Management Options


Operative versus Nonoperative Management




Knee function

Return to sport

Meniscal injury



Knee function


Reijman et al BMJ 2021

- RCT of 160 patients

- randomized to early ACLR v rehabilitation and optional delayed reconstruction

- 50% in rehabilitation group underwent delayed reconstruction

- significantly better IKDC scores in early ACLR group at 2 years (85 v 80) but perhaps not clinical significant


Frobell et al BMJ 2013

- RCT of 120 patients

- early ACL reconstruction or functional rehab with option of delayed reconstruction

- 1/3 of patients in ACL rehab group chose to have ACL reconstructed

- at five year follow up, no difference in early ACLR / delayed ACLR / rehabiliation alone


Return to sport


Randsborg et al Am J Sports Med 2022

- 1000 patients 7 years post surgery

- 70% return to sport


Meniscal Injury


Sanders et al Am J Sports Med 2016

- database study of 1000 patients with ACL tear

- matched to cohort of 1000 patients without ACL tear

- early ACLR v delayed ACLR v nonoperative

- at 13 years follow up, patients treated nonoperatively had a higher risk of meniscal injury, OA and TKR




Daniels Am J Sports Med 1994

- higher OA in reconstructed knee v non operative

- even if remove those knees that had meniscal surgery





Operative Management




1.  Continued instability not responsive to physiotherapy and strengthening


2.  Reparable bucket handle meniscus tear

Repairing in the setting of ACL deficiency has a lower success


3.  Adolescent


4.  Reinjury with meniscal or cartilage damage


Patient is demonstrating instability


5.  Wish to return to pivoting sports


Clinical scenarios


1.  ACL tear +  Meniscus tear


Displaced bucket handle meniscus and acute locked knee


Acute meniscus repair + delayed ACLR

- reduced rate of meniscus healing

- an unstable knee may retear the meniscus


Acute ACLR and meniscal repair

- advantage is single surgery / high rate meniscus healing

- problem is risk arthrofibrosis




Majeed et al J Orthop Traumatol 2015

- level IV study of 83 patients with ACL injury and meniscal repair

- meniscal repair failure in 14.5% of patients undergoing early ACLR

- meniscal repair failure in 27% of patients undergoing delayed ACLR


Korpershoek et al Orthop J Sports Med 2020

- systematic review

- level 3 evidence that ACLR in the ACL deficient knee protects the repair



2.  ACL + Medial Collateral




Grade II MCL

- 75% chance ACL rupture




Rehab MCL

- perform delayed reconstruction of ACL if symptomatic instability


ROM knee brace to limit extension

- 2 weeks 30-60°

- 2-4 weeks 30-90°

- 4-5 weeks 15˚ - 90

- 6th week 0 – 90˚


Indication for surgery

- MCL torn off tibia (usually off femur) and flipped up and over the pes anserinus

- won't heal in this position

- MRI all patients with MCL tenderness over tibal insertion


Patient with MCL and ACL instability

- reconstruct ACL

- reassess MCL at end of case

- if mildly unstable, advance / imbricate MCL on femoral side +/- tighten medial head gastrocnemius

- if severely unstable, reconstruct with hamstring or tendoachilles allograft


MCL Advancement


4.  ACL + large medial chondral lesion


Consider HTO + ACL




Surgical Options


1.  Primary Repair


High failure rate



1. No clot formation 2° synovial fluid

2. Tension on ligament

3. Intrinsically poor healing potential


2.  Extra-Articular Augmentation


Lateral extra-articular procedures 

- prevent anterior subluxation LFC in extension

- unpopular due to poor long term results


1.  Ellison Procedure


A.  Strip of ITB Deep to LCL 

- placing it anterior in a bone trough

B.  Plication the capsular ligament


2.  MacIntosh Procedure


ITB left attached distally

- deep to LCL

- subperiosteal tunnel in LFC

- thru intermuscular septum

- back on itself distally


ACL Ellison APACL Ellison LateralMacIntosh ACL Scar ITB


3.  ACL Reconstuction


Graft Incorporation


1.  Central necrosis 

- 6 weeks post op

- strength of the graft if 70% of original at this time


2.  Synovialisation

- up to 6 months post op


ACL Graft 6 months0001ACL Graft 6 months0002


3.  Revascularisation


4.  Ligamentisation 

- 6 to 18 months

- longitudinal orientation of collagen

- normal tendon at 2 years



- acts as scaffold for fibroblasts

- graft undergoes ischaemic necrosis & then becomes enveloped with vascular synovial tissue

- occurs at 4-6 weeks post-op

- neovascularisation & cellular proliferation 3/12