL tear and a grade lll of
another primary restrain (e.g. medial collateral ligament, fibula collateral ligament
or posterior collateral ligament) and athletic active patient with acute ACL tear and
repairable meniscus tear. In chronic tear are functionally disabling giving away
who are unwilling to modify their athletic participation, active patient with
functional instability and repairable meniscus and patient who experience giving
away with activity of daily living.
The ideal graft for anterior cruciate ligament (ACL) reconstruction should
reproduce the complex anatomy of the ACL, provide the same biomechanical
properties as the native ACL, permit strong and secure fixation, promote rapid
biologic incorporation, and minimize donor site morbidity. The most popular and
successful surgical replacements for the ACL have been biologic tissue grafts
because of their potential for graft remodeling and integration into the joint. It can
be as autograft or allograft. The advantages of autograft include low risk of adverse
inflammatory reaction and no risk of disease transmission. Allograft use avoids
donor site morbidity, decreases surgical time, and diminishes postoperative pain.
Various autograft choices have been used. The most common current graft choices
are

the

bone-patellar

tendon-bone

graft

(BPTB)

and

the

quadruple

semitendinosus/gracilis tendon graft. The bone-patellar tendon-bone graft is taken

from the central third of the patellar tendon between 8 to 11mm with its adjacent
patellar and tibial bone blocks. BPTB has high ultimate tensile load (approximately
2376 N), its stiffness (approximately 812 N/mm) (Woo et al, 1991), and the
possibility for rigid fixation with its attached bony ends.
BPTB has been most commonly criticized for its potential graft harvest site
morbidity. Patellofemoral pain is the most common, ranging from occasional

93

symptoms to interference with activities of daily living and sports. However,

similar rates of patellofemoral pain have been reported in ACL-deficient knees that
have been treated nonoperatively or in knees reconstructed with hamstrings
(Johnson et al, 1993). Therefore, the etiology of anterior knee pain following
BPTB ACL reconstruction and cannot be entirely due to the graft harvest.
Shelbourne et al (1997) believes that immediate restoration of knee hyperextension
following ACL reconstruction places the graft in the intercondylar notch
preventing scar tissue formation and reduced the anterior knee problems seen
following BPTB ACL reconstruction. Quadriceps weakness also may occur
following BPTB, which is contributed by the injury and by the harvesting
procedure. However, Stringhan et al (1996) reported no different between allograft
and autograft to suggest weakness is related to harvesting procedure. Yasuda et al
(1995) also demonstrated no different in quadriceps power between BPTB and
Harmstring autograft. Weakness of quadriceps compare to hamstring only
significant at 1 year but similar at 2 years (Corry et al, 1999).
A patch of numbness lateral to the incision from cutting the infrapatellar branch of
the saphenous nerve and a tender residual scar are commonly seen following
BPTB harvest. Both conditions usually improve, if not resolve completely over
time and rarely cause functional impairment. Other complications include patella
tendon rupture, patella fracture and patella tendonitis. Patellar tendon rupture is a
rare complication of BPTB ACL reconstruction. Complications usually occur
within 10 months but may occur after 3 or 6 years (Marmuto et al, 1996).
The use of the hamstring tendon graft is increasing with its relatively low donor
site morbidity and preservation of the extensor mechanism. Hamstring tendon graft
use has evolved from a single-strand semitendinosus tendon graft to a quadruplestrand semitendinosus/gracilis tendon graft, where both the semitendinosus and
gracilis tendons are folded in half and combined. The dimension of a round, 10mm quadruple semitendinosus/gracilis tendon graft is more comparable with that
of the intact ACL, and its ultimate tensile load has been reported to be as high as

94

4108 N. The quadruple semitendinosus /gracilis tendon graft also provides a

multiple-bundle replacement graft that may better approximate the function of the
two-bundle ACL (Hamner et al, 1999).
The disadvantages are concern over tendon healing within the osseous tunnels, the
lack of rigid bony fixation and weakening the hamstring. However, Yasuda et al
(1995) reported, harvesting the semitendinosis and gracilis does not affect
quadriceps muscle strength at all and reduce hamstring strength significantly only
at 1 month after surgery in ipsilateral knee. Rodeo et al (1993) evaluated tendonto-bone healing under physiologic loads in a dog model. At the 2, 4, and 8-week
intervals all specimens failed by tendon pull out. At the 12 and 26-week time
periods all grafts failed at the clamp or mid-substance. He recommends protecting
the healing process following hamstring ACL reconstruction for at least 8 weeks.
There is no different between BPTB and hamstring autograft in terms of ligament
stability, range of motion, and general symptoms (Corry et al, 1999). But lower
donor site morbidity, kneeling pain and less thigh atrophy at 1 year.
The quadriceps tendon graft for ACL reconstruction has also gained recent
attention. Biomechanical studies have shown the ultimate tensile load of this graft
to be as high as 2352 N. This replacement graft has been found to have adequate
tensile properties, as well as size, for ACL reconstruction. The quadriceps tendon
graft has become an alternative replacement graft, especially for revision ACL
surgeries and for knees with multiple ligament injuries.
Graft type

Intact ACL
Bone-patellar tendon-bone (10 mm)
Quadruple hamstring graft
Quadriceps tendon (10 mm)
Anterior tibialis
Posterior tibialis

Ultimate strength (N)

Stiffness (N/mm)

2160
2376
4108
2352
3412
3391

242
35
53
463
344
302

Biomechanical properties of ACL Graft (Miller et al. graft selection in anterior cruciate ligament
reconstruction. Orthop Clin N Am 2002; 33; 676).

95

The morbidity associated with autograft harvest and the supply of allograft has
increased the interest in allograft. Allograft is now commonly used for multiple
ligament reconstructions, revision ligament reconstructions, and for patients who
are not high-performance athletes. Four areas are of particular concern when using
allograft: immunogenicity of the allografts, preservation and secondary
sterilization of the grafts, remodeling and its effects on mechanical properties and
most importantly, the potential of transmission of disease. The decrease in tensile
properties with sterilization and preservation as well as risk of inflammatory
reaction and its slower biologic incorporation has been a concern.
The most commonly used allografts include BPTB, Achilles' tendon, hamstrings,
anterior tibialis, and posterior tibialis. Allograft needs adequate preparation
because of potential and risk of disease transmission. There have been three
reported incidences of disease transmission from bonepatellar tendonbone
allograft used to reconstruct the ACL (Conrad et al, 1995).
Allograft is usually preserved by deep freezing or freeze-drying. Deep freezing
without drying has little or no effect on the mechanical properties of ligaments,
with no significant differences in the stiffness, ultimate load, or modulus noted
between treated and control ligaments (Jackson et al, 1991). However, freeze-thaw
treatments can damage cells and matrices, resulting in inferior biomechanical
properties.
Sterilization of allograft tissues must be optimal to avoid contamination but
expensive and time-consuming. Secondary sterilization can be achieved by
ethylene oxide or gamma irradiation, but each has detrimental effects on the
allograft. Ethylene oxide derivatives remain on the tissue and can cause persistent
synovitis, graft failure and cystic changes around the graft tunnels. Thus it is not
recommended for allograft sterilization (Jackson et al, 1993) Gamma irradiation
can reduce the risk of disease transmission; but, it also has adverse effects on the
tensile properties of ligaments. Irradiation alters tissue morphology, during which
collagen fascicles become separated and the ligaments become visibly crimped.

96

Currently, allograft are usually harvested in a sterile environment and kept sterile
by deep freezing, or low-dose irradiation is used to achieve sterilization. Animal
studies shown that deep frozen gamma radiated ACL allograft have the potential to
attain the biomechanical properties of the normal ACL. Salehpour et al (1995)
compared human BTB treated with either no irradiation or 4-Mrad. No significant
difference was seen at low functional loads determined by static and cyclic creep
tests, but the 4-Mrad group had significantly decreased stiffness, maximal force,
and viscoelasticity.

(Chapman s Orthopaedic Surgery ,3rd edition, LWW,2001)

Jackson et al (1993) reported in their animal study comparing goat patellar tendon
allograft and autograft. Autografts had smaller increases in anteroposterior laxity,
higher ultimate tensile load and more advanced biologic incorporation when
compared with allograft-reconstructed knees. That indicates that allografts have
slower incorporation than autografts at 6 months after surgery. Allograft tissue

97

revascularizes as with autograft tissue and becomes viable after implantation. The
rate of graft incorporation and remodeling are slower for allograft than autograft
reconstructions. In addition the allograft tissue deteriorate after implantation.
However, minimal differences between allograft and autograft reconstruction at 3
to 5 years of follow-up.
Noyes et al ( 1990 ) reported at a mean follow-up of 7 years that 78% of fascia lata
and 82% of BPTB allografts had restored knee stability after acute ACL
reconstruction with 14% overall failure rate,17% failure in chronic ACL ruptures,
8% with autograft BTB. He recommended BPTB use for primary ACL
reconstruction and allograft for revision surgery or for special circumstances if
autograft is not available.
Well designed rehabilitation program plays an important role in the functional
outcome following anterior cruciate reconstruction surgery. There are two different
rehabilitation programs for isolated anterior cruciate reconstructed patient;
accelerated rehabilitation program and regular rehabilitation program. The
accelerated program is used in young and active patient. It differ in the rate of
progression in the various stage of rehabilitation and time needed before start
running and return back to sport.
Following

anterior

cruciate

reconstruction,

joint

stiffness, arthrofibrosis,

quadriceps weakness, extensor mechanism dysfunction and donor site pain may
occur. It could be a result of immobilization. Shelbourne et al (1990) reported an
improved clinical outcome following accelerated rehabilitation program. Better
strength and range of motion, fewer complications such as arthrofibrosis, laxity
and failure, less patellafemoral pain and earlier return to sport.
Preoperatively, the aim of physiotherapy are to reduce pain, inflammation and
swelling, to restore full range of movement, achieve normal gait, prevent muscle
atrophy and mental preparation. Following surgery, emphasized on full knee
extension and gradual restoration of flexion range of motion. Weight-bearing as

98

tolerated to full weight-bearing at two weeks. Closed kinetic chain, proprioceptive

and strengthening exercise are initiated within two weeks postoperatively. A
combination of open chain and closed kinetic chain are incorporated and progress
as tolerated. Functional activities such as running begins between 8 to 10 weeks,
jumping between 10 to 14 weeks, cutting 12 to 16 weeks and gradual return to
running and cutting sports at 4 to 6 months and jumping sports at 6 to 9 months
(Wilk et al, 2003). The initial graft strength, graft fixation and graft maturation and
incorporation have to be considered at every stage of rehabilitation program.

Conclusion
In our setting bone patella tendon bone graft is the first choice for anterior cruciate
reconstruction with minimal intraoperative and postoperative complication.
Reference ACL
1.

Albright J C, Carpenter J E , Graft B K. Knee and leg. Soft tissue

trauma. In : Orthopaedic Knowledge Update 6. Rosemont (IL). American
Acedemy of Orthopaedic Surgeon; 1999 :p 533-59.

2.

Allen P R, Denham R A, Swan AV. Late degenerative changes after

meniscectomy. Factors affecting the knee after operation. J Bone Joint Surg
1984 ; 66-B : 666-71.

3.

Bach B R , Warren R F, Flynn W M et al. Arthrometric evaluation of the

knees that have a torn anterior cruciate ligament. J Bone Joint Surg 1990;
72-A :1299-306.

4.

Beynnon B D, Johnson R J, Fleming B C et al. The effect of functional

knee bracing on the anterior cruciate ligament in the weightbearing and
nonweightbearing knee. Am J Sports Med 1997; 25 : 353-9.

5.

Buss D D, Min R, Skyhar M et al. Nonoperative treatment of acute

anterior cruciate ligament injuries in a selected group of patients. Am J
Sports Med 1995; 23 :160-5.

99

6.

Casteleyn P P , Handelberg F. Nonoperative management of anterior

cruciate ligament injuries in the general population. J Bone Joint Surg.
1996; 78-B : 446-51.

7.

Charles H B . ACL reconstruction with autogenous patellar tendon graft.

In : Angus E Strover (eds). Intra-Articular Reconstruction of the Anterior
Cruciate Ligament. Butterworth- Heinamann,1993 : p 27-117

8.

Conrad E U, Gretch D R, Obermeyer KR et al. Transmission of the

hepatitis-C virus by tissue transplantation. J Bone Joint Surg 1995; 77-A :
214-24.

9.

Daniel D M, Malcolm L L, Losse G . Instrumented measurement of

anterior laxity of the knee. J Bone Joint Surg 1985 ; 67-A : 720-6.

10.

DeHaven K E. Diagnosis of acute knee injuries with hemarthrosis. Am J

Sports Med 1980 ; 8 :9-14.

11.

DeJour H, Neyret P, Bonnin M: Instability and Osteoarthritis. In: Fu FH,

Harner CD, Vince KG (eds): Knee Surgery, vol 1. Balitmore, Williams &
Wilkins, 1994 : p859-875

12.

Girgis F G, Marhall J L, Monajem . The cruciate ligaments of the knee

joint. Anatomical, functional and experimental analysis. Clin Orthop 1975;
106 : 216-31.

13.

Finsterbush A, Frankl U, Matan Y et al. Secondary damage to the knee

after isolated injury of the anterior cruciate ligament. Am J Sports Med
1990. 18:475-9.

14.

Fischer S P, Fox J M, Del Pizzo W . Accuracy of diagnoses from

magnetic resonance imaging of the knee. J Bone Joint Surg 1991; 73-A :210.

15.

Hamner D L , Brown C H, Steiner M E . Hamstring tendon grafts for

reconstruction of the anterior cruciate ligament : biomechanical evaluation
of the use multiple strands and tensioning technique. J Bone Joint Surg.
1999 ; 74-A : 549-57.

100

16.

Corry I S, Webb J M, Clingeleffer A J et al . Arthroscopic Reconstruction

of the Anterior Cruciate Ligament A Comparison of Patellar Tendon
Autograft and Four-Strand Hamstring Tendon Autograft . Am J Sports Med
1999; 444-54.

17.

Jackson D W, Grood E S, Cohn B T et al. The effect of insitu freezing on

the anterior cruciate ligament;an experimental study in goat. .J Bone Joint
Surg. 1991; 73-A : 201-213.

18.

Jackson D W, Grood E S, Goldstein J D et al A comparison of patellar

tendon autograft and allograft used for anterior cruciate ligament
reconstruction in the goat model . Am J Sports Med 1993; 21:176-85.

19.

James D F . Isolated Anterior cruciate ligament injury. In: Michael W

Chapman (eds) :Chapmans Orthopaedic Surgery. 3 rd Edition; Lippincott
William & Wilkins, 2001.

20.

Johnson L L . The outcome of a free autogenous semitendinosus tendon

graft in human anterior cruciate reconstructive surgery: A histological
study. Arthroscopy 1993 ; 9: 131-42 .

21.

Marmuto J , Mitsunaga M , Richardson A . Late patellar tendon

rupture after removal of the central third for anterior cruciate ligament
reconstruction. Am J Sports Med 1996 ; 24 : 698-701.

22.

Mary L I. The female ACL: why is it more prone to injury ?. Orthop Clin
N Am 2002 ; 33 : 637-51.

23.

McDaniel WJ , Dameron TB . The untreated anterior cruciate ligament

rupture. Clin Orthop 1983 ; 158-63.

24.

Miller S L, Gladestone J N. Graft selection in anterior cruciate ligament

reconstruction. Orthop Clin N Am 2002 ; 33 ; 676-84.

25.

Moore SL. Imaging of anterior cruciate ligament. Orthop Clin. N Am 2003;

33 : 663-74.

101

26.

Noyes F R, Bassett R, Grood E et al . Arthroscopy in acute traumatic

hemarthrosis of the knee: incidence of anterior cruciate tears and other
injuries. J Bone Joint Surg 1980; 62-A : 687-95.

27.

Noyes F R, Barber S D, Mangine R E. Bonepatellar tendon bone and

fascia lata allografts for reconstruction of the anterior cruciate ligament. J
Bone Joint Surg 1990; 72-A :1125-36.

28.

ODonoghue D. Surgical treatment of fresh injuries to the major ligaments

of the knee. J Bone Joint Surg 1950; 32-A :721-38.

29.

Rodeo S, Arnocsky S, Torzilli P et al. Tendon healing in a bone tunnel. J

Bone Joint Surg 1993 ; 75-A :1795-803.

30.

Roos H, Ornell M, Gardsell P et al. Soccer after anterior cruciate

ligament injury: An incompatible combination? A national survey of
incidence and risk factors and a 7-year follow-up of 310 players. Acta
Orthop Scand 1995; 66 : 107-12.

31.

Salehpour A, Butler DL, Proch FS et al. Dose-dependent response of

gamma radiation on mechanical properties and related biomechanical
composition of goat bonepatellar tendonbone allografts. J Orthop Res
1995 ; 13 : 848-906.

32.

Sherman M F, Warren R F, Marshall J L . A clinical and radiographical

analysis of 127 anterior cruciate insufficient knees. Clin Orthop. 1988 ; 227
: 229-37.

33.

Shelbourne K D, Nitz P A . Accelerated rehabilitation after anterior

cruciate ligament reconstruction .. Am J Sports Med 1990; 18 : 292-9.

34.

Shelbourne K D, Trumper R V . Preventing anterior knee pain after

anterior cruciate ligament reconstruction. Am J Sports Med 1997; 25 : 41-7.

35.

Shelton W R , Barrett G R , Dukes A . Early season anterior cruciate

ligament tears: A treatment dilemma. Am J Sports Med 1997 ; 25 : 656-8.

36.

Shino K, Inoue M, Nakamura H

et al . Arthroscopic follow-up of

anterior cruciate ligament reconstruction using allogeneic tendon.

Arthroscopy 1989 ; 5 : 165-71.

102

37.

Shoemaker S C, Markolf K L . The role of the meniscus in the anteriorposterior stability of the loaded anterior cruciate-deficient knee: Effects of
partial versus total excision. J Bone Joint Surg 1986 ; 68-A :71-79.

38.

Stringhan et al . Comparison of anterior cruciate ligament reconstruction

using patellar tendon autograft of allograft. Arthroscopy 1996 ; 12: 414-21.

39.

Wilk K E , Reinold M M , Hooks T R . Recent advances in the

rehabilitation of isolated and combined anterior cruciate ligament injuries.
Orthop Clin N Am 2003 ; 34: 107-37.

40.

Woo S , Hollis M , Adam D . Tensile properties of the human femur

anterior cruciate ligament-tibial complex. Am J Sports Med 1991 ; 19 :21725.

41.

Yasuda K, Tsjino J, Ohkoshi Y et al.

Graft site morbidity with

autogenous semitendinosus and gracilis tendons. Am J Sports Med 1995 ;

23 : 706-14.
42.

Zarins B, Rowe C R. Combined anterior cruciate ligament reconstruction

using semitendinosus tendon and iliotibial tract. J Bone Joint Surg 1986;
68-A : 160-77.